An Adaptive Randomized Neoadjuvant Two Arm Trial in Triple-negative Breast Cancer Comparing a Mono Atezolizumab Window Followed by a Atezolizumab - CTX Therapy With Atezolizumab - CTX Therapy (neoMono)
Phase: PHASE2
Conditions: Triple-negative Breast Cancer
Sponsor: Palleos Healthcare GmbH

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
     Confidential 
Page 1 of 118 
Title Page 
 
 
 
 
 
Protocol Title:  
An adaptive randomized neoadjuvant two arm trial in triple-negative 
breast cancer comparing a mono Atezolizumab window followed by a 
Atezolizumab - CTX therapy with Atezolizumab – CTX therapy 
(neoMono) 
 
 
Protocol Number:  
 
Phaon 1 
Protocol Version:  
 
7.0 
EudraCT Number: 
 
2020-001651-40 
Short Title: 
 
 
neoMono 
 
 
 
Testing Objective:  
Pathological complete response in TNBC neoadjuvant treatment with PD-L1 
inhibitor (Atezolizumab) monotherapy window of two weeks followed by 
Atezolizumab in combination with CTX versus neoadjuvant CTX with Atezolizumab. 
 
 
 
Sponsor Name and Legal Registered Address: 
palleos healthcare GmbH 
Taunusstr. 5a 
65183 Wiesbaden 
Germany
NCT04770272

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 5 of 118 
Table of Contents 
 
1. 
Synopsis 
9 
2. 
Schedule of Activities (SOA) 
23 
3. 
Introduction 
27 
3.1. Study rationale and background 
27 
3.2. Study goal and medical need 
31 
3.3. Benefit/Risk Assessment 
31 
4. 
Objectives 
32 
4.1. Primary Objectives 
32 
4.2. Secondary Objectives 
32 
4.3. Translational Research objectives 
33 
5. 
Study design 
33 
5.1. Overall design 
33 
5.2. End of treatment (EOT) 
35 
5.3. Surgery 
35 
5.4. Early stopping Rules 
35 
5.5. Follow up Treatment 
35 
5.6. End of Study (EOS) definition 
36 
5.7. Participants and study completion 
36 
5.8. Justification for dose 
37 
5.8.1. Atezolizumab 840 mg 
37 
5.8.2. Atezolizumab 1200 mg 
37 
5.8.3. Carboplatin, Paclitaxel, Epirubicin and Cyclophosphamide 
37 
6. Study population 
37 
6.1. Inclusion criteria 
38 
6.2. Exclusion criteria 
39 
7. Treatments 
40 
7.1. Definition of study treatment: Investigational Medicinal Product (IMP) 
40 
7.2. Treatments administered 
41 
7.2.1. Atezolizumab 
41 
7.2.2. Carboplatin, Paclitaxel, Epirubicin and Cyclophosphamide 
41 
7.2.3. TNBC directed therapy in adjuvant phase 
41 
7.3. Treatment plans 
42 
7.3.1. Biopsies and overall plan 
42 
7.3.2. Atezolizumab (Tecentriq®) 
44 
7.3.3. Carboplatin 
44 
7.3.4. Paclitaxel 
45 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 6 of 118 
7.3.5. Epirubicin 
45 
7.3.6. Cyclophosphamide 
45 
7.3.7. TNBC directed therapies during adjuvant phase 
45 
7.3.8. Medication error 
45 
7.4. Dose modification and treatment delays 
45 
7.4.1. Atezolizumab 
46 
7.4.1.1. Administration of Atezolizumab 
46 
7.4.1.2. Atezolizumab dose modification 
46 
7.4.1.3. Management of Atezolizumab-specific Adverse Events 
47 
7.4.2. Delays in cycles 
48 
7.4.3. Paclitaxel and Carboplatin Dosage and Modifications 
49 
7.4.3.1. Carboplatin dosage 
49 
7.4.3.2. Dose reductions/modifications of Paclitaxel and Carboplatin 
49 
7.4.3.3. Hypersensitivity reactions to Paclitaxel 
52 
7.4.4. Epirubicin and Cyclophosphamide 
52 
7.4.5 QT corrected interval (QTc) prolongation management 
54 
7.5. Method of treatment assignment 
54 
7.6. Blinding 
54 
7.7. Preparation/Handling/Storage/Accountability 
54 
7.7.1. Drug packaging, labeling, dispensing and storage 
55 
7.7.1.1. Packaging and labeling 
55 
7.7.1.2. Dispensing and storage 
55 
7.7.2. Drug accountability and compliance 
56 
7.8. Concomitant therapy 
56 
7.8.1. Interaction with other medicinal products and other forms of interaction 
57 
7.8.2. Prophylactic premedication regimen for treatment with chemotherapeutic agents 
57 
7.8.3. Use of prophylactic antibiotics and Granulocyte colony stimulating factor (G-CSF) with CTX 57 
7.8.4. Radiation 
57 
7.8.5. Other anti-cancer treatments 
58 
8. Discontinuation/Withdrawal criteria 
58 
8.1. Discontinuation of study treatment 
58 
8.2. Lost to follow-up 
59 
9. Study assessments and procedures 
59 
9.1. Screening 
59 
9.2. Screen failures 
62 
9.3. Randomization and active treatment phase 
62 
9.3.1. Randomization 
62 
9.3.2. Baseline visit: day 1 of treatment 
62 
9.3.3. Neoadjuvant visits after baseline 
63 
9.3.4. End of treatment (EOT) visit in the neoadjuvant phase: 
63 
9.4. Ultrasound assessment 
63 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 7 of 118 
9.5. Surgery 
63 
9.6. Adjuvant therapy and Follow-up visits 
64 
9.7. End of Study visit 
64 
9.8. Efficacy assessments: primary, secondary and translational efficacy parameters 
65 
9.8.1. Primary endpoint: Pathological complete response 
65 
9.8.2. Secondary Endpoints 
65 
9.8.3. Additional Translational Endpoints 
66 
9.9. Adverse Events 
67 
9.9.1. Time Period and Frequency for Collecting AE and SAE Information 
69 
9.9.2. Method of Detecting AEs and SAEs 
69 
9.9.3. Follow-up of AEs and SAEs 
69 
9.9.4. Regulatory Reporting Requirements for SAEs 
70 
9.9.5. Reporting of SAEs 
70 
9.9.6. Reporting of AESIs 
71 
9.9.7. Reporting of Special Situations 
72 
9.9.8. Reporting of Death Events 
72 
9.9.9. Pregnancy 
73 
9.9.10. Annual Safety Report 
73 
9.9.11. Safety monitoring 
74 
9.9.11.1. DSMB 
74 
9.9.11.2. Cardiac safety monitoring 
74 
9.10. Safety assessments 
75 
9.10.1. Physical examination 
75 
9.10.2. Vital signs and ECOG performance test 
75 
9.10.3. Electrocardiogram 
75 
9.10.4. Clinical safety laboratory assessments 
75 
9.11. Markers for translational research 
76 
9.12. Protocol violations 
76 
10. Statistical considerations 
76 
10.1. Rationale and sample size determination 
77 
10.2. Analysis populations 
78 
10.3. Statistical analyses 
78 
10.3.1. Analysis of primary endpoint 
79 
10.3.2. Analysis of secondary endpoints 
79 
10.3.2.1. Biomarkers and response endpoints 
79 
10.3.2.2. Survival analysis 
80 
10.3.3. Safety analyses 
80 
10.3.4. Other analyses 
80 
10.3.5. Interim analyses 
80 
10.4. Missing values 
81 
11. References 
82 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 8 of 118 
12. Appendices 
90 
12.1. Appendix 1: Breast Cancer Stages 
90 
12.2. Appendix 2: Clinical laboratory tests 
91 
12.3. Appendix 3: Tests for translational research 
91 
12.4. Appendix 4: Cardiac safety monitoring 
92 
12.5. Appendix 5: Fluid retention severity grading 
93 
12.6. Appendix 6: ECOG Performance Status 
94 
12.7. Appendix 7: Karnofsky Index 
94 
12.8. Appendix 8: Adverse Events: definitions and procedures for recording, evaluating, follow-up, and 
reporting 
95 
12.9. Appendix 9: Statistical design and methods 
101 
12.10. Appendix 10: Study governance considerations 
109 
12.10.1. Regulatory and ethical considerations 
109 
12.10.2. Financial disclosure 
110 
12.10.3. Safety issues and serious breaches of the protocol or ICH GCP 
110 
12.10.4. Informed consent process 
110 
12.10.5. Data protection 
111 
12.10.6. Publication policy 
111 
12.10.7. Data quality assurance 
112 
12.10.8. Risk Based Monitoring (RBM) strategy 
112 
12.10.9. Source documents 
113 
12.10.10. Site closures 
113 
12.10.11. Study design and management: initiation, managing, funding of the clinical trial 
114 
12.10.12. Patient expenses/payments 
114 
12.10.13. Insurance 
114 
12.10.14. Steering Committee (SC) 
114 
12.11. Appendix 11: Abbreviations and trademarks 
115 
 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 9 of 118 
1. Synopsis 
 
 
Principal 
Investigator 
Prof. Dr. med. Hans-Christian Kolberg 
 
Institution 
Phaon scientific GmbH 
Taunusstraße 5a 
65183 Wiesbaden 
Germany 
Sponsor 
Palleos healthcare GmbH 
Taunusstraße 5a 
65183 Wiesbaden 
Germany 
Full 
Study Title 
 
An adaptive randomized neoadjuvant two arm trial in triple-negative breast cancer 
comparing a mono Atezolizumab window followed by a Atezolizumab-CTX therapy with 
Atezolizumab-CTX therapy (neoMono) 
 
Study Type 
Clinical Trial 
Study 
Short Title 
neoMono 
Study ID 
Phaon1 
Trial 
registration 
Clinicaltrials.gov, clinicaltrialsregister.eu 
Study design 
Randomized, open-label, adaptive, two arm, multicenter, Phase II trial 
Clinical Phase 
Phase II 
Background 
and 
Rationale 
 
 
Triple negative breast cancer (TNBC) 
 
Breast cancer is a heterogeneous disease consisting of several disease subtypes that differ 
with regard to molecular phenotype, treatability and prognosis (Sørlie et al., 2001). As one of 
these subtypes, TNBC is defined by both absence of immunostaining for estrogen receptor 
(ER), progesterone receptor (PR), and lack of overexpression/amplification of human 
epidermal growth factor receptor 2 (HER2/neu) (Dent et al., 2007). TNBC accounts for 
approximately 15% - 20% of breast cancer cases (Bauer et al., 2007) and is associated with 
younger age at diagnosis, premenopausal status, more advanced disease stage, higher 
grade, higher mitotic indices, family history of breast cancer, germline mutations in breast 
cancer (BRCA), and more aggressive clinical course than other breast cancer subtypes 
(Bauer et al., 2007). Improvement of systemic treatment of TNBC represents an unmet 
medical need.  
 
Whereas former clinical studies defined the complete lack of ER, PR and HER2/neu as triple 
negative, current recommendations such as the German AGO recommendations are 
considering ER/PR low tumors (i.e. < 10% positive cells on Immunohistochemistry (IHC)) as 
belonging to the same subgroup (Ditsch et al., 2019). The ER low-positive group is 
characterized molecularly by having features of triple-negative cancer in the majority of cases 
(Iwamoto et al., 2012). This includes basal-like phenotype, high incidence of germline BRCA 
mutation, and high-risk score by OncotypeDX. Also, distant-disease-free survival is similar to 
TNBC in these cases. Therefore, a low threshold of 1% for ER positivity, may lead to the false 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 10 of 118 
exclusion of biologically ER negative tumors from correctly targeted strategies and instead to 
the categorization of these tumors as ER positive with consecutive treatment 
recommendations (Deyarmin et al., 2013; Dixon et al., 2019; Sanford et al., 2015; Yi et al., 
2014). The effect of endocrine therapy on survival outcomes in these patients remains 
unclear (Raghav et al., 2012). These data are justifying the inclusion of ER/PR low patients 
in trials on TNBC. However, after neoadjuvant therapy endocrine therapy has to be discussed 
as an option. 
 
Choice of Chemotherapy (CTX) in TNBC 
 
Currently, poly-CTX is the only systemic treatment option for patients with early TNBC. 
Fortunately, patients with TNBC carry an increased chance of pathological complete 
remission (pCR) compared to patients with non-TNBC (Cortazar et al., 2014; Houssami et 
al., 2012) and in case of pCR prognosis is excellent (Liedtke et al., 2008). However, prognosis 
is unfavorable compared to other breast cancer subtypes, in case of non-pCR.  
 
 
There is an accumulating body of evidence suggesting that platinum salts should be added 
to Anthracycline/Taxane CTX in case of TNBC. In addition to historical data suggesting that 
platinum-containing CTX may be particularly beneficial for patients with TNBC (O. Gluz et al., 
2009) the GeparSixto trial (Untch et al., 2016) and the CALGB 40603 trial (Sikov et al., 2015) 
have provided prospective evidence supporting the use of platinum-salts among patients with 
TNBC. Consequently, an Anthracycline/Taxane/Carboplatin-containing poly-CTX regimen is 
regarded as standard-of-care (SOC) for neoadjuvant treatment of patients with TNBC in 
Germany and is recommended in the current AGO recommendations (Ditsch et al., 2019). 
Furthermore, current and recent clinical trials such as Keynote-522 and NeoTRIP (see below) 
include a platinum-containing poly-CTX regimen. 
 
Immunotherapy 
 
Recently, targeted therapy of regulatory immune pathways has become an important tool in 
clinical applications. In contrast to conventional chemotherapeutics, immune checkpoint 
inhibitors do not target the tumor cells themselves but molecules which are part of the T-cell 
regulatory cascade. The main focus lies on the removal of inhibitory mechanisms by which 
the tumor escapes from a T-cell response (Pardoll, 2012). Atezolizumab (Trade name: 
Tecentriq®) is a humanized antibody against programmed cell death 1 ligand 1 (PD-L1) that 
has shown tolerability and tumor responses in patients with advanced malignancies. PD1 is 
localized on T-cells, B-cells, tumor-infiltrating lymphocytes (TILs), dendritic cells (DCs), 
natural killer T-cells and activated monocytes. Its ligands PD-L1 and -L2 are expressed on a 
variety of cancer types, e.g. breast, ovary, lung, colon, melanoma, kidney and bladder (Alme 
et al., 2016). For some cancer types PD-L1 and -L2 expression could be associated with 
tumor progression and poor prognosis (Thompson et al., 2007). Recently combination 
therapies consisting of conventional agents and immune checkpoint inhibitors showed a high 
clinical relevance in cancer therapy (Sharma & Allison, 2015). Treatment of tumor tissues 
which lack an immunologic microenvironment with markers like CD8+ T-cells, CD4+ T-cells 
or PD-L1, could be improved by combination therapies. Conventional cancer therapies, e.g. 
CTX, radiation, surgery, anti-angiogenetic or hormonal, can induce tumor cell death, resulting 
in a release of antigens (Crittenden et al., 2015; Slovin et al., 2013). 
 
Immunotherapy in TNBC 
 
Among breast cancer subtypes, TNBC is a preferable target for immunotherapy. Hence, there 
is a large and increasing body of evidence for use of immunotherapy in TNBC (Marra et al., 
2019). Consequently, and in particular based on the results of the IMpassion130 trial (Peter 
Schmid, 2018), Atezolizumab has been approved for PD-L1 (IHC) positive metastatic TNBC 
(mTNBC) in the first line of therapy in combination with nab-Paclitaxel. 
 
In the neoadjuvant setting, data regarding the use of immunotherapy are heterogeneous. In 
the Keynote-522 trial, among 602 patients Pembrolizumab in combination with 4 cycles of 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 11 of 118 
Paclitaxel + Carboplatin followed by 4 cycles of Doxorubicin or Epirubicin + 
Cyclophosphamide showed a statistically significant improvement in pCR (ypT0/Tis, ypN0) 
vs. placebo in combination with CTX: 64.8% (95% CI, 59.9 - 69.5) vs. 51.2% (95% CI, 44.1 - 
58.3), p = 0.00055 regardless of PD-L1 IC-status (P. Schmid et al., 2019). 
 
Another neoadjuvant trial in TNBC, the NeoTRIP study presented at the SABCS 2019, 
investigated Atezolizumab 1200 mg q3w in combination with 8 cycles of Carboplatin and nab-
Paclitaxel versus the same neoadjuvant CTX alone. pCR rates between both groups did not 
differ significantly. After surgery patients received 4 cycles of Epirubicin and 
Cyclophosphamide, results of the 5 year follow-up are awaited in 2024 (Gianni et al., 2019). 
Compared to Keynote-522 trial the results of the NeoTRIP trial are implying the conclusion 
that neoadjuvant therapy schedules investigating checkpoint inhibitors in TNBC should 
include an Anthracycline. This is in line with previously published data pointing to a synergistic 
effect of Anthracyclines and checkpoint inhibitors (Matsushita & Kawaguchi, 2018). 
 
Immunotherapy window before neoadjuvant combined immune- and poly-CTX 
 
In the GeparNuevo trial a significant effect of the checkpoint inhibitor Durvalumab in 
combination with neoadjuvant CTX compared to CTX alone could only be demonstrated in a 
subgroup of patients (n = 117) treated with a pre-therapeutic (i.e. before initiation of poly-
CTX) 2-week Durvalumab-monotherapy-window (Loibl et al., 2019). An increase in pCR in 
association with Durvalumab was seen only in patients treated with the pre-therapeutic 
durvalumab monotherapy (pCR 61.0% vs 41.4%, OR = 2.22, 95% CI 1.06 - 4.64, p = 0.035; 
interaction p = 0.048). Among patients without pre-therapeutic window (n = 57), pCR rates 
were 37.9 vs. 50.0%. 
 
A biological rationale for the window effect can be found in the systematic biomarker analysis 
of the GeparNuevo trial. Patients received a re-biopsy after the 2-week window in both arms. 
The change of intra-tumoral TILs (iTILs) between baseline and after the window-phase 
significantly predicted achieving a pCR with Durvalumab in univariate (OR = 5.15, 95% CI 
1.10 – 24.05, p = 0.037) and multivariate regression analysis (OR = 9.36, 95% CI 1.26 – 
69.65, p = 0.029). In the placebo Arm, the change of iTILs did not predict pCR (univariate 
analysis OR = 1.19, 95% CI 0.65 – 2.17, p = 0.581 and multivariate analysis OR = 1.22, 95% 
CI 0.65 – 2.27, p = 0.540). An increase of iTILs in post-window samples compared with pre-
therapeutic samples was predictive of pCR specifically in the Durvalumab arm. Probably due 
to the small sample size the interaction test did not formally meet statistical significance (p = 
0.085). However, these data support the hypothesis that checkpoint inhibitors induce a 
modulation of the immune-microenvironment by stimulating lymphocytes to migrate from the 
stroma into the tumor-cell nests before introduction of cytotoxic CTX. This increased 
infiltration of immune cells into the tumor cell nests might be an indicator of a response to the 
checkpoint inhibitor. Promoting this initial immune response by addition of a poly-CTX could 
lead to an immunogenic cell death, possibly explaining the increased pCR rate in the window 
arm. Based on the results of the GeparNuevo trial (and particularly given the size of the effect) 
a single arm neoadjuvant trial combining poly-CTX with Pembrolizumab, the 
NeoImmunoBoost trial was amended for the inclusion of a 2-week immunotherapy window at 
the beginning of the therapy (ClinicalTrials.gov Identifier: NCT03289819).  
 
The investigation of the effect of a 2-week immunotherapy monotherapy window before 
combination immune- and poly-CTX in a randomized prospective clinical trial has the 
potential to define a new treatment standard. 
 
Dosing of immunotherapy 
 
In contrast to the approved dose in the metastatic setting of ongoing trials, in the neoadjuvant 
setting Atezolizumab is applied in a 3-weekly dose of 1200 mg in combination with carboplatin 
and paclitaxel (https://clinicaltrials.gov/ct2/show/NCT03281954; 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 12 of 118 
https://clinicaltrials.gov/ct2/show/NCT03595592). Due to the investigational nature of the 
monotherapy window we chose the approved 2-weekly dose of 840 mg for the 2-week 
window phase and the approved 3-weekly dose of 1200 mg for the neoadjuvant phase. 
 
Duration of immunotherapy 
 
The question, if it is sufficient to add immunotherapy to the neoadjuvant phase of the 
treatment in TNBC or if an adjuvant application is necessary, is still unclear and study designs 
are heterogeneous. There are trials like the NeoTRIP trial (Gianni et al., 2019) and the 
NeoImmunoBoost trial (ClinicalTrials.gov Identifier: NCT03289819) adding the checkpoint 
inhibitor only to the neoadjuvant phase, whereas in Keynote-522 (P. Schmid et al., 2019) the 
immunotherapy agent was both added to the neoadjuvant phase continued as adjuvant 
treatment and after surgery. The results regarding the follow-up of this trial are still immature. 
A large adjuvant trial, IMpassion030 is investigating the effect of Atezolizumab in the adjuvant 
setting only (ClinicalTrials.gov Identifier: NCT03498716), however, results are not expected 
to be published before 2023. Whereas the neoadjuvant application of immunotherapy in 
combination with poly-CTX is already a new treatment paradigm, this is much less clear for 
the adjuvant use of these drugs. Therefore, it has to be considered adequate for current study 
designs in TNBC to include immunotherapy in the neoadjuvant treatment phase only. 
However, studies should anticipate a potential change regarding adjuvant immunotherapy 
and prepare to amend study protocols to incorporate adjuvant immunotherapy after robust 
results of the studies discussed above are being published. 
 
Neoadjuvant therapy and window-of-opportunity trials in breast cancer 
 
Neoadjuvant CTX trials include a population with therapy naïve tumor. Data from window-of-
opportunity trials including repeat tumor biopsies allow the creation of prediction models for 
clinical response based on the results of early biopsies (Tan et al., 2018). The biomarkers 
used in these models have been tested in different tumor-biologies in the neoadjuvant setting. 
For instance, the IMPACT trial and the POETIC trial have demonstrated that short-term 
changes in proliferation by Ki-67 expression in the neoadjuvant setting may be able to predict 
outcome (Dowsett et al., 2005, 2011). 
Furthermore, among patients treated as part of the triple negative subprotocol of the ADAPT 
Trial (NCT01815242), low-cellularity (< 500 vital tumor cells) at week 3 was strongly 
associated with response to therapy. Higher levels of TILs were associated with pCR, both 
at baseline and after 3 weeks of neoadjuvant CTX. Ki-67 expression after 3 weeks was 
potentially associated with pCR (Oleg Gluz et al., 2015; Liedtke et al., 2018). 
Due to the fact that many patients had less than 500 tumor cells in the re-biopsy after 
3 weeks, which made an evaluation impossible, a 2-week approach is preferred. Accordingly, 
the Combined score based on tumor cellularity and TILs (CelTIL)-Score (Nuciforo et al., 
2017), integrates cellularity and TILs and thus avoids the problem of non-evaluable patients. 
Its predictive value regarding CTX response in a neoadjuvant therapy setting has been 
demonstrated. 
Recently, it has also been demonstrated that TILs after 3 weeks are significantly associated 
with response to checkpoint inhibitors (Loi et al., 2019). 
The inconsistent clinical data regarding neoadjuvant checkpoint inhibitor therapy with and 
without Anthracyclines (Gianni et al., 2019; P. Schmid et al., 2019) make it mandatory to 
investigate the biological effects described above not only of CTX in general in combination 
with Atezolizumab but also separately according to CTX regimen, e.g. Carboplatin and 
Paclitaxel versus Epirubicin and Cyclophosphamide in the setting of a sequential use. 
 
Follow-up duration 
 
TNBC is known to show early recurrence in case of disease relapse. For instance, in an 
analysis among 1,118 patients who received neoadjuvant CTX at M.D. Anderson Cancer 
Center for stage I-III breast cancer from 1985 to 2004, recurrence and death rates were 
higher for TNBC only in the first 3 years. In fact, hazard functions for disease recurrence 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 13 of 118 
among patients with TNBC compared with non-TNBC have been demonstrated to cross at 
2.5 years of follow-up, demonstrating lower incidences of disease recurrence among patients 
with TNBC compared to other breast cancer subtypes thereafter (Liedtke et al., 2008). In a 
preplanned interim analysis performed after 100 pCR events, patients with TNBC did not 
show a significant benefit from an atezolizumab monotherapy window suggesting that the 
primary endpoint would not be reached. Based on these results and in accordance with the 
study stopping rules, the patient recruitment was permanently stopped in August 2022. 
However, patients in both treatment arms demonstrated the highest pCR rates ever reported 
in phase II/III trials with TNBC patients treated with neoadjuvant immune checkpoint inhibitors 
(Kolberg et al., 2023, compare with Loibl et al. 2019; Schmid et al., 2020; Foldi et al., 2022; 
Huober et al., 2022). Given that novel post-neoadjuvant treatment options (on and off-trial) 
have emerged such as pembrolizumab, the post-neoadjuvant treatment in the follow-up 
phase of this study will most certainly be highly heterogeneous. Thus, completion of follow-
up to 3 years is no longer justified. Therefore, follow-up will be limited to 2 years and only 
clinically significant survival signals may be observed. 
 
Study goal and medical need 
 
The goal of this study is: 
 
a) Compare efficacy of neoadjuvant CTX with PD-L1-inhibition (Atezolizumab) and 
Atezolizumab 2-week window to CTX with PD-L1-inhibition (Atezolizumab)  
 
b) to identify biomarkers predicting (early) response to or resistance against Atezolizumab 
(alone and with CTX)) allowing patients stratification in future clinical trials. 
 
Investigationa
l Medicinal 
Product (IMP) 
/ Intervention 
Atezolizumab: 840 mg day 1 for 2 weeks in Arm A Atezolizumab mono-window, then 1200 
mg day 1 every 3 weeks plus Carboplatin, Paclitaxel, Epirubicin and Cyclophosphamide in 
both, Arm A & B 
 
Study 
Population 
 
The study will include patients with primary, treatment naïve triple negative early breast 
cancer. 
 
Study Design 
 
 
After primary local diagnosis the patients will undergo screening which includes a centralized 
confirmation of TNBC subtypes.  
Patients will be randomized to Arm A and B. Randomization will be stratified by PD-L1 IC-
status and anatomic tumor stage (AJCC 8th edition Anatomic Stage Groups I, II and III). 
Patients in Arm A will be treated for a total of 2 weeks with an Atezolizumab mono-therapy of 
840 mg day 1 for 2 weeks before undergoing a biopsy after the 2-week cycle has ended. 
They will then continue with a 12-week therapy with a combination of Paclitaxel 80 mg/m² IV 
weekly x 12 doses + Carboplatin AUC of 2 IV weekly x 12 doses + Atezolizumab 1200 mg 
day 1 every 3 weeks for 4 doses. Every 3-week-interval is considered 1 cycle, therefore 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 14 of 118 
Carboplatin/Paclitaxel/Atezolizumab therapy will be applied for four 3-week cycles (12 weeks 
total). This will be followed by Epirubicin 90 mg/m2 + Cyclophosphamide 600 mg/ m² every 3 
weeks for 4 cycles + Atezolizumab 1200 mg day 1 every 3 weeks for 4 doses.  
Patients in Arm B will be treated with a 12-week regimen of Paclitaxel 80 mg/m² IV weekly x 
12 doses + Carboplatin AUC of 2 IV weekly x 12 doses + Atezolizumab 1200 mg Day 1 every 
3 weeks for 4 doses without a mono-therapy window. Every 3-week-interval is considered 1 
cycle, therefore Carboplatin/Paclitaxel/Atezolizumab therapy will be applied for four 3-week 
cycles (12 weeks total). This will be followed by Epirubicin 90 mg/m² + Cyclophosphamide 
600 mg/m² every 3 weeks for 4 cycles + Atezolizumab 1200 mg day 1 every 3 weeks for 4 
doses. 
Both groups, A and B will undergo a biopsy after 2 weeks of Carboplatin + Paclitaxel + 
Atezolizumab therapy. Furthermore, in both arms, for patients with a tumor size greater 
10 mm in diameter, which have not achieved a 50% decrease in tumor volume (or if not 
assessable a decrease by 50% in diameter), another biopsy (the third in Arm A, the second 
in Arm B) will be performed after 2 weeks of Epirubicin + Cyclophosphamide + 
Atezolizumab therapy. 
Patients in both arms will undergo surgery after 29 - 30 weeks therapy in total for Arm A and 
27 - 28 weeks therapy in total for Arm B (3 - 4 weeks after last dose of neoadjuvant therapy) 
and move on to a treatment by local SOC. Further considerations with regards to 
immunological treatment in the adjuvant setting will be considered when further results are 
published. Safety and toxicities under therapy will be supervised via regular DSMB meetings. 
After surgery, patients will be treated according to the local TNBC directed therapy SOC. 
Thereafter the patients will be followed-up until 24 months after baseline. 
 
It is planned to perform up to 4 efficacy interim analyses in blocks of 40 patients after 100, 
140, 180 and 220 patients evaluable for the primary endpoint pCR, assuming an equal 
sample size in both arms.  
At each interim analysis, decision rules based on predictive probabilities (PP) of trial success 
will be evaluated by the sponsor to determine whether the trial is to continue with patient 
recruitment, or whether to stop early for futility or success respectively. The DSMB will provide 
an independent review of these decisions and the interim efficacy results. 
 
Objective(s) 
 
 
Primary Objective: 
 
1. Compare efficacy in terms of pCR in TNBC with Atezolizumab 2-week monotherapy 
window followed by neoadjuvant CTX with Atezolizumab (Arm A) to neoadjuvant 
CTX with Atezolizumab (Arm B). 
 
Secondary Objectives:  
 
1. Assess and compare safety of Atezolizumab monotherapy window of 2 weeks 
followed by neoadjuvant treatment with Atezolizumab in combination with CTX 
(Arm A) to neoadjuvant CTX with Atezolizumab (Arm B). 
2. Assess and compare efficacy of Atezolizumab mono-therapy window of 2 weeks 
followed by neoadjuvant treatment with Atezolizumab in combination with CTX 
(Arm A) to neoadjuvant CTX with Atezolizumab (Arm B) in patients with an ER/PR 
expression of < 1% and an ER/PR expression of 1% to 10%. 
3. Compare efficacy of Atezolizumab mono-therapy window of 2 weeks followed by 
neoadjuvant treatment with Atezolizumab in combination with CTX (Arm A) to 
neoadjuvant CTX with Atezolizumab (Arm B) per alternative pCR definitions. 
4. Compare early biological response (2 weeks in both arms) of Atezolizumab mono-
therapy window of 2 weeks followed by neoadjuvant treatment with Atezolizumab in 
combination with CTX (Arm A) to neoadjuvant CTX with Atezolizumab (Arm B), as 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 15 of 118 
measured by Complete Cell Cycle Arrest (CCCA), decrease of Ki-67 expression (≥ 
30%), low cellularity and TILs (≥ 60%), or a combined early response. 
5. Compare early biological response (2 weeks in Arm B vs. 4 weeks in Arm A) of 
Atezolizumab mono-therapy window of 2 weeks followed by neoadjuvant treatment 
with Atezolizumab in combination with CTX (Arm A) to neoadjuvant CTX with 
Atezolizumab (Arm B), as measured by CCCA, decrease of Ki-67 expression (≥ 
30%), low cellularity and TILs (≥ 60%), or a combined early response.  
6. Assess and compare the prognostic and predictive values of the biomarkers 
(measured after 2 weeks and 4 weeks): CCCA, decrease of Ki-67 expression (≥ 
30% and continuous), low cellularity and TILs (≥ 60% and continuous), or a 
combined early response, with respect to the outcome pCR.  
7. Compare the efficacy of Atezolizumab mono-therapy window of 2 weeks followed 
by neoadjuvant treatment with Atezolizumab in combination with CTX (Arm A) to 
neoadjuvant CTX with Atezolizumab (Arm B), as measured by disease free survival 
(DFS).  
8. Compare the efficacy of Atezolizumab mono-therapy window of 2 weeks followed 
by neoadjuvant treatment with Atezolizumab in combination with CTX (Arm A) to 
neoadjuvant CTX with Atezolizumab (Arm B), as measured by overall survival (OS). 
9. Compare the efficacy of Atezolizumab mono-therapy window of 2 weeks followed 
by neoadjuvant treatment with Atezolizumab in combination with CTX (Arm A) to 
neoadjuvant CTX with Atezolizumab (Arm B), as measured by event free survival 
(EFS). 
 
 
 
Translational objectives: 
 
1. Identify candidate genes for response/resistance to Atezolizumab (Sokolenko & 
Imyanitov, 2017). 
2. Analyze the influence of immune markers (e.g. PD-1/L1) via circulating tumor 
deoxyribonucleic acid (ctDNA) as predictor for response to Atezolizumab (Appendix 
B) (Raja et al., 2018; Saliou et al., 2016).  
3. Evaluate the influence of intrinsic subtype on response to Atezolizumab (Llombart-
Cussac et al., 2017). 
4. Assess the continuous ER/PR/HER2 expression (via polymerase chain reaction) as 
a predictive factor for response/resistance to Atezolizumab (Park et al., 2014). 
5. Assess a specific DNA panel (Appendix A) via ctDNA as a predictive factor for 
response/resistance to Atezolizumab (Keup et al., 2019). 
6. Evaluate the influence of polymorphisms via ctDNA on response to Atezolizumab 
(Mcardle et al., 2018). 
7. Compare immune markers, polymorphisms, DNA panel activity, and ctDNA levels 
(Raja et al., 2018) after 14/28 days (+/- 2 days) of treatment between mono- and 
non-mono-therapy patients. 
8. Evaluate T-Cell influence (CD 3/4/8) on the response to Atezolizumab. 
9. Identify immune markers as candidate genes for response/resistance to 
Atezolizumab (Appendix C) (Oleg Gluz et al., 2019; Lee et al., 2015; Sokolenko & 
Imyanitov, 2017; Yang et al., 2018). 
10. Assess and compare the prognostic and predictive values of the biomarkers: 
CCCA, Ki-67, low cellularity, TILs and CelTIL score after switch of the CTX to 
Epirubicin and Cyclophosphamide with respect to the outcome pCR in patients with 
less than 50% tumor shrinkage after 4 cycles of 
Carboplatin/Paclitaxel/Atezolizumab +/- the 2-week Atezolizumab window. 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 16 of 118 
11. Develop a new single drug RNA-based biomarker signature to predict 
response/resistance to Atezolizumab. 
12. Assess and compare the prognostic and predictive values of the biomarkers 
(measured after 2 weeks and 4 weeks): CCCA, decrease of Ki-67 expression (≥ 
30% and continuous), low cellularity and TILs (≥ 60% and continuous) with respect 
to the outcomes DFS and OS.  
13. Assess optimal cut-offs for decrease of Ki-67 expression, TILs and the CelTIL score 
with respect to prediction of pCR, DFS and OS and compare with existing cut-offs. 
 
Hypotheses 
 
 
Primary Hypothesis: 
 
1. Atezolizumab mono-therapy window of 2 weeks followed by neoadjuvant treatment 
with Atezolizumab in combination with CTX (Arm A) is superior to neoadjuvant CTX 
with Atezolizumab (Arm B).  
 
Secondary Hypothesis: 
 
1. A monotherapy Atezolizumab window of 2 weeks followed by neoadjuvant 
treatment with Atezolizumab in combination with CTX has an acceptable toxicity 
profile. 
2. There is an increased response rate in the subgroup of patients with ER/PR 
expression of < 1% as compared to patients with ER/PR expression of 1% to 10%. 
3. Atezolizumab mono-therapy window of 2 weeks followed by neoadjuvant treatment 
with Atezolizumab in combination with CTX (Arm A) is superior to neoadjuvant CTX 
with Atezolizumab (Arm B) per alternative pCR definitions. 
4. Early biological response (2 weeks in both arms), as measured by CCCA, decrease 
of Ki-67 expression (≥ 30%), low cellularity and TILs (≥ 60%), or a combined early 
response, is increased in Arm A with Atezolizumab mono-therapy window of 2 
weeks followed by neoadjuvant treatment with Atezolizumab in combination with 
CTX. 
5. Early biological response (2 weeks in Arm B vs. 4 weeks in Arm A), as measured 
by CCCA, decrease of Ki-67 expression (≥ 30%), low cellularity and TILs (≥60%), 
or a combined early response, is increased in Arm A with Atezolizumab mono-
therapy window of 2 weeks followed by neoadjuvant treatment with Atezolizumab in 
combination with CTX. 
6. The following biomarkers, measured after 2 and 4 weeks respectively, are 
prognostic and predictive with respect to outcome pCR: CCCA, decrease of Ki-67 
expression (≥ 30% and continuous), low cellularity and TILs (≥ 60% and 
continuous), or a combined early response.  
7. There is an increased efficacy in Arm A with Atezolizumab mono-therapy window of 
2 weeks followed by neoadjuvant treatment with Atezolizumab in combination with 
CTX, as measured by DFS. 
8. There is an increased efficacy in Arm A with Atezolizumab mono-therapy window of 
2 weeks followed by neoadjuvant treatment with Atezolizumab in combination with 
CTX, as measured by OS. 
9. There is an increased efficacy in Arm A with Atezolizumab mono-therapy window of 
2 weeks followed by neoadjuvant treatment with Atezolizumab in combination with 
CTX, as measured by EFS. 
 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 17 of 118 
 
 
Translational hypothesis: 
 
1. There are candidate genes for response/resistance to Atezolizumab. 
2. Immune markers (e.g. PD-1/L1) via ctDNA serve as predictor for response to 
Atezolizumab (Raja et al., 2018; Saliou et al., 2016). 
3. Intrinsic subtype has an influence on response to Atezolizumab (Llombart-Cussac 
et al., 2017). 
4. The continuous ER/PR/HER2 expression (via polymerase chain reaction) is a 
predictive factor for response/resistance to Atezolizumab (Park et al., 2014). 
5. A specific DNA panel via ctDNA is a predictive factor for response/resistance to 
Atezolizumab (Keup et al., 2019). 
6. Polymorphisms via ctDNA influence the response to Atezolizumab (Mcardle et al., 
2018). 
7. Immune markers, polymorphisms, DNA panel activity, and ctDNA levels (Raja et 
al., 2018) after 14/28 days (+/- 2 days) of treatment between mono- and non-mono-
therapy patients show different influences on the response. 
8. T-Cells (CD 3/4/8) influence the response to Atezolizumab. 
9. There are immune markers for response/resistance to Atezolizumab. 
10. Biological response measured by CCCA, Ki-67, low cellularity, TILs and CelTIL 
score after switch of the CTX to Epirubicin and Cyclophosphamide is predictive and 
prognostic with respect to the outcome pCR in patients with less than 50% tumor 
shrinkage after 4 cycles of Carboplatin/Paclitaxel/Atezolizumab +/- the two-week 
Atezolizumab window. 
11. There is an RNA-based biomarker signature to predict response/resistance to 
Atezolizumab. 
12. Biomarkers measured after 2 or 4 weeks respectively are prognostic and predictive 
with respect to the outcomes DFS and OS. 
13. Optimal cut-offs can be found for decrease of Ki-67 expression, TILs and the 
CelTIL score with respect to prediction of pCR, DFS and OS. 
 
Endpoints/ 
Outcome(s) 
 
Objective 
Endpoints 
Primary 
1. 
a 
Secondary 
1. 
b 
2. 
c 
3. 
d, e, f 
4. 
i, j, k, l, m 
5. 
i, j, k, l, m 
6. 
a 
7. 
n 
8. 
o 
9. 
p 
Translational 
1. 
a, z 
2. 
a, r 
3. 
a, s 
4. 
a, s 
5. 
a, t 
6. 
a, t 
7. 
t, r 
8. 
a, r 
9. 
a, r 
10. 
a, u, v, w, x, y 
11. 
a, z 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 18 of 118 
12. 
n, o, i, j, k, l 
13. 
a, n, o, g, h, q 
 
Primary Endpoint: 
a) pCR defined as no residual invasive tumor cells in the breast and in the lymph nodes 
(ypT0/is, ypN0) 
 
Secondary Endpoints: 
b) Safety (incidence, relationship, seriousness, and severity of all AEs, SAEs, AESIs 
coded by medical dictionary for regulatory activities (MedDRA), summarized by 
Preferred Term and System Organ Class and graded according to common 
terminology criteria of adverse events (CTCAE) V5.0) 
c) pCR defined as no residual invasive tumor cells in the breast and in the lymph nodes 
(ypT0/is, ypN0) in patients with an ER/PR expression of < 1% and an ER/PR 
expression of 1% to 10% 
d) pCR defined as no tumor cells (invasive or non-invasive) in the breast but also in the 
lymph nodes (ypN0, ypT0) 
e) Near pCR defined as residual tumor < 5 mm in the breast irrespective of in situ and 
lymph nodes status 
f) 
pCR defined as no invasive tumor in the breast, irrespective of lymph node status 
g) Decrease of Ki-67 expression versus baseline after 14/28 days (+/- 2 days) of 
treatment as continuous predictor 
h) TILs after 14/28 days (+/- 2 days) of treatment as continuous predictor 
i) 
CCCA: Ki-67 expression ≤ 2.7% after 14/28 days (+/- 2 days) of treatment 
j) 
Low cellularity: < 500 tumor cells after 14/28 days (+/- 2 days) of treatment 
k) Decrease of Ki-67 expression versus baseline by 30% or more after 14/28 days (+/- 2 
days) of treatment  
l) 
TILs ≥ 60% after 14/28 days (+/- 2 days) of treatment 
m) Combined early response defined by 
o 
CCCA (Ki-67 expression < 2.7%) or 
o 
low cellularity or 
o 
decrease of Ki-67 expression (versus baseline) by 30% or more or 
o 
TILs ≥ 60%  
n) DFS1 defined as time from the first date of no disease [i.e. date of surgery] to the first 
occurrence of disease recurrence or death from any cause 
o) OS defined as length of time from randomization to death from any cause 
p) EFS defined as length of time after randomization till death from any cause, failure to 
achieve remission after induction therapy, relapse in any site, or second malignancy. 
 
Additional translational endpoints 
q) CelTIL score as defined by (Nuciforo et al., 2017) 
r) 
Immune markers (e.g. PD-1/L1) via ctDNA  
s) Intrinsic subtype continuous ER/PR/HER2 expression 
t) 
Specific DNA panel 
u) Ki-67 expression as a continuous variable after 14 days (+/- 2 days) of treatment with 
Epirubicin and Cyclophosphamide in patients with less than 50% tumor shrinkage after 
4 cycles of Carboplatin/Paclitaxel/Atezolizumab +/- the 2-week Atezolizumab window 
measured by tumor volume (or if not assessable by volume a decrease by 50% in 
diameter) through sonographic assessment 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 19 of 118 
v) TILs as a continuous variable after 14 days (+/- 2 days) of treatment with Epirubicin 
and Cyclophosphamide in patients with less than 50% tumor shrinkage after 4 cycles 
of Carboplatin/Paclitaxel/Atezolizumab +/- the 2-week Atezolizumab window 
w) CCCA: Ki-67 expression ≤ 2.7% after 14 days (+/- 2 days) of treatment with Epirubicin 
and Cyclophosphamide in patients with less than 50% tumor shrinkage after 4 cycles 
of Carboplatin/Paclitaxel/Atezolizumab +/- the 2-week Atezolizumab window 
x) Low cellularity: < 500 tumor cells after 14 days (+/- 2 days) of treatment with Epirubicin 
and Cyclophosphamide in patients with less than 50% tumor shrinkage after 4 cycles 
of Carboplatin/Paclitaxel/Atezolizumab +/- the 2-week Atezolizumab window 
y) CelTIL score as defined by (Nuciforo et al., 2017) after 14 days (+/- 2 days) of 
treatment with Epirubicin and Cyclophosphamide in patients with less than 50% tumor 
shrinkage after 4 cycles of Carboplatin/Paclitaxel/Atezolizumab +/- the 2-week 
Atezolizumab window 
z) Genome-wide gene expression analysis for RNA-based biomarker signature related to 
response/resistance to Atezolizumab 
 
Key 
Inclusion 
Criteria 
 
Key Inclusion Criteria: 
 
● 
Female and male patients, age at diagnosis 18 years and above  
● 
Written informed consent prior to admission to this study 
● 
Histologically confirmed unilateral primary invasive carcinoma of the breast 
● 
Clinical T1c – T4d 
● 
Stage N0-N3 until 21 patients (5%) with stage N3 are randomized, thereafter 
N0 - N2 
● 
TNBC defined by and confirmed by central pathology: 
o 
ER negative (< 10% positive cells in IHC) and PR negative (<10% positive 
cells on IHC)  
o 
HER2 negative breast cancer: 
▪ 
Either defined by IHC: IHC scores of 0 - 1 or an IHC score of 2 in 
combination with a negative in-situ-hybridization (ISH) 
▪ 
Or defined by ISH: negative ISH  
● 
Identifiable PD-L1 IC-status by central pathology (positive or negative) by means of 
VENTANA PD-L1 (SP142) Assay; positive status is defined by PD-L1 expression 
on IC on ≥ 1% of the tumor area, negative status is defined by PD-L1 expression on 
IC on < 1% of the tumor area 
● 
No clinical evidence for distant metastasis (cM0)  
● 
Tumor block available for translational research 
● 
Performance Status Eastern Cooperative Oncology Group (ECOG) ≤ 1 or KI ≥ 80% 
● 
Negative pregnancy test (urine or serum) within 7 days prior to screening in 
premenopausal patients 
● 
Women of childbearing potential and male patients with partners of childbearing 
potential must accept to implement a highly effective (less than 1% failure rate 
according to Pearl index) including at least one non-hormonal contraceptive 
measures during the study treatment and for 5 months following the last dose of 
study treatment such as:  
o 
Intrauterine device (IUD) 
o 
bilateral tubal occlusion 
o 
vasectomised partner 
o 
sexual abstinence 
● 
The patient must be accessible for treatment and follow-up 
● 
Normal cardiac function: 
o 
Normal electrocardiogram (ECG) (within 6 weeks prior to screening) 
o 
Normal left ventricular ejection fraction (LVEF) on echocardiography 
● 
Normal thyroid function 
o 
Normal TSH and FT4            

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 20 of 118 
● 
Blood counts within 14 days prior screening: 
o 
ANC must be ≥1,500/mm3 
o 
Platelet count must be ≥ 100,000 / mm3 
o 
Hemoglobin must be ≥ 10 g/dl 
● 
Hepatic functions: 
o 
Total bilirubin must be ≤ 1 upper limit of normal (ULN) for the lab unless the 
patient has a bilirubin elevation > 1 x ULN to 1.5 x ULN due to Gilbert’s 
disease or similar syndrome involving slow conjugation of bilirubin  
o 
Alkaline phosphatase (ALK) must be ≤ 2.5 x ULN for the lab  
o 
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) 
must be ≤ 1.5 x ULN for the lab.  
o 
Patients with AST and ALT or ALK > 1 x ULN are eligible for inclusion if 
liver imaging (computerized tomography (CT), magnetic resonance imaging 
(MRI), positron emission tomography (PET)-CT, or PET scan) performed 
within 3 months prior to randomization (and part of SOC) does not 
demonstrate metastatic disease and the requirements in criterion (just 
above) are met  
o 
Patients with ALK that is > 1 x ULN but less than or equal to 2.5 x ULN or 
with unexplained bone pain are eligible if bone imaging does not 
demonstrate metastatic disease. 
o 
Creatinine clearance ≥ 40 ml/min performed 28 days prior to screening 
Key 
Exclusion 
Criteria 
 
Key Exclusion Criteria: 
 
● 
Previous history of malign diseases, non-melanoma skin cancer and carcinoma of the 
cervix are allowed if treated with curative intent 
● 
Any other disease, metabolic dysfunction, physical examination finding, or clinical 
laboratory finding that, in the investigator's opinion, gives reasonable suspicion of a 
disease or condition that contraindicates the use of Paclitaxel, Carboplatin, Epirubicin, 
Cyclophosphamide or Atezolizumab 
● 
Psychological, familial, sociological or geographical conditions that do not permit 
compliance with the study protocol 
● 
Concurrent treatment with other drugs that are contraindicating the use of the study 
drugs 
● 
Existing pregnancy 
● 
Breastfeeding 
● 
Sequential breast cancer 
● 
Concurrent treatment with other experimental drugs and participation in another clinical 
trial or clinical research project (except registry study) within 30 days prior to study entry  
● 
Severe and relevant co-morbidity that would interact with the application of cytotoxic 
agents or the participation in the study including but not confined to: 
o 
Uncompensated chronic heart failure or systolic dysfunction (LVEF < 55%, 
congestive heart failure (CHF) New York Heart Association (NYHA) classes II-
IV), 
o 
unstable arrhythmias requiring treatment i.e., atrial tachycardia with a heart rate 
≥ 100/min at rest, significant ventricular arrhythmia (ventricular tachycardia) or 
higher-grade AV-block, 
o 
Angina pectoris within the last 6 months requiring anti-anginal medication, 
o 
Clinically significant valvular heart disease, 
o 
Evidence of myocardial infarction on ECG, 
o 
Poorly controlled hypertension (e.g., systolic > 180 mmHg or diastolic > 
100 mmHg). 
● 
Inadequate organ function including but not confined to:  
o 
hepatic impairment as defined by bilirubin > 1.5 x ULN  
o 
pulmonary disease (severe dyspnea at rest requiring oxygen therapy) 
● 
Abnormal blood values: 
o 
Platelet count below 100,000/mm3 
o 
AST/ALT > 1.5 x ULN  

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 21 of 118 
o 
Hypokalaemia > CTCAE grade 1 
o 
Neutropenia > CTCAE grade 1 
o 
Anaemia > CTCAE grade 1 
● 
Administration of a live, attenuated vaccine within 4 weeks before cycle 1 day 1 or 
anticipation that such a vaccine will be required during the study  
● 
Treatment with systemic immunosuppressive medications (including but not limited to 
interferons, IL-2) within 28 days or 5 half-lives of the drug, whichever is longer, prior to 
randomization 
● 
Treatment with systemic immunosuppressive medications (including but not limited to 
Prednisone, Cyclophosphamide, Azathioprine, Methotrexate, Thalidomide, and anti-
tumor necrosis factor (anti-TNF) agents) within 14 days prior to screening or 
anticipation of need for systemic immunosuppressive medications during the study 
● 
Patients with prior allogeneic stem cell or solid organ transplantation 
● 
Active or history of autoimmune disease or immune deficiency, including but not limited 
to myasthenia gravis, myositis, autoimmune hepatitis, systemic lupus erythematosus, 
rheumatoid arthritis, inflammatory bowel disease, antiphospholipid syndrome, Wegener 
granulomatosis, Sjögren syndrome, Guillain-Barré syndrome, or multiple sclerosis with 
the following exceptions: 
o 
Patients with a history of autoimmune-related hypothyroidism on a stable 
dose of thyroid replacement hormone may be eligible for this study. 
o 
Patients with controlled Type 1 diabetes mellitus on a stable dose of insulin 
regimen may be eligible for this study. 
o 
Patients with eczema, psoriasis, lichen simplex chronicus, or vitiligo with 
dermatologic manifestations only (e.g., patients with psoriatic arthritis are 
excluded) are permitted provided all of following conditions are met: Rash 
must cover < 10% of body surface area; Disease is well controlled at 
baseline and requires only low-potency topical corticosteroids; No 
occurrence of acute exacerbations of the underlying condition requiring 
psoralen plus ultraviolet A radiation, Methotrexate, retinoids, biologic 
agents, oral calcineurin inhibitors, or high-potency or oral Corticosteroids 
within the previous 12 months. 
● 
History of idiopathic pulmonary fibrosis, organizing pneumonia (e.g., bronchiolitis 
obliterans), drug-induced pneumonitis, idiopathic pneumonitis, or evidence of active 
pneumonitis on screening chest CT scan  
● 
History of HIV infection, hepatitis B or hepatitis C infection 
● 
Patients with significant cardiovascular disease 
● 
Patients with inadequate hematological and end-organ function 
● 
Patients receiving therapeutic anti-coagulants  
● 
Stage N3, as soon as 21 patients with stage N3 are randomized 
 
 
Statistical 
Rationale and 
Sample Size 
Calculation 
 
 
 
 
 
 
 
 
 
 
 
neoMono adapts the idea of a proof-of-concept trial that uses Bayesian posterior and 
predictive probabilities for inference about the primary hypothesis. Up to 4 planned efficacy 
interim analyses provide decision points for early stopping for success or futility, the results 
of which will be independently reviewed by the DSMB. 
 
A detailed explanation of statistical methods and the design with literature sources is provided 
in an appendix to this document.  
 
The primary analysis is based on non-informative uniform (beta) priors for the pCR rates 
𝑝𝐴and 𝑝𝐵 in Arms A (experimental) and B (control) respectively. The proof-of-concept trial 
uses a dual criterion to simultaneously test for significant and relevant superiority at different 
levels of certainty by requiring posterior probabilities, conditional on observed response 
counts 𝑥𝐴,  𝑥𝐵 respectively in the two arms, to exceed the following thresholds: 
𝑃(𝑝𝐴> 𝑝𝐵 | 𝑥𝐴,  𝑥𝐵) ≥0.975   ⋀   𝑃(𝑝𝐴−𝑝𝐵> 𝛿 | 𝑥𝐴,  𝑥𝐵) ≥0.85, 
                                             significance                   relevance 
with a clinically meaningful difference of 𝛿= 0.05. 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 22 of 118 
 
 
The trial is planned to have a maximal sample size of  𝑁𝑚𝑎𝑥= 370 evaluable patients, with 
up to 4 planned interim analyses in order to assess early futility or success of the trial based 
on posterior predictive probabilities 𝑃𝑃 for trial success. That is, the probability of claiming 
superiority in terms of the dual criterion if the trial were to continue to the maximal sample 
size 𝑁𝑚𝑎𝑥, conditional on the responses observed in the trial so far (see statistical appendix 
for mathematical details).  
 
During the trial, up to 4 interim analyses are to be performed and reviewed by the DSMB 
after 100, 140, 180 and 220 patients evaluable for the primary endpoint. The following 
decision rules will be implemented at each interim analysis point: 
 
● 
If 𝑃𝑃< 0.025 the trial is stopped for futility 
● 
If 𝑃𝑃>  0.975 the trial is stopped for success 
The maximal sample size 𝑁𝑚𝑎𝑥was determined by Monte Carlo simulation of the full adaptive 
trial with the parameters above using 108 repetitions and calculating the global operating 
characteristics (OC, power and type I error) in different scenarios of interest.  
 
𝑁𝑚𝑎𝑥= 370 is the smallest maximal sample size for the trial to reach at least 80% power to 
rightly claim superiority in the scenario 𝑝𝐴=  60%, 𝑝𝐵= 45% and at most a 2.5% type I error 
rate to wrongly claim superiority in the scenario 𝑝𝐴= 45%, 𝑝𝐵= 45%. (see tables below; see 
statistical appendix for further details and a justification of pCR assumptions).  
 
We assume an analysis dropout rate of 10% for the primary objective, where an analysis 
dropout is defined as any patient for whom a critical analysis-enabling covariate or the primary 
endpoint is not measurable for any reason, thus requiring 412 patients to be randomized (206 
per arm with 1:1 randomization). In addition, we account for a 10% screening failure rate. As 
a result, the expected number of patients to be recruited is set to 458. 
 
Scenario 
Operating  
Characteristics 
P(correct 
early stop) 
𝔼[sample size] 
H0 significance: 
 𝑝𝐴= 45%,   𝑝𝐵= 45% 
type 1 error: 2.4% 
68.5 % 
296 
H0 relevance: 
 𝑝𝐴= 49%,   𝑝𝐵= 45% 
type 1 error: 10.9% 
46.3% 
321 
H1: 𝑝𝐴= 60%,  𝑝𝐵= 45% 
power: 80.1% 
34.9% 
332 
Number of 
study centers 
 
40 sites in Germany 
Study 
Duration: 
 
First patient in (FPI): Mar 2021 
Last patient in (LPI): Aug 2022 (due to recruitment stop) 
Last patient last visit (LPLV): Aug 2024 
Recruitment period: 17 months 
Expected recruitment rate: 0.5 patients/site/month 
 
GCP 
Statement: 
This study will be conducted in compliance with the protocol, the current version of 
the Declaration of Helsinki, the ICH-GCP as well as all national legal and regulatory 
requirements.  
 
 

 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                      Confidential                                 
Page 23 of 118 
● 1 DFS is defined as: time from surgery to: Ipsilateral invasive breast tumor recurrence (i.e., 
an invasive breast cancer involving the same breast parenchyma as the original primary 
lesion) 
● Ipsilateral local-regional invasive breast cancer recurrence (i.e., an invasive breast cancer in 
the axilla, regional lymph nodes, chest wall, and/or skin of the ipsilateral breast) 
● Distant recurrence (i.e., evidence of breast cancer in any anatomic site – other than the two 
abovementioned sites – that has either been histologically confirmed or clinically diagnosed 
as recurrent invasive breast cancer) 
● contralateral invasive breast cancer  
● Ipsilateral or contralateral ductal carcinoma in situ (DCIS)  
● Second primary non-breast invasive cancer (with the exception of non-melanoma skin 
cancers and in situ carcinoma of any site) 
● Death attributable to any cause including breast cancer, non-breast cancer, or unknown 
cause (but cause of death should be specified if possible) 
2. Schedule of Activities (SOA) 
 
The SOA table provides an overview of the protocol visits and procedures. 
 
Due to logistical reasons, it may be difficult for participating sites to carry out all screening 
assessments in the period indicated. Therefore, specific timelines will be given for the different 
tests to confirm disease status. 
 
Since treatment times in Arm A and B are different (26 weeks in Arm A; 24 weeks in Arm B) and 
the fact that there is a shift in time between the 24 weeks treatment of Atezolizumab associated 
with Carboplatin, Paclitaxel, Epirubicin and Cyclophosphamide between Arm A and B, the SOA 
table is presented separately for Arm A and B. 
 
Table 1: Schedule of Activities (on the following pages) 
Table 1a: Arm A 
Table 1b: Arm B 
 

 
 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                                                                                              Confidential 
 
Page 24 of 118 
 
 
 
 
 
Schedule and assesssment
Screenin
g visit
Randomi
sation 
(no 
patient 
visit)
Baseline 
visit : day 
1 
treatment
Visit 1 
after 
baseline
**
Visit 2 
**
Visit 3 
**
Visit 4 
**
Visit 5 
**
Visit 6 
**
Visit 
7** 
Visit 8 
**
Visit 9 
**
Visit 
10 **
Visit 
11 **
Visit 
12** 
Visit 
13 **
Visit 
14 **
Visit 
15** 
Visit 
16 **
Visit 
17** 
Visit 
18** 
Visit 
19** 
Visit 
20 **
Visit 
21 **
Visit 
22 **
Visit 
23** 
Visit 
24** 
EOT Visit 3 
weeks after 
last dose 
chemo**
Surgery: 3-4 
weeks after 
last dose 
chemo
Follow up every 6 
months after surgery 
(if no surgery will be 
performed: 6 
months after 
EOT)*** (j)
EOS visit: 
week 104 or 
month 24*** 
(j)
week
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
wk 29
wk 29-30
until year 2 after 
baseline
day*
-17
-10 to -3
1
8
15
22
29
36
43
50
57
64
71
78
85
92
99
106
113
120
127
134
141
148
155
162
169
176
Atezolizumab 840 mg IV, day 1
X
Atezolizumab 1200 mg IV Day 1 every 3 weeks for 4 doses
X
X
X
X
X
X
X
X
Paclitaxel 80 mg/m2 IV weekly X 12 doses
X
X
X
X
X
X
X
X
X
X
X
X
Carboplatin AUC of 2 IV day 1 every week X 12 doses
X
X
X
X
X
X
X
X
X
X
X
X
Epirubicin 90 mg/m² every 3 weeks for 4 cycles
X
X
X
X
Cyclophosphamide 600 mg/m² every 3 weeks for 4 cycles
X
X
X
X
ICF (before any study procedure
 starts)
X
Medical history
X
Core Biopsy (a)
X SOC
X 
X
X
physical examination (b)
X
X
X
X 
X
X
X
X
X
X
X 
SOC
SOC
Ultrasound (breast, lymph nodes, SoC) ( c )
X
X
X
X 
SOC
SOC
Other imaging:  Mammography, chest X Ray or CT thorax; bone 
scan; liver imaging (SOC) (d)
X 
SOC
SOC
central pathology  ( e )
X
X
X
X
X
clinical assessment
X
X
X 
X 
X 
X
X
X
X
X
X
X
X
pregnancy test and check of adequate contraception measures 
(f)
X
(X)
X
X
X
X
X
X
X
every 4 weeks until 
month 5 after last 
chemo
LVEF (g)
X
X
X
SOC
ECG (h)
X
X
X
SOC
Laboratory (hematology, biochemistry) (i)
X
X
X 
X 
X 
X
X
X
X
X
X
SOC
Laboratory (hematology)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
blood sample for translational research 
X
X 
X
X
X
Randomization****
X
surgery
X
start of adjuvant CTX / Follow up (SoC)
SOC
(Serious) Adverse Event, AESIs, pregnancies
Concomittant medication
continously
Table 1a: Schedule of Activity ARM A
Study Procedures
continuosly

 
 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                                                                                              Confidential 
 
Page 25 of 118 
 
 
 
* timing different depending on test (see below); ** time of visits with a window of 2 days; ***time of visits with a window of +/-14 days
**** Randomisation : performed  by investigator once all I/E criteria are fullfilled.  Atezolizumab is ordered at Roche; chemo agents are ordered at central pharmacy;  patient is contacted for baseline visit (no patient visit for randomisation)
(a): SOC core biopsy available prior to randomization
(b): physical examination at screening should be done within 7 days of screening
( c, d):  Ultrasound is performed within 4 weeks prior to screening, other imaging procedures are performed within 3 months before randomization. After that they are performed as SOC .
( e ): central pathology results need to be available before randomisation. In case central pathology does not confirm local pathology results for TNBC, the patient will not be randomised and considered as screen failure.
(g): LEVF at screening within 6 weeks before screening visit; then after 4 cycles and at EOT 
(h): ECG at screening within 6 weeks before screening visit; then after 4 cycles and at EOT
(i): laboratory analyses at screening should be done within 14 days before screening visit
(j): Follow-up visits could also be performed at a local gynecologist/oncologist. In this case, site contacts patients by phone.
EOT visit should not be later than 3 weeks from last neoadjuvant treatment
surgery is recommended to be performed within 3-4 weeks after completion of neoadjuvant treatment  
(f): pregnancy test at screening should not be older than 7 days, otherwise it has to be redone. In addition, if at baseline the pregnancy test is older than 10 days, it has to be redone. During treatment and FU, pregnancy tests have to be performed every 4 weeks
runtil 5 months after last dose of neoadjuvant treatment 

 
 
 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
                                                                                              Confidential 
 
Page 26 of 118 
 
 
 
 
 
Schedule and assesssment
Screening 
visit
Randomis
ation (no 
patient 
visit)
Baseline 
visit : day 
1 
treatment
Visit 1 
after 
baseline
**
Visit 
2 **
Visit 
3 **
Visit 
4 **
Visit 
5 **
Visit 
6 **
Visit 
7 **
Visit 
8 **
Visit 
9 **
Visit 
10 **
Visit 
11 **
Visit 
12 **
Visit 
13 **
Visit 
14 **
Visit 
15 **
Visit 
16 **
Visit 
17 **
Visit 
18**
Visit 
19 **
Visit 
20 **
Visit 
21** 
Visit 
22 **
Visit 
23 **
EOT Visit 3 
weeks after 
last dose 
chemo**
Surgery: 3-4 
weeks after 
last dose 
chemo
Follow up every 6 months 
after surgery (if no surgery 
will be performed: 6 
months after EOT)*** (j)
EOS visit: 
week 104 
or month 
24*** (j)
week
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
 wk  27
wk 27-28 
until year 2 after baseline
day*
-17
-10 to -3
1
8
15
22
29
36
43
50
57
64
71
78
85
92
99
106
113
120
127
134
141
148
155
162
Atezolizumab 1200 mg IV Day 1 every 3 weeks for 4 doses
X
X
X
X
X
X
X
X
Paclitaxel 80 mg/m2 IV weekly X 12 doses
X
X
X
X
X
X
X
X
X
X
X
X
Carboplatin AUC of 2 IV day 1 every week X 12 doses
X
X
X
X
X
X
X
X
X
X
X
X
Epirubicin 90 mg/m² every 3 weeks for 4 cycles
X
X
X
X
Cyclophosphamide 600 mg/m² every 3 weeks for 4 cycles
X
X
X
X
ICF (before any study procedure starts)
X
Medical history
X
Core Biopsy (a)
X SOC
X 
X
physical examination (b)
X
X
X
X 
X 
X
X
X
X
X 
SOC
SOC
Ultrasound (breast, lymph nodes, SoC) ( c )
X
X 
X
X 
SOC
SOC
Other imaging: Mammography,  chest X Ray or CT thorax; bone scan; liver 
imaging (SOC) : (d)
X 
SOC
SOC
central pathology  ( e )
X
X
X
X
clinical assessment
X
X
X
X
X
X
X
X
X
X
SOC
X
pregnancy test and check of adequate contraception measures (f)
X
(X)
X
X
X
X
X
X
every 4 weeks until month 5 
after last chemo
LVEF (g)
X
X
X
SOC
ECG (h)
X
X
X
SOC
Laboratory (hematology, biochemistry) (i)
X
X
X 
X 
X
X
X
X
X
X
SOC
Laboratory (hematology)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
blood sample for translational research 
X
X
X
X
Randomization****
X
surgery
X
start of adjuvant CTX / Follow up (SoC)
SOC
(Serious) Adverse Event, AESIs, pregnancies
Concomittant medication
continously
Table 1b: Schedule of Activity  B
Study Procedures
continuosly
* timing different depending on test (see below); ** time of visits with a window of 2 days; ***time of visits with a window of +/-14 days
**** Randomisation : performed  by investigator once all I/E criteria are fullfilled.  Atezolizumab is ordered at Roche; chemo agents are ordered at central pharmacy;  patient is contacted for baseline visit (no patient visit for randomisation)
(a): SOC core biopsy available prior to randomization
(b): physical examination at screening should be done within 7 days of screening
( c, d):  Ultrasound is performed within 4 weeks prior to screening, other imaging procedures are performed within 3 months before randomization. After that they are performed as SOC .
( e ): central pathology results need to be available before randomisation. In case central pathology does not confirm local pathology results for TNBC, the patient will not be randomised and considered as screen failure.
(g): LEVF at screening within 6 weeks before screening visit; then after 4 cycles and at EOT 
(h): ECG at screening within 6 weeks before screening visit; then after 4 cycles and at EOT
(i): laboratory analyses at screening should be done within 14 days before screening visit
(j): Follow-up visits could also be performed at a local gynecologist/oncologist. In this case, site contacts patients by phone.
(i): laboratory analyses at screening should be done within 14 da(i): labora(i): labora(i): labora(i): labor(i): la (i): la (i): la(i): la(i): la (i): la (i): la (i): la (i): lab(i): lab(i): lab(i): lab(i): lab(i): lab(i): lab(i): lab(i): lab(i): lab(i): lab(i): lab(i): lab(i): lab(i): laborato (i): laboratory(i): laboratory analyses at(i): labora
EOT visit should not be later than 3 weeks from last neoadjuvant treatment
surgery is recommended to be performed within 3-4 weeks after completion of neoadjuvant treatment  
(f): pregnancy test at screening should not be older than 7 days, otherwise it has to be redone. In addition, if at baseline the pregnancy test is older than 10 days, it has to be redone. During treatment and FU, pregnancy tests have to be performed every 4 weeks until 5 months after last dose of 
neoadjuvant treatment 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 27 of 118 
3. Introduction 
 
3.1. Study rationale and background 
 
TNBC 
Breast cancer is a heterogeneous disease consisting of several disease subtypes that differ with 
regard to molecular phenotype, treatability and prognosis (Sørlie et al., 2001). As one of these 
subtypes, TNBC is defined by both absence of immunostaining for ER, PR, and lack of 
overexpression/amplification of HER2/neu (Dent et al., 2007). TNBC accounts for approximately 
15% - 20% of breast cancer cases (Bauer et al., 2007) and is associated with younger age at 
diagnosis, premenopausal status, more advanced disease stage, higher grade, higher mitotic 
indices, family history of breast cancer, germline mutations in BRCA, and more aggressive clinical 
course than other breast cancer subtypes (Bauer et al., 2007). Improvement of systemic treatment 
of TNBC represents an unmet medical need.  
 
Whereas former clinical studies defined the complete lack of ER, PR and HER2/neu as triple 
negative, current recommendations such as the German AGO recommendations are considering 
ER/PR low tumors (i.e. < 10% positive cells on IHC) as belonging to the same subgroup (Ditsch 
et al., 2019). The ER low-positive group is characterized molecularly by having features of triple-
negative cancer in the majority of cases (Iwamoto et al., 2012). This includes basal-like phenotype, 
high incidence of germline BRCA mutation, and high-risk score by OncotypeDX. Also, distant-
disease-free survival is similar to TNBC in these cases. Therefore, a low threshold of 1% for ER 
positivity, may lead to the false exclusion of biologically ER negative tumors from correctly targeted 
strategies and instead to the categorization of these tumors as ER positive with consecutive 
treatment recommendations (Deyarmin et al., 2013; Dixon et al., 2019; Sanford et al., 2015; Yi et 
al., 2014). The effect of endocrine therapy on survival outcomes in these patients remains unclear 
(Raghav et al., 2012). These data are justifying the inclusion of ER/PR low patients in trials on 
TNBC. However, after neoadjuvant therapy endocrine therapy has to be discussed as an option. 
 
Choice of CTX in TNBC  
Currently, poly-CTX is the only systemic treatment option for patients with early TNBC. 
Fortunately, patients with TNBC carry an increased chance of pCR compared to patients with non-
TNBC (Cortazar et al., 2014; Houssami et al., 2012) and in case of pCR prognosis is excellent 
(Liedtke et al., 2008). However, prognosis is unfavorable compared to other breast cancer 
subtypes, in case of non-pCR.  
There is an accumulating body of evidence suggesting that platinum salts should be added to 
Anthracycline/Taxane CTX in case of TNBC. In addition to historical data suggesting that platinum-
containing CTX may be particularly beneficial for patients with TNBC (O. Gluz et al., 2009) the 
GeparSixto trial (Untch et al., 2016) and the CALGB 40603 trial (Sikov et al., 2015) have provided 
prospective evidence supporting the use of platinum-salts among patients with TNBC. 
Consequently, an Anthracycline/Taxane/Carboplatin-containing poly-CTX regimen is regarded as 
SOC for neoadjuvant treatment of patients with TNBC in Germany and is recommended in the 
current AGO recommendations (Ditsch et al., 2019). Furthermore, current and recent clinical trials 
such as Keynote-522 and NeoTRIP (see below) include a platinum-containing poly-CTX regimen. 
 
Immunotherapy 
Recently, targeted therapy of regulatory immune pathways has become an important tool in 
clinical applications. In contrast to conventional chemotherapeutics, immune checkpoint inhibitors 
do not target the tumor cells themselves but molecules which are part of the T-cell regulatory 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 28 of 118 
cascade. The main focus lies on the removal of inhibitory mechanisms by which the tumor escapes 
from a T-cell response (Pardoll, 2012). Atezolizumab (trade name: Tecentriq®) is a humanized 
antibody against PD-L1 that has shown tolerability and tumor responses in patients with advanced 
malignancies. PD1 is localized on T-cells, B-cells, TILs, DCs, natural killer T-cells and activated 
monocytes. Its ligands PD-L1 and -L2 are expressed on a variety of cancer types, e.g. breast, 
ovary, lung, colon, melanoma, kidney and bladder (Alme et al., 2016). For some cancer types PD-
L1 and -L2 expression could be associated with tumor progression and poor prognosis (Thompson 
et al., 2007). Recently combination therapies consisting of conventional agents and immune 
checkpoint inhibitors showed a high clinical relevance in cancer therapy (Sharma & Allison, 2015). 
Treatment of tumor tissues which lack an immunologic microenvironment with markers like CD8+ 
T-cells, CD4+ T-cells or PD-L1, could be improved by combination therapies. Conventional cancer 
therapies, e.g. CTX, radiation, surgery, anti-angiogenetic or hormonal, can induce tumor cell 
death, resulting in a release of antigens (Crittenden et al., 2015; Slovin et al., 2013). 
 
Immunotherapy in TNBC 
Among breast cancer subtypes, TNBC is a preferable target for immunotherapy. Hence, there is 
a large and increasing body of evidence for use of immunotherapy in TNBC (Marra et al., 2019). 
Consequently, and in particular based on the results of the IMpassion130 trial (Peter Schmid, 
2018), Atezolizumab has been approved for PD-L1 IC-positive mTNBC in the first line of therapy 
in combination with nab-Paclitaxel. 
 
In the neoadjuvant setting, data regarding the use of immunotherapy are heterogeneous. In the 
Keynote-522 trial, among 602 patients Pembrolizumab in combination with 4 cycles of Paclitaxel 
+ Carboplatin followed by 4 cycles of Doxorubicin or Epirubicin + Cyclophosphamide showed a 
statistically significant improvement in pCR (ypT0/Tis, ypN0) vs. placebo in combination with CTX: 
64.8% (95% CI, 59.9 - 69.5) vs. 51.2% (95% CI, 44.1 - 58.3), P = 0.00055 regardless of PD-L1 
IC-status (P. Schmid et al., 2019). 
 
Another neoadjuvant trial in TNBC, the NeoTRIP study presented at the SABCS 2019, 
investigated Atezolizumab 1200 mg q3w in combination with 8 cycles of Carboplatin and nab-
Paclitaxel versus the same neoadjuvant CTX alone. pCR rates between both groups did not differ 
significantly. After surgery patients received 4 cycles of Epirubicin and Cyclophosphamide, results 
of the 5 year follow-up are awaited in 2024 (Gianni et al., 2019). Compared to Keynote-522 trial 
the results of the NeoTRIP trial are implying the conclusion that neoadjuvant therapy schedules 
investigating checkpoint inhibitors in TNBC should include an Anthracycline. This is in line with 
previously published data pointing to a synergistic effect of Anthracyclines and checkpoint 
inhibitors (Matsushita & Kawaguchi, 2018). 
 
Immunotherapy window before neoadjuvant combined immune- and poly-CTX 
In the GeparNuevo trial a significant effect of the checkpoint inhibitor Durvalumab in combination 
with neoadjuvant CTX compared to CTX alone could only be demonstrated in a subgroup of 
patients (n = 117) treated with a pre-therapeutic (i.e. before initiation of poly-CTX) two-week 
Durvalumab-mono-therapy-window (Loibl et al., 2019). An increase in pCR in association with 
Durvalumab was seen only in patients treated with the pre-therapeutic Durvalumab mono-therapy 
(pCR 61.0% vs. 41.4%, OR = 2.22, 95%CI 1.06 - 4.64, p = 0.035; interaction p = 0.048). Among 
patients without pre-therapeutic window (n = 57), pCR rates were 37.9% vs. 50.0%. 
A biological rationale for the window effect can be found in the systematic biomarker analysis of 
the GeparNuevo trial. Patients received a re-biopsy after the 2-week window in both arms. The 
change of iTILs between baseline and after the window-phase significantly predicted achieving a 
pCR with Durvalumab in univariate (OR = 5.15, 95% CI 1.10 – 24.05, p = 0.037) and multivariate 
regression analysis (OR = 9.36, 95% CI 1.26 – 69.65, p = 0.029). In the placebo arm, the change 
of iTILs did not predict pCR (univariate analysis OR = 1.19, 95% CI 0.65 – 2.17, p = 0.581 and 
multivariate analysis OR = 1.22, 95% CI 0.65 – 2.27, p = 0.540). An increase of iTILs in post-

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 29 of 118 
window samples compared with pre-therapeutic samples was predictive of pCR specifically in the 
Durvalumab arm. Probably due to the small sample size the interaction test did not formally meet 
statistical significance (p = 0.085). However, these data support the hypothesis that checkpoint 
inhibitors induce a modulation of the immune-microenvironment by stimulating lymphocytes to 
migrate from the stroma into the tumor-cell nests before introduction of cytotoxic CTX. This 
increased infiltration of immune cells into the tumor cell nests might be an indicator of a response 
to the checkpoint inhibitor. Promoting this initial immune response by addition of a poly-CTX could 
lead to an immunogenic cell death, possibly explaining the increased pCR rate in the window arm. 
Based on the results of the GeparNuevo trial (and particularly given the size of the effect) a single 
arm neoadjuvant trial combining poly-CTX with Pembrolizumab, the NeoImmunoBoost trial was 
amended for the inclusion of a 2-week immunotherapy window (ClinicalTrials.gov Identifier: 
NCT03289819).  
 
The investigation of the effect of a 2-week immunotherapy mono-therapy window before 
combination immune- und poly-CTX in a randomized prospective clinical trial has the potential to 
define a new treatment standard. 
 
Dosing of immunotherapy 
In contrast to the approved dose in the metastatic setting of ongoing trials, in the neoadjuvant 
setting Atezolizumab is applied in a 3-weekly dose of 1200 mg in combination with Carboplatin 
and Paclitaxel (https://clinicaltrials.gov/ct2/show/NCT03281954; 
https://clinicaltrials.gov/ct2/show/NCT03595592). Due to the investigational nature of the mono-
therapy window we chose the approved 2-weekly dose of 840 mg for the 2-week window phase 
and the approved 3-weekly dose of 1200 mg for the neoadjuvant phase. 
 
Duration of immunotherapy 
The question, if it is sufficient to add immunotherapy to the neoadjuvant phase of the treatment in 
TNBC or if an adjuvant application is necessary, is still unclear and study designs are 
heterogeneous. There are trials like the NeoTRIP trial (Gianni et al., 2019) and the 
NeoImmunoBoost trial (ClinicalTrials.gov Identifier: NCT03289819) adding the checkpoint 
inhibitor only to the neoadjuvant phase, whereas in Keynote-522 (P. Schmid et al., 2019) the 
immunotherapy agent was both added to the neoadjuvant phase continued as adjuvant treatment 
and after surgery. The results regarding the follow-up of this trial are still immature. A large 
adjuvant trial, IMpassion030 is investigating the effect of Atezolizumab in the adjuvant setting only 
(ClinicalTrials.gov Identifier: NCT03498716), however, results are not expected to be published 
before 2023. Whereas the neoadjuvant application of immunotherapy in combination with poly-
CTX is already a new treatment paradigm, this is much less clear for the adjuvant use of these 
drugs. Therefore, it has to be considered adequate for current study designs in TNBC to include 
immunotherapy in the neoadjuvant treatment phase only. However, studies should anticipate a 
potential change regarding adjuvant immunotherapy and prepare to amend study protocols to 
incorporate adjuvant immunotherapy after robust results of the studies discussed above are being 
published. 
 
Neoadjuvant therapy and window-of-opportunity trials in breast cancer 
Neoadjuvant CTX trials include a population with therapy naïve tumor. Data from window-of-
opportunity trials including repeat tumor biopsies allow the creation of prediction models for clinical 
response based on the results of early biopsies (Tan et al., 2018). The biomarkers used in these 
models have been tested in different tumor-biologies in the neoadjuvant setting. For instance, the 
IMPACT trial and the POETIC trial have demonstrated that short-term changes in proliferation by 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 30 of 118 
Ki-67 expression in the neoadjuvant setting may be able to predict outcome (Dowsett et al., 2005, 
2011). 
Furthermore, among patients treated as part of the triple negative subprotocol of the ADAPT Trial 
(NCT01815242), low-cellularity (< 500 vital tumor cells) at week 3 was strongly associated with 
response to therapy. Higher levels of TILs were associated with pCR, both at baseline and after 3 
weeks of neoadjuvant CTX. Ki-67 expression after three weeks was potentially associated with 
pCR (Oleg Gluz et al., 2015; Liedtke et al., 2018). 
Due to the fact that many patients had less than 500 tumor cells in the re-biopsy after 3 weeks, 
which made an evaluation impossible, a 2-week approach is preferred. Accordingly, the CelTIL-
Score (Nuciforo et al., 2017), integrates cellularity and TILs and thus avoids the problem of non-
evaluable patients. Its predictive value regarding CTX response in a neoadjuvant therapy setting 
has been demonstrated. 
Recently, it has also been demonstrated that TILs after 3 weeks are significantly associated with 
response to checkpoint inhibitors (Loi et al., 2019). 
The inconsistent clinical data regarding neoadjuvant checkpoint inhibitor therapy with and without 
Anthracyclines (Gianni et al., 2019; P. Schmid et al., 2019) make it mandatory to investigate the 
biological effects described above not only of CTX in general in combination with Atezolizumab 
but also separately according to CTX regimen, e.g. Carboplatin and Paclitaxel versus Epirubicin 
and Cyclophosphamide in the setting of a sequential use. 
 
Follow-up duration 
TNBC is known to show early recurrence in case of disease relapse. For instance, in an analysis 
among 1,118 patients who received neoadjuvant CTX at M.D. Anderson Cancer Center for stage 
I-III breast cancer from 1985 to 2004, recurrence and death rates were higher for TNBC only in 
the first 3 years. In fact, hazard functions for disease recurrence among patients with TNBC 
compared with non-TNBC have been demonstrated to cross at 2.5 years of follow up, 
demonstrating lower incidences of disease recurrence among patients with TNBC compared to 
other breast cancer subtypes thereafter (Liedtke et al., 2008). In a preplanned interim analysis 
performed after 100 pCR events, patients with TNBC did not show a significant benefit from an 
atezolizumab monotherapy window suggesting that the primary endpoint would not be reached. 
Based on these results and in accordance with the study stopping rules, the patient recruitment 
was permanently stopped in August 2022. However, patients in both treatment arms demonstrated 
the highest pCR rates ever reported in phase II/III trials with TNBC patients treated with 
neoadjuvant immune checkpoint inhibitors (Kolberg et al, 2023, compare with Loibl et al. 2019; 
Schmid et al., 2020; Foldi et al., 2022; Huober etal., 2022). Given that novel post-neoadjuvant 
treatment options (on and off-trial) have emerged such as pembrolizumab, the post-neoadjuvant 
treatment in the follow-up phase of this study will most certainly be highly heterogeneous. Thus, 
completion of follow-up to 3 years is no longer justified. Therefore, follow-up will be limited to 2 
years and only clinically significant survival signals may be observed. If patients perform follow-
up care at their local gynecologist/oncologist, the study follow-up visits will be performed by the 
site staff by phone. 
 
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 31 of 118 
3.2. Study goal and medical need 
 
The goal of this study is: 
 
• 
Compare efficacy of PD-L1-inhibition (Atezolizumab) 2-week mono-therapy window 
followed by neoadjuvant CTX with Atezolizumab to CTX with PD-L1-inhibition 
(Atezolizumab).  
 
• 
To identify biomarkers predicting (early) response to or resistance against Atezolizumab 
(alone and with CTX) allowing patients stratification in future clinical trials. 
 
3.3. Benefit/Risk Assessment 
 
Based on preclinical and clinical data, treatment of Atezolizumab in combination with CTX 
including Carboplatin, Paclitaxel, Epirubicin and Cyclophosphamide is expected to be tolerable, 
and toxicities of the treatment are expected to be manageable and reversible upon dose reduction, 
treatment interruption, or discontinuation. Patients in this study will be carefully monitored for key 
toxicities that have been observed with Atezolizumab or CTX with Carboplatin, Paclitaxel, 
Epirubicin or Cyclophosphamide (see respective SmPCs). Risk will be further minimized by 
adherence to inclusion/exclusion criteria (see section 6), avoidance of prohibited medication (see 
section 7.8), close safety monitoring (see section 9.9) and dose-adjustment guidelines (see 
section 7.4). 
An independent data safety monitoring board (DSMB) (see section 9.9.11.1.) will be constituted 
and will monitor safety as outlined in the protocol and in the DSMB Charter. In addition, the DSMB 
will review scheduled interim efficacy analyses and decision rules for stopping the trial early. 
 
Immunotherapy with Atezolizumab used in combination with nab-Paclitaxel has been licensed for 
mTNBC and is currently being investigated in the curative/neoadjuvant setting; results of the first 
studies (KEYNOTE-522) with immunotherapy in this setting (P. Schmid et al., 2019) have 
demonstrated a significant and clinically relevant benefit of 15% regarding pCR in TNBC. The 
recently published “Dear Investigator Letter” for study MO39196 /IMpassion131 indicated a lack 
of efficacy for the combination of Atezolizumab and Paclitaxel in first-line patients with PD-L1 IC 
positive mTNBC. While in MO39196 a mono-CTX backbone (i.e. Paclitaxel) is used in combination 
with immune checkpoint blockade in mTNBC, the aforementioned KEYNOTE-522 study is using 
a combination of Pembrolizumab with a poly-CTX backbone consisting of Paclitaxel, Carboplatin, 
Epirubicine and Cyclophosphamide in early TNBC. Since the neoMono study is using the same 
CTX backbone in the same population, the KEYNOTE-522 study is considered to a greater extend 
indicative for the outcome of the neoMono study than the IMpassion131 study. 
 
The start of neoadjuvant CTX in Arm A of the study will be delayed by 2 weeks due to the 2-week 
immunotherapy window. This delay is not expected to have any impact of the short-term or long-
term outcomes of study patients. In a pooled analysis, Loibl et al. investigated the impact of the 
interval between the time of biopsy and the start of CTX in a meta-analysis of 6 neoadjuvant trials. 
The time between biopsy and CTX did neither influence the pCR overall rate nor in subgroups. In 
multivariable logistic regression analysis length of this interval did also not independently predict 
pCR or influence DFS or OS, neither in all patients nor in subgroups (Loibl et al., 2017). 
Furthermore, recent data suggests, that an immunotherapy mono-therapy-window before 
immunotherapy/CTX 
combination 
therapy 
might 
even 
further 
enhance 
efficacy 
of 
immunotherapy/CTX combination therapy for patients with TNBC. 
 
Patients taking part in the study may therefore benefit by receiving immunotherapy in both arms 
(Atezolizumab alone or in combination with CTX). This is perceived as the future SOC. 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 32 of 118 
4. Objectives  
 
4.1. Primary Objectives 
 
1. Compare efficacy in terms of pCR in TNBC with Atezolizumab 2-week monotherapy 
window followed by neoadjuvant CTX with Atezolizumab (Arm A) to neoadjuvant CTX with 
Atezolizumab (Arm B). 
 
4.2. Secondary Objectives  
 
1. Assess and compare safety of Atezolizumab mono-therapy window of 2 weeks followed 
by neoadjuvant treatment with Atezolizumab in combination with CTX (Arm A) to 
neoadjuvant CTX with Atezolizumab (Arm B). 
2. Assess and compare efficacy of Atezolizumab mono-therapy window of 2 weeks followed 
by neoadjuvant treatment with Atezolizumab in combination with CTX (Arm A) to 
neoadjuvant CTX with Atezolizumab (Arm B) in patients with an ER/PR expression of < 
1% and an ER/PR expression of 1% to 10%. 
3. Compare efficacy of Atezolizumab mono-therapy window of 2 weeks followed by 
neoadjuvant treatment with Atezolizumab in combination with CTX (Arm A) to neoadjuvant 
CTX with Atezolizumab (Arm B) per alternative pCR definitions. 
4. Compare early biological response (2 weeks in both arms) of Atezolizumab mono-therapy 
window of 2 weeks followed by neoadjuvant treatment with Atezolizumab in combination 
with CTX (Arm A) to neoadjuvant CTX with Atezolizumab (Arm B), as measured by CCCA, 
decrease of Ki-67 expression (≥ 30%), low cellularity and TILs (≥60%), or a combined early 
response. 
5. Compare early biological response (2 weeks in Arm B vs 4 weeks in Arm A) of 
Atezolizumab mono-therapy window of 2 weeks followed by neoadjuvant treatment with 
Atezolizumab in combination with CTX (Arm A) to neoadjuvant CTX with Atezolizumab 
(Arm B), as measured by CCCA, decrease of Ki-67 expression (≥ 30%), low cellularity and 
TILs (≥60%), or a combined early response.  
6. Assess and compare the prognostic and predictive values of the biomarkers (measured 
after 2 weeks and 4 weeks): CCCA, decrease of Ki-67 expression (≥ 30% and continuous), 
low cellularity and TILs (≥ 60% and continuous), or a combined early response, with 
respect to the outcome pCR.  
7. Compare the efficacy of Atezolizumab mono-therapy window of 2 weeks followed by 
neoadjuvant treatment with Atezolizumab in combination with CTX (Arm A) to neoadjuvant 
CTX with Atezolizumab (Arm B), as measured by disease free survival (DFS).  
8. Compare the efficacy of Atezolizumab mono-therapy window of 2 weeks followed by 
neoadjuvant treatment with Atezolizumab in combination with CTX (Arm A) to neoadjuvant 
CTX with Atezolizumab (Arm B), as measured by OS. 
9. Compare the efficacy of Atezolizumab mono-therapy window of 2 weeks followed by 
neoadjuvant treatment with Atezolizumab in combination with CTX (Arm A) to neoadjuvant 
CTX with Atezolizumab (Arm B), as measured by event free survival (EFS). 
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 33 of 118 
4.3. Translational Research objectives 
 
1. Identify candidate genes for response/resistance to Atezolizumab (Sokolenko & Imyanitov, 
2017). 
2. Analyze the influence of immune markers (e.g. PD-1/L1) via ctDNA as predictor for 
response to Atezolizumab (Appendix B) (Raja et al., 2018; Saliou et al., 2016).  
3. Evaluate the influence of intrinsic subtype on response to Atezolizumab (Llombart-Cussac 
et al., 2017). 
4. Assess the continuous ER/PR/HER2 expression (via polymerase chain reaction) as a 
predictive factor for response/resistance to Atezolizumab (Park et al., 2014). 
5. Assess a specific DNA panel (Appendix A) via ctDNA as a predictive factor for 
response/resistance to Atezolizumab (Keup et al., 2019). 
6. Evaluate the influence of polymorphisms via ctDNA on response to Atezolizumab (Mcardle 
et al., 2018). 
7. Compare immune markers, polymorphisms, DNA panel activity, and ctDNA levels (Raja et 
al., 2018) after 14/28 days (+/- 2 days) of treatment between mono- and non-mono-therapy 
patients. 
8. Evaluate T-Cell influence (CD 3/4/8) on the response to Atezolizumab. 
9. Identify immune markers as candidate genes for response/resistance to Atezolizumab 
(Appendix C) (Oleg Gluz et al., 2019; Lee et al., 2015; Sokolenko & Imyanitov, 2017; Yang 
et al., 2018). 
10. Assess and compare the prognostic and predictive values of the biomarkers: CCCA, Ki-67, 
low cellularity, TILs and CelTIL score after switch of the CTX to Epirubicin and 
Cyclophosphamide with respect to the outcome pCR in patients with less than 50% tumor 
shrinkage after 4 cycles of Carboplatin/Paclitaxel/Atezolizumab +/- the 2 week 
Atezolizumab window. 
11. Develop a new single drug RNA-based biomarker signature to predict response/resistance 
to Atezolizumab. 
12. Assess and compare the prognostic and predictive values of the biomarkers (measured 
after 2 weeks and 4 weeks): CCCA, decrease of Ki-67 expression (≥30% and continuous), 
low cellularity and TILs (≥ 60% and continuous) with respect to the outcomes DFS and OS.  
13. Assess optimal cut-offs for decrease of Ki-67 expression, TILs and the CelTIL score with 
respect to prediction of pCR, DFS and OS and compare with existing cut-offs. 
 
5. Study design 
 
5.1. Overall design 
 
This is a randomized, open-label, adaptive, two arm, multicenter phase II trial comparing a pre-
surgical combination of Atezolizumab 2 weeks before biopsy followed by Carboplatin + Paclitaxel 
+ Atezolizumab and then by Epirubicin + Cyclophosphamide + Atezolizumab (Arm A) with a direct 
treatment consisting of Carboplatin + Paclitaxel + Atezolizumab and then Epirubicin + 
Cyclophosphamide + Atezolizumab (Arm B) in patients with operable TNBC breast cancer. 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 34 of 118 
 
Figure 1: Overall Design. 
After primary local diagnosis the patients will undergo screening which includes a centralized 
confirmation of TNBC subtypes (including triple-negative like subtype (ER/PR < 10%)).  
Patients will be randomized to Arm A and B. Randomization will be stratified by PD-L1 IC-status 
and anatomic tumor stage (AJCC 8th edition Anatomic Stage Groups I, II and III). Patients in Arm 
A will be treated for a total of 2 weeks with 840 mg Atezolizumab mono-therapy before undergoing 
a biopsy after the 2-week cycle has ended. They will then continue with a 12-week therapy with a 
combination of Paclitaxel 80 mg/m² IV weekly x 12 doses + Carboplatin AUC of 2 IV weekly x 12 
doses + Atezolizumab 1200 mg day 1 every 3 weeks for 4 doses. Every 3-week-interval is 
considered 1 cycle, therefore Carboplatin/Paclitaxel/Atezolizumab therapy will be applied for four 
3-week cycles (12 weeks total). This will be followed by Epirubicin 90 mg/m2 + Cyclophosphamide 
600 mg/m² every 3 weeks for 4 cycles + Atezolizumab 1200 mg day 1 every 3 weeks for 4 doses.  
Patients in Arm B will be treated with a 12-week regimen of Paclitaxel 80 mg/m² IV weekly x 12 
doses + Carboplatin AUC of 2 IV weekly x 12 doses + Atezolizumab 1200 mg day 1 every 3 weeks 
for 4 doses without a mono-therapy window. Every 3-week-interval is considered one cycle, 
therefore Carboplatin/Paclitaxel/Atezolizumab therapy will be applied for four 3-week cycles (12 
weeks total). This will be followed by Epirubicin 90 mg/m² + Cyclophosphamide 600 mg/m² every 
3 weeks for 4 cycles + Atezolizumab 1200 mg day 1 every 3 weeks for 4 doses. 
Both groups, A and B will undergo a biopsy after 2 weeks of Carboplatin + Paclitaxel + 
Atezolizumab therapy. Furthermore, in both arms, for patients with a tumor size greater 10 mm in 
diameter, which have not achieved a 50% decrease in tumor volume (or if not assessable a 
decrease by 50% in diameter), another biopsy (the third in Arm A, the second in Arm B) will be 
performed after 2 weeks of Epirubicin + Cyclophosphamide + Atezolizumab therapy. 
Patients in both arms will undergo surgery after 29 - 30 weeks therapy in total for Arm A and 
27 - 28 weeks therapy in total for Arm B (3 - 4 weeks after last dose of neoadjuvant therapy) and 
move on to a treatment by local SOC. Further considerations with regards to immunological 
treatment in the adjuvant setting will be considered when further results of those regimes are more 
mature and published. Safety and toxicities under therapy will be supervised via regular DSMB 
meetings. After surgery, patients will be treated according to the local TNBC directed therapy 
SOC. Thereafter the patients will be followed-up until 24 months after baseline. 
 
It is planned to perform up to 4 efficacy interim analyses in blocks of 40 patients after 100, 140, 
180 and 220 patients evaluable for the primary endpoint pCR, assuming an equal sample size in 
both arms. At each interim analysis, decision rules based on predictive probabilities of trial success 
(see section 5.4) will be evaluated by the sponsor to determine whether the trial is to continue with 
patient recruitment, or whether to stop early for futility or success respectively. The DSMB will 
provide an independent review of these decisions and the interim efficacy results. 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 35 of 118 
5.2. End of treatment (EOT) 
 
EOT is defined as 21 days after the last dose of neoadjuvant therapy and prior to surgery.  
The EOT visit will be performed no later than 4 weeks from the last dose of neoadjuvant therapy. 
For details on procedures to be performed at the EOT visit, see the SOA table 1. 
 
 
5.3. Surgery 
 
After completion of 24 weeks (Arm B) or 26 weeks (Arm A) of neoadjuvant treatment, surgery is 
planned for all patients. Surgery is recommended to be performed within 3 - 4 weeks from last 
dose of neoadjuvant therapy in both arms. This would be at week 29 - 30 for Arm A and week 27 
- 28 for Arm B.  
In case of disease progression or toxicity of study treatment systemic treatment will be stopped 
prematurely and surgery or switch to non-cross resistant therapy will be performed immediately. 
 
 
5.4. Early stopping Rules 
 
During the trial, up to 4 interim analyses are to be performed after 100, 140, 180 and 220 patients 
evaluable for the primary endpoint in an intention-to-treat (ITT) collective. Analyses of pCR rates 
are based on predictive probabilities PP for trial success. That is, the probability of claiming 
superiority in terms of a dual criterion if the trial was to continue to the maximal sample size, 
conditional on the responses observed in the trial so far (see section 11 and statistical appendix 
9 for details). 
The following decision rules will be implemented at each interim analysis point: 
● If PP < 0.025 the trial recruitment is stopped early for futility 
● If PP > 0.975 the trial recruitment is stopped early for success 
Interim analyses will be carried out and reported by the sponsor statistician. Based on these 
reports, the sponsor will carry out decisions regarding the continuation of recruitment according to 
the decision rules above. At each interim analysis timepoint, the DSMB will provide an 
independent review of interim efficacy results and trial design execution. 
 
 
5.5. Follow up Treatment 
Patients will receive a TNBC directed therapy according to local SOC: defined by S3-guideline and 
recommendation of the AGO Mamma in its latest version. The duration of the follow-up period of 
2 years in this study is explained in section 3.1. If the patients are receiving follow-up care at their 
local oncologist/gynecologist, the study site may perform the neoMono follow-up visits by phone 
regarding the parameters listed below on the scheduled dates (see SOA tables). 
Further considerations with regards to immunological treatment in the adjuvant setting will be 
considered when further results of those regimes are more mature and published. 
Patient data will be collected every 6 months starting from surgery (week 29 - 30 after baseline for 
Arm A and week 27 - 28 after baseline for Arm B) until year 2 (or month 24) or until relapse to 
document: 
 
● Invasive disease-free survival 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 36 of 118 
● OS 
● Further therapy  
● Long term toxicities  
● Relapse (local relapse) 
● 2nd primary malignancy  
● First treatment for metastatic breast cancer or 2nd primary malignancy 
● Results for biopsy of distant metastases (if feasible) 
 
In addition, pregnancy test and check of highly effective contraceptive measures will be performed 
every 4 weeks until 5 months following the last dose of CTX + Atezolizumab. 
 
Blood tests will be performed according to SOC. 
Physical examination and clinical assessment are performed according to SOC. 
Patients who relapse or suffer from 2nd primary malignancy will only be followed for survival. Any 
distant metastasis occurring should be biopsied and the result should be reported in the case 
report form (CRF). 
 
 
5.6. End of Study (EOS) definition 
A patient is considered to have completed the study when month 24 or 2 years after baseline is 
reached. 
The EOS is defined as the date of the last visit of the last participant in the study or last scheduled 
procedure shown in the SOA for the last participant in the trial globally (2 years after baseline).  
 
 
5.7. Participants and study completion 
 
This is an adaptive trial that uses Bayesian posterior and predictive probabilities to make inference 
about the primary hypothesis. Regular interim analyses allow for continuous learning during the 
trial and provide opportunities for adaptation, in particular for early stopping for success or futility. 
This has the potential to reduce the trial length, sample size and costs. 
 
● Drug dosing  
Arm A: Atezolizumab 840 mg day 1 mono-therapy over a 2-week cycle and then Atezolizumab 
1200 mg IV on day 1 on 3-week cycle (4 cycles) in combination with Paclitaxel 80 mg/m2 IV 
weekly x 12 doses and Carboplatin AUC of 2 IV day 1 weekly for 12 doses (12 weeks). This 
will be followed by Epirubicin 90 mg/m2 plus Cyclophosphamide 600 mg/m2 every 3 weeks 
for 4 cycles (12 weeks) with a total of 26 weeks treatment. 
Arm B: Atezolizumab 1200 mg IV on day 1 on 3-week cycle (4 cycles) in combination with 
Paclitaxel 80 mg/m2 x 12 doses and Carboplatin AUC of 2 IV weekly x 12 doses. This will be 
followed by Epirubicin 90 mg/m2 plus Cyclophosphamide 600 mg/m2 every 3 weeks for 
4 cycles (12 weeks) with a total of 24 weeks treatment. 
● Approximately 458 participants will be screened in 40 sites in Germany to achieve 
approximately 412 patients randomly assigned (1:1 randomization, 206 patients in each arm) 
to study treatment (the screen failure rate is estimated at 10%).  
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 37 of 118 
● After randomization, the analysis drop-out rate (see section 10.1 for definition) is estimated at 
10% and therefore a total number of 370 patients will be evaluable (185 evaluable patients per 
treatment group). 
 
● Planned Timelines:  
o First patient in (FPI): March 2021 
o Recruitment end: last patient in (LPI): January 2023 (Recruitment period of 23 months). 
Planned recruitment was stopped in August 2022 due to interim analysis results (resulting 
in shortened recruitment period of 17 months). 
o Study end: last patient last visit (LPLV): August 2024 
o Maximum number of patients per site: 10% of all randomized patients (n = 42 patients). 
This number may be increased in sites that show good quality of data based on key 
performance indexes used in the study.  
 
 
5.8. Justification for dose 
 
5.8.1. Atezolizumab 840 mg 
 
Atezolizumab (Tecentriq®) in combination with nab-Paclitaxel is indicated for the treatment of 
adult patients with unresectable locally advanced or mTNBC whose tumors have PD-L1 
expression ≥ 1% and who have not received prior CTX for metastatic disease. 
More details can be found in the Investigator’s Brochure (IB) of Atezolizumab. 
 
5.8.2. Atezolizumab 1200 mg 
 
In contrast to the approved dose in the metastatic setting ongoing trials, in the neoadjuvant setting 
Atezolizumab is applied in a dose of 1200 mg in combination with Carboplatin and Paclitaxel 
(https://clinicaltrials.gov/ct2/show/NCT03281954; https://clinicaltrials.gov/ct2/show/NCT0359559
2). Due to the investigational nature of the mono-therapy window we chose the approved 2-weekly 
dose of 840 mg for the 2-week window phase and the approved 3-weekly dose of 1200 mg for the 
neoadjuvant phase. 
 
5.8.3. Carboplatin, Paclitaxel, Epirubicin and Cyclophosphamide 
These CTX agents are approved by the competent authorities in Germany. All details can be found 
in the Summary of Product Characteristics (SmPCs) of the respective study drugs. 
 
6. Study population 
 
The study will include patients with primary, treatment naïve TNBC. 
 
Patient eligibility must be reviewed and documented by an appropriate member (principal 
investigator (PI) or delegated sub-investigator registered for the study) of the investigator’s study 
team before patients are included in the study.  
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 38 of 118 
Prospective approval of protocol deviations to recruitment and enrollment criteria, also known as 
protocol waivers or exemptions, is not permitted, according to “No waiver policy” (ICH-GCP). 
 
Following the diagnostic core biopsy and identification of a TNBC tumor, and after informed 
consent is obtained the patients meeting the inclusion/exclusion criteria will be randomized.  
 
 
6.1. Inclusion criteria 
 
● Female and male patients, age at diagnosis 18 years and above  
● Written informed consent prior to admission to this study 
● Histologically confirmed unilateral primary invasive carcinoma of the breast 
● Clinical T1c – T4d * 
● Stage N0 - N3 until 21 patients (5%) with stage N3 are randomized, thereafter N0 - N2 
● TNBC defined by and confirmed by central pathology:   
o ER negative (< 10% positive cells in IHC) and PR negative (< 10% positive cells on 
IHC)  
o HER2 negative breast cancer: 
▪ 
Either defined by IHC: ICH scores of 0 - 1 or an ICH score of 2 in combination 
with a negative ISH 
▪ 
Or defined by ISH: negative ISH  
● Identifiable PD-L1 IC-status by central pathology (positive or negative) by means of 
VENTANA PD-L1 (SP142) assay; positive status is defined by PD-L1 expression on IC on 
≥ 1% of the tumor area, negative status is defined by PD-L1 expression on IC on < 1% of the 
tumor area 
● No clinical evidence for distant metastasis (cM0)  
● Tumor block available for translational research 
● Performance Status ECOG ≤ 1 or KI ≥ 80% 
● Negative pregnancy test (urine or serum) within 7 days prior to screening in premenopausal 
patients 
● Women of childbearing potential and male patients with partners of childbearing potential 
must accept to implement a highly effective (less than 1% failure rate according to Pearl 
index) including at least one non-hormonal contraceptive measures during the study 
treatment and for 5 months following the last dose of study treatment such as:  
o IUD 
o bilateral tubal occlusion 
o vasectomized partner 
o sexual abstinence 
● The patient must be accessible for treatment and follow-up 
● Normal cardiac function: 
o Normal ECG (within 6 weeks prior to screening) 
o Normal LVEF on ECG 
● Normal thyroid function 
o Normal TSH and FT4 
● Blood counts within 14 days prior screening: 
o absolute neutrophile count (ANC) must be ≥ 1,500/mm3 
o Platelet count must be ≥ 100,000/mm3 
o Hemoglobin must be ≥ 10 g/dl 
● Hepatic functions: 
o Total bilirubin must be ≤ 1 upper limit of normal (ULN) for the lab unless the patient 
has a bilirubin elevation > 1 x ULN to 1.5 x ULN due to Gilbert’s disease or similar 
syndrome involving slow conjugation of bilirubin  
o ALK must be ≤ 2.5 x ULN for the lab  
o AST and ALT must be ≤1.5 x ULN for the lab.  

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 39 of 118 
o Patients with AST and ALT or ALK > 1 x ULN are eligible for inclusion if liver imaging 
(CT, MRI, PET-CT, or PET scan) performed within 3 months prior to randomization 
(and part of SOC) does not demonstrate metastatic disease and the requirements in 
criterion (just above) are met  
o Patients with ALK that is > 1 x ULN but less than or equal to 2.5 x ULN or with 
unexplained bone pain are eligible if bone imaging does not demonstrate metastatic 
disease. 
o Creatinine clearance ≥ 40ml/min performed 28 days prior to screening 
 
*TNM staging according to the Union for International Cancer Control (UICC) classification, see 
Appendix 1 
 
 
6.2. Exclusion criteria 
 
● Previous history of malign diseases, non-melanoma skin cancer and carcinoma of the cervix 
are allowed if treated with curative intent 
● Any other disease, metabolic dysfunction, physical examination finding, or clinical laboratory 
finding that, in the investigator's opinion, gives reasonable suspicion of a disease or 
condition that contraindicates the use of Paclitaxel, Carboplatin, Epirubicin, 
Cyclophosphamide or Atezolizumab 
● Psychological, familial, sociological or geographical conditions that do not permit compliance 
with the study protocol 
● Concurrent treatment with other drugs that are contraindicating the use of the study drugs 
● Existing pregnancy 
● Breastfeeding 
● Sequential breast cancer 
● Concurrent treatment with other experimental drugs and participation in another clinical trial 
or clinical research project (except registry study) within 30 days prior to study entry  
● Severe and relevant co-morbidity that would interact with the application of cytotoxic agents 
or the participation in the study including but not confined to: 
o Uncompensated chronic heart failure or systolic dysfunction (LVEF < 55%, CHF 
NYHA classes II-IV), 
o unstable arrhythmias requiring treatment i.e., atrial tachycardia with a heart rate 
≥ 100 bpm at rest, significant ventricular arrhythmia (ventricular tachycardia) or 
higher-grade AV-block, 
o Angina pectoris within the last 6 months requiring anti-anginal medication, 
o Clinically significant valvular heart disease, 
o Evidence of myocardial infarction on ECG, 
o Poorly controlled hypertension (e.g., systolic > 180 mmHg or diastolic > 100 mmHg). 
● Inadequate organ function including but not confined to:  
o hepatic impairment as defined by bilirubin > 1.5 x ULN  
o pulmonary disease (severe dyspnea at rest requiring oxygen therapy) 
● Abnormal blood values: 
o 
Platelet count below 100,000/mm3 
o 
AST/ALT > 1.5 x ULN  
o 
Hypokalaemia > CTCAE grade 1 
o 
Neutropenia > CTCAE grade 1 
o 
Anaemia > CTCAE grade 1 
● Administration of a live, attenuated vaccine within 4 weeks before cycle 1 day 1 or 
anticipation that such a vaccine will be required during the study  
● Treatment with systemic immunosuppressive medications (including but not limited to 
interferons, IL-2) within 28 days or 5 half-lives of the drug, whichever is longer, prior to 
randomization 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 40 of 118 
● Treatment with systemic immunosuppressive medications (including but not limited to 
Prednisone, Cyclophosphamide, Azathioprine, Methotrexate, Thalidomide, and anti-TNF 
factor agents) within 14 days prior to screening or anticipation of need for systemic 
immunosuppressive medications during the study 
● Patients with prior allogeneic stem cell or solid organ transplantation 
● Active or history of autoimmune disease or immune deficiency, including but not limited to 
myasthenia gravis, myositis, autoimmune hepatitis, systemic lupus erythematosus, 
rheumatoid arthritis, inflammatory bowel disease, antiphospholipid syndrome, Wegener 
granulomatosis, Sjögren syndrome, Guillain-Barré syndrome, or multiple sclerosis with the 
following exceptions: 
o Patients with a history of autoimmune-related hypothyroidism on a stable dose of 
thyroid replacement hormone may be eligible for this study. 
o Patients with controlled Type 1 diabetes mellitus on a stable dose of insulin regimen 
may be eligible for this study. 
o Patients with eczema, psoriasis, lichen simplex chronicus, or vitiligo with dermatologic 
manifestations only (e.g., patients with psoriatic arthritis are excluded) are permitted 
provided all of following conditions are met: Rash must cover < 10% of body surface 
area; Disease is well controlled at baseline and requires only low-potency topical 
corticosteroids; No occurrence of acute exacerbations of the underlying condition 
requiring psoralen plus ultraviolet A radiation, Methotrexate, retinoids, biologic agents, 
oral calcineurin inhibitors, or high-potency or oral corticosteroids within the previous 
12 months. 
● History of idiopathic pulmonary fibrosis, organizing pneumonia (e.g., bronchiolitis obliterans), 
drug-induced pneumonitis, idiopathic pneumonitis, or evidence of active pneumonitis on 
screening chest CT scan 
● History of HIV infection, hepatitis B or hepatitis C infection. 
● Patients with significant cardiovascular disease 
● Patients with inadequate hematological and end-organ function 
● Patients receiving therapeutic anti-coagulants  
● Stage N3, as soon as 21 patients with stage N3 are randomized 
 
7. Treatments 
 
7.1. Definition of study treatment: Investigational Medicinal Product (IMP) 
 
Study treatment is defined as neoadjuvant therapy i.e.: Atezolizumab, Carboplatin, Paclitaxel, 
Epirubicin and Cyclophosphamide are considered IMPs. 
After surgery adjuvant therapy is administered as per SOC TNBC and is not considered as study 
treatment.  
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 41 of 118 
7.2. Treatments administered 
 
Table 2: Schedule of administration of study drugs 
 
 
7.2.1. Atezolizumab 
 
For patients randomized in Arm A and B in the neoadjuvant treatment phase, Roche will provide 
the study sites with Atezolizumab labeled study-specifically. 
In Arm A: Roche will provide 206 treatments of Atezolizumab 840 mg and 1648 treatments of 
Atezolizumab (206 x 8 cycles) 1200 mg. 
In Arm B: Roche will provide 1648 treatments of Atezolizumab (206 x 8 cycles) 1200 mg. 
This includes the number of Atezolizumab treatments needed for 206 patients randomized in each 
treatment arm, including the 10% potential analysis drop outs. 
Documentation of preparation and distribution of Atezolizumab has to be recorded in accordance 
with the SmPC (prescribing information/ "Fachinformation"). 
 
7.2.2. Carboplatin, Paclitaxel, Epirubicin and Cyclophosphamide 
 
These chemotherapeutic agents in Arm A and in Arm B are considered IMPs in the neoadjuvant 
phase of the study. They will be provided to sites and labeled study-specifically. As these drugs 
are approved in Germany, they will be used according to currently valid SmPC. 
 
7.2.3. TNBC directed therapy in adjuvant phase 
 
TNBC directed therapy in the adjuvant phase (Arm A and Arm B) is used according to German 
SOC defined by S3-guideline and recommendation of the AGO Mamma (in its latest version) and 
will not be provided to sites nor be labeled study-specifically (use according to currently valid 
SmPC). 
Further considerations with regards to immunological treatment in the adjuvant setting will be 
considered when further results of those regimes are more mature and published. 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 43 of 118 
approaches are taken (e.g. PD-L1 IC-Status will be performed by means of large surface 
sections). 
After construction of TMAs or execution of other approaches, the remaining tumor blocks will be 
stored at the Institute of Pathology of the University Clinic Erlangen. 
● TNBC status: ER negative (< 10% positive cells in IHC), PR negative (< 10% positive cells on 
IHC) and HER2 negative: either defined by IHC: ICH scores of 0 - 1 or an ICH score of 2 in 
combination with a negative ISH; or defined by ISH: negative ISH.  
 
● In case the central pathology results does not confirm the local laboratory assessment of 
TNBC, the patient will be considered as a screening failure and will not be randomized. 
 
● PD-L1 IC-status: Patients with TNBC whose tumors have PD-L1 expression ≥ 1% (PD-L1 
expression on IC with the VENTANA PD-L1 (SP142) assay)) and patients with non-
determinable PD-L1 expression will be identified. Randomization of patients will be stratified 
by PD-L1 IC-status and anatomic tumor stage (AJCC 8th edition Anatomic Stage Groups I, II 
and III). Positive status is defined by PD-L1 expression on IC on ≥ 1% of the tumor area, 
negative status is defined by PD-L1 expression on IC on < 1% of the tumor area. 
 
● Following the diagnostic core biopsy and confirmed identification of a TNBC tumor by the 
central pathology laboratory, the patients meeting the inclusion/exclusion criteria after 
informed consent was obtained will be subsequently randomized to the neoadjuvant therapy: 
 
o Arm A: Atezolizumab for 2 weeks followed by Carboplatin + Paclitaxel + Atezolizumab 
for 12 weeks and then followed by Epirubicin + Cyclophosphamide + Atezolizumab for 
12 weeks (total treatment phase of 26 weeks). 
o Arm B: directly randomized to Carboplatin + Paclitaxel + Atezolizumab (12 weeks) and 
then followed by Epirubicin + Cyclophosphamide + Atezolizumab for 12 weeks, for a 
total treatment phase of 24 weeks. 
 
● Core Biopsies will be taken as described above.  
 
● After completion of 24 - 26 weeks of targeted therapy within either of the two treatment arms, 
the patients will undergo surgery and pCR will be assessed by local pathology. All patients will 
be treated according to local SOC after surgery. 
 
● Definitive surgical treatment must be performed according to current Arbeitsgemeinschaft 
Gynäkologische Onkologie e.V (AGO) guidelines for operable breast cancer (T1c – 4d, stage 
N0-N3, cM0). Margins of the resected specimen from definitive surgery must be histologically-
free of invasive carcinoma and/or ductal carcinoma in situ. Lobular carcinoma in-situ (except 
LN3) will not be considered a positive margin.  
 
● TMA of all core biopsies and surgery samples will be used for translational research 
(Nanostring Ncounter: PAM 50, Appendix C) and genome-wide gene expression analysis for 
RNA-based biomarker signature related to response/resistance to Atezolizumab using 
ArrayXS microarrays (Appendix D). 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 44 of 118 
7.3.2. Atezolizumab (Tecentriq®) 
 
● Dose: 1200 mg concentrate for solution for infusion. After dilution (according to SmPc), 1 mL 
of solution contains approximately 4.4 mg of Atezolizumab. The recommended dose of 
Tecentriq® is 1200 mg administered intravenously every three weeks. Tecentriq® is for 
intravenous use. The infusions must not be administered as an intravenous push or bolus. 
 
● Dose of 840 mg concentrate: 14 mL of Tecentriq® concentrate should be withdrawn from the 
vial and diluted into a 250 mL polyvinyl chloride (PVC), polyolefin (PO), polyethylene (PE), or 
polypropylene (PP) infusion bag containing sodium chloride 9 mg/mL (0.9%) solution for 
injection. After dilution, 1 mL of solution should contain approximately 3.2 mg of Tecentriq® 
(840 mg/264 mL). 
 
● The initial dose of Tecentriq® (both dosages) must be administered over 60 minutes. If the 
first infusion is well tolerated, all subsequent infusions may be administered over 30 minutes. 
 
● Instructions on dilution and handling of the medicinal product before administration: chemical 
and physical in-use stability has been demonstrated for up to 24 hours at ≤ 30 °C and for up 
to 30 days at 2 °C to 8 °C from the time of preparation. 
 
● From a microbiological point of view, the prepared solution for infusion should be used 
immediately. If not used immediately, in-use storage times and conditions prior to use are the 
responsibility of the user and would normally not be longer than 24 hours at 2 °C to 8 °C or 8 
hours at ambient temperature (≤ 25 °C) unless dilution has taken place in controlled and 
validated aseptic conditions. 
 
● Route: Intravenous infusion for both dosages. 
 
● Schedule: The 840 mg will be administered once at day 1 of a 2-week cycle. The 1200 mg 
dose will be administered every 3 weeks over 4 cycles. 
 
● Traceability: In order to improve the traceability of biological medicinal products, the trade 
name and the batch number of the administered product should be clearly recorded in the 
patient file. 
 
● Mechanism of action: Atezolizumab is an Fc-engineered, humanized IgG1 anti-programmed 
death-ligand 1 (PD-L1) monoclonal antibody produced in Chinese hamster ovary cells by 
recombinant DNA technology. 
 
7.3.3. Carboplatin 
 
● Dose: AUC of 2 IV weekly X 12 doses 
● Route: Intravenous infusion. The solution for infusion is given as a short IV infusion over 
15 - 60 minutes. 
● Schedule: every week for 12 weeks (12 cycles).  
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 45 of 118 
7.3.4. Paclitaxel 
● Dose: 80 mg/m2, day 1 
● Route: 1-hour intravenous infusion. During the first 5 minutes, the infusion must be done drop 
by drop in order to reduce the incidence of acute hypersensitivity reaction. 
● Schedule: every week for 12 weeks (12 cycles).  
 
7.3.5. Epirubicin 
    
● Dose: 90 mg/m2, day 1 
● Route: IV over 3 - 5 min or according to local standard. 
● Schedule: 4 cycles (1 cycle = 3 weeks) over 12 weeks. 
 
7.3.6. Cyclophosphamide 
 
● Dose: 600 mg/m2, day 1 
● Route: IV from 30 min to 2 hours or according to local standard. 
● Schedule: 4 cycles (1 cycle = 3 weeks) over 12 weeks. 
 
7.3.7. TNBC directed therapies during adjuvant phase 
 
Standard TNBC directed therapies will be used as according to German SOC as defined through 
S3-guideline and recommendations of the AGO Mamma (in its latest version) during adjuvant 
phase. 
 
 
For approved drugs, refer to the current version of the respective SmPC provided by the 
manufacturers. 
 
7.3.8. Medication error 
In the neoadjuvant phase, all medication is administered at the hospital. Refer to the SmPC or IB 
for the respective drugs administered. 
 
7.4. Dose modification and treatment delays 
Adverse Events will be graded using the National Cancer Institiute Common Toxicity Criteria (NCI 
CTC), version 5.0. For modification of dose and treatment in case of immune-related side effects 
refer to the section 6.7 of the current IB of Tecentriq® (Atezolizumab). Dose reduction is planned 
for the CTX containing treatment arm in case of severe hematological and/or non-hematological 
toxicities. Dose adjustments are to be made according to the organ system showing the greatest 
degree of toxicity. In case of several toxicities in one patient and conflicting recommendations, the 
most conservative dose adjustment has to be followed. Doses which have been reduced for 
toxicity must not be re-escalated with the exception of liver function tests that improve within 
ranges given. In case of persistent toxicity attributed to CTX, the possibility of a dose reduction in 
accordance with drug-specific recommendations as given below should always be considered. It 
should be noted that once a dose reduction of CTX has been carried out, it must be adhered to 
for all subsequent cycles. A second dose reduction step for Paclitaxel/Carboplatin and 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 46 of 118 
Epirubicin/Cyclophosphamide during the study is not intended (7.4.3.2, Table 3 and 7.4.4, Table 
5). 
If an AE occurs during therapy with an already reduced dose, the investigator has to consider the 
pausing of the causative substance. If the criteria for resumption of therapy (retreatment criteria) 
are met, the therapy should be resumed at the already reduced dose. Alternatively, it is at the 
discretion of the investigator to terminate the treatment with the causative substance. 
 
To ensure adequate monitoring and toxicity management during administration of study treatment, 
the administration of study drugs will be performed in a monitored setting where there is immediate 
access to trained personnel and adequate equipment and medicine to manage potentially serious 
reactions. 
 
7.4.1. Atezolizumab 
 
 7.4.1.1. Administration of Atezolizumab 
 
First infusion: 
● No premedication is administered 
● Record patient’s vital signs (heart rate, respiratory rate, blood pressure, and temperature) 
at the following time points: 
o Within 60 minutes prior to infusion 
o During infusion or after infusion, if clinically indicated 
● Infuse Atezolizumab (1 vial in 250 mL NaCl solution) over 60 (± 15) min 
● Patients will be informed about the possibility of delayed post-infusion symptoms and 
instructed to contact their study physician if they develop such symptoms. 
 
Subsequent infusion: 
● If the patient tolerated the 1st infusion well without infusion-associated adverse events, the 
2nd infusion will be delivered over 30 (± 10) min; record patient vital signs (heart rate, 
respiratory rate, blood pressure, and temperature) as clinically indicated. 
● If patient experienced infusion-related reaction during any previous infusion premedication 
may be administered for cycles ≥ 2 at the discretion of the treating physician (see Table 
48 of the current IB of Tecentriq® (Atezolizumab). 
● If the patient had an infusion-related reaction during the previous infusion, the subsequent 
infusion must be delivered over 60 (± 15) min. 
● Record patient’s vital signs (heart rate, respiratory rate, blood pressure, and temperature) 
at the following time points: 
o Within 60 min prior to infusion 
o During infusion or after infusion, if clinically indicated 
● If no reaction occurs, continue subsequent infusions over 30 (± 10) min with the same 
schedule for recording vital signs as above (within 60 min prior to infusion, during infusion 
or after infusion, if clinically indicated). 
 
7.4.1.2. Atezolizumab dose modification 
For modification of dose and treatment in case of immune-related side effects refer to the section 
6.7 of the current IB of Tecentriq® (Atezolizumab). 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 47 of 118 
7.4.1.3. Management of Atezolizumab-specific Adverse Events 
The current version of the IB of Tecentriq® (Atezolizumab) provides detail information about 
Adverse Events (AEs) experienced by patients. 
Side effects associated or possibly associated with Atezolizumab treatment should be managed 
according to standard medical practice. Additional tests, such as autoimmune serology or 
biopsies, should be used to evaluate for a possible immunogenic aetiology. 
For organ-specific management guidelines of immune-related adverse events (irAEs) see section 
6.7 of the current IB of Tecentriq® (Atezolizumab) including management guidelines for pulmonary 
events, pneumonitis, hepatic events, gastrointestinal events (diarrhea or colitis), endocrine events, 
ocular events, immune-mediated myocarditis, infusion-related reactions, pancreatic events, 
pancreatitis, dermatologic events, neurologic disorders, immune-mediated meningoencephalitis, 
renal events, immune-mediated myositis. Recent data have reported that immune-mediated 
pericardial disorders including pericarditis, pericardial effusion and cardiac tamponade are 
associated with use of immune checkpoint inhibitors as a class of medications [source Dear 
Investigator Letter (DIL), Identified Risk: Immune-Mediated Pericardial Disorders with Tecentriq® 
(atezolizumab) use; 27-Jul-2022]. Based on these data, immune-mediated pericardial disorders 
are now considered to be an identified risk for Atezolizumab. Atezolizumab should be withheld for 
patients with suspected immune-mediated pericardial disorders. Caution should be used when 
considering the use of Atezolizumab in a patient who has previously experienced a pericardial 
disorder on prior treatment with other immune-stimulatory anticancer agents. 
Further recently identified important risks associated with use of Atezolizumab are immune-
mediated myelitis and immune-mediated facial paresis [source Dear Investigator Letter (DIL), 
Identified Risks: Immune-Mediated Myelitis and Immune-mediated Facial Paresis with Tecentriq® 
(atezolizumab) use; 21-Nov-2022]. Atezolizumab should be withheld for patients with grade 1 or 
2 immune-mediated facial paresis. Patients should be monitored for clinical signs and symptoms 
that are suggestive of myelitis and may present with signs and symptoms of sensory and/or motor 
neuropathy regarding facial paresis. Diagnostic workup is essential for an accurate 
characterization to differentiate between alternative etiologies. Consider referring patient to 
neurologist. 
Although most irAEs observed with immunomodulatory agents have been mild and self-limiting, 
such events should be recognized early and treated promptly to avoid potential major 
complications. Discontinuation of Atezolizumab may not have an immediate therapeutic effect, 
and in severe cases, immune-related/ immune–mediated toxicities may require acute 
management with topical corticosteroids, systemic corticosteroids, or other immunosuppressive 
agents. 
The investigator should consider the benefit-risk balance a given patient may be experiencing 
prior to further administration of Atezolizumab. In patients who have met the criteria for permanent 
discontinuation, resumption of Atezolizumab may be considered if the patient is deriving benefit 
and has fully recovered from the immune-related event. Patients can be re-challenged with 
Atezolizumab only after the approval has been documented by both the investigator (or an 
appropriate delegate) and the sponsor. According to DIL (Identified Risk: Immune-Mediated 
Pericardial Disorders with Tecentriq® (atezolizumab) use; 27-Jul-2022), Atezolizumab should be 
permanently withdrawn for any grade confirmed immune-mediated pericardial disorders. 
According to recent DIL (Identified Risks: Immune-Mediated Myelitis and Immune-mediated Facial 
Paresis with Tecentriq® (atezolizumab) use; 21-Nov-2022), Atezolizumab should be permanently 
withdrawn for ≥ grade 2 immune-mediated myelitis as well as for ≥ grade 3 immune-mediated 
facial paresis. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 48 of 118 
 
For suspected immune-related adverse reactions, thorough evaluation to confirm aetiology or 
exclude other causes should be performed. Based on the severity of the adverse reaction, 
Atezolizumab should be withheld, and corticosteroids administered. Upon improvement to grade 
≤ 1, corticosteroid should be tapered over ≥ 1 month. Based on limited data from clinical studies 
in patients whose immune-related adverse reactions could not be controlled with systemic 
corticosteroid use, administration of other systemic immunosuppressants may be considered. 
Atezolizumab must be permanently discontinued for any grade 3 immune-related adverse reaction 
that recurs and for any grade 4 immune-related adverse reactions, except for endocrinopathies 
that are controlled with replacement hormones. According to DIL (Identified Risk: Immune-
Mediated Pericardial Disorders with Tecentriq® (atezolizumab) use; 27-Jul-2022), Atezolizumab 
should be permanently withdrawn for any grade confirmed immune-mediated pericardial 
disorders. According to recent DIL (Identified Risks: Immune-Mediated Myelitis and Immune-
mediated Facial Paresis with Tecentriq® (atezolizumab) use; 21-Nov-2022), Atezolizumab should 
be permanently withdrawn for ≥ grade 2 immune-mediated myelitis as well as for ≥ grade 3 
immune-mediated facial paresis. 
For further recommendations for the management of irAEs please refer to the ASCO Clinical 
Practice Guideline: “Management of Immune-Related Adverse events in Patients Treated with 
Immune Checkpoint Inhibitor Therapy”. 
 
7.4.2. Delays in cycles 
If therapy cycles are partially or completely delayed due to an adverse event, a strict hierarchy 
applies. Atezolizumab, as the leading substance, determines the sequence and duration of the 
therapy cycles. Specifically, this means: 
1. If a CTX side effect is anticipated, Atezolizumab therapy may be continued, and CTX must 
be modified according to the drug-specific information given below. Regarding the 
modification of CTX administration, please note: 
i. 
If a dose modification of a chemotherapeutic agent has been carried out, the dose 
modification does apply to the entire further course of therapy. 
ii. 
If on the day of therapy administration (day 1, 8 or 15), a toxicity does not allow the 
administration of the causative chemotherapeutic substance, the administration of 
this substance is cancelled on this day. If the criteria for resuming the therapy are 
met on the next day of therapy administration (day 1, 8 or 15) the therapy may be 
resumed in a modified form (see below for details). 
iii. 
If CTX (either Paclitaxel/Carboplatin or Epirubicin/Cyclophosphamide) had been 
interrupted (and Atezolizumab therapy continued), the CTX doses (day 1, 8 or 15) 
must not be made up and thereby extending the length of an Atezolizumab cycle 
beyond day 21. Rather, the following cycle will resume Atezolizumab combination 
therapy with either Paclitaxel/Carboplatin or Epirubicin/Cyclophosphamide on day 
1. 
 
2. If a side effect of Atezolizumab is assumed (i.e., in particular an immunologic side effect) 
and therapy with Atezolizumab is interrupted (see current IB of Tecentriq®), Atezolizumab 
is omitted as the leading substance and CTX is to be continued independently. In this case, 
the duration and sequence of therapy shall be based on 12 weekly doses of 
"Paclitaxel/Carboplatin" or four 3-weekly doses of "Epirubicin/Cyclophosphamide". 
In the event, that the start of a new cycle is delayed due to treatment-related toxicity, procedures 
required on day 1 (as per SOA) of the given cycle will be performed when either Atezolizumab or 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 49 of 118 
CTX is resumed. New cycle day 1 procedures that were performed prior to knowing the need to 
delay the start of the cycle do not need to be repeated:  
● if not required to determine whether study drug may be resumed and  
● If performed within 7 days prior to study drug resumption.  
 
If the AE that led to the treatment interruption recovers within the same cycle, then re-dosing in 
that cycle is allowed. Doses omitted for toxicity are not replaced within the same cycle.  
In the event of a treatment interruption for reasons other than treatment-related toxicity (e.g., non-
cancer related surgery) lasting > 3 weeks, treatment resumption will be decided in consultation 
with the sponsor (Medical Monitor (MM)). 
 
7.4.3. Paclitaxel and Carboplatin Dosage and Modifications 
 
7.4.3.1. Carboplatin dosage 
Carboplatin dosage is based on Area under the curve (AUC). AUC can be calculated using 
the following mathematical formula, which includes renal function. This will reduce the risk of 
overdosing or under dosing because of individual differences in renal function.  
● 
 
● 
Formula according to Calvert:  
Total dose (mg) = (target AUC*) x (GFR {glomerular filtration rate} + 25)  
For more information, refer to the SmPC. 
 
7.4.3.2. Dose reductions/modifications of Paclitaxel and Carboplatin 
Treatment should be delayed for at least 1 week for an absolute neutrophil count less than 
1.0 x 109/L and /or a platelet count less than 100 x 109/L. For resumption of Paclitaxel/Carboplatin 
therapy, absolute neutrophile count has to be ≥ 1.5 x 109/L and platelets ≥ 100 x 109/L and other 
treatment-related hematological and treatment-related non-hematological toxicity need to be 
resolved to ≤ grade 1 (except for alopecia and fatigue for which resolution is not required). If 
Paclitaxel/Carboplatin is delayed for at least 1 week due to treatment-related toxicity, dose 
reduction of the presumably causative medication may be considered. Should neutrophil count 
and/or platelet count persist below the value of absolute neutrophil count less than 1.0 x 109/L 
and/or a platelet count less than 100 x 109/L for more than 14 days, please contact the sponsor 
(MM). 
If dose reductions of either of the two drugs are indicated, the dose should be reduced by one 
dose-level. The following dosing levels are applicable (see table 3 below): 
 
Table 3: Dosing level reduction for Paclitaxel and Carboplatin* 
 
Paclitaxel (mg/m2) 
Carboplatin (AUC) 
Level 0 (initial dose): 
80 
2.0 
Level -1 
64 
1.6 
* See also general information given for persistent CTX related toxicity under 7.4. 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 50 of 118 
If toxicity does not resolve during a 14-day monitoring interval, drug exposure should be 
interrupted with continued monitoring for an additional 14 days. 
If treatment is being interrupted for more than 21 days, the investigator must contact the sponsor 
and the subject’s condition needs to be reviewed before therapy may be resumed. 
Detailed recommendations for dose interruptions/modifications in case of specific treatment-
emergent AEs are provided in the following sections. 
Subjects experiencing any of the following toxicities during the previous cycle should have their 
CTX reduced for all subsequent cycles by 1 dose level as outlined in table 4 (below): 
 
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 51 of 118 
Table 4: Dose modifications for Paclitaxel and/or Carboplatin 
Dose Modifications for Carboplatin and Paclitaxel (a) 
Toxicity 
Adjustment for treatment component 
believed to be associated with specific 
toxicity, continue other treatment 
component per protocol 
ANC < 0.5 x 109/L for ≥ 5 days 
Decrease 1 level (b) 
Febrile neutropenia (≥ 38.5 °C) associated with ANC 
< 1.0 x 109/L 
Decrease 1 level (b) 
≥ Grade 3 thrombocytopenia or in presence of 
significant bleeding or requiring blood transfusion  
at first occurrence 
Decrease 1 level (b) 
Grade 2 sensory neuropathy lasting > 7 days 
Withheld Paclitaxel till neuropathy improves to ≤ 
grade 1 and decrease 1 level 
Grade 3 sensory neuropathy 
Withheld Paclitaxel. Treatment may be resumed at a 
reduction of 1 level in subsequent cycles after 
neuropathy improves to ≤ grade 1 
Grade 4 sensory neuropathy 
Withheld Paclitaxel. Treatment may be resumed at a 
reduction of 1 level in subsequent cycles after 
neuropathy improves to ≤ grade 1. If neuropathy 
does not improve to ≤ grade 1 within 6 weeks, 
discontinue treatment 
Abnormal Bilirubin value: 
Grade 1 
 
Grade 2 
Grade 3 or 4 
 
Re-test bilirubin value every week, continue study 
treatment 
Hold treatment until improvement to grade 1. Restart 
treatment at a lower dose level 
Discontinue treatment 
Abnormal AST/ALT values (c): 
Grade 1 
Grade 2 
 
Grade 3 or 4 
 
Continue study treatment 
Hold Paclitaxel until improvement to Grade 1. Restart 
Paclitaxel at a lower dose level 
Discontinue Paclitaxel 
Renal toxicity ≥ 2 (serum creatinine > 1.5 x ULN) 
Recalculate Carboplatin dose to AUC 1.6 
Weight change ≥ 10% from baseline 
Recalculate Carboplatin dose 
Other grade ≥ 3 toxicities (d) 
Adjust dose or discontinue therapy as medically 
indicated after discussion with sponsor 
 
(a): Despite adequate/maximal medical intervention and/or prophylaxis 
(b): platelets have to recover to ≥ 100 x 109/L (and neutrophils have to be ≥ 1.5 x 109/L) before the start of 
the next cycle. If platelets have not recovered at day 35, discontinue treatment. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 52 of 118 
(c): In the case of liver toxicity under Paclitaxel, it must be examined in individual cases, depending on 
the clinical situation, whether further laboratory tests or, if necessary, invasive diagnostics (liver biopsy) 
can exclude other triggering factors of an increase in transaminases. 
(d): Except grade 3 fatigue, transient joint or muscle pain for which no dose modifications are required. 
  
7.4.3.3. Hypersensitivity reactions to Paclitaxel 
 
If hypersensitivity reactions occur, minor symptoms (flushing, skin reactions, lower back pain, 
hypotension, tachycardia) might require temporary interruption of application. In case of severe 
reactions (hypotension/dyspnea/requiring medication, angioedema, generalized urticaria) 
immediate discontinuation of study drug administration is required. 
In case of severe hypersensitivity reactions, Paclitaxel should not be re-challenged. 
 
7.4.4. Epirubicin and Cyclophosphamide 
 
Treatment should be delayed for at least 1 week for an absolute neutrophil count less than 
1.0 x 109/L and /or a platelet count less than 100 x 10 9/L. For resumption of therapy, the absolute 
neutrophile count has to be ≥ 1.5 x10 9/L and treatment-related non-hematological toxicity has to 
be resolved to ≤ grade 1 (except for alopecia and fatigue for which resolution is not required).). 
Should neutrophil count and/or platelet count persist below the above-mentioned value for more 
than 14 days, please contact the sponsor. 
If dose reductions of either of the two drugs are indicated, the dose should be reduced by one 
dose-level. The following dosing levels are applicable: 
 
 
Table 5: Dosing level reduction for Epirubicin and Cyclophosphamide* 
 
Epirubicin (mg/m2) 
Cyclophosphamide (mg/m2) 
Level 0 (initial dose): 
90 
600 
Level -1 
75 
450 
* See also general information given for persistent CTX related toxicity under 7.4. 
 
If toxicity does not resolve during a 14-day monitoring interval, drug exposure should be 
interrupted with continued monitoring for an additional 14 days.  
If treatment is being interrupted for more than 21 days, the investigator must contact the sponsor 
and the subject’s condition needs to be reviewed before therapy may be resumed. 
Detailed recommendations for dose interruptions/modifications in case of specific treatment-
emergent AEs are provided in the following sections. If subjects experience any of the following 
toxicities during the previous cycle should have their CTX reduced for all subsequent cycles by 1 
dose level as outlined in table 6 (below): 
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 53 of 118 
 
Table 6: Dose modifications for Epirubicin/Cyclophosphamide 
Dose Modifications for Epirubicin and Cyclophosphamide (a) 
Toxicity 
Adjustment for treatment component 
believed to be associated with specific 
toxicity, continue other treatment 
component per protocol 
ANC < 0.5 x 10 9/L for ≥ 5 days 
Decrease 1 level (b) 
Febrile neutropenia (≥ 38,5 °C) associated with ANC 
< 1.0 x 10 9/L 
Decrease 1 level (b) 
≥ Grade 3 thrombocytopenia or in presence of 
significant bleeding or requiring blood transfusion  
at first occurrence 
Decrease 1 level (b) 
Abnormal Bilirubin value: 
Grade 1 
 
Grade 2 
Grade 3 or 4 
 
Re-test bilirubin value every week, continue study 
treatment 
 
Hold treatment until improvement to grade 1. Restart 
treatment at a lower dose level 
 
Repeat biochemical tests every two days; liver 
ultrasound should be performed immediately. Call 
the sponsor to discuss the case 
 
 
Abnormal AST/ALT values: 
Grade 1 
Grade 2 
Grade 3 or 4 
 
Continue study treatment 
 
Hold treatment until improvement to grade 1. Restart 
treatment at a lower dose level 
 
Discontinue treatment 
Mucositis and dysphagia 
May occur with Epirubicin administration. Temporary 
withhold Epirubicin if these side effects are moderate 
to severe (≥ grade 2), but re-institute full dose once 
they resolve 
Cystitis 
May occur with Cyclophosphamide administration. 
Temporary withhold Cyclophosphamide if cystitis is 
moderate to severe. Encourage the patient to drink 
large amounts of water; if urine culture is positive, 
antibiotics will be given 
Cardiac toxicity 
The maximum cumulative dose of Epirubicin is 
900 mg/m2. The maximum cumulative dose planned 
in the neoMono trial is 360 mg/m2. At this cumulative 
dose cardiac effects are infrequent. 
Epirubicin will be discontinued if: 
1. CHF appears; 
2. Persistent arrhythmia (including sinus tachycardia 
with no demonstrable cause) appears; 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 54 of 118 
3. Asymptomatic decrease of LVEF to below 45% 
      Call the sponsor to discuss the case 
Other grade ≥ 3 toxicities (c) 
Adjust dose or discontinue therapy as medically 
indicated after discussion with sponsor 
 
(a): Despite adequate/maximal medical intervention and/or prophylaxis 
(b): platelets have to recover to ≥ 100 x 10 9/L (and neutrophils have to be ≥ 1.5 x 109L) before the start of 
the next cycle. If platelets have not recovered at day 35, discontinue treatment. 
(c): Except grade 3 fatigue, transient joint or muscle pain for which no dose modifications are required. 
 
7.4.5 QT corrected interval (QTc) prolongation management 
 
In the event of QTc prolongation of > 480 and ≤ 500 ms, possible reversible causes such as serum 
electrolytes abnormalities, or usage of concomitant medications with the potential to prolong the 
QTc interval should be evaluated. If such reversible causes are identified, then they should be 
corrected accordingly (i.e. correction of electrolyte abnormalities with supplements to within 
normal limits and/or discontinuation - if possible - of concomitant medications with the potential to 
prolong the QT interval).  
If the QTc remains > 480 ms and ≤ 500 ms for more than 2 cycles, or if grade 2 QTc prolongation 
recurs in the absence of other alternative causes or despite correction of alternative causes, 
discontinuation should be considered in consultation with a cardiologist and the study Medical 
Monitor. 
 
 
7.5. Method of treatment assignment 
 
Pre-Coded central 
Randomization  
Upon successful screening, participants will be assigned a unique 
number (subject ID) in ascending numerical order and will be randomized 
centrally to one of the 2 arms of the study with a randomization ratio of 
1:1, according to the randomization schedule generated prior to the study 
by the Statistics Department at palleos healthcare GmbH. Randomization 
will be realized by permuted block design, stratified by PD-L1 IC-status 
and anatomic tumor stage (AJCC 8th edition Anatomic Stage Groups I, II 
and III). 
 
 
7.6. Blinding 
 
This is an open-label study with no blinding at site level. Potential bias will be reduced by 
organizing a central randomization as described in section 7.5. 
 
 
7.7. Preparation/Handling/Storage/Accountability 
 
Refer to section 7.1 for the definition of IMP. 
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 55 of 118 
7.7.1. Drug packaging, labeling, dispensing and storage 
 
7.7.1.1. Packaging and labeling 
The Roche-provided Atezolizumab will be labeled study-specific for the neoadjuvant therapy 
phase in patients randomized to Arm A (2-week-window of Atezolizumab mono-therapy followed 
by 12 weeks of Atezolizumab + Carboplatin + Paclitaxel) and then by 12 weeks of Atezolizumab 
+ Epirubicin + Cyclophosphamide and for Arm B (12 weeks of Atezolizumab + Carboplatin + 
Paclitaxel) and then by 12 weeks of Atezolizumab + Epirubicin + Cyclophosphamide. It will be 
labelled at Roche and sent directly to the study site. 
 
Carboplatin, Paclitaxel, Epirubicin and Cyclophosphamide administered during the neoadjuvant 
phase are considered as IMPs. Therefore, these commercial drugs will be labelled study-
specifically by the central pharmacy and provided to the study sites. 
 
7.7.1.2. Dispensing and storage 
For preparation of the CTX, which is commercial product, solutions and storage, please refer to 
the SmPCs of the drugs.  
For Atezolizumab preparation, see the local prescription information and section 7.3.2.  
● Keep the vial in the outer carton in order to protect from light. Vials of Atezolizumab are shipped 
at a temperature ranging from 2°C - 8°C and must be placed in a refrigerator (at the same 
temperature range) immediately upon receipt and should remain refrigerated until immediately 
prior to use. Temperature logs must be maintained on the refrigerator (in accordance with local 
pharmacy practice).  
● If a temperature deviates from the allowed 2 - 8°C range either during shipment or storage, 
contact the sponsor to determine if the drug is still appropriate for use. The vials must not be 
frozen or shaken. Store the vials within the outer carton and protect them from light. The 
medication must not be used beyond the use by date provided on the outer carton. 
The following general rules will be applied for all study medication:  
● Storage and dispensation of study medication must be carefully documented by the 
investigator.  
● The investigator will confirm receipt of the first and all subsequent batches of study drugs in 
writing to the sponsor. The investigator or designee must confirm appropriate temperature 
conditions have been maintained during transit for all study treatment received and any 
discrepancies are reported and resolved before use of the study treatment. 
● All drug supplies must be stored in accordance with the manufacturer's instructions, and 
separately from normal clinic stocks present at the study site. The investigator is responsible 
for assurance of adequate storage, protected from exposure to any environmental changes. 
Moreover, the study medication must be stored in a lockable room or locker, so that only the 
investigator and specifically designated study personnel can have access. 
● Only participants enrolled in the study may receive study treatment and only authorized site 
staff may supply or administer study treatment. 
● Documentation of preparation and distribution of the study medication has to be documented 
in accordance with the SmPCs (prescribing information/ "Fachinformation"). 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 56 of 118 
 
7.7.2. Drug accountability and compliance 
● Atezolizumab as well as the standard CTX agents will be administered by the study staff during 
patient’s visits and accountability will be documented and recorded in the CRF.  
● Accountability will be assessed by maintaining adequate drug dispensing and return records 
for all study treatments. Any dose modification must be recorded. 
 
● The drug records must contain documentation of drug shipments received by the sponsor 
(date and quantity received). 
 
● The drug dispensing log must be current and contain: 
o The study number of the patient to whom this drug was administered 
o The date(s) and quantity of the study medication administered to the patient. 
 
● Copies of the dispensing and inventory logs must be available for inspection by the monitor. 
 
● All used and partially used Atezolizumab vials and chemotherapeutic agents must be 
destroyed either on-site or per site’s specific procedures for handling and disposing of 
hazardous drugs. The specific procedures for destructions of IMPs are to be provided to the 
monitor for review. 
 
● Unused Atezolizumab vials will be disposed only according to the process approved by the 
provider (Roche). Vials that are not opened will be returned according to the process 
established by Roche. Partially used vials may only be destroyed upon written approval from 
the provider Roche. The release of Atezolizumab in the environment should be minimized. 
Any unused medicinal product or waste material should be disposed also in accordance with 
local requirements. 
 
● Written documentation of destruction must contain the following: 
o Identity (batch number, patient number) of investigational products destroyed 
o Quantity of investigational products destroyed 
o Date of destruction 
o Method of destruction 
o Name and signature of the responsible person who discarded the investigational 
product. 
 
 
7.8. Concomitant therapy 
 
● 
Any existing concomitant medication not compatible with study medication has to be checked 
and excluded during the neoadjuvant phase where study medication is administered. 
● 
Any medication or vaccine (including over-the-counter or prescription medicines, vitamins, 
and/or herbal supplements) that the participant is receiving at the time of enrollment or 
receives during the study must be recorded along with: 
o Reason for use 
o Dates of administration including start and end dates 
o Dosage information including dose and frequency 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 57 of 118 
The MM should be contacted if there are any questions regarding concomitant or prior 
therapy. 
 
● 
Concomitant therapy during targeted treatment for permitted prophylactic premedication: 
premedication for nausea and infusion reactions (e.g., acetaminophen or other analgesics, 
anti-histamines such as diphenhydramine or corticosteroids) may be given at the 
investigator’s discretion.  
 
● 
Ancillary treatments will be given as medically indicated. Any concomitant medication must 
be documented in the CRF. 
 
7.8.1. Interaction with other medicinal products and other forms of interaction 
 
● 
No formal pharmacokinetic drug interaction studies have been conducted with Atezolizumab. 
Since Atezolizumab is cleared from the circulation through catabolism, no metabolic drug-
drug interactions are expected. 
 
● 
The use of systemic corticosteroids or immunosuppressant before starting Atezolizumab 
should be avoided because of their potential interference with the pharmacodynamic activity 
and efficacy of Atezolizumab. However, the use of Paclitaxel in the study necessitates the 
use of Dexamethasone at 8 mg and this will be allowed (has to be below 10 mg). Systemic 
corticosteroids or other immunosuppressant can be used to treat immune-related adverse 
reactions after starting Atezolizumab.  
 
7.8.2. Prophylactic premedication regimen for treatment with chemotherapeutic agents  
 
Proposed premedication regimens for the administration of chemotherapeutic agents should be 
applied according to local SOC. 
 
 
7.8.3. Use of prophylactic antibiotics and Granulocyte colony stimulating factor (G-CSF) 
with CTX 
 
Primary/secondary G-CSF and antibiotics prophylaxis should be given according to SOC as 
defined by S3-guideline and recommendation of the AGO Mamma (in its latest version). No 
primary G-CSF prophylaxis is indicated in association with Atezolizumab. 
 
7.8.4. Radiation 
 
Patients will be treated according to local SOC.  
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 58 of 118 
7.8.5. Other anti-cancer treatments  
Administration of further antitumor therapy (i.e. in case of disease progression or persistence of 
residual tumor after neoadjuvant CTX) after study medication is completed or stopped is at the 
discretion of the investigator. Therapy should be documented in the CRF accordingly.  
In case of relapse after surgery (i.e. during follow-up) further treatment again is at the discretion 
of the investigator and should be documented in the CRF. 
 
8. Discontinuation/Withdrawal criteria  
 
8.1. Discontinuation of study treatment 
● The term "interruption" refers to a patient stopping the study treatment during the course 
of the study, but then re-starting it at a later time in the study. The reason for dosing 
interruption will be collected on the appropriate CRF. 
● The term "discontinuation" or withdrawal refers to a patient's withdrawal from the study 
treatment after baseline visit and administration to study drugs in Arm A or B until the 
planned end of the study (up to 24 months after baseline).  
● The reason for discontinuation from treatment will be collected on the appropriate CRF. 
● Patients may withdraw from the study at any time at their own request, or they may be 
withdrawn at any time at the discretion of the investigator or sponsor for safety or 
behavioral reasons, or the inability of the patient to comply with the protocol-required 
schedule of study visits or procedures at a given study site.  
● Patients must be withdrawn from the active treatment phase in case of: 
o Disease progression  
o Symptomatic deterioration (i.e., global deterioration of health status without 
objective evidence of disease progression)  
o Need for new or additional anticancer therapy not specified in the protocol 
o Unacceptable toxicity 
o Investigator’s conclusion that discontinuing therapy is in the patient’s best interest 
o Lost to follow-up 
o Withdrawal of patient consent (follow-up permitted by patient or request of 
cessation of follow-up) 
o Death 
● The investigator should inquire about the reason for withdrawal, request that the patient 
returns for a final visit, if applicable, and follow-up with the patient regarding any unresolved 
AEs.  
● Patients who discontinue the active treatment phase (neoadjuvant treatment phase) 
should have end of treatment/withdrawal evaluations performed as soon as possible but 
no later than 4 weeks from the last dose of investigational products and prior to initiation 
of any new anticancer therapy. Data to be collected for the end of study 
treatment/withdrawal visit are described in the SOA tables. Unless a patient actively 
withdraws consent, every effort should be made to continue collecting further endpoints 
and any auxiliary variables that may be informative with regard to missing values, if this is 
feasible in any way. These data are required to apply the intention-to-treat principle and to 
handle missing values in the statistical analysis. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 59 of 118 
● If a patient opts to discontinue from the active treatment phase as a result of an 
unacceptable adverse drug reaction, "withdrawal of consent" should not be the reason for 
discontinuation. Instead, the reason for discontinuation of active treatment phase must be 
recorded as "Unacceptable toxicity". 
● If the patient withdraws from the study, and also withdraws consent for disclosure of future 
information, no further evaluations should be performed, and no additional data should be 
collected. The sponsor may retain and continue to use any data collected before such 
withdrawal of consent. 
 
 
8.2. Lost to follow-up 
 
If a patient does not return for a scheduled visit, every effort should be made to contact the patient. 
After three unsuccessful attempts to contact the patient, the patient should be considered “lost to 
follow-up”.  
 
The following actions must be taken if a participant fails to return to the clinic for a required study 
visit: 
 
● The site must attempt to contact the patient and reschedule the missed visit as soon as 
possible and counsel the patient on the importance of maintaining the assigned visit 
schedule and ascertain whether or not the patient wishes to and/or should continue in the 
study. 
● Before a patient is deemed lost to follow up, the investigator or designee must make every 
effort to regain contact with the patient (where possible, 3 telephone calls and, if necessary, 
a certified letter to the patient’s last known mailing address or local equivalent methods). 
These contact attempts should be documented in the patient’s medical record. 
 
9. Study assessments and procedures 
 
9.1. Screening 
 
Table 7: Study assessments during screening 
 
INVESTIGATIONS 
TIMING  
Patient informed 
consent 
Obtained 
Prior to study entry1 
 
Diagnostic core biopsy 
Obtained 
Prior to randomization  
TNBC status 
   
Prior randomization 
Anatomic tumor stage 
group I, II, III 
   
Within 4 weeks prior to 
screening 
Ultrasound status 
   
Within 4 weeks prior to 
screening 
Demographic 
information, Medical 
History including:  
● 
Diagnosis of unilateral primary invasive breast 
cancer from core biopsy 
Within 7 days prior to 
screening 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 60 of 118 
History and physical 
examination 
● 
Assessment of cN and cT status 
● 
Receptor status (Triple negative) at diagnosis 
● 
Menopausal 
status 
and 
highly 
effective 
contraceptive measures 
● 
General medical history including cardiac history 
and allergy 
● 
Concurrent illness and existing signs and 
symptoms 
● 
Concomitant medications and their indication 
used within one month prior to study entry 
Physical examination as defined in section 9.10.1 
Imaging 
 
 
Mandatory for all patients (as per SOC defined by 
S3-guideline and recommendations of the AGO 
Mamma). 
● 
Contralateral mammography and ultrasound 
(Breast, lymph nodes) 
● 
CT scans 
● 
Bone scan; additional bone X-ray in case of hot 
spots in bone scan in high risk patients 
● 
Liver imaging (CT) 
Other instrumental examinations as indicated by 
radiologist. 
≤ 3 months prior to 
randomization and part of 
SOC 
 
Laboratory 
 
Hematology and Biochemistry tests as defined in 
appendix 2 
 
Blood sample for translational research (refer to 
section 9.11) 
≤ 14 days prior to 
screening 
 
 
Pregnancy test urine or serum (if applicable) 
≤ 7 days prior to screening 
Clinical Assessment 
Includes palpation and inspection of the breast 
At screening visit 
Check for adequate 
contraception 
measures (if applicable) 
As defined in section 6.1 
 
ECG 
ECG 
≤ 6 weeks prior to 
screening 
LVEF 
Echocardiography 
≤ 6 weeks prior to 
screening 
 
• 
1Voluntary, dated, and signed informed consent must be obtained before any study specific 
procedures are performed (except certain imaging assessments, see this section below). 
• 
All screening evaluations must be completed and reviewed to confirm that potential 
participants meet all eligibility criteria.  
• 
The investigator will maintain a screening log to record details of all participants screened and 
to confirm eligibility or record reasons for screening failure, as applicable. Procedures 
conducted as part of the participant’s routine clinical management (e.g. blood count, imaging, 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 61 of 118 
etc.) and obtained before signing of the ICF may be utilized for screening or baseline purposes 
provided the procedures met the protocol-specified criteria and were performed within the time 
frame defined in the SOA. For timing of baseline examinations and examinations during 
treatment please refer to table 1. 
• 
Physical examination will include: 
✔ Complete physical examination as defined in section 9.10.1 
✔ Height and Weight  
✔ Vital signs (heart rate, respiratory rate, blood pressure, and temperature) 
✔ ECOG or Karnofsky index (KI) for performance status. The score used at screening 
has to be used during the whole study for one patient 
✔ Clinical tumor assessment  
 
• 
Laboratory work-up will include hematology and biochemistry as defined in appendix 2.  
• 
Blood sample for translational research as defined in 9.11. 
• 
Radiographic tumor assessments that were performed before signing the informed consent 
form (ICF) as routine procedures (but within 3 months prior to screening) do not need to be 
repeated and may be used as baseline assessments. 
• 
The windows permitted for the various procedures are described in the table 1. 
• 
A postmenopausal state is defined as no menses for 12 months without an alternative medical 
cause. A high follicle stimulating hormone (FSH) level in the postmenopausal range may be 
used to confirm a post-menopausal state in women not using hormonal contraception or 
hormonal replacement therapy. However, in the absence of 12 months of amenorrhea, a single 
FSH measurement is insufficient. 
• 
Adequate contraceptive measures will be checked and documented in premenopausal 
patients: 
o IUD 
o bilateral tubal occlusion 
o vasectomised partner 
o sexual abstinence 
 
• 
Pregnancy testing:  
For women of childbearing potential, a serum or urine pregnancy test will be performed at 
screening visit within 7 days prior that visit. A negative pregnancy result is required before 
the patient may receive the study treatment (baseline visit, day 1 of treatment). If at 
baseline visit, the pregnancy test is older than 10 days, it has to be redone. No routine 
pregnancy test will be carried out in postmenopausal. Pregnancy tests will also be done 
whenever a potential pregnancy is suspected. In the case of a positive human 
choriongonadotropin (hCG) test, the patient will be withdrawn from study treatment but will 
remain on study for follow up until birth. 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 62 of 118 
9.2. Screen failures 
 
• 
Screen failures are defined as participants who consent to participate in the clinical study 
but are not subsequently randomly assigned to study treatment. A minimal set of screen 
failure information is required to ensure transparent reporting of screen failure participants 
to meet the Consolidated Standards of Reporting Trials publishing requirements and to 
respond to queries from regulatory authorities. Minimal information includes demography, 
screen failure details, eligibility criteria, and any serious adverse event (SAE). 
• 
In this protocol the screen failure rate is estimated to be 10%. 
• 
Patients for whom the TNBC diagnosis performed by the local laboratory is not confirmed 
by the centralized pathology laboratory with be considered as screen failures and will not 
be randomized. 
• 
Individuals who do not meet the criteria for participation in this study (screen failure) cannot 
be rescreened. 
 
 
9.3. Randomization and active treatment phase 
 
9.3.1. Randomization 
 
The principal investigator will check all inclusion/exclusion criteria and if all inclusion/exclusion 
criteria are met, the patient can be randomized to Arm A or B through the electronic data capture 
(EDC) system. Randomization will be stratified by PD-L1 IC-status and anatomic tumor stage 
(AJCC 8th edition Anatomic Stage Groups I, II and III).  
The investigator will then order the relevant treatment as described below and in parallel the 
investigator will contact the patient for the baseline visit: 
 - Atezolizumab will be ordered by the study site to Roche directly as per SOA. 
- The CTX agents (Paclitaxel, Carboplatin, Epirubicin and Cyclophosphamide) will be sent to the 
central pharmacy and dispatched to the investigator upon request. 
 
9.3.2. Baseline visit: day 1 of treatment 
 
• 
Day 1 of therapy: Arm A: Atezolizumab 840 mg and Arm B: Atezolizumab 1200 mg + 
Paclitaxel 80 mg/m2 + Carboplatin AUC of 2 IV 
• 
Physical examination 
• 
Clinical assessment 
• 
Pregnancy test (should not be older than 10 days, otherwise it has to be redone) 
• 
Blood sample for hematology and biochemistry and for translational research 
• 
Safety assessment & Concomitant medication 
 
 
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 63 of 118 
9.3.3. Neoadjuvant visits after baseline 
 
Patients randomized to Arm A will have 24 visits after baseline; patients randomized to Arm B will 
have 23 visits after baseline. Refer to tables 1a and 1b SOA tables for Arm A and Arm B for details 
of assessments. 
 
9.3.4. End of treatment (EOT) visit in the neoadjuvant phase:  
The EOT visit will be performed 3 weeks after last dose of CTX (Epirubicin-Cyclophosphamide), 
i.e.; week 29 in Arm A and at week 27 in Arm B. 
 
The following procedures will be performed: 
● Physical examination 
● 
Ultrasound (breast, lymph nodes) 
● Clinical assessment 
● Pregnancy test 
● LVEF  
● ECG 
● Laboratory (hematology, biochemistry) 
● Blood sample for translational research 
● Safety assessment & concomitant medication 
Please note that Safety assessment and concomitant medication are checked at every patient 
visit. For details on procedures during the active treatment phase, see SOA table 1. 
 
9.4. Ultrasound assessment 
 
The tumor (marker lesion) is measured in all three dimensions. The two longest diameters must 
be documented. Progressive disease (PD) is defined as ≥ 20% increase of at least 5 mm in the 
sum of the longest diameters of the target lesions compared with the smallest sum of the longest 
diameters recorded. In case of PD, the therapy should be changed or surgery performed at 
discretion of the investigator.  
Response will be evaluated by clinical and ultrasound assessment as SOC throughout the study. 
The tumor needs to be marked with a clip before the first cycle of CTX to be able to reliably identify 
the region of the former tumor at the time of surgery. 
 
9.5. Surgery 
 
Surgery will be performed 3 - 4 weeks after last dose of the neoadjuvant treatment (week 29 - 30 
for Arm A and week 27 - 28 for Arm B). Refer to section 5.3. A surgery sample of the breast 
(paraffin embedded) will be sent to the central pathology for analysis. 
 
 
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 64 of 118 
9.6. Adjuvant therapy and Follow-up visits 
 
• 
All visits will be performed as SOC. During these visits, the following will be assessed: 
physical examination, clinical assessment, ultrasound, (breast, lymph nodes), routine 
blood tests.  
• 
In addition, for childbearing potential women, pregnancy test will be performed every 4 
weeks until 5 months following the last dose of Atezolizumab: 
 
o The investigator will prescribe at the EOT visit of the neoadjuvant therapy phase, a 
monthly pregnancy test for 5 months.  
o The patient will perform the pregnancy test as prescribed and communicate monthly 
the result to the investigational site staff.  
o The investigational site staff will ensure that the information is received monthly and 
will also question the patient on the maintenance of the adequate contraceptive 
measures. The pregnancy test result and the information on the maintenance of the 
adequate contraceptive measures will be documented in the patient records and in the 
CRF. 
 
• 
If patients are receiving follow-up care at their local gynecologist/oncologist, the study 
follow-up visits will be performed by the study site staff by phone (see 5.5).  
Safety assessment, adjuvant therapy and concomitant medication will be assessed at all visits. 
 
 
9.7. End of Study visit 
 
EOS visit will be performed at month 24 (week 104) after randomization or earlier in case of study 
discontinuation. The following procedures  will be performed as SOC: 
• 
Physical examination 
• 
Ultrasound (breast, lymph nodes) 
• 
Clinical assessment 
• 
Safety assessment and concomitant medication 
 
If the end-of-study examination according to SOC take place at the patient's local oncologist/ 
gynecologist after 24 months, the site will contact the patients by phone to document the 
parameter listed under Section 5.5. 
 
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 65 of 118 
9.8. Efficacy assessments: primary, secondary and translational efficacy parameters 
Mapping of endpoints, as defined below, to objectives: 
 
Table 8: Mapping Objectives to Endpoints 
 
Objective 
Endpoints 
Primary 
1. 
a 
Secondary 
1. 
b 
2. 
c 
3. 
d,e,f 
4. 
i , j, k, l, m 
5. 
i , j, k, l, m 
6. 
a 
7. 
n 
8. 
o 
9. 
p 
Translational 
1. 
a, z 
 
2. 
a, r 
 
3. 
a, s 
 
4. 
a, s 
 
5. 
a, t 
 
6. 
a, t 
 
7. 
t, r 
 
8. 
a, r 
 
9. 
a, r 
 
10. 
a, u, v, w, x, y 
 
11. 
a, z 
 
12. 
n, o, i, j, k, l 
 
13. 
a, n, o, g, h, q 
 
 
 
9.8.1. Primary endpoint: Pathological complete response  
 
a) pCR defined as no residual invasive tumor cells in the breast and in the lymph nodes 
(ypT0/is, ypN0) 
 
9.8.2. Secondary Endpoints 
 
b) Safety (incidence, relationship, seriousness, and severity of all AEs, SAEs, adverse events 
of special interest (AESIs) coded by MedDRA, summarized by Preferred Term and System 
Organ Class and graded according to CTCAE 5.0) 
c) pCR defined as no residual invasive tumor cells in the breast and in the lymph nodes 
(ypT0/is, ypN0) in patients with an ER/PR expression of < 1% and an ER/PR expression 
of 1% to 10%. 
d) pCR defined as no tumor cells (invasive or non-invasive) in the breast and in the lymph 
nodes (ypN0, ypT0)    
e) Near pCR defined as residual tumor < 5 mm in the breast irrespective of in-situ and lymph 
nodes status 
f) pCR defined as no invasive tumor in the breast, irrespective of lymph node status 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 66 of 118 
g) Decrease of Ki-67 expression versus baseline after 14/28 days (+/- 2 days) of treatment 
as continuous predictor 
h) TILs after 14/28 days (+/- 2 days) of treatment as continuous predictor 
i) CCCA: Ki-67 expression ≤ 2.7% after 14/28 days (+/- 2 days) of treatment 
j) Low cellularity: < 500 tumor cells after 14/28 days (+/- 2 days) of treatment 
k) Decrease of Ki-67 expression versus baseline by 30% or more after 14/28 days (+/- 2 
days) of treatment  
l) TILs ≥ 60% after 14/28 days (+/- 2 days) of treatment 
m) Combined early response defined by 
o CCCA Ki-67 expression ≤ 2.7% or 
o low cellularity or 
o decrease of Ki-67 expression (versus baseline) by 30% or more or 
o TILs ≥ 60%  
n) DFS1 defined as time from the first date of no disease [i.e. date of surgery] to the first 
occurrence of disease recurrence or death from any cause 
o) OS defined as length of time from randomization to death from any cause 
p) EFS defined as length of time after randomization till death from any cause, failure to 
achieve remission after induction therapy, relapse in any site, or second malignancy 
 
1 DFS is defined as time from surgery to: 
• 
Ipsilateral invasive breast tumor recurrence (i.e., an invasive breast cancer involving the 
same breast parenchyma as the original primary lesion) 
• 
Ipsilateral local-regional invasive breast cancer recurrence (i.e., an invasive breast cancer 
in the axilla, regional lymph nodes, chest wall, and/or skin of the ipsilateral breast) 
• 
Distant recurrence (i.e., evidence of breast cancer in any anatomic site – other than the 
two abovementioned sites – that has either been histologically confirmed or clinically 
diagnosed as recurrent invasive breast cancer) 
• 
contralateral invasive breast cancer  
• 
Ipsilateral or contralateral DCIS  
• 
Second primary non-breast invasive cancer (with the exception of non-melanoma skin 
cancers and in-situ carcinoma of any site) 
• 
Death attributable to any cause including breast cancer, non-breast cancer, or unknown 
cause (but cause of death should be specified if at all possible) 
 
9.8.3. Additional Translational Endpoints 
 
q) CelTIL score as defined by (Nuciforo et al., 2017) 
r) Immune markers (e.g. PD-1/L1) via ctDNA  
s) Intrinsic subtype continuous ER/PR/HER2 expression 
t) Specific DNA panel 
u) Ki-67 expression as a continuous variable after 14 days (+/- 2 days) of treatment with 
Epirubicin and Cyclophosphamide in patients with less than 50% tumor shrinkage after 4 
cycles of Carboplatin/Paclitaxel/Atezolizumab +/- the 2-week Atezolizumab window 
measured by tumor volume (or if not assessable by volume a decrease by 50% in diameter) 
through sonographic assessment 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 67 of 118 
v) TILs as a continuous variable after 14 days (+/- 2 days) of treatment with Epirubicin and 
Cyclophosphamide in patients with less than 50% tumor shrinkage after 4 cycles of 
Carboplatin/Paclitaxel/Atezolizumab +/- the 2-week Atezolizumab window 
w) CCCA: Ki-67 expression ≤ 2.7% after 14 days (+/- 2 days) of treatment with Epirubicin and 
Cyclophosphamide in patients with less than 50% tumor shrinkage after 4 cycles of 
Carboplatin/Paclitaxel/Atezolizumab +/- the 2-week Atezolizumab window 
x) Low cellularity: < 500 tumor cells after 14 days (+/- 2 days) of treatment with Epirubicin and 
Cyclophosphamide in patients with less than 50% tumor shrinkage after 4 cycles of 
Carboplatin/Paclitaxel/Atezolizumab +/- the 2-week Atezolizumab window 
y) CelTIL score as defined by (Nuciforo et al., 2017) after 14 days (+/- 2 days) of treatment 
with Epirubicin and Cyclophosphamide in patients with less than 50% tumor shrinkage after 
4 cycles of Carboplatin/Paclitaxel/Atezolizumab +/- the 2-week Atezolizumab window 
z) Genome-wide gene expression analysis for RNA-based biomarker signature related to 
response/resistance to Atezolizumab 
 
 
9.9. Adverse Events 
 
The definitions of an AE or SAE can be found in Appendix 8. 
AEs will be reported by the participant (or, when appropriate, by a caregiver, surrogate, or the 
participant's legally authorized representative) to the investigator. 
The investigator and any designees are responsible for detecting, documenting, and recording 
events that meet the definition of an AE or SAE and remain responsible for following up all AEs 
and SAEs regardless of the event is serious or considered related to the study treatment or study 
procedures. For all AEs, sufficient information should be obtained by the investigator to determine 
the causality of the AE. 
Subjects must be carefully monitored for AEs. This monitoring includes clinical laboratory tests. 
AEs should be assessed in terms of their seriousness, intensity, and relationship to the study drug 
and reported according to the NCI CTCAE v5.0. 
All AEs have to be recorded in the patient’s medical record and on the AE CRF. Investigators 
should use correct medical terminology/concepts when recording AEs on the AE CRF and avoid 
colloquialisms and abbreviations. Only one AE term should be recorded in the event field on the 
AE CRF. All AE terms will be coded with the most recent MedDRA version by the sponsor. 
As part of ongoing safety reviews conducted by the sponsor, any non-SAE that is determined by 
the sponsor to be serious will be reported by the investigator as an SAE. To assist in the 
determination of event seriousness further information may be requested from the investigator to 
provide clarity and understanding of the event in the context of the clinical study. 
An isolated laboratory abnormality that is assigned grade 4, according to CTCAE v5.0 definition, 
is not reportable as SAE unless the investigator assesses that the event meets standard ICH 
criteria for an SAE. 
The criteria for determining whether an abnormal test finding should be reported as an AE are as 
follows: 
• 
The test result is associated with accompanying symptoms, and/or 
• 
The test result requires additional diagnostic testing or medical/surgical intervention, 
and/or 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 68 of 118 
• 
The test result leads to a change in study drug dosing or discontinuation from the study, 
and/or 
• 
The test result leads to significant additional concomitant drug treatment, or other therapy, 
and/or 
• 
The test result is considered to be an AE by the investigator or sponsor. 
Merely repeating an abnormal test, in the absence of any of the above conditions, does not 
constitute an AE. Any abnormal test result that is determined to be an error does not require 
reporting as an AE. 
If the clinically significant laboratory abnormality is a sign of a disease or syndrome (e.g. ALK and 
bilirubin 5 x the upper limit of normal associated with cholecystitis), only the diagnosis (e.g., 
cholecystitis) needs to be recorded on the AE CRF. 
If the clinically significant laboratory abnormality is not a sign of a disease or syndrome (e.g. ALK 
and bilirubin 5 x ULN associated with cholestasis), the abnormality itself (i.e., cholestasis) should 
be recorded as an AE or SAE on the CRF. 
If the laboratory abnormality can be characterized by a precise clinical term, the clinical term 
should be recorded as the AE or SAE. For example, an elevated serum potassium level of 
5.2 mmol/L should be recorded as “hyperkalemia”. 
AEs occurring secondary to other events (e.g., cascade events or clinical sequelae) should be 
identified by their primary cause, with the exception of severe or serious secondary events. A 
medically significant secondary AE that is separated in time from the initiating event should be 
recorded as an independent event on the AE CRF. For example: 
• 
If diarrhea results in mild dehydration with no additional treatment required, it is sufficient 
to record only diarrhea in the AE CRF. 
• 
If diarrhea results in severe dehydration, both events should be recorded separately on 
the CRF. 
• 
If a severe gastrointestinal hemorrhage leads to a renal failure, both events should be 
recorded separately on the eCRF. 
• 
If dizziness leads to a fall and a consequent fracture, all three events should be recorded 
separately on the eCRF. 
However, medically significant AEs occurring secondary to an initiating event that are separated 
in time should be recorded as independent events on the CRF. For example, if a severe 
gastrointestinal hemorrhage leads to renal failure, both events should be recorded separately on 
the CRF. 
AE without resolution between patient evaluation time points should only be recorded once in the 
eCRF with the highest CTC Grade occurring. A persistent AE is one that extends continuously for 
longer than one sequence of CTX (three month sequence of Carboplatin/Paclitaxel/ Atezolizumab 
or Epirubicin/Cyclophosphamide/Atezolizumab), without resolution between patient evaluation 
time points. Such events should only be recorded once in the eCRF, except if the common 
terminology criteria (CTC) grade changes after start of the next sequence of CTX. In such cases, 
an AE with a certain CTC grade must be completed with end date and outcome as soon as the 
CTC grade changes. Subsequently a new AE with the same event term and the current CTC 
grade should be documented. 
A recurrent AE is one that occurs and resolves between patient evaluation time points and 
subsequently recurs. Each recurrence of an AE should be recorded as a separate event on the 
AE CRF. 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 69 of 118 
9.9.1. Time Period and Frequency for Collecting AE and SAE Information 
 
A preexisting medical condition that is present at the screening visit for this study should be 
recorded on the Medical History CRF.  
A preexisting medical condition should be recorded as an AE only if the frequency, severity or 
character of the condition worsens during the study. When recording such events on the AE CRF, 
it is important to convey the concept that the preexisting condition has changed by including 
applicable descriptors (e.g., “more frequent headaches”). 
After informed consent has been obtained but prior to initiation of study treatment, only 
SAEs caused by a protocol-mandated intervention (e.g., invasive procedures such as biopsies, 
discontinuation of medications) should be reported. 
After initiation of study treatment, non-SAEs will be recorded until 30 days after the last dose 
of study treatment or until initiation of new anti-cancer therapy, whichever occurs first, and SAEs 
and AESIs will continue to be reported until 90 days after the last dose of study treatment or until 
initiation of new anti-cancer therapy. 
All SAEs will be recorded in the AE CRF and reported to the sponsor within 24 hours of first 
awareness, or immediately upon awareness, if the SAE is fatal or life-threatening (i.e., causes an 
immediate risk of death) – regardless of the extend of available information. The above time 
frames also apply to any additional information (i.e., follow-up information) concerning previously 
submitted reports of a SAE. 
Investigators are not obligated to actively seek AEs or SAEs in former study participants. However, 
if the investigator learns of any SAE and AESI, including a death, at any time after a participant 
has been discharged from the study, and he/she considers the event to be reasonably related to 
the study treatment or study participation, the investigator must promptly notify the sponsor. 
The method of recording, evaluating, and assessing causality of AEs, SAEs and AESIs and the 
procedures for completing and transmitting SAE reports are provided in Appendix 8. 
 
9.9.2. Method of Detecting AEs and SAEs 
 
The investigator has to report all directly observed AEs and all spontaneously reported AEs by the 
study patient. In addition, each study patient will be questioned about AEs. 
Care will be taken not to introduce bias when detecting AEs and/or SAEs. Open-ended and non-
leading verbal questioning of the participant is the preferred method to inquire about AE 
occurrences. 
At the last scheduled visit, the investigator should instruct each patient to report to the investigator 
any subsequent AEs that the patient’s personal physician believes to be possibly related to prior 
study treatment. 
 
9.9.3. Follow-up of AEs and SAEs 
 
After the initial AE/SAE report, the investigator is required to proactively follow each participant at 
subsequent visits/contacts. All SAEs will be followed until resolution, stabilization, the event is 
otherwise explained, or the participant is lost to follow-up. Further information on follow-up 
procedures is given in Appendix 8. 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 70 of 118 
9.9.4. Regulatory Reporting Requirements for SAEs 
 
The sponsor will promptly evaluate all SAEs and AESIs against cumulative product experience to 
identify and expeditiously communicate possible new safety findings to regulatory authority, 
Independent Ethics Committees (IEC), Marketing Authorization Holders, and investigators 
according to German regulatory requirements. 
To determine reporting requirements for single AE cases, the sponsor will assess the 
expectedness of these events using the following reference documents: 
● Atezolizumab IB 
● Local prescribing information (“Fachinformation”) for Paclitaxel, Carboplatin, Epirubicin, 
Cyclophosphamide 
Investigator safety reports must be prepared for suspected unexpected serious adverse reactions 
(SUSAR) according to local regulatory requirements and sponsor policy and forwarded to 
investigators as necessary (fatal or life-threatening events within 7 calendar days, all other events 
within 15 calendar days). 
An investigator who receives an investigator safety report describing a SAE or other specific safety 
information (e.g., summary or listing of SAEs) from the sponsor will review and then file it along 
with the IB or prescribing information/"Fachinformation" and will notify the IEC, if appropriate 
according to local requirements. 
 
9.9.5. Reporting of SAEs 
 
All SAEs, whether or not deemed drug-related or expected, must be reported by the investigator. 
Reporting has to be performed within 24 hours of first becoming aware of the event or immediately 
upon awareness if the SAE is fatal or life-threatening by means of EDC (RAVE). 
In case the EDC is not available for the Investigator, the study-specific paper-based SAE 
Reporting Form has to be sent to the following address by fax or email: 
 
palleos healthcare GmbH 
Taunusstraße 5a 
65183 Wiesbaden 
Tel: +49 (0)611 950190 19 
Fax: +49 (0)611 950190 29 
Email: SAE@palleos.com 
The sponsor will forward each SAE Report to the Drug Safety Department of Roche Pharma AG, 
Germany. 
It is important that information regarding an SAE be reported within the established timelines. If a 
report is delayed, the reason for the delay should be clearly explained. 
Examples of reasons for delay: 
● Information missed due to clerical issues at the site 
● Correction of previously transmitted information 
 
There are no non-reportable protocol-specified SAEs in this study. All SAEs will be reported by 
the investigator as described above and will be managed accordingly in the safety database. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 71 of 118 
9.9.6. Reporting of AESIs 
 
Certain types of adverse events (Adverse Events of Special Interest), as identified below, are 
reportable to the sponsor under the reporting processes and requirements for SAEs, even if they 
are not classified as serious. Like a SAE, an AESI has to be reported within 24 hours of awareness 
electronically in the EDC or, if the EDC is not available, on a SAE Reporting Form and followed 
up to determine outcome. 
● Cases of potential drug-induced liver injury (DILI) that include an elevated ALT or AST in 
combination with either an elevated bilirubin or clinical jaundice, as defined by Hy’s Law 
and based on the following observations: 
o Treatment-emergent ALT or AST > 3 x baseline value in combination with total 
bilirubin > 2 x ULN (of which ≥ 35% is direct bilirubin) 
o Treatment-emergent ALT or AST > 3 x baseline value in combination with clinical 
jaundice 
● Suspected Transmission of Infectious Agents via a Medicinal Product, as defined below:  
o Any organism, virus, or infectious particle (e.g., prion protein-transmitting 
transmissible spongiform encephalopathy), pathogenic or non-pathogenic, is 
considered an infectious agent. A transmission of an infectious agent may be 
suspected from clinical symptoms or laboratory findings that indicate an infection 
in a patient exposed to a medicinal product. This term applies only when a 
contamination of study treatment is suspected. 
 
● AESIs suggestive of potential immune-related aetiology: 
o Immune-related Pneumonitis 
o Immune-related Colitis 
o Immune-related Hepatitis, including AST or ALT > 10 x ULN 
o Immune-related Endocrinopathies: hypothyroidism, hyperthyroidism, adrenal 
insufficiency, hypophysistis, pancreatitis, type-1-diabetes mellitus) 
o Systemic lupus erythematosus 
o Immune-related Neurological disorders: Guillain-Barré syndrome, myasthenic 
syndrome/myasthenia gravis, meningoencephalitis 
o Events suggestive of hypersensitivity, infusion-related reaction, cytokine release 
syndrome, influenza-like illness, systemic inflammatory response syndrome, 
systemic immune activation, macrophage activating syndrome, hemophagocytic 
lymphohistiocytosis 
o Immune-related Nephritis 
o Immune-related Occular toxicities (e.g., uveitis, retinitis) 
o Immune-related Myositis 
o Myopathies, including rhabdomyolysis 
o Grade ≥ 2 cardiac disorders (e.g., atrial fibrillation, myocarditis, pericarditis) 
o Immune-related Myocarditis 
o Immune-related Vasculitis 
o Autoimmune hemolytic anemia 
o Severe cutaneous reactions (e.g., Stevens-Johnson syndrome, dermatitis 
bullous, toxic epidermal necrolysis) 
 
Atezolizumab is associated with immune-related adverse reactions and there should always be a 
high level of suspicion that new symptoms are immune-mediated and related to treatment with 
Atezolizumab.  
If an AE is suspected to be immune-related, thorough examination is necessary to confirm 
aetiology or to exclude other causes. The events listed above represent the currently identified 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 72 of 118 
risks during treatment with Atezolizumab. Other AEs suggestive of potential immune-related 
aetiology grade ≥ 2 should be managed and reported in the same way. 
 
9.9.7. Reporting of Special Situations 
 
Certain events, as identified below, are reportable to the sponsor under the reporting processes 
and requirements for SAEs, even if they are not directly related to an AE. Like a SAE, such a 
special situation is to be reported within 24 hours of awareness electronically in the EDC or, if the 
EDC is not available, on a SAE Reporting Form and followed up to determine outcome. 
● Overdose: This refers to the accidental or intentional administration of a quantity of an 
investigational medicinal product given per administration or cumulatively, which is above 
the maximum recommended dose according to the dose being studied per protocol. 
 
● Misuse: This refers to situations where the investigational medicinal product is intentionally 
and inappropriately used by the patient in a manner that is not in accordance to the 
protocol. 
 
● Abuse: This corresponds to the persistent or sporadic, intentional excessive use of the 
self-administered studied investigational medicinal product, which is accompanied by 
harmful physical or psychological effects. 
 
● Medication Error: A medication error is an unintended deviation from the protocol, in the 
drug treatment process that leads to, or has the potential to lead to, harm to the patient. 
This would include medication errors (potential or confirmed) that were intercepted prior to 
the administration of the investigational medicinal product to the patient. 
 
● Occupational exposure: This refers to an event that occurs when during performance of 
job duties, a person (whether a healthcare professional or otherwise) gets in unplanned 
direct contact with the product. 
 
● Breastfeeding: This refers to a situation in which infants following exposure to a medicinal 
product from breast milk. 
 
Reports of special situations may or may not include information about clinical consequences 
(i.e., AEs) that have to be recorded in the AE CRF 
 
 
9.9.8. Reporting of Death Events 
 
Deaths that occur during the protocol-specified AE reporting period will be recorded on a Death 
Report Form (DRF) in the EDC and in parallel expeditiously reported to the sponsor as a SAE 
Report. An independent DSMB will monitor the frequency of deaths from all causes. 
When recording a death in the EDC, the event or condition that caused or contributed to the fatal 
outcome should be recorded as the single medical concept in the EDC. If the cause of death is 
unknown and cannot be ascertained at the time of reporting, record “Unexplained Death” on the 
DRF in the EDC. 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 73 of 118 
9.9.9. Pregnancy 
 
Pregnancy testing will be performed in premenopausal patients monthly during Atezolizumab 
treatment and until 5 months following the last dose of Atezolizumab. 
Pregnancies and suspected pregnancies (including a positive pregnancy test regardless of age or 
disease state) of a female subject or the female partner of a male patient occurring while the 
subject is treated with study drug, or within 5 months of the subject’s last dose of study drug, are 
considered reportable events. The pregnancy, suspected pregnancy, or positive pregnancy test 
shall be reported by the investigator to the sponsor on the paper-based Pregnancy Reporting 
Form to the following address within 24 hours:  
palleos healthcare GmbH 
Taunusstraße 5a 
65183 Wiesbaden 
Germany 
Tel: +49 (0)611 950190 19 
Fax: +49 (0)611 950190 29 
Email: SAE@palleos.com 
The sponsor will forward each Pregnancy Reporting Form to the Drug Safety Department of Roche 
Pharma AG, Germany. 
 
The female subject may be referred to an obstetrician-gynecologist (not necessarily one with 
reproductive toxicity experience) or another appropriate healthcare professional for further 
evaluation. 
The investigator will follow the female subject until completion of the pregnancy and must notify 
the sponsor immediately about the outcome of the pregnancy (either normal or abnormal 
outcome).  
Any abortion should be classified as SAE (as the sponsor considers abortions to be medically 
significant), recorded on the AE CRF and reported to the sponsor immediately on SAE Reporting 
Form (according to section 9.9.5). 
Any congenital anomaly/birth defect in a child born to a female patient or a female partner of a 
male study patient exposed to study treatment should be classified as SAE, recorded on the AE 
CRF and reported to the sponsor immediately on SAE Reporting Form (according to section 
9.9.5). 
Attempts should be made to collect and report infant health information. If the Authorization for 
the Use and Disclosure of Infant Health Information had been signed by both parents who have 
custody, the infant's health status at birth should be recorded on the Clinical Trial Pregnancy 
Reporting Form. In addition, the Sponsor may collect follow-up information on the infant's health 
status at 6 and 12 months after birth. 
 
9.9.10. Annual Safety Report 
 
The sponsor will prepare an annual safety report in form of a Development Safety Update Report 
(DSUR) and submit the report to the Competent Authorities and Ethics Committee. A copy of the 
DSUR is shared with Roche after completion. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 74 of 118 
9.9.11. Safety monitoring 
9.9.11.1. DSMB 
This study will use a DSMB whose members are therapeutic area experts and a statistician who 
are not employed by the sponsor of the study and have no material conflict of interest. 
Overall safety will be assessed on an ongoing basis during the conduct of the study. The DSMB 
will also review the findings from the protocol defined interim analyses. The DSMB will monitor 
cumulative safety data at least once every 6 months during the course of the study. At the interim 
analyses, both efficacy and safety will be reviewed and recommendations will be based on the 
totality of data.  
In particular, the DSMB will convene as soon as results for an interim efficacy analysis are 
available. Interim analysis reports prepared by the sponsor statistician will communicate data, 
decisions and consequences pertaining to the continuation of the ongoing trial according to the 
adaptive design with its decision rules for early stopping (see section 5.4), so that the DSMB may 
provide an independent review of trial design execution by the sponsor. 
Safety monitoring will include protocol-defined AEs, SAEs and AESIs. 
The DSMB can recommend changes to the study including study termination, if concern arises 
over the benefit risk profile of Atezolizumab and its combination therapy. 
The DSMB related tasks and responsibilities will be defined in the DSMB charter. 
 
9.9.11.2. Cardiac safety monitoring 
Atezolizumab, Paclitaxel, Epirubicin and Cyclophosphamide and Carboplatin have rare reports of 
cardiovascular incidents (see SmPCs and current version of Atezolizumab IB).  
Cardiac safety evaluation will include evaluation of cardiac AEs, measurement of LVEF by 
echocardiography and ECG as noted in the SOA table (section 2 table 1). Cardiac assessments 
should be performed according to the current clinical guidelines. It is the responsibility of the 
investigator to ensure that adequate resources and technical equipment for performance of 
echocardiography and ECG are available.  
These examinations should be performed according to current clinical guidelines. A consultation 
by a cardiologist should be considered in case of a clinically relevant pathologic finding (as 
assessed by the investigator). The decision whether to continue or hold the treatment with TN-
targeted agents has to be made as a result of the values of LVEF following the algorithm below. 
Table 9: Cardiovascular safety monitoring 
Cardiovascular Toxicity Occurrence 
Actions 
 
Cardiovascular Toxicity 
(e.g. arrhythmias, CHF or 
LVEF grade ≥ 3)  
grade ≥ 3 
First 
Discontinue study treatment; 
Manage the cardiac condition; 
Patients under E/C/Atezolizumab regime 
may continue with 
Carboplatin/Paclitaxel/Atezolizumab when 
recovered to grade ≤ 1 
Second 
Permanently discontinue all study treatment 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 75 of 118 
9.10. Safety assessments 
 
Planned time points for all safety assessments are provided in the SOA.  
 
9.10.1. Physical examination 
● A complete physical examination will include at a minimum, assessments of the 
cardiovascular, respiratory, gastrointestinal, skin, breast, lymph nodes and neurological 
systems. Height and weight will also be measured and recorded. Investigators should pay 
special attention to clinical signs related to previous serious illnesses. 
● Baseline cancer related signs and symptoms will be recorded at the cycle 1 cay 1 visit and 
then reported as AEs during the trial if they worsen in severity or increase in frequency. 
 
9.10.2. Vital signs and ECOG performance test 
● Vital signs (to be taken before blood collection for laboratory tests) will consist of pulse and 
blood pressure. 
● Performance Status: The ECOG performance status scale or KI will be used (see Appendix 
6). 
 
9.10.3. Electrocardiogram 
● 12-lead ECG will be obtained as outlined in the SOA (see table 1) using an ECG machine 
with a 10-second rhythm strip. ECG measurements will include PQ interval, QT interval, 
RR interval, and QRS complex. It is preferable that the machine used has a capacity to 
calculate the standard intervals automatically. 
● At each time point at which triplicate ECG are required, 3 individual ECG tracings should 
be obtained as closely as possible in succession, but no more than 2 min apart to 
determine the mean QTc interval.  
● ECG interval readings by the ECG recorder’s algorithm will be read and interpreted at the 
investigational site for eligibility determination and patient safety monitoring and 
documentation stored in the source documents. 
● Additional ECGs may be performed as clinically indicated at any time. 
 
9.10.4. Clinical safety laboratory assessments 
● See Appendix 2 for the list of clinical laboratory tests to be performed and to the SOA for 
the timing and frequency.  
● The investigator must review the laboratory report, document this review, and record any 
clinically relevant changes occurring during the study in the AE section of the CRF. The 
laboratory reports must be filed with the source documents. Clinically significant abnormal 
laboratory findings are those which are not associated with the underlying disease, unless 
judged by the investigator to be more severe than expected for the participant's condition. 
● All laboratory tests with values considered clinically significantly abnormal during 
participation in the study or within 30 days after the last dose of study treatment should be 
repeated until the values return to normal or baseline or are no longer considered clinically 
significant by the investigator or Medical Monitor. 
● If such values do not return to normal/baseline within a period of time judged reasonable 
by the investigator, the etiology should be identified, and the sponsor notified. 
● All protocol-required laboratory assessments, as defined in Appendix 2, must be 
conducted in accordance with the SOA.  

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 76 of 118 
 
If laboratory values from non-protocol specified laboratory assessments performed at the 
institution’s local laboratory require a change in participant management or are considered 
clinically significant by the investigator (e.g., SAE or AE or dose modification), then the results 
must be recorded in the CRF. 
 
9.11. Markers for translational research 
 
Translational analyses are planned especially regarding biomarkers of early prediction of 
resistance and response to immune therapies. It is expected that the landscape regarding 
biomarkers identifying resistance and response to immune therapies will change dramatically in 
the next two years. The definition of translational analyses of interest will take these future findings 
into account and cannot be presented at the time of submission of the protocol. 
A detailed description of blood sampling is given in Appendix 3. 
 
9.12. Protocol violations 
 
Protocol Violations (PVs) can be detected in several different ways, e.g.: 
● Detection of PVs by Data Management by applying edit checks to the data base 
● Investigator proactively notifies sponsor personnel (clinical monitors, project manager) of 
PVs which have occurred at his investigational site 
● PVs are detected during remote or on-site monitoring visits by clinical monitors 
● PVs are detected during audits or regulatory inspections. 
All PVs will be categorized as follows: source data; ICF, inclusion and exclusion criteria, 
randomization, primary endpoints, therapeutic scheme, SAE reporting, and others as planned by 
the study team. PVs are then analyzed by the Medical Monitor (MM). 
Subsequently, the Medical Monitor will grade the PVs either in serious or non-serious breaches of 
the trial protocol and decides whether the patient can remain in the trial despite the PV or not. 
The PVs will be acknowledged at each study site by the investigator. Sites will be trained again 
on the study procedures as required to avoid recurrence of PVs. 
If applicable, PVs assessed as serious breaches of the trial protocol have to be notified to the ethic 
committees (ECs) (leading EC and concerned local EC) and the regulatory authorities. All PVs 
will be regularly analyzed and require appropriate corrective and preventive action (CAPA) which 
will be overseen by the palleos healthcare GmbH study team. 
10. Statistical considerations  
 
Detailed methodology for summary and statistical analyses of the data collected in this study will 
be documented in a Statistical Analysis Plan (SAP), which will be dated and maintained by the 
sponsor. This document may modify the plans outlined in the protocol; however, any major 
modifications will also be reflected in a protocol amendment. 
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 77 of 118 
10.1. Rationale and sample size determination 
 
The neoMono statistical design adapts the idea of a proof-of-concept trial and uses Bayesian 
posterior and predictive probabilities for inference about the primary hypothesis. Up to 4 planned 
efficacy interim analyses provide decision points for early stopping for success or futility. A detailed 
explanation of statistical methods and the design with literature sources is provided in Appendix 9. 
The primary objective is to show superiority of experimental Arm A vs. control Arm B in terms of 
pCR to neoadjuvant treatment. 
The primary analysis is based on non-informative uniform (beta) priors for the pCR rates 𝑝𝐴and 
𝑝𝐵 in Arms A (experimental) and B (control) respectively. As in a proof-of-concept trial, a dual 
criterion is used to simultaneously test for significant and relevant superiority at different levels of 
certainty by requiring posterior probabilities, conditional on observed response counts 𝑥𝐴,  𝑥𝐵∈𝑁0  
respectively in the two arms, to exceed the following thresholds: 
𝑃(𝑝𝐴> 𝑝𝐵 | 𝑥𝐴,  𝑥𝐵) ≥0.975      ⋀      𝑃(𝑝𝐴−𝑝𝐵> 𝛿 | 𝑥𝐴,  𝑥𝐵) ≥0.85, 
significance                                     relevance 
with a clinically meaningful difference of 𝛿= 0.05 (see Appendix 9 for a rationale). 
The trial is planned to have a maximal sample size of  𝑁𝑚𝑎𝑥= 370 evaluable patients, with up 
to 4 planned interim analyses in order to assess early futility or success of the trial based on 
posterior predictive probabilities 𝑃 for trial success. That is, the probability of claiming superiority 
in terms of the dual criterion if the trial were to continue to the maximal sample size 𝑁𝑚𝑎𝑥, 
conditional on the responses observed in the trial so far (see statistical Appendix 9 for 
mathematical details).  
During the trial, up to 4 interim analyses are to be performed after 100, 140, 180 and 220 
patients evaluable for the primary endpoint in an ITT collective. Interim analysis results will 
be presented to the DSMB for independent review. The following decision rules will be 
implemented at each interim analysis point: 
● If 𝑃𝑃< 0.025 the trial is stopped early for futility 
● If 𝑃𝑃>  0.975 the trial is stopped early for success 
Interim analyses will be carried out and reported by the sponsor statistician. Based on these 
reports, the sponsor will carry out decisions regarding the continuation of recruitment according to 
the decision rules above. At each interim analysis timepoint, the DSMB will provide an 
independent review of interim efficacy results and trial design execution. 
The maximal sample size 𝑁𝑚𝑎𝑥 was determined by Monte Carlo simulation of the full adaptive trial 
with the parameters above using 108 repetitions and calculating the global operating 
characteristics (power and type I error) in different scenarios of interest. Multiple testing is implicitly 
accounted for by the simulation. 
𝑁𝑚𝑎𝑥= 370 is the smallest maximal sample size for the trial to reach at least 80% power with the 
given interim analysis time points to rightly claim superiority in the scenario 𝑝𝐴=  60%, 𝑝𝐵= 45% 
and at most a 2.5% type I error rate to wrongly claim superiority in the scenario 𝑝𝐴= 45%, 𝑝𝐵=
45%. (see tables below; see statistical appendix for further details and a justification of pCR 
assumptions).  
We assume an analysis dropout rate of 10% for the primary objective, where an analysis dropout 
is defined as any patient for whom a critical analysis-enabling covariate or the primary endpoint is 
not measurable for any reason, thus requiring 412 patients to be randomized (206 per arm with 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 78 of 118 
1:1 randomization). In addition, we account for a 10% screening failure rate. As a result, the 
expected number of patients to be recruited is set to 458. 
 
 
Scenario 
Operating  
Characteristics 
P(correct 
early stop) 
𝔼[sample 
size] 
H0 significance: 
 𝑝𝐴= 45%,   𝑝𝐵= 45% 
type 1 error: 2.4% 
68.5 % 
296 
H0 relevance: 
 𝑝𝐴= 49%,   𝑝𝐵= 45% 
type 1 error: 10.9% 
46.3% 
321 
H1: 𝑝𝐴= 60%,  𝑝𝐵= 45% 
power: 80.1% 
34.9% 
332 
 
(Expected sample sizes refer to the number of recruited patients at the time of analysis and are 
based on assumptions of average recruitment rates explained in Appendix 9.) 
See Appendix 9 for additional visualization of early stopping probabilities in different effect 
scenarios. 
 
 
10.2. Analysis populations 
 
Population 
Description 
ITT (intent-to-treat) 
Full population containing all participants allocated to one of the two 
treatment arms. 
PP (per protocol) 
Population subset including only participants that are compliant with 
the protocol in terms of eligibility, interventions, and treatment plan as 
well as outcome assessment. This population will be used for 
sensitivity analyses of the primary endpoint. 
AT (as treated, safety) 
All participants randomly assigned to study treatment and who 
received at least one dose of study treatment. Participants will be 
analyzed according to the treatment they actually received. 
 
10.3. Statistical analyses 
The statistical analysis plan will be developed and finalized before first-patient-in. It will describe 
the participant populations and provide the mathematical details of all statistical methods and 
analyses, as well as additional literature references. This section provides a brief summary of the 
planned statistical analyses of primary and secondary endpoints. For details on the objectives and 
endpoints, see sections 4 and 9.8.  
All efficacy analyses will be based on the intention-to-treat (ITT population. A sensitivity analysis 
on the per-protocol population will be carried out for the primary endpoint. 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 79 of 118 
10.3.1. Analysis of primary endpoint  
The primary endpoint is pCR. The associated estimators are pCR proportions in both arms and 
their risk difference. 
The primary analysis is based on the joint posterior distribution of pCR prevalence in experimental 
and control arm, relative to an uninformative uniform prior distribution (see appendix 9 for details). 
Based on the posterior distribution, the two events of relevant and significant superiority of the 
experimental arm (risk difference) are simultaneously evaluated to yield a hypothesis test in terms 
of the dual criterion described in section 10.1.  
If both probability thresholds specified by the dual criterion are exceeded simultaneously, 
superiority of the experimental arm is accepted. During interim analyses, superiority may be 
accepted based on thresholds specified for the predictive probability distribution of the dual 
criterion event (see section 10.1). In any case, marginal posterior distributions of pCR rates in 
both arms, as well as the posterior distribution of the risk difference will be reported, including 
corresponding expected value and 95% high posterior density interval (see also Appendix 9). 
 
10.3.2. Analysis of secondary endpoints 
Secondary endpoints include additional pCR definitions, biomarkers as continuous endpoints, 
biomarkers as thresholded binary response parameters, and survival outcomes. 
Hypothesis testing for comparing efficacy endpoints across treatment arms is omitted in favor of 
reporting comparative estimators such as risk difference, odds ratios or hazard ratios with 
associated interval estimates. No further multiplicity adjustments are planned for secondary 
analyses, except in situations where joint prior distributions may be specified to that effect in 
Bayesian models. 
In the following, we state fully Bayesian analyses whenever a non-informative prior distribution 
can be defined unambiguously for the estimand of interest (in which case the analyses should 
agree with maximum-likelihood based inference, see e.g. [6]). Otherwise, the primary reported 
inference will be based on maximum-likelihood methods for a common probability model. 
Additional supportive analyses using Bayesian inference with vague prior distributions for the 
same probability model may be specified in the SAP. 
 
10.3.2.1. Biomarkers and response endpoints 
 
Binary efficacy endpoints and thresholded biomarker endpoints (secondary objectives 2 – 5) will 
be analyzed in terms of their proportions in the respective treatment arms, analogous to section 
10.3.2. As described in Appendix 9, we report posterior distributions for the risk difference 
(difference between proportions of responders), from which expected values are derived as point 
estimators, together with 95% high posterior density intervals (see e.g. (Gelman et al., 2013)). In 
addition, marginal posterior distributions for individual proportions will be reported.  
Prognostic and predictive quality of biomarkers (secondary objective 6) will be evaluated by 
logistic regression on pCR. We report inference for univariate models (with and without treatment 
interaction terms) and multivariate models, including a selection of additional baseline parameters 
to be specified in the SAP, as well as subset selection procedures (e.g. LASSO, see (Tibshirani, 
1996)) together with measures of robustness such as bootstrap inclusion frequencies of selected 
predictors (see (Royston & Sauerbrei, 2008)). A supportive Bayesian analysis may be carried out 
by employing t-family joint prior distributions for regression coefficients (see (Gelman et al., 2013), 
chp. 14). 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 80 of 118 
10.3.2.2. Survival analysis 
 
For the analysis of survival endpoints (secondary objectives 7 - 9) a semi-parametric constant 
hazard model is employed (see (Ibrahim et al., 2014) and (Klein & Moeschberger, 2010) 
respectively). The model is extended to account for proportional hazards between the two 
treatment arms in a Cox regression with treatment arm and additional predictors (baseline 
characteristics and biomarkers) as covariates. Time-varying regression coefficients may be 
employed to investigate deviations from the proportional hazard assumption. 
Maximum likelihood point estimates for the survival functions (Kaplan-Meier method), the hazard 
ratios (Cox regression model), as well as median and n-year survival probabilities will be reported 
with (point-wise) 95% confidence intervals (see (Klein & Moeschberger, 2010)). Further details 
and additional supportive analyses will be specified in the SAP. 
 
10.3.3. Safety analyses 
 
The AT population will be the primary population for safety evaluation, comprising all patients who 
received at least one dose of study medication. Summaries of AEs and other safety parameters 
will be provided as appropriate. 
AEs will be classified using the MedDRA classification system. The severity of the AEs will be 
graded according to the NCI CTCAE v5.0 whenever possible. AEs will be summarized by 
treatment and by the frequency of patients experiencing treatment emergent AEs corresponding 
to MedDRA system organ class preferred terms.  
AEs will be summarized by cycle and by relatedness to trial treatment. Detailed information 
collected for each AE will include a description of the event, duration, whether the AE was serious, 
intensity, relationship to study drug, action taken, and clinical outcome. Emphasis in the analysis 
will be placed on AEs classified as treatment emergent. 
AEs leading to death or discontinuation of trial treatment, events classified as NCI CTCAE v5.0 
Grade 3 or higher, trial drug-related events, and SAEs will be considered with special attention. 
 
10.3.4. Other analyses 
 
Analyses of translational objectives will be described in the revised statistical analysis plan before 
final database lock and will be presented separately from the main clinical study report. 
 
10.3.5. Interim analyses 
 
During the trial, up to 4 interim analyses are to be performed after 100, 140, 180 and 220 patients 
evaluable for the primary endpoint in an ITT collective. Interim analysis results and any decisions 
for early stopping will be presented to the DSMB for independent review. Analyses of pCR rates 
are based on posterior predictive probabilities 𝑃𝑃 for trial success. That is, the probability of 
claiming superiority in terms of the dual criterion if the trial were to continue to the maximal sample 
size 𝑁𝑚𝑎𝑥, conditional on the responses observed in the trial so far (see statistical Appendix 9 for 
full mathematical details). 
The following decision rules will be implemented at each interim analysis point: 
● If 𝑃𝑃< 0.025 the trial is stopped early for futility 
● If 𝑃𝑃>  0.975 the trial is stopped early for success 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 81 of 118 
See Appendix 9 for additional visualization of early stopping probabilities in different effect 
scenarios. Note that recruitment will be ongoing continuously without interruption. Interim analyses 
are to be performed only as long as recruitment is not stopped or completed at 𝑁𝑚𝑎𝑥. Performing 
less than 4 interim analyses will not negatively impact the operating characteristics, see SAP and 
statistical Appendix 9 for further details. 
 
 
10.4. Missing values 
 
The sponsor will make every effort to prevent the occurrence of missing values, in particular for 
primary and secondary efficacy endpoints or analysis-enabling covariates, as well as treatment 
documentation. Reasons for missingness will be documented and queried whenever feasible. All 
efforts will be made to continue collection of auxiliary variables, in particular those that may relate 
to reasons of missingness, as well as efficacy outcomes for patients with missing primary 
parameters or in cases of treatment discontinuation, unless informed consent is withdrawn. 
If missing values occur, robust statistical inference will be guided by the following sources: 
● CHMP. 
"EMA 
Guideline 
on 
Missing 
Data 
in 
Confirmatory 
Clinical 
Trials 
(EMA/CPMP/EWP/1776/99)." (2010). 
● National Research Council. (2010). The Prevention and Treatment of Missing Data in 
Clinical Trials. Panel on Handling Missing Data in Clinical Trials. Committee on National 
Statistics, Division of Behavioral and Social Sciences and Education. Washington, DC: 
The National Academies Press. 
● Molenberghs, G., Fitzmaurice, G., Kenward, M. G., Tsiatis, A., & Verbeke, G. (Eds.). 
(2014). Handbook of missing data methodology. CRC Press. 
A descriptive analysis of the number and proportion, timing, pattern, and reasons for missing 
values will be provided. An emphasis will be placed on displaying differences between treatment 
groups. Reasons for missingness will be investigated to check for potential bias and for validity of 
assumptions regarding the putative missing data mechanism. 
Inference for the primary objective will address missing values by employing a full data model, 
including a missing data mechanism (see Molenberghs et al. (2014), chp. 5.4). The missing data 
distribution part of the model will feature a sensitivity parameter that indexes the missing data 
mechanism (see also Molenberghs et al. (2014), chp. 18). For the primary analysis, the sensitivity 
parameter will be centered at Missing At Random (MAR) assuming (Bayesian) ignorability of 
missing data, which will result in Bayesian proper imputation for inference. 
Further sensitivity analyses may be carried out by centering the sensitivity parameter at different 
plausible Not Missing At Random scenarios (NMAR), in addition to performing a responder 
analysis. Further details will be provided in the SAP. 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 82 of 118 
11. References 
Alme, A. K., Karir, B. S., Faltas, B. M., & Drake, C. G. (2016). Blocking immune checkpoints in prostate, 
kidney, and urothelial cancer: An overview. Urologic Oncology: Seminars and Original 
Investigations, 34, 171–181. 
Bauer, K. R., Brown, M., Cress, R. D., Parise, C. A., & Caggiano, V. (2007). Descriptive analysis of 
estrogen receptor (ER)‐negative, progesterone receptor (PR)‐negative, and HER2‐negative 
invasive breast cancer, the so‐called triple‐negative phenotype. Cancer, 109(9), 1721–1728. 
Cortazar, P., Zhang, L., Untch, M., Mehta, K., Costantino, J. P., Wolmark, N., Bonnefoi, H., Cameron, D., 
Gianni, L., & Valagussa, P. (2014). Pathological complete response and long-term clinical benefit 
in breast cancer: The CTNeoBC pooled analysis. The Lancet, 384(9938), 164–172. 
Crittenden, M., Kohrt, H., Levy, R., Jones, J., Camphausen, K., Dicker, A., Demaria, S., & Formenti, S. 
(2015). Current clinical trials testing combinations of immunotherapy and radiation. Seminars in 
radiation oncology, 25, 54–64. 
Dent, R., Trudeau, M., Pritchard, K. I., Hanna, W. M., Kahn, H. K., Sawka, C. A., Lickley, L. A., Rawlinson, 
E., Sun, P., & Narod, S. A. (2007). Triple-negative breast cancer: Clinical features and patterns of 
recurrence. Clinical cancer research, 13(15), 4429–4434. 
Deyarmin, B., Kane, J. L., Valente, A. L., van Laar, R., Gallagher, C., Shriver, C. D., & Ellsworth, R. E. 
(2013). Effect of ASCO/CAP guidelines for determining ER status on molecular subtype. Annals of 
Surgical Oncology, 20(1), 87–93. https://doi.org/10.1245/s10434-012-2588-8 
Ditsch, N., Untch, M., Thill, M., Müller, V., Janni, W., Albert, U.-S., Bauerfeind, I., Blohmer, J., Budach, W., 
Dall, P., Diel, I., Fasching, P. A., Fehm, T., Friedrich, M., Gerber, B., Hanf, V., Harbeck, N., 
Huober, J., Jackisch, C., … Wöckel, A. (2019). AGO Recommendations for the Diagnosis and 
Treatment of Patients with Early Breast Cancer: Update 2019. Breast Care (Basel, Switzerland), 
14(4), 224–245. PubMed. https://doi.org/10.1159/000501000 
Dixon, J. M., Cameron, D. A., Arthur, L. M., Axelrod, D. M., Renshaw, L., Thomas, J. S., Turnbull, A., 
Young, O., Loman, C. A., Jakubowski, D., Baehner, F. L., & Singh, B. (2019). Accurate Estrogen 
Receptor Quantification in Patients with Negative and Low-Positive Estrogen-Receptor-
Expressing Breast Tumors: Sub-Analyses of Data from Two Clinical Studies. Advances in 
Therapy, 36(4), 828–841. https://doi.org/10.1007/s12325-019-0896-0 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 83 of 118 
Dowsett, M., Smith, I. E., Ebbs, S. R., Dixon, J. M., Skene, A., Griffith, C., Boeddinghaus, I., Salter, J., 
Detre, S., & Hills, M. (2005). Short-term changes in Ki-67 during neoadjuvant treatment of primary 
breast cancer with anastrozole or tamoxifen alone or combined correlate with recurrence-free 
survival. Clinical Cancer Research, 11(2), 951s–958s. 
Dowsett, M., Smith, I., Robertson, J., Robison, L., Pinhel, I., Johnson, L., Salter, J., Dunbier, A., Anderson, 
H., & Ghazoui, Z. (2011). Endocrine therapy, new biologicals, and new study designs for 
presurgical studies in breast cancer. Journal of the National Cancer Institute Monographs, 
2011(43), 120–123. 
Foldi, J., Silber, A., Reisenbichler, E., Singh, K., Fischbach, N., Persicom J., Adelson, K., Katoch, A., 
Horowitz, N., Lannin, D., Chagpar, A., Park, T., Marczyk, M., Frederick, C., Burrello, T., Ibrahim, 
E., Qing, T., Bai, Y., Blenman, K., Rimm, D.L., Pusztai, L. (2021). Neoadjuvant durvalumab plus 
weekly nab-paclitaxel and dose-dense doxorubicin/cyclophosphamide in triple-negative breast 
cancer. NPJ Breast Cancer 7(1):9 
 
Gelman, A., Stern, H. S., Carlin, J. B., Dunson, D. B., Vehtari, A., & Rubin, D. B. (2013). Bayesian data 
analysis. Chapman and Hall/CRC. 
Gianni, L., Huang, C.-S., Egle, D., Bermejo, B., Zamagni, C., & Thill, M. (2019, Dezember 12). Combining 
Atezolizumab with Neoadjuvant Chemotherapy Does Not Improve Pathologic Complete Response 
Rates for Patients with Triple-Negative Breast Cance. SABCS 2019, Marc. 
https://www.sabcs.org/sabcs/2019/pressreleases/2_6Gtsra67gcb4_Atezolizumab%20with%20Ne
oadjuvant%20Chemo%20Does%20Not%20Improve%20pCR%20Rates%20for%20Patients%20wi
th%20TNBC.pdf 
Gluz, O., Liedtke, C., Gottschalk, N., Pusztai, L., Nitz, U., & Harbeck, N. (2009). Triple-negative breast 
cancer—Current status and future directions. Annals of Oncology, 20(12), 1913–1927. 
Gluz, Oleg, Kolberg‐Liedtke, C., Prat, A., Christgen, M., Gebauer, D., Kates, R., Paré, L., Grischke, E.-M., 
Forstbauer, H., & Braun, M. (2019). Efficacy of de‐escalated chemotherapy according to PAM50 
subtypes, immune and proliferation genes in triple‐negative early breast cancer: Primary 
translational analysis of the WSG‐ADAPT‐TN trial. International journal of cancer. 
Gluz, Oleg, Nitz, U., Christgen, M., Grischke, E.-M., Forstbauer, H., Braun, M. W., Warm, M., Uleer, C., 
Aktas, B., & Schumacher, C. (2015). Efficacy of 12 weeks neoadjuvant Nab-Paclitaxel combined 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 84 of 118 
with Carboplatinum vs. Gemcitabine in triple-negative breast cancer: WSG-ADAPT TN 
randomized phase II trial. American Society of Clinical Oncology. 
Huober, J., Barrios, C.H., Niikura, N., Jarząb, M., Chang, Y.C., Huggins-Puhalla, S.L., Pedrini, J., 
Zhukova, L., Graupner, V., Eiger, D., Henschel, V., Gochitashvili, N., Lambertini, C., Restuccia, 
E., Zhang, H.; IMpassion050 Trial Investigators. (2022). Atezolizumab With Neoadjuvant Anti- 
Human Epidermal Growth Factor Receptor 2 Therapy and Chemotherapy in Human Epidermal 
Growth Factor Receptor 2-Positive Early Breast Cancer: Primary Results of the Randomized  
Phase III IMpassion050 Trial. J Clin Oncol. 40(25):2946-2956. 
 
Houssami, N., Macaskill, P., von Minckwitz, G., Marinovich, M. L., & Mamounas, E. (2012). Meta-analysis 
of the association of breast cancer subtype and pathologic complete response to neoadjuvant 
chemotherapy. European journal of cancer, 48(18), 3342–3354. 
Ibrahim, J. G., Chen, M.-H., & Sinha, D. (2014). Bayesian Survival Analysis. In N. Balakrishnan, T. Colton, 
B. Everitt, W. Piegorsch, F. Ruggeri, & J. L. Teugels (Hrsg.), Wiley StatsRef: Statistics Reference 
Online (S. stat06003). John Wiley & Sons, Ltd. https://doi.org/10.1002/9781118445112.stat06003 
Iwamoto, T., Booser, D., Valero, V., Murray, J. L., Koenig, K., Esteva, F. J., Ueno, N. T., Zhang, J., Shi, 
W., Qi, Y., Matsuoka, J., Yang, E. J., Hortobagyi, G. N., Hatzis, C., Symmans, W. F., & Pusztai, L. 
(2012). Estrogen receptor (ER) mRNA and ER-related gene expression in breast cancers that are 
1% to 10% ER-positive by immunohistochemistry. Journal of Clinical Oncology: Official Journal of 
the American Society of Clinical Oncology, 30(7), 729–734. 
https://doi.org/10.1200/JCO.2011.36.2574 
Keup, C., Storbeck, M., Hauch, S., Hahn, P., Sprenger-Haussels, M., Tewes, M., Mach, P., Hoffmann, O., 
Kimmig, R., & Kasimir-Bauer, S. (2019). Cell-Free DNA Variant Sequencing Using CTC-Depleted 
Blood for Comprehensive Liquid Biopsy Testing in Metastatic Breast Cancer. Cancers, 11(2), 238. 
Klein, J. P., & Moeschberger, M. L. (2010). Survival analysis: Techniques for censored and truncated data 
(2. ed., corr. 3. print). Springer. 
Kolberg, H.C., Schumacher, J., Erber, R., Braun, M., Heinrich, B., Hoffmann, O., Fasching, P.A., Kunz, G., 
Lux, M.P., Schem, C., Grischke, E.-M., Deryal, M., Lübbe, K., Hartmann, A., Kasimir-Bauer, S. & 
Kolberg-Liedtke, C. (2023). Comparison of a mono Atezolizumab window followed by 
Atezolizumab and chemotherapy with Atezolizumab and chemotherapy in triple negative breast 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 85 of 118 
cancer – an interim analysis of the adaptive randomized neoadjuvant trial NeoMono. Cancer Res 
(5_Supplement): PD11-03. 
 
Lee, H. J., Lee, J.-J., Song, I. H., Park, I. A., Kang, J., Yu, J. H., Ahn, J.-H., & Gong, G. (2015). Prognostic 
and predictive value of NanoString-based immune-related gene signatures in a neoadjuvant 
setting of triple-negative breast cancer: Relationship to tumor-infiltrating lymphocytes. Breast 
cancer research and treatment, 151(3), 619–627. 
Liedtke, C., Feuerhake, F., Garke, M., Christgen, M., Kates, R. E., Grischke, E.-M., Forstbauer, H., Braun, 
M. W., Warm, M. R., & Hackmann, C. (2018). Impact of tumor-infiltrating lymphocytes on 
response to neoadjuvant chemotherapy in triple-negative early breast cancer: Translational 
subproject of the WSG-ADAPT TN trial. American Society of Clinical Oncology. 
Liedtke, C., Mazouni, C., Hess, K. R., André, F., Tordai, A., Mejia, J. A., Symmans, W. F., Gonzalez-
Angulo, A. M., Hennessy, B., & Green, M. (2008). Response to neoadjuvant therapy and long-
term survival in patients with triple-negative breast cancer. Journal of clinical oncology, 26(8), 
1275–1281. 
Llombart-Cussac, A., Cortés, J., Paré, L., Galván, P., Bermejo, B., Martínez, N., Vidal, M., Pernas, S., 
López, R., & Muñoz, M. (2017). HER2-enriched subtype as a predictor of pathological complete 
response following trastuzumab and lapatinib without chemotherapy in early-stage HER2-positive 
breast cancer (PAMELA): An open-label, single-group, multicentre, phase 2 trial. The Lancet 
Oncology, 18(4), 545–554. 
Loi, S., Schmid, P., Aktan, G., Karantza, V., & Salgado, R. (2019). 4O Relationship between tumor 
infiltrating lymphocytes (TILs) and response to pembrolizumab (pembro)+ chemotherapy (CT) as 
neoadjuvant treatment (NAT) for triple-negative breast cancer (TNBC): Phase Ib KEYNOTE-173 
trial. Annals of Oncology, 30(Supplement_3), mdz095–003. 
Loibl, S., Untch, M., Burchardi, N., Huober, J., Sinn, B. V., Blohmer, J.-U., Grischke, E.-M., Furlanetto, J., 
Tesch, H., & Hanusch, C. (2019). A randomised phase II study investigating durvalumab in 
addition to an anthracycline taxane-based neoadjuvant therapy in early triple-negative breast 
cancer: Clinical results and biomarker analysis of GeparNuevo study. Annals of Oncology, 30(8), 
1279–1288. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 86 of 118 
Loibl, S., Werutsky, G., Nekljudova, V., Seiler, S., Blohmer, J. U., Denkert, C., Hanusch, C., Huober, J. B., 
Jackisch, C., Kummel, S., Schneeweiss, A., Untch, M., Rhiem, K., Fasching, P. A., Von Minckwitz, 
G., & Furlanetto, J. (2017). Impact in delay of start of chemotherapy and surgery on pCR and 
survival in breast cancer: A pooled analysis of individual patient data from six prospectively 
randomized neoadjuvant trials. Journal of Clinical Oncology, 35(15_suppl), 571–571. 
https://doi.org/10.1200/JCO.2017.35.15_suppl.571 
Marra, A., Viale, G., & Curigliano, G. (2019). Recent advances in triple negative breast cancer: The 
immunotherapy era. BMC medicine, 17(1), 90. 
Matsushita, M., & Kawaguchi, M. (2018). Immunomodulatory effects of drugs for effective cancer 
immunotherapy. Journal of oncology, 2018. 
Mcardle, S. E., Foulds, G. A., Vadakekolathu, J., Abdel-Fatah, T., Reeder, S., Johnson, C., Hood, S., 
Moseley, P. M., Chan, S. Y., & Pockley, A. G. (2018). Immune-phenotyping and transcriptomic 
profiling of peripheral blood mononuclear cells from patients with breast cancer: Identification of a 
3 gene signature which predicts relapse of triple negative breast cancer. Frontiers in immunology, 
9, 2028. 
Nuciforo, P., Pascual, T., Cortés, J., Llombart-Cussac, A., Fasani, R., Paré, L., Oliveira, M., Galvan, P., 
Martínez, N., & Bermejo, B. (2017). A predictive model of pathologic response based on tumor 
cellularity and tumor-infiltrating lymphocytes (CelTIL) in HER2-positive breast cancer treated with 
chemo-free dual HER2 blockade. Annals of Oncology, 29(1), 170–177. 
Pardoll, D. M. (2012). The blockade of immune checkpoints in cancer immunotherapy. Nature Reviews 
Cancer, 12(4), 252. 
Park, M. M., Ebel, J. J., Zhao, W., & Zynger, D. L. (2014). ER and PR immunohistochemistry and HER2 
FISH versus oncotype DX: implications for breast cancer treatment. The breast journal, 20(1), 37–
45. 
Raghav, K. P. S., Hernandez-Aya, L. F., Lei, X., Chavez-Macgregor, M., Meric-Bernstam, F., Buchholz, T. 
A., Sahin, A., Do, K.-A., Hortobagyi, G. N., & Gonzalez-Angulo, A. M. (2012). Impact of low 
estrogen/progesterone receptor expression on survival outcomes in breast cancers previously 
classified as triple negative breast cancers. Cancer, 118(6), 1498–1506. 
https://doi.org/10.1002/cncr.26431 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 87 of 118 
Raja, R., Kuziora, M., Brohawn, P. Z., Higgs, B. W., Gupta, A., Dennis, P. A., & Ranade, K. (2018). Early 
reduction in ctDNA predicts survival in patients with lung and bladder cancer treated with 
durvalumab. Clinical Cancer Research, 24(24), 6212–6222. 
Royston, P., & Sauerbrei, W. (2008). Multivariable Model-Building. John Wiley & Sons, Ltd. 
https://doi.org/10.1002/9780470770771 
Saliou, A., Bidard, F.-C., Lantz, O., Stern, M.-H., Vincent-Salomon, A., Proudhon, C., & Pierga, J.-Y. 
(2016). Circulating tumor DNA for triple-negative breast cancer diagnosis and treatment decisions. 
Expert review of molecular diagnostics, 16(1), 39–50. 
Sanford, R. A., Song, J., Gutierrez-Barrera, A. M., Profato, J., Woodson, A., Litton, J. K., Bedrosian, I., 
Albarracin, C. T., Valero, V., & Arun, B. (2015). High incidence of germline BRCA mutation in 
patients with ER low-positive/PR low-positive/HER-2 neu negative tumors. Cancer, 121(19), 
3422–3427. https://doi.org/10.1002/cncr.29572 
Schmid, P., Cortés, J., Dent, R., Pusztai, L., McArthur, H. L., Kuemmel, S., Bergh, J., Denkert, C., Park, Y. 
H., & Hui, R. (2019). KEYNOTE-522: Phase III study of pembrolizumab (pembro)+ chemotherapy 
(chemo) vs placebo (pbo)+ chemo as neoadjuvant treatment, followed by pembro vs pbo as 
adjuvant treatment for early triple-negative breast cancer (TNBC). Annals of Oncology, 30, v853–
v854. 
Schmid, P., Cortes, J., Pusztai, L., McArthur, H., Kümmel, S., Bergh, J., Denkert, C., Park, Y.H., Hui, R.,  
Harbeck, N., Takahashi, M., Foukakis, T., Fasching, P.A., Cardoso, F., Untch, M., Jia, L., 
Karantza, V., Zhao, J., Aktan, G.,  Dent R, O'Shaughnessy J (2020). KEYNOTE-522 
Investigators. Pembrolizumab for Early Triplenegative Breast Cancer. N Engl J Med. 27, 
382(9):810-821. 
Schmid, Peter. (2018). ESMO 2018 presidential symposium—IMpassion130: Atezolizumab+ nab-
paclitaxel in triple-negative breast cancer. ESMO open, 3(6), e000453. 
Sharma, P., & Allison, J. P. (2015). The future of immune checkpoint therapy. Science, 348(6230), 56–61. 
Sikov, W. M., Berry, D. A., Perou, C. M., Singh, B., Cirrincione, C. T., Tolaney, S. M., Kuzma, C. S., 
Pluard, T. J., Somlo, G., & Port, E. R. (2015). Impact of the addition of carboplatin and/or 
bevacizumab to neoadjuvant once-per-week paclitaxel followed by dose-dense doxorubicin and 
cyclophosphamide on pathologic complete response rates in stage II to III triple-negative breast 
cancer: CALGB 40603 (Alliance). Journal of clinical oncology, 33(1), 13. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 88 of 118 
Slovin, S. F., Higano, C. S., Hamid, O., Tejwani, S., Harzstark, A., Alumkal, J. J., Scher, H. I., Chin, K., 
Gagnier, P., & McHenry, M. B. (2013). Ipilimumab alone or in combination with radiotherapy in 
metastatic castration-resistant prostate cancer: Results from an open-label, multicenter phase I/II 
study. Annals of Oncology, 24(7), 1813–1821. 
Sokolenko, A. P., & Imyanitov, E. N. (2017). Molecular tests for the choice of cancer therapy. Current 
pharmaceutical design, 23(32), 4794–4806. 
Sørlie, T., Perou, C. M., Tibshirani, R., Aas, T., Geisler, S., Johnsen, H., Hastie, T., Eisen, M. B., Van De 
Rijn, M., & Jeffrey, S. S. (2001). Gene expression patterns of breast carcinomas distinguish tumor 
subclasses with clinical implications. Proceedings of the National Academy of Sciences, 98(19), 
10869–10874. 
Tan, W., Yang, M., Yang, H., Zhou, F., & Shen, W. (2018). Predicting the response to neoadjuvant 
therapy for early-stage breast cancer: Tumor-, blood-, and imaging-related biomarkers. Cancer 
Management and Research, 10, 4333. 
Thompson, R. H., Dong, H., Lohse, C. M., Leibovich, B. C., Blute, M. L., Cheville, J. C., & Kwon, E. D. 
(2007). PD-1 is expressed by tumor-infiltrating immune cells and is associated with poor outcome 
for patients with renal cell carcinoma. Clinical cancer research, 13(6), 1757–1761. 
Tibshirani, R. (1996). Regression Shrinkage and Selection via the Lasso. Journal of the Royal Statistical 
Society. Series B (Methodological), 58(1), 267–288. JSTOR. 
Untch, M., Jackisch, C., Schneeweiss, A., Conrad, B., Aktas, B., Denkert, C., Eidtmann, H., Wiebringhaus, 
H., Kümmel, S., & Hilfrich, J. (2016). Nab-paclitaxel versus solvent-based paclitaxel in 
neoadjuvant chemotherapy for early breast cancer (GeparSepto—GBG 69): A randomised, phase 
3 trial. The lancet oncology, 17(3), 345–356. 
Yang, B., Chou, J., Tao, Y., Wu, D., Wu, X., Li, X., Li, Y., Chu, Y., Tang, F., & Shi, Y. (2018). An 
assessment of prognostic immunity markers in breast cancer. NPJ breast cancer, 4(1), 35. 
Yi, M., Huo, L., Koenig, K. B., Mittendorf, E. A., Meric-Bernstam, F., Kuerer, H. M., Bedrosian, I., Buzdar, 
A. U., Symmans, W. F., Crow, J. R., Bender, M., Shah, R. R., Hortobagyi, G. N., & Hunt, K. K. 
(2014). Which threshold for ER positivity? A retrospective study based on 9639 patients. Annals of 
Oncology: Official Journal of the European Society for Medical Oncology, 25(5), 1004–1011. 
https://doi.org/10.1093/annonc/mdu053 
  

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 89 of 118 
Appendix A: Genes based on QIAseq Targeted DNA Panels 
 
AKT1, AKT serine/threonine kinase 1; AR, Androgen receptor; BRCA1, DNA repair associated; 
BRCA2, BRCA2, DNA repair associated; EGFR, Epidermal growth factor receptor; ERCC4, ERCC 
excision repair 4, endonuclease non-catalytic subunit; ERBB2, Erb-b2 receptor tyrosine kinase 2, 
encoding for HER2; ERBB3, Erb-b2 receptor tyrosine kinase 3; ESR1, Estrogen receptor gene; 
FGFR1, fi3broblast growth factor receptor 1; KRAS, KRAS proto-oncogene, GTPase; MUC16, 
mucin 16, cell surface associated; PIK3CA, Phosphatidylinositol-4,5-bisphosphate 3-kinase 
catalytic subunit alpha; PIK3R1, phosphoinositide-3-kinase regulatory subunit 1; PTEN, 
phosphatase and tensin homolog; PTGFR, prostaglandin F receptor; TGFB1, transforming growth 
factor beta 1  
 
Appendix B: Genes based on nCounter® PanCancer Immune Profiling Panel 
 
Please see more details on page 3 of 
http://www.biosystems.com.ar/archivos/folletos/228/pdf.pdf 
 
Appendix C: Genes based on nCounter® PanCancer Immune Profiling Panel and PAM50 
 
Please see more details: https://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GPL17071 
 
Please see more details on page 3 of 
http://www.biosystems.com.ar/archivos/folletos/228/pdf.pdf 
 
Genes from Yang et al.(2018): 
Immunity Genes: APOBEC3G, CCL5, CCR2, CD2, CD27, CD3D, CD52, CORO1A, CXCL9, 
GZMA, GZMK, HLA-DMA, IL2RG, LCK, PRKCB, PTPRC, and SH2D1A. 
Proliferation genes: AURKA, BIRC5, CCNB1, CCNE1, CDC20, CDC6, CENPF, CEP55, EXO1, 
MKI-67, KIF2C, MELK, MYBL2, NDC80, ORC6, PTTG1, RRM2, TYMS, and UBE2C 
 
Appendix D: Genome-wide gene expression analysis for RNA-based biomarker signature 
related to response/resistance to Atezolizumab using ArrayXS microarrays 
For RNA-based biomarker signature, TMA of all core biopsies (FFPE blocks) will be used. 
Please see more details: https://www.oak-labs.com/gene-expression-ffpe-human/index.phtml 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 90 of 118 
12. Appendices 
 
12.1. Appendix 1: Breast Cancer Stages 
 
UICC classification 
 
The neoMono study will include patients with T1c-T4c TNBC. This will include: 
 
● T1c: the tumor is larger than 10 mm but 20 mm or smaller 
● T2: the tumor is larger than 20 mm but not larger than 50 mm 
● T3: the tumor is larger than 50 mm 
● T4: 
o T4a means the tumor has grown into the chest wall 
o T4b means the tumor has grown into the skin 
o T4c means the tumor has grown into the chest wall and skin 
o T4d means inflammatory breast cancer 
 
The neoMono study will include patients with stage N0-N3. 
Regional lymph nodes include: 
● Lymph nodes located under the arm, called the axillary lymph nodes 
● Above and below the collarbone 
● Under the breastbone, called the internal mammary lymph nodes 
 
N stages include: 
 
N0: Either of the following: 
● No cancer was found in the lymph nodes. 
● Only areas of cancer smaller than 0.2 mm are in the lymph nodes. 
 
N1: The cancer has spread to 1 to 3 axillary lymph nodes and/or the internal mammary lymph 
nodes. If the cancer in the lymph node is larger than 0.2 mm but 2.0 mm or smaller, is it called 
"micro metastatic" (N1mi). 
 
N2: The cancer has spread to 4 to 9 axillary lymph nodes. Or it has spread to the internal 
mammary lymph nodes, but not the axillary lymph nodes. 
 
N3: The cancer has spread to 10 or more axillary lymph nodes. Or it has spread to the lymph 
nodes located under the clavicle, or collarbone. It may have also spread to the internal mammary 
lymph nodes. Cancer that has spread to the lymph nodes above the clavicle, called the 
supraclavicular lymph nodes, is also described as N3. 
 
Only patients with cM0 stage will be included. cM0 refers to patients who have no clinical 
indication of distant metastases. 
 
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 91 of 118 
For definition of tumor staging according to AJJC, please refer to: 
 
Eight edition/editor-in-chief, Mahul B. Amin, MD, FCAP; editors, Stephen B. Edge, MD, FACS [and 
16 others]; Donna M. Gress, RHIT, CTR - Technical editor; Laura R. Meyer, CAPM - Managing 
editor"AJCC cancer staging manual", American Joint Committee on Cancer, Springer (2017) 
 
12.2. Appendix 2: Clinical laboratory tests 
 
● The tests detailed in Table 10 will be performed by the investigator`s local laboratory.  
● Protocol-specific requirements for inclusion or exclusion of participants are detailed in 
Section 6.1 and Section 6.2 of the protocol. 
● Additional tests may be performed at any time during the study as determined necessary 
by the investigator or required by local regulations. 
 
Table 10: Hematology and biochemistry assessments 
Laboratory 
Assessments 
Parameters 
Hematology 
WBC 
WBC Count with Differential*: 
Neutrophils 
Lymphocytes 
Monocytes 
Eosinophils 
Basophils 
Platelet Count 
Hemoglobin 
Clinical 
Chemistry1 
Aspartate 
Aminotransferase 
(AST) 
Alanine 
Aminotransferase 
 (ALT) 
Total (and direct**) 
bilirubin 
 
Creatinine 
 
 
 
Sodium 
Potassium 
 
 
TSH; FT4 
 
 
 
Investigators must document their review of each laboratory safety report. 
* Differential WBC Count is mandatory before start of CTX. During the ongoing therapy, it is 
sufficient to analyze WBC/leucocytes, neutrophils, platelets and hemoglobin. 
** Direct bilirubin has only to be assessed if total bilirubin shows values beyond normal range. 
 
12.3. Appendix 3: Tests for translational research 
 
Blood samples 
Blood for translational research is drawn at the time points described in section 2, SOA. 
For patients in Arm A, 5 blood samples will be taken over the whole period of the study: one at 
baseline and 4 during the neoadjuvant treatment. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 92 of 118 
For patients in Arm B, 4 blood samples will be taken over the whole period of the study: one at 
baseline and 3 during the neoadjuvant treatment.  
At each time point, 4 collection tubes à 8.5 mL blood (total amounts 34 mL) will be withdrawn from 
the patient. Collection tubes will be supplied together with corresponding adapters and butterflies. 
Each tube contains 1.5 mL fixate that stabilizes the samples for up to 7 days. After withdrawing 
the blood, each collection tube should be inverted gently. 
Blood should be withdrawn and shipped only from Monday to Thursday to avoid any delay over 
a weekend. Holidays should also be considered when sampling and shipment of blood samples 
are planned. 
Shipment of the blood samples should take place on the same day using overnight shipment to 
the laboratory at the University Hospital Essen using the supplied shipment containers to: 
Klinik für Frauenheilkunde und Geburtshilfe 
Universitätsklinikum Essen 
z.Hd. Frau Prof. Dr. Sabine Kasimir-Bauer 
Forschungslabor, Ebene -1, Raum-1.06 
Hufelandstraße 55 
45147 Essen 
 
The laboratory processes the samples (Separation of plasma and solid blood component by 
centrifugation) and subsequently stores all blood samples at -80 °C. 
From blood samples the multiplexed gene expression panels specified in Appendix A - C will be 
analyzed. 
 
12.4. Appendix 4: Cardiac safety monitoring 
 
Cardiac safety evaluation 
 
Cardiac safety monitoring for toxicity of CTX combination and toxicity other than CTX combination 
has been reported. Hence, cardiac AEs should be followed closely. 
Refer to section 9.9.11.2 of the protocol for cardiac safety evaluation. 
 
 
Definitions of cardiac toxicity 
 
Cardiac toxicity will be classified as follows: 
 
⮚ Cardiac death  
Cardiac death will be defined as death due to one of the following: 
● Confirmed CHF 
● Myocardial infarction 
● Documented primary arrhythmia 
● Probable cardiac death i.e. sudden death without documented aetiology.  
An autopsy is preferred in cases where cause of death has a cardiac aetiology. 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 93 of 118 
⮚  
Congestive Heart Failure (CHF) 
Clinical signs and symptoms suggesting CHF (dyspnoea, tachycardia, cough, neck vein 
distension, cardiomegaly, hepatomegaly, paroxysmal nocturnal dyspnoea, orthopnoea, peripheral 
edema, etc.) must be investigated. 
The suspicion of CHF, based on the signs and symptoms mentioned above, must be confirmed 
by a LVEF decrease in echocardiography, with a chest X-ray. LVEF assessment should be 
repeated 4 to 7 days afterwards to confirm a diagnosis of CHF. 
 
⮚  
Cardiac arrhythmias, grade 3 or grade 4 
The NCI Common Toxicity Criteria, version 5.0 will be used to classify an arrhythmia as grade 3, 
which is symptomatic and requiring treatment, or grade 4 which is an arrhythmia considered to be 
life-threatening e.g. an arrhythmia associated with CHF, hypotension, syncope, shock. 
 
⮚ Cardiac ischemia/Infarction, grade 3 or grade 4 
The NCI Common Toxicity Criteria, version 5.0 will be used to classify the severity of cardiac 
ischemia/infarction. Grade 3 ischemia is defined as angina without evidence of infarction. Grade 4 
is defined as an acute myocardial infarction. 
Patients showing one of those symptoms will consult a cardiologist and will be followed as defined 
by the institution’s routine. 
 
Cardiac safety analysis 
The incidence of cardiac AEs (cardiac deaths, CHF, grade 3 or grade 4 ischemia/infarction, grade 
3 or grade 4 arrhythmias) will be calculated for each treatment arm. 
 
Reporting of cardiac toxicities 
Cardiac toxicities will be documented in the CRF at each visit during treatment and follow-up. 
 
12.5. Appendix 5: Fluid retention severity grading 
 
Edema 
Severity grading 
Effusion 
• Asymptomatic  
and/or 
• Very well tolerated   
and/or 
• Dependent in evening only 
 
MILD 
1 
• Asymptomatic 
• No intervention required 
• Moderate functional impairment 
and/or 
• Pronounced and well tolerated 
and/or 
• Dependent throughout day 
 
MODERATE 
2 
•Symptomatic: 
- exertional dyspnoea and/or 
- chest pain and/or 
• ECG changes and/or 
• Abdominal distension 
• Drainage may be required 
 
• Significant impairment of function  
and/or 
• Pronounced and not well tolerated  
and/or 
• Generalized anasarca 
SEVERE 
3 
• Symptomatic effusion 
- dyspnoea at rest and/or 
- tamponade and/or 
- pronounced abdominal distension 
• Drainage urgently required 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 94 of 118 
12.6. Appendix 6: ECOG Performance Status  
Eastern Cooperative Oncology Group (ECOG) Performance Status Description Grade  
Description 
 
Grade 
Fully active, able to carry on all pre-disease performance without restriction. 
 
0 
Restricted in physically strenuous activity, but ambulatory and able to carry 
out work of a light or sedentary nature, i.e., light housework, office work. 
 
1 
Ambulatory and capable of all self-care but unable to carry out any work 
activities. Up and about more than 50% of waking hours. 
 
2 
Capable of only limited self-care, confined to bed or chair more than 50% of 
waking hours. 
 
3 
Completely disabled. Cannot carry on any self-care. Totally confined to bed 
or chair. 
 
4 
 
 
 
12.7. Appendix 7: Karnofsky Index 
100 – Normal; no complaints; no evidence of disease. 
90 – Able to carry on normal activity; minor signs or symptoms of disease. 
80 – Normal activity with effort; some signs or symptoms of disease. 
70 – Cares for self; unable to carry on normal activity or to do active work. 
60 – Requires occasional assistance, but is able to care for most of their personal needs. 
50 – Requires considerable assistance and frequent medical care. 
40 – Disabled; requires special care and assistance. 
30 – Severely disabled; hospital admission is indicated although death not imminent. 
20 – Very sick; hospital admission necessary; active supportive treatment necessary. 
10 – Moribund; fatal processes progressing rapidly. 
  0 – Dead 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 95 of 118 
12.8. Appendix 8: Adverse Events: definitions and procedures for recording, evaluating, 
follow-up, and reporting 
 
Reporting of SAEs 
SAE Reporting to Palleos 
Electronic reporting is the preferred method to transmit SAE information to the Safety Manager of 
palleos healthcare GmbH. 
Facsimile or email transmission of the SAE paper CRF is an alternative method to transmit this 
information to the Safety Manager of palleos healthcare GmbH. Contacts for paper-based SAE 
reporting can be found in Section 9.9.5. 
 
Definition of AE 
AE Definition 
An AE is any untoward medical occurrence in a patient or clinical study participant, temporally 
associated with the use of study treatment, whether or not considered related to the study treatment. 
NOTE: An AE can therefore be any unfavorable and unintended sign (including an abnormal 
laboratory finding), symptom, or disease (new or exacerbated) temporally associated with the use of 
study treatment. 
 
 
Events Meeting the AE Definition  
● Any abnormal laboratory test results (hematology, clinical chemistry, or urinalysis) or other safety 
assessments (e.g., ECG, radiological scans, vital signs measurements), including those that 
worsen from baseline, considered clinically significant in the medical and scientific judgment of 
the investigator (i.e., not related to progression of underlying disease). 
● Exacerbation of a chronic or intermittent pre-existing condition including either an increase in 
frequency and/or intensity of the condition. 
● New conditions detected or diagnosed after study treatment administration even though it may 
have been present before the start of the study. 
● Signs, symptoms, or the clinical sequelae of a suspected drug-drug interaction. 
● Signs, symptoms, or the clinical sequelae of a suspected overdose of either study treatment or a 
concomitant medication. Overdose per se will not be reported as an AE/SAE unless it is an 
intentional overdose taken with possible suicidal/self-harming intent. Such overdoses should be 
reported regardless of sequelae. 
● Signs, symptoms, or the clinical sequelae of a drug abuse. 
● Signs, symptoms, or the clinical sequelae of a drug withdrawal. 
● Hypersensitivity 
● Events that are related to a protocol-mandated intervention, including those that occur prior to 
assignment of study treatment (e.g. screening invasive procedures such as biopsies. 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 96 of 118 
Events NOT Meeting the AE Definition  
● Any clinically significant abnormal laboratory findings or other abnormal safety assessments 
which are associated with the underlying disease, unless judged by the investigator to be more 
severe than expected for the participant’s condition. 
● The disease/disorder being studied or expected progression, signs, or symptoms of the 
disease/disorder being studied, unless more severe than expected for the participant’s condition. 
● Medical or surgical procedure (e.g. endoscopy, appendectomy): the condition that leads to the 
procedure is the AE. 
● Situations in which an untoward medical occurrence did not occur (Social and/or convenience 
admission to a hospital). 
● Anticipated day-to-day fluctuations of pre-existing disease(s) or condition(s) present or detected 
at the start of the study that do not worsen. 
 
Definition of SAE 
If an event is not an AE per definition above, then it cannot be an SAE even if serious conditions 
are met (e.g., hospitalization for signs/symptoms of the disease under study, death due to 
progression of disease). 
An SAE is defined as any untoward medical occurrence that, at any dose: 
Results in death 
Is life-threatening 
The term 'life-threatening' in the definition of 'serious' refers to an event in which the participant was 
at risk of death at the time of the event. It does not refer to an event, which hypothetically might have 
caused death, if it were more severe. 
Requires inpatient hospitalization or prolongation of existing hospitalization 
In general, hospitalization signifies that the participant has been detained at the hospital or 
emergency ward for observation and/or treatment that would not have been appropriate in the 
physician’s office or outpatient setting. 
Complications that occur during hospitalization are AEs. 
If a complication prolongs hospitalization or fulfills any other serious criteria, the event is serious. 
When in doubt as to whether “hospitalization” occurred or was necessary, the AE should be 
considered serious. 
Any AE leading to hospitalization or prolongation of hospitalization will be considered as serious, 
UNLESS at least one of the following exceptions is met:  
- The admission is pre-planned (i.e., elective or scheduled surgery arranged prior to the start of 
the study) or  
- The admission is not associated with an adverse event (e.g., social hospitalization for purposes 
of respite care). 
- The admission is designated to perform an efficacy measurement for the study 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 97 of 118 
- The admission is designated to receive scheduled therapy for the target disease of the study 
However, it should be noted that invasive treatment during any hospitalization may fulfil the criteria 
of ‘medically important’ and as such may be reportable as a SAE dependent on clinical judgment. In 
addition, where local regulatory authorities specifically require a more stringent definition, the local 
regulation takes precedent. 
Results in persistent disability/incapacity 
The term disability means a substantial disruption of a person’s ability to conduct normal life functions. 
This definition is not intended to include experiences of relatively minor medical significance such as 
uncomplicated headache, nausea, vomiting, diarrhea, influenza, and accidental trauma (e.g. 
sprained ankle) which may interfere with or prevent everyday life functions but do not constitute a 
substantial disruption. 
Is a congenital anomaly/birth defect 
Other situations 
Medical or scientific judgment should be exercised in deciding whether SAE reporting is appropriate 
in other situations such as important medical events that may not be immediately life-threatening or 
result in death or hospitalization but may jeopardize the participant or may require medical or surgical 
intervention to prevent one of the other outcomes listed in the above definition. These events should 
usually be considered serious. 
Examples of such events include invasive or malignant cancers, intensive treatment in an emergency 
room or at home for allergic bronchospasm, blood dyscrasias or convulsions that do not result in 
hospitalization, or development of drug dependency or drug abuse. 
As guidance for determination of important medical events refer to the “WHO Adverse Reaction 
Terminology – Critical Terms List”. These terms either refer to or might be indicative of a serious 
disease state. Such reported events warrant special attention, because of their possible association 
with a serious disease state and may lead to more decisive action than reports on other terms. 
The terms “severe” and “serious” are not synonymous. Severity refers to the intensity of an AE 
(rated according to NCI CTCAE v5.0; see below); the event itself may be of relatively minor 
medical significance (such as severe headache without any further findings). 
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 98 of 118 
Recording an AE and/or SAE 
 
AE and SAE Recording 
When an AE/SAE occurs, it is the responsibility of the investigator to review all documentation (e.g., 
hospital progress notes, laboratory reports, and diagnostics reports) related to the event. 
The investigator will record all relevant AE/SAE information in the CRF. 
SAEs have to be reported to the sponsor within the protocol-specified timeframes either electronically 
or paper-based as specified above. 
It is not acceptable for the investigator to send photocopies of the participant’s medical records to 
palleos healthcare GmbH in lieu of completion of the AE/SAE CRF page. 
There may be instances when copies of medical records for certain cases are requested by palleos 
healthcare GmbH. In this case, all participant identifiers, with the exception of the participant number, 
will be redacted on the copies of the medical records before submission to palleos healthcare GmbH. 
The investigator will attempt to establish a diagnosis of the event based on signs, symptoms, and/or 
other clinical information. Whenever possible the diagnosis (not the individual signs/symptoms) will 
be documented as the AE/SAE. 
 
 
 
Assessment of Severity 
The investigator will make an assessment of severity for each AE and SAE reported during the study 
and assign it according to NCI CTCAE v5.0 to one of the following grades:  
Grade 1/Mild: An event that is easily tolerated by the participant, causing minimal discomfort 
and not interfering with everyday activities. 
Grade 2/Moderate: An event that causes sufficiently discomfort and interferes with normal 
everyday activities. 
Grade 3/Severe: An event that prevents normal everyday activities. An AE that is assessed 
as severe should not be confused with an SAE. Severe is a category utilized for rating the 
intensity of an event; and both AEs and SAEs can be assessed as severe. 
An event is defined as ‘serious’ when it meets at least 1 of the predefined outcomes as 
described in the definition of an SAE, NOT when it is rated as severe. 
Grade 4/Life-threatening: An event that places the patient or subject at immediate risk of death 
and indicates urgent interventions. 
Grade 5/Fatal: Death related to AE. 
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 99 of 118 
Assessment of Causality 
The investigator is obligated to assess the relationship between study treatment and each occurrence 
of each AE/SAE. 
A "reasonable possibility" of a relationship conveys that there are facts, evidence, and/or arguments 
to suggest a causal relationship, rather than a relationship cannot be ruled out. 
The investigator will use clinical judgment to determine the relationship. 
Alternative causes, such as underlying disease(s), concomitant therapy, and other risk factors, as 
well as the temporal relationship of the event to study treatment administration will be considered 
and investigated. 
The investigator will also consult the IB and/or SmPC, for marketed products, in his/her assessment. 
For each AE/SAE, the investigator must document in the medical notes that he/she has reviewed the 
AE/SAE and has provided an assessment of causality. 
There may be situations in which an SAE has occurred, and the investigator has minimal information 
to include in the initial report to palleos healthcare GmbH. However, it is very important that the 
investigator always makes an assessment of causality for every event before the initial transmission 
of the SAE data to palleos healthcare GmbH. 
The investigator may change his/her opinion of causality in light of follow-up information and create 
a SAE follow-up report with the updated causality assessment. 
The causality assessment is one of the criteria used when determining regulatory reporting 
requirements. 
Causal relationship between the study treatment and a certain AE will be graded according to the 
following criteria (WHO-UMC system): 
Certain 
- 
Event or laboratory test abnormality, with plausible time relationship to drug intake 
- 
Cannot be explained by disease or other drugs 
- 
Response to withdrawal plausible (pharmacologically, pathologically) 
- 
Event definitive pharmacologically or phenomenologically (i.e. an objective and specific 
medical disorder or a recognized pharmacological phenomenon) 
- 
Rechallenge satisfactory, if necessary 
Probable/Likely 
- 
Event or laboratory test abnormality, with reasonable time relationship to drug intake 
- 
Unlikely to be attributed to disease or other drugs 
- 
Response to withdrawal clinically reasonable 
- 
Rechallenge not required 
Possible 
- 
Event or laboratory test abnormality, with reasonable time relationship to drug intake 
- 
Could also be explained by disease or other drugs 
- 
Information on drug withdrawal may be lacking or unclear 
Unlikely 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 100 of 118 
- 
Event or laboratory test abnormality, with a time to drug intake that makes a relationship 
improbable (but not impossible) 
- 
Disease or other drugs provide plausible explanations 
- 
Conditional/Unclassified 
- 
Event or laboratory test abnormality 
- 
More data for proper assessment needed, or 
- 
Additional data under examination 
Unassessable/Unclassifiable 
- 
Report suggesting an adverse reaction 
- 
Cannot be judged because information is insufficient or contradictory 
- 
Data cannot be supplemented or verified 
For patients receiving combination therapy, causality will be assessed individually for each protocol-
mandated therapy. 
 
Sponsor`s Assessment of Expectedness 
The specificity or severity of an unexpected AE or SUSAR is not consistent with the current IB or 
SmPC for the study treatment. 
Also, reports which add significant information on specificity or severity of a known, already 
documented AE constitute unexpected AEs. 
For example, an event more specific or more severe than described in the SmPC (prescribing 
information/"Fachinformation") would be considered “unexpected”. 
Specific examples would be; (a) acute renal failure as a labelled AE with a subsequent new report of 
interstitial nephritis and (b) hepatitis with a first report of fulminant hepatitis.  
An expected AE with fatal outcome must be regarded as unexpected, if the IB or SmPC does not 
explicitly state the option of fatal outcome for this event. 
 
Follow-up of AEs and SAEs 
The investigator is obligated to perform or arrange for the conduct of supplemental measurements 
and/or evaluations as medically indicated or as requested by palleos healthcare GmbH to elucidate 
the nature and/or causality of the AE or SAE as fully as possible. This may include additional 
laboratory tests or investigations, histopathological examinations, or consultation with other health 
care professionals. 
If a participant dies during participation in the study or during a recognized follow-up period, the 
investigator will provide palleos healthcare GmbH with a copy of any post-mortem findings including 
histopathology. 
New or updated information concerning AEs will be recorded in the originally completed CRF. 
The investigator will submit any updated SAE data to palleos healthcare GmbH within 24 hours of 
receipt of the information. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 101 of 118 
New, updated, or corrected information about a previously reported SAE should be submitted on a 
new SAE Report Form that includes the data that are new or revised from the previous report. Follow-
up information should never be added to a previously submitted report form. 
 
12.9. Appendix 9: Statistical design and methods 
 
In the neoMono trial we employ Bayesian inference calculus to report posterior probability 
distributions in the inference step (details are provided in subsection 1.2 below, for a general 
reference see [7]). In particular, inference for the primary objective is focused on comparing 
efficacy between an experimental Arm A versus a control Arm B. Efficacy is measured in terms of 
the endpoint pCR rate. In the following, the effect θ denotes a difference in pCR rates of 
experimental Arm A relative to Arm B. 
Primary objective  
For the inference step of the primary objective, we adapt the idea of a proof-of-concept trial ([1], 
see also [2] – [5] for additional examples) to show superiority of an experimental arm versus a 
control arm in terms of a simultaneous dual criterion: 
1. Significance: high confidence that the effect θ of experimental arm relative to control is 
bigger than zero  
Pr(θ > 0 | data) ≥ 1 – α 
2. Relevance: moderate confidence that the experimental effect, relative to control, is larger 
than a clinically meaningful difference δ 
Pr(θ > δ | data) ≥ γ 
We choose a clinically meaningful difference of 𝛿 = 0.05. Given that both burden and expense for 
the addition of 14 d Atezolizumab mono-window in Arm A is low for the patients, a 𝛿 of 5% is 
sufficient to consider a result clinically relevant in this context. As a reference for this choice, 
consider also the Taxane meta-analysis by Peto et al. in [10]. As probability threshold for accepting 
significant superiority, 1 – α = 0.975 is chosen, and γ = 0.85 for relevant superiority. Both 
thresholds must be exceeded simultaneously to accept superiority in terms of the dual criterion. A 
more formal statement is provided in the next section after introducing additional notation. The 
use of the dual criterion is motivated by requiring more certainty during interim decision-making 
based on lower sample sizes. Inclusion of a relevance criterion decreases the chance of acting 
based on spurious sampling results at an interim analysis and also notably reduces the type I error 
rate in simulations of the trial. 
Bayesian inference calculus 
For a complete summary and derivation of all probability terms involved in a proof-of-concept trial 
with binary endpoints, see [2]. Below we give a short description for illustrative purposes. 
Bayesian inference calculus formalizes all uncertainty in a given problem context in terms of 
probability distributions. Before observing data, prior distributions are assigned to all random 
variables in the problem context. After observing data, an inference step is carried out by updating 
prior probabilities to conditional posterior probabilities via Bayes theorem. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 102 of 118 
We assign a joint uniform prior to pCR rates (pA, pB) in experimental (A) and control arm (B) 
respectively to obtain a joint posterior distribution as product of beta distributions. In the notation 
of a Bayesian hierarchical model where 𝑥𝐴, 𝑥𝐵∈{0, 1, … , 𝑛} denote observed responses in the two 
arms with n patients evaluable in each arm, 
𝑝𝐴∼𝑈(0,1) 
𝑝𝐵∼𝑈(0,1) 
𝑝𝐴|𝑥𝐴∼𝐵𝑒𝑡𝑎(𝛼𝐴,  𝛽𝐴) 
𝑝𝐵|𝑥𝐵∼𝐵𝑒𝑡𝑎(𝛼𝐵,  𝛽𝐵) 
Assuming a uniform prior distribution entails the knowledge that pCR can be obtained in both arms 
but expresses complete uncertainty with respect to its actual rate. The main inference step is 
realized by reporting the joint posterior probability distribution 
Pr(pA , pB | xA, xB) = P(pA | xA) P(pB | xB) 
This leads to the following parametrization for the joint posterior distribution above which realizes 
the update step via Bayes theorem from uniform prior to informed posterior: 
𝛼𝐴= 1 + 𝑥𝐴,      𝛽𝐴= 1 + 𝑛−𝑥𝐴 
𝛼𝐵= 1 + 𝑥𝐵,      𝛽𝐵= 1 + 𝑛−𝑥𝐵 
 
The joint distribution and its marginals are the basis for all further inference and can be used to 
● directly derive Pr(θ ≥ δ | xA, xB) for θ = pA – pB (see [2] for details), 
● compute point estimators (expected value) for θ, pA and pB,  
● compute confidence intervals (high posterior density interval) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fig. 1: Exemplary posterior density function for a hypothetical pCR rate p. 
We report full (marginal) posterior distributions for the inference step. The primary objective can 
now be stated as follows. 
Primary objective: to show superiority in terms of the dual criterion, i.e. accept superiority of 
experimental arm over control arm at the end of the trial if 
𝑃(𝑝𝐴> 𝑝𝐵 | 𝑥𝐴,  𝑥𝐵) ≥0.975      ⋀      𝑃(𝑝𝐴−𝑝𝐵> 𝛿 | 𝑥𝐴,  𝑥𝐵) ≥0.85 
 
Bayesian confidence  
interval:  
high posterior  
density interval 
point estimator:  
expected value 
exemplary posterior density function 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 103 of 118 
with a clinically meaningful difference of 𝛿= 0.05. 
Planned interim analyses 
Prior estimates for pCR rates in the two therapy arms are subject to a high degree of uncertainty. 
To make an attempt at accounting for ethical and financial risks of the trial in the statistical design 
we make use of the flexibility provided by Bayesian inference calculus to plan a maximal number 
of interim analyses, so as to be able to conclude the trial for futility or success at an early time, 
depending on the true unknown effect size. 
We employ predictive probabilities of trial success to specify stopping rules for futility and success 
and use Monte Carlo simulations of the full trial, including a grid of interim analyses to be 
determined, 
to 
evaluate 
corresponding 
frequentist 
operating 
characteristics 
(see 
recommendations in [6], and further theory in [7], chp. 4). 
Assuming a balanced randomization between arms, at the i’th interim analysis 𝑚𝑖 additional 
patients are yet to be observed per arm. A predictive probability PP(i) is then defined informally 
as 
PP(i) := P{trial success | current pCR rates in arms A and B}. 
More formally (see also [2] and [7] for reference), at an interim analysis where in both arms n < 
nmax patients have been observed, with nmax the maximum sample size per arm,  
• 
let Y be the number of responses in the potential m = nmax – n future patients of one particular 
arm after x responses have been observed in n patients so far,  
 
𝑌∼𝐵𝑒𝑡𝑎𝐵𝑖𝑛𝑜𝑚𝑖𝑎𝑙(𝑚,  1 + 𝑥,  1 + 𝑛−𝑥) 
 
• 
let B(i, j, 𝛿) = Pr(θ ≥ 𝛿 | XA = xA + YA, XB = xB + YB, YA = i, YB = j), where θ = pA – pB, 
• 
let 𝐼𝑖,𝑗 = 𝐼[B(i, j, 0) ≥ 0.975  ⋀  B(i, j, 0.05) ≥ 0.85] be the indicator function of the dual criterion, 
then 
 
 
𝑃𝑃∶= 𝐸[𝐼𝑖,𝑗|𝑥𝐴, 𝑥𝐵, 𝑛] = ∑
∑
Pr(𝑌𝐴= 𝑖 | 𝑥𝐴, 𝑛, 𝑚) × Pr(𝑌𝐵= 𝑗 | 𝑥𝐵, 𝑛, 𝑚) × 𝐼𝑖,𝑗.
𝑚
𝑗=0
𝑚
𝑖=0
 
 
At any interim analysis the trial is stopped early for futility if 𝑃𝑃≤0.025, or stopped early for 
success if 𝑃𝑃≥0.975, i.e. predictive probabilities for trial success in terms of the dual criterion are 
exceedingly low or high, respectively. 
 
The statistical design is evaluated by simulation (further details follow below) to determine an 
optimal grid of interim analyses, assuming that recruitment is ongoing during the analyses and will 
not be stopped. The analysis grid ends once the actual recruitment state affords no further 
decision making in terms of early termination. The analysis grid is chosen to provide a positive 
cost-benefit ratio with regard to the possibility of early termination. That is, we require a high 
probability of early termination if a true effect is absent, and generally an expected sample size 
that is significantly lower than a planned maximum Nmax = 2nmax across different pCR scenarios 
that might obtain during the trial. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 104 of 118 
The chosen grid starts with the first interim analysis after a burn-in period of 100 patients evaluable 
(50 per arm) and continues in blocks of 40 (20 per arm) unless recruitment is stopped early or has 
reached 𝑁𝑚𝑎𝑥. Assuming a moderate to high recruitment rate of 15 patients per month (e.g. 30 
sites each recruiting 0.5 patients per month), we estimate a period of 32 weeks between 
randomization of the last patient in a block of 20 to monitored data of baseline and surgery results 
ready for analysis in each block. This creates an assumed minimum offset of 120 patients that 
have been recruited during the preparation of each interim analysis and defines the last feasible 
interim analysis time point in terms of evaluable patients before the trial has reached maximum 
recruitment numbers. At that point, the recruitment state affords no further decision making. The 
planned number of interim analyses thus depends on the maximal sample size that is estimated 
in simulations, as described in the following section. 
Sample size calculation and operating characteristics 
As recommended in [6], chp. VI.A, we calibrate the maximal sample size Nmax according to 
frequentist operating characteristics (OC) by numerical simulation. That is, we perform 10 million 
repetitions in a comprehensive Monte Carlo simulation of the full adaptive trial with all interim 
analyses. Based on the simulation results we count decisions for accepting or rejecting the dual 
criterion superiority hypothesis stated in section 1.2. By evaluating corresponding relative counts 
in dedicated scenarios for a nullhypothesis (𝑝𝐴= 𝑝𝐵) or specific alternative (e.g. 𝑝𝐴−𝑝𝐵≥0.15) 
type I error rate and power are determined respectively for a given maximal sample size and 
interim analysis grid. 
Note that multiple testing issues are automatically addressed here by controlling the global type I 
and II error rates in the full trial simulation.  
Due to the nature of the dual criterion, the nullhypothesis scenarios for the true effect size θ entail 
0 ≤𝜃≤0.05. We require for the nullhypothesis with respect to significant superiority (scenario 
𝑝𝐴= 𝑝𝐵) that the type I error rate 𝛼≤0.025. In the context of a proof-of-concept trial, a larger 𝛼 
around 0.1 is acceptable for the nullhypothesis with respect to relevant superiority (scenario 0 <
 𝜃≤0.05). With regard to a specific alternative hypothesis, the trial must yield a power ≥0.8 to 
detect a difference in pCR rates of 𝜃= 0.15, which is suggested based on preliminary results 
published in [8]. A visual representation of the different 𝜃 scenarios and required operating 
characteristics is given in Fig. 2 below. 
 
Fig. 2: Scenarios for true effect size 𝜃 and required operating characteristics. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 105 of 118 
Based on extensive simulation results, 𝑁𝑚𝑎𝑥= 370 (185 per arm) evaluable was determined, with 
a planned grid of 4 interim analyses to be performed at the following counts for patients 
evaluable, assuming balanced randomization across both arms: 
[100, 140, 180, 220] 
Following results in the Keynote-522 trial (see [9]), investigating 602 patients treated with 
Pembrolizumab in combination with 4 cycles of Paclitaxel + Carboplatin followed by 4 cycles of 
Doxorubicin or Epirubicin + Cyclophosphamide, we chose a conservative lower bound for pCR 
rates at 45% to anchor the following scenarios for the true effect 𝜃: 
 
Scenario 
OC 
P(correct early stop) 
expected 
sample size 
H0 significance: 
 𝑝𝐴= 45%,   𝑝𝐵= 45% 
type I error: 2.4% 
68.5% 
296 
H0 relevance: 
 𝑝𝐴= 49%,   𝑝𝐵= 45% 
type I error: 10.9% 
46.3% 
321 
H1: 𝑝𝐴= 60%,  𝑝𝐵= 45% 
power: 80.1% 
34.9% 
332 
 
Note that our primary measure of confidence is given in terms of the Bayesian posterior probability 
thresholds (see section 1.2, primary objective dual criterion), which we fix a priori and then proceed 
to select a sample size such that the common standards for frequentist operating characteristics 
in case of one-sided superiority (i.e. 𝛼= 0.025, 1 −𝛽= 0.8) are met as upper or lower bounds 
respectively. We accept the slightly conservative type I error rate that obtains as a result in 
conjunction with the discrete event space.  
We assume an analysis dropout rate of 10% for the primary objective, where an analysis dropout 
is defined as any patient for whom a critical analysis-enabling covariate or the primary endpoint is 
not measurable for any reason, thus requiring 412 patients to be randomized, i.e. 206 per arm in 
a 1:1 randomization. In addition, we account for a 10% screening failure rate. As a result, the 
maximum number of patients to be recruited is set to 458.  
In Fig. 3 below we show how the probability of early stopping changes as a function of effect size. 
The graph shows a trough in overall stopping probability (black) in between the H1 scenario and 
the H0-relevance scenario, where early discriminatory power based on the predictive probabilities 
is lowest. While in the H0 scenario the futility stopping criterion is most active (red graph), the roles 
change and early stopping for success (blue) increases beyond the trough area. Note that in the 
H0 scenario the blue success curve is practically zero, whereas the red futility curve is still of 
substantial magnitude in the H1 scenario, which reflects the different utility weighting of type I error 
(only 2.5%) and type II error (20% acceptable) at the level of probabilities for early termination 
causes. 
In addition, we show in Figs. 4 and 5 cumulative stopping probabilities (for all causes) across the 
interim and final analysis time points for the dedicated H0 and H1 scenarios respectively, as a 
function of expected recruited patient numbers using the same recruitment assumptions as before. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 106 of 118 
 
Fig. 3: Probability of early stop as a function of effect size. Stopping for any reason is counted 
(black graph), including erroneous stopping decisions (type I or II error, depending on the scenario, 
cmp. Fig. 2). Directional stopping is indicated by the two additional graphs, red for futility and blue 
for success. 
 
 
Fig. 4: Cumulative stopping probabilities (for all causes) across interim analyses in H0 scenario. 
 
No. recruited patients, assuming 120 patients recruitment offset (see text above) 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 107 of 118 
 
Fig. 5: Cumulative stopping probabilities (stopping for all causes) across interim analyses in H1 
scenario. 
 
References 
[1] Fisch, Roland, et al. "Bayesian design of proof-of-concept trials." Therapeutic innovation & 
regulatory science 49.1 (2015): 155-162. 
[2] Sverdlov, Oleksandr, Yevgen Ryeznik, and Sheng Wu. "Exact Bayesian inference comparing 
binomial proportions, with application to proof-of-concept clinical trials." Therapeutic innovation & 
regulatory science 49.1 (2015): 163-174. 
[3] Roychoudhury, Satrajit, Nicolas Scheuer, and Beat Neuenschwander. "Beyond p-values: A 
phase II dual-criterion design with statistical significance and clinical relevance." Clinical Trials 
15.5 (2018): 452-461. 
[4] Pulkstenis, Erik, Kaushik Patra, and Jianliang Zhang. "A Bayesian paradigm for decision-
making in proof-of-concept trials." Journal of biopharmaceutical statistics 27.3 (2017): 442-456. 
[5] Smith, Claire L., et al. "Applications of Bayesian statistical methodology to clinical trial design: 
A case study of a phase 2 trial with an interim futility assessment in patients with knee 
osteoarthritis." Pharmaceutical statistics 18.1 (2019): 39-53. 
[6] FDA GUIDANCE. "Adaptive Designs for Clinical Trials of Drugs and Biologics." Center for 
Biologics Evaluation and Research (CBER) (2019).  
[7] Berry, Scott M., et al. Bayesian adaptive methods for clinical trials. CRC press, 2010. 
[8] Loibl, S., Untch, M., Burchardi, N., Huober, J. B., Blohmer, J. U., Grischke, E.-M., … Rezai, M. 
(2018). Randomized phase II neoadjuvant study (GeparNuevo) to investigate the addition of 
durvalumab to a taxane-anthracycline containing chemotherapy in triple negative breast cancer 
(TNBC). American Society of Clinical Oncology. 
No. recruited patients, assuming 120 patients recruitment offset (see text above) 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 108 of 118 
[9] Schmid P. et al., ESMO 2019 Congress. Keynote-522: Phase 3 study of pembrolizumab + 
chemotherapy vs placebo + chemotherapy as neoadjuvant treatment, followed by pembrolizumab 
vs placebo as adjuvant treatment for early-stage high-risk triple-negative breast cancer. Annals of 
Oncology (2019) 30 (suppl_5): v851-v934. 10.1093/annonc/mdz394 
[10] Comparisons between different polychemotherapy regimens for early breast cancer: meta-
analyses of long-term outcome among 100,000 women in 123 randomised trials. Early Breast 
Cancer Trialists' Collaborative Group (EBCTCG), Peto R, Davies C, Godwin J, Gray R, Pan HC, 
Clarke M, Cutter D, Darby S, McGale P, Taylor C, Wang YC, Bergh J, Di Leo A, Albain K, Swain 
S, Piccart M, Pritchard K Lancet. 2012;379(9814):432 
 
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 109 of 118 
12.10. Appendix 10: Study governance considerations 
 
 12.10.1. Regulatory and ethical considerations 
 
This study will be conducted in accordance with the protocol and with the following: 
● Consensus ethical principles derived from international guidelines including the 
Declaration of Helsinki and Council for International Organizations of Medical Sciences 
(CIOMS) International Ethical Guidelines 
 
● Applicable ICH Good Clinical Practice (GCP) Guidelines 
 
● Applicable laws and regulations. For this protocol, the European regulation 536/2014 for 
clinical studies (if applicable) and the German drug law (AMG) as well as the German GCP 
Ordinance apply. 
✔ The protocol, protocol amendments, ICF, SmPCs, and other relevant documents 
must be submitted to the relevant Competent Authority and an IEC by the sponsor 
and reviewed and approved by the CA and IEC before the study is initiated.  
✔ Any amendments to the protocol will require CA and IEC approval before 
implementation of changes made to the study design, except for changes 
necessary to eliminate an immediate hazard to study participants.  
● The sponsor will be responsible for the following: 
✔ Providing written summaries of the status of the study to the CA and IEC annually  
✔ Notifying the CA and IEC of SAEs or other significant safety findings as required by 
the German drug law. 
● The investigator will be responsible for the following: 
✔ Providing oversight of the conduct of the study at the site and adherence to ICH 
guidelines, the IEC, European regulation 536/2014 for clinical studies (if applicable, 
when the portal will be available), and all other applicable local regulations. 
✔ Maintaining all study and site-specific approvals and correspondence with the CA 
and IEC within the investigator site file. 
✔ Patient Alert Card: all prescribers of Tecentriq® (Atezolizumab) must be familiar with 
the safety section of the Tecentriq® (Atezolizumab) IB and with the SmPCs of the 
chemotherapeutic agents used as IMP in the neoadjuvant phase. The prescriber 
must discuss the risks of Tecentriq® (Atezolizumab) therapy and of the CTX 
administration with the patient. The patient will be provided with the Patient Alert 
Card and instructed to carry the card at all times.  
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 110 of 118 
12.10.2. Financial disclosure 
 
Investigators and deputy will provide the sponsor with sufficient, accurate financial information as 
requested to allow the sponsor to submit complete and accurate financial disclosure statements 
to the IECs. Investigators are responsible for providing information on financial interests during 
the course of the study and for 1 year after completion of the study. 
 
12.10.3. Safety issues and serious breaches of the protocol or ICH GCP 
 
A “serious breach” is a breach which is likely to effect to a significant degree: 
● The safety of physical or mental integrity of the subjects of the trial; or  
● The scientific value of the trial. 
 
The PI at each participating site is responsible for notifying the sponsor within 24 hours of 
becoming aware of a serious breach. 
The sponsor is responsible for notifying the regulatory authorities (leading EC, local EC, 
competent authority (CA) and national CA) in writing of any serious breach (refer to section 9.12 
Protocol Violations). 
 
12.10.4. Informed consent process 
 
● The informed consent document(s) used during the informed consent process must be 
reviewed and approved by the sponsor, approved by the IEC before use, and available 
for inspection. 
● The investigator or his/her representative will explain the nature and objectives of the 
study and the possible risks associated with participation to the study patient or her 
legally authorized representative and answer all questions regarding the study.  
● Participants must be informed that their participation is voluntary. Participants or their 
legally authorized representative will be required to sign a statement of informed 
consent that meets the requirements of regulatory and legal regulations and the ICH 
GCP guidelines. 
● The investigator will retain the original of each patient’s signed consent document. The 
patient or its legally authorized representative will be provided with a copy of the signed 
ICF(s). 
● The medical record must include a statement that written informed consent was 
obtained before the participant was enrolled in the study and the date the written 
consent was obtained. The authorized person obtaining the informed consent must 
also sign and date the ICF. 
● Participants must be re-consented to the most current version of the ICF(s) during their 
participation in the study.  
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 111 of 118 
12.10.5. Data protection 
 
● Study patients will be assigned a unique identifier by the sponsor. Any study patient 
records or datasets that are transferred to the sponsor will contain the identifier only; 
study patients names or any information which would make the participant identifiable 
will not be transferred. The European General Data protection Regulation as well as 
the AMG will apply for this study. 
● The study patients must be informed that their personal study-related data will be used 
by the sponsor in accordance with local data protection law. The level of disclosure 
must also be explained to the study patient.  
● The participant must be informed that her medical records may be examined by Clinical 
Quality Assurance auditors or other authorized personnel appointed by the sponsor, 
by appropriate IEC members, and by inspectors from regulatory authorities. 
● By signing the ICF the patient gives this consent to the above-mentioned handling of 
his study-related data. 
 
12.10.6. Publication policy 
 
● The results of this study may be published or presented at scientific meetings. If this is 
foreseen, the investigators agree to submit all manuscripts or abstracts to ROCHE 
before submission. This allows ROCHE to protect proprietary information and to 
provide comments.  
● Any publication will comply with the requirements for publication of study results and 
refer to the recommendations of the International Committee of Medical Journal Editors 
for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical 
Journals (http://www.icmje.org/icmje-recommendations.pdf). 
● ROCHE will be mentioned as financier within publications of the results of this trial.   
● ROCHE will support the first publication of trial results in their entirety and not as 
individual site data.  
● ROCHE will have an opportunity to review the first publication 60 days (14 days for 
abstracts) before it will be submitted for publication or otherwise disclosed. 
● In case of Congress presentations ROCHE will have an opportunity for review at least 
15 days before submission. 
● For any publication/abstract review, the ROCHE’s proposed changes will be taken into 
consideration. 
● After the first publication of the trial results the participating investigators shall be at 
liberty to publish trial results in accordance with the sponsor. 
● Authorship will be determined by mutual agreement and in line with International 
Committee of Medical Journal Editors authorship requirements. 
 
 
 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 112 of 118 
12.10.7. Data quality assurance 
 
● All participant data relating to the study will be recorded on electronic CRF. The 
investigator is responsible for verifying that data entries are accurate and correct by 
electronically signing the CRF.  
● The investigator must maintain accurate documentation (source data) that supports 
the information entered in the CRF.  
● The investigator must permit study-related monitoring, audits, IEC review, and 
regulatory agency inspections and provide direct access to source data documents.  
● The sponsor is responsible for the data management of this study including quality 
checking of the data.  
● The clinical monitors will perform an ongoing off-site combined with a risk-assessed 
on-site monitoring to confirm that data entered into the CRF by authorized site 
personnel are accurate, complete, and selected critical data are verifiable from source 
documents, that the safety and rights of participants are being protected; and that the 
study is being conducted in accordance with the currently approved protocol and any 
other study agreements, ICH GCP, and all applicable regulatory requirements (refer to 
Risk based monitoring (RBM) below).  
● During onsite monitoring visits investigator(s) and their relevant staff must be available. 
● Records and documents, including signed ICFs, pertaining to the conduct of this study 
must be retained by the investigator for 10 years after study completion or 
discontinuation unless local regulations or institutional policies require a longer 
retention period. No records may be destroyed during the retention period without the 
written approval of the sponsor. No records may be transferred to another location or 
party without written notification to the sponsor.  
 
12.10.8. Risk Based Monitoring (RBM) strategy 
 
Monitoring clinical data is a quality control (QC) activity which involves a system of ongoing checks 
to detect failures, to correct them, and prevent the failure from recurring. The overall goal of 
monitoring is to produce clinical data consistently.   
In this protocol, the RBM strategy will be applied as followed: RBM is an adaptive approach that 
directs monitoring focus and activities to the areas which have the most potential to impact patient 
safety and data quality. RBM provides an ability to evaluate and plan for risks before a study starts 
and continuously adapt monitoring activities to areas that have the most potential to impact patient 
safety and data quality. Study oversight is accomplished through an appropriate mix of central, 
off-site and on-site monitoring activities. 
On-site monitoring visit: In person evaluation carried out by sponsor/CRO personnel at the 
investigational site. On-site monitoring visits will focus on reviewing completeness and accuracy 
of ICFs, drug supply reconciliation, source document verification (SDV) and Source Data Review 
(SDR) of original records, and other issues that may occur during the course of the clinical trial. 
The activities are conducted regardless of the type of study, safety risks, phase of the study, stage 
of the study, or experience of the site personnel conducting the study. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 113 of 118 
Off-site monitoring or remote monitoring: Evaluation carried out by sponsor/CRO personnel 
outside the investigative site. It is a centralized review of individual site data. Data check is 
accomplished through regular phone monitoring with the study site personnel using monitoring 
questionnaires. 
Central monitoring: Review of centralized data focusing on risk indicator data between 
investigative sites within a clinical trial or across studies. This review may be performed by medical 
monitors, data managers, project managers, statisticians. 
The risks will be evaluated through a Key Risk Indicator (KRI) analysis which determines 
risks that could affect patient safety, data integrity, and/or regulatory compliance and: 
● Identifies how and by which functions risks will be managed 
● Categorizes risks which will be managed by and affect the monitoring plan (MP) 
● Determines overall risk level (green, yellow, red) for monitoring activities 
● Ensures that monitoring strategies (mitigation actions) are tailored to risks that are focused 
on critical data and processes 
 
The detailed risk analysis is described in the risk management plan (RMP). The monitoring 
processes are described in the study MP. 
 
12.10.9. Source documents 
 
● 
Source documents provide evidence for the existence of the participant and substantiate the 
integrity of the data collected. Source documents are filed at the investigator’s site. 
● 
Data reported on the eCRF that are transcribed from source documents must be consistent 
with the source documents or the discrepancies must be explained. The investigator may 
need to request previous medical records or transfer records, depending on the study. Also, 
current medical records must be available. 
● 
Any source document that is not directly integrated in the patient’s notes and created 
separately for the study or documented electronically may be used as “source document” only 
if this is specifically documented in the protocol. If a copy is made from an original document, 
the copy must be certified. In that case it will be made available at every study visit and will 
be filed and archived as study relevant source documents. 
 
12.10.10. Site closures 
 
The sponsor reserves the right to close the study site or terminate the study at any time for any 
reason at the sole discretion of the sponsor. In any other case, study sites will be closed upon 
study completion. An active study site is considered closed when all required documents and 
study supplies have been collected and a study-site closure visit has been performed. For sites 
which didn’t recruit patients (inactive site) no closure visit is necessary. 
The investigator may initiate study-site closure at any time, provided there is reasonable cause 
and sufficient notice is given in advance of the intended termination. 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 114 of 118 
Reasons for the early closure of a study site by the sponsor or investigator may include but are 
not limited to: 
● Failure of the investigator to comply with the protocol, the requirements of the IEC or local 
health authorities, the sponsor's procedures, or GCP guidelines 
● No recruitment of study patients by the investigator in a defined period as defined by the 
sponsor study team. 
 
12.10.11. Study design and management: initiation, managing, funding of the clinical trial 
 
The study is funded by ROCHE. palleos healthcare GmbH is conducting this trial as a sponsor 
(organizing, managing and running the clinical trial) 
 
12.10.12. Patient expenses/payments 
 
There are no participants study payments designated. 
 
12.10.13. Insurance 
 
The sponsor will provide patient insurance for the clinical trial for all study participants in 
accordance with the AMG. 
 
12.10.14. Steering Committee (SC) 
 
The SC members are listed on page 3. The role of the SC will be to provide overall supervision of 
the trial and to ensure that it is being conducted in accordance with the principles of GCP and the 
relevant regulations. The SC will provide advice to the investigators on all aspects of the trial.  

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 115 of 118 
12.11. Appendix 11: Abbreviations and trademarks 
 
AE 
Adverse event 
AESI 
Adverse event of special interest 
AGO 
Arbeitsgemeinschaft Gynäkologische Onkologie E.V 
ALK 
Alkaline phosphatase 
ALT 
Alanine aminotransferase 
AMG 
“Arzneimittelgesetz” (German drug law) 
ANC 
Absolute neutrophile count 
Anti-TNF 
Anti-tumor necrosis factor 
AST 
Aspartate aminotransferase 
AT 
As treated 
AUC 
Area under the curve 
BRCA 
Breast cancer 
CA 
Competent authority 
CAPA 
Corrective and preventive action 
CCCA 
Complete Cell Cycle Arrest 
CelTIL 
Combined score based on tumor cellularity and TILs 
CHF 
Congestive heart failure 
CIOMS 
Council for International Organizations of Medical Sciences 
CT 
Computerized tomography 
CTC 
Common Terminology Criteria 
CTCAE 
Common Terminology Criteria for Adverse Events 
ctDNA 
circulating tumor Deoxyribonucleic acid 
CTX 
Chemotherapy 
DC 
Dendritic cell 
DCIS 
Ductal carcinoma in-situ 
DFS 
Disease Free Survival 
DRF 
Death report form 
DSMB 
Data Safety Monitoring Board 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 116 of 118 
DSUR 
Development Safety Update Report 
EC 
Ethic committee 
ECG 
Electrocardiogram 
ECOG 
Eastern Cooperative Oncology Group 
EDC 
Electronic Data Capture 
EFS 
Event Free Survival 
EGFR 
Epidermal growth factor receptor 
EOS 
End of study 
EOT 
End of treatment 
(e)CRF 
(Electronic) case report form 
ER 
Estrogen receptor 
FPI 
First patient in 
GCP 
Good clinical practice 
G-CSF 
Granulocyte Colony Stimulating Factor 
hCG 
Human Choriongonadotropin 
HER 
Human epidermal growth factor receptor 
IB 
Investigator’s brochure 
ICF 
Informed consent form 
IEC 
Independent Ethics Committee 
IHC  
ImmunoHistoChemistry 
IMP 
Investigational Medicinal Product 
irAE 
Immune-related adverse event 
ISH 
In-Situ-Hybridization 
ITT 
Intention-to-treat 
IUD 
Intrauterine device 
IV 
Intravenous 
KI 
Karnofsky index 
KRI 
Key Risk Indicator 
LPLV 
Last patient last visit 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 117 of 118 
LVEF 
Left ventricular ejection fraction 
MAR 
Missing at random 
MedDRA 
Medical Dictionary for Regulatory Activities 
MM 
Medical monitor 
MP 
Monitoring plan 
MRI 
Magnetic Resonance Imaging 
mTNBC 
Metastatic triple negative breast cancer 
NCI 
National Cancer Institute 
NMAR 
Not-missing at random 
NYHA 
New York Heart Association 
OS 
Overall survival 
pCR 
Pathological complete response 
PD 
Progressive disease 
PD-L1 
Programmed cell Death 1 Ligand 1 
PET 
Positron emission tomography 
PI 
Principal investigator 
PP 
Per Protocol 
PP (italic) 
Predictive probability 
PR 
Progesterone Receptor 
QC 
Quality control 
QTc 
QT corrected interval 
RBM 
Risk based monitoring 
RMP 
Risk management plan 
SAE 
Serious adverse event 
SC 
Steering Committee 
SDR 
Source data review 
SmPC 
Summary of Product Characteristics 
SOA 
Schedule of Activity 
SOC 
Standard of Care 

 
 
 
 
2023-10-24_Protocol neoMono_V7.0_final 
 
 
Confidential 
Page 118 of 118 
SUSAR 
Suspected unexpected serious adverse reaction 
TILs 
Tumor-Infiltrating Lymphocytes 
TMA 
Tissue Microarrays 
TNBC 
Triple Negative Breast Cancer 
UICC 
The Union for International Cancer Control 
ULN 
Upper Limit of Normal