Cancer: Rapid Diagnostics and Immune Assessment for SARS-CoV-2 (COVID-19)
Conditions: Infectious Disease, Cancer, Coronavirus Infection
Sponsor: Royal Marsden NHS Foundation Trust

 
 
 
 
 
 
 
CARDS 
 
Cancer: Rapid Diagnostics and Immune assessment for SARS-CoV-2 (COVID-19) 
 
Clinical Protocol Version 3.0, Dated 10th July 2020 
 
 
Chief Investigator:  Dr Sheela Rao 
Royal Marsden Gastrointestinal & Lymphoma Trials Unit  
Study Sponsor: The Royal Marsden NHS Foundation Trust, 
Downs Road, Sutton, Surrey SM2 5PT 
Research Ethics Committee Newcastle & North Tyneside 1 REC No 20/NE/0139 
RM CCR: 5287 
 
 
Study Sponsor: 
Royal Marsden NHS Foundation Trust 
Downs Road 
Sutton, Surrey SM2 5PT 
United Kingdom 
Telephone: +44 (0)20 8661 3279 
 
Chief Investigator: 
Dr Sheela Rao 
Royal Marsden NHS Foundation Trust 
Downs Road 
Sutton, Surrey SM2 5PT 
United Kingdom 
Telephone: +44 (0) 208 661 3159 
 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 2 of 42 
 
2 
 
Trial Physician: 
Dr David Lau 
GI and Lymphoma Unit 
Royal Marsden NHS Foundation Trust 
Telephone: +44 (0)20 8642 6011 ext 4485 
Email: david.lau2@rmh.nhs.uk  
Senior Trial Managers: 
Ms Sue Cromarty 
Ms Shannon Kidd 
Gastrointestinal & Lymphoma Trials Unit 
Telephone: +44 (0)20 8661 3807  
Email: shannon.kidd@rmh.nhs.uk,  
sue.cromarty@rmh.nhs.uk  
Lead Statistician 
Ms Clare Peckitt 
Royal Marsden NHS Foundation Trust 
Downs Road, Sutton, Surrey SM2 5PT 
United Kingdom 
Telephone: +44 (0)20 8915 6261 
Senior Statistician: 
Ms Maria Aresu 
Royal Marsden NHS Foundation Trust 
Downs Road, Sutton, Surrey SM2 5PT 
United Kingdom 
Telephone: +44 (0)208 661 3224 
Confidentiality Notice 
This document contains confidential information of the Gastrointestinal & Lymphoma Trials Unit of 
the Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London.  
This document must not be disclosed to anyone other than the study staff and members of the 
Newcastle & North Tyneside 1 Research Ethics Committee. 
The information in this document cannot be used for any purpose other than the evaluation or 
conduct of the clinical investigation without the prior written consent of the Gastrointestinal & 
Lymphoma Trials Unit of the Royal Marsden NHS Foundation Trust. 
 
 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 3 of 42 
 
3 
 
 
PROTOCOL SIGNATURE PAGE 
 
Study title: Cancer: Rapid Diagnostics and Immune assessment for SARS-CoV-2 
 
Acronym: CARDS 
Protocol version number: 3.0 
Version date: 10th July 2020 
Approved by Chief Investigator: 
 
____________________________ 
Name: Dr Sheela Rao 
Date:  
 
Investigator’s Agreement 
I have read the attached protocol entitled CARDS (version 3.0, dated 10th July 2020) and agree to 
abide by all provisions set forth therein. 
I agree to comply with the principles of Good Clinical Practice (GCP), the EU and GCP Directives 
(2001/20/EC; 2005/28/EC) and The Medicines for Human Use (Clinical Trials) Regulations and 
Amendment Regulations 2006 (Statutory Instrument 2006 No. 1928). 
 
I agree to ensure that the confidential information contained in this document will not be used for 
any purpose other than the evaluation or conduct of the clinical investigation without the prior 
written consent of the Gastrointestinal & Lymphoma Trials Unit of the Royal Marsden NHS 
Foundation Trust. 
 
 
Signature 
 
 
Name of Principal Investigator 
 
 
Centre Name 
 
 
Date     (DD/MM/YYYY) 
 
 
 
 
 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 4 of 42 
 
4 
 
 
Co-investigators & Research Team 
 
RMH denotes ‘The Royal Marsden NHS Foundation Trust.’ 
 
Investigator: 
 
 
Professor David Cunningham (RMH) 
 
Investigator: 
 
 
Dr Ian Chau (RMH) 
Investigator: 
 
 
Dr David Watkins (RMH) 
Investigator: 
 
 
Dr Naureen Starling (RMH) 
Investigator: 
 
 
Dr Charlotte Fribbens (RMH) 
Investigator: 
 
 
Dr Susana Banerjee (RMH) 
Investigator: 
 
 
Dr Alison Reid (RMH) 
Investigator: 
 
 
Professor Mary O’Brien (RMH) 
Investigator: 
 
 
Dr Sophie McGrath (RMH) 
Investigator: 
 
 
Dr David Lau (RMH) 
Trial Managers:  
 
Shannon Kidd (RMH) 
 
 
 
 
Sue Cromarty (RMH) 
Microbiologists:  
Dr Unell Riley (RMH) 
 
Dr Firza Gronthoum (RMH) 
Tissue Coordinator: 
 
Ms Ruwaida Begum (RMH) 
Statistician: 
 
 
Ms Clare Peckitt (RMH)/ Maria Aresu (RMH) 
Research nurse(s): 
 
Ms Julie Duncan (RMH)/ Ms Alexandra Diaz (RMH) 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 5 of 42 
 
5 
 
Collaborators:  
Dr Timothy Planche (St George’s University of London) 
 
Prof Sanjeev Krishna (St George’s University of London) 
 
 
 
Dr Joe Fitchett (Mologic) 
 
Trial Management Group: 
Dr Sheela Rao 
Professor David Cunningham 
Dr Ian Chau 
Dr Naureen Starling 
Dr David Watkins 
Dr David Lau 
Ruwaida Begum 
Clare Peckitt/ Maria Aresu 
Sue Cromarty 
Shannon Kidd 
Julie Duncan 
Shelby Hatt 
Protocol design and development: Dr Sheela Rao, Dr Timothy Planche, Clare Peckitt, Maria Aresu, 
Sue Cromarty, Shannon Kidd and Dr David Lau. 
 
This protocol has yet to be reviewed and approved by the Committee for Clinical Research (CCR), 
Research and Ethics Committee (REC) and Health Research Authority (HRA). 
 
 
 
Note: All queries about this trial should be addressed to the GI & Lymphoma Trials Unit, including 
clinical queries. Clinical queries will then be referred to the Trial Physician or Chief Investigator. 
 
 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 6 of 42 
 
6 
 
Contents 
1. Protocol synopsis ................................................................................................................................ 8 
2. Objectives .......................................................................................................................................... 11 
3. Background ....................................................................................................................................... 11 
4. Rationale ........................................................................................................................................... 13 
5. Hypothesis ......................................................................................................................................... 16 
6. Aims ................................................................................................................................................... 16 
7. End Points ......................................................................................................................................... 17 
7.1 Primary endpoint ........................................................................................................................ 17 
7.2 Secondary endpoints .................................................................................................................. 17 
7.3 Exploratory endpoints:................................................................................................................ 18 
8. Inclusion/Exclusion Criteria ............................................................................................................... 18 
8.1 Number of patients ..................................................................................................................... 18 
8.2 Inclusion criteria .......................................................................................................................... 18 
8.3 Exclusion criteria ......................................................................................................................... 19 
8.4 Subject withdrawal criteria ......................................................................................................... 19 
9. Methodology ..................................................................................................................................... 20 
9.1 Informed consent ........................................................................................................................ 20 
9.2 SARS-CoV-2 infection confirmation (Arm A) ............................................................................... 20 
9.3 Asymptomatic patients with no clinical suspicion of COVID-19 (Arm B) .................................... 20 
9.4 Personal protective equipment (PPE) ......................................................................................... 21 
10. Data acquisition .............................................................................................................................. 22 
11. Data analysis ................................................................................................................................... 22 
11.1 Baseline assessments ................................................................................................................ 22 
11.2 Specimen collection .................................................................................................................. 23 
12. Study Organisation/ Trial Monitoring and Management Strategy ................................................. 27 
12.1 Responsibilities ......................................................................................................................... 27 
12.2 Start date .................................................................................................................................. 28 
12.3 Patient screening and enrolment ............................................................................................. 28 
12.4 Patient withdrawal .................................................................................................................... 29 
12.5 Study duration .......................................................................................................................... 29 
12.6 End of study .............................................................................................................................. 30 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 7 of 42 
 
7 
 
13. Safety reporting .............................................................................................................................. 30 
14. Evaluation of Outcome/Statistical Considerations ......................................................................... 30 
14.1 Sample size ................................................................................................................................ 30 
14.2 Analysis plan ............................................................................................................................. 31 
14.3 Study monitoring ...................................................................................................................... 32 
15. Regulatory & Ethics Committee Approval ...................................................................................... 33 
15.1 Ethical considerations ............................................................................................................... 33 
15.2 Informed consent ...................................................................................................................... 34 
15.3 Patient confidentiality ............................................................................................................... 34 
16. Data Handling and Record Keeping ................................................................................................ 35 
16.1 Investigator Signatory Obligations ............................................................................................ 35 
16.2 Data Handling ............................................................................................................................ 35 
16.3 Study Documentation and Archive ........................................................................................... 36 
16.4 Quality assurance/audit ............................................................................................................ 36 
16.5 Annual reporting to REC ........................................................................................................... 37 
16.6 Sample labelling, storage and destruction ............................................................................... 37 
16.7 Use of information .................................................................................................................... 37 
17. Financing, Indemnity & Insurance .................................................................................................. 37 
18. Publication Policy ............................................................................................................................ 38 
19.  Abbreviations ................................................................................................................................. 38 
20. Protocol Summary of Changes ........................................................................................................ 40 
21. References ...................................................................................................................................... 41 
 
 
 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 8 of 42 
 
8 
 
1. Protocol synopsis 
 
Study title:  
Cancer: Rapid Diagnostics and Immune assessment for SARS-CoV-2 
 
Chief investigator: 
 
Dr Sheela Rao 
 
Study centres: 
The Royal Marsden NHS Foundation Trust  
 
Study period: 
Approximately 1 year 
 
Follow up duration: 
Up to 84 days 
 
Main objective: 
This observational study will investigate how host cancer status and 
immune 
phenotype 
links 
to 
SARS-CoV-2 
infection 
clinical 
presentation, seroconversion, and viral clearance. The study will also 
evaluate rapid antigen/antibody lateral flow tests. 
Methodology: 
Arm A: Suspected acute COVID-19 infection 
Throat/nose swabs, saliva and blood will be collected from patients 
undergoing investigation for suspected SARS-CoV-2 infection at the 
Royal Marsden NHS Foundation Trust on Day 0. Patients who are 
positive for SARS-CoV-2 by throat/nose RT-PCR or have a high 
clinical suspicion for acute COVID-19 will have further samples 
collected on D7 (if an inpatient), D14, D28, D42 and D56.  
 
Arm B: Asymptomatic patients with no clinical suspicion of COVID-
19 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 9 of 42 
 
9 
 
Blood will be collected from patients who do not have symptoms of 
COVID-19. Repeat blood will be collected on D28, D56 and D84. 
 
Research tests including serology and antigen/antibody lateral flow 
tests will be performed at St George’s University NHS Trust. 
Exploratory analyses including, but not limited to HLA-KIR profiling, 
blood immune cell activation and transcriptome and lateral flow 
testing will be carried out. Viral and immunological data will be 
collated in a link-anonymised manner and correlated to clinical 
outcome data. Samples will also be used to develop more rapid 
SARS-CoV-2 testing and assist in the future planning of ongoing or 
delayed treatment in cancer patients. 
 
Number of patients: 
 
Arm A: Up to 60 patients with confirmed diagnosis of SARS-CoV-2 by 
RT-PCR over the study period. 
Arm B: Up to 150 patients with no clinical suspicion of COVID-19 
Main inclusion criteria:  
1) Suspected COVID-19 infection undergoing diagnostic testing by 
SARS-CoV-2 RT-PCR or within 14 days of confirmed COVID-19 
infection by SARS-CoV-2 RT-PCR (Arm A) OR 
 
No symptoms of SARS-CoV-2 infection (Arm B) 
 
 
2) Metastatic or advanced solid organ malignancy, including 
lymphoma 
 
 
 
 
OR 
Early stage solid organ malignancy having received or planning to 
commence radiotherapy, chemotherapy or targeted agents 
 
3) Patient is ≥ 18 years of age. 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 10 of 42 
 
10 
 
 
4) Patient can understand the patient information sheet and is able 
to provide written informed consent. 
 
Exclusion criteria 
 
There are no exclusion criteria for this study. 
 
 
Primary endpoint:  
Proportion of patients, at each sample timepoint, with a positive 
detection of IgM and IgG specific antibodies to SARS-CoV-2. (Arms A 
and B) 
 
 
 
Secondary endpoints:  
To describe the clinical course of SARS-CoV-2 infection in cancer 
patients. This will include duration and severity of clinical symptoms, 
supportive treatments given, cancer treatments received and 
outcome of SARS-CoV-2 infection. (Arm A) 
Proportion of patients, at each sample timepoint, with SARS-CoV-2 
viral clearance by throat/nose swab by RT-PCR. (Arm A)  
Time from start of symptoms to Day 0 testing in the study. (Arm A) 
Feasibility of SARS-CoV-2 antigen testing with a throat/nose or saliva 
lateral flow assay (Arm A)  
Feasibility of SARS-CoV-2 antibody testing with a rapid lateral flow 
assay (Arms A & B) 
Exploratory analyses: 
Investigate antigen dynamics over time to compare with 
quantitative RT-PCR (Arm A) 
 
To examine HLA-KIR interactions that shape CD8 anti-viral responses 
(Arms A&B) 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 11 of 42 
 
11 
 
 
To explore the relationship between host immune genotype (e.g. 
HLA-KIR) and peripheral blood immune phenotype with viral 
clearance (Arms A&B) 
 
To investigate blood immune cell activation and transcriptome in 
participants (Arms A&B) 
 
2. Objectives 
This observational study will investigate how host cancer status and immune phenotype links to 
SARS-CoV-2 infection clinical presentation, seroconversion, and viral clearance. The study will also 
evaluate rapid antigen/antibody lateral flow tests.  
3. Background  
On 12 January 2020, a novel coronavirus was identified as the cause of an outbreak of unexplained 
pneumonia in Wuhan City, Hubei Province, China. This coronavirus was later named SARS-CoV-2, 
and the disease it causes COVID-19 [1]. 
SARS-CoV-2 is a non-segmented, positive sense RNA virus and part of the family of coronaviruses. 
Similar to the Systemic Acute Respiratory Syndrome (SARS) virus, it binds to the angiotensin-
converting enzyme 2 (ACE2) receptor located on type II alveolar cells and intestinal epithelia. SARS-
CoV-2 can result in a severe Acute Respiratory Distress Syndrome (ARDS) which is characterised by 
diffuse alveolar damage and direct viral cytopathic effect on pneumocytes [2]. Some patients who 
develop COVID-19 may respond with a fulminant “cytokine storm” reaction.  Co-morbidities such as 
hypertension, kidney disease and diabetes have been linked to poorer prognosis and clinical 
outcomes. However, a proportion of patients of younger age and without comorbidities also develop 
severe disease. 
As of 23 March 2020, a total of 374,921 COVID-19 cases have been reported in 168 countries with a 
total of over 16,411 deaths (case fatality amongst confirmed cases of 4.4%) [3] (John Hopkins’s 
Coronavirus Resource centre). Over 293,425 cases and 13,258 deaths have been reported from 
countries outside mainland China. The World Health Organisation (WHO) declared on the 12th of 
March 2020 the SARS-CoV-2 outbreak a pandemic in the context of a Public Health Emergency of 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 12 of 42 
 
12 
 
International Concern (PHEIC). Europe has rapidly become the epicentre of the pandemic and in the 
UK, cases are increasing daily. 
Based upon small observational studies, cancer patients are thought to be more susceptible in 
infection during a viral pandemic. In a retrospective analysis of a 1524 patients with a diagnosis of 
COVID-19 at a tertiary care hospital in Wuhan, China, a history of cancer (n=18) were at a higher risk 
of SARS-CoV-2 infection (OR 2.31; 95% CI 1.89-3.02). [3] In a chart review of 355 fatal cases of SARS-
CoV-2 infection in an Italian center, the median age of 79.5 years. The vast majority of patients had 
at least one medical co-morbidity. Strikingly, 20.8% patients had a history of cancer. [4] By contrast,  
an analysis of a UK-wide prospective database of cancer patients with COVID-19 infection (n=800) 
found the risk of death is driven mainly by age, gender and morbidities, rather than systemic anti-
cancer therapy or radiotherapy. [5]  
Amongst cancer patients at a French cancer centre, the rate of seroconversion 15 days after SARS-
CoV-2 infection was 30% versus 71% when compared to healthcare workers. [6]  
Little is known of the duration and severity of SARS-CoV-2 infection in cancer patients. Hence, SARS-
CoV-2 pandemic poses of clinical dilemma in the provision of anti-cancer therapy. NICE guidance 
states the level of immunosuppression associated with treatments, capacity issues and the risk of 
cancer not being treated with the risk of immunosuppression and becoming seriously ill from SARS-
CoV-2 infection. There is little data available which could inform clinicians on the timing of 
resumption of systemic anticancer treatment following recovery of SARS-CoV-2 infection. Similarly, 
the susceptibility of patients receiving immunotherapy to severe SARS-CoV-2 infection remains 
unclear. 
Because of the lack of a validated serological test, the actual number, and therefore the proportion, 
of people that develop asymptomatic infections remains unknown. This means that an accurate case 
fatality estimate remains elusive. Due to the rise of the number of samples to diagnose, tests are 
taking longer than expected. Among the foremost priorities to facilitate public health interventions 
is a reliable laboratory diagnosis. Prompt case confirmation is necessary to ensure rapid and 
effective contact tracing, implementation of infection prevention and control measures according to 
WHO recommendations, and collection of relevant epidemiological and clinical information. 
The SARS-CoV-2 antigen and antibody lateral flow assay (LFA) development has been led by Mologic, 
a company based in Bedford, England. We will use prototype LFA and ELISA that are ready for 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 13 of 42 
 
13 
 
preliminary evaluation, and subsequently use these tests on-site to evaluate the test at POC. LFA 
have been developed for SARS-CoV-2 antigen detection in throat/nose swabs and detection of IgG 
and IgM in blood/serum and SARS-CoV-2 antigen detection, IgG, IgM and IgA in saliva. Saliva is a 
convenient sample to use as it is far easier to use than blood or throat/nose swabs for potential self-
testing. 
The use of diagnostics developed within this study will improve the management of cases of COVID-
19 in cancer patients. The LFA are rapid, easy to use and designed to be affordable globally. The 
rapid diagnosis of SARS-CoV-2 with antigen detection will allow cancer patients to be rapidly triaged 
in hospital and General practitioner (GP) surgeries.  The use of antibody detection will allow both for 
diagnosis of immunological response to acute infections as well as after patients have recovered. To 
utilise these tests appropriately an understanding of dynamic immunopathological changes over 
time is necessary. 
Characterisation of immune response and susceptibility and its association with viral clearance and 
disease progression in large cohorts with varied disease severity is important to assist clinical risk 
prediction outcomes and inform clinical decisions in relation to delaying cancer treatment. Immune 
response characteristics may have predictive and prognostic value, with early adaptive immune 
responses possibly correlated with improved clinical outcomes [7].  
4. Rationale  
This study is a collaboration between in the GI & Lymphoma Unit (RMH), the Infectious Diseases and 
Microbiology Units (St Georges Hospital) and our commercial partner Mologic Ltd who have been 
funded by DFID/Wellcome Trust to develop SARS-CoV-2 assays. This prospective study is intended to 
prospectively monitor cancer patients infected with SARS-CoV-2. This study will be valuable to 
understanding the clinical presentation and course of SARS-CoV-2 infection in this population as well 
as the virological parameters such as viral clearance by RT-PCR and IgM/IgG seroconversion. Serial 
measurement of SARS-CoV-2 antibody titres in asymptomatic individuals will provide insights into 
the longitudinal immune status of cancer patients. 
This project will evaluate point-of-care/point-of-need (POC/PON) tests for the detection of the novel 
strain of coronavirus (2019 nCoV). We are working with Mologic Ltd, to develop a rapid, accurate 
and low cost, lateral flow assay (LFA) to detect viral circulating antigens and IgM/G against SARS-
CoV-2 in less than 15 minutes. These POC/PON tests are intended for the rapid triage of patients 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 14 of 42 
 
14 
 
with fever and/or cough and to identify patients likely to be immune from previous infections. In 
addition, we will evaluate ELISA assays, also produced by Mologic to detect IgG and IgM (and 
possibly IgA) against SARS-CoV-2. Comparison of antibody and antigen dynamics over time will 
compare with ELISA and quantitative RT-PCR. Mologic have been instrumental in developing rapid 
tests for Ebola virus disease and dengue. 
The ultimate diagnosis of SARS-Cov-2 is performed by laboratory testing as the clinical features are 
non-disease specific. Diagnostic testing of Covid-19 is currently undertaken using real-time reverse 
transcriptase PCR (RT-PCR) to detect the viral ribonucleic acid (RNA). These assays are sensitive but 
require transfer of samples to reference laboratories and thus results are obtained with a delay. In 
the UK, results are reported with a delay of 2-4 days, impeding the correct triage of patients, correct 
isolation measures and therefore putting the community and healthcare workers at risk. 
A fast and reliable diagnostic assay that could be used at the POC is yet to be developed. Our 
collaborators have been working closely with Mologic Ltd in 2020 on the development of highly 
sensitive POC/PON tests to facilitate diagnosis at the point of need and to reduce the consequences 
of diagnostic delay. Dual antigen and antibody test development has been led by Mologic. We will 
use prototype lateral flow tests and ELISA that are ready for preliminary evaluation, and 
subsequently use the lateral flow tests at St Georges University of London to evaluate the test at the 
point of need. Left over and anonymised samples will be used to evaluate other diagnostics if 
appropriate, an amendment will be submitted if this is the case.   
The information from our study will add significantly to the understanding of SARS-CoV-2 diagnostics 
and control and will improve the evidence-base for the management of cancer patients. 
Furthermore, data from this study could inform the timing and treatment for cancer patients who 
have recovered from SARS-CoV-2 infection.  
This study may also serve as a valuable platform for assessing patients who may be at exceptional 
risk of a poor outcome with SARS-CoV-2 infection. Depending on the number of patients assessment 
for a biomarker of interest, exploratory analyses may be undertaken to assess the role of a 
prognostic or predictive role of these biomarkers in relation to the patients’ clinical course and 
recovery.   
SARS-CoV-2 can lead to acute respiratory distress syndrome (ARDS) and fulminant “cytokine storm”. 
A recent case report of an immunocompetent patient diagnosed with a non-severe case of COVID-19 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 15 of 42 
 
15 
 
showed an increase in antibody-secreting cells (ASCs), immunoglobulin M (IgM), IgG antibodies 
follicular helper T cells (TFH cells), activated CD4+ T cells and CD8+ T cells. This patient did not 
experience ARDS or require supplemental oxygen and made a full recovery [7]. Evidence was 
provided of recruitment of immune cell populations (ASCs, TFH cells and activated CD4+ and CD8+ T 
cells), together with IgM and IgG SARS-CoV-2-binding antibodies, prior to resolution of symptoms. 
These immunological changes appear to persist for at least 7 days following resolution of symptoms. 
The kinetics and immune responses associated with clinical resolution of COVID-19 were analysed, 
showing that ASCs and TFH were recruited as part of the immune response during the acute phase 
of COVID-19 illness and continued to be prominent during convalescence. ASCs appeared in the 
blood at the time of viral clearance (day 7; 1.48%) before peaking on day 8 (6.91%). TFH cells were 
shown to occur concurrently in blood at day 7 (1.98%) continuing to increase on day 8 (3.25%) and 
day 9 (4.46%) of illness. When compared to healthy control participants, the peak of both ASCs and 
cTFH cells was markedly higher in the patient with COVID-19 (0.61% ± 0.40% and 1.83% ± 0.77%, 
respectively (average ± s.d.); n = 5) [7]. Given their immunosuppressed state, cancer patients are 
likely to have different immunological responses to COVID-19. 
Secondary haemophagocytic lymphohistiocytosis (sHLH) is a hyperinflammatory syndrome 
characterised by a fulminant and fatal hypercytokinaemia leading to multiorgan failure, most 
frequently triggered by viral infections [8]. Cardinal features of sHLH include unremitting fever, 
cytopenias, and hyperferritinaemia.  In a prospective cohort study of 41 patients confirmed to have 
COVID-19 disease a cytokine profile resembling sHLH was associated with disease severity. This 
profile was characterised by increased interleukin (IL)-2, IL-7, monocyte chemoattractant protein 1, 
macrophage inflammatory protein 1-α, and tumour necrosis factor-α, granulocyte-colony 
stimulating factor, interferon-γ inducible protein 10. 
In a retrospective multicenter study comparing 68 death cases (68/150, 45%) and 82 discharged 
cases (82/150, 55%) in patients with laboratory-confirmed infection of SARS-CoV-2, a significant 
difference was seen in C-reactive protein (CRP) and interleukin-6 (IL-6) between the two groups [9]. 
Further work needs to be done urgently to characterise immune parameters in cohorts of cancer 
patients with COVID-19 with varied clinical presentations and disease severities to identify predictive 
and prognostic biomarkers. It is vital to investigate how cancer patients with an impaired immune 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 16 of 42 
 
16 
 
system links to viral clearance and seroconversion and this forms one of the underlying aims of our 
study. The impact of systemic anti-cancer therapy on the host immunity status is unclear.  
 
5. Hypothesis 
Arm A: We hypothesise that cancer patients with SARS-CoV-2 infection will acquire immunity by 
seroconversion (IgG/IgM) which is measureable by an ELISA assay. Furthermore, we hypothesise the 
study cohort will clear SARS-CoV-2 virus by analysis of throat/nose swab RT-PCR.  
Arm B: We hypothesise systemic cancer treatments will result in a lower level of SARS-CoV-2 
antibodies. 
Arms A & B: We also hypothesise that antigen/antibody point of care testing by saliva, throat/nose 
swabs and blood will be a feasible diagnostic tool for the detection and monitoring of SARS-CoV-2 
infection.   
 
6. Aims 
Arm A: This is a prospective study which aims to define the clinical characteristics of SARS-CoV-2 
infection in cancers patients. The aim is to collect clinical data, throat/nose swabs, saliva and blood 
longitudinally to investigate viral clearance and seroconversion.  
 
Arm B: The arm of the study will investigate the prevalence of SARS-CoV-2 antibodies amongst 
patients with cancer. Clinical data and blood samples will be collected longitudinally to assess the 
impact of systemic therapy on SARS-CoV-2 antibody titres. 
  
In parallel, the study will also evaluate an antigen (Arm A) and IgG/IgM antibody (Arms A & B): point 
of care test (lateral flow assay) for the development of rapid detection of SARS-CoV-2. 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 17 of 42 
 
17 
 
7. End Points 
7.1 Primary endpoint 
Proportion of patients, at each sample timepoint, with a positive detection of IgM and IgG specific 
antibodies to SARS-CoV-2. Both IgM and IgG seroconversion will be reported separately. (Arms A & 
B) 
7.2 Secondary endpoints 
The secondary endpoints are as follows: 
 
The primary endpoint is to describe the clinical course of SARS-CoV-2 infection in cancer 
patients. This will include duration and severity of clinical symptoms, supportive treatments 
given, cancer treatments received and outcome of SARS-CoV-2 infection. (Arm A) 
 
 
Proportion of patients, at each sample timepoint, with SARS-CoV-2 viral clearance by 
throat/nose swab by RT-PCR.  (Arm A) 
 
 
Time from start of symptoms to Day 0 testing in the study. (Arm A) 
 
 
Feasibility of SARS-CoV-2 antigen testing with a throat/nose or saliva lateral flow assay (Arm 
A) will be assessed by the following  
1) Proportion of samples successfully collected, processed and result obtained 
2) Proportion of samples with a positive result by lateral flow by the gold standard (throat/nose RT-
PCR) 
If both of these are greater than 80% then the test would be considered successful and further 
research worthwhile. 
 
 
Feasibility of SARS-CoV-2 antibody testing with a rapid lateral flow assay will be assessed by 
the following (Arms A&B) 
o 1) Proportion of samples successfully collected, processed and result obtained 
o 2) Proportion of samples with a positive result by lateral flow by the gold standard 
(laboratory serology) 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 18 of 42 
 
18 
 
If both of these are greater than 80% then the test would be considered successful and further 
research worthwhile. 
 
7.3 Exploratory endpoints: 
  
The following endpoints and analyses are planned to be performed: 
 
Investigate antigen dynamics over time to compare with quantitative RT-PCR (Arm A) 
 
To examine HLA-KIR interactions that shape CD8 anti-viral responses (Arms A & B) 
 
To explore the relationship between host immune genotype (e.g. HLA-KIR) and peripheral 
blood (Arms A & B)immune cell phenotype with viral clearance (Arms A & B) 
 
To investigate blood immune cell activation and transcriptome in participants (Arms A & B) 
 
As the pandemic evolves, the priority of these exploratory endpoints are subject to change. Any 
other exploratory analyses not specified in this protocol will be ratified by the TMG prior to analysis. 
8. Inclusion/Exclusion Criteria 
8.1 Number of patients 
Arm A: Up to 60 patients with solid tumour malignancy or lymphoma with confirmed diagnosis of 
SARS-CoV-2 by RT-PCR will be recruited over the study period.  
Arm B: Up to 150 patients with solid tumour malignancy or lymphoma with no clinical suspicion of 
COVID-19 
Patients will be recruited from the Royal Marsden NHS Foundation Trust in both the inpatient and 
outpatient setting. 
 
8.2 Inclusion criteria 
 
1) Suspected COVID-19 infection undergoing diagnostic testing by SARS-CoV-2 RT-PCR or within 14 
days of confirmed COVID-19 infection by SARS-CoV-2 RT-PCR (Arm A)  
OR 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 19 of 42 
 
19 
 
No symptoms of SARS-CoV-2 infection (Arm B) 
 
 
2) Metastatic or advanced solid organ malignancy, including lymphoma 
 
 
 
 
OR 
Early stage solid organ malignancy having received or planning to commence radiotherapy, 
chemotherapy or targeted agents 
 
3) Patient is ≥ 18 years of age. 
 
4) Patient can understand the patient information sheet and is able to provide written informed 
consent. 
8.3 Exclusion criteria 
There are no exclusion criteria for this study. 
 
8.4 Subject withdrawal criteria 
Patients have the right to withdraw fully or partially from the study at any time and for any reason 
without prejudice to his or her future medical care by the physician at the institution. Patients who 
are withdrawn from the study will be replaced. 
Reasons for removal of patients from the study may include: 
 
withdrawal of consent (see above) 
 
administrative decision by the Investigator, Chief Investigator or Sponsor 
 
ineligibility 
 
patient non-compliance 
 
Patients enrolled to the study who have tested negative for SARS-CoV-2 by RT-PCR and have a low 
clinical suspicion of COVID-19 will be withdrawn. No further follow-up will be conducted. Patients 
who have previously provided written consent who have previously tested negative for SARS-CoV-2 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 20 of 42 
 
20 
 
can have the D0 assessments repeated if there are new symptoms suggestive of SARS-CoV-2 
infection. 
9. Methodology 
9.1 Informed consent 
All patients will be consented by any health care professional with GCP training who has been 
delegated by the Principal investigator can obtain consent from eligible patients. All staff taking 
consent will have received training and be approved as competent in taking consent for this study by 
the chief investigator. 
 
9.2 SARS-CoV-2 infection confirmation (Arm A) 
Following a baseline throat/nose swab, if SARS-CoV-2 infection is confirmed, clinical data and 
additional samples are collected at the study time-points outlined in section 11. If SARS-CoV-2 
infection is negative and deemed by the Investigator to have low clinical suspicion of SARS-CoV-2 
infection no further samples or data will be collected and the patient will come off study. In the case 
the SARS-CoV-2 throat/nose swab is equivocal, the patient will remain on study and repeat testing 
will be performed as per local standard (Figure 1, Table 2). If a patient has a negative swab result but 
deemed by the Investigator to have a high clinical suspicion of SARS-CoV-2 infection, then the 
patient will remain on study. Patients who are within 14 days of a positive for SARS-CoV-2 by RT-PCR 
are eligible for entry into Arm A and the initial visit will be designated D0. 
 
9.3 Asymptomatic patients with no clinical suspicion of COVID-19 (Arm B) 
Patients with no current symptoms of COVID-19 will be eligible for inclusion in Arm B. Following 
written consent, samples (blood) will be collected from patients. Blood will be collected from 
patients on Day 0, 28, 56 and 84 (Figure 1, Table 3). Attempts will be made to ensure these blood 
collections will coincide with standard of care hospital visits. 
Patients enrolled in Arm B develop COVID-19 symptoms or have confirmed COVID-19 can be invited 
to participate in Arm A. Patients will have to provide written consent for Arm A. 
 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 21 of 42 
 
21 
 
 
9.4 Personal protective equipment (PPE) 
All staff performing study assessments including informed consent will require adequate personal 
protective equipment and adherence to infection control guidelines as per hospital guidance. 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 22 of 42 
 
22 
 
Figure 1 study schema (Arms A and B):  
10. Data acquisition 
Clinical data including demographics, medical history, medications, vital signs and symptom 
assessment will be collected as described in the schedule of assessments at the time of study visits. 
Additional information will be supplemented from the electronic patient records as appropriate. 
Standard investigations such as haematology, biochemistry and imaging assessments will only be 
performed if indicated by the treating unit. Results of such investigations will be recorded in the CRF.  
11. Data analysis 
11.1 Baseline assessments 
Following initial eligibility checks and informed consent, the following baseline data will be collected. 
For Arm A and B: 
 
Patient demographics 
 
Medical history (including history of malignancy and treatment) 
 
Concomitant medications 
 
SARS-CoV-2 symptom assessment 
 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 23 of 42 
 
23 
 
 
For Arm A only: 
 
Vital signsHaematology, biochemistry and imaging results (if performed as part of clinical 
management) 
 
11.2 Specimen collection 
The schedule of visits and specimen collection for Arm A and B is outlined in Tables 2 and 3 
respectively. Each study visit has a window period to allow for flexibility of visits due to logistics and 
bank holidays. Refer to the lab manual for full details regarding the specimen collection and 
handling. 
 
Throat/nose swabs 
Throat/nose swabs will initially be collected at baseline (D0) as part of the diagnostic workup for 
SARS-CoV-2 infection. Subsequent throat/nose swabs will be taken at D7 (if an inpatient), D14, D28, 
D42 and D56. Two samples will be taken, one for standard of care testing and one for lateral flow 
assay and storage for further analysis later such as quantitative PCR.  
 
Saliva 
Saliva will be collected at each study visit, by asking the participant to provide a small amount of 
saliva (approximately 0.5mL) will be collected. Saliva will be tested by the lateral flow assay when 
available and excess material stored. 
 
Blood 
Approximately 30mL of blood will be taken at each study visit (Table 1).  
 
 
 
Table 1 Blood specimens to be collected in CARDS study 
Sample type 
Key analyte 
Serum (SST) 
SARS-CoV-2 antibody testing ie IgG, IgM 
Whole blood (EDTA) 
Immune profiling 
 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 24 of 42 
 
24 
 
As the assays are currently under investigation, results of the research assays (i.e. LFA, IgG/IgM 
serology) will not be made known to clinical teams. 
 
 
 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 25 of 42 
 
25 
 
 
 
Table 2. Schedule of assessments (Arm A) 
Assessment 
D0 
SARS-CoV-2 swab result check* 
D7a 
+/- 3 days 
D14 
+/- 3 days 
D28 
+/- 3 days 
D42 
+/- 3 days 
D56 
+/- 3 days 
Informed consent 
X 
 
 
 
 
 
Registration 
X 
 
 
 
 
 
Patient demographics 
X 
 
 
 
 
 
Medical historyb 
X 
 
 
 
 
 
Concomitant medications 
X 
X 
X 
X 
X 
X 
Symptom assessment 
X 
X 
X 
X 
X 
X 
Vital signsc 
X 
X 
X 
X 
X 
X 
Haematologyd 
X 
X 
X 
X 
X 
X 
Biochemistryd 
X 
X 
X 
X 
X 
X 
Imaging assessmentd 
X 
X 
X 
X 
X 
X 
Throat/nose swabe 
X 
X 
X 
X 
X 
X 
 
Blood (serum and EDTA 
whole blood)f 
X 
X 
X 
X 
X 
X 
Salivag 
X 
X 
X 
X 
X 
X 
 
Schedule of Assessments Table Key 
* Not applicable if patients have tested positive for SARS-CoV-2 prior to D0. If negative and has a low 
clinical suspicion of SARS-CoV-2 infection, the patient will be removed from the study.  
a: Only if an inpatient. D7 visit will be omitted for patients in the outpatient setting. 
b: Includes past medical history, oncological history 
c: Includes temperature, blood pressure, heart rate, respiratory rate, oxygen saturations by pulse 
oximetry. 
d: Results only to be recorded in CRF if performed as part of clinical management. 
e: Two samples will be taken, one for diagnostic testing and one for research purposes and storage 
for further analysis. 
f: For collection of serum and whole blood. See laboratory manual for full details 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 26 of 42 
 
26 
 
g: See laboratory manual for collection details. 
 
 
 
 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 27 of 42 
 
27 
 
Arm B: 
Blood 
Approximately 30mL of blood will be taken at each study visit (D0, D28, D56, D84). The blood 
samples taken are outlined in Table 3. 
 
 
Table 3. Schedule of assessments (Arm B)  
Assessment 
D0 
D28 
+/- 10 days 
D56 
+/- 10 days 
D84 
+/- 10 days 
Informed consent 
X 
 
 
 
Registration 
X 
 
 
 
Patient demographics 
X 
 
 
 
Medical history a 
X 
 
 
 
Concomitant medications 
X 
 
 
 
Symptom assessmentb 
X 
X 
X 
X 
Blood (serum and EDTA 
whole blood)b 
X 
X 
X 
X 
 
Schedule of Assessments Table Key 
a: Includes past medical history, oncological history 
b: See laboratory manual for full details 
 
12. Study Organisation/ Trial Monitoring and Management Strategy 
12.1 Responsibilities 
The Chief Investigator is responsible for forwarding the following documents to the study sponsor 
for review before study initiation from the sponsor can occur:  
 
Signed and dated protocol signature page (see Investigator’s Agreement on page 3)  
 
Copy of local research and development office and site specific assessment approvals, or 
equivalents thereof.  

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 28 of 42 
 
28 
 
 
Copy of approved patient information sheet and informed consent form on headed paper 
which will be used at the site  
 
Up-to-date curricula vitae of the Principal Investigator (hand-signed and hand-dated within 1 
year) 
 
GCP training certificate (which must be within 3 years)  
 
Contact details for key study personnel and completed, signed site delegation log  
 
Signed study contract/ HRA statement of activities   
Delegation logs will be kept which outline the allocation of responsibilities following adequate 
training: patients enrolment, monitoring study progress, the day-to-day running of the study, data 
collection, Case Report Forms, consent forms, data analysis, and data storage.  
Specimen collection will be performed by staff trained/experienced in the collection as per standard 
of care. This will not necessarily be a member of the study team. The study team will ensure the 
samples are anonymised prior to being sent for analysis. 
Transportation and storage will be arranged by a dedicated Translational team in the GI & 
Lymphoma Unit. Members of the team are GCP and IATA trained and certificates are available for 
review. 
12.2 Start date 
The study is reviewed and approved by the Committee for Clinical Research (CCR) only (as sponsor) 
prior to external regulatory review. Once REC/HRA review and approval is gained local R&D 
confirmation of capacity and capability is required before the study can start at a participating site. 
 
12.3 Patient screening and enrolment 
Patients will be considered as enrolled in the study after informed consent and registration has 
occurred. Any health care professional with GCP training who has been delegated by the Principal 
Investigator can obtain consent from eligible patients. At registration, each patient will be assigned a 
study subject identification number which will be used to identify the patient. 
Before patients may be enrolled into the trial, the sponsor must receive proof that all required 
regulatory approval (both local and, if relevant, national) has been obtained for the site. 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 29 of 42 
 
29 
 
Before registration, each potential patient must be given a patient information sheet, and informed 
consent obtained according to the requirements of GCP. The registration case report forms (CRFs) 
must also be completed. Only patients fulfilling all inclusion criteria and not any exclusion criteria 
should be registered. Any queries about eligibility should be addressed directly with the clinical 
team.  
A study subject identification number will be issued initially to the patient by the healthcare 
professional performing the patient registration – instructions will be provided separately. Once 
eligibility has been reviewed and the researcher is satisfied that the patient meets the criteria for 
study registration the subject identification number will be assigned to the patient. Completed 
registration CRFs must be sent to the GI & Lymphoma Trials Office at the Royal Marsden Hospital. 
The GI & Lymphoma Trials Office will check for completeness, complete the relevant CRF page and 
send back to the study personnel at the participating site responsible for recruitment of the patient. 
 
12.4 Patient withdrawal 
Withdrawal of full consent for a study means that the patient does not wish to or is unable to 
continue further study participation. Any patient may withdraw full consent to participate in the 
study at any time during the study. The investigator will discuss with the patient the most 
appropriate way to withdraw to maintain the patient’s care. In this case, the patient’s data already 
collected up to the point of withdrawal will still be included in the analysis of data, and the patient 
censored from that point onwards. 
Withdrawal of partial consent means that the patient does not wish to undergo any further 
procedures (e.g. blood tests or swabs) but is still willing to collaborate in providing further data by 
continuing on study (e.g. permit further data collection from hospital records). Participants will have 
the opportunity to request for their samples to be discarded. 
 
12.5 Study duration 
The study is expected to take up to 6-9 months to complete accrual. If the recruitment target is 
reached before the predicted end date, then the trial will close early to any further recruitment. 
Conversely, if the target recruitment is not achieved by the estimated end date, the trial recruitment 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 30 of 42 
 
30 
 
period may be extended until the target number of patients is achieved depending on the overall 
status of the SARS-CoV-2 pandemic. 
Individual participants whose throat/nose swab RT-PCR does not confirm SARS-CoV-2 infection and 
do not have a high clinical suspicion of SARS-CoV-2 infection at D0 will come off study at this time 
and no further clinical data or samples will be collected. Research samples will be destroyed. This 
only applies to Arm A. 
12.6 End of study 
The ‘end of study’ will be defined as the date that the last patient has had their last visit, or when 
adequate follow up has occurred for all the study end points to assessed and reported, whichever is 
sooner. At this point, the ‘end of trial notification’ will be submitted to the relevant regulatory 
authorities and ethics committees. 
13. Safety reporting 
The risks of an adverse event related to study specify procedures have been deemed to be minimal. 
Therefore, any AEs arising from the study procedures will not be recorded for the purposes of this 
study. 
14. Evaluation of Outcome/Statistical Considerations 
14.1 Sample size  
Arm A 
Based upon the current SARS-CoV-2 infection rates at the Royal Marsden NHS Foundation Trust, up 
to  60 patients (up to 50 patients with solid tumour or 10 with lymphoma) with confirmed SARS-CoV-
2 infection by RT-PCR could be recruited in 6-9 months, assuming uptake of 40% (As per positivity 
rates in April 2020) in screening 150 patients.  
For the primary endpoint, seroconversion, and the RT-PCR and LFA viral clearance secondary 
endpoints: 
Arm A - Up to 60 SARS-CoV-2 positive patients are expected to be recruited in the study; the 
proportion of patients can be estimated with a 95% CI with a width of + 12.7%. In the 50 patient 
solid tumour cohort then this will be estimated with a 95% CI with a width of + 13.9%.  
 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 31 of 42 
 
31 
 
To account for lower recruitment rate of SARS-CoV-2 positive patients, the following table presents 
the maximum width of the 95% C.I.s, given a 50% observed proportion for the primary endpoint, 
according to different sample sizes (N).  
An observed proportion of 50% has been selected, which is conservative and gives the widest 
possible 95% CI. (Table 4) 
 
Table 4: 
N 
Proportion of patients, with a positive detection 
of IgM and IgG specific antibodies to SARS-CoV-2. 
With of 95% CI 
10 
50% 
+ 31.0% 
20 
50% 
+ 21.9% 
30 
50% 
+ 17.9% 
50 
50% 
+ 13.9% 
60 
50% 
+ 12.7% 
 
 
Arm B 
For the primary endpoint up to 150 patients are expected to be recruited in Arm B.  Considering a 
10% antibody positivity rate [10], the proportion of patients can be estimated with a 95% CI with a 
width of + 4.8%. 
 
The clinical course of SARS-CoV-2 infection secondary endpoint is descriptive so no power 
calculation is required. 
 
Due to the dynamic changes in the prevalence of SARS-CoV-2 infection during the pandemic, the 
study may be halted prematurely. 
14.2 Analysis plan 
The primary endpoint will be presented as the proportion of patients at each sample time-point with 
95% confidence interval Arms A and B will be reported separately. 
Continuous data will be summarised as n, mean, standard deviation, median, minimum value and 
maximum value. Categorical data will be presented as frequencies and percentages. 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 32 of 42 
 
32 
 
Arm A: 
The secondary endpoint, viral clearance, will be presented as the proportion of patients at each 
sample time-point with 95% confidence interval. 
The clinical course of SARS-CoV-2 infection described as patient characteristics, and cancer 
diagnosis, will be summarised, as well as duration and severity of clinical symptoms, supportive 
treatments given, cancer treatments received and outcome of SARS-CoV-2 infection. 
 
Feasibility of SARS-CoV-2 antigen testing with a lateral flow assay will be assessed by the following 
1 
Proportion of samples successfully processed and result obtained, with 95% confidence 
interval 
2 Proportion of samples processed with a positive result by lateral flow, by the gold standard 
(throat/nose RT-PCR) 
 
Arm B: 
Feasibility of SARS-CoV-2 antibody testing with a lateral flow assay will be assessed by the following 
1 
Proportion of samples successfully processed and result obtained, with 95% confidence 
interval 
2 Proportion of samples processed with a positive result by lateral flow, by the gold standard 
(SARS-CoV-2 laboratory serology test) 
 
The formal statistical analysis plan will be developed based on the size of the available cohort and 
the performance of the experiment assays. The analysis will be developed in a separate molecular 
and statistical analysis plan which will be drafted and approved by the Trial Management Group 
(TMG) with statistical input. However, the above gives a guide as to the planned analyses.  
 
14.3 Study monitoring 
The study will be centrally monitored using the following procedures: 
 
Central Eligibility checking at registration  
Registration eligibility criteria will be reviewed when CRFs are received by the GI & Lymphoma Trials 
Office. Registration will only take place once central checking of documents is complete and any 
queries addressed.  

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 33 of 42 
 
33 
 
 
Statistical Monitoring  
The trial statistician will regularly examine the data for anomalies and outliers, such as too few or 
too many events. Queries will be raised by the trial coordinators (or other appropriately delegated 
team member) in such situations and communication with the clinical teams will take place. In 
addition statistical monitoring of unusual dates and inconsistent data will take place. Again these will 
raise queries via the trial coordinators (or other appropriately delegated team members.) 
 
RM GI Unit Research Meetings  
Recruitment will be discussed in the Unit Research meetings.  
 
Trial Management Group (TMG) meetings  
The role of the Trial Management Group (TMG) is to monitor all the aspects of the conduct and 
progress of the study, ensuring that the protocol is adhered to.  The TMG will develop and approve 
the molecular analysis plan. Any issues will be raised and addressed at the TMG meetings. The TMG 
will meet at minimum frequency of every 3 months. The minutes of the meeting will be documented 
in the Trial Master File (TMF) and copied to the Sponsor. 
15. Regulatory & Ethics Committee Approval 
15.1 Ethical considerations 
Ethical considerations relating to this trial will carried out in accordance to the Declaration of 
Helsinki (1996). 
A copy of the protocol, proposed informed consent form, other written patient information, and any 
proposed advertising material must be submitted to an independent ethics committee and any 
other relevant regulatory authorities, subject to the regulations of the country of each participating 
site, for written approval. A copy of the written approval of the protocol and informed consent form 
must be received by the sponsor before recruitment of patients into the study. 
The investigator must submit and, where necessary, obtain approval from the independent ethics 
committee concerned and any other relevant regulatory authorities for all subsequent protocol 
amendments and changes to the informed consent document. The investigator should notify the 
same of deviations from the protocol. 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 34 of 42 
 
34 
 
 
15.2 Informed consent 
Before a patient’s participation in the clinical study, the investigator (or a member of the study team 
named in the site signature log and authorised by the site Principal Investigator) is responsible for 
obtaining written informed consent from the patient. This can only take place after the patient has 
been given adequate time to consider participation, and adequate explanation of the aims, methods, 
anticipated benefits, and potential hazards of the study, and must take place prior to any protocol-
specific procedures. 
 
The acquisition of informed consent should be documented in the patient’s medical records, and the 
informed consent form should be signed and personally dated by the patient and by the authorised 
person who conducted the informed consent discussion.  The original signed informed consent form 
should be retained in accordance with institutional policy and GCP, and a copy of the signed consent 
form should be provided to the patient or consultee. 
 
If a potential patient is illiterate or visually impaired and does not have a consultee, the investigator 
must provide an impartial witness to read the informed consent form to the patient and must allow 
for questions.  Thereafter, both the patient and the witness must sign the informed consent form to 
attest that informed consent was freely given and understood.   
 
In the event a study participant loses capacity to provide ongoing consent (e.g. due to medical 
illness), ongoing participation will be discussed with the participant’s consultee. The consultee will 
be provided with the Consultee information sheet and, if in agreement, provide written confirmation 
for continued study participation on the consultee declaration form. Withdrawal from the study will 
also be considered if ongoing participation is not believed to be in the patient’s best interests. 
 
15.3 Patient confidentiality 
The investigator must ensure that the patient’s confidentiality is maintained in compliance with the 
UK Data Protection Act of 2018 and the General Data Protection Regulation (GDPR). On the case 
report forms or other documents submitted to the sponsor, patients should be identified by their 
initials and a patient study subject identification number only. Documents that are not for 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 35 of 42 
 
35 
 
submission to the Sponsor (e.g., signed informed consent forms) should be kept in strict confidence 
by the Investigator. 
16. Data Handling and Record Keeping 
16.1 Investigator Signatory Obligations 
Each clinical study report or case report form should be signed by the investigator or a member of 
the study team named in the site signature log and authorised by the site principal investigator. 
Original copies of all completed case report forms should be retained by the site once they have 
been emailed to the GI & Lymphoma Trials Unit. 
 
16.2 Data Handling 
In compliance with GCP guidelines, it is required that the investigator and institution permit 
authorised representatives of the sponsor and of the regulatory agency(s) direct access to review 
the patient’s original medical records for verification of study-related procedures and data. Direct 
access includes examining, analysing, verifying, and reproducing any records and reports that are 
important to the evaluation of the study. The investigator is obligated to inform and obtain the 
consent of the patient to permit named representatives to have access to his/her study-related 
records without violating the confidentiality of the patient. 
In this study anonymisation will be carried out by allocating a study subject identification number for 
samples which will be linked with a study subject identification number for patient outcome data, all 
patient identifiers will be removed. Tissue samples will be coded on entry to the study so that in all 
circumstances researchers carrying out the analysis will not have access to details that identify the 
patient and will see all data in an anonymised form. 
 
Clinical data will be entered on to a MACRO database, which is held within a password protected 
environment with access controlled. 
 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 36 of 42 
 
36 
 
16.3 Study Documentation and Archive  
The investigator should maintain a list of appropriately qualified persons to whom he/she has 
delegated study duties.  All persons authorised to make entries and/or corrections on case report 
forms will be included on the site signature log. 
Source documents are original documents, data, and records from which the patient’s Case Report 
Form data are obtained.  These include but are not limited to hospital records, clinical and office 
charts, laboratory and pharmacy records, diaries, radiographs, and correspondence.  The 
investigator and study staff are responsible for maintaining a comprehensive and centralised filing 
system of all study-related (essential) documentation, suitable for inspection at any time by 
representatives from the sponsor and/or applicable regulatory authorities.  Elements should include: 
 
Patient files containing completed case report forms, informed consent forms, and patient 
identification list 
 
Study files containing the protocol with all amendments, copies of pre-study documentation, 
and all correspondence to and from the sponsor and institutional review board. 
In addition, all original source documents supporting entries in the case report forms must be 
maintained and be readily available to permit trial related monitoring, audits, REC review and 
regulatory inspections where appropriate.  
No study document should be destroyed without prior written agreement between the sponsor and 
the investigator.  Should the investigator wish to assign the study records to another party or move 
them to another location, he/she must notify the sponsor in writing of the new responsible person 
and/or the new location.  
Sponsor should ensure that all trial related documentation be retained for maximum period of time 
as specified in the UK clinical trials regulations.  
 
16.4 Quality assurance/audit 
Systems of quality assurance, including all elements described in this protocol will be implemented. 
Quality control is applied to each stage of data handling to ensure that data is accurate, reliable and 
processed correctly. All data and documentation related to this study will be available for GCP audit. 
All research staff will assist in all aspects of audit/inspection. 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 37 of 42 
 
37 
 
 
16.5 Annual reporting to REC 
An Annual Progress Report will be submitted to the Research Committee. 
 
16.6 Sample labelling, storage and destruction 
In order to protect patient identity all samples will not be labelled with any information that may 
lead to the direct identification of the patient concerned, including patient name, date of birth, 
National Health Service (NHS) or hospital number. Instead, tissue and other specimens from each 
patient will be labelled with the study name, the study subject identification number (assigned at 
registration) and initials.  
 
Samples will be stored indefinitely in secure facilities at St George’s University Hospitals NHS 
Foundation Trust and offsite approved storage facilities (UK). However, the patient retains the right 
to have the sample material destroyed at any time.  
 
The sponsor will be the exclusive owner of any data, discoveries, or derivative materials from the 
sample materials and is responsible, via the Chief Investigator, for the destruction of the sample(s) at 
the request of the research patient.  
 
16.7 Use of information 
All unpublished information relating to this study is considered confidential. 
 
17. Financing, Indemnity & Insurance 
The study sponsor is the Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 
5PT, United Kingdom. This study has been financed by the Royal Marsden Cancer Charity and the 
NIHR Biomedical Research Centre. Material Transfer Agreements (MTA) will be executed with St 
Georges Hospital. 
No specific compensation arrangement exists for harmful events which might arise from 
participation in the study. However, the study is covered for negligent claims occurring with the NHS 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 38 of 42 
 
38 
 
by Crown indemnity. There is no pre-existing arrangement for non-negligent claims arising from the 
conduct of the study. 
18. Publication Policy 
The investigators will co-ordinate publication strategies, presentations and peer review publication. 
Authorship of any publications resulting from this study will be determined on the basis of the 
Uniform Requirement for Manuscripts Submitted to Biomedical Journals (International Committee 
of Medical Journal Editors, 2005), which states:  
 
Authorship credit should be based on (1) substantial contributions to conception and design, 
acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising 
it critically for important intellectual content; (3) final approval of the version to be 
published. Authors should meet conditions 1, 2, and 3.  
 
When a large, multicentre group has conducted the work, the group should identify the 
individuals who accept direct responsibility for the manuscript. These individuals should fully 
meet the criteria for authorship defined above.  
 
Acquisition of funding, collection of data, or general supervision of the research group, 
alone, does not justify authorship.  
 
All persons designated as authors should qualify for authorship, and all those who qualify 
should be listed.  
 
Each author should have participated sufficiently in the work to take public responsibility for 
appropriate portions of the content.  
 
19.  Abbreviations 
 
ACE2   
 Angiotensin-Converting Enzyme 2 
ARDS 
 
Acute respiratory distress syndrome 
ASCs  
 
Antibody-Secreting Cells 
CI   
 
Confidence Interval 
COVID-19  
Coronavirus Disease 2019 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 39 of 42 
 
39 
 
CRF 
 
Case Report Form 
CRP  
 
C-reactive Protein 
D  
 
Day number 
DFID  
 
Department for International Development 
EDTA 
 
Ethylenediaminetetraacetic Acid 
ELISA 
 
Enzyme-Linked Immunosorbent Assay 
GCP 
 
Good Clinical Practice 
GP   
 
General Practitioner 
IL 
 
interleukin 
LFA 
 
Lateral flow assay 
OS 
 
Overall Survival 
HLA-KIR 
Human leukocyte antigen, killer-cell immunoglobulin-like receptor 
HRA 
 
Health Research Authority 
IgA  
 
Immunoglobulin A 
IgG 
 
Immunoglobulin G 
IgM  
 
Immunoglobulin M 
NHS 
 
National Health Service 
NICE 
 
National Institute for Health and Care Excellence 
NIHR   
National Institute for Health Research  
PHEIC  
 Public Health Emergency of International Concern 
POC 
 
Point of care 
PON 
 
Point of need 
 
 
REC 
 
Research Ethics Committee 
RNA 
 
Ribonucleic Acid 
RT-PCR  
Reverse Transcription-Polymerase Chain Reaction 
SARS 
 
Severe acute respiratory syndrome 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 40 of 42 
 
40 
 
sHLH 
 
Secondary haemophagocytic lymphohistiocytosis 
s.d. 
 
standard deviation 
TFH cells 
follicular helper T cells 
TMF 
 
Trial Master file 
TMG 
 
Trial Management Group 
WHO 
 
World Health Organisation 
20. Protocol Summary of Changes  
Version 
Summary of changes 
v2.2 (first approved version) 
Changes to accommodate R&D and HRA/REC 
recommendations 
3.0 
Change of study title:  
Cancer: Rapid Diagnostics and Immune 
assessment for SARS-CoV-2 (COVID-19) 
 
Updated list of study personnel: 
Investigators 
Dr Susana Banerjee (RMH) 
Dr Alison Reid (RMH) 
Professor Mary O’Brien (RMH) 
Dr Sophie McGrath (RMH) 
 
Research nurse(s) 
Ms Alexandra Diaz (RMH) 
 
Updated eligibility criteria 
Eligibility criteria: 
1) Suspected COVID-19 infection undergoing 
diagnostic testing by SARS-CoV-2 RT-PCR or 
within 14 days of confirmed COVID-19 infection 
by SARS-CoV-2 RT-PCR (Arm A) OR 
No symptoms of SARS-CoV-2 infection (Arm B) 
 
 
2) Metastatic or advanced solid organ 
malignancy, including lymphoma 
 
OR 
Early stage solid organ malignancy having 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 41 of 42 
 
41 
 
received or planning to commence radiotherapy, 
chemotherapy or targeted agents 
 
Rationale: 
1 To allow recruitment of patients with recently 
confirmed COVID-19  
2 
To facilitate Arm B of study 
3 
Amended to allow patients planned to 
commenced anti-cancer therapy 
 
 
Addition of Arm B:  
Asymptomatic patients with no clinical suspicion 
of COVID-19. 
Study procedures for Arm B and schedule of 
assessments outlined 
Existing study arm from v2.2 has been 
designated Arm A 
 
 
Throat/nose SARS-CoV-2 results 
For Arm A, patients with a SARS-CoV-2 negative 
nose/throat AND low clinical suspicion of COVID-
19 will be removed from the study. 
 
Number of patients: 
Arm A: “Approximately 60 patients” – revised to 
“up to 60 patients” 
Arm B “Up to 150 patients”  
 
 
21. References 
1. 
Organisation WH. Novel Coronavirus (2019-nCoV) situation. Report 1. 21 January 2020. 
https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200121-
sitrep-1-2019-ncov.pdf. Accessed 6th April 2020,  (2020). 
2. 
Xu Z, Shi L, Wang Y et al. Pathological findings of COVID-19 associated with acute 
respiratory distress syndrome. The Lancet. Respiratory medicine, 8(4), 420-422 (2020). 
3. 
Liang W, Guan W, Chen R et al. Cancer patients in SARS-CoV-2 infection: a nationwide 
analysis in China. The Lancet Oncology, 21(3), 335-337 (2020). 

CARDS 
RMH CCR No: 5287 
IRAS no: 282755 
Version Date: 10th July 2020 
Version Number: 3.0 
 
Page 42 of 42 
 
42 
 
4. 
Onder G, Rezza G, Brusaferro S. Case-Fatality Rate and Characteristics of Patients Dying in 
Relation to COVID-19 in Italy. JAMA,  (2020). 
5. 
Lee LYW, Cazier JB, Starkey T, Turnbull CD, Kerr R, Middleton G. COVID-19 mortality in 
patients with cancer on chemotherapy or other anticancer treatments: a prospective 
cohort study. The Lancet, 395(10241), 1919-1926 (2020). 
6. 
Solodky ML, Galvez C, Russias B et al. Lower detection rates of SARS-COV2 antibodies in 
cancer patients versus health care workers after symptomatic COVID-19. Annals of 
Oncology). 
7. 
Thevarajan I, Nguyen THO, Koutsakos M et al. Breadth of concomitant immune responses 
prior to patient recovery: a case report of non-severe COVID-19. Nature Medicine,  (2020). 
8. 
Huang C, Wang Y, Li X et al. Clinical features of patients infected with 2019 novel 
coronavirus in Wuhan, China. Lancet (London, England), 395(10223), 497-506 (2020). 
9. 
Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 
based on an analysis of data of 150 patients from Wuhan, China. Intensive care medicine,  
(2020). 
10. 
Statistics 
OfN. 
Coronavirus 
(COVID-19) 
Infection 
Survey, 
2nd 
July 
2020, 
https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/condition
sanddiseases/bulletins/coronaviruscovid19infectionsurveypilot/2july2020 Accessed 9th 
July 2020.  (2020).