Please select the eligibility criteria that correspond to the clinical trial below.
Title: A Randomized Phase III Trial of Platinum Chemotherapy Plus Paclitaxel With Bevacizumab and Atezolizumab Versus Platinum Chemotherapy Plus Paclitaxel and Bevacizumab in Metastatic (Stage IVB), Persistent, or Recurrent Carcinoma of the Cervix
Brief Summary: The study will integrate the efficacy of combining the anti programmed death-ligand 1 (anti-PD-L1) agent atezolizumab with the current standard of care in Stage IVB , persistent or recurrent carcinoma of the cervix, namely cisplatin or carboplatin/paclitaxel/bevacizumab. It will be explored the combination of bevacizumab plus atezolizumab, with no patient selection based on PD-L1 expression, allowing an all-comer assessment of atezolizumab activity.

The study is a randomized open label phase III trial to investigate the impact of atezolizumab in combination with bevacizumab and cisplatin or carboplatin /paclitaxel chemotherapy on overall survival and will employ the intent to treat principle, and random assignment to one of the 2 arms will be balanced according to disease histology (squamous cell carcinoma vs adenocarcinoma), prior platinum therapy as a radiation sensitizer (no prior cis-Radiotherapy (RT) versus prior cis-RT) and chemotherapy backbone (cisplatin vs carboplatin).

This trial will be run in an open label design due to the following considerations: the control arm is the standard of care for women diagnosed with metastatic, persistant or recurrent cervical cancer because of its impact on overall survival and the primary endpoint of the study is overall survival (OS), so blinding is not needed to ensure a robust assessment.


Options:
A: Inclusion Criteria:

1. histologically proven uterine cervical cancer
2. squamous cell carcinoma, adenocarcinoma, or adenosquamous cell carcinoma of the uterine cervix
3. one of the followings, 1)primary stage Ⅳb cervical cancer, 2)the first relapse or persistent cervical cancer after curative first line treatments, 3)the second relapse or persistent cervical cancer after curative second line treatments including radiation, systemic chemotherapy, hormonal therapy, or vaccination therapy for the first relapse
4. Patients may have been previously treated with less than 50 Gy of palliative radiation therapy
5. Patients have received no prior treatment or a certain interval must have elapsed from the last administration of previous treatments including palliative radiation therapy
6. one of the followings, 1)There is at least one metastatic lesion outside the pelvic cavity except paraaortic LN and/or inguinal LN, 2)There is no metastatic lesion outside the pelvic cavity except paraaortic LN and/or inguinal LN and some of the lesions have been irradiated, 3)All lesions are localized inside the pelvic cavity, and some of them have been irradiated
7. no prior surgical therapy for metastatic lesions of the lung or inside the pelvic cavity
8. no bilateral hydronephrosis
9. no prior chemotherapy including more than two platinum-containing regimens
10. no prior chemotherapy including taxane
11. age: 20 to75 years
12. PS: 0-2
13. ANC ≧1,500 /mm3, Plt≧10.0×104/mm3, T-bil≦1.5 mg/dl, GOT（AST）≦100IU/l, sCre ≦1.2 mg/dl, Ccr≧50ml/min in using the Cockcroft-Gault equation, and normal ECG
14. written informed consent

Exclusion Criteria:

1. patients who have some neurologically functional disorder
2. symptomatic CNS metastasis
3. hypersensitive to alcohol
4. active infection
5. HBs antigen positive
6. uncontrollable hypertension
7. history of myocardiac infarction within six months
8. unstable angina
9. uncontrollable diabetes
10. Patients with a concomitant or prior invasive malignancy (except intramucosal malignancy which are curable with local therapy) who have had any evidence of the disease within the last 5 years
11. women during pregnancy or breast-feeding
12. patients with psychiatric illness
13. patients who have been treated with the systemic steroids medication
B: Inclusion Criteria:

* Recurrent or persistent squamous, adenosquamous or adenocarcinoma of the uterine cervix not amenable to curative treatment with surgery and/or radiotherapy
* No prior therapy (radiation, chemotherapy, hormonal therapy or immunotherapy) for recurrence or persistence. May have received platinum in combination with radiation as part of up-front treatment or adjuvant treatment
* Must have measurable disease as defined by RECIST criteria
* Must have at least one "target lesion" to assess response
* Performance status of 0 or 1
* Patients with ureteral obstruction must undergo stent or nephrostomy tube placement prior to study entry
* At least 4 weeks must have elapsed since prior treatment
* Age \>= 18 years
* Patients of childbearing potential must have a negative pregnancy test, use effective means of contraception
* Signed informed consent
* Bone marrow function: ANC \>= 1500/ul; platelets \>= 100,000 /ul
* Renal function: creatinine \<= 1,5 X ULN (if \> 1.5 creatinine clearance must be \> 60 ml/min)
* Hepatic function: bilirubin \<= 1.5 X ULN, AST and alkaline phosphatase \<= 2.5 X ULN
* Neurologic function: neuropathy \< CTC grade 1
* Coagulation: PT INR \<= 1.5

Exclusion Criteria:

* Evidence of sepsis or severe infection
* Prior therapy for recurrence
* Patients with serious, non-healing wound, ulcer or bone fracture
* Patients with history or evidence of nervous system disease, including primary brain tumor, brain metastases, seizure not controlled with standard medical therapy, CVA, stroke, TIA or subarachnoid hemorrhage within 6 months of 1st date of treatment on study
* Patients with history of other invasive malignancy (treatment within last 5 years) other than non-melanoma skin cancer
* Patient with clinically significant cardiovascular disease defined as:
* Inadequately controlled hypertension (systolic \> 150 and/or diastolic \> 100 on antihypertensive medications); prior history of hypertensive crisis or hypertensive encephalopathy
* Unstable angina within 6 months of enrollment
* NYHA Grade II or greater congestive heart failure
* Serious cardiac arrythmia requiring medication
* Grade 2 or greater peripheral vascular disease; claudication within 6 months
* History of myocardial infarction within 6 months
* Previously diagnosed coagulopathy, disseminated intravascular coagulopathy, immune thrombocytopenia purpura, thrombotic thrombocytopenia purpura or tumor involving major vessels
* Significant vascular disease: aortic aneurysm, aortic dissection
* Active thromboembolic disease: pulmonary embolism, deep venous thrombosis
* Major surgical procedure, open biopsy or significant traumatic injury within 28 days prior to day 1 of study; anticipation of need for major surgical procedure during course of the study
* Minor surgical procedure other than central venous access placement, within 7 days prior to day 1 of study
* Patients with proteinuria - patients with urine protein of 1+ on dipstick or \>=30 mg/dl at baseline should undergo UPCR; patients with UPCR of \>=1.0 should be excluded
* Patients who are pregnant or lactating
* No prior investigational agent within 30 days or planned participation in an experimental drug study
* Patients whose circumstances do not permit completion of study or required follow-up
* Prior therapy with bevacizumab or topotecan. Prior platinum therapy allowed as part of initial treatment
* History of abdominal fistula, GI perforation or intra-abdominal abscess within 6 months prior to study enrollment.
* Known hypersensitivity to any component of bevacizumab
C: Inclusion Criteria:

1. Female patients must be ≥18 years of age.
2. Signed informed consent before any study-specific procedure
3. Able (in the investigator´s judgment) to comply with the study protocol
4. GOG/Eastern Cooperative Oncology Group (ECOG) performance status of 0-1
5. Life expectancy ≥3 months
6. Histologically- or cytologically-confirmed diagnosis of metastatic (stage IVB), persistent, or recurrent cervical cancer (histologies other than squamous cell, adenocarcinoma, or adenosquamous will be excluded) not amenable for curative treatment with surgery and/or radiation therapy. The inclusion of patients with adenocarcinoma histology will be capped to 20% of the whole study population.
7. No prior systemic anti-cancer therapy for metastatic or recurrent disease.
8. Measureable disease by RECIST v1.1 criteria.
9. A tumor specimen is mandatory at study entry.
10. Adequate organ function:

    Hemoglobin ≥9 g/dL ANC ≥1.5 × 109/L Lymphocyte count ≥0.5 × 109/L Platelet count ≥100 x 109/L
11. Adequate liver function:

    Serum albumin ≥2.5 g/dL Total serum bilirubin ≤1.5 ×ULN AST and ALT ≤2.5 × upper limit normal (ULN) or ≤5 × ULN if tumor involvement (liver) is present
12. Adequate renal function:

    Patients with serum creatinine \<1.5 × ULN Urine dipstick for proteinuria \<2+.
13. Adequate coagulation:

    Blood coagulation parameters (PTT, PT/INR): PT such that international normalized ratio (INR) is ≤ 1.5 (or an in-range INR, usually between 2 and 3, if a patient is on a stable dose of therapeutic warfarin for management of venous thrombosis including pulmonary thromboembolus) and a PTT \<1.5 × ULN.
14. Negative Test Results for Hepatitis:

    Negative hepatitis B surface antigen (HBsAg) test at screening Negative total hepatitis B core antibody (HBcAb) test at screening, or positive total HBcAb test followed by a negative hepatitis B virus (HBV) DNA test at screening.The HBV DNA test will be performed only for patients who have a positive total HBcAb test.

    Negative hepatitis C virus (HCV) antibody test at screening, or positive HCV antibody test followed by a negative HCV RNA test at screening.The HCV RNA test will be performed only for patients who have a positive HCV antibody test.
15. Toxicities related to previous treatments must be recovered to \< grade 2 (with the exception of alopecia).
16. Female participants must be postmenopausal (≥ 12 months of non-therapy-induced amenorrhoea) or surgically sterile (absence of ovaries and/or uterus, or who received therapeutic radiation to the pelvis) or otherwise have a negative serum pregnancy test within 7 days of the first study treatment and agree to abstain from heterosexual intercourse or use single or combined contraceptive methods that result in a failure rate of \<1% per year during the whole treatment period of the study and for at least 5 months (if the last study dose contained atezolizumab) or 6 months (if the last study dose contained bevacizumab) after the last dose of study treatment.

    * Abstinence is acceptable only if it is in line with the preferred and usual lifestyle of the patient. Periodic abstinence (e.g., calendar, ovulation, symptothermal or postovulation methods) and withdrawal are not acceptable methods of contraception

Exclusion Criteria:

1. Disease that is suitable for local therapy administered with curative intent
2. Prior radiotherapy delivered using cobalt (rather than a linear accelerator)
3. Patients with Stage IVA not amendable to concurrent chemo-radiation as primary treatment will not be eligible.
4. Ongoing disease involving the bladder or rectum at screening/baseline
5. Evidence of abdominal free air
6. Bilateral hydronephrosis, unless it can be alleviated by ureteral stent(s) or percutaneous drainage
7. Patients previously treated with chemotherapy except when used concurrently with radiation therapy. Patients who have received either concurrent paclitaxel with radiation therapy or carboplatin/paclitaxel as adjuvant therapy are ineligible for the study.
8. Prior treatment with any anti-VEGF drug, including bevacizumab, CD137 agonists or immune checkpoint blockade therapies, anti-PD1, or anti-PDL1 therapeutic antibodies or anti-CTLA 4.
9. Patients with a concomitant malignancy other than non-melanoma skin cancer. Patients with a prior invasive malignancy (except non-melanoma skin cancer ) who have had any evidence of disease within the last 5 years or whose prior malignancy treatment contraindicates the current protocol therapy.
10. Known brain metastases or spinal cord compression. It is mandatory to perform a scan of the brain in cases of suspected brain metastases (CT or MRI) or spinal cord compression (MRI).
11. History or evidence, following a neurological examination, of central nervous system (CNS) disorders, unless properly treated with standard medical treatment,(e.g. uncontrolled epileptic seizures). History of cerebrovascular accident (CVA, stroke), transient ischemic attack (TIA) or subarachnoid hemorrhage within six months of the first date of treatment on this study.
12. Patients with serious non-healing wound, ulcer, or bone fracture.
13. Acute intestinal obstruction or sub-occlusion episode in the last 6 months.
14. Active GI bleeding or GI ulcer
15. History of Crohn's disease or inflammatory bowel disease
16. Prior bowel resection ≤6 weeks preceding first study dose
17. History of diverticulitis requiring medical intervention
18. NCI CTCAE (version 5.0) grade ≥2 enteritis
19. Major surgical procedure, open biopsy or significant traumatic injury within 28 days prior to Day 1, Cycle 1.
20. Core biopsy or other minor surgical procedure, excluding placement of a vascular access device, within 7 days prior to Day 1, Cycle 1.
21. Patients with active bleeding or pathologic conditions that carry high risk of bleeding, such as known bleeding disorder, coagulopathy, or tumor involving major vessels.
22. Current or recent (within 10 days before the first dose of study drug) chronic daily treatment with aspirin (\>325 mg/day), clopidogrel (\>75 mg/day), or current or recent (within 10 days before first dose of bevacizumab) use of therapeutic oral or parenteral anticoagulants or thrombolytic agents for therapeutic purposes.
23. Patients with pre-existing Grade 2 or greater peripheral neuropathy.
24. History of any grade ≥3 venous thromboembolic event (VTE)
25. Patients with clinically significant cardiovascular disease.
26. Left ventricular ejection fraction defined by MUGA/ECHO below the institutional lower limit of normal.
27. Uncontrolled tumor-related pain
28. Uncontrolled pleural effusion, pericardial effusion, or ascites requiring recurrent drainage procedures (once monthly or more frequently). Patients with indwelling catheters (e.g., PleurX) are allowed.
29. Uncontrolled hypercalcemia (\>1.5 mmol/L ionized calcium or calcium \>12 mg/dL or corrected serum calcium \> ULN) or symptomatic hypercalcemia requiring continued use of bisphosphonate therapy or denosumab.
30. History of autoimmune disease, including but not limited to myasthenia gravis, myositis, autoimmune hepatitis, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, vascular thrombosis associated with antiphospholipid syndrome, Wegener's granulomatosis, Sjögren's syndrome, Guillain-Barré syndrome, multiple sclerosis, vasculitis, glomerulonephritis or celiac disease.

    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
31. History of radiation pneumonitis in the radiation field (fibrosis) is permitted.
32. Active tuberculosis
33. Severe infections within 4 weeks prior to Cycle 1, Day 1, including but not limited to hospitalization for complications of infection, bacteremia, or severe pneumonia
34. Signs or symptoms of infection within 2 weeks prior to Cycle 1, Day 1
35. Received therapeutic oral or IV antibiotics within 2 weeks prior to Cycle 1, Day 1
36. Known human immunodeficiency virus (HIV)
37. Administration of a live, attenuated vaccine within 4 weeks before Cycle 1, Day 1 or anticipation that such a live attenuated vaccine will be required during the study Influenza vaccination should be given during influenza season only
38. Any other diseases, metabolic dysfunction, physical examination finding, or clinical laboratory finding giving reasonable suspicion of a disease or condition that contraindicates the use of an investigational drug or that may affect the interpretation of the results or render the patient at high risk from treatment complications
39. Treatment with systemic immunostimulatory agents (including but not limited to IFNs, IL-2) within 6 weeks or 5 half-lives of the drug, whichever is shorter, prior to Cycle 1, Day 1
40. Treatment with systemic immunosuppressive medications (including but not limited to prednisone, cyclophosphamide, azathioprine, methotrexate, thalidomide, and anti-tumor necrosis factor \[anti-TNF\] agents) within 2 weeks prior to Cycle 1, Day 1 The use of corticosteroids is allowed as premedication for paclitaxel-based regimen. All patients should be premedicated prior to receiving chemotherapy (including with corticosteroids) according to the prescription information of paclitaxel and cisplatin/carboplatin and the institutional standard of care guidance.
41. Currently participating or has participated in a study of an investigational agent and received study therapy or used an investigational device within 4 weeks prior to the first dose of study treatment.
42. Prior anti-cancer monoclonal antibody (mAb), prior chemotherapy, targeted small molecule therapy as first line treatment for the treatment of metastatic or recurrent cervical cancer.
43. Women that are breastfeeding or pregnant
44. Known hypersensitivity to bevacizumab, atezolizumab or any of theirs excipients (including Cremophor)
45. Demonstration of any other neurological or metabolic dysfunction, found upon physical examination or laboratory tests involving a reasonable suspicion of the existence of a disease or condition that contraindicates the use of an experimental drug, or that involves an increased risk to the patient of treatment-related complications
46. No medical or psychiatric illness that may impede the performance of a systemic or surgical treatment.
D: Inclusion Criteria:

* Patients must have primary stage IVB, recurrent or persistent squamous cell carcinoma, adenosquamous carcinoma, or adenocarcinoma of the cervix which is not amenable to curative treatment with surgery and/or radiation therapy
* All patients must have measurable disease; measurable disease is defined as at least one lesion that can be accurately measured in at least one dimension (longest dimension to be recorded); each lesion must be \>= 20 mm when measured by conventional techniques, including palpation, plain x-ray, computed tomography (CT), and magnetic resonance imaging (MRI), or \>= 10 mm when measured by spiral CT; biopsy confirmation is required if the lesion(s) measures \< 30 mm or if the treating physician determines it is clinically indicated; patients must have at least one "target lesion" to be used to assess response on this protocol as defined by Response Evaluation Criteria in Solid Tumors (RECIST); this lesion should be the one that was biopsied if one was performed; tumors within a previously irradiated field will be designated as "non-target" lesions unless progression is documented or a biopsy is obtained to confirm persistence at least 90 days following completion of radiation therapy
* Absolute neutrophil count (ANC) \>= 1500/mcl
* Platelets \>= 100,000/mcl
* Serum creatinine =\< upper limit of normal (ULN) (Common Toxicity Criteria \[CTC\] grade 0) or calculated creatinine clearance (Jeliffe formula) \>= 60 ml/min
* Bilirubin =\< 1.5 x institutional normal
* Serum glutamic oxaloacetic transaminase (SGOT) =\< 2.5 x institutional normal
* Alkaline phosphatase =\< 2.5 x institutional normal
* Prothrombin time (PT) such that international normalized ratio (INR) is =\< 1.5 (or an in-range INR, usually between 2 and 3, if a patient is on a stable dose of therapeutic warfarin for management of venous thrombosis including pulmonary thrombo-embolus)
* Partial thromboplastin time (PTT) \< 1.2 times the upper limit of normal
* Urine protein-creatinine ratio (UPC ratio) \< 1.0
* Patients must have a GOG performance status of 0 or 1
* Patients must have recovered from the effects of surgery, radiation therapy, or chemoradiotherapy; at least six weeks must have elapsed from the last administration of chemoradiotherapy, and at least three weeks must have elapsed from the last administration of radiation therapy alone; at least six weeks must have elapsed from the time of any major surgical procedure prior to randomization
* Patients must have signed an approved informed consent and authorization permitting release of personal health information
* Patients must meet all of the pre-entry requirements, including baseline QOL questionnaire
* Patients must be free of active infection requiring antibiotics

Exclusion Criteria:

* Patients with bilateral hydronephrosis which cannot be alleviated by ureteral stents or percutaneous drainage
* Patients previously treated with chemotherapy except when used concurrently with radiation therapy

  * Patients who have received concurrent paclitaxel and/or concurrent topotecan with radiation therapy are ineligible
* Patients with craniospinal metastases
* Patients with a concomitant malignancy other than non-melanoma skin cancer
* Patients with a prior invasive malignancy (except non-melanoma skin cancer) who have had any evidence of disease within the last 5 years or whose prior malignancy treatment contraindicates the current protocol therapy
* Patients with serious non-healing wound, ulcer, or bone fracture; this includes history of abdominal fistula, gastrointestinal perforation or intra-abdominal abscess for which an interval of 3 to 6 months must pass before study entry; in addition, the patient must have undergone correction (or spontaneous healing) of the perforation/fistula and/or the underlying process causing the fistula/perforation; patients with granulating incisions healing by secondary intention with no evidence of fascial dehiscence or infection are eligible but require weekly wound examinations
* Patients with active bleeding or pathologic conditions that carry high risk of bleeding, such as known bleeding disorder, coagulopathy, or tumor involving major vessels
* Patients with history or evidence upon physical examination of central nervous system (CNS) disease, including primary brain tumor, seizures not controlled with standard medical therapy, any brain metastases, or history of cerebrovascular accident (CVA, stroke), transient ischemic attack (TIA) or subarachnoid hemorrhage within six months of the first date of treatment on this study
* Patients with clinically significant cardiovascular disease; this includes:

  * Uncontrolled hypertension, defined as systolic \> 150 mm Hg or diastolic \> 90 mm Hg
  * Myocardial infarction or unstable angina \< 6 months prior to registration
  * New York Heart Association (NYHA) grade II or greater congestive heart failure
  * Serious cardiac arrhythmia requiring medication; this does not include asymptomatic, atrial fibrillation with controlled ventricular rate
  * CTCAE grade 2 or greater peripheral vascular disease (at least brief \[\< 24 hours (hrs)\]) episodes of ischemia managed non-surgically and without permanent deficit)
  * History of CVA within six months
* Patients with known hypersensitivity to Chinese hamster ovary cell products or other recombinant human or humanized antibodies
* Patients with or with anticipation of invasive procedures as defined below:

  * Major surgical procedure, open biopsy or significant traumatic injury within 28 days prior to the first date of bevacizumab therapy
  * Major surgical procedure anticipated during the course of the study; this includes, but is not limited to abdominal surgery (laparotomy or laparoscopy) prior to disease progression, such as colostomy or enterostomy reversal, interval or secondary cytoreductive surgery, or second look surgery; please consult with the study chair prior to patient entry for any questions related to the classification of surgical procedures
  * Core biopsy, within 7 days prior to randomization
* Patients who are pregnant or nursing; bevacizumab should not be administered to pregnant women; bevacizumab should not be administered to nursing women; patients of childbearing potential must agree to use contraceptive measures during study therapy and for at least six months after completion of bevacizumab therapy
* Patients who have received prior therapy with any anti-vascular endothelial growth factor (VEGF) drug, including bevacizumab
* Patients with clinical symptoms or signs of gastrointestinal obstruction and who require parenteral hydration and/or nutrition
* Patients with medical history or conditions not otherwise previously specified which in the opinion of the investigator should exclude participation in this study; the investigator should feel free to consult the Study Chair or Study Co-Chairs for uncertainty in this regard
* Patients with significant peripheral vascular disease
* Patients with pre-existing grade 2 or greater peripheral neuropathy

Answer: C