Clinical trial NCT03916510
Conditions: Locally Advanced Rectal Cancer
Keywords: locally advanced rectal cancer Enadenotucirev oncolytic virus adenovirus dose escalation Time To Event Continual Reassessment Method chemoradiotherapy phase 1
Sponsor: University of Oxford
Start date: 2019-07-29; Completion date: 2023-02-24
Enrollment: 12 participants; Allocation: NON_RANDOMIZED; Intervention model: SEQUENTIAL

Brief summary:
The use of chemoradiotherapy (CRT), in combination with surgery is the standard of care in the treatment of locally advanced rectal cancer. However some patients don't respond well to radiation.

More advanced radiotherapy techniques, that result in fewer toxicities, means that we are now able to combine new anti-cancer agents into standard treatment. Targeting the tumour early in this way has the potential to improve response rates.

Enadenotucirev is a specific type of anti-cancer virus that only targets cancer cells. It acts in the same way as any virus and can only survive by replicating inside cancer cells and not normal, non-cancerous cells. This means that it can selectively target and destroy tumours, without directly affecting normal cells. It also has the ability to attract cells from the body's immune system to help fight the cancer.

The addition of enadenotucirev to standard chemoradiotherapy treatment may have a combined effect on the cancer cells with potentially few, additional side effects.

This trial aims to determine the optimal dose and frequency of the virus to give by gradually increasing the number of doses each successive patient receives, and then increasing the dose of the virus itself. Each patient will receive a minimum of 3 doses, up to a maximum of 8, spread over the course of their 5 week standard chemoradiotherapy treatment. Patients will be closely monitored at all times to ensure that with each dosing group, there aren't excessive side effects.

Patients will then undergo surgery as part of their standard of care and be followed up for up to 4-6 weeks post-surgery.

This trial aims to determine the optimal dose and frequency that can then be used in future studies with the possibility of exploring the addition of Enadenotucirev to other chemoradiotherapy treatments.

Detailed description:
At present identifying novel radiosensitising agents in colorectal cancer is an area of high need for patients considering sphincter preserving surgery or needing down staging to facilitate surgery.

Although the combination of Enadenotucirev with chemoradiation is novel, there is a wealth of evidence to support the rationale for combining this class of agent with radiation and chemotherapy.

Enadenotucirev is a group B oncolytic virus under development for the systemic treatment of metastatic or advanced epithelial tumours. Enadenotucirev is a chimeric adenovirus type 11p (Adp/adenovirus type 3 (Ad3) virus, discovered through a process of bio-selection from a library of chimeric viruses produced from a pool of adenoviruses from seven different serotypes utilizing human HT-29 colorectal cancer (CRC) cells.

Enadenotucirev shows selective and potent toxicity in humans carcinoma cells with only very limited or no toxicity to normal (non-cancerous) human cells. Other than humans, there is no known permissive species for Enadenotucirev. The principle advantage of oncolytic therapy is that the virus replicates only in diseased cells meaning that the concentration of drug is amplified at the site of pathology so that it is higher in the tumour than in healthy tissue. Virus particles spread from cell to cell within a tumour nodule until they reach non-permissive normal tissues, in principle destroying all viable tumour cells they encounter.

While the overall understanding of the mechanism of action of Enadenotucirev in humans is still under investigation, it is now well established from non-clinical and clinical studies that the mechanism of anti-cancer efficacy of oncolytic viruses not only involves direct infection and lysis of tumour cells, but that immune responses stimulated via an increased release of tumour-associated antigens and immune-inflammatory activation signals play a key role.

CEDAR is dual endpoint, dose escalation phase 1 trial using a time to event continual reassessment method (TiTE CRM). Response and Toxicity endpoints will be combined in dose escalation models to identify the optimal dose schedule. Dose decisions are made using the statistical model which uses number of Dose Limiting Toxicities (DLT) experienced in different dosing schedules, instead of just using the data from that particular dose, as in the case of 3+3 model, meaning it uses all available data to make a dose decision.

This primary objective is to determine the optimal dose and frequency of the virus by firstly gradually increasing the number of doses each successive patient receives, and then increasing the dose of the virus itself. All participants will receive 3 loading doses in weeks 1-2, prior to initiation of standard chemoradiotherapy. Further doses of Enadenotucirev will either be given after or during and after standard chemoradiotherapy and this is dependent on which of the 4 different dose groups they are assigned to. The individual doses given will be either 1x10\^12 viral particles (vp) or 3x10\^12 vp.

Each patient will receive a minimum of 3 doses, up to a maximum of 8, spread over the course of 9 weeks. Patients will be closely monitored at all times to ensure that with each dosing group, there aren't excessive side effects.

Patients will then undergo surgery as part of their standard of care and be followed up for 4-6 weeks after surgery.

Dose Limiting Toxicities (DLTs)

DLTs are defined as any of the following occurring between the start of trial treatment until the Week 13 visit and assessed as possibly, probably or definitely related to enadenotucirev or the interaction between enadenotucirev and radiotherapy and/or capecitabine.

Renal:

o Development of proteinuria, 2+ as measured by urinalysis and confirmed with an albumin/creatinine ratio of \>3g/mmol with a 24-hour urinary protein ≥1g/24h or if there is a decline in estimated glomerular filtration rate (eGFR) (where a decline in eGFR is defined as eGFR \<60ml/min/1.73m2 or a drop in eGFR by 20% from screening, baseline of previous visit), following administration of enadenotucirev, shall be classified as a DLT. No further doses of enadenotucirev will be administered to that patient.

Acute hematologic toxicity:

* Infection (documented clinically or microbiologically) with grade 3 or 4 neutropenia (absolute neutrophil count (ANC) \<1.0 x 10\^9/L)
* Neutropenia grade 4 (ANC \< 0.5 x 10\^9/L) lasting for ≥7 days
* Febrile neutropenia grade 4 (fever of unknown origin without clinically or microbiologically documented infection) (ANC \<1000/mm3 with a single temperature of \>38.3 degrees Celsius or a sustained temperature of \>=38 degrees Celsius for more than one hour)
* Thrombocytopenia grade 3 (Platelet count \< 50 x 10\^9/L) in the presence of bleeding or requiring platelet transfusion
* Thrombocytopenia grade ≥ 4 (Platelet count \< 25 x 10\^9/L)
* Anemia grade 3 in the presence of blood transfusion dependency as judged by the Principal Investigator
* Anemia grade ≥ 4
* Clinically significant bleeding attributed to grade 3 thrombocytopenia or requiring platelet transfusion or other grade ≥3 clotting disorder or occurring concurrently with Grade 2 or 3 activated partial thromboplastin time (aPTT) prolongation, unless there is a clear explanation for the event, such as tumour-related bleeding in the presence of Lupus Anticoagulant.
* Any other grade ≥3 non-hematological toxicity with the exception of: aPTT prolongation
* Clotting event (i.e. deep vein thrombosis, pulmonary embolism) occurring concurrently with Grade 2 or 3 aPTT prolongation

Acute non-hematologic toxicity:

* Any documented ≥ grade 4 non-hematologic toxicity in the presence of maximal support/active management
* Grade ≥3 cystitis or radiation dermatitis onset within 2 weeks of starting radiotherapy or lasting more than 2 weeks after the end of radiotherapy
* Grade ≥3 proctitis or diarrhea onset within 2 weeks of starting radiotherapy
* Grade ≥3 nausea or vomiting not controlled by optimal outpatient anti-emetic treatment
* Grade ≥3 diarrhea despite optimal outpatient anti-diarrheal medication use
* Grade ≥3 hematuria or neuropathic pain
* Other grade 3 ≥ effects thought to be due to the combination of enadenotucirev with radiotherapy
* Missing 2 consecutive doses of enadenotucirev due to enadenotucirev toxicity
* An elevation of alanine transaminase (ALT) or aspartate aminotransferase (AST) \>5 x upper limit of normal lasting 8 days or more
* A concurrent elevation of ALT or AST \>3 × upper limit of normal and total bilirubin \>2 × upper limit of normal in whom there is no evidence of biliary obstruction or other causes that can reasonably explain the concurrent elevation
* Death due to drug related complications
* Grade ≥3 cytokine release syndrome

General:

* Discontinuation of the active treatment due to toxicity definitely attributable to enadenotucirev, irrespective of the grade of toxicity
* Missing 3 consecutive fractions of radiotherapy, related to enadenotucirev, as judged by the Principal Investigator
* Any toxicity causing a delay of radiotherapy completion by greater than one week

Arms: arm 1: * Chemotherapy: 900 mg/m2 capecitabine twice daily, Mon-Fri (on radiotherapy days) for 5 weeks, except on days patients received enadenotucirev.
* Radiotherapy: 50 Gy in 25 fractions.
* Enadenotucirev: 3 x loading doses pre-chemoradiation (low-low-low\*).

  * Low = 1x10\^12 viral particles High = 3x10\^12 viral particles arm 2: * Chemotherapy: 900 mg/m2 capecitabine twice daily, Mon-Fri (on radiotherapy days) for 5 weeks, except on days patients received enadenotucirev.
* Radiotherapy: 50 Gy in 25 fractions.
* Enadenotucirev: 3 x loading doses pre-chemoradiation (low-low-low\*). 3 x maintenance doses post-chemoradiation (low-low-low\*).

  * Low = 1x10\^12 viral particles High = 3x10\^12 viral particles arm 3: * Chemotherapy: 900 mg/m2 capecitabine twice daily, Mon-Fri (on radiotherapy days) for 5 weeks, except on days patients received enadenotucirev.
* Radiotherapy: 50 Gy in 25 fractions.
* Enadenotucirev: 3 x loading doses pre-chemoradiation (low-low-low\*). 3 x maintenance doses post-chemoradiation (low-high-high\*).

  * Low = 1x10\^12 viral particles High = 3x10\^12 viral particles arm 4: * Chemotherapy: 900 mg/m2 capecitabine twice daily, Mon-Fri (on radiotherapy days) for 5 weeks, except on days patients received enadenotucirev.
* Radiotherapy: 50 Gy in 25 fractions.
* Enadenotucirev: 3 x loading doses pre-chemoradiation (low-high-high\*). 2 x concurrent doses on week 1, days 1 and 5 of chemoradiation (high-high\*). 3 x maintenance doses post-chemoradiation (low-high-high\*).

  * Low = 1x10\^12 viral particles High = 3x10\^12 viral particles
Interventions: intervention 1: Enadenotucirev intervention 2: Capecitabine intervention 3: Radiotherapy
Intervention descriptions: intervention 1: Enadenotucirev is a live replicating oncolytic adenovirus; it is considered a BioSafety Level 1 (BSL-1) infectious substance. intervention 2: Capecitabine is a chemotherapy drug licensed for use in rectal cancer, it is a non-cytotoxic pre-cursor of the cytotoxic 5-fluorouracil. Due to Capecitabine not being taken on Enadenotucirev dosing days it is considered an investigational medicinal product within this trial. intervention 3: 50 Gy/25#

Protocol documents:
Prot_000.pdf: 
CEDAR Protocol
Full title: A Phase 1 trial of the safety, tolerability and biological effects of 
intravenous Enadenotucirev, a novel oncolytic virus, in combination with 
chemoradiotherapy in locally advanced rectal cancer
Short title: Chemoradiation with Enadenotucirev as a radiosensitiser in 
locally Advanced Rectal cancer
Protocol Version & date: 
V4.0_05May2021 
Protocol Number: 
OCTO_081 
EudraCT Number: 
2017-003501-18 
REC Number: 
18/SC/0583 
IRAS Project ID: 
238087 
Sponsor:  
University of Oxford   
Funders:  
Cancer Research UK (A24474) & PsiOxus Therapeutics 
Limited 
Conflict of Interest statement 
Details of potential conflicts of interest are given on page 3 
Confidentiality Statement 
This document contains confidential information that must 
not be disclosed to anyone other than the Sponsor, the Trial 
Office, the Investigator Team, host NHS Trust(s), regulatory 
authorities, and members of the Research Ethics Committee 
unless authorised to do so.   


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Key trial contacts
Chief Investigator 
Professor Maria  A. Hawkins 
Medical Physics and Biomedical Engineering  
Malet Place Engineering Building  
University College London 
Gower Street 
London, WC1E 6BT 
Email: m.hawkins@ucl.ac.uk 
Co-Investigators 
Dr Richard Adams 
Professor Timothy Maughan
Dr Séan M. O'Cathail  
Professor Somnath Mukherjee  
Oxford Clinical Trial Office (OCTO)
CEDAR Trial Office 
Oncology Clinical Trials Office (OCTO)
Department of Oncology, The University of Oxford 
Old Road Campus Research Building 
Oxford OX3 7DQ, UK 
Tel:+44 (0)1865 617087 
Email: octo-cedar@oncology.ox.ac.uk
Website: https://www.oncology.ox.ac.uk/research/srf/oncology-clinical-
trials-office-octo
Sponsor 
Ms Heather House 
University of Oxford, Clinical Trials and Research Governance Team 
1st Floor, Boundary Brook House 
Churchill Drive 
Headington 
Oxford OX3 7GB 
Statisticians 
Jane Holmes, Medical Statistician 
Centre for Statistics in Medicine (CSM) 
University of Oxford 
Botnar Research Centre 
Windmill Road 
Oxford OX3 7LD  
Tel: 01865 223452 
Email: jane.holmes@csm.ox.ac.uk 
Alex Ooms, Medical Statistician 
Centre for Statistics in Medicine (CSM) 
University of Oxford 
Botnar Research Centre 
Windmill Road 
Oxford OX3 7LD  
Tel: 01865 737867 
Email: alexander.ooms@ndorms.ox.ac.uk 
Trial Management Group 
TMG Chair: Professor Maria Hawkins (Chief Investigator) 
Independent Oversight Committee 
Trial oversight will be provided by the Radiotherapy and Imaging 
Oversight Committee (RIOC) 
RIOC Chair: Prof. Peter Hoskin 


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Other key contacts
Translational Research Collaborators 
Professor Leonard Seymour 
Department of Oncology, University of Oxford 
Email: len.seymour@oncology.ox.ac.uk 
Dr Kerry Fisher 
Department of Oncology, University of Oxford 
Email: kerry.fisher@oncology.ox.ac.uk 
During office hours: Clinical Queries should be directed to the Trial Manager (details as above) for action. 
Out of office hours: call the Oxford University Hospitals NHS Trust switchboard on Tel: 01865 741166 and ask to speak 
to the CEDAR trial out of hours clinician. 
Patient Registration: To register a patient on the trial please email the completed and scanned Registration Form to the 
CEDAR Trial Office: octo-CEDAR@oncology.ox.ac.uk 
Protocol Authors and conflict of interest statement 
Translational Research Collaborators Len Seymour and Kerry Fisher own equity in PsiOxus Therapeutics Limited – their 
role within the trial is limited to scientific advisors. They are not involved directly in the trial design, management or 
interpretation of trial results and have no decision making roles at any stage of the trial. 
PsiOxus are providing enadenotucirev and contribute to funding for CEDAR. 


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TABLE OF CONTENTS 
KEY TRIAL CONTACTS............................................................................................................................................................ 2
PROTOCOL AUTHORS AND CONFLICT OF INTEREST STATEMENT ..................................................................................................... 3
PROTOCOL SYNOPSIS ................................................................................................................................................. 7
SUMMARY SCHEDULE OF EVENTS .................................................................................................................................. 8
TRIAL FLOW CHART ........................................................................................................................................................... 10
ABBREVIATIONS ....................................................................................................................................................... 11
1
INTRODUCTION ..................................................................................................................................... 12
1.1
BACKGROUND .................................................................................................................................................... 12
1.2
INVESTIGATIONAL MEDICINAL PRODUCT(S) USED IN THE TRIAL .................................................................................... 13
1.3
RATIONALE FOR THE TRIAL .................................................................................................................................... 15
2
TRIAL DESIGN......................................................................................................................................... 17
3
OBJECTIVES AND ENDPOINTS ................................................................................................................ 17
4
PATIENT SELECTION ............................................................................................................................... 18
4.1
ELIGIBILITY CRITERIA ............................................................................................................................................ 18
4.2
PROTOCOL DEVIATIONS AND WAIVERS TO ENTRY CRITERIA........................................................................................... 19
4.3
RE-SCREENING IF PATIENT DOES NOT MEET INCLUSION/EXCLUSION CRITERIA FIRST TIME ROUND ......................................... 19
4.4
PATIENT REGISTRATION PROCEDURE ....................................................................................................................... 20
5
TRIAL ASSESSMENTS AND PROCEDURES ................................................................................................ 20
5.1
INFORMED CONSENT ........................................................................................................................................... 20
5.2
SCREENING/BASELINE EVALUATIONS ...................................................................................................................... 21
5.3
PRE-TREATMENT EVALUATION ............................................................................................................................... 22
5.3.1
EVALUATION SCHEDULE A .................................................................................................................................... 22
5.3.2
EVALUATION SCHEDULE B ..................................................................................................................................... 23
5.4
POST DOSE EVALUATIONS ..................................................................................................................................... 23
5.5
WEEKS 1/2 ....................................................................................................................................................... 24
5.6
WEEK 3 ............................................................................................................................................................ 24
5.6.1
DOSING GROUPS 1, 2 & 3 ................................................................................................................................... 24
5.6.2
DOSING GROUP 4 ............................................................................................................................................... 24
5.7
WEEK 4, 5, 6, 7 ................................................................................................................................................. 24
5.7.1
WEEK 4 ONLY .................................................................................................................................................... 24
5.7.1
WEEK 4, 5, 6, 7 - OTHER ASSESSMENTS.................................................................................................................. 24
5.7.2
WEEK 7 ONLY .................................................................................................................................................... 25
5.8
WEEK 8, 9 ........................................................................................................................................................ 25
5.8.1
DOSING GROUP 1 ............................................................................................................................................... 25
5.8.2
DOSING GROUPS 2, 3 & 4 .................................................................................................................................... 25
5.9
END OF TRIAL EVALUATIONS AT 13 WEEKS (+/- 3 DAYS) ............................................................................................. 25
5.10
FOLLOW-UP EVALUATIONS (POST 14+ WEEKS) ......................................................................................................... 26
6
EARLY PATIENT WITHDRAWAL .............................................................................................................. 26
7
SAMPLES FOR LABORATORY ANALYSIS .................................................................................................. 27
7.1
SAMPLES TO BE ANALYSED IN LOCAL TRUST’S LABORATORIES ....................................................................................... 27
7.2
SAMPLES TO BE SENT TO AND ANALYSED IN A CENTRAL LABORATORY ............................................................................ 27
7.3
LABELLING AND CONFIDENTIALITY OF SAMPLES SENT .................................................................................................. 27
7.4
CLINICAL REPORTING OF EXPLORATORY RESEARCH ASSAY RESULTS................................................................................. 27
7.5
TRIAL SAMPLE RETENTION AT END OF TRIAL .............................................................................................................. 27
7.6
WITHDRAWAL OF CONSENT FOR SAMPLE COLLECTION AND/OR RETENTION .................................................................... 28
8
INVESTIGATIONAL MEDICINAL PRODUCTS (IMPS) ................................................................................. 28
8.1
NAME OF IMPS ................................................................................................................................................. 28
8.2
TREATMENT DOSE AND DURATION ......................................................................................................................... 28
8.3
MANAGEMENT OF DRUG ADMINISTRATION .............................................................................................................. 29
8.4
SPECIAL PRECAUTIONS ......................................................................................................................................... 30


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8.5
DOSE MODIFICATION ........................................................................................................................................... 30
8.6
COMPLIANCE ..................................................................................................................................................... 31
8.7
MANAGEMENT OF OVERDOSE ............................................................................................................................... 31
9
DOSE LIMITING TOXICITY ....................................................................................................................... 31
9.1
DEFINITION OF A DOSE LIMITING TOXICITY (DLT) ...................................................................................................... 31
9.2
TOXICITY ASSOCIATED WITH ENADENOTUCIREV ......................................................................................................... 32
9.3
MANAGEMENT OF ENADENOTUCIREV TOXICITY ......................................................................................................... 33
9.4
TOXICITY ASSOCIATED WITH CAPECITABINE ............................................................................................................... 34
9.5
MANAGEMENT OF CAPECITABINE TOXICITY .............................................................................................................. 34
10
OTHER TREATMENTS (NON-IMPS) ......................................................................................................... 35
10.1
SUPPORT MEDICATION ......................................................................................................................................... 35
10.2
CONCOMITANT MEDICATION AND NON-DRUG THERAPIES ........................................................................................... 35
10.3
PROHIBITED THERAPIES ........................................................................................................................................ 35
10.4
(POTENTIAL) DRUG INTERACTIONS ......................................................................................................................... 35
11
DRUG MANAGEMENT ............................................................................................................................ 36
11.1
DRUG SUPPLIES .................................................................................................................................................. 36
11.2
DRUG ORDERING ................................................................................................................................................ 36
11.3
IMP RECEIPT ..................................................................................................................................................... 36
11.4
HANDLING AND STORAGE ..................................................................................................................................... 36
11.5
LABELLING ......................................................................................................................................................... 37
11.6
DOSING DISPENSING ............................................................................................................................................ 37
11.7
DRUG ACCOUNTABILITY........................................................................................................................................ 37
11.8
DRUG RETURNS FROM PATIENTS ............................................................................................................................ 37
11.9
DRUG DESTRUCTION ............................................................................................................................................ 37
11.10
OCCUPATIONAL SAFETY ........................................................................................................................................ 38
12
RADIOTHERAPY (AND CHEMORADIOTHERAPY) ..................................................................................... 38
12.1
MANAGEMENT OF UNSCHEDULED GAPS .................................................................................................................. 38
12.2
RADIOTHERAPY TOXICITY ...................................................................................................................................... 38
12.3
RADIOTHERAPY QUALITY ASSURANCE ...................................................................................................................... 39
13
EVALUATION OF RESPONSE ................................................................................................................... 39
13.1
TUMOUR ASSESSMENT ......................................................................................................................................... 39
13.2
MRI TUMOUR RESPONSE ..................................................................................................................................... 39
13.3
PATHOLOGICAL TUMOUR RESPONSE ....................................................................................................................... 39
14
SAFETY REPORTING ............................................................................................................................... 39
14.1
ADVERSE EVENT DEFINITIONS ............................................................................................................................... 40
14.2
CLINICAL LABORATORY ABNORMALITIES AND OTHER ABNORMAL ASSESSMENTS AS AES AND SAES ...................................... 40
14.3
DETERMINING ADVERSE EVENT CAUSALITY ............................................................................................................... 41
14.4
SUMMARY OF TRIAL SAFETY REPORTING REQUIREMENTS ............................................................................................. 42
14.5
REFERENCE SAFETY INFORMATION (RSI) FOR ASSESSMENT OF EXPECTEDNESS ................................................................. 44
14.6
SUSPECTED UNEXPECTED SERIOUS ADVERSE DRUG REACTIONS (SUSARS) .................................................................... 44
14.7
EXPEDITED REPORTING OF SAES ............................................................................................................................ 44
14.8
FOLLOW-UP OF SERIOUS ADVERSE EVENTS .............................................................................................................. 44
14.9
REPORTING ADVERSE EVENTS ON THE CRF .............................................................................................................. 44
14.10
EVENTS EXEMPT FROM BEING REPORTED AS AE/ SAES............................................................................................... 45
14.11
INFORMING INVESTIGATORS OF NEW SAFETY INFORMATION ........................................................................................ 45
15
PREGNANCY ........................................................................................................................................... 45
16
DEFINING THE END OF TRIAL ................................................................................................................. 46
17
STATISTICAL CONSIDERATIONS .............................................................................................................. 46
17.1
CEDAR: EVALUATION OF TREATMENT SCHEDULES .................................................................................................... 46
17.2
DOSE SELECTION DURING THE TRIAL ........................................................................................................................ 46
17.3
STOPPING THE TRIAL EARLY ................................................................................................................................... 47


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17.4
IMPORTANCE OF RAPID DATA RETURN ..................................................................................................................... 47
18
STATISTICAL ANALYSIS PLAN ................................................................................................................. 47
18.1
INCLUSION IN ANALYSIS ........................................................................................................................................ 47
18.2
INTERIM ANALYSES ............................................................................................................................................. 47
18.3
PROCEDURES FOR REPORTING ANY DEVIATION(S) FROM THE PROTOCOL ......................................................................... 48
18.4
FINAL ANALYSIS .................................................................................................................................................. 48
19
TRIAL COMMITTEES ............................................................................................................................... 48
19.1
TRIAL MANAGEMENT GROUP (TMG) .................................................................................................................... 48
19.2
SAFETY REVIEW COMMITTEE (SRC) ....................................................................................................................... 48
19.3
INDEPENDENT RADIOTHERAPY & IMAGING OVERSIGHT COMMITTEE (RIOC) .................................................................. 48
20
DATA MANAGEMENT ............................................................................................................................ 48
20.1
DATABASE CONSIDERATIONS ................................................................................................................................. 48
20.2
CASE REPORTS FORMS (CRFS) ............................................................................................................................... 48
20.3
ACCOUNTING FOR MISSING, UNUSED, OR SPURIOUS DATA. .......................................................................................... 49
21
CLINICAL TRIAL REPORT ......................................................................................................................... 49
22
TRIAL SITE MANAGEMENT ..................................................................................................................... 49
22.1
TRIAL SITE RESPONSIBILITIES .................................................................................................................................. 49
22.2
TRIAL SITE SET UP AND ACTIVATION ........................................................................................................................ 49
22.3
TRIAL DOCUMENTATION ....................................................................................................................................... 49
23
REGULATORY AND ETHICAL CONSIDERATIONS ...................................................................................... 49
23.1
ETHICAL CONDUCT OF THE TRIAL AND ETHICS APPROVAL ............................................................................................. 50
23.2
REGULATORY AUTHORITY APPROVAL ...................................................................................................................... 50
23.3
NHS RESEARCH GOVERNANCE .............................................................................................................................. 50
23.4
PROTOCOL AMENDMENTS .................................................................................................................................... 50
23.5
URGENT SAFETY MEASURES .................................................................................................................................. 50
23.6
TEMPORARY HALT ............................................................................................................................................... 50
23.7
SERIOUS BREACHES ............................................................................................................................................. 51
23.8
TRIAL REPORTS .................................................................................................................................................. 51
24
EXPENSES AND BENEFITS ....................................................................................................................... 51
25
QUALITY ASSURANCE ............................................................................................................................ 51
25.1
RISK ASSESSMENT ............................................................................................................................................... 51
25.2
MONITORING .................................................................................................................................................... 51
25.3
AUDIT AND REGULATORY INSPECTION ..................................................................................................................... 52
26
RECORDS RETENTION & ARCHIVING ...................................................................................................... 52
27
PATIENT CONFIDENTIALITY .................................................................................................................... 52
28
TRIAL FUNDING ..................................................................................................................................... 53
29
SPONSORSHIP AND INDEMNITY ............................................................................................................ 53
29.1
SPONSORSHIP .................................................................................................................................................... 53
29.2
INDEMNITY ........................................................................................................................................................ 53
29.3
CONTRACTS/AGREEMENTS ................................................................................................................................... 53
30
PUBLICATION POLICY ............................................................................................................................. 53
31
REFERENCES ........................................................................................................................................... 54
APPENDIX 1: ECOG PERFORMANCE SCALE ................................................................................................................ 57
APPENDIX 2: MRI ASSESSED TUMOUR REGRESSION GRADING (mrTRG) ................................................................... 58
APPENDIX 3: NEOADJUVANT RECTAL SCORE ............................................................................................................ 59


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PROTOCOL SYNOPSIS 
Full Title : 
A Phase 1 trial of the safety, tolerability and biological effects of intravenous 
enadenotucirev, a novel oncolytic virus, in combination with chemoradiotherapy in 
locally advanced rectal cancer 
Short Title: 
Chemoradiation with Enadenotucirev as a radiosensitiser in locally Advanced Rectal 
cancer 
Trial Acronym: 
CEDAR 
Clinical Phase: 
Phase 1 
Trial Design: 
Interventional 
Objectives 
Endpoints 
Primary Endpoint: 
Determine the optimal dose and 
frequency of enadenotucirev that can be 
administered with chemoradiation 

Dose limiting toxicities 

MRI tumour regression grade 
Secondary Endpoints: 
Ability to deliver enadenotucirev 
concurrently with chemoradiation 
Treatment tolerance measured by 
proportion of patients completing at least 
80% of the prescribed capecitabine dose 
and at least 20 fractions of radiotherapy 
To measure local response rate to 
combined therapy 

MRI tumour regression grade 

Pathological complete response rate 

Neoadjuvant rectal score 
Investigational 
Medicinal Product(s) 
Name of drug 
Formulation, dose, route of administration 
- Enadenotucirev  
- Capecitabine 
- Solution, diluted and delivered 
intravenously 
There are 2 potential doses given over 4 
different dosing levels:  

1 x 1012 vp (viral particles) 

3 x 1012 vp 
- Tablet, 900mg/m2, oral administration 
Other interventions: 
Neoadjuvant radiotherapy 
Treatment Duration 
9 weeks 
Follow-up duration 
Trial follow-up visits continue until week 13.  Following this, patients will receive surgery 
and on-going follow up as standard of care.   
End of Trial 
Last Patient Last Visit (i.e. 4-6 weeks post-surgery visit)  


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SUMMARY SCHEDULE OF EVENTS
Procedure
Screening / 
Baseline 
Day -14 - 1 
Week 1/2
Week 33
Week 4
Week 5
Week 6
Week 7
Week 8/95
Week 13 
(+/- 3 days) 
EOT VISIT 
Week 
14 +  
4-6 
weeks 
post-
surgery 
Dosing 
day 1 
Dosing 
day 2 
Dosing 
day 3 
Day 1
Day 56 
Dosing 
day 1 
Dosing 
day 2 
dosing 
day 3 
Informed 
consent  
X 
Demographic & 
medical history
X 
Height
X 
Weight
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vital signs 1
X 
X 
X 
X 
X 
X6
X 
X 
X 
X 
X 
X 
X 
X 
Haematology
X 
X12
X12
X 
X6, 12
X 
X 
X 
X 
X12
X7, 12
X 
Biochemistry
X 
X12
X12
X 
X6, 12
X 
X 
X 
X 
X12
X7, 12
X 
Coagulation 
profile 
X 
X12
X12
X 
X6, 12
X 
X 
X 
X 
X12
X7, 12
X 
Urine dipstick
X 
X 
X 
X 
X6
X 
X 
X 
X 
X 
X7
X 
Pregnancy test 
(FCBP only) 
X 
ECG
X 
DPYD deficiency 
test14
X 
Enadenotucirev
X2
X2
X2
X3
(dose 
schedule 
4 only) 
X3
(dose 
schedule 
4 only) 
X5
(dose 
schedules 
2,3 & 4) 
X5
(dose 
schedules 
2,3 & 4) 
X5
(dose 
schedules 
2,3 & 4) 
Radiotherapy
XXXXX
XXXXX
XXXXX
XXXXX
XXXXX
Capecitabine
(X)XXX(X)
XXXXX
XXXXX
XXXXX
XXXXX
Tumour  Biopsy
X9
X
Investigational 
Blood Sample 
X8
X8 
DAY 10 
X
X
Faecal sample & 
questionnaire13
(Optional) 
X
X
X
X
X
AE assessments 
X 
X 
X 
X 
X6
X 
X 
X 
X 
X 
X 
X 
X 
X 
DLT 
assessments 
X 
X 
X 
X 
X6
X 
X 
X 
X 
X 
X 
X 
X 
Physical exam 
X 
X 
X 
X 
X 
X6
X 
X 
X 
X 
X 
X 
X 
X 


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Procedure
Screening / 
Baseline 
Day -14 - 1 
Week 1/2
Week 33
Week 4
Week 5
Week 6
Week 7
Week 8/95
Week 13 
(+/- 3 days) 
EOT VISIT 
Week 
14 +  
4-6 
weeks 
post-
surgery 
Dosing 
day 1 
Dosing 
day 2 
Dosing 
day 3 
Day 1
Day 56 
Dosing 
day 1 
Dosing 
day 2 
dosing 
day 3 
ECOG 
Performance 
Status 
X 
X 
X 
X 
X 
X6
X 
X 
X 
X 
X 
X 
X 
X 
X 
Concomitant 
Meds 
X 
X 
X 
X 
X 
X6
X 
X 
X 
X 
X 
X 
X 
X 
CT Chest/Abdo/
Pelvis
X4
X10
Pelvic MRI
X4
X11
Surgery
X 
Neoadjuvant 
rectal score 
(NAR) 
X 
Pathological 
resection 
specimen 
findings 
X 
1 - Vital signs include: systolic / diastolic blood pressure (BP), pulse rate, respiratory rate and temperature  
2 - Virus loading administration given on at least alternate days for 3 doses.  
3 - For dosing schedules 1, 2 & 3, no enadenotucirev dosing is required in week 3. A single visit should be completed to assess the patient  
4 - Standard of care diagnostic CT and pelvic MRI are acceptable as baseline imaging if performed within 62 days (CT) & 42 days (MRI) of start of treatment.  If > 62 (CT) or 42(MRI) days these should 
be repeated after patient has given informed consent (within 14 days of consent date).  Whole body PET-CT is an acceptable alternative to CT.   
5 - For dosing schedules 1 no enadenotucirev dosing is required in weeks 8-9.  A single visit should be completed to assess the patient post completion of CRT with the 2nd & 3rd visits omitted 
6 - These assessments apply to schedules 4 only 
7- These assessments apply to groups 2, 3 & 4 
8. Additional, investigational blood sample must be taken AFTER consent/ registration, for the week 4 blood sample aim to be on the same day of the biopsy 
9. Archival tumour tissue sample 
10. Only complete if local site policy 
11. Pelvic MRI for week 13 visit can be +/- 7 days 
12. Additional blood sample – (taken as standard at other time points)  
13. Not applicable to all sites 
14. Any time before trial enrolment (see Section 9.4).  


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Trial Flow chart  


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ABBREVIATIONS 
ADR 
Adverse Drug Reaction 
AE 
Adverse Event 
ALT/ AST 
Alanine/ Aspartate Transaminase 
ANC 
Absolute Neutrophil Count 
BP 
Blood Pressure 
BSA 
Body Surface Area 
CRF 
Case Report Form 
CRT 
Chemoradiotherapy 
CRM 
Circumferential Resection Margin 
CRUK 
Cancer Research United Kingdom 
CSM 
Centre for Statistics in Medicine 
CT 
Computed Tomography 
CTA 
Clinical Trial Agreement/ Clinical Trial Authorisation 
DLT 
Dose Limiting Toxicity 
DSMC 
Data and Safety Monitoring Committee 
ECOG 
Eastern Co-operative Oncology Group 
ECG 
Electrocardiogram 
Enadenotucirev 
Enadenotucirev 
FBC 
Full Blood Count 
GCP 
Good Clinical Practice  
Gy 
Gray 
Hb 
Haemoglobin 
HCG 
Human Chorionic Gonadotropin 
HTA 
Human Tissue Act 
IB 
Investigator Brochure 
IHC 
Immunohistochemistry 
IMP 
Investigational Medicinal Product 
IMRT 
Intensity Modulated Radiotherapy 
IV 
Intravenous 
LARC 
Locally advanced rectal cancer 
LCCR 
Long course chemo-radiotherapy 
LDH 
Lactate dehydrogenase 
LPLV 
last visit of the last patient undergoing the trial 
MDT 
Multi-disciplinary team 
MHRA 
Medicines and Healthcare products Regulatory Agency 
MRF 
Mesorectal Fascia 
MRI 
Magnetic Resonance Imaging 
mrTRG 
Magnetic resonance Tumour Regression Grade 
MTD 
Maximum Tolerated Dose 
NCI CTCAE 
National Cancer Institute - Common Terminology Criteria for Adverse Events 
OAR 
Organs At Risk 
OCTO 
Oncology Clinical Trials Office 
OCTRU 
Oxford Clinical Trials Research Unit 
PD 
Pharmacodynamic 
PI 
Principal Investigator 
PK 
Pharmacokinetic 
pCR 
Pathological complete response 
PT 
Prothrombin Time 
REC 
Research Ethics Committee 
RIOC 
Radiotherapy & Imaging Oversight Committee 
RSI 
Reference safety information  
RTTQA 
Radiotherapy Trials Quality Assurance 
SAR 
Serious Adverse Reaction 


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SOP 
Standard Operating Procedure 
SPC 
Summary of Product Characteristics 
SRC 
Safety Review Committee 
SUSAR 
Suspected Unexpected Serious Adverse Drug Reaction 
TiTE CRM 
Time To Event Continual Reassessment Method 
TME 
Total Mesorectal Excision 
TMG 
Trial Management Group 
TNM 
Tumour, Node and Metastasis Staging System 
ULN 
Upper Limit of Normal 
Vp 
Viral particles 
WBC 
White Blood Cells 
1
INTRODUCTION 
1.1 Background  
The use of radiotherapy (RT), in combination with chemotherapy and/or surgery, is the main curative treatment 
modality and standard of care in locally advanced rectal cancer. Improvements in locoregional control and overall 
survival have been realised with small increments in each of the combined modality treatments (surgery, radiotherapy 
and chemotherapy). Precision radiotherapy is delivered as highly conformal image guided external beam radiotherapy 
and offers opportunities to combine novel anticancer agents due to reduced toxicity. Despite the promise of increased 
cure rates when pairing novel treatment modalities with precision radiotherapy, the majority of phase I clinical trials 
are generally conducted in non-curative, metastatic populations. An alternative approach of targeting tumours earlier 
in their history might increase cure rates especially when the additional agents augment local tumour control and /or 
ablate micro- or oligo metastatic disease. The strategy holds tremendous potential to increase survival for a significant 
number of patients who might otherwise develop metastases, and/or fail locally.  
In 2010-12 11,567 people were diagnosed with rectal cancer in UK (1). Locally advanced rectal cancer (LARC) is 
defined by the presence of T3/4 disease and/or nodal involvement in the absence of distal metastatic disease. 
Patients with locally advanced disease requiring radiotherapy can represent up to 30% of this population and often 
have a poor outcome. The lack of a universally accepted standard radiotherapy treatment remains a challenge.  
Optimal outcomes are achieved with a multidisciplinary approach, with the aim of achieving local control with 
successful sphincter preservation and reducing the risk of distant recurrence. For many years, the standard of care has 
been a multimodal approach incorporating neoadjuvant long-course chemoradiotherapy (CRT) with concurrent 
fluoropyrimidine followed by total mesorectal excision surgery. With this approach, local recurrence rates have fallen 
from 30%-45% to <10%. Attempts to add additional chemotherapy, such as oxaliplatin or irinotecan have not 
meaningfully improved outcomes, whilst concurrent biologic therapies (vascular endothelial growth factor (VEGF), 
epidermal growth factor receptor (EGFR), Poly(ADP-ribose) polymerase (PARP) inhibitors, etc.) have shown, in part, 
promising results at the expense of increased toxicity but possibly did not enhance radiosensitisation as local control 
remains unchanged. This paradigm as intensification of local treatments to achieve better response have had limited 
impact due to increased toxicity, and more than one in 5 patients still develop metastatic disease (2).  
An alternative approach is to offer short course radiotherapy, 25Gy over 5 fractions in one week, and proceed to 
surgery within a week. This approach is often coupled with neoadjuvant or adjuvant courses of chemotherapy. 
Multiple studies have failed to show the superiority of one approach over the other (3,4).  
The current research paradigm includes two priority research areas: treatment de-intensification with the option of 
organ preservation (surgery deferral) and treatment intensification using total neoadjuvant treatment (TNT) approach 
where chemotherapy is used prior to chemoradiation, or short course radiotherapy, and surgery.  These are on the 
highest priority list for cancer related questions on the Association of Coloproctology of Great Britain and Ireland 
(ACPGBI) which were designed to reach a consensus on prioritizing clinical research questions in colorectal disease (5). 
At present identifying novel radiosensitising agents in colorectal cancer is an area of high need for patients 
considering sphincter preserving surgery or needing downstaging to facilitate surgery, and neoadjuvant systemic 
treatment is thought to be required for patients at risk of developing metastases, especially as the use of adjuvant 
chemotherapy is controversial in terms of benefit. Radical surgery can be associated with significant morbidity and 


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mortality in elderly populations and these patients would benefit from improving radiation response. Rectal cancer 
also offers excellent translational opportunities as the majority of patients proceed to surgery.  
Oncolytic viruses are novel anticancer agents that target, selectively replicate in, and kill cancer cells, spreading 
through the tumour microenvironment, generating local and systemic immune response both to themselves as well as 
the dying tumour. Radiotherapy elicits a multitude of biological responses and the evidence from experimental 
models suggests that the irradiated tumour is “converted” in an in situ vaccine (6,7).  There is some evidence that 
higher dose per fraction radiotherapy may be more useful in eliciting an immune response, providing further rationale 
for the inclusion of patients receiving short course radiotherapy.  RT can modulate the expression of a large number of 
cellular genes involved in cell cycle checkpoints, cellular stress, DNA repair and apoptosis (8). Combining radiotherapy 
with immunotherapy is emerging as a further opportunity to improve therapeutic results and is a seen as a priority for 
research. Enadenotucirev would address the combined requirements as the therapy would act as both a local (DDR 
inhibitor/ direct tumour kill) and systemic (immune response) agent. 
1.2 Investigational Medicinal Product(s) used in the trial  
Enadenotucirev 
Enadenotucirev is a group B oncolytic adenovirus under development for the systemic treatment of metastatic or 
advanced epithelial tumours. Enadenotucirev is a chimeric adenovirus type 11p (Ad11p)/adenovirus type 3 (Ad3) 
virus, discovered through a process of bio-selection from a library of chimeric viruses produced from a pool of 
adenoviruses from seven different serotypes utilizing human HT-29 colorectal cancer (CRC) cells (9) . 
Enadenotucirev shows selective and potent toxicity in human carcinoma cells with only very limited or no toxicity to 
normal (non-cancerous) human cells. Other than humans, there is no known permissive species for enadenotucirev. 
The principal advantage of oncolytic therapy is that the drug (the virus) replicates only in diseased cells meaning that 
the concentration of drug is amplified at the site of pathology so that it is higher in the tumour than in healthy tissue. 
Virus particles spread from cell to cell within a tumour nodule until they reach non-permissive normal tissues, in 
principle destroying all viable tumour cells they encounter (10,11)  
While the overall understanding of the mechanism of action of enadenotucirev in humans is still under investigation, 
it is now well established from both non-clinical and clinical studies that the mechanism of anti-cancer efficacy of 
oncolytic viruses not only involves direct infection and lysis of tumour cells, but that immune responses stimulated via 
an increased release of tumour-associated antigens and immune-inflammatory activation signals also play a key role. 
The direct oncolytic efficacy of enadenotucirev has been demonstrated in a number of non-clinical studies with 
human tumour cells in vitro and in vivo. Replication of the enadenotucirev virus in carcinoma cells results in direct 
necrolytic killing of carcinoma cells by a non-apoptotic, immunogenic cell death mechanism which would be expected 
to trigger immune cells. However, it has not been possible to directly demonstrate this mechanism in non-clinical 
studies due to the human specificity of enadenotucirev. Full details of the enadenotucirev non-clinical development 
are provided in the Investigator’s Brochure.  
Two clinical studies of enadenotucirev given as a monotherapy are completed and two studies of enadenotucirev in 
combination regimens are on-going. The two completed studies were a first in human study that included dose 
escalation and dosing schedule evaluation in metastatic epithelial solid tumours (ColoAd1-1001) and a mechanism of 
action study (ColoAd1-1002). The on-going studies are dose finding studies of intraperitoneal administration or 
intravenous (IV) infusion of enadenotucirev in combination with paclitaxel and IV infusion of enadenotucirev in 
combination with nivolumab. 
In the completed studies, a total of five subjects received intratumoural injections of enadenotucirev. These were well 
tolerated and no subjects had any treatment related adverse events. However, systemic exposure to enadenotucirev 
was much lower than with IV infusions. Seventy three subjects have received IV infusions of enadenotucirev at doses 
from 1 x 1010 vp to 1 x 1013 vp. Of these, 40 subjects received a single cycle of treatment and 33 subjects received 
repeat cycles of treatment up to a maximum of six cycles. Findings in these subjects can be summarised as follows: 

Dose-limiting toxicities of acute lung injury and dyspnoea with hypoxia were experienced after the first 
dose with 1 x 1013 vp 

The overall frequency and severity of adverse events including severe hypoxia and increased 
transaminases following doses of 6 x 1012 vp resulted in this dose being determined as not tolerated 


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
A dose of 3 x 1012 vp is considered the maximum tolerated dose (MTD) 

At the MTD the majority of subjects experience adverse events of an inflammatory nature particularly 
pyrexia and chills which have onset within 24 hours of dosing. The frequency of these type of events is 
lower after subsequent doses and appear to reflect the cytokine responses to treatment 

Adverse events relating to general disorders and gastrointestinal disorders were the most common type 
of events considered related to treatment with IV infusion of enadenotucirev 

Further experience with enadenotucirev is required to understand the frequency and severity of other 
common events such as nausea, vomiting and fatigue and other findings such as thrombocytopenia and 
proteinuria 

Serious adverse events (SAEs) were reported in about a third of subjects. The majority of the SAEs were 
single cases. However, there were seven reports of obstruction of the intestines which were considered 
unrelated to treatment in five subjects. The other two subjects had early onset after dosing but also had 
other predisposing conditions, such as a history of abdominal surgery, although the obstruction could also 
be explained by tumour flare. Other SAEs occurring in more than one subject were hypoxia, pyrexia and 
dyspnoea in three, three and two subjects, respectively 

There was no apparent difference in tolerability when 3 x 1012 vp were dosed with the 3-weekly or weekly 
schedule 

Viral kinetic data suggest enadenotucirev has a half-life of 17 minutes in keeping with other described iv 
adenoviruses. No infectious virus was detected later than 48 hours after dosing in blood samples 

Shedding data has indicated a positive signal by qualitative polymerase chain reaction (qPCR) analysis from 
rectal and buccal swabs and urine samples with little evidence for long-term shedding after dosing. 
However, the analysis cannot discriminate between infectious virus and inactive virus or fragments of viral 
deoxyribonucleic acid (DNA) 

Anti-enadenotucirev antibodies have been measured in the majority of subjects and levels increase until 
about Day 15 then plateau irrespective of whether a subject receives one or repeated cycles of treatment  
A further DLT of Grade 4 acute renal injury has also been seen in a single subject with Stage IV colon cancer in the on-
going study with enadenotucirev and nivolumab. The subject presented with clinical symptoms from around Day 21 
with marked decline in renal function by Day 28 and required long term dialysis; the patient subsequently died from 
disease progression. Although the subject met the eligibility criteria for study entry (with adequate renal function) he 
had a past history of methotrexate-related renal injury and chronic kidney disease that was not declared at study 
entry. 
Two similar events had also been reported in the completed study of enadenotucirev monotherapy (Study ColoAd1-
1001). Review of the available data from the 61 patents treated in this study appears to indicate two separate time 
periods following enadenotucirev administration when there are discernible effects on renal function (although the 
majority of these are noted to not have been considered of clinical significance or reported as adverse events). The 
first in the acute period following dosing (on Days 1, 3, 5) where proteinuria, reduction in albumin, reduction in blood 
pressure and reduced renal function are likely to be related to cytokine-mediated vascular leakage, in turn recovering 
over time. In some subjects, similar findings occur around Day 21 onwards, again, in most cases, resolving over time. 
The latter appear not to be related to dose or schedule.   
In the overall context of three patients out of 100 treated with intravenous enadenotucirev presenting with significant 
renal injury, the measures that have been and are to be implemented in the on-going studies of enadenotucirev are 
considered appropriate to managing the potential risk to patients in the context of treatment of their underlying 
disease. These measures, excluding those considered broadly to be at increased risk of renal injury, serve to identify 
any decline in renal function quickly with a view to implementing early intervention to any renal injury to in turn limit 
the damage of any recurrence of such an event 
Low-High-High dosing regimen 
Since the cytokine release is believed to be the most important mediator of the adverse effects of viral therapy, this 
tolerising effect allows subsequent doses to be delivered with a lower risk of high grade side effects. Splitting the dose 
may therefore allow a higher and more effective dose without dose limiting toxicities.  


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After the first dose has been administered, the cytokine response to subsequent doses of enadenotucirev is 
attenuated when delivered within a few days of the first dose.  
Attenuation of this cytokine response by administration of a well-tolerated day 1 dose of enadenotucirev to 
desensitise the cytokine response would allow the potential for delivery of higher subsequent doses to be tolerated. 
In turn this may allow more virus to be delivered to the tumour and increase the potential of clinical benefit. This type 
of dosing schedule is referred to as  a “low-high-high” dosing regimen and has been successfully implemented in 
clinical studies of other systemically administered oncolytic viruses (Laurie et al, 2006). 
Dosing groups 1 & 2 remain unchanged and will use a ‘low-low-low’ dosing regimen where are all 3 doses pre and post 
chemoradiotherapy will be given at 1x1012VP. 
The low-high-high dosing regimen will be used for the pre and post chemoradiotherapy doses of enadenotucirev in 
dosing groups 3 & 4. The low dose is 1 x 1012VP and the high dose is 3 x 1012VP. All pre and post chemoradiotherapy 
doses will continue to be given on non-consecutive days, over a 7 day period. 
Capecitabine 
Capecitabine is a chemotherapy drug licensed for use in rectal cancer, it is a non-cytotoxic pre-cursor of the cytotoxic 
5-fluourouracil (see SPC for more details).   
1.3 Rationale for the trial 
Non-clinical  
Although the proposed trial of enadenotucirev with radiation is novel, there is a wealth of evidence to support the 
rationale for combining this class of agent with radiation. Adenoviruses have developed a range of interactions with 
cellular DNA damage repair proteins to allow successful viral replication.  This has implications for the initiation of a 
number of DNA repair pathways activated in response to radiation-induced damage, in particular all adenoviral 
serotypes tested appear to target NHEJ repair (12). The hypothesis that oncolytic adenovirus infection would work 
synergistically with radiotherapy has been tested by a number of groups.   The combination of CG7870 with radiation 
resulted in a synergistic increase in cell killing, both in vitro and in vivo in the LNCaP xenograft model, than either agent 
alone (13). Toth et al studied 3 Ad5-based vectors and combined them with radiation in A549 lung cancer cells (14)[1]. 
Again, they found that in vivo and in vitro tumour cell kill was increased with the combination approach than was seen 
with either agent alone. Similar findings have been noted with a variety of different adenoviral vectors in other cell 
types including ovarian cancer cell lines (15) and glioma xenografts (16).  Importantly however the effect of 
radiosensitization does not appear to extend to normal tissues. The combination of Ad5/CMV/p53 synergistically 
radiosensitised two non-small cell lung cancer cell lines (A549 and H322) in vitro and in xenograft models, in a synergistic 
fashion, but showed increased radiosensitization effect on normal lung fibroblasts  (17). 
Clinical 
To date, clinical experience with virus/radiation combinations has been limited to local (most commonly intratumoural) 
administration.  This mode of delivery facilitates direct infection ensuring correct dosing and avoids rapid hepatic uptake 
seen with systemic delivery (18). The downside is only tumour types that can be easily accessed with a needle, such as 
skin, head and neck cancers, prostate cancers, are considered suitable for clinical trials.  Nevertheless, the results of 
these studies provide us with useful mechanistic indicators as well as guiding assessment of toxicity.  Whilst the authors 
acknowledge there are other oncolytic viruses in clinical practice we will focus on the clinical experience with adenoviral 
agents.  
A study of intraprostatic injection of an oncolytic Ad5 PSE/PBN E1A-AR (Ad5: adenovirus 5; PSE: prostate-specific 
enhancer; PBN: rat probasin promoter; E1A: early region 1A; AR: androgen receptor), combined with either low or high 
dose rate radiation therapy, showed few side effects (19).  Although DNA damage, as assessed by γH2AX foci, viral 
replication and viral induced cell death all favoured the high dose radiation arm, the side effect profile was similar in 
both arms.  This indicates that the therapeutic efficacy is separate from the toxicity, in contrast to traditional 
radiosensitisers where a higher dose often increases both efficacy and toxicity. These findings support the large body 
of preclinical data, along other prostate specific adenovirus constructs, that there is little additive toxicity to that seen 
with either agent alone (20).  
A Phase I trial of intraprostatic injection of a replication competent adenovirus in combination with radical dose (74Gy 
delivered in daily 2 Gy fractions)  of  intensity modulated radiotherapy (IMRT) showed no significant differences in  
gastro-intestinal or genitourinary toxicity in comparison to the toxicity seen when administering the adenovirus as a 


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single agent (21).  The investigational agent had already proven safe and efficacious as a single agent (22).  These results 
were confirmed in a follow on randomized Phase II trial (23).  There was a non-significant 42% reduction in biopsy 
positivity in the investigational arm suggesting improved efficacy and synergy with radiation. Clinical outcomes at 2 
years show no difference, likely reflecting the excellent prognosis of both groups.  A Phase II/III (ReCAP) open label 
adaptive trial of 280 men, randomized to combination treatment or radiation efficacy with biochemical failure free 
survival as the primary endpoint (24). Other groups have shown that administering a different type of adenovirus is 
safe, both concurrently and after radiation to the prostate (25,26) ,when all cells should be at maximal damage and 
repair rates. Again, the viral compound was administered intratumourally.  
There is also evidence from early phase clinical trials that a combination approach of radical dose (76Gy delivered in 
2.17 Gy daily fractions) with Ad5 replication defective adenoviral vector stimulates a systemic response (27).  IMRT was 
commenced 48 hours after the second of three doses of the viral agent, therefore patients were effectively loaded and 
then treated concurrently.  Again, drug was administered intraprostatically.  Both HLA DR+ CD8+ and CD4+ T cells were 
increased in the combination arm compared to the radiation alone arm suggesting the potential development of a Th1 
response.  
In a mixed solid tumour cohort an adenovirus vector under the control of EGF-1 promoter was combined with radiation 
in 36 patients (28). 70% of subjects showed evidence of a partial response with the main side effects relating to 
intratumoural administration of the agent. Using the same agent in combination with chemoradiation for squamous 
cell carcinomas of the Head and Neck in a Phase I dose escalation trial was performed (29), again with intratumoural 
administration.  The main dose limiting toxicity seen was thrombosis with no increase in acute radiation side effects 
incidence or intensity, underlining the safety of the combination approach.  Loco regional response was 83.3%.  
Preclinical studies with this agent have shown impressive ability to suppress regional metastatic node formation 
highlighting its ability to influence intrinsic tumour biology (30).  The same agent was also combined with incrementally 
increasing doses in combination with radiation in soft tissue extremity sarcoma (31).  No dose limiting toxicity (DLT) was 
noted and the combination was well tolerated.  91% of patients undergoing surgery showed a pathological complete 
response to treatment highlighting significant potential synergy between both agents.  The same adenovirus composite 
has been successfully combined with radical chemoradiotherapy (50.4Gy delivered in 1.8Gy daily fractions concurrently 
with fluoropyrimidine) for locally advanced pancreatic cancer in a non-randomized Phase I/II setting (32).  The main 
DLTs were pancreatitis and cholangitis but no specific increases in observed acute radiotherapy or chemotherapy side 
effects, respectively, were seen. The adenovirus was administered intratumourally.   
Combination of yet another adenovirus, designed to transfer p53 to malignant cells, in a radically treated non- small cell 
lung cancer population has shown impressive response data (33).  This prospective Phase II trial of 60 Gy in combination 
showed no evidence of pathologically viable tumour in 63% of patients (12 out of 19) evaluable.  The most common 
adverse events were virus related; fevers (79%) and chills (53%).   
On-going studies in brain malignancies such as glioblastoma multiforme (GBM) are also encouraging. Intratumoural 
injection at the time of surgery of an adenoviral vector expressing herpes simplex virus (HSV) thymidine kinase gene, 
combined with radical chemoradiation post operatively (34), has been tested prospectively. 12 of 13 patients completed 
therapy, at varying dose levels in this Phase Ib trial, with no DLTs or significant toxicity.  A phase II trial is on-going 
(NCT00589875).  Further evidence of safety in GBM patients is provided by the small phase I study which used a 
conditionally replicating HSV, G207 (35).  Following two prior safety studies with single agents use they showed, in 9 
patients, that intratumoural injection followed by 5Gy of radiation twenty four hours later had no increased risk of 
toxicity. Preclinical data with G207 also points to efficacy in other tumour sites such as head and neck SCC and lung 
cancer (36,37).   
Chemoradiotherapy induces DNA damage. The central hypothesis is that enadenotucirev will, selectively, downregulate 
DNA repair pathways in rectal cancer cells, making them more susceptible to DNA damage already incurred.  The high 
selectivity of enadenotucirev means normal tissue sensitization should be negligible. Enadenotucirev also has the 
potential to induce an oncosis phenotype cell death in malignant cells adding a complimentary, cytotoxic mechanism of 
action.  
The aim of the trial is to find the treatment schedule that has the optimal response-toxicity trade-off with no more than 
35% probability of a DLT.  This is on the basis that G3+ adverse event rate for CRT, historically, is approximately 30% 
(38,39).  However, these radiotherapy techniques have been superseded and toxicity is expected to be lower from CRT.  
Recent studies with novel radiosensitisers such as oxaliplatin reported G3/G4 toxicity in the order of 25% (40).  


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2
TRIAL DESIGN 
CEDAR is a dual endpoint, dose escalation phase I trial using a time to event continual reassessment method (TiTE CRM). 
Response and Toxicity endpoints will be combined via dose escalation rules to identify the optimal dose schedule. At 
most, 30 patients will be recruited to the trial. 
Dose escalation will be achieved by first increasing the frequency of administration of enadenotucirev followed by 
increasing the dose of enadenotucirev as detailed in the trial flow chart. These dose schedules are considered ordered 
with increasing toxicity expected from one dose schedule to the next. 
See section 8 and 17.2 for further details. 
3
OBJECTIVES AND ENDPOINTS 
Primary Objective 
Endpoints/ Outcome measures 
Time point(s) of evaluation of 
this end point 

Determine the optimal dose 
and frequency of 
enadenotucirev that can be 
administered with 
chemoradiation 

Dose limiting toxicity 

MRI tumour regression grade 

From Day 1 to Week 13 

Week 13 
Secondary Objectives 
Endpoints 

Ability to deliver 
enadenotucirev concurrently 
with chemoradiation 

Treatment tolerance measured by 
proportion of patients completing at least 
80% of the intended Capecitabine dose and 
at least 20 fractions of radiotherapy 

Week 9 

To measure local response 
rate to combined therapy 
compared to pre-treatment 
status 

MRI tumour regression grade 

Pathological complete response 

Neoadjuvant Rectal (NAR) score 

Week 13 

Post resection 

Post resection 
Tertiary/Exploratory Objectives 
Endpoints 

To identify ‘proof of concept’ 
that enadenotucirev 
replicates in the tumour 

IHC staining of hexon protein coat, viral gDNA 
and viral mRNA gene expression in tumour 
cells 

Archival tumour tissue 

Week 4 biopsy  

Resection sample  

To analyse gene expression 
changes in rectal cancer in 
response to enadenotucirev 

Whole genome RNA expression via RNA 
sequencing/ Nanostring gene expression 
analysis 

Archival tumour tissue 

Week 4 biopsy 

Resection sample 

Analyse changes in circulating 
tumour DNA in response to 
chemoradiation and enad 

ctDNA analysis exploring clearance of ctDNA 
and any/or emerging changes in persisting 
ctDNA 

Baseline (Pre 1st loading 
dose) 

Week 4 

Week 13 

4-6 weeks post-surgery 

Assess the changes in 
microbiome taxa during 
therapy 

Extraction of DNA and 16S sequencing and 
meta-transcriptomics from faecal samples 

Baseline (pre-enad) 

End of week 1 / 2 

End of week 4 

End of week 7 

Week 13 

Analyse the immune 
microenvironment as 
evidenced by immune cell 
infiltrates 

Multiplex Immunohistochemistry of immune 
cell markers 

Archival tumour tissue 

Week 4 biopsy 

Resection sample 


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4
PATIENT SELECTION 
Written informed consent must be obtained before any trial specific procedures are performed. The Investigator will 
determine patient eligibility based on the following criteria.  
4.1 Eligibility criteria 
Inclusion criteria:  
A patient will be eligible for inclusion in this trial if all of the following criteria apply. 
1.
Histologically confirmed invasive adenocarcinoma of the rectum. 
2.
Locally advance colorectal cancer as defined by pelvic MRI with a threatened circumferential resection 
margin (cT3mrf+ve), or inclusion of an adjacent organ, or low tumours at/below the level of the levators or 
enlarged pelvic side wall nodes or selected by the multidisciplinary team MDT for treatment with 
neoadjuvant (chemo)radiotherapy, regardless of TNM classification
3.
Patients with oligometastatic disease suitable for radical treatment are permitted provided that the site 
specific MDT deems them suitable for chemoradiation
4.
Male or female, Age  18 years.
5.
ECOG performance score of 0 - 1
6.
The patient is willing and able to comply with the protocol scheduled biopsy, follow-up visits and 
examinations for the duration of the trial.
7.
Written (signed and dated) informed consent.
8.
Adequate renal function demonstrated by:
-
Creatinine ≤1.5 ULN and estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73m2 (or measured 
creatinine clearance ≥60 mL/min) 
and 
-
Urine dipstick for proteinuria at screening and baseline negative or trace. Patients may be included with 
results of 1+ if they have a spot urinary albumin creatinine ratio (ACR) of either:  
(i) ≤3 mg/mmol or
(ii) >3  mg/mmol with a 24 hour urinary protein <1.0 g/24hours 
and 
-
Serum complement components C3 and C4 within the normal range 
9.
Haematological and biochemical indices within the ranges shown below: 
Lab Test 
Value required 
Haemoglobin (Hb) 
≥90 g/L 
Absolute neutrophil count 
 ≥1.5x109/L 
Platelet count 
≥100x109/L 
Bilirubin 
< 1.5 upper limit of normal  
Aspartate transaminase and/or alanine transaminase 
≤3 x upper limit of normal 
INR 
≤1.5 
aPTT 
Within laboratory normal range 
Exclusion criteria: 
A patient will not be eligible for the trial if any of the following apply: 
1.
Pregnant or breast-feeding women, or women of childbearing potential unless effective methods of 
contraception are used. 
2.
Pulmonary lymphangitis  (if metastatic disease present) 
3.
Past medical history: 
a.
Known history or evidence of significant immunodeficiency due to underlying illness and/or 
medication (e.g. systemic corticosteroids, or other immunosuppressive medications including 
cyclosporine, azathioprine, interferons in the 4 weeks before the first dose of trial treatment) 
b.
Splenectomy 
c.
Prior allogeneic or autologous bone marrow or organ transplantation 


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d.
Patients with a history of, or active, known or suspected auto-immune disease or a syndrome that 
requires systemic or immunosuppressive agents; patients with vitiligo, type I diabetes mellitus, 
residual hypothyroidism due to autoimmune disease only requiring hormone replacement, psoriasis 
not requiring systemic treatment or conditions not expected to recur in the absence of an external 
trigger are permitted to enrol 
e.
History of idiopathic pulmonary fibrosis, drug-induced pneumonitis, or evidence of active 
pneumonia or pneumonitis on computed tomography scan  
f.
Active viral disease or known positive serology for HIV, hepatitis B or hepatitis C 
g.
Active infections requiring antibiotics, physician monitoring, or recurrent fevers >38.0˚C associated 
with a clinical diagnosis of active infection 
h.
Prior pelvic radiotherapy 
i.
Any other active malignancy, with the exception of adequately treated cone-biopsied in situ 
carcinoma of the cervix uteri and non-melanoma skin lesions. 
j.
Uncontrolled cardiorespiratory comorbidity (e.g. severe pulmonary fibrosis, inadequately controlled 
angina or myocardial infarction in the last 6 months) 
k.
Major disturbance in bowel function (e.g. severe incontinence, Crohn’s disease, >6 loperamide/day), 
risk of bowel obstruction due to tumour- exception defunctioning colostomy performed 
l.
Treatment with any COVID-19 vaccine in the 28 days before the first dose of enadenotucirev, unless 
the vaccine is known to not be based on an adenoviral vector (e.g. mRNA vaccines) 
m. Treatment with any vaccine (including known non-adenoviral COVID-19 vaccines) in the 7 days 
before first dose of enadenotucirev 
4.
Use of the following antiviral agents: ribavirin, adefovir, lamivudine or cidofovir within 7 days prior to the first 
dose of trial treatment; or pegylated interferon in the 14 days before the first dose of trial treatment 
5.
Treatment with any other investigational agent, or participation in another interventional clinical trial within 
28 days prior to enrolment. In follow up for an interventional trials and observational studies are allowed 
6.
History of DVT or pulmonary embolus in the 12 months before the first dose of study treatment 
7.
History of significant bleeding requiring hospitalisation in the 12 months before the first dose of study 
treatment 
8.
Patients receiving therapeutic or prophylactic anticoagulation therapy 
9.
Known dihydropyrimidine dehydrogenase (DPYD) deficiency 
10. Prior chemotherapy is allowed as long as >28 days since the last administration and any toxicity has resolved 
to NCI CTCAE grade 1 or less 
11. Other psychological, social or medical condition, physical examination finding or a laboratory abnormality 
that the Investigator considers would make the patient a poor trial candidate or could interfere with protocol 
compliance or the interpretation of trial results. 
4.2 Protocol deviations and waivers to entry criteria 
Protocol adherence is a fundamental part of the conduct of a clinical trial.  Changes to the approved protocol need 
prior approval unless for urgent safety reasons. 
Investigators must contact OCTO to obtain guidance and/or clarification as necessary if unsure whether the patient 
satisfies all the entry criteria and to clarify matters of clinical discretion.  OCTO will contact the chief investigator or 
clinical coordinators as necessary.  
Investigators should not request a protocol waiver to enter a patient who does not satisfy the inclusion and 
exclusion criteria. 
The investigator must document and explain any deviations from the approved protocol. The investigator should 
promptly report any important deviations that might impact patient safety, data integrity or be a possible serious 
breach (see 23.7 below) to the trial office.  
4.3 Re-screening if patient does not meet inclusion/exclusion criteria first time round 
Screen failures are ineligible and will not be rescreened unless imaging is not within the required timeframe - this 
should be repeated and patient reconsidered for the trial. 


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4.4 Patient registration procedure 
The site must contact OCTO to check the availability of a screening slot and if available reserve the slot prior to giving 
out a Patient Information Sheet. A screening number should be requested prior to screening the patient and the site 
should register the participant within 2 weeks of receiving the screening number or relinquish the slot unless an 
extension is agreed with the trial office. 
Before entering a patient onto the trial, the Principal Investigator or designee will confirm eligibility. If in any doubt 
the Chief Investigator must be consulted before entering the patient. Details of the query and outcome of the decision 
must be documented on the registration/ eligibility checklist. Protocol waivers should not be requested to enter 
patients who are not eligible.  
Site staff will complete the trial Registration Form and email the form to the Trial Office to further confirm the patient’s 
eligibility. The original Registration Form should be retained at site. 
A Screening Log must be kept of all patients considered for the trial including any that are subsequently excluded; the 
reason for exclusion must be recorded on this form. A copy of the Screening Log must be sent to the trial office on 
request, but without patient identifiers. The original log must be retained on site in the ISF. 
To register a patient:
After checking patient eligibility site staff will complete the trial Registration Form.  Scan the Registration Form and 
email to:    octo-CEDAR@oncology.ox.ac.uk
The trial office will check the submitted form and register the patient on the trial.  Confirmation of the patient’s trial 
number will be emailed to the PI & other relevant site contacts. 
Enadenotucirev dosing schedule assignment will be determined pre-registration and confirmed by email to the PI & 
other relevant site contacts. See sections 8.2 and 17.2 for information on dosing schedules and dosing group 
decisions. 
5
TRIAL ASSESSMENTS AND PROCEDURES 
Please refer to the Schedule of Events given at the front of this protocol. Details of all protocol evaluations and 
investigations must be recorded in the patient’s medical record for extraction onto the CRF.  
5.1 Informed consent 
Potential participants will be given a current, approved version of the Patient Information Sheet and Consent Form. 
They will also receive clear verbal information about the trial detailing no less than: the nature of the trial; the 
implications and constraints of the protocol; the known side effects and any risks involved in taking part.  It will be 
explained that they will be free to withdraw from the trial at any time, for any reason, without prejudice to future care, 
and with no obligation to give a reason for withdrawal. They will have at least 24 hours to consider the information 
provided and the opportunity to question the Investigator, their GP or other independent parties before deciding 
whether to participate. Once registered onto the trial, the patients GP will be notified via a letter with specific consent 
for this process being obtained. 
The Investigator who obtains consent must be suitably qualified and experienced. All delegates must be authorised by 
the Principal Investigator to obtain consent.  The Investigator is responsible for ensuring that the trial consent 
procedures comply with current applicable GCP Regulatory and ethical requirements. Informed consent discussions and 
outcomes must be well documented in the medical record. The Investigator must be satisfied that the patient has made 
an informed decision before taking consent.  The patient and the Investigator must personally sign and date the current 
approved version of the Informed Consent Form in each other’s presence. A copy of the Patient Information Sheet and 
signed Consent Form will be given to the participant. The original signed form will be retained at the trial site, ideally in 
the Investigator Site File (if local policy permits) and one copy held in the medical records. When required, a copy will 
also be provided to the tissue bank to evidence consent for storage of samples.


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Contraceptive/ Pregnancy counselling 
All participants must be advised on the need to use reliable methods of contraception during the trial. The advice 
should include:  
(1) The acceptable methods, including: male or female sterilization, implants, injectables, combined oral 
contraceptives, some intrauterine devices (IUDs), and abstinence.  
(2) The recommendation that a barrier method should be used in addition to another form of contraception. 
(3) Males should continue to take these precautions for a minimum 6 months after the last dose of trial drug.  
(4) Females should continue to take these precautions a minimum of 6 months after the last dose of trial drug. 
(5) That any pregnancy (also applies to females partners of male trial subjects) occurring within 6 months of the 
last administration of trial drug will be followed up and the outcome of all pregnancies (spontaneous 
miscarriage, elective termination, normal birth or congenital abnormality) will be reported and followed up 
even if participant is discontinued from the trial.  
5.2  Screening/Baseline evaluations  
Potential participants will be identified by their existing clinical care team at surgical clinics, oncological clinics or 
multidisciplinary team meetings.   Local clinical teams can confirm they are potential eligible for the trial and can 
therefore be approached. After the patient has been approached and deemed potentially eligible, the following 
screening and eligibility assessments must be performed/ obtained within the 2 weeks before the patient receives the 
first trial dose (with the exceptions of CT & MRI which must be within 62 & 42 days of start of treatment respectively, 
and standard of care tests which have been done, before consent, but within 21 days before the first treatment day).  

Written informed consent  

Demographic details including age, gender 

Medical History to include cancer history, prior cancer therapies and procedures, reproductive status, and 
clinically significant disease history and concomitant diseases.   

Concomitant medications (including prescription drugs, over-the-counter drugs, herbal/ homeopathic 
remedies, nutritional supplements) used by the subject within 14 days before the start of trial treatment 

Complete physical examination to include lungs, abdomen, heart and symptom driven examination. Any 
abnormality identified at baseline should be recorded

Height, weight and body surface area (BSA) 

ECOG performance status 

Vital signs: systolic / diastolic blood pressure (BP), pulse rate, respiratory rate and temperature. 

Screening blood tests: 
o
Haematology – Hb, white blood cells (WBC) with differential count (neutrophils and lymphocytes) 
and platelets 
o
Biochemistry – sodium, potassium, calcium, phosphate, urea, creatinine, total protein, albumin, 
bilirubin, alkaline phosphatase (alk phos), AST and/or ALT and LDH  
o
Coagulation screen (aPTT and INR) 

Pregnancy test (females of childbearing potential only): serum or urine Human Chorionic Gonadotropin (HCG) 
test to rule out pregnancy at trial entry; results must be obtained and reviewed before the first dose of IMP is 
administered.  

Electrocardiogram (ECG) 

Dihydropyrimidine dehydrogenase (DPYD) deficiency test (any time before trial enrolment)  

Urine dipstick for protein  

Confirm histological diagnosis from pathology report

CT chest/ abdomen/ pelvis- diagnostic CT may be used if within 62 days of first trial dose.  Repeat CT to be 
scheduled within 14 days of informed consent, if > 62 days.  Whole body PET-CT is an acceptable alternative.

Pelvic MRI- diagnostic MRI may be used if within 42 days of first trial dose.  Repeat MRI to be scheduled 
within 14 days of informed consent if > 42 days. 

Investigational blood sample (after informed consent) 

Faecal sample collection & diet questionnaire (collected at patients’ home after informed consent (optional) 
and before 1st dose of enadenotucirev – not applicable to all participating sites) 
Results of standard-of-care tests or examinations performed before obtaining informed consent and within 21 days 
before the start of trial treatment may be used; such tests do not need to be repeated for screening.   


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All screening evaluations must be completed and reviewed to confirm that subjects meet all eligibility criteria before 
the first dose of trial treatment. The Investigator will maintain a screening log to record details of all subjects screened 
and to confirm eligibility or record reasons for screening failure, as applicable.  
The CRF will only be completed for those subjects who are eligible for the trial and then subsequently registered. At 
the time of enrolment, each eligible subject will be assigned a unique subject number and the next sequential number 
to be allocated. 
Also, pre dose assessments (section 5.3.1) need to be taken within 72 hours prior to first loading dose at the start of 
week 1. 
It is recommended that the investigational blood sample is taken during a regularly scheduled visit such as the 
planning CT appointment to minimise extra visits. However, it can be done at any stage prior to the first dose of 
enadenotucirev.  
5.3 Pre-treatment evaluation 
Evaluation schedule A applies to all patients prior to day 1 of any dose or sequence of treatment. 
The table below summarises what pre dose evaluations (schedule A or B) should be undertaken for each patient on 
any given day, depending on which dosing group they are assigned to (Section 8.2 and 17.2 for more information).  
Loading and after loading doses of enadenotucirev should be given on 3 non-consecutive days over a 7-day period 
during weeks 1-2-and 8-9 (e.g. Mon, Wed, Fri or Fri, Mon, Wed or other convenient schedule). Doses given during the 
1st week of chemoradiation should be given on day 1 and day 5. On each dosing day the following assessments are 
required: 
Dosing group 1-4 
Dosing Day 1 
Dosing Day 2 
Dosing Day 3 
Week 1/2  
A 
B 
A 
Dosing group 4 
Dosing Day 1 (Day 1 CRT) 
Dosing Day 2 (Day 5 CRT)  
Week 3  
A 
A 
Dosing groups 2, 3 & 4 
Dosing Day 1 
Dosing Day 2 
Dosing Day 3 
Week 8/9  
A 
B 
A 
5.3.1
Evaluation schedule A 
Pre- Dose – the following assessments can be completed within 72 hours prior to the dose. Vital signs to be completed 
on day of dosing 

Adverse events and DLTs since the previous assessment 

New or changes to existing medications 

Physical examination of major body systems  

Weight 

ECOG performance status 
Local laboratory assessments:   
o
Urine dipstick – if 2+ or greater proteinuria enadenotucirev dosing should be interrupted pending 
completion of 24 hour urine collection to exclude significant proteinuria, see further guidance in section 
9.3. 


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o
Routine blood samples  
o
Haematology – Hb, white blood cells (WBC) with differential count (neutrophils and 
lymphocytes) and platelets 
o
Biochemistry – sodium, potassium, calcium, phosphate, urea, creatinine, total protein, 
albumin, bilirubin, alkaline phosphatase (alk phos), AST and/or ALT and LDH  
o
Coagulation screen (aPTT and INR) 
TO BE COMPLETED ON DAY OF DOSING:

Vital sign measurements: systolic / diastolic blood pressure (BP), pulse rate, respiratory rate and 
temperature 
5.3.2
Evaluation schedule B 
Pre- Dose 

Adverse events and DLTs since the previous assessment 

New or changes to existing medications 

Physical examination of major body systems  

Vital sign measurements: systolic / diastolic blood pressure (BP), pulse rate, respiratory rate and 
temperature 

Weight 

ECOG performance status 
It is recommended that subjects also receive antipyretic prophylaxis, steroid prophylaxis and hydration at the time of 
each injection of enadenotucirev (See section 8.3). The recommended regime is: 

1 hour prior to administration 
o
IV hydrocortisone 100mg  
o
PO Paracetamol 1000mg  
5.4 Post dose evaluations 
Once the enadenotucirev has been administered to the patient the following post dose evaluations should be carried 
out:  

Vital sign measurements (systolic / diastolic blood pressure (BP), pulse rate, respiratory rate and 
temperature): 
First Dose: 
After the first dose of enadenotucirev the patient’s vital signs must be monitored at the following time points: 

Immediately after the end of the infusion 

30 minutes (±5 minutes) post end of infusion 

1 hour (±15 minutes) post end of infusion 

4 hour (±15 minutes) post end of infusion 

6 hour (±15 minutes) post end of infusion 
Subsequent doses: 
On all subsequent doses the patient’s vital signs must be monitored at the following time points: 

Immediately after the end of the infusion 

30 minutes (±5 minutes) post end of infusion 

1 hour (±15 minutes) post end of infusion 

3 hour (±15 minutes) post end of infusion 


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They will also receive a further dose of Hydrocortisone (IV) and paracetamol (PO) at 3 hours [See section 8.3].  If they 
are clinically well and vital signs are normal they can be discharged. If not improving consider admission for further 
active management. 
5.5 Weeks 1/2 
The following assessments should be completed for all patients: 
Dosing day 1: 
-
Pre dose – Evaluation Schedule A (5.3.1) 
-
Post dose evaluations (5.4) 
Dosing day 2: 
-
Pre dose – Evaluation Schedule B (5.3.2) 
-
Post dose evaluations (5.4) 
Dosing day 3: 
-
Pre dose – Evaluation Schedule A (5.3.1) 
-
Post dose evaluations (5.4) 
Faecal sample (after last dose of enadenotucirev): 
Home collection and postage of faecal sample & diet questionnaire (optional consent required and may not be 
applicable to all participating sites) 
5.6 Week 3 
5.6.1
Dosing Groups 1, 2 & 3 
Day 1 – Evaluation Schedule A (5.3.1) 
5.6.2
Dosing group 4 
Dosing day 1 & 5: 
-
Pre dose – Evaluation Schedule A (5.3.1) 
-
Post dose evaluations (5.4) 
5.7 Week 4, 5, 6, 7 
5.7.1
Week 4 only 
The following assessments should be completed for all patients, during week 4 only and in addition to the 
assessments in 5.7.2.  
Tumour biopsy 
During week 4 (second week of chemoradiation) a biopsy of the tumour is mandated as part of the trial. This should 
be performed at endoscopy by an experienced endoscopist. Under direct visualisation (proctoscopy) a maximum of 3 
samples of tissue will be taken, each measuring less than 6mm. 
Investigational blood sample 
An investigational blood sample will also be taken on day 10 of chemoradiation. (See Laboratory manual) 
Faecal sample (after week 4 treatment): 
Home collection and postage of faecal sample & diet questionnaire (optional consent required and may not be 
applicable to all participating sites) 
5.7.1
Week 4, 5, 6, 7 - Other assessments 
To be completed, for all patients, as standard of care prior to chemoradiation: 
– Evaluation Schedule A (5.3.1) 


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5.7.2
Week 7 only 
Faecal sample (after week 7 treatment): 
Home collection and postage of faecal sample & diet questionnaire (optional consent required and may not be 
applicable to all participating sites) 
5.8 Week 8, 9  
5.8.1
Dosing group 1  
Day 1 Evaluation Schedule A (5.3.1) 
5.8.2
Dosing groups 2, 3 & 4 
Dosing day 1: 
-
Pre dose – Evaluation Schedule A (5.3.1) 
-
Post dose evaluations (5.4) 
Dosing day 2: 
-
Pre dose – Evaluation Schedule B (5.3.2) 
-
Post dose evaluations (5.4) 
Dosing day 3: 
-
Pre dose – Evaluation Schedule A (5.3.1) 
-
Post dose evaluations (5.4) 
5.9 End of trial evaluations at 13 weeks (+/- 3 days) 
The following assessments should be completed for all patients: 

Adverse events and DLTs since the previous assessment 

New or changes to existing medications 

Physical examination of major body systems  

Vital sign measurements: systolic / diastolic blood pressure (BP), pulse rate, respiratory rate and 
temperature 

Weight 

ECOG performance status 

Local laboratory assessments: 
o
Urine dipstick  
o
Blood samples for laboratory safety tests: 
o
Haematology – Hb, white blood cells (WBC) with differential count (neutrophils and 
lymphocytes) and platelets 
o
Biochemistry – sodium, potassium, calcium, phosphate, urea, creatinine, total protein, 
albumin, bilirubin, alkaline phosphatase (alk phos), AST and/or ALT and LDH  
o
Coagulation screen (aPTT and INR) 
MRI: 
Patients should also have their standard of care, post treatment MRI scan to assess for response. Can be up to +/- 7 
days of week 13. 
Investigational blood sample 
An investigational blood sample will also be taken during week 13, at the same time as the other blood tests. 
Faecal sample: 
Home collection and postage of faecal sample & diet questionnaire (optional consent required and may not be 
applicable to all participating sites) 


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5.10 Follow-up evaluations (post 14+ weeks) 
The patient will return to follow-up as per standard care in the NHS, with surgery completed as per standard care at 
week 14+. A further visit to the trial team 4-6 weeks after surgery should occur to formally record the following: 
1.
Pathological resection specimen findings as per the RCPath reporting guidelines recorded on CRF 
2.
Neoadjuvant rectal score details 
3.
Any surgical and other complications – AE assessments 
4.
ECOG performance status 
5.
Investigational Blood sample taken 
If patient has not received surgery due to complete clinical response, they should be followed up as per standard of 
care. Confirmation of their complete clinical response will be obtained from their medical records if available. 
6
EARLY PATIENT WITHDRAWAL 
Treatment Withdrawal 
During the course of the trial, a patient may withdraw early from treatment.  This may happen for a number of reasons, 
including: 

Unacceptable toxicity 

AE/SAEs requiring discontinuation 

Loss to follow-up 

Significant protocol deviation or inability to comply with trial procedures 

Clinical decision 

Patient decision 
When the patient stops treatment early, the ‘End of Treatment’ Form needs to be completed, and any other relevant 
CRFs (e.g. SAE Form).  The reason for and date of withdrawing from treatment early should be clearly documented in 
the medical records. The following evaluations should be carried out on early withdrawal unless the patient has 
withdrawn consent also. 
Physical examination of major body systems  
Adverse events and DLTs since the previous assessment 
Vital sign measurements: systolic / diastolic blood pressure (BP), pulse rate, respiratory rate and temperature 
ECOG performance status 
Local laboratory assessments: 
o
Blood samples for laboratory safety tests: 
o
Haematology – Hb, white blood cells (WBC) with differential count (neutrophils and 
lymphocytes) and platelets 
o
Biochemistry – sodium, potassium, calcium, phosphate, urea, creatinine, total protein, 
albumin, bilirubin, alkaline phosphatase (alk phos), AST and/or ALT and LDH  
o
Coagulation screen (aPTT and INR) 
Patients who have stopped treatment early should continue to be followed-up for toxicity, response and survival, unless 
patient consent for follow-up is withdrawn. 
Consent Withdrawal 
Consent withdrawal means that a patient has expressed a wish to withdraw from the trial altogether.  Under these 
circumstances, the site needs to document all relevant discussions in the patient notes and notify the Trial Office, which 
will allow the office to mark all future CRFs as not applicable.  
Under these conditions, investigators are still responsible to follow up any SAEs until resolution. 
Patient evaluability and replacement 
All patients enrolled in the trial and who received at least one dose of enadenotucirev will be considered evaluable. 
Patients who are not evaluable will be replaced. The TMG may decide to replace a patient if they withdraw from the 
trial for a reason other than a DLT.  The dose of a patient replacing a non-evaluable patient will be assigned in the same 
way as all other patients and they will not necessarily be allocated the same dose as the non-evaluable patient they 
replace.
Patients who do not complete the response primary endpoint evaluation will be treated as non-responders. 


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7
SAMPLES FOR LABORATORY ANALYSIS 
7.1 Samples to be analysed in local Trust’s laboratories 
Diagnostic Laboratories 
Samples for haematology, biochemistry and urinalysis will be labelled with standard patient identifiers and sent to the 
local hospital diagnostic laboratory. Results will be processed in the standard way and entered into the routine 
hospital reporting system. Samples will be stored, held, reported and subsequently destroyed in accordance with 
standard local laboratory practice.  
Pathology 
The routine diagnostic pathology samples and additional research samples taken at biopsies and during surgery will 
also be labelled, processed and reported according to local hospital protocols.  
7.2 Samples to be sent to and analysed in a Central Laboratory 
The following samples are required to be collected for shipment to central laboratories:   
Time Point 
Screening/Baseline 
Week 1 / 2 
Week 4 
Week 7 
Week 13 
Week 14 + 
4-6 weeks 
post-surgery 
Investigational blood 
sample 
X
X
X
X
Tumour sample for viral 
load and gene expression 
X (archived 
diagnostic sample) 
X (biopsy) 
X 
(resection) 
Faecal sample
(optional consent required 
– may not be applicable to 
all sites) 
X 
X 
X 
X 
X 
Assay/sample handling and storage will be managed according to separate written instructions. The following sections 
summarise the arrangements for collection, close to patient handling, timings, and analytical laboratories responsible. 
7.3 Labelling and confidentiality of samples sent 
All samples sent to analytical Laboratories will be labelled with the trial patient number, sampling time-point and 
date/time taken.  Should a laboratory receive any samples carrying unique patient identifiers the recipient must 
immediately obliterate this information and re-label as well as informing the trial office. 
7.4 Clinical reporting of exploratory research assay results 
Although the results of the CEDAR trial research assays are exploratory, and the assays performed are not to current 
NHS standards, clinically relevant genetic information could be revealed. Relevant results will be confirmed by an 
appropriate expert before the patient and their clinical care team are informed and changes may be made to their 
clinical care if required. Due to the exploratory nature of the assays and the subsequent results, patients will be given 
the option to decide if they would like to be informed of any clinically relevant genetic information via the consent 
form. The local site Principal Investigator will be notified by the appropriate expert if any clinically relevant genetic 
information is revealed. At this stage, patients will only be referred to by their unique trial number with it only being 
possible for the site team to re-identify the patient so that they can be contacted if required and if they provided 
consent.  
7.5 Trial sample retention at end of trial 
The Chief Investigator has overall responsibility for custodianship of the trial samples. Laboratories are instructed to 
retain any surplus samples pending instruction from the Chief Investigator on use, storage or destruction.  It is possible 
that new or alternative assays may be of future scientific interest. At the end of the research trial any surplus samples 
may be retained for use in other projects that have received ethical approval.  Hence, any surplus trial samples may be 
analysed as part of a separate ethically approved project, transferred to a licensed tissue bank where they will be 
managed in accordance with applicable host institution policies and the Human Tissue Act (HTA) requirements.  


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7.6 Withdrawal of consent for sample collection and/or retention 
A patient may withdraw consent to provide samples for research at any time without giving a reason. The Investigator 
must ensure that their wishes are recorded in the medical record and will inform the Trial Office accordingly. The 
investigator should discuss with patients the valuable use of samples that have already been provided and under 
circumstances where these samples have already been processed and anonymised, it would not be possible to destroy 
such samples. 
8
INVESTIGATIONAL MEDICINAL PRODUCTS (IMPS)  
8.1 Name of IMPs 
The trial is investigating the unlicensed drug enadenotucirev in combination with chemoradiotherapy.  The 
chemotherapy agent used is capecitabine.  Enadenotucirev and capecitabine are both considered IMPs.   
8.2 Treatment dose and duration 
Enadenotucirev 
All participants will receive 3 x loading doses in weeks 1-2, prior to initiation of chemoradiotherapy. Loading doses 
should be given on 3 non-consecutive days over a 7-day period (e.g. Mon, Wed, Fri or Fri, Mon, Wed or other 
convenient schedule).  
There are 2 different dosing patterns for the 3 loading doses.  
-
Low-Low-Low, for dosing groups 1 & 2;  3 individual doses of 1x1012VP given 
-
Low-High-High, for dosing groups 3 & 4; 3 individual doses of (1) 1 x 1012VP, (2) 3 x 1012VP, (3) 3 x 1012VP 
given
Further doses of enadenotucirev after the 3 loading doses are dependent on the dose schedule assigned, as per table 
below. See section 17.2 for information on dose decision making and allocation 
1 Low-Low-Low = 3 x doses at 1x1012VP 
2 Low-High-High = 3 Doses, (1) 1 x 1012VP, (2) 3 x 1012VP, (3) 3 x 1012VP 
* 3 doses administered on 3 non-consecutive days over 7 days 
Dose Schedules 2 & 3: 
After loading doses and completion of CRT, 3 x maintenance doses outlined in the table above of enadenotucirev will 
be delivered in weeks 8-9 for all participants assigned to dose schedules 2 & 3. Maintenance doses should be given on 
3 non-consecutive days over a 7 day period. As with the loading doses, the maintenance doses are given in 2 different 
dosing patterns dependant on dosing schedule: 
-
Low-Low-Low, for dosing group 2; 3 individual doses of 1x1012VP given 
-
Low-High-High, for dosing group 3; 3 individual doses of (1) 1 x 1012VP, (2) 3 x 1012VP, (3) 3 x 1012VP given 
Dose schedule 4: 
After loading doses, participants assigned to dosing schedule 4 will receive enadenotucirev concurrently with CRT 
during their 1st week of CRT, as indicated in the table. This will consist of two doses delivered, one on the first and 
then last day of CRT in that week, post radiotherapy. Each dose will be given at 3x1012VP 
Dose schedule 
Loading x 3 (pre CRT) 
(3 doses given on 3 non-
consecutive days over a 7 
day period) 
Concurrent 
Maintenance x 3 
(post CRT) 
(3 doses given on 3 non-
consecutive days over a 7 
day period) 
Week 1 Day 1  CRT 
(week 3 day 1)
Week 1 Day 5 CRT 
(week 3 day 5)
1 (start level) 
Low-Low-Low1*
2 
Low-Low-Low1*
Low-Low-Low1*
3 
Low-High-High2*
Low-High-High2*
4 
Low-High-High2*
3 x 1012 vp 
3 x 1012 vp 
Low-High-High2*


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NB Morning and evening doses of capecitabine are to be omitted on enadenotucirev dosing days.  
Participants will also receive 3 x maintenance doses of enadenotucirev delivered in weeks 8-9 after completion of CRT. 
Maintenance doses should be given on 3 non-consecutive days over a 7 day period and will be given as the Low-High-
High dosing pattern consisting of 3 individual doses of (1) 1 x 1012VP, (2) 3 x 1012VP, (3) 3 x 1012VP 
Capecitabine 
Capecitabine must not be taken on enadenotucirev dosing days. 
With the exception of enadenotucirev dosing days capecitabine should be taken twice daily (morning and evening) 
Monday to Friday for 5 weeks, concurrently with radiotherapy.   
Capecitabine is taken daily at a dose of 900 mg/m2 (the standard dose used for chemoradiotherapy treatment of 
locally advanced rectal cancer). Sites should use national dose banding tables for capecitabine. 
CRT Week
(trial week)
1
(trial week 3)
2
(trial week 4)
3
(trial week 5)
4
(trial week 6)
5
(trial week 7)
Days
1-5
8-12
15-19
22-26
29-33
Radiotherapy: 50 Gy/25# 
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Oral 
capecitabine* 
900 mg/m2
orally bd  
Mon – Fri x 5 
weeks  
Dose 
schedules 
1, 2 & 3 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Dose 
schedule 4 
- 
- 
X 
X 
X 
X 
X 
X 
- 
- 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
8.3 Management of drug administration 
Enadenotucirev 
Enadenotucirev is a live replicating oncolytic adenovirus; it is considered a BioSafety Level 1 (BSL-1) infectious 
substance.  Appropriate precautions should be followed for a BSL-1 substance, as per section 8.4 and local site policy. 
Subjects must receive antipyretic prophylaxis, steroid prophylaxis and hydration at the time of each injection of 
enadenotucirev. The recommended regime is: 

1 hour prior to administration 
o
IV hydrocortisone 100mg  
o
PO Paracetamol 1000mg  

3 hours following administration 
o
IV hydrocortisone 100mg 
o
PO Paracetamol 1000mg 
It is also strongly recommended that all patients have loperamide prescribed prior to commencement of treatment, in 
case of development of diarrhoea (see section 9.3). 
Patients should also be given a prescription for oral paracetamol 1000mg four times daily to be taken in the 24 hours 
after receiving enadenotucirev. 
The enadenotucirev infusion solution should be made up as per the administration protocol. Once diluted in the 
infusion bag/syringe it must be administered to the patient within 6 hours of preparation.  The diluted solution is 
stable at room temperature (20-26oC) for up to 1 hour.  If not administered within 1 hour it can be stored at +2°C to 
8oC for no longer than 6 hours until administration. The full infusion volume must be administered over a 15 minute 
(+/- 5minutes) period for all dosing groups.  


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NOTE: At the time of administration, the extension set used to administer enadenotucirev can be primed with saline. 
At the end of infusion, the line will also need to be flushed with saline. This will ensure that all 30 mL of diluted 
enadenotucirev are administered to the patient. 
The patient should be observed after administration as per post-dosing assessments detailed in section 5.3.  N.B. 
serious infusion reactions have been observed in previous trials of enadenotucirev, appearing to reflect cytokine 
responses to treatment.  In the event of a serious infusion reaction the infusion should be discontinued and the 
patient monitored and treated as per standard local protocol for management of cytokine release syndrome.  Further 
guidance on managing toxicities is given in section 9.2. 
Capecitabine 
Refer to the Summary of Product Characteristics (SPC) for full prescribing information and details of drug 
reconstitution, administration and stability (http://www.medicines.org.uk/emc/). 
Patients will be instructed to take capecitabine tablets twice a day starting in the morning/evening, starting on the 
first day of radiotherapy. Tablets will be taken twice daily on every day that radiotherapy is given (therefore excluding 
the weekends). Capecitabine must not be taken on enadenotucirev dosing days.
It is recommended that patients are carefully monitored for ophthalmologic complications, such as keratitis and corneal 
disorders, especially if they have a prior history of eye disorders. Treatment of eye disorders should be initiated 
promptly. For patients with diabetes mellitus, caution must be exercised as it may be aggravated. 
Patients should be instructed to take the drug twice daily as above only on the days radiotherapy is delivered.  Doses 
should be omitted on enadenotucirev dosing days.  Where the start of radiotherapy is delayed for scheduling reasons 
the start of concurrent chemotherapy should also be delayed. 
Missed doses/dosing day will not be made up. The next dose must be taken as scheduled. Doses should NOT be doubled 
to make up for missed doses. 
If a patient vomits after taking the tablets, they should not take another dose. The next doses should be taken as 
scheduled.  
If a patient has taken their morning dose of capecitabine on an enadenotucirev dosing day, administration of 
enadenotucirev should be delayed to the next day of radiotherapy.  Patients should be reminded to take their evening 
dose as normal and to not take capecitabine the following day. If delay of enadenotucirev dosing is not possible, 
enadenotucirev can still be administered and patients reminded to omit their evening capecitabine dose. 
Any unused tablets should be returned to pharmacy (via research nurse). All patients are asked to keep a record of their 
capecitabine use in their site specific diary card. Diary cards will be reconciled by site staff and confirmation of 
capecitabine use to be recorded on the relevant CRF. 
8.4 Special precautions 
Enadenotucirev is a live replicating oncolytic adenovirus that has not been genetically modified, it is considered a 
BioSafety Level 1 (BSL-1) infectious substance.  BSL-1 agents pose minimal potential hazard to personnel. Sites should 
follow local procedure for handling a BSL-1 biological agent, it is suggested that this includes: 

No eating and drinking in areas where enadenotucirev doses are prepared or administered 

Safe disposal of used vials and all equipment used to prepare and administer enadenotucirev 
8.5 Dose modification  
Enadenotucirev 
No dose modifications may be made. With the exception of renal injury, specifically proteinuria of 2+ where 
enadenotucirev must be delayed and or discontinued (see section 9.3), treatment may be interrupted because of a 
non‐DLT of Grade 3 or higher, at the discretion of the Investigator. Treatment may be resumed when all toxicities 
have returned to grade 2 or less, at the discretion of the Investigator. If two consecutive doses of enadenotucirev are 
missed due to enadenotucirev related toxicity, this constitutes a DLT, and no further enadenotucirev will be 
administered. If the subject misses a dose of enadenotucirev for any reason other than toxicity the dose should not be 
made up. The scheduling should continue as normal, from the next planned dose of enadenotucirev. If radiotherapy is 


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withheld for toxicity or other reasons, enadenotucirev should also be withheld and the dosing schedule should 
continue from the next planned dose once radiotherapy has resumed. 
Capecitabine  
In the event of haematological toxicity or other adverse events capecitabine dose may be modified as per standard of 
care (treatment interruption or dose reduction).  Dose adjustments are to be made according to the greatest degree 
of toxicity and in accordance with the local hospital protocol.  Once the dose has been reduced, it should not be 
increased at a later time.  
8.6 Compliance 
Enadenotucirev 
All doses of enadenotucirev will be delivered intravenously at a research site.  Site staff will maintain records of 
enadenotucirev administration. 
Capecitabine 
Patients will be instructed to keep a record of compliance with capecitabine treatment, by means of using a patient 
diary card provided to the patient by the site. Patients should be asked to bring completed diary cards or other records 
and all their unused / remaining capecitabine tablets (empty, open or unopened) with them to each clinic visit. The 
patient diary cards should not be sent to the Trial Office but kept by the centre to monitor patient drug compliance.  
Accountability logs are required for capecitabine to determine that patients have received at least 80% of the prescribed 
treatment dose. Returns should be reconciled against the patient diary and the reason for any discrepancy documented. 
Site staff will collect and count patient returns which must be recorded on the drug accountability log. 
8.7 Management of overdose 
In the case of enadenotucirev overdose the patient should be monitored for evidence of toxicity and standard 
supportive treatment provided based on any signs or symptoms experienced.  
In the case of capecitabine overdose refer to guidance provided in the SPC. 
Administration of a dose of trial drug exceeding that permitted by the trial protocol should be notified to the trial 
office.  Any toxicity resulting from administration of an overdose of trial drug should also be reported as an adverse 
event/ serious adverse event (as appropriate) as per reporting processes detailed in section 14. 
9
DOSE LIMITING TOXICITY 
9.1 Definition of a dose limiting toxicity (DLT)  
All patients who have received at least one dose of enadenotucirev will be evaluable for DLTs. DLTs are defined as any 
of the following occurring between the start of trial treatment until the Week 13 visit and by the principal investigator 
(PI) or agreed designee assessed as possibly, probably or definitely related to enadenotucirev or the interaction 
between enadenotucirev and radiotherapy and/or capecitabine. Patients who experience a DLT will receive no further 
trial treatment.  
Dose limiting toxicities must be reported within 24 hours of the site becoming aware using the SAE form and scan and 
email as a PDF attachment to octo‐safety@oncology.ox.ac.uk and send an email notification to octo-
CEDAR@oncology.ox.ac.uk. 
DLTs will be defined as per NCI CTCAE v4.03, except for proteinuria, and include: 
Renal: 
o
Development of proteinuria, 2+ as measured by urinalysis and confirmed with an albumin/creatinine ratio of 
>3g/mmol with a 24‐hour urinary protein ≥1g/24h or if there is a decline in eGFR (where a decline in eGFR is 
defined as eGFR <60ml/min/1.73m2 or a drop in eGFR by 20% from screening, baseline of previous visit), 
following administration of enadenotucirev, shall be classified as a DLT. No further doses of enadenotucirev will 
be administered to that patient.  
Acute hematologic toxicity:  
o
Infection (documented clinically or microbiologically) with grade 3 or 4 neutropenia (absolute neutrophil count 
(ANC) <1.0 x 109/L) 
o
Neutropenia grade 4 (ANC < 0.5 x 109/L) lasting for ≥7 days 


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o
Febrile neutropenia grade 4 (fever of unknown origin without clinically or microbiologically documented 
infection) (ANC <1000/mm3 with a single temperature of >38.3 degrees C or a sustained temperature of >=38 
degrees C for more than one hour)
o
Thrombocytopenia grade 3 (Platelet count < 50 x 109/L) in the presence of bleeding or requiring platelet 
transfusion 
o
Thrombocytopenia grade ≥ 4 (Platelet count < 25 x 109/L) 
o
Anemia grade 3 in the presence of blood transfusion dependency as judged by the PI 
o
Anemia grade ≥ 4 
o
Clinically significant bleeding attributed to grade 3 thrombocytopenia or requiring platelet transfusion or other 
grade ≥3 clotting disorder or occurring concurrently with Grade 2 or 3 aPTT prolongation, unless there is a clear 
explanation for the event, such as tumour-related bleeding in the presence of Lupus Anticoagulant. 
o
 Any other grade ≥3 non‐hematological toxicity with the exception of: activated partial thromboplastin time 
(aPTT) prolongation 
o
Clotting event (i.e. deep vein thrombosis [DVT], pulmonary embolism [PE]) occurring concurrently with Grade 2 or 
3 aPTT prolongation 
Acute non-hematologic toxicity: 
o
Any documented ≥ grade 4 non‐hematologic toxicity in the presence of maximal support/active management 
o
Grade ≥3 cystitis or radiation dermatitis onset within 2 weeks of starting radiotherapy or lasting more than 2 
weeks after the end of radiotherapy. 
o
Grade ≥3 proctitis or diarrhea onset within 2 weeks of starting radiotherapy 
o
Grade ≥3 nausea or vomiting not controlled by optimal outpatient anti‐emetic treatment 
o
Grade ≥3 diarrhea despite optimal outpatient anti‐diarrheal medication use 
o
Grade ≥3 hematuria or neuropathic pain 
o
Other grade 3 ≥ effects thought to be due to the combination of enadenotucirev with radiotherapy 
o
Missing 2 consecutive doses of enadenotucirev due to enad toxicity 
o
An elevation of ALT or AST >5 x ULN lasting 8 days or more 
o
A concurrent elevation of ALT or AST >3 × ULN and total bilirubin >2 × ULN in whom there is no evidence of biliary 
obstruction or other causes that can reasonably explain the concurrent elevation 
o
Death due to drug related complications 
o
Grade ≥3 cytokine release syndrome 
General: 
o
Discontinuation of the active treatment due to toxicity definitely attributable to enadenotucirev, irrespective of 
the grade of toxicity 
o
Missing 3 consecutive fractions of radiotherapy, related to enadenotucirev, as judged by the PI or designee 
o
Any toxicity causing a delay of radiotherapy completion by greater than one week 
This is not an exhaustive list. All suspected DLTs should be discussed with the Chief Investigator and the Trial 
Management Group. 
9.2 Toxicity associated with Enadenotucirev 
Below is a summary table of commonly reported treatment related adverse events (≥10% patients) by incidence and 
preferred term following IV infusion of enadenotucirev at the doses used in the trial.  Further explanation can be 
found below the table. 
Preferred Term 
Dose level (1 x1012) 
Dose level (3 x1012) 
Pyrexia 
39% 
75% 
Chills 
33% 
75% 
Fatigue 
6% 
35% 
Nausea 
17% 
40% 
Asthenia 
39% 
25% 
Vomiting 
17% 
30% 
Decreased Appetite 
17% 
45% 
Diarrhoea 
11% 
10% 
Flu like illness 
6% 
30% 
ALT increased 
0 % 
5% 
Fibrin d-dimer increased 
0% 
20% 


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Hypertension 
0 % 
30% 
Musculoskeletal pain 
11% 
10% 
AST increased  
0% 
5% 
Thrombocytopenia 
6% 
5% 
Neutropenia 
22% 
0% 
Platelet count decreased 
6% 
10% 
Proteinuria 
0% 
20% 
Headache 
11% 
10% 
Inflammatory/influenza-like Symptoms 
Pyrexia has been reported in the majority of patients at doses of 1 x 1012 vp. Chills are very common above 1 x 1012 vp. 
Additionally, influenza-like illness, the diagnostic term used when multiple symptoms including pyrexia and chills were 
reported, has been reported frequently at these doses. These symptoms usually have onset shortly after dosing and 
are manageable with antipyretic medication. Other symptoms typical of an influenza-like illness such as myalgia, 
arthralgia and musculoskeletal pain have been reported across the dose range but much less frequently. These events 
have not been reported as SAEs. General symptoms such as asthenia, fatigue and malaise may be attributed to an 
inflammatory response to viral particles but are also frequently seen in cancer patients. They were commonly 
reported in the studies with enadenotucirev but with no clear dose relationship. Gastrointestinal symptoms such as 
nausea, vomiting and diarrhoea may also be attributed to an inflammatory response to viral particles. The incidence 
of diarrhoea was predominantly above the MTD. Nausea and vomiting appeared dose-related with an increase in 
frequency at doses of 3 x 1012 vp and above. There was one non-serious CTCAE Grade 2 infusion-related reaction after 
the first dose of 6 x 1012 vp. The details are unknown but no action was required and the patient continued to receive 
enadenotucirev. 
9.3 Management of enadenotucirev toxicity 
Nausea and vomiting should be treated with antiemetics and hydration as per institutional protocol. 
Flu-like syndrome should be treated with supportive measures, antipyrexials (e.g. paracetamol) and hydration. If 
acute respiratory symptoms such as hypoxia develop  then symptomatic treatment with supplemental oxygen and 
bronchodilators may be used if clinically indicated. Hospitalisation for observation during the dosing period may be 
considered according to Investigator judgement and circumstances of the patient. 
Antivirals may be used to treat patients that exhibit prolonged and/or difficult to manage toxicity that is thought to be 
due to viral replication. High dose steroid therapy may be required to manage the associated inflammatory response. 
Diarrhoea: It is strongly recommended that all patients have loperamide prescribed prior to commencement of 
treatment, in case of development of diarrhoea. Loperamide is recommended as the initial antidiarrhoeal medication.  
Patients should be instructed to contact the trial site for further guidance if diarrhoea is not controlled after 12 hours 
of loperamide treatment. Codeine phosphate up to 30 mg 4 times a day can be added if diarrhoea is not controlled 
with 16mg of loperamide per day.  
Serious infusion reaction: These have been observed in a small number of participants in previous trials of 
enadenotucirev, appearing to reflect cytokine responses to treatment. Infusion reactions are more common with the 
first infusion, although reactions cannot be excluded on subsequent infusions, even if no reaction was seen during the 
first.  In the event of a serious infusion reaction discontinue the infusion and monitor and treat the patient as per 
standard local protocol for management of cytokine release syndrome (e.g. vigilant supportive care, maintenance of 
adequate hydration and blood pressure, and corticosteroids and or other appropriate immunosuppression). Extensive 
comorbidities and older age should be closely monitored for cardiac function and immunosuppression should be 
instituted earlier. Cytokine release syndromes of grade 3 or higher are considered a DLT so no further drug should be 
administered.  
Renal injury:  Three patients out of 123 patients (2.4%) have developed significant renal impairment while receiving 
enadenotucirev. Whilst no confirmed pathophysiology has been identified it is felt to be due to vascular leakage due 
to cytokine release. Proteinuria of 2+ on a urine dipstick should therefore be further investigated, due to the potential 
risk of serious renal injury, with 24 hour urine collection for protein/creatinine ratio. If preferable locally, a urine 
protein- to-creatinine ratio or urine albumin – to – creatinine ratio are also acceptable in lieu of a 24 hour collection 
test. Additional blood tests should also be up to date including a serum albumin and serum creatinine. A consultation 
with nephrology is advised for specialist input. Specifically, early specialist intervention for investigation and 
treatment if decline in renal function is detected will include: 


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1. Full renal work-up, including examination of urine sediment, discussion with renal team and then commence high 
dose corticosteroids and then, if further decline in renal function; 
2. Renal biopsy, followed by plasmapheresis should be considered with close involvement of the renal team. 
No enadenotucirev is to be administered after the development of proteinuria as this constitutes a DLT.   
Refer to section 8.5 for guidance on dose modification/ interruption due to toxicity. 
aPTT Prolongation 
If at any time a patient has Grade 2 or 3 aPTT prolongation, planned biopsies and IT treatment should not go ahead 
until the results of the following tests have been received: 
1. aPTT 1:1 mixing studies (required for real-time treatment decisions) 
2. Hexagonal phase phospholipid (Staclot Lupus Anticoagulant) assay (or local equivalent test for Lupus Anticoagulant) 
(required for real-time treatment decisions) 
If Lupus Anticoagulant is not shown to be present, planned biopsies and IT treatment may not go ahead. If Lupus 
Anticoagulant is shown to be present, planned biopsies and IT treatment may go ahead (provided that the other 
clotting parameters such as platelet count and International Normalised Ratio and/or prothrombin time are within 
acceptable ranges). 
In addition, the following analyses will be conducted: 
1. Anti-cardiolipin antibodies by enzyme-linked immunosorbent assay (ELISA) (immunoglobulin G [IgG] and 
immunoglobulin M [IgM]) 
2. Anti-beta2-glycoprotein I antibodies by ELISA (IgG and IgM) 
3. Additional laboratory testing for further characterisation of Lupus Anticoagulant 
Patients with aPTT prolongation should be followed up every 2 months until aPTT has normalised to Grade 1 or less, 
or disease progression. 
Once confirmed, tests for Lupus Anticoagulant do not need to be repeated. 
9.4 Toxicity associated with capecitabine  
Haematological toxicity 
Myelosuppression is uncommonly observed with capecitabine. Neutropenia and thrombocytopenia should be 
monitored according to the recommended protocol and appropriate dose modifications made. Anaemia may occur 
cumulatively and should be corrected during radiotherapy to maintain the haemoglobin > 10g/dL. The FBC should be 
taken and reviewed (up to 3 days) prior to Day 1 of each cycle of chemotherapy. 
Gastrointestinal toxicity 
Nausea and vomiting is an overlapping toxicity of both capecitabine and enadenotucirev. Anorexia, nausea and 
occasional vomiting may persist. Nausea occurs less commonly with capecitabine. Diarrhoea occurs with capecitabine 
and patients should receive advice regarding discontinuation of therapy and use of loperamide or codeine phosphate 
(see section 9.3 ). Clinicians should be aware of infective causes of diarrhoea (e.g. Clostridium difficile), and patients 
should be tested in cases of concern. Antibiotic treatment is not recommended routinely but may be required in such 
circumstances. Stomatitis occurs with capecitabine and patients should receive advice regarding good oral care, and 
the use of mouthwash (e.g. Corsodyl™). 
DPYD deficiency 
If a patient has not received capecitabine in the past DPD testing should be undertaken as per Institutional protocol. 
Patients with partial or full DPD deficiency are not eligible for the study. Occasionally (approximately 1-3%) a patient 
may have a markedly exaggerated toxicity due to reduced 5FU catabolism. If this occurs, await full recovery of 
toxicities. Further treatment should be discussed with the Chief Investigator or one of the clinical co-investigators. 
9.5 Management of capecitabine toxicity  
Toxicity due to capecitabine administration may be managed by symptomatic treatment and/or modification of the 
dose as per standard of care.  Further information on dose modification is provided in section 8.5.  Patients taking 
capecitabine should be informed of the need to interrupt treatment immediately if moderate or worse toxicity occurs. 
Detailed information can be found in the product SPCs available from www.medicines.org.uk 


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10 OTHER TREATMENTS (NON-IMPS) 
10.1 Support medication 
Local anti-emetic and anti-diarrheal policy may be followed.  Medications for the standard management of symptoms 
or supportive care for cancer or for the management of the effects of enadenotucirev may be administered at the 
Investigator’s discretion; unless they are excluded concomitant medications.  
Antipyretic prophylaxis:  Subjects must receive antipyretic prophylaxis and hydration at the time of each injection of 
enadenotucirev (as per section 8.3) unless clinically excluded (e.g. allergic to paracetamol, when alternatives should 
be used such as NSAIDS). 
10.2 Concomitant medication and non-drug therapies 
Concomitant medication may be given as medically indicated.  All patients will be asked to provide a complete list of 
prescription and over-the-counter medications that have been taken within the previous 4 weeks prior to the first 
treatment visit.  They must also inform the Investigator about any new medication started while in the trial. 
10.3 Prohibited therapies 
Any COVID-19 vaccine in the 28 days before OR after any dose of enadenotucirev, unless the vaccine is known to not 
be based on an adenoviral vector. 
-
COVID-19 vaccines known to not be based on an adenoviral vector (e.g., the mRNA-1273 SARS-CoV-2 
[Moderna Therapeutics] and BNT162b2 [BioNTech/Pfizer] mRNA COVID-19 vaccines or other non-
adenoviral vaccines) are excluded in the 7 days before OR after any dose of enadenotucirev 
Any other vaccine, in the 7 days before OR after any dose of enadenotucirev. 
Medications inducing immune suppression (e.g. systemic corticosteroids or other immunosuppressive medications) in 
the 14 days after the last dose of enadenotucirev unless they are:  

Required as part of emergency therapy  

Required for the treatment of adverse events  

Used as an inhaled agent for bronchospasm or COPD 
Anti-viral agents e.g. ribavirin, adefovir, lamivudine or cidofovir in the 7 days after each trial treatment; or PEG-IFN in 
the 14 days after each dose of trial treatment and only then if the benefit of their use will outweigh the possible risks. 
Any systemic cancer therapy other than capecitabine and any local therapy to the primary tumour or its metastases 
during trial treatment. 
10.4 (Potential) Drug Interactions 
Enadenotucirev 
Enadenotucirev is sensitive to the effects of cidofovir and likely to be sensitive to other agents with known anti-viral 
effects, therefore these medications are prohibited as detailed in the previous section.  Systemic cancer therapy may 
have an inhibitory effect on enadenotucirev, hence capecitabine should not be administered on enadenotucirev 
dosing days.  Refer to the current Investigator Brochure for further detail. 
The inflammatory reactogenicity observed with COVID-19 vaccinations may overlap with the acute cytokine driven 
symptoms observed shortly after dosing with EnAd-based IMP (including chills, pyrexia and potential acute respiratory 
symptoms). To mitigate against this risk patients in this trial should not be treated with EnAd-based IMP within one 
week of receiving any vaccination (either first or second dose). Additionally, patients should not receive a vaccination 
within one week of their last dose of EnAd-based IMP.  
In addition, several COVID-19 vaccines based on adenoviruses have now been approved. Due to the specific potential 
for overlap in immune responses between adenovirus-based vaccines and EnAd-based IMP, a default requirement 
that patients do not receive a COVID-19 vaccine in the 28 days before or after any dose of EnAd-based IMP has been 
added to the protocol. If the COVID-19 vaccine is known to be non-adenoviral (e.g. mRNA vaccines), then a 7-day 
exclusion before or after any dose of EnAd-based IMP is required. 


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Capecitabine - advisory 
Capecitabine interacts with several medications and investigators should refer to the SPC for full guidance.  For ease of 
reference the following are the main interactions: 

Coumarin-derivative anticoagulants e.g. warfarin- more frequent is monitoring required when administered 
with capecitabine due to altered coagulation parameters.  Effects may occur up to several months after 
initiating capecitabine therapy. 

Phenytoin- increased phenytoin plasma concentrations resulting in symptoms of phenytoin intoxication in 
single cases have been reported during concomitant use of capecitabine. Patients should be regularly 
monitored for increased phenytoin plasma concentrations.  

Folinic/ folic acid has an effect on the pharmacodynamics of capecitabine and its toxicity may be enhanced.   

Capecitabine must not be administered concomitantly with sorivudine or its chemically related analogues (e.g. 
brivudine) 

Aluminium hydroxide or magnesium hydroxide containing antacids – cause a small increase in plasma 
concentrations of capecitabine and its metabolite 5DFCR (5’-deoxy-5-flurocytidine) 

Cytochrome p450 down regulation by capecitabine may affect the following class of drugs – angiotensin II 
blockers (losartan, valsartan); oral hypoglycaemic agents (glipizide, tolbutamide, rosiglitazone); NSAIDS 
(indomethacin, celecoxib, diclofenac, ibuprofen) 

Concomitant use of allopurinol with capecitabine should be avoided 
11 DRUG MANAGEMENT 
11.1 Drug supplies 
Enadenotucirev will be supplied free of charge to the local hospital pharmacies.  Enadenotucirev is provided as single 
use vials containing 1.4 x 1012 viral particles in 0.7mL aliquots in 2mL type 1 borosilicate glass vial with a butyl stopper 
and an aluminium crimp seal.  Each vial of enadenotucirev is issued in a plastic tamper-evident container. 
Capecitabine as a tablet for oral use should be supplied from trial site’s own stock and funded locally.  
All supportive medication is to be sourced and funded locally. 
11.2 Drug ordering 
Initial supplies of enadenotucirev are dispatched by Fisher Bioservices, on behalf of Psioxus after Psioxus have been 
informed by OCTO that all approvals are in place and the site is open to recruitment. Subsequent supplies should be 
ordered from OCTO by site pharmacy using the drug request form provided. Email the completed form to octo-
cedar@oncology.ox.ac.uk. 
The Principal Investigator and Pharmacy are responsible for liaising to ensure that adequate stock levels are held as 
necessary to supply the recruited patients.  
If a vial of enadenotucirev is accidentally destroyed, i.e. by dropping the vial or through contamination, the pharmacist 
can contact octo-cedar@oncology.ox.ac.uk for replacement patient supplies and submit a drug request form if 
required.  
11.3 IMP Receipt 
Sites should contact the trials office via email (octo-cedar@oncology.ox.ac.uk) to confirm receipt of enadenotucirev 
and complete confirmation of receipt as per the supplier’s instructions.   
If supplies are damaged on arrival contact the Trial Office. Damaged supplies should be destroyed on site as per local 
policy and a drug destruction form completed. See section 11.9 – drug destruction.  
11.4 Handling and storage 
Enadenotucirev should remain frozen solid at all times during transit and storage. The enadenotucirev vial should be 
kept inside a secondary container and should be quickly transferred to the designated, controlled-access freezer for 
storage below -80°C (with normal ±-10°C tolerance).  


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The temperature will be monitored during transport and site storage and logs will need to be reviewed at site before 
the virus is dispensed. Temperature excursions should be reviewed and the trials office notified. The virus should be 
quarantined until a decision has been made that it is still fit for purpose or that it must be destroyed.  
Enadenotucirev is a live replicating oncolytic adenovirus, it is considered a BioSafety Level 1 (BSL-1) infectious 
substance. Appropriate precautions should be followed for a BSL-1 substance, as per section 8.4 and local site policy. 
11.5 Labelling  
Enadenotucirev 
Enadenotucirev vials supplied to sites will have been labelled for clinical trial use as per the requirements of Eudralex 
Volume 4: Annex 13 ‘Investigational Medicinal Products’ of the European Union guide to Good Manufacturing Practice 
(GMP). 
Site pharmacies are permitted to add additional labels to the IMP at site as per standard local procedures (e.g. 
addition of site and patient identifiers) providing the original label is not obscured.
Capecitabine 
Labelling will be as per local practice. 
11.6 Dosing dispensing 
Enadenotucirev is a live replicating oncolytic adenovirus, it is considered a BioSafety Level 1 (BSL-1) infectious 
substance.  Appropriate precautions should be followed for a BSL-1 substance, as per section 8.4 and local site policy.  
The enadenotucirev infusion solution should be made up as per the administration protocol. Once diluted in the 
infusion bag/syringe it must be administered to the patient within 6 hours of preparation.  The diluted solution is 
stable at room temperature (20-26oC) for up to 1 hour.  If not administered within 1 hour it can be stored at +2°C to 
8oC for no longer than 6 hours until administration. 
11.7 Drug accountability 
Drug accountability is the responsibility of the site pharmacist listed on the trial delegation log. Full drug accountability 
records must be maintained for capecitabine and enadenotucirev. Hospitals may amend the Drug Accountability Logs 
provided by the trial office or use their own documentation if it captures all the information requested on the Drug 
Accountability Logs and has been approved by the Trial Office in advance. 
Copies of completed accountability logs must be supplied to the trial office on request. 
11.8 Drug returns from patients 
Site staff will collect and count patient returns of capecitabine. Returns should be reconciled against the patient diary 
and the reason for any discrepancy documented. Returns must be recorded in the patient’s CRF and accountability 
log. The returns can then be disposed of according to local policy.  
11.9 Drug destruction 
Enadenotucirev: 
Used vials 
Disposal at site according to local hospital policy. 
Expired Virus  
Disposal at site according to local hospital policy. A dated 
certificate of disposal should be completed and retained in the 
Pharmacy File and a copy emailed to the trial’s office. 
Virus left unused 
At the end of the trial, once authorised to do so, any unused drug 
should be disposed of at site according to local hospital policy. A 
dated certificate of disposal should be completed. The original 
should be placed in the Pharmacy File and a copy emailed to the 
Trials Office. 
Capecitabine: 
Patient returns will be disposed of as per local hospital policy. 


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11.10 Occupational safety 
Enadenotucirev is a live replicating oncolytic adenovirus; it is considered a BioSafety Level 1 (BSL-1) infectious 
substance. Appropriate precautions should be followed for a BSL-1 substance, as per section 8.4  and local site policy.  
12 RADIOTHERAPY (AND CHEMORADIOTHERAPY) 
Patients registered for the trial will receive standard chemoradiation treatment which consists of Capecitabine 
900mg/m2 orally twice a day in equal doses (Mon-Fri) on the days of radiotherapy for 25 daily treatments. The 
radiotherapy protocol mandates the use of intravenous contrast CT simulation with minimum 3 mm CT slices. Patients 
are immobilised supine with customised pelvic immobilization equipment, with a comfortably full bladder.  
50Gy in 25 fractions will be delivered to the primary tumour and macroscopically involved lymph nodes as a 
simultaneous integrated boost and 45Gy in 25 fractions to the pelvis/mesorectal nodes and elective pelvic lymph 
nodes at risk, prescribed according to recommendations by the International Commission on Radiation Units and 
Measurements (ICRU-50/62), to be delivered Monday to Friday as an intensity modulated radiotherapy planned 
single-phase treatment. An adapted atlas will be provided to aid with radiotherapy localization (Elective Clinical Target 
Volumes in Anorectal Cancer: An RTOG Consensus Panel Contouring Atlas). Each case will be reviewed to ensure 
consistency of radiotherapy delineation and radiotherapy dose delivery as described in section 12.3. Patients are 
reviewed weekly during RT (as per standard of care) and prior to each administration of enadenotucirev. 
Please refer to the accompanying radiotherapy trial document for details on volumes, margins, organ at risk 
constraints’, plan optimisation and quality assurance to ensure that standard of care is consistent across the sites.   
12.1 Management of unscheduled gaps  
CEDAR patients will be treated as RCR category 1 patients. Unscheduled gaps in radiotherapy should be limited to no 
more than 2 consecutive planned fractions where possible. Any toxicity resulting in delay in radiotherapy for greater 
than one week is considered a DLT (see section 9.1). 
12.2 Radiotherapy toxicity 
The acute adverse events expected for chemoradiotherapy are summarised in the following table. This data is derived 
from TROG 01.04 which randomised patients, in a neoadjuvant setting, to either 25Gy in 5 fractions or 50.4Gy in 28 
fractions with continuous fluorouracil(4). The management of radiation side effects should be as per local protocol. 
Where a side effect is attributable to either capecitabine or radiation, capecitabine should be held first and continue 
with daily fractions of treatment. 
Long course chemoradiation*
Toxicity
Grade
Rate 
(%) 
Grade 
Rate 
(%) 
Radiation dermatitis
3
5.6
4
0
Diarrhoea
3
13.6
4
0.6
Proctitis
3
3.7
4
0
Pain
3
1.9
4
0
Dysuria
3
1.2
4
0
Urinary Frequency
3
1.9
4
0
Haematuria
3
0
4
0
Neuropathic pain
3
0
4
0
Perineal pain
3
1.9
4
0
Nausea
3
3.1
4
0
Vomiting
3
1.9
4
0
Fatigue
3
3.7
4
0
*Data from TROG 01.04 (39) 


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12.3 Radiotherapy quality assurance 
In the first instance, any queries regarding radiotherapy quality assurance for CEDAR should be addressed to the 
national Radiotherapy Trials QA group (RTTQA) contact (CEDAR.RTTQA@wales.nhs.uk or www.rttrialsqa.org.uk). 
Real time review of all patients will be required for the first patient treated in each site and there will be timely 
retrospective review of radiotherapy for the rest of the patients. All images, outlines, plan and dose data (DICOM) should 
be submitted to the RTTQA contact who will co‐ordinate review of the data to check protocol compliance as each patient 
is recruited. 
13 EVALUATION OF RESPONSE 
13.1 Tumour assessment 
A clinical endoscopic and magnetic resonance imaging (MRI) evaluation of the rectal cancer, and in line with the 
protocol, must be performed before starting the trial treatment. To ensure compatibility, the radiological assessments 
used to assess response must be performed using identical techniques.  Imaging based evaluation is preferred to 
evaluation by clinical examination when both methods have been used to assess the anti-tumour effect of a treatment.  
Baseline evaluations 
These will include radiological measurements of the extent of disease by MRI scan, in accordance with best practice 
guidelines (41) by referencing the UICC 8th edition of the TNM staging classification (42).  All areas of disease present 
must be mentioned (even if specific lesions are not going to be followed for response) and the measurements of all 
measurable lesions must be recorded on the scan reports. Any non-measurable lesions must be stated as being present. 
For clinical measurements, documentation by colour photography at endoscopy including an estimate of the size of the 
lesion is recommended. 
13.2 MRI Tumour response 
Following treatment, a repeat MRI should be performed, approximately six weeks after the last fraction of 
chemoradiation.  This is considered to be standard of care in the UK.  The MRI should be reported according to MRI 
assessed Tumour Regression Grading (mrTRG). This has previously shown excellent prediction of favourable and 
unfavourable histopathology (43). It has also been shown to predict disease free survival and overall survival (44). The 
full mrTRG 5 point scale is included in Appendix 2 and will be grouped for purposes of analysis and dose escalation. 
Scores of 1 or 2 will be classified as responders and scores of 3, 4 or 5 will be classified as non-responders. 
A CT scan (Chest, Abdo, Pelvis) may also be completed after treatment if local site policy specifies, but is not required 
as part of the trial.  
13.3 Pathological Tumour response 
The final resected tumour should be assessed by an experienced lower gastrointestinal pathologist and staged according 
to the Royal College of Pathologists recommended standard datasets as per standard of care.  A pathological complete 
response (pCR) is staged as ypT0N0.  
Toxic death:
Any death to which IMP toxicity is thought to have a major contribution. 
Early death:
Death during the first three weeks of treatment that is not a toxic death. 
14 SAFETY REPORTING 
The Investigator will monitor each patient for clinical and laboratory evidence of adverse events on a routine basis 
throughout their participation in the trial. Should an Investigator become aware of any trial drug related SAEs following 
this period these must also be reported as stated below. Adverse event monitoring starts from the time the patient 
consents to the trial until they have completed their 4-6 weeks post-surgery visit. All reportable AEs will be followed to 
a satisfactory conclusion. Any reportable drug-related AEs that are unresolved at the end of treatment visit are to be 
followed up by the Investigator until resolution or stabilisation. 
All AEs reported to the trial office will be processed according to internal SOPs. The trial office may request additional 
information for any AE as judged necessary. 


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14.1 Adverse Event Definitions 
An Adverse Event or experience (AE) is any untoward medical occurrence in a trial subject temporally associated with 
the administration of an investigational medicinal product (IMP) or a comparator product, whether or not considered 
related to the IMP or a comparator product. An AE can therefore be any unfavourable and unintended sign, symptom, 
disease (new or exacerbated) and /or significant abnormal laboratory or physiological observation temporally 
associated with the use of a medicinal product. For marketed medicinal products, this also includes failure to produce 
expected benefits (i.e. lack of efficacy), abuse or misuse. 
A Serious Adverse Event (SAE) is any AE, regardless of dose, causality or expectedness, that: 
Results in death 
Is life-threatening  
This refers to an event in which the subject was at risk of death at 
the time of the event.  It does not refer to an event, which 
hypothetically might have caused death, if it were more severe. 
Requires in-patient 
hospitalisation  
or prolongs existing inpatient 
hospitalisation  
In general, hospitalisation signifies that the subject has been 
admitted (usually involving at least an overnight stay) at the hospital 
or emergency ward for observation and/or treatment that would 
not have been appropriate in the physician’s office or out-patient 
setting.  Complications that occur during hospitalisation are AEs.  If 
a complication prolongs hospitalisation or fulfils any other serious 
criteria, the event is serious.  When in doubt as to whether 
hospitalisation occurred or was necessary, the AE should be 
considered serious. 
Results in persistent or significant 
incapacity or disability 
This means a substantial disruption of a person’s ability to conduct 
normal life functions.  It does not include experiences of relatively 
minor medical significance or accidental trauma (e.g. sprained 
ankle), which do not constitute a substantial disruption. 
Is a congenital anomaly or birth 
defect 
Is any other medically other 
medically important event 
Defined as an event that may jeopardise the patient or may require 
intervention to prevent one of the outcomes listed above. Any new 
primary cancer must be reported as an SAE. 
An Adverse Drug Reaction (ADR) is an AE which is considered to be causally related to any dose of the IMP.  This means 
that a causal relationship between the IMP and the AE is at least a reasonable possibility, i.e., the relationship cannot 
be ruled out. 
An Unexpected Drug Reaction is an adverse drug reaction, the nature or severity of which, is not consistent with 
applicable product information (referring to information in SPC or IB).
A Suspected Unexpected Serious Adverse Drug Reaction (SUSAR) is a serious adverse drug reaction, the nature or 
severity of which is not consistent with the applicable product information (e.g. Investigator’s Brochure for an 
unapproved investigational product or SPC for an approved product). 
14.2 Clinical laboratory abnormalities and other abnormal assessments as AEs and SAEs 
Abnormal laboratory findings (e.g., clinical chemistry, haematology and urinalysis) or other abnormal assessments (e.g., 
ECGs, X-rays and scans) that are judged by the investigator as clinically significant will be recorded as AEs or SAEs if they 
meet the definitions given above. 


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Clinically significant abnormal laboratory findings or other abnormal assessments that are detected during the trial or 
are present at baseline and significantly worsen following the start of the trial will be reported as AEs or SAEs.  However, 
clinically significant abnormal laboratory findings or other abnormal assessments that are associated with the disease 
being studied, unless judged by the investigator as more severe than expected for the patient’s condition, or that are 
present or detected at the start of the trial and do not worsen, will not be reported as AEs or SAEs.  
The investigator will exercise his or her medical and scientific judgment in deciding whether an abnormal laboratory 
finding or other abnormal assessment is clinically significant.  
14.3 Determining adverse event causality 
A Serious Adverse Reaction (SAR) is a SAE that may be related to trial treatment. The assessment of “relatedness” must 
be determined by a medically qualified individual and is primarily the responsibility of the PI at site or agreed designee. 
SAEs that will be considered related will include any SAE that is documented as possibly, probably or definitely related 
to protocol treatment. The assessment of relatedness is made using the following: 
Classification 
Relationship 
Definition 
 Drug/RT-related 
Definitely related 

Starts within a time related to the trial drug/RT administration 
and

No obvious alternative medical explanation. 
Probably related 

Starts within a time related to the trial drug/RT administration 
and

Cannot be reasonably explained by known characteristics of 
the patient’s clinical state. 
Possibly related 

Starts within a time related to the trial drug/RT administration 
and

A causal relationship between the trial drug/RT and the 
adverse event is at least a reasonable possibility. 
not drug/RT 
related 
Probably not 
related 

The time association or the patient’s clinical state is such that 
the trial drug/RT is not likely to have had an association with 
the observed effect. 
Definitely not 
related 

The AE is definitely not associated with the trial drug/RT 
administered. 
The Investigator must endeavour to obtain sufficient information to confirm the causality of the adverse event (i.e. 
relation to surgery, trial drug, background treatment, other illness, progressive malignancy etc.) and give their opinion 
of the causal relationship between each AE and trial drug.  This may require instituting supplementary investigations of 
significant AEs based on their clinical judgement of the likely causative factors and/or include seeking a further specialist 
opinion. 


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14.4 Summary of trial safety reporting requirements 
Event 
DLT  
SAE
AE/SAE 
AE/SAE 
AE/SAE defined as Dose limiting toxicity (DLT) defined as per NCI 
CTCAE v4.03
Email reporting form within 
24 hours 
Report in 
AE CRF 
Non 
reportable 
Absolute neutrophil count (ANC) <0.5 x 109/L for ≥7days  
X 
X 
X 
Febrile Neutropenia (ANC <1000/mm3 with a single temperature of 
>38.3 degrees C or a sustained temperature of >=38 degrees C for 
more than one hour.)  
X 
X 
X 
Infection (documented clinically or microbiologically) with Grade 3 or 
4 neutropenia (absolute neutrophil count <1.0 x 109/L) 
X 
X 
X 
Thrombocytopenia grade 3 (Platelet count < 50 x 109/L) in the 
presence of bleeding or requiring platelet transfusion 
X 
X 
X 
Platelets <25 x 109/L (Grade ≥4) 
X 
X 
X 
Clinically significant bleeding attributed to  grade 3 thrombocytopenia 
or requiring platelet transfusion or other ≥3 grade clotting disorder or 
occurring concurrently with Grade 2 or 3 aPTT prolongation, unless 
there is a clear explanation for the event, such as tumour-related 
bleeding in the presence of Lupus Anticoagulant
X 
X 
X 
Clotting event (i.e. deep vein thrombosis [DVT], pulmonary embolism 
[PE]) occurring concurrently with Grade 2 or 3 aPTT prolongation 
x 
x 
x 
Grade ≥3 diarrhoea for more than 3 consecutive days during within 2 
weeks of starting radiotherapy
X
X 
X 
Grade ≥3  pneumonitis
X 
X 
X 
Grade ≥3  cytokine release syndrome 
X 
X 
X 
A concurrent elevation of ALT or AST >3 × ULN and total bilirubin 
>2 × ULN in whom there is no evidence of biliary obstruction or 
other causes that can reasonably explain the concurrent elevation 
X 
X 
X 
Grade ≥3 nausea or vomiting not controlled by optimal outpatient 
anti‐emetic treatment 
X 
X 
X 
Grade ≥3 diarrhoea despite optimal outpatient anti‐diarrhoeal 
medication use 
X 
X 
X 
Other grade ≥ 3  effects thought to be directly treatment related to 
the combination of enadenotucirev with radiotherapy or 
chemotherapy 
X 
X 
X 
Missing 3 consecutive fractions of radiotherapy, related to 
enadenotucirev, as judged by the investigator 
X 
X 
X 
Any toxicity causing a delay of radiotherapy completion by greater 
than one week
X
X 
X 
Missing 2 consecutive doses of enadenotucirev due to toxicity 
X 
X 
X 
Death due to drug related complications 
X 
X 
X 
Medically important events in the context of this trial (considered 
dose limiting and possibly, probably or definitely related to 
enadenotucirev combined with Radiotherapy +/‐ chemotherapy 
Email reporting form 
within 24 hours 
Report in AE 
CRF 
Non 
reportable 
Any AE not listed above that is grade ≥3 
X 
X 
X 
AE considered more severe than expected 
X
X 
X 


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AE Grade <3 that is unexpected and thought to be directly treatment 
related to the combination of enadenotucirev with radiotherapy +/‐ 
chemotherapy 
X
X 
X 
AE resulting in withdrawal 
X
X 
X 
Any late grade  ≥3 toxicities – onset 12 weeks after completion of 
radiotherapy 
X
X 
X 
Any late grade  2 toxicities – onset 12 weeks after completion of 
radiotherapy 
X 
Acute Hypersensitivity reaction to enadenotucirev
X 
X 
X 
Expected non‐dose limiting toxicities  
Email reporting form 
within 24 hours 
Report in AE 
CRF 
Non 
reportable 
See section 9.2
If grade≥4 
X 
All other AEs, abnormal assessments or laboratory results 
Email reporting form 
within 24 hours 
Report in AE 
CRF 
Non 
reportable 
All other AEs, assessments, abnormal laboratory results, if clinically 
significant 
If grade≥3  
X 
AE is life‐threatening  
X 
X 
AE requires in‐patient hospitalisation or prolongs existing inpatient 
hospitalisation  
X 
X 
AE results in persistent or significant incapacity or disability 
X 
X 
AE is a congenital anomaly or birth defect 
X 
X 
AE is any other medically important event 
X 
X 
AE related to surgery (wound dehiscence, life threatening 
complication requiring ICU management, single organ dysfunction 
including dialysis) 
X 
X 
Disease progression and resultant death 
Email reporting form 
within 24 hours 
Report in AE 
CRF 
Non 
reportable 
Hospitalisation (for progression or procedures planned prior to 
informed consent  ) 
X 
Clinical symptoms of progression 
X 
Death 
Possibly related 
directly to 
enadenotucirev 
or the 
combination of 
enadenotucirev 
+ 
radiotherapy 
+/‐ 
chemotherapy 
Report 
death and
reason on 
death
notification
CRF


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14.5 Reference safety information (RSI) for assessment of expectedness 
The reference safety information (RSI) for the trial is: 

For enadenotucirev: section 6.2 of the IB for enadenotucirev, which lists all the expected side effects associated 
with the use of enadenotucirev 

For capecitabine: the SPC version provided by OCTO (approved for use in this trial by the MHRA). It is not 
specified that any particular brand of Capecitabine must be prescribed, however irrespective of the brand 
prescribed, the RSI to be referenced is provided by OCTO. N.B: This may not be the latest SPC version available 
online. 
A copy of the current approved version of the RSI document must be held in the Site File for reference. Any change or 
update to the RSI during the trial will be made via substantial amendment.  
Expected AEs due to radiotherapy are listed in section 12.2. 
14.6 Suspected Unexpected Serious Adverse Drug Reactions (SUSARs) 
All SUSARS must be reported to the responsible Authority and main REC by the Trial Office within the required timelines: 

Fatal or life threatening SUSARs will be reported within 7 days of the Trial Office receiving the initial report. 
Any additional information will be reported within eight days of sending the first report. 

All other SUSARs will be reported within 15 days of the Trial Office receiving the initial report 
In addition, other safety issues qualify for expedited reporting where they might materially alter the current risk 
assessment of an IMP or be sufficient to change IMP administration or the overall conduct of the trial.  
14.7 Expedited reporting of SAEs 
The following SAE reporting requirements apply regardless of the Investigator’s assessment of the causality or 
expectedness of the SAE.  All SAEs should be reported on the trial SAE Report Form (see SAE Report Form and completion 
guidelines). 
 If a Serious Adverse Event occurs that requires reporting, a Serious Adverse Event reporting form should be completed 
and emailed within 24 hours of becoming aware of the event to: 
Pharmacovigilance Office, OCTO: octo-safety@oncology.ox.ac.uk
Tel no:  +44 (0) 01865 617082 
If the SAE has not been reported within the specified timeframe, a reason for lateness must be provided when 
sending the SAE Report Form. 
Investigators should also adhere to their local Trust policy for incident and SAE reporting in research. 
14.8 Follow-up of Serious Adverse Events 
A follow-up report must be completed when the SAE resolves, is unlikely to change, or when additional information 
becomes available. If the SAE is a suspected SUSAR then follow up information must be provided as requested by the 
trial office. 
If new or amended information on a reported SAE becomes available, the Investigator should report this on a new SAE 
Form using the completion guidelines.  If using the original form to notify further information, you must initial and date 
all new or amended information so that all changes are clearly identified.  
SAEs that are considered to be probably and definitely unrelated to the trial intervention will not be followed up and 
monitored. 
14.9 Reporting Adverse Events on the CRF 
All AEs, including Serious AEs must be recorded on the case report forms (CRF) for that patient (unless otherwise 
specified in section 14). The information provided will include date of onset, event diagnosis (if known) or 


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sign/symptom, severity, time course, duration and outcome and relationship of the AE to trial drug.  Any concomitant 
medications or other any therapy used to treat the event must be listed. The Investigator will provide an “other” cause 
for serious AEs considered to be unrelated to the trial drug.  Sites should ensure data entered into the CRF is consistent 
with the SAE report information where applicable. 
Each separate AE episode must be recorded. For example, if an AE resolves completely or resolves to baseline and then 
recurs or worsens again, this must be recorded as a separate AE. For AEs to be considered intermittent, the events must 
be of similar nature and severity. 
AEs may be spontaneously reported by the patient and/or in response to an open question from trial personnel or 
revealed by observation, physical examination, or other diagnostic procedures. Any clinically relevant deterioration in 
laboratory assessments or other clinical finding is considered an AE. 
AEs which are serious and occur from the first dose of trial treatment up to and including 30 days after administration 
of the last dose of trial treatment must be reported to OCTO. Any SAE that occurs at any time after completion of trial 
treatment or after the designated follow-up period that the sponsor-investigator and/or co-investigator consider to be 
related to any trial drug must be reported to OCTO.  
Terms and Grading of Events 
All adverse events and toxicities must be graded according to the NCI Common Terminology Criteria for adverse 
events (NCI-CTCAE) Version 4.03.  
14.10 Events exempt from being reported as AE/ SAEs 
Progression of underlying disease 
Disease progression and resultant death will be captured on the CRF.  Adverse events including hospitalisation that are 
clearly consistent with disease progression will not be reported as individual AE/SAEs. Clinical symptoms of progression 
will only be reported as adverse events if the symptom cannot be determined as exclusively due to the progression of 
the underlying malignancy, or does not fit the expected pattern of progression for the disease under trial. 
Every effort should be made to document the objective progression of underlying malignancy.  In some cases, the 
determination of clinical progression may be based on symptomatic deterioration. For example, progression may be 
evident from clinical symptoms, but is not supported by tumour measurements. Or, the disease progression is so evident 
that the investigator may elect not to perform further disease assessments.  
Death on trial 
Death due to disease under trial is to be recorded on the Death CRF providing the death is not unexpected or if a causal 
relationship suspected. The investigator must clearly state whether the death was expected or unexpected and whether 
a causal relationship to the trial IMP or other protocol treatment intervention is suspected.  
Elective admissions and supportive care 
Elective admissions to hospital for patient convenience or for planned procedures or investigations or treatment as 
specified in this protocol and standard supportive care are not SAEs, and do not require SAE reporting.
14.11 Informing Investigators of new safety information 
The Trial Office or the Chief Investigator will ensure that all investigators are kept informed in a timely manner, as new 
safety profile information becomes available. Principal Investigators are responsible for briefing their trial team and 
onward transmission to their R&D office as appropriate. 
15 PREGNANCY  
Pregnancies (in a participant or partner) occurring while participating in this trial require expedited reporting. This 
includes any pregnancy (also applies to female partners of male trial subjects) occurring within 6 months of the last 
administration of trial drug even if participant is discontinued from the trial. A Pregnancy Form should be completed 
and sent to the trial office within the same timelines as an SAE. All reported pregnancies should be followed and the 
outcome reported using the same form. If the outcome of the pregnancy meets any of the criteria for seriousness, it 
must also be reported as an SAE.  Examples of pregnancy outcomes that are SAEs include reports of: 


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
Congenital anomalies or developmental delay, in the foetus or the child. 

Foetal death and spontaneous abortion.      

Suspected adverse reactions in the neonate that are classified as serious 
Women who become pregnant should be withdrawn from trial treatment immediately. 
16 DEFINING THE END OF TRIAL  
For this trial the end of the trial is defined as: “The last visit of the last patient undergoing the trial (LPLV)” i.e. when 
(i.e. 4-6 weeks post-surgery visit) or has progressed or died.  
Recruitment will be stopped when either: 

Sufficient patients have been recruited to achieve the primary and secondary objectives of the trial, as per the trial 
design & statistical model detailed in sections 2 and 17 (maximum 30 patients)  or

When a defined stopping rule is met.  
The sponsor and the Chief Investigator reserve the right to terminate the trial earlier at any time. In terminating the 
trial, they must ensure that adequate consideration is given to the protection of the participants’ best interests. 
17 STATISTICAL CONSIDERATIONS  
17.1 CEDAR: Evaluation of treatment schedules 
The trial will use a model-based approach using the toxicity and efficacy primary endpoints to recommend the treatment 
schedule for future patients, and to recommend the optimal dose at the trial’s conclusion.  
We are using both efficacy and toxicity endpoints because although toxicity is expected to increase with increasing dose, 
it is possible that the relationship between efficacy and dose may not be a monotonically increasing one. This means 
that the optimal dose may not be the maximum tolerated dose. However, there will be no formal combination of the 
efficacy and toxicity data, both endpoints will contribute information independently to dose choice via dose escalation 
rules. 
Toxicity data can be used continuously throughout the trial through the use of the TiTE-CRM. We will use a 2-parameter 
logistic regression model to model the relationship between dose and toxicity. Data for patients who have completed 
the 13 week toxicity window or experienced a dose limiting toxicity will contribute full information to this model. Only 
partial information is known for patients who are currently on trial within the toxicity window, or those who withdraw 
during treatment for reasons other than a DLT i.e. patient choice. This partial information contributes to the model, 
weighted proportionally to the observed portion of their toxicity time window and the proportion of treatment 
received, and treating them as not experiencing a dose limiting toxicity. 
We will use a 3-parameter logistic regression model to model the relationship between dose and efficacy. Patients are 
assessed for the efficacy endpoint in week 13. Patients who have not reached this time point yet will not provide any 
information to this model. Patients who have reached the time point for this endpoint and did not have the evaluation, 
or who withdrew or died prior to evaluation will be treated as non-responders. 
Specification of priors and simulation results are given in the SAP. 
17.2 Dose selection during the trial 
The first two patients will be assigned to treatment schedule 1 and followed to week 13. Thereafter, the toxicity and 
response models will be fitted every time a new patient is screened and the treatment schedule recommended for the 
next patient will be the minimum of the doses recommended by the toxicity and efficacy models. 
Define:  

a target toxicity interval as (0.2, 0.35) 

a safety criterion such that a dose is considered safe to give if the posterior probability that the DLT rate is 
greater than 0.35 on the dose is less than 35% (i.e. P(risk of DLT > 0.35 |Dose, Data) < 0.35) 


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Then the dose that is recommended by the toxicity model is the dose with the highest posterior probability of DLT rate 
lying in the target toxicity interval among those doses that satisfy the safety criterion. 
The treatment schedule recommended by the efficacy model is the dose with the highest posterior mean probability of 
response. 
A further restriction on escalation is that an untried dose can only be given if at least 2 patients have been given the 
dose below for at least 8 weeks. 
The toxicity and efficacy models are for guidance only and the TMG may overrule the recommendation, but only in 
favour of a lower dosing schedule than the model recommends.  
See Neuenschwander, Branson and Gsponer (2008). Critical aspects of the Bayesian approach to phase I cancer trials. 
Stats in Med, 27:2420-2439 for details of the toxicity model. 
17.3 Stopping the trial early 
In the event that all dose levels are toxic, the trial will have a built in rule to stop the trial before reaching the maximum 
number of patients. If P(risk of DLT > 0.35|dose = 1, current data) > 0.65 for the lowest dose level and at least three 
patients have complete data for the toxicity endpoint (a DLT or have completed the toxicity window) we will stop the 
trial. 
17.4 Importance of rapid data return 
Patient Status Update CRF 
Analysis will be performed in real-time based on all relevant available data to best inform the treatment schedule to 
allocate to the next patient. The patient status update CRF is a custom built CRF that will capture all of the required data 
and should be entered promptly upon request. E.g. the next working day.  
Data entered will also be used for safety monitoring. For these reasons, it is important that data is collected and made 
available on OpenClinica swiftly and no more than 5 working days of the initial event and within 14 days of receipt of a 
data query unless otherwise specified.  
18 STATISTICAL ANALYSIS PLAN 
For all analyses, patients will be included according to the treatment schedule to which they are assigned. All patients 
who receive at least one dose of enadenotucirev, regardless of how much treatment received and follow-up completed, 
will contribute to analysis. It is therefore important that every effort is made to encourage patients, including those 
patients who do not receive/complete their allocated treatment, to attend for follow-up clinic visits to avoid bias in the 
analysis of the results. 
Further details can be found in the Statistical Analysis Plan. 
18.1 Inclusion in analysis 
All patients enrolled in the trial and who received at least one dose of enadenotucirev will be accounted for and included 
in the analyses. The number of patients who were not evaluable, who died or withdrew before treatment began will be 
recorded. 
Baseline characteristics will be summarised for all enrolled patients. Patients who died or withdrew before treatment 
started or do not complete the required safety observations will be described and evaluated separately. 
Evaluable for toxicity: All patients will be evaluable for toxicity from the time of their first treatment. 
18.2 Interim Analyses 
The trial will use the model based design to propose treatment schedules and will be updated prior to each TMG 
meeting to recommend a treatment schedule for each patient recruited. 


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18.3 Procedures for reporting any deviation(s) from the protocol 
Any deviations from the original statistical plan will be described and justified in the final report. 
18.4 Final analysis 
Primary analysis will be after all patients have completed their 13 week, end of treatment visit.   
19 TRIAL COMMITTEES 
19.1 Trial Management Group (TMG) 
The Chief Investigator will chair a TMG responsible for overseeing the successful conduct and publication of the trial. 
The TMG will include Chief Investigator, Co‐ Investigators, Clinical Trial Manager, Trial Statistician and others as required. 
The TMG will meet as necessary to discuss toxicity data and to decide on dose escalation. TMG membership and decision 
making procedures will be documented in the TMG charter. 
19.2 Safety Review Committee (SRC) 
There is no independent Data and Safety Monitoring Committee (DSMC) for this trial. The Safety Review Committee 
(SRC) will be convened as required to review DLTs and dose escalation decisions, made by the TMG. In the event of the 
TMG being unable to conclude on a dose recommendation, the SRC will meet to decide. The main outcomes will be 
analysed as stated in the analysis plan and will not be analysed as an interim analysis. The SRC will consist of: 
1. Trial Statistician 
2. OCTO trial management representative 
3. Either: 
a. One Medical Oncologist and one Clinical Oncologist or 
b. Two Clinical Oncologists 
The SRC Charter document for this trial will define the exact membership and who should be present for decisions to 
be made. Further internal or external experts may be consulted by the SRC, as necessary. Any PI can request an ad hoc 
SRC meeting at any time in order to facilitate the immediate communication of any emerging safety issues during the 
course of the trial. 
19.3 Independent Radiotherapy & Imaging Oversight Committee (RIOC) 
RIOC will act as the TSC. The role of RIOC is to provide oversight for the trial on behalf of the Sponsor and Funder(s).  
The RIOC will provide overall supervision of the safe and effective conduct of the trial. The RIOC will review trial progress 
against agreed milestones, adherence to protocol, and patient safety, and consider new information. The RIOC has 
responsibility for deciding if the trial needs to be stopped early on grounds of safety or efficacy.  
20 DATA MANAGEMENT 
20.1 Database considerations 
Data management will be performed via a web-based, bespoke trial database (OpenClinica). OpenClinica is a 
dedicated and validated clinical trials database designed for electronic data capture. See: http://www.openclinica.org.   
The trial office will provide sites with instructions and a video link for training purposes.  
The participants will be identified by a unique trial specific number and/or code in any database. The name and any 
other identifying detail will NOT be included in any trial data electronic file. 
20.2 Case reports forms (CRFs) 
The Investigator and trial site staff will ensure that data collected on each subject is recorded in the CRF as accurately 
and completely as possible. All appropriate laboratory data, summary reports and Investigator observations will be 
transcribed into the CRFs from the relevant source data held in the site medical record(s). CRFs entries will not contain 
any source data (unless otherwise specified in the completion instructions provided by the trial office). It is important 
to ensure that:

the relevant CRFs are completed. 


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
The key data items (Patient Status Update CRF) that are used in the statistical model to calculate next 
recommended dose will be completed for all patients by the deadline requested by OCTO; this data return is 
essential for TMG decision making 

all CRF data are verifiable in the source documentation or the discrepancies must be explained.  

CRF sections are completed in a timely fashion, as close to the visit or event being recorded as possible. 

Data queries are resolved and documented by authorised trial staff in a timely fashion. The reason for the 
change or correction should be given where appropriate. 

As much data as possible is entered and cleaned in preparation for each trial database lock point. 
Note: ‘in a timely fashion’ means within no more than 5 working days of the initial event and within 14 days of receipt 
of a data query unless otherwise specified.  
The above considerations also apply to patients who are withdrawn early. If a patient withdraws from the trial, the 
reason must be noted on the appropriate form and the patient must be followed-up as per protocol.  
20.3 Accounting for missing, unused, or spurious data. 
The statistical analysis plan will describe the procedure for accounting for missing, unused or spurious data. 
21 CLINICAL TRIAL REPORT  
All clinical data will be presented at the end of the trial as data listings. These will be checked to confirm the lists 
accurately represents the data collected during the course of the trial.  The trial data will then be locked and a final data 
listing produced. The clinical trial report will be based on the final data listings. The locked trial data may then be used 
for analysis and publication.  
22 TRIAL SITE MANAGEMENT 
22.1 Trial site responsibilities 
The Principal Investigator (the PI or lead clinician for the trial site) has overall responsibility for conduct of the trial, but 
may delegate responsibility where appropriate to suitably experienced and trained members of the trial site team.  All 
members of the trial site team must complete the delegation log provided prior to undertaking any trial duties.  The PI 
must counter sign and date each entry in a timely manner, authorising staff to take on the delegated responsibilities.  
22.2 Trial site set up and activation 
The Principal Investigator leading the investigational trial site is responsible for providing all required core 
documentation.  Mandatory Site Training organised by the trial office must be completed before the site can be 
activated. The Trial Office will check to confirm that the site has all the required trial information/documentation and is 
ready to recruit.  The site will then be notified once they are activated on the trial database and able to enter patients. 
22.3 Trial documentation 
The trial office will provide an Investigator File and Pharmacy File to each investigational site containing the documents 
needed to initiate and conduct the trial.  The trial office must review and approve any local changes made to any trial 
documentation including Patient Information and Consent Forms prior to use. Additional documentation generated 
during the course of the trial, including relevant communications must be retained in the site files as necessary to 
reconstruct the conduct of the trial. 
23 REGULATORY AND ETHICAL CONSIDERATIONS 
The Sponsor and Investigators will ensure that this protocol will be conducted in compliance with the UK Clinical Trials 
Regulations1 and the applicable policies of the sponsoring organisation. Together, these implement the ethical principles 
of the Declaration of Helsinki (1996) and the regulatory requirements for clinical trials of an investigational medicinal 
product under the European Union Clinical Trials Directive. 
1 The Medicines for Human Use (Clinical Trials) Regulations (S.I. 2004/1031) and any subsequent amendments to it. 


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23.1 Ethical conduct of the trial and ethics approval 
The protocol, Patient Information Sheet, Consent Form and any other information that will be presented to potential 
trial patients (e.g. advertisements or information that supports or supplements the informed consent) will be reviewed 
and approved by an appropriately constituted, independent Research Ethics Committee (REC). Principal Investigators 
will be approved by the REC. 
23.2 Regulatory Authority approval 
This trial will be conducted under a UK Medicines and Healthcare Products Regulatory Agency (MHRA) Clinical Trials 
Authorisation (CTA). Approval to conduct the trial will be obtained from the Responsible Authority prior to initiating the 
trial.  
23.3 NHS Research Governance 
Investigators are responsible for ensuring they obtain local Trust management agreement to conduct the trial in 
accordance with local arrangements and policies. 
23.4 Protocol amendments 
Amendments are changes made to the research following initial approval. A ‘substantial amendment’ is an 
amendment to the terms of the Responsible Authority application (if applicable), the REC application, or to the 
protocol or any other supporting documentation, that is likely to affect to a significant degree: 

the safety or physical or mental integrity of the subjects of the trial; 

the scientific value of the trial; 

the conduct or management of the trial; or 

the quality or safety of the investigational medicinal product(s) used in the trial. 
Non-substantial amendments are those where the change(s) involve only minor logistical or administrative aspects of 
the trial. 
All amendments will be generated and managed according to the trial office standard operating procedures to ensure 
compliance with applicable regulation and other requirements. Written confirmation of all applicable REC, regulatory 
and local approvals must be in place prior to implementation by Investigators. The only exceptions are for changes 
necessary to eliminate an immediate hazard to trial patients (see below). 
It is the Investigator’s responsibility to update patients (or their authorised representatives, if applicable) whenever new 
information (in nature or severity) becomes available that might affect the patient’s willingness to continue in the trial.  
The Investigator must ensure this is documented in the patient’s medical notes and the patient is re-consented if 
appropriate. 
23.5 Urgent safety measures 
The sponsor or Investigator may take appropriate urgent safety measures to protect trial participants from any 
immediate hazard to their health or safety. Urgent safety measures may be taken without prior authorisation. The trial 
may continue with the urgent safety measures in place. The Investigator must inform the trial office IMMEDIATELY if 
the trial site initiates an urgent safety measure:
The notification must include: 

Date of the urgent safety measure; 

Who took the decision; and 

Why the action was taken. 
The Investigator will provide any other information that may be required to enable the trial office to report and manage 
the urgent safety measure in accordance with the current regulatory and ethical requirements for expedited reporting 
and close out. The Trial office will follow written procedures to implement the changes accordingly.    
23.6 Temporary halt 
The sponsor and Investigators reserve the right to place recruitment to this protocol on hold for short periods for 
administrative reasons or to declare a temporary halt. 
A temporary halt is defined a formal decision to: 


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
interrupt the treatment of subjects already in the trial for safety reasons; 

stop recruitment on safety grounds; or 

stop recruitment for any other reason(s) considered to meet the substantial amendment criteria, including 
possible impact on the feasibility of completing the trial in a timely manner. 
The trial office will report the temporary halt via an expedited substantial amendment procedure. The trial may not 
restart after a temporary halt until a further substantial amendment to re-open is in place.  If it is decided not to 
restart the trial this will be reported as an early termination. 
23.7 Serious Breaches 
The Medicines for Human Use (Clinical Trials) Regulations require the Sponsor to notify any "serious breaches" to the 
MHRA within 7 days of the sponsor becoming aware of the breach. A serious breach is defined as “A breach of GCP or 
the trial protocol which is likely to effect to a significant degree:  

the safety or physical or mental integrity of the subjects of the trial; or 

the scientific value of the trial” 
Investigators must notify the Trials Office within one working day if any serious breach of GCP is suspected.  The Trial 
Office will review the event and, if appropriate will report a serious breach to the REC, Regulatory Authority and the 
NHS host organisation within 7 days of the Trial Office becoming aware of the breach. 
23.8 Trial Reports 
This protocol will comply with all current applicable Regulatory Authority, Research Ethics Committee and Sponsor 
reporting requirements.  
The trial office will determine which reports need to be circulated to Principal Investigators and other interested parties. 
Trial sites are responsible for forwarding trial reports they receive to their local Trust as required. 
24 EXPENSES AND BENEFITS 
Reasonable travel expenses for the additional trial related visits, in excess of standard of care as per local practice, will 
be covered by PsiOxus Therapeutics (Up to a total of £120.00 per patient) 
The local arrangements will also be explained to the patient during the informed consent discussions prior to trial 
entry.  E.g. hospital transport or parking permits. 
25 QUALITY ASSURANCE 
25.1 Risk assessment  
A risk assessment and a monitoring plan will be prepared before the trial opens and will be reviewed throughout the 
trial if necessary in the light of significant changes while the trial is on-going or in response to outcomes from monitoring 
activities.  Monitoring plans will be amended as appropriate. 
25.2 Monitoring 
Regular monitoring will be performed according to the monitoring plan. Data will be evaluated for compliance with 
the protocol, completeness and accuracy. The investigator and institutions involved in the trial will permit trial -
related monitoring and provide direct on-site access to all trial records and facilities if required. They will provide 
adequate time and space for the completion of monitoring activities. 
Trial sites will be monitored centrally by checking incoming data for compliance with the protocol, consistency, 
completeness and timing.  The case report data will be validated using appropriate set criteria, range and verification 
checks.  The trial site must resolve all data queries in a timely manner.   All queries relating to key outcome and safety 


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data and any requiring further clarification will be referred back to the trial site for resolution. For other non-critical 
data items, OCTO staff may resolve data queries centrally providing the correct answer is clear. Such changes will be 
clearly identified in the CRF and the trial site informed. 
Trial sites will also be monitored remotely and/or by site visit as necessary to ensure their proper conduct of the trial.  
OCTO staff will be in regular contact with site personnel to check on progress and deal with any queries that they may 
have. Monitoring reports will be sent to the site in a timely fashion.  The Investigator is expected to action any points 
highlighted through monitoring and must ensure that corrective and preventative measures are put into place as 
necessary to achieve satisfactory compliance. 
Sites will provide copies of the following participant information to the trial office on request for remote monitoring 
purposes. All patient personal identifiers must be obliterated from the information except where explicit consent for 
release of personal information has been obtained from the patient:  

Participant screening log  

Anonymised baseline and post-treatment MRI reports 
25.3 Audit and Regulatory Inspection 
All aspects of the trial conduct may be subject to internal or external quality assurance audit to ensure compliance 
with the protocol, GCP requirements and other applicable regulation or standards. It may also be subject to a 
regulatory inspection. Such audits or inspections may occur at any time during or after the completion of the trial. 
Investigators and their host Institution(s) should understand that it is necessary to allow auditors/inspectors direct 
access to all relevant documents, trial facilities and to allocate their time and the time of their staff to facilitate the 
audit or inspection visit. Anyone receiving notification of a Regulatory Inspection that will (or is likely to) involve this 
trial must inform the Trial Office without delay. 
26 RECORDS RETENTION & ARCHIVING 
During the clinical trial and after trial closure the Investigator must maintain adequate and accurate records to enable 
the conduct of a clinical trial and the quality of the research data to be evaluated and verified.  All essential documents 
must be stored in such a way that ensures that they are readily available, upon request for the minimum period required 
by national legislation or for longer if needed.  The medical files of trial subjects must be retained in accordance with 
applicable national legislation and the host institution policy. 
Retention and storage of laboratory records for clinical trial samples must also follow these guidelines. 
Retention and storage of central laboratory records supporting PK or PD endpoints and the disposition of samples 
donated via the trial must also comply with applicable legislation and Sponsor requirements. 
It is the University of Oxford’s policy to store data for a minimum of 5 years. Investigators may not archive or destroy 
trial essential documents or samples without written instruction from the trial office. 
Data from this trial may contribute towards a marketing authorisation and as a result, essential clinical trial 
documents (including CRF’s), other than the patients’ medical notes, will need to be held for a minimum of 15 years 
after completion or discontinuation of the trial.  
27 PATIENT CONFIDENTIALITY 
Personal data recorded on all documents will be regarded as confidential, and to preserve each patient’s anonymity, 
only their initials and year of birth will be recorded on the CRFs.  
The Investigator site must maintain the patient’s anonymity in all communications and reports related to the research. 
The Investigator site team must keep a separate log of enrolled patients’ personal identification details as necessary to 
enable them to be tracked. These documents must be retained securely, in strict confidence. They form part of the 
Investigator Site File and are not to be released externally. 


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28 TRIAL FUNDING 
The CEDAR trial is funded in part by the Clinical Research Committee (Early Phase & Feasibility Studies) on behalf of 
Cancer Research UK (CRUK/17/015). The Oncology Clinical Trials Office is supported by Cancer Research UK core 
funding. PsiOxus Therapeutics Limited are providing a grant and enadenotucirev to support the trial. This trial is further 
supported via the University of Oxford core clinical and research infrastructure underpinned by strategic research 
programme grant funds. This trial is on the NIHR portfolio; local research network support should be available at each 
site taking part to support entry of participants into this trial.   
29 SPONSORSHIP AND INDEMNITY 
29.1 Sponsorship 
The Sponsor will provide written confirmation of Sponsorship and authorise the trial commencement once satisfied 
that all arrangements and approvals for the proper conduct of the trial are in place. A separate trial delegation 
agreement, setting out the responsibilities of the Chief Investigator and Sponsor will be put in place between the 
parties.  
29.2 Indemnity 
The University has a specialist insurance policy in place which would operate in the event of any participant suffering 
harm as a result of their involvement in the research (Newline Underwriting Management Ltd, at Lloyd’s of London).  
NHS indemnity operates in respect of the clinical treatment which is provided.  
29.3 Contracts/Agreements 
This trial is subject to the Sponsor’s policy requiring that written contracts/agreements are agreed formally by the 
participating bodies as appropriate.  A Clinical Trial Agreement (CTA) will be placed between the Sponsor and 
participating organisations prior to site activation.   
The Sponsor will also set up written agreements with any other external third parties involved in the conduct of the 
trial as appropriate.  
30 PUBLICATION POLICY 
The sponsor will retain ownership of all data arising from the trial.  The intention is to publish this research in a specialist 
peer reviewed scientific journal on completion of the trial. The results may also be presented at scientific meetings 
and/or used for a thesis. The Investigators will be involved in reviewing drafts of the manuscripts, abstracts, press 
releases and any other publications arising from the trial and retain final editorial control. Authors will acknowledge 
that the trial was Sponsored by and performed with the support of the Sponsor and other funding bodies as appropriate. 


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31 REFERENCES 
1.  
Bowel cancer incidence statistics [Internet]. Cancer Research UK. 2015 [cited 2016 Nov 17]. Available from: 
http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-
cancer/incidence 
2.  
Guren MG, Kørner H, Pfeffer F, Myklebust TÅ, Eriksen MT, Edna T-H, et al. Nationwide improvement of rectal 
cancer treatment outcomes in Norway, 1993-2010. Acta Oncol Stockh Swed. 2015 Nov;54(10):1714–22.  
3.  
Bujko K, Nowacki MP, Nasierowska-Guttmejer A, Michalski W, Bebenek M, Kryj M. Long-term results of a 
randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally 
fractionated chemoradiation for rectal cancer. Br J Surg. 2006 Oct 1;93(10):1215–23.  
4.  
Ngan SY, Burmeister B, Fisher RJ, Solomon M, Goldstein D, Joseph D, et al. Randomized trial of short-course 
radiotherapy versus long-course chemoradiation comparing rates of local recurrence in patients with T3 rectal 
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1;30(31):3827–33.  
5.  
Tiernan J, Cook A, Geh I, George B, Magill L, Northover J, et al. Use of a modified Delphi approach to develop 
research priorities for the association of coloproctology of Great Britain and Ireland. Colorectal Dis Off J Assoc 
Coloproctology G B Irel. 2014 Dec;16(12):965–70.  
6.  
Formenti SC, Demaria S. Combining Radiotherapy and Cancer Immunotherapy: A Paradigm Shift. JNCI J Natl 
Cancer Inst. 2013 Feb 20;105(4):256–65.  
7.  
Vanpouille-Box C, Pilones KA, Wennerberg E, Formenti SC, Demaria S. In situ vaccination by radiotherapy to 
improve responses to anti-CTLA-4 treatment. Vaccine. 2015 Dec 16;33(51):7415–22.  
8.  
Kaliberov SA, Buchsbaum DJ. Cancer Treatment with Gene Therapy and Radiation Therapy. Adv Cancer Res. 
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9.  
Kuhn I, Harden P, Bauzon M, Chartier C, Nye J, Thorne S, et al. Directed Evolution Generates a Novel Oncolytic 
Virus for the Treatment of Colon Cancer. PLOS ONE. 2008 Jun 18;3(6):e2409.  
10.  
Bell JC, Garson KA, Lichty BD, Stojdl FD. Oncolytic Viruses: Programmable Tumour Hunters. Curr Gene Ther. 
2002 May 1;2(2):243–54.  
11.  
Parato KA, Senger D, Forsyth PAJ, Bell JC. Recent progress in the battle between oncolytic viruses and tumours. 
Nat Rev Cancer. 2005 Dec;5(12):965–76.  
12.  
Forrester NA, Sedgwick GG, Thomas A, Blackford AN, Speiseder T, Dobner T, et al. Serotype-Specific Inactivation 
of the Cellular DNA Damage Response during Adenovirus Infection. J Virol. 2011 Mar;85(5):2201–11.  
13.  
Dilley J, Reddy S, Ko D, Nguyen N, Rojas G, Working P, et al. Oncolytic adenovirus CG7870 in combination with 
radiation demonstrates synergistic enhancements of antitumor efficacy without loss of specificity. Cancer Gene 
Ther. 2005 Apr 15;12(8):715–22.  
14.  
Toth K, Tarakanova V, Doronin K, Ward P, Kuppuswamy M, Locke JE, et al. Radiation increases the activity of 
oncolytic adenovirus cancer gene therapy vectors that overexpress the ADP (E3-11.6K) protein. Cancer Gene 
Ther. 2003;10(3):193–200.  
15.  
Emdad L, Sarkar D, Lebedeva IV, Su Z-Z, Gupta P, Mahasreshti PJ, et al. Ionizing radiation enhances adenoviral 
vector expressing mda-7/IL-24-mediated apoptosis in human ovarian cancer. J Cell Physiol. 2006 
Aug;208(2):298–306.  
16.  
Geoerger B, Grill J, Opolon P, Morizet J, Aubert G, Lecluse Y, et al. Potentiation of radiation therapy by the 
oncolytic adenovirus dl1520 (ONYX-015) in human malignant glioma xenografts. Br J Cancer. 2003 Aug 
4;89(3):577–84.  


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Protocol Template V5.0_28Nov2014 
17.  
Kawabe S, Munshi A, Zumstein LA, Wilson DR, Roth JA, Meyn RE. Adenovirus-mediated wild-type p53 gene 
expression radiosensitizes non-small cell  lung cancer cells but not normal lung fibroblasts. Int J Radiat Biol. 2001 
Feb;77(2):185–94.  
18.  
Green NK, Herbert CW, Hale SJ, Hale AB, Mautner V, Harkins R, et al. Extended plasma circulation time and 
decreased toxicity of polymer-coated adenovirus. Gene Ther. 2004 Jun 24;11(16):1256–63.  
19.  
Liu C, Zhang Y, Liu MM, Zhou H, Chowdhury W, Lupold SE, et al. Evaluation of continuous low dose rate versus 
acute single high dose rate radiation combined with oncolytic viral therapy for prostate cancer. Int J Radiat Biol. 
2010 Mar;86(3):220–9.  
20.  
Chen Y, DeWeese T, Dilley J, Zhang Y, Li Y, Ramesh N, et al. CV706, a Prostate Cancer-specific Adenovirus 
Variant, in Combination with Radiotherapy Produces Synergistic Antitumor Efficacy without Increasing Toxicity. 
Cancer Res. 2001 Jul 15;61(14):5453–60.  
21.  
Freytag SO, Movsas B, Aref I, Stricker H, Peabody J, Pegg J, et al. Phase I trial of replication-competent 
adenovirus-mediated suicide gene therapy combined with IMRT for prostate cancer. Mol Ther J Am Soc Gene 
Ther. 2007 May;15(5):1016–23.  
22.  
Freytag SO, Stricker H, Peabody J, Pegg J, Paielli D, Movsas B, et al. Five-year follow-up of trial of replication-
competent adenovirus-mediated suicide gene therapy for treatment of prostate cancer. Mol Ther J Am Soc 
Gene Ther. 2007 Mar;15(3):636–42.  
23.  
Freytag SO, Stricker H, Lu M, Elshaikh M, Aref I, Pradhan D, et al. Prospective randomized phase 2 trial of 
intensity modulated radiation therapy with or without oncolytic adenovirus-mediated cytotoxic gene therapy in 
intermediate-risk prostate cancer. Int J Radiat Oncol Biol Phys. 2014 Jun 1;89(2):268–76.  
24.  
Lu M, Freytag SO, Stricker H, Kim JH, Barton K, Movsas B. Adaptive seamless design for an efficacy trial of 
replication-competent adenovirus-mediated suicide gene therapy and radiation in newly-diagnosed prostate 
cancer (ReCAP Trial). Contemp Clin Trials. 2011 May;32(3):453–60.  
25.  
Teh BS, Aguilar-Cordova E, Kernen K, Chou CC, Shalev M, Vlachaki MT, et al. Phase I/II trial evaluating combined 
radiotherapy and in situ gene therapy with or without hormonal therapy in the treatment of prostate cancer--a 
preliminary report. Int J Radiat Oncol Biol Phys. 2001 Nov 1;51(3):605–13.  
26.  
DeWeese TL, van der Poel H, Li S, Mikhak B, Drew R, Goemann M, et al. A phase I trial of CV706, a replication-
competent, PSA selective oncolytic adenovirus, for the treatment of locally recurrent prostate cancer following 
radiation therapy. Cancer Res. 2001 Oct 15;61(20):7464–72.  
27.  
Fujita T, Teh BS, Timme TL, Mai W-Y, Satoh T, Kusaka N, et al. Sustained long-term immune responses after in 
situ gene therapy combined with radiotherapy and hormonal therapy in prostate cancer patients. Int J Radiat 
Oncol Biol Phys. 2006 May 1;65(1):84–90.  
28.  
Senzer N, Mani S, Rosemurgy A, Nemunaitis J, Cunningham C, Guha C, et al. TNFerade biologic, an adenovector 
with a radiation-inducible promoter, carrying the human tumor necrosis factor alpha gene: a phase I study in 
patients with solid tumors. J Clin Oncol Off J Am Soc Clin Oncol. 2004 Feb 15;22(4):592–601.  
29.  
Seiwert TY, Darga T, Haraf D, Blair EA, Stenson K, Cohen EEW, et al. A phase I dose escalation study of Ad 
GV.EGR.TNF.11D (TNFerade Biologic) with concurrent chemoradiotherapy in patients with recurrent head and 
neck cancer undergoing reirradiation. Ann Oncol Off J Eur Soc Med Oncol. 2013 Mar;24(3):769–76.  
30.  
MacGill RS, Davis TA, Macko J, Mauceri HJ, Weichselbaum RR, King CR. Local gene delivery of tumor necrosis 
factor alpha can impact primary tumor growth and metastases through a host-mediated response. Clin Exp 
Metastasis. 2007;24(7):521–31.  
31.  
Mundt AJ, Vijayakumar S, Nemunaitis J, Sandler A, Schwartz H, Hanna N, et al. A Phase I trial of TNFerade 
biologic in patients with soft tissue sarcoma in the  extremities. Clin Cancer Res Off J Am Assoc Cancer Res. 2004 
Sep 1;10(17):5747–53.  


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32.  
Hecht JR, Farrell JJ, Senzer N, Nemunaitis J, Rosemurgy A, Chung T, et al. EUS or percutaneously guided 
intratumoral TNFerade biologic with 5-fluorouracil and radiotherapy for first-line treatment of locally advanced 
pancreatic cancer:  a phase I/II study. Gastrointest Endosc. 2012 Feb;75(2):332–8.  
33.  
Swisher SG, Roth JA, Komaki R, Gu J, Lee JJ, Hicks M, et al. Induction of p53-regulated genes and tumor 
regression in lung cancer patients after intratumoral delivery of adenoviral p53 (INGN 201) and radiation 
therapy. Clin Cancer Res Off J Am Assoc Cancer Res. 2003 Jan;9(1):93–101.  
34.  
Chiocca EA, Aguilar LK, Bell SD, Kaur B, Hardcastle J, Cavaliere R, et al. Phase IB study of gene-mediated 
cytotoxic immunotherapy adjuvant to up-front surgery and intensive timing radiation for malignant glioma. J 
Clin Oncol Off J Am Soc Clin Oncol. 2011 Sep 20;29(27):3611–9.  
35.  
Markert JM, Razdan SN, Kuo HC, Cantor A, Knoll A, Karrasch M, et al. A phase 1 trial of oncolytic HSV-1, G207, 
given in combination with radiation for recurrent GBM demonstrates safety and radiographic responses. Mol 
Ther. 2014 May;22(5):1048–55.  
36.  
Adusumilli PS, Stiles BM, Chan MK, Chou TC, Wong RJ, Rusch VW, et al. Radiation therapy potentiates effective 
oncolytic viral therapy in the treatment of lung cancer. Ann Thorac Surg. 2005 Aug;80(2):409-16-7.  
37.  
Kim SH, Wong RJ, Kooby DA, Carew JF, Adusumilli PS, Patel SG, et al. Combination of mutated herpes simplex 
virus type 1 (G207 virus) with radiation for the treatment of squamous cell carcinoma of the head and neck. Eur 
J Cancer. 2005 Jan;41(2):313–22.  
38.  
Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, et al. Preoperative versus Postoperative 
Chemoradiotherapy for Rectal Cancer. N Engl J Med. 2004 Oct 21;351(17):1731–40.  
39.  
Ansari N, Solomon MJ, Fisher RJ, Mackay J, Burmeister B, Ackland S, et al. Acute Adverse Events and 
Postoperative Complications in a Randomized Trial of Preoperative Short-course Radiotherapy Versus Long-
course Chemoradiotherapy for T3 Adenocarcinoma of the Rectum: Trans-Tasman Radiation Oncology Group 
Trial (TROG 01.04). Ann Surg. 2017 May;265(5):882–8.  
40.  
Rödel C, Graeven U, Fietkau R, Hohenberger W, Hothorn T, Arnold D, et al. Oxaliplatin added to fluorouracil-
based preoperative chemoradiotherapy and postoperative chemotherapy of locally advanced rectal cancer (the 
German CAO/ARO/AIO-04 study): final results of the multicentre, open-label, randomised, phase 3 trial. Lancet 
Oncol. 2015 Aug 1;16(8):979–89.  
41.  
Rectal Cancer: ESMO Clinical Practice Guidelines | ESMO [Internet]. [cited 2017 Aug 8]. Available from: 
http://www.esmo.org/Guidelines/Gastrointestinal-Cancers/Rectal-Cancer 
42.  
Wiley: TNM Classification of Malignant Tumours, 8th Edition - James D. Brierley, Mary K. Gospodarowicz, 
Christian Wittekind [Internet]. [cited 2017 Aug 8]. Available from: 
http://www.wiley.com/WileyCDA/WileyTitle/productCd-1119263573.html 
43.  
Patel UB, Brown G, Rutten H, West N, Sebag-Montefiore D, Glynne-Jones R, et al. Comparison of Magnetic 
Resonance Imaging and Histopathological Response to Chemoradiotherapy in Locally Advanced Rectal Cancer. 
Ann Surg Oncol. 2012 Sep 1;19(9):2842–52.  
44.  
Patel UB, Taylor F, Blomqvist L, George C, Evans H, Tekkis P, et al. Magnetic resonance imaging-detected tumor 
response for locally advanced rectal cancer predicts survival outcomes: MERCURY experience. J Clin Oncol Off J 
Am Soc Clin Oncol. 2011 Oct 1;29(28):3753–60.  
45.  
Thall Peter F., Cook John D. Dose‐Finding Based on Efficacy–Toxicity Trade‐Offs. Biometrics. 2004 Aug 
27;60(3):684–93.  
46.  
Brock K, Billingham L, Copland M, Siddique S, Sirovica M, Yap C. Implementing the EffTox dose-finding design in 
the Matchpoint trial. BMC Med Res Methodol. 2017 Jul 20;17:112.  
47.  
George TJ, Allegra CJ, Yothers G. Neoadjuvant Rectal (NAR) Score: a New Surrogate Endpoint in Rectal Cancer 
Clinical Trials. Curr Colorectal Cancer Rep. 2015;11(5):275–80.  


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APPENDIX 1: ECOG PERFORMANCE SCALE 
Activity Performance Description 
Score 
Fully active, able to carry out all on all pre-disease performance without restriction. 
0 
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or 
sedentary nature, e.g. light housework, office work. 
1 
Ambulatory and capable of all self-care, but unable to carry out any work activities.  Up and about 
more than 50% of waking hours.  
2 
Capable of only limited self-care.  Confined to bed or chair more than 50% of waking hours.  
3 
Completely disabled. Cannot carry out any self-care. Totally confined to bed or chair. 
4 


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APPENDIX 2: MRI ASSESSED TUMOUR REGRESSION GRADING (mrTRG) 
TRG score
mrTRG description
1
No/minimal fibrosis visible (tiny linear scar) and no tumour signal
2
Dense fibrotic scar (low signal intensity) but no macroscopic tumour signal (indicates no or 
microscopic tumour)
3
Fibrosis predominates but obvious measureable areas of tumour signal visible
4
Tumour signal predominates with little/minimal fibrosis
5
Tumour signal only: no fibrosis, includes progression of tumour
For the purposes of trial analysis and dose escalation, scores of 1 or 2 will be classified as responders and scores of 3, 
4 or 5 will be classified as non-responders.  


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APPENDIX 3: NEOADJUVANT RECTAL SCORE 
Where: 
cT is an element of the set {1, 2, 3, 4},  
pT is in {0, 1, 2, 3, 4},  
pN is in {0, 1, 2}.  
cT clinical tumour stage,  
pT pathologic tumour stage, 
pN pathologic nodal stage 
The neoadjuvant rectal score (47) outperforms pCR at predicting DFS and OS in clinical trials using neoadjuvant 
therapy for rectal cancer. It similarly performs well at predicting DFS and OS in trials using pre-op chemo and 
chemoradiotherapy (TNT). It is an NCI-approved short-term endpoint for phase II clinical trial performance.  The final 
score ranges from 0-100 where a higher score equates to a worse prognosis.  

SAP_001.pdf: 
______________________________________          
SAP Version No: 2.0 
 
OCTRU-OST-001_V3.0_16Feb2018 
Date: 04Jan2021 
 
Effective Date 23Feb2018 
SAP Author: Jane Holmes, Alexander Ooms 
Page 1 of 19 
 
 
 
 
Full title: A Phase 1 study of the safety, tolerability and biological effects of 
intravenous EnAdenotucirev, a novel oncolytic virus, in combination with 
chemoradiotherapy in locally advanced rectal cancer 
 
Statistical Analysis Plan 
Version 2.0 – 4th January 2021 
 
Based on Protocol version 3.0_11Aug2020 
Trial registration: 2017-003501-18 
 
Role 
Name 
Title   
Signature  
Date 
Author 
Jane Holmes 
Senior 
Medical 
Statistician 
 
04Jan2021 
Author 
Alexander Ooms 
Medical Statistician 
 
04Jan2021 
Chief Investigator 
Maria Hawkins 
Chief Investigator  
 
04Jan2021 
 
Oxford Clinical Trials Research Unit (OCTRU) 
Centre for Statistics in Medicine (CSM) 
 
                                 
                     
 
 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
Funded by Cancer Research UK (A24474) & PsiOxus Therapeutics Limited 
Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
______________________________________          
SAP Version No: 2.0 
 
OCTRU-OST-001_V3.0_16Feb2018 
Date: 04Jan2021 
 
Effective Date 23Feb2018 
SAP Author: Jane Holmes, Alexander Ooms 
Page 2 of 19 
 
 
CONTENTS 
 
INTRODUCTION ............................................................................................................................... 4 
1.1 
KEY PERSONNEL ...................................................................................................................................... 4 
1.2 
CHANGES FROM PREVIOUS VERSION OF SAP ............................................................................................... 5 
 
BACKGROUND AND OBJECTIVES ....................................................................................................... 6 
2.1 
BACKGROUND AND RATIONALE ................................................................................................................. 6 
2.2 
OBJECTIVES ........................................................................................................................................... 6 
 
STUDY METHODS ............................................................................................................................. 7 
3.1 
TRIAL DESIGN/FRAMEWORK ..................................................................................................................... 7 
3.2 
RANDOMISATION AND BLINDING ............................................................................................................... 8 
3.3 
SAMPLE SIZE .......................................................................................................................................... 8 
3.4 
STATISTICAL INTERIM ANALYSIS, DATA REVIEW AND STOPPING GUIDELINES ..................................................... 8 
3.5 
TIMING OF FINAL ANALYSIS ...................................................................................................................... 9 
3.6 
BLINDED ANALYSIS .................................................................................................................................. 9 
3.7 
STATISTICAL ANALYSIS OUTLINE ................................................................................................................ 9 
 
STATISTICAL PRINCIPLES................................................................................................................. 10 
4.1 
STATISTICAL SIGNIFICANCE AND MULTIPLE TESTING ................................................................................... 10 
4.2 
DEFINITION OF ANALYSIS POPULATIONS ................................................................................................... 10 
 
TRIAL POPULATION AND DESCRIPTIVE ANALYSES ........................................................................... 10 
5.1 
REPRESENTATIVENESS OF STUDY SAMPLE AND PATIENT THROUGHPUT .......................................................... 10 
5.2 
WITHDRAWAL FROM TREATMENT AND/OR FOLLOW-UP .............................................................................. 10 
5.3 
BASELINE COMPARABILITY OF RANDOMISED GROUPS ................................................................................. 10 
5.4 
UNBLINDING ........................................................................................................................................ 11 
5.5 
DESCRIPTION OF COMPLIANCE WITH INTERVENTION ................................................................................... 11 
5.6 
RELIABILITY .......................................................................................................................................... 11 
 
ANALYSIS ....................................................................................................................................... 11 
6.1 
OUTCOME DEFINITIONS ......................................................................................................................... 11 
6.2 
ANALYSIS METHODS ............................................................................................................................. 12 
6.2.1 
Primary analysis – optimal dose and frequency of enadenotucirev that can be administered with 
chemoradiation ......................................................................................................................................... 12 
6.2.2 
Secondary and tertiary analyses .................................................................................................. 14 
6.3 
MISSING DATA ..................................................................................................................................... 14 
6.4 
SENSITIVITY ANALYSIS ............................................................................................................................ 14 
6.5 
PRE-SPECIFIED SUBGROUP ANALYSIS ........................................................................................................ 14 
6.6 
SUPPLEMENTARY/ ADDITIONAL ANALYSES AND OUTCOMES ........................................................................ 14 
6.7 
HARMS ............................................................................................................................................... 14 
6.8 
HEALTH ECONOMICS AND COST EFFECTIVENESS (WHERE APPLICABLE) ........................................................... 14 
6.9 
META-ANALYSES (IF APPLICABLE) ............................................................................................................ 14 
 
VALIDATION OF THE PRIMARY ANALYSIS ........................................................................................ 14 
 
SPECIFICATION OF STATISTICAL PACKAGES ..................................................................................... 15 
 
REFERENCES .................................................................................................................................. 15 
APPENDIX: GLOSSARY OF ABBREVIATIONS ............................................................................................. 15 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
Funded by Cancer Research UK (A24474) & PsiOxus Therapeutics Limited 
Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
______________________________________          
SAP Version No: 2.0 
 
OCTRU-OST-001_V3.0_16Feb2018 
Date: 04Jan2021 
 
Effective Date 23Feb2018 
SAP Author: Jane Holmes, Alexander Ooms 
Page 3 of 19 
 
 
 APPENDIX 1 SIMULATION RESULTS AND DOSE DECISION TREE ........................................................ 16 
 APPENDIX 2 TEMPLATE FOR FIRST DOSE DECISION MEETING .......................................................... 16 
 APPENDIX 3 TEMPLATE TABLES AND FIGURES FOR FINAL STATISTICAL REPORT ............................... 16 
 APPENDIX 4 DEFINITION OF DLT ..................................................................................................... 17 
 APPENDIX 5 DEFINITION OF MRI TUMOUR REGRESSION GRADE...................................................... 19 
 
 
 
 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
Funded by Cancer Research UK (A24474) & PsiOxus Therapeutics Limited 
Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
______________________________________          
SAP Version No: 2.0 
 
OCTRU-OST-001_V3.0_16Feb2018 
Date: 04Jan2021 
 
Effective Date 23Feb2018 
SAP Author: Jane Holmes, Alexander Ooms 
Page 4 of 19 
 
 
 INTRODUCTION 
This document details the proposed data presentation and analysis for the main paper(s) and final study 
reports from the Cancer Research UK & PsiOxus Therapeutics Limited Multicentre of intravenous 
EnAdenotucirev in combination with chemoradiotherapy in the treatment of locally advanced rectal cancer 
(CEDAR).  The results reported in these papers should follow the strategy set out here.  Subsequent analyses 
of a more exploratory nature will not be bound by this strategy, though they are expected to follow the broad 
principles laid down here.  The principles are not intended to curtail exploratory analysis (for example, to 
decide cut-points for categorisation of continuous variables), nor to prohibit accepted practices (for example, 
data transformation prior to analysis), but they are intended to establish the rules that will be followed, as 
closely as possible, when analysing and reporting the trial.  
The analysis strategy will be available on request when the principal papers are submitted for publication in a 
journal.  Suggestions for subsequent analyses by journal editors or referees, will be considered carefully, and 
carried out as far as possible in line with the principles of this analysis strategy; if reported, the source of the 
suggestion will be acknowledged. 
Any deviations from the statistical analysis plan will be described and justified in the final report of the trial.  
The analysis should be carried out by an identified, appropriately qualified and experienced statistician, who 
should ensure the integrity of the data during their processing.  Examples of such procedures include quality 
control and evaluation procedures. 
1.1 
Key personnel 
Author(s) (Trial statistician(s)) 
Alexander Ooms, Medical Statistician 
Centre for Statistics in Medicine (CSM) 
University of Oxford 
Botnar Research Centre 
Windmill Road 
Oxford OX3 7LD  
Tel: 01865 223475 
 
Email: alexander.ooms@csm.ox.ac.uk 
 
Jane Holmes, Senior Medical Statistician 
Centre for Statistics in Medicine (CSM) 
University of Oxford 
Botnar Research Centre 
Windmill Road 
Oxford OX3 7LD  
Tel: 01865 2233452 
Email: jane.holmes@csm.ox.ac.uk 
 
 
Reviewers 
Steven Davis (Trial Manager) 
 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
Funded by Cancer Research UK (A24474) & PsiOxus Therapeutics Limited 
Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
______________________________________          
SAP Version No: 2.0 
 
OCTRU-OST-001_V3.0_16Feb2018 
Date: 04Jan2021 
 
Effective Date 23Feb2018 
SAP Author: Jane Holmes, Alexander Ooms 
Page 5 of 19 
 
 
Approver (Senior Statistician, Chief Investigator) 
Professor Maria  A. Hawkins 
Medical Physics and Biomedical Engineering 
Malet Place Engineering Building 
University College London 
Gower Street 
London, WC1E 6BT 
Email: m.hawkins@ucl.ac.uk 
 
Jane Holmes, Senior Medical Statistician 
 
1.2 
Changes from previous version of SAP 
A summary of key changes from earlier versions of SAP, with particular relevance to protocol changes that 
have an impact on the design, definition, sample size, data quality/collection and analysis of the outcomes will 
be provided. Include protocol version number and date. 
Version number 
Issue date 
Author of 
this issue 
Protocol Version & Issue 
date 
Significant 
changes 
from 
previous version together with 
reasons 
V1.0_20Jan2020 
Alexander 
Ooms, 
Jane 
Holmes 
Protocol_V2.0_20Nov2019 
Not applicable as this is the 1st issue 
V2.0_04Jan2021 
Alexander 
Ooms, 
Jane 
Holmes 
Protocol_V3.0_11Aug2020 
Updated to be in line with most 
recent protocol 
 
 
 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
Funded by Cancer Research UK (A24474) & PsiOxus Therapeutics Limited 
Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
______________________________________          
SAP Version No: 2.0 
 
OCTRU-OST-001_V3.0_16Feb2018 
Date: 04Jan2021 
 
Effective Date 23Feb2018 
SAP Author: Jane Holmes, Alexander Ooms 
Page 6 of 19 
 
 
 BACKGROUND AND OBJECTIVES 
2.1 
Background and rationale  
 
Full Title : 
A Phase 1 trial of the safety, tolerability and biological effects of intravenous 
enadenotucirev, a novel oncolytic virus, in combination with chemoradiotherapy 
in locally advanced rectal cancer 
Short Title: 
Chemoradiation with Enadenotucirev as a radiosensitiser in locally Advanced 
Rectal cancer 
Trial Acronym: 
CEDAR 
Clinical Phase: 
Phase 1 
Trial Design: 
Interventional 
 
Objectives 
Endpoints 
Primary Endpoint: 
Determine the optimal dose and 
frequency of enadenotucirev that can be 
administered with chemoradiation 
 
Dose limiting toxicities 
 
MRI tumour regression grade 
Secondary Endpoints: 
Ability 
to 
deliver 
enadenotucirev 
concurrently with chemoradiation 
Treatment 
tolerance 
measured 
by 
proportion of patients completing at 
least 80% of the prescribed capecitabine 
dose and at least 20 fractions of 
radiotherapy 
To measure local response rate to 
combined therapy 
 MRI tumour regression grade 
 Pathological complete response rate 
 Neoadjuvant rectal score 
Investigational 
Medicinal Product(s) 
Name of drug 
Formulation, 
dose, 
route 
of 
administration 
- 
Enadenotucirev  
 
 
 
 
 
 
 
- 
Capecitabine 
Solution, 
diluted 
and 
delivered 
intravenously 
There are 2 potential doses given 
over 4 different dosing levels:  
 
1 x 1012 vp (viral particles) 
 
3 x 1012 vp 
 
- Tablet, 900mg/m2, oral 
administration  
Other interventions: 
Neoadjuvant chemoradiotherapy 
 
Treatment Duration 
9 weeks 
 
Follow-up duration 
Trial follow-up visits continue until week 13.  Following this, patients will receive 
surgery and on-going follow up as standard of care. 
End of Trial 
Last Patient Last Visit (i.e. 4-6 weeks post-surgery visit)  
 
2.2 
Objectives 
 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
Funded by Cancer Research UK (A24474) & PsiOxus Therapeutics Limited 
Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
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Primary Objective 
Endpoints/ Outcome measures 
Time point(s) of evaluation of 
this end point  
 Determine the optimal dose 
and frequency of 
enadenotucirev that can be 
administered with 
chemoradiation 
 
Dose limiting toxicity 
 
MRI tumour regression grade 
 
From Day 1 to Week 13 
 
Week 13 
Secondary Objectives 
Endpoints 
 
 Ability to deliver 
enadenotucirev concurrently 
with chemoradiation 
 
Treatment tolerance measured by 
proportion of patients completing at least 
80% of the intended Capecitabine dose and 
at least 20 fractions of radiotherapy 
 Week 9 
 To measure local response 
rate to combined therapy 
compared to pre-treatment 
status 
 MRI tumour regression grade 
 Pathological complete response 
 Neoadjuvant Rectal (NAR) score 
 Week 13 
 Post resection 
 Post resection 
Tertiary/Exploratory 
Objectives 
Endpoints 
 
 To identify ‘proof of concept’ 
that enadenotucirev 
replicates in the tumour 
 IHC staining of hexon protein coat, viral gDNA 
and viral mRNA gene expression in tumour 
cells 
 
Archival tumour tissue 
 
Week 4 biopsy  
 
Resection sample  
 To analyse gene expression 
changes in rectal cancer in 
response to enadenotucirev 
 
Whole genome RNA expression via RNA 
sequencing/ Nanostring gene expression 
analysis 
 
Archival tumour tissue 
 
Week 4 biopsy  
 Resection sample 
 Analyse changes in circulating 
tumour DNA in response to 
chemoradiation and 
enadenotucirev 
 
ctDNA analysis exploring clearance of 
ctDNA and any/or emerging changes in 
persisting ctDNA 
 Baseline (Pre 1st loading 
dose) 
 Week 4 
 Week 13 
 4-6 weeks post-surgery 
 Assess the changes in 
microbiome taxa during 
therapy 
 
Extraction of DNA and 16S sequencing 
and meta-transcriptomics from faecal 
samples 
 Baseline (pre-enad) 
 End of week 1 / 2 
 End of week 4 
 End of week 7 
 Week 13 
 Analyse the immune 
microenvironment as 
evidenced by immune cell 
infiltrates 
 
Multiplex immunohistochemistry of 
immune cell markers 
 Archival tumour tissue 
 Week 4 biopsy 
 Resection sample 
Note: Objectives in grey are not described in this SAP and will not be undertaken by the trial statistician. 
 STUDY METHODS 
3.1 
Trial Design/framework 
Provide a brief description of trial design including type of trial (e.g. parallel group, multi-arm, cross-over, 
factorial), and brief description of the interventions.  
Describe the framework such as superiority, non-inferiority, equivalence including which comparisons will be 
presented on this basis. 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
Funded by Cancer Research UK (A24474) & PsiOxus Therapeutics Limited 
Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
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Effective Date 23Feb2018 
SAP Author: Jane Holmes, Alexander Ooms 
Page 8 of 19 
 
 
 
This is a dual-endpoint dose finding phase I trial. The trial will use a model-based approach using the toxicity 
and efficacy primary endpoints to recommend the treatment schedule for future patients, and to recommend 
the optimal dose at the trial’s conclusion. 
 
We are using both efficacy and toxicity endpoints because although toxicity is expected to increase with 
increasing dose, it is possible that the relationship between efficacy and dose may not be a monotonically 
increasing one. This means that the optimal dose may not be the maximum tolerated dose. However there 
will be no formal combination of the efficacy and toxicity data, both endpoints will contribute information 
independently to dose choice via dose escalation rules. 
 
3.2 
Randomisation and Blinding 
This is not a randomised trial. 
3.3 
Sample Size 
At most, 30 patients will be recruited. Simulations have been used to justify this sample size, results are given 
in Appendix 1. 
3.4 
Statistical Interim Analysis, Data Review and Stopping guidelines 
The TMG will meet as necessary to discuss toxicity data and to decide on dose escalation. The first interim 
analysis will occur after the first 2 patients have been followed for 13 weeks. Subsequently there will be an 
interim analysis each time a dose-escalation decision is required. The TMG will include Chief Investigator, Co-
Investigators, clinical Trial Manager, Trial Statistician and others as required. TMG membership and decision 
making procedures are documented in the TMG charter (V1.0, 26th November 2019) and is stored in the TMF. 
Dose-escalation decisions will be based on all currently available data and guided by the pre-specified model. 
Analysis will follow the methods for primary analysis and are described in Section 6.2.1 
The template for the first TMG dose decision report is given in Appendix 2. Changes may be made to this 
template as the trial progresses, but note that the original template will not be updated as it refers only to the 
first dose decision meeting. 
There is no independent Data and Safety Monitoring Committee (DSMC) for this trial. The Safety Review 
Committee (SRC) will be convened as required to review DLTs and dose escalation decisions, made by the 
TMG. In the event of the TMG being unable to conclude on a dose recommendation, the SRC will meet to 
decide. The SRC will consist of: 
 
1. Trial Statistician 
2. OCTO trial management representative 
3. Either: 
a. One Medical Oncologist and one Clinical Oncologist or 
b. Two Clinical Oncologists 
 
The SRC Charter document for this trial is stored in the TMF and will define the exact membership and who 
should be present for decisions to be made. Further internal or external experts may be consulted by the SRC, 
as necessary. Any PI can request an ad hoc SRC meeting at any time in order to facilitate the immediate 
communication of any emerging safety issues during the course of the trial. 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
Funded by Cancer Research UK (A24474) & PsiOxus Therapeutics Limited 
Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
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RIOC (Radiotherapy and Imaging Oversight Committee) will act as the TSC and convenes roughly every 6 
months. The role of RIOC is to provide oversight for the trial on behalf of the Sponsor and Funder(s) as 
described in the charter.  The RIOC will provide overall supervision of the safe and effective conduct of the 
trial. The RIOC will review trial progress against agreed milestones, adherence to protocol, and patient safety, 
and consider new information. The RIOC has responsibility for deciding if the trial needs to be stopped early 
on grounds of safety or efficacy.  
 
The trial may stop early for safety. In the event that all dose levels are toxic, the trial will stop before reaching 
the maximum number of patients. If P(risk of DLT > 0.35|dose = 1, current data) > 0.65 for the lowest dose 
level and at least three patients have complete data for the toxicity endpoint (a DLT or have completed the 
toxicity window) we will stop the trial. 
3.5 
Timing of Final Analysis 
 
Primary and secondary outcomes will be analysed after all patients have completed their end of treatment 
visit, usually at week 13. Analyses for all tertiary outcomes will be documented elsewhere and will not be 
undertaken by the trial statistician. 
 
3.6 
Blinded analysis 
This is not a blinded trial. 
 
3.7 
Statistical Analysis Outline 
For all analyses, patients will be included according to the treatment schedule to which they are assigned. All 
patients who receive at least one dose of enadenotucirev, regardless of how much treatment received and 
follow-up completed, will contribute to analysis. It is therefore important that every effort is made to 
encourage patients, including those patients who do not receive/complete their allocated treatment, to 
attend for follow-up clinic visits to avoid bias in the analysis of the results. 
 
All patients enrolled in the trial and who received at least one dose of enadenotucirev will be accounted for 
and included in the analyses. The number of patients who were not evaluable, who died or withdrew before 
treatment began will be recorded. 
 
Baseline characteristics will be summarised for all enrolled patients. Patients who died or withdrew before 
treatment started or do not complete the required safety observations will be described and evaluated 
separately. 
 
Evaluable for toxicity: All patients will be evaluable for toxicity from the time of their first treatment. 
 
The trial will use the model based design to propose treatment schedules and will be updated prior to each 
TMG meeting to recommend a treatment schedule for each patient recruited. 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
Funded by Cancer Research UK (A24474) & PsiOxus Therapeutics Limited 
Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
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SAP Version No: 2.0 
 
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Date: 04Jan2021 
 
Effective Date 23Feb2018 
SAP Author: Jane Holmes, Alexander Ooms 
Page 10 of 19 
 
 
 STATISTICAL PRINCIPLES 
4.1 
Statistical Significance and Multiple Testing 
There will be no statistical significance level defined for CEDAR as it is a dose-finding trial and schedule 
recommendations will be based on the posterior probabilities calculated by the dose-toxicity and dose-
response models using all available data at each time. 
4.2 
Definition of Analysis Populations  
Main: all patients who received at least one dose of enadenotucirev.   
Surgical: All patients who underwent surgery after treatment 
Sensitivity: Patients who received the full prescribed dose of enadenotucirev, i.e. did not miss any dose, or had 
a DLT. If a patient is still on treatment and has received their full prescribed dose of enadenotucirev so far, 
they will be included in this population. 
 
For dose-escalation decisions during the trial, the population analysed will be the main and sensitivity 
populations. However, for the efficacy endpoint, patients who have not reached this time point yet will not 
provide any information to the efficacy model. Patients who have reached the time point for this endpoint 
and did not have the evaluation, withdrew or died prior to evaluation will be treated as non-responders. 
 
 TRIAL POPULATION AND DESCRIPTIVE ANALYSES 
5.1 
Representativeness of Study Sample and Patient Throughput 
The flow of participants through each stage of the trial, including numbers of participants assigned to a 
schedule, receiving intended treatment, completing the study protocol, and analysed for the primary outcome 
is provided following CONSORT.  Protocol violations/deviations and information relating to the screening data 
including the number of ineligible patients entering the study, together with reasons will be reported. 
Information on number of participants screened, found to be ineligible (with reasons where available), refused 
to participate (with reasons where available) will also be included. 
A CONSORT diagram will be prepared, an example CONSORT diagram is given in Appendix 3. 
 
5.2 
Withdrawal from treatment and/or follow-up 
Withdrawals/loss to follow-up together with reasons will be reported by treatment schedule. 
 
5.3 
Baseline Characteristics 
Baseline characteristics, including important prognostic, demographic and clinical variables will be reported 
overall for the main population.   
Numbers (with percentages) for binary and categorical variables and means (and standard deviations), or 
medians (with lower and upper quartiles) for continuous variables will be presented. 
 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
Funded by Cancer Research UK (A24474) & PsiOxus Therapeutics Limited 
Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
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SAP Version No: 2.0 
 
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Effective Date 23Feb2018 
SAP Author: Jane Holmes, Alexander Ooms 
Page 11 of 19 
 
 
5.4 
Unblinding 
The trial is not blinded. 
 
5.5 
Description of Compliance with Intervention 
A summary of enadenotucirev received will be presented by assigned treatment schedule. Compliance to 
chemotherapy and radiotherapy is a secondary outcome and will be presented as described in Section 6.2. 
5.6 
Reliability 
The NAR score will be hand checked for 5 patients. 
 ANALYSIS 
6.1 
Outcome Definitions 
Primary outcome: 
 
Safety: Binary toxicity measure defined by the occurrence of a DLT or not. This is recorded during the 
13 weeks of follow-up after starting treatment. The definition of a DLT is given Appendix 4. 
 
Efficacy: MRI tumour regression grade. This is a 5 point scale that is coded as a binary variable, with 
scores of 1 or 2 defining a responder and scores of 3, 4 or 5 a non-responder. It is measured at 13 
weeks. Patients who did not have the evaluation, or who withdrew or died prior to evaluation will be 
treated as non-responders. During the trial, for dose-escalation decisions a patient who has not yet 
reached this time point will not be included in analysis at this decision point. See Appendix 5 for the 
definition of MRI tumour regression grade 
See Section 6.2.1 Primary analysis for definition of the optimal dose. 
For dose-escalation interim analyses the safety and efficacy data is taken from the patient status update 
CRF. For the final determination of the MTD at the end of the trial, the safety outcome will be taken from 
the BW135_DLT_Assssment and BW166_Adverse_Events CRFs and the efficacy outcome taken from the 
BW156_Week13_Pelvic_MRI CRF.  
Secondary outcomes: 
 
Treatment tolerance. This is the amount of capecitabine and radiotherapy received, coded as 
completing at least 80% of the intended capecitabine dose and at least 20 fractions of radiotherapy. 
Measured at week 9. Compliance is taken from the BW150_Capecitabine and BW145_Radiotherapy 
CRF. 
 
MRI tumour regression grade. See definition for primary outcome, but here it will not be 
dichotomised. MRI tumour regression grade is taken from the BW156_Week13_Pelvic_MRI CRF. 
 
Pathological complete response. This variable relates to the resected tumour so will only be observed 
for patients undergoing surgery. It is measured on a 4 point scale, with a score of 1 denoting 
pathological complete response, and scores 2:4 denoting no pathological complete response. 
Pathological complete response is taken from the BW156_Week13_Pelvic_MRI CRF. 
 
Neoadjuvant Rectal (NAR) score. This score ranges from 0-100 with a higher score equating to a worse 
prognosis. It is a derived outcome which components measured on the resected tumour and at initial 
tumour staging. Therefore, this will only be observed for patients undergoing surgery. It is defined as 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
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Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
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o 𝑁𝐴𝑅= 
[5𝑝𝑁−3(𝑐𝑇−𝑝𝑇)+12]2
9.61
, where 
o  cT  is clinical tumour stage and is an element of the set {1, 2, 3, 4} 
o pT is pathological tumour stage and takes a value in {0, 1, 2, 3, 4} 
o pN is pathological nodal stage is in {0, 1, 2} 
o pT and pN are taken from the BW160_Surgery_Details CRF and denoted ypT and ypN, cT is 
taken from the BW070_Screen_Pelvic_MRI CRF. 
Tertiary outcomes: 
 
IHC staining of hexon protein coat, viral gDNA and viral mRNA gene expression in tumour cells – not 
covered in this SAP as analysis is not carried out by the trial statistician 
 
Whole genome RNA expression via RNA sequencing/ Nanostring gene expression analysis – not 
covered in this SAP as analysis is not carried out by the trial statistician 
 
ctDNA analysis exploring clearance of ctDNA and any/or emerging changes in persisting ctDNA – not 
covered in this SAP as analysis is not carried out by the trial statistician 
 
Extraction of DNA and 16S sequencing and meta-transcriptomics from faecal samples – not covered 
in this SAP as analysis is not carried out by the trial statistician 
 
Multiplex immunohistochemistry of immune cell markers – not covered in this SAP as analysis is not 
carried out by the trial statistician 
 
6.2 
Analysis Methods 
6.2.1 Primary analysis – optimal dose and frequency of enadenotucirev that can be administered with 
chemoradiation 
The optimal dose and frequency of enadenotucirev will be estimated using toxicity and efficacy endpoints 
using the main population. The same analysis is used during dose escalation as well as for final analysis. 
 
Toxicity endpoint 
Toxicity data can be used continuously throughout the trial through the use of the TiTE-CRM. We will use a 2-
parameter logistic regression model to model the relationship between dose and toxicity. Data for patients 
who have completed the 13 week toxicity window or experienced a dose limiting toxicity will contribute full 
information to this model. Only partial information is known for patients who are currently on trial, within the 
toxicity window. This partial information contributes to the model, weighted proportionally to the observed 
portion of their toxicity time window and the proportion of treatment received, and treating them as not 
experiencing a dose limiting toxicity. The weight function is defined in the equation below as wj. 
 
There are 4 treatment schedules which are coded as i = (1, 2, 4, 6):4. Assuming dose 6 is the reference dose, 
d*, we have treated J patients with dose xj, j=1, … J, then we model the probability of a DLT occurring using 
the weighted likelihood given by 
𝐿(𝜃) = ∏[g (𝜃𝑥𝑗) ∗𝑤𝑗]
𝑦𝑗[1 −g (𝜃𝑥𝑗) ∗𝑤𝑗]
1−𝑦𝑗
𝐽
𝑗=1
 
where 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
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yj = 1 if a DLT occurred and 0 otherwise and 
g (𝜃𝑥𝑗)  = logit(𝜃𝑥𝑗) = log(α) + β log(𝑥𝑗/𝑑∗) 
𝑤𝑗= {
1 if 𝑦𝑗= 1
1
2(
𝑢𝑗
𝑇+
𝑣𝑗
𝐷𝑖
) if 𝑦𝑗=0 
𝑢𝑗=  time patient has been followed for, 𝑇 = total DLT window = 13 weeks 
𝑣𝑗= amount of dose recieved, 𝐷𝑖 = total dose for treatment schedule i 
 
We assume priors for  and  of  
log(α)  ~ Normal(log(0.3/0.7), var = 1.44) 
log(β)  ~ Normal(-0.1, var = 0.25) 
𝑐𝑜𝑟𝑟(𝛼, 𝛽) = 0 
We can then calculate the posterior probability of toxicity for each treatment schedule. 
 
See Neuenschwander, Branson and Gsponer (2008) and Cheung YK and Chappell R (2000) for descriptions of 
the model. 
 
Efficacy endpoint 
We will use a 3-parameter logistic regression model to model the relationship between dose and efficacy. 
Patients are assessed for the efficacy endpoint in week 13. Patients who have not reached this time point yet 
will not provide any information to this model. Patients who have reached the time point for this endpoint 
and did not have the evaluation, or who withdrew or died prior to evaluation will be treated as non-
responders. 
 
Let zj denote 1 if the patient responded and 0 otherwise. Then we assume 
 
 
 
 
𝑧𝑗|𝑥𝑗  ~ Bernoulli(∅𝑥𝑗) 
logit(∅𝑥𝑗)  ~ 𝛾1 + 𝛾2log(𝑥𝑗/𝑑∗) + 𝛾3[log(𝑥𝑗/𝑑∗)]2 
𝜋( 𝛾1, 𝛾2, 𝛾3) ~ 𝑀𝑉𝑁((
−0.5
0.5
0
) , (
7
0
0
0
7
0
0
0
4
)) 
 
We can then calculate the posterior probability of efficacy for each treatment schedule. 
 
Definition of MTD 
At each analysis the optimal dose is defined as the minimum of the doses recommended by the toxicity and 
efficacy models. Define: 
 
A target toxicity interval as (0.2, 0.35) 
 
A safety criterion such that a dose is considered safe to give if the posterior probability that the DLT 
rate is greater than 0.35 on the dose is less than 35%, i.e. P(risk of DLT > 0.35 | Dose, Data) < 0.35 
 
Then the dose that is recommended by the toxicity model is the dose with the highest posterior probability of 
DLT rate lying in the target toxicity interval among those doses that satisfy the safety criterion. The treatment 
schedule recommended by the efficacy model is the dose with the highest posterior mean probability of 
response. The optimal dose is then the minimum of these 2 doses. 
 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
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Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
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Dose-escalation rules 
The dose suggested for the next patient is the optimal dose as defined above. However, escalation to an 
untried dose is subject to no dose skipping, and is only permissible if at least 2 patients have been given the 
dose immediately below for at least 8 weeks. There is no restriction on de-escalation. 
 
6.2.2 Secondary and tertiary analyses 
There will be no formal analysis of the secondary or tertiary objectives. See template in appendix 3 for tables 
and figures that will be presented. 
 
6.3 
Missing Data  
Every effort will be made for complete collection and recording of data. To minimise missing data, a dedicated 
CRF has been designed which captures only that data required to for dose-escalation decisions. 
No data imputation is planned. 
6.4 
Sensitivity Analysis 
Sensitivity analyses will be carried out during the trial for dose-decision meetings and also for final analysis for 
estimating the optimal dose. In addition to repeating the analysis using the sensitivity population defined in 
Section 4.2, we will also repeat the analysis using different weight functions. Therefore the 2 sensitivity 
analyses are: 
1) Sensitivity population and analysis using weights according to length of follow-up only, i.e. not taking 
into account how much dose has been received 
2) Main population but with the most toxic scenario, i.e. we assume that all patients currently in follow-
up within the DLT Window of 13 weeks have a DLT 
 
6.5 
Pre-specified Subgroup Analysis 
No subgroup analyses are planned. 
6.6 
Supplementary/ Additional Analyses and Outcomes 
There are no supplementary or additional analyses planned. 
6.7 
Harms  
This analysis will be based on the main population and will be presented as given in Appendix 2. 
6.8 
Health Economics and Cost Effectiveness (where applicable) 
There is no health economics and cost effectiveness analysis.  
6.9 
Meta-analyses (if applicable) 
No meta-analysis is planned. 
 VALIDATION OF THE PRIMARY ANALYSIS 
Before the trial starts, code for generating dose decisions will be validated by creating 2 large datasets, one 
for efficacy and one for toxicity, and comparing results from analysis using standard logistic regression with 
the trial code. Although results will not be identical due to the differences between frequentist and Bayesian 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
Funded by Cancer Research UK (A24474) & PsiOxus Therapeutics Limited 
Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
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analyses, with fairly vague priors and a large dataset parameter estimates should be similar. Validation will be 
stored in the statistical eTMF. 
 SPECIFICATION OF STATISTICAL PACKAGES 
All analysis will be carried out using appropriate validated statistical software such as STATA, SAS, SPLUS or R. 
The relevant package and version number will be recorded in the Statistical report. 
 
 REFERENCES 
 
Neuenschwander, Branson and Gsponer (2008). Critical aspects of the Bayesian approach to phase I cancer 
trials. Stats in Med, 27:2420-2439 for details of the toxicity model. 
 
Cheung YK, Chappell R. Sequential designs for phase I clinical trials with late-onset toxicities. Biometrics. 
2000;56:1177–82. 
 
Gamble C, Krishan A, Stocken D, Lewis S, Juszczak E, Dore C, Williamson PR, Altman DG, Montgomery A, Lim 
P. Berlin K, Senn S, Day S, Barbachano Y, Loder E. Guidelines for the Content of Statistical Analysis Plans in 
Clinical Trials. JAMA. 2017 Dec 19;318(23):2337-2343. doi: 10.1001/jama.2017.18556. 
 
APPENDIX: GLOSSARY OF ABBREVIATIONS  
SAP 
 
Statistical Analysis Plan 
DSMC  
Data and Safety Monitoring Committee  
TSC 
 
Trial Steering Committee 
CI 
 
Chief Investigator 
CRF 
 
Case Report Form 
 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
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APPENDIX 1 SIMULATION RESULTS AND DOSE DECISION TREE 
This is a separate document which is signed by the trial statistician, senior statistician and CI 
 
 
APPENDIX 2 TEMPLATE FOR FIRST DOSE DECISION MEETING 
This is a separate document which is signed by the trial statistician, senior statistician and CI 
 
 
APPENDIX 3 TEMPLATE TABLES AND FIGURES FOR FINAL STATISTICAL REPORT 
This is a separate document which is signed by the trial statistician, senior statistician and CI 
 
 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
Funded by Cancer Research UK (A24474) & PsiOxus Therapeutics Limited 
Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
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APPENDIX 4 DEFINITION OF DLT 
Definition of DLT as given in Protocol V3.0, 11th August 2019 
 
All patients who have received at least one dose of enadenotucirev will be evaluable for DLTs.  
DLTs are defined as any of the following occurring between the start of trial treatment until the Week 13 visit  
and by the principal investigator (PI) assessed as possibly, probably or definitely related to enadenotucirev or 
the interaction between enadenotucirev and radiotherapy and/or capecitabine. Patients who experience a 
DLT will receive no further trial treatment.  
Dose limiting toxicities must be reported within 24 hours of the site becoming aware using the SAE form and 
scan and email as a PDF attachment to octo-safety@oncology.ox.ac.uk and send an email notification to octo-
CEDAR@oncology.ox.ac.uk. 
 
DLTs will be defined as per NCI CTCAE v4.03, except for proteinuria, and include: 
 
Renal: 
o Development of proteinuria, 2+ as measured by urinalysis and confirmed with an albumin/creatinine 
ratio of >3g/mmol, following administration of enadenotucirev, shall be classified as a DLT. No further 
doses of enadenotucirev will be administered to that patient.  
 
Acute hematologic toxicity:  
o 
Infection (documented clinically or microbiologically) with grade 3 or 4 neutropenia (absolute neutrophil count 
(ANC) <1.0 x 109/L) 
o 
Neutropenia grade 4 (ANC < 0.5 x 109/L) lasting for > 6 days 
o 
Febrile neutropenia grade 4 (fever of unknown origin without clinically or microbiologically documented infection) 
(ANC <1.0 x 109/L, fever >38.5oC) 
o 
Thrombocytopenia grade 3 (Platelet count < 50 x 109/L) in the presence of bleeding or requiring platelet 
transfusion 
o 
Thrombocytopenia grade ≥ 4 (Platelet count < 25 x 109/L) 
o 
Anemia grade 3 in the presence of blood transfusion dependency as judged by the PI 
o 
Anemia grade ≥ 4 
o 
Clinically significant bleeding attributed to grade 3 thrombocytopenia or requiring platelet transfusion or other 
grade ≥3 clotting disorder or occurring concurrently with Grade 2 or 3 aPTT prolongation, unless there is a clear 
explanation for the event, such as tumour-related bleeding in the presence of Lupus Anticoagulant. 
o 
Any other grade ≥3 non-hematological toxicity with the exception of: activated partial thromboplastin time (aPTT) 
prolongation 
o 
Clotting event (i.e. deep vein thrombosis [DVT], pulmonary embolism [PE]) occurring concurrently with Grade 2 or 
3 aPTT prolongation 
 
Acute non-hematologic toxicity: 
o 
Any documented ≥ grade 4 non-hematologic toxicity in the presence of maximal support/active management 
o 
Grade ≥3 cystitis or radiation dermatitis onset within 2 weeks of starting radiotherapy or lasting more than 2 weeks 
after the end of radiotherapy. 
o 
Grade ≥3 proctitis or diarrhea onset within 2 weeks of starting radiotherapy 
o 
Grade ≥3 nausea or vomiting not controlled by optimal outpatient anti-emetic treatment 
o 
Grade ≥3 diarrhea despite optimal outpatient anti-diarrheal medication use 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
Funded by Cancer Research UK (A24474) & PsiOxus Therapeutics Limited 
Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
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o 
Grade ≥3 hematuria or neuropathic pain 
o 
Other grade 3 ≥ effects thought to be due to the combination of enadenotucirev with radiotherapy 
o 
Missing 2 consecutive doses of enadenotucirev due to toxicity 
o 
An elevation of ALT or AST >5 x ULN lasting 8 days or more 
o 
A concurrent elevation of ALT or AST >3 × ULN and total bilirubin >2 × ULN in whom there is no evidence of biliary 
obstruction or other causes that can reasonably explain the concurrent elevation 
o 
Death due to drug related complications 
o 
Grade ≥3 cytokine release syndrome 
 
General: 
o 
Discontinuation of the active treatment due to toxicity definitely attributable to enadenotucirev, irrespective of the 
grade of toxicity 
o 
Missing 3 consecutive fractions of radiotherapy, related to enadenotucirev, as judged by the PI 
o 
Any toxicity causing a delay of radiotherapy completion by greater than one week 
This is not an exhaustive list. All suspected DLTs should be discussed with the Chief Investigator and the Trial 
Management Group. 
 
 


 
Chemoradiation with EnaDenotucirev as a radiosensitiser in locally Advanced Rectal cancer 
Funded by Cancer Research UK (A24474) & PsiOxus Therapeutics Limited 
Registry number: 2017-003501-18 (EudraCT), Protocol Number: OCTO_081 
 
 
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SAP Version No: 2.0 
 
OCTRU-OST-001_V3.0_16Feb2018 
Date: 04Jan2021 
 
Effective Date 23Feb2018 
SAP Author: Jane Holmes, Alexander Ooms 
Page 19 of 19 
 
 
 
APPENDIX 5 DEFINITION OF MRI TUMOUR REGRESSION GRADE 
Definition as given in Protocol V3.0, 11th August 2020 
 
TRG score 
mrTRG description 
1 
No/minimal fibrosis visible (tiny linear scar) and no tumour signal 
2 
Dense fibrotic scar (low signal intensity) but no macroscopic tumour signal (indicates no or 
microscopic tumour) 
3 
Fibrosis predominates but obvious measureable areas of tumour signal visible 
4 
Tumour signal predominates with little/minimal fibrosis 
5 
Tumour signal only: no fibrosis, includes progression of tumour 
 
For the purposes of trial analysis and dose escalation, scores of 1 or 2 will be classified as responders and 
scores of 3, 4 or 5 will be classified as non-responders.