Patent Publication Number: US-2016231315-A1

Title: Factors

Description:
FIELD OF THE INVENTION 
     The present invention relates to a method of cancer therapy which employs a factor or a set of factors to predict whether a patient will benefit from treatment with an immunotherapeutic agent. 
     In particular, the method predicts the clinical benefit to a potential patient of an MVA vector expressing a human 5T4 gene, such as Trovax®. More particularly, the method relates to those patients with renal, colorectal or prostate cancer. 
     BACKGROUND TO THE INVENTION 
     Tumor cells are notoriously poor immunogens despite the fact that many antigens that are over-expressed or unique to tumor cells (tumor-associated antigens) have been identified. The reasons for this apparent lack of immunogenicity may be that cancer antigens are generally not presented to the immune system in a micro-environment that favors the activation of immune cells which would lead to the killing of the tumor cells. Although no single known mechanism can explain poor tumor immunogenicity in all experimental models studied, the molecular basis can be separated conceptually into distinct groupings: i) lack of expression of co-stimulatory molecules essential for effective immune induction, ii) production, of immuno-inhibitory substances and iii) variability in the expression of antigen by tumors. 
     Much progress has been made in the identification of tumor-associated antigens (TAA) that are potentially useful in the development of recombinant anti-cancer vaccines. TAAs can be divided into three major categories: i) non-self viral antigens e.g. E6/E7 from human papilloma virus (HPV), ii) altered self-antigens e.g. MUC-1 and iii) non-mutated self-antigens e.g. 5T4 and carcinoembryonic antigen (CEA). 
     Vaccinia virus (VV), a member of the poxvirus family, has been developed as a recombinant expression vector for the genetic delivery of antigens. Animals injected with a recombinant VV (rVV) have been shown to produce both antibody and CTL responses to the exogenous proteins. In contrast to tumor cells VV infection appears to create an optimal environment for the induction of an efficacious immune response. Recombinant VV expressing murine homologues of TAA, which, in murine models, are classed as self-antigens, have also been shown to induce TAA specific immune responses in murine models, illustrating that such constructs are potentially able to overcome immune tolerance to self-antigens. In vivo models demonstrate that the immune responses generated are able to prevent tumor establishment and in some cases are able to actively treat established tumors. These data also indicate that it is possible to turn an anti-viral response into an anti-cancer response by presenting a TAA in the context of viral antigens. 
     Recombinant W vectors expressing the self-antigen CEA have been constructed and have been evaluated for toxicity and to a lesser extent efficacy in late stage colorectal cancer. Such rVV vectors were well tolerated and both antibody and cell mediated immune responses to the self-antigen CEA were reported. Lack of tumor response data in these trials may be due to the patient population which had very advanced tumors and had already failed prior chemotherapy. To date over 700 people have been vaccinated with rVV and other poxviruses expressing TAAs in a spectrum of cancer immunotherapy clinical trials. There have been no reports of toxicity either from the virus itself or as a result of the immune response induced to the TAA beyond local injection site reactions and transient pyrexia. 
     Suitable methods and suitable clinical markers, however, that can guide such immunotherapeutic methods would be extremely beneficial. 
     Renal cell carcinoma (RCC) has been reported to be the tenth most common cancer in the US and studies suggest a continued rise in RCC incidence. Although most patients with early stage RCC can be cured surgically, approximately 33% of patients present with metastatic disease for which the treatment is usually not curative. In addition, approximately 50% of patients who undergo potentially curative surgery for less advanced disease can be expected to develop a recurrence with distant metastases. Five-year survival for patients with de novo metastatic or recurrent disease ranges between 0% and 20%. 
     Clinical factors associated with patients with metastatic RCC when they are treated with cytokines (interferon, and interleukin), chemotherapy or a variety of historic therapies have been reported to include tumour-, patient-, and disease-related factors, such as performance status (PS), time from diagnosis to therapy, number of metastatic sites, visceral metastasis, haemoglobin, calcium, lactate dehydrogenase, inflammation markers, and others. 
     Choueriri et al, Cancer (2007), 110(3): 543-550 reviewed the records of patients with metastatic renal cell carcinoma (RCC) who were treated with anti-VEGF agents—bevacizumab, sunitinib, sorafenib and axitinib—with a view to identifying patients who are more likely to benefit from these agents. The article reports that although many factors were associated individually with progression-free survival (PFS) on univariate analysis, only 5 factors were identified as independent predictors of a poor outcome on subsequent multivariate analysis. With the least favourable feature listed first, the following factors were identified: initial Eastern Cooperative Oncology Group performance status (ECOG PS)≧1 vs 0, time from diagnosis to current treatment &lt;2 years vs ≧2 years, abnormal baseline corrected serum calcium &lt;8.5 mg/dL or &gt;10 mg/dL vs 8.5-10 mg/dL, high platelet count &gt;300 K/μL vs≦300 K/μL, and higher absolute neutrophil count (ANC)&gt;4.5 K/μL vs ≦4.5 K/μL. 
     Choueriri et al however only teaches that these factors were associated with PFS for patients with metastatic RCC who received four specific VEGF-targeted therapies. It does not teach a skilled worker what factors may or may not be important for other therapies and other cancers. It is unclear whether the same factors reported previously are relevant to patients who are treated with, for example, immunotherapies. 
     Colorectal carcinoma (CRC) is one of the most common cancers in Western societies, being second only to lung cancer as a cause of death from malignancy. It is the second most common cancer in England and Wales. Approximately 24,000 men and women develop the disease each year, and over half of these die from it. 
     Fusek et al, World J Gastroenterol (2004), 10(13): 1890-1892 aimed to examine the calcium metabolism in patients with CRC and control patients. Seventy newly diagnosed CRC patients were included. The healthy control group was age and gender matched. They conclude that their results further strengthen the possibility that serum calcium might be a pathogenic and prognostic factor in the development of CRC. They say that their data draw attention to the possibility that by increasing calcium intake, the multi-levelled pathogenic process leading to tumorigenesis might be influenced. They go on to state that in order to prove this, further studies are necessary. 
     Fusek et al, however, does not indicate whether or not serum calcium might be a pathogenic and prognostic factor for any of the drug therapies used to treat CRC and other cancers. 
     Thus, there remains a need for suitable methods and suitable clinical markers that can guide immunotherapeutic methods. 
     SUMMARY 
     The invention provides materials and methods that address one or more needs in the fields of cancer therapy, immunotherapy, or related fields. 
     Some aspects of the invention relate to materials and methods for monitoring or determining the efficacy of an immunotherapy. Improved monitoring permits improvement of therapy for individual subjects; and more rapid determination of which subjects benefit from the therapy. Subjects obtaining less benefit can more quickly be given modified or different therapeutic regimens. 
     STATEMENTS OF THE INVENTION 
     Baseline Platelet Counts 
     We have identified that immunotherapy performs better in cancer patients with a lower baseline platelet count. 
     Thus, in one aspect the invention provides a method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring a level of platelets in a sample from the cancer patient, and (b) comparing the level of platelets in the sample to a reference level of platelets, wherein a lower level of platelets in the sample correlates with increased benefit to the patient. 
     By “lower level” we include patients who have a level or count of baseline platelets below the median for a patient in need of immunotherapy or below or towards the bottom end of normal levels. 
     A further method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involves (a) measuring a level of platelets in a sample from the cancer patient, and (b) classifying the patient as belonging to either a first or second group of patients, wherein the first group of patients having low levels of platelets is classified as having an increased likelihood of benefit than the second group of patients having high levels of platelets. 
     The invention also provides a method for monitoring the effectiveness of a course of treatment for a patient with cancer. The method involves (a) determining a level of platelets in a sample from the cancer patient prior to immunotherapy treatment, and (b) determining the level of platelets in a sample from the patient after treatment, whereby comparison of the platelet level prior to treatment with the platelet level after treatment indicates the effectiveness of the treatment. 
     By “receiving immunotherapy” we also include patients who are being assessed for immunotherapy. 
     In other words the present invention provides a method of predicting the responsiveness of a patient or patient population with cancer to treatment with immunotherapy, or for selecting patients or patient populations that may respond to immunotherapy, comprising comparing the differential levels of platelets wherein a platelet level below a reference level is associated with benefit. 
     By “lower level” we include a patient or patient population who have a level of platelets either below a reference level for a patient or patient population who have been diagnosed with cancer and are therefore in need of treatment, such as immunotherapy; or below a reference level for a normal individual or population. By “reference level” we include a level which represents a level below which the administration of immunotherapy will confer a clinical benefit to the patient or patient population, such as improved overall survival, increased progression-free survival, decreased risk of tumour recurrence or spread. 
     In one embodiment the lower level will include a patient or patient population who have a level of platelets below the median for a patient or patient population who have been diagnosed with cancer and are therefore in need of treatment, such as immunotherapy, it will also include a patient or patient population who have a level of platelets which is below the median for a normal individual or patient population. 
     In one embodiment, the platelet level or count associated with a more favourable outcome is about ≦400×10 9 /L, about ≦350×10 9 /L, or about ≦300×10 9 /L. More particularly, the platelet level associated with a more favourable outcome is about ≦287×10 9 /L. In a preferred embodiment the baseline platelet count is about ≦281×10 9 /L, ≦281.5×10 9 /L, about ≦275.5×10 9 /L, about ≦273×10 9 /L, about ≦250×10 9 /L, ≦232×10 9 /L, about ≦225×10 9 /L, or about ≦215×10 9 /L. Especially preferred are platelet levels of ≦287×10 9 /L, ≦281×10 9 /L, or even more preferred ≦232×10 9 /L. These levels may be particularly associated with patients with RCC or CRC. 
     In one embodiment, the platelet level associated with a more favourable outcome in RCC is about ≦400×10 9 /L, about ≦350×10 9 /L, or about ≦300×10 9 /L. More particularly, the platelet level associated with a more favourable outcome in RCC is about ≦287×10 9 /L. In a preferred embodiment the baseline platelet count in RCC is about ≦281×10 9 /L, ≦281.5×10 9 /L, about ≦275.5×10 9 /L, about ≦273×10 9 /L, about ≦250×10 9 /L, ≦232×10 9 /L, about ≦225×10 9 /L, or about ≦215×10 9 /L. Especially preferred are platelet levels associated with RCC of ≦287×10 9 /L, ≦281×10 9 /L, or even more preferred ≦232×10 9 /L. 
     The above referenced platelet levels are reported in connection with a patient population diagnosed with RCC in which the platelet levels ranged from 114 to 1074×10 9 /L and the median platelet level is 281×10 9 /L; an RCC patient population and a CRC patient population in which the median platelet levels were 273×10 9 /L, but the levels or their equivalents in relation to other patient populations may be generally applicable to the field of immunotherapy. 
     A normal platelet count in a healthy person (1+ year) is between 130,000 and 400,000 per mm 3  (microlitre) of blood (130-400×10 9 /L). 
     Haemoglobin Levels 
     We have identified that immunotherapy performs better in cancer patients with a higher baseline haemoglobin level. 
     Thus, in one aspect the invention provides a method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring a level of haemoglobin in a sample from the cancer patient, and (b) comparing the level of haemoglobin in the sample to a reference level of haemoglobin, wherein a higher level of haemoglobin in the sample correlates with increased benefit to the patient. 
     By “higher level” we include patients who have a level of baseline haemoglobin above the median for a patient in need of immunotherapy or above or towards the upper end of normal levels. 
     A further method for determining a prognosis for survival for a cancer patient receiving immunotherapy treatment involves (a) measuring a level of haemoglobin in a sample from the cancer patient, and (b) classifying the patient as belonging to either a first or second group of patients, wherein the first group of patients having high levels of haemoglobin is classified as having an increased likelihood of survival than the second group of patients having low levels of haemoglobin. 
     The invention also provides a method for monitoring the effectiveness of a course of treatment for a patient with cancer. The method involves (a) determining a level of a haemoglobin in a sample from the cancer patient prior to immunotherapy treatment, and (b) determining the level of haemoglobin in a sample from the patient after treatment, whereby comparison of the haemoglobin level prior to treatment with the haemoglobin level after treatment indicates the effectiveness of the treatment. 
     By “receiving immunotherapy” we also include patients who are being assessed for immunotherapy, i.e. patients who could potentially benefit from treatment for cancer. 
     In other words the present invention provides a method of predicting the responsiveness of a patient or patient population with cancer to treatment with immunotherapy, or for selecting patients or patient populations that may respond to immunotherapy comprising comparing the differential levels of haemoglobin wherein a haemoglobin level above a reference level is associated with benefit. 
     By “higher level” we include a patient or patient population who have a level of haemoglobin above a reference level for a patient or patient population who have been diagnosed with cancer and are therefore in need of treatment, such as immunotherapy; or above a reference level for a normal individual or population. By “reference level” we include a level which represents a level above which the administration of immunotherapy will confer a clinical benefit to the patient or patient population, such as improved overall survival, increased progression-free survival, decreased risk of tumour recurrence or spread. 
     In one embodiment the higher level will include a patient or patient population who have a level of haemoglobin above the median for a patient or patient population who have been diagnosed with cancer and are therefore in need of treatment, such as immunotherapy; or above the median for a normal individual or patient population. 
     In one embodiment, the haemoglobin level associated with a more favourable outcome is about a ≧100 g/L, or more preferably about a ≧125 g/L, or even more preferably about a ≧130 μmol/L or about a ≧132 g/L. In one even more preferred embodiment, the haemoglobin level associated with a more favourable outcome is greater than about a ≧140 g/L or about a ≧145 g/L. In an especially preferred embodiment, the haemoglobin level associated with a more favourable outcome is about a ≧153 g/L. These levels may be particularly associated with patients with RCC or CRC. 
     In one embodiment, the haemoglobin level associated with a more favourable outcome in RCC is about a ≧100 g/L, or more preferably about a ≧125 g/L, or even more preferably about ≧130 μmol/L or about a ≧132 g/L. In one even more preferred embodiment, the haemoglobin level associated with a more favourable outcome in RCC is greater than about a ≧140 g/L or about a ≧145 g/L. In an especially preferred embodiment, the haemoglobin level associated with a more favourable outcome in RCC is about a ≧153 g/L. These haemoglobin levels are reported in connection with an RCC patient population in which the haemoglobin levels ranged from 65-190 g/L and a median haemoglobin level of ≧132 g/L, but the levels or their equivalents may be generally applicable in relation to other patient populations to the field of immunotherapy. 
     The haemoglobin level in a normal population has been reported as being in the range of 118-168 g/L. Haemoglobin levels have however been reported to vary according to gender and age. Thus, the reference range of 118-168 g/L has been reported as being the normal range for males of 65+ years. For males of 18-64 years the haemoglobin level in a normal population has been reported as being in the range of 138-172 g/L. For females of 18-64 years the haemoglobin level in a normal population has been reported as being in the range of 120-156 g/L. For females of 65+ years the haemoglobin level in a normal population has been reported as being in the range of 111-155 g/L. 
     Monocyte Levels 
     We have identified that immunotherapy performs better in cancer patients with a lower baseline monocyte level. 
     Thus, in one aspect the invention provides a method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring a level of monocytes in a sample from the cancer patient, and (b) comparing the level of monocytes in the sample to a reference level of monocytes, wherein a lower level of monocytes in the sample correlates with increased benefit to the patient. 
     By “lower level” we include patients who have a level of baseline monocytes below the median for a patient in need of immunotherapy or below or towards the lower end of normal levels. 
     A further method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involves (a) measuring a level of monocytes in a sample from the cancer patient, and (b) classifying the patient as belonging to either a first or second group of patients, wherein the first group of patients having low levels of monocytes is classified as having an increased likelihood of benefit than the second group of patients having high levels of monocytes. 
     The invention also provides a method for monitoring the effectiveness of a course of treatment for a patient with cancer. The method involves (a) determining a level of monocytes in a sample from the cancer patient prior to immunotherapy treatment, and (b) determining the level of monocytes in a sample from the patient after treatment, whereby comparison of the monocyte level prior to treatment with the monocyte level after treatment indicates the effectiveness of the treatment. 
     By “receiving immunotherapy” we also include patients who are being assessed for immunotherapy, i.e. patients who could potentially benefit from treatment for cancer. 
     In other words the present invention provides a method of predicting the responsiveness of a patient or patient population with cancer to treatment with immunotherapy, or for selecting patients or patient populations that may respond to immunotherapy, comprising comparing the differential levels of monocytes wherein a monocyte level below a reference level is associated with benefit. 
     By “lower level” we include a patient or patient population who have a level of monocytes either below a reference level for a patient or patient population who have been diagnosed with cancer and are therefore in need of treatment, such as immunotherapy, or below a reference level for a normal individual or population. By “reference level” we include a level which represents a level below which the administration of immunotherapy will confer a clinical benefit to the patient or patient population, such as improved overall survival, increased progression-free survival, decreased risk of tumour recurrence or spread. 
     In one embodiment the lower level will include a patient or patient population who have a level of monocytes below the median for a patient or patient population who have been diagnosed with cancer and are therefore in need of treatment, such as immunotherapy; it will also include a patient or patient population who have a level of monocytes which is below the median for a normal individual or patient population. 
     In one embodiment, the monocyte level associated with a more favourable outcome is about ≦1.10×10 9 /L or about ≦1.0×10 9 /L, or more preferably about ≦0.80×10 9 /L, about ≦0.60×10 9 /L, or about ≦0.40×10 9 /L. Even more particularly, the monocyte level associated with a more favourable outcome is about ≦0.20×10 9 /L. These levels may be particularly associated with patients with RCC. 
     Reference ranges for monocytes in a normal patient population have been reported as 0.20-1.10 GI/L (0.20-1.10×10 9 /L) (1+ years) absolute [monocytes % 0.0-12.0 (18+ years)]. 
     White Blood Cell (WBC) Levels 
     We have identified that immunotherapy performs better in cancer patients with a lower baseline white blood cell (WBC) level or count. 
     Thus, in one aspect the invention provides a method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring a level of WBCs in a sample from the cancer patient, and (b) comparing the level of WBCs in the sample to a reference level of WBCs, wherein a lower level of WBCs in the sample correlates with increased benefit to the patient. 
     By “lower level” we include patients who have a level of baseline WBCs below the median for a patient in need of immunotherapy or below or towards the bottom end of normal levels. 
     A further method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involves (a) measuring a level of WBCs in a sample from the cancer patient, and (b) classifying the patient as belonging to either a first or second group of patients, wherein the first group of patients having low levels of WBCs is classified as having an increased likelihood of benefit than the second group of patients having high levels of WBCs. 
     The invention also provides a method for monitoring the effectiveness of a course of treatment for a patient with cancer. The method involves (a) determining a level of WBCs in a sample from the cancer patient prior to immunotherapy treatment, and (b) determining the level of WBCs in a sample from the patient after treatment, whereby comparison of the WBC level prior to treatment with the WBC level after treatment indicates the effectiveness of the treatment. 
     By “receiving immunotherapy” we also include patients who are being assessed for immunotherapy, i.e. patients who could potentially benefit from treatment for cancer. 
     In other words the present invention provides a method of predicting the responsiveness of a patient or patient population with cancer to treatment with immunotherapy, or for selecting patients or patient populations that may respond to immunotherapy, comprising comparing the differential levels of WBCs wherein a WBC level below a reference level is associated with benefit. 
     By “lower level” we include a patient or patient population who have a level of WBCs either below a reference level for a patient or patient population who have been diagnosed with cancer and are therefore in need of treatment, such as immunotherapy, or below a reference level for a normal individual or population. By “reference level” we include a level which represents a level below which the administration of immunotherapy will confer a clinical benefit to the patient or patient population, such as overall survival, increased progression-free survival, decreased risk of tumour recurrence or spread. 
     In one embodiment the lower level will include a patient or patient population who have a level of WBCs below the median for a patient or patient population who have been diagnosed with cancer and are therefore in need of treatment, such as immunotherapy; it will also include a patient or patient population who have a level of WBCs which is below the median for a normal individual or patient population. 
     In one embodiment, the WBC level associated with a more favourable outcome is about ≦10.8 GI/L, about ≦10.4 GI/L, about ≦10.0 GI/L, about ≦9.6 GI/L, about ≦9.2 GI/L, about ≦8.8 GI/L, about ≦8.4 GI/L, about ≦8.0 GI/L, about ≦7.6 GI/L, about ≦7.2 GI/L, about ≦6.8 GI/L, about ≦6.4 GI/L, about ≦5.0 GI/L, about ≦4.6 GI/L, about ≦4.2 GI/L, about ≦3.8 GI/L, about ≦3.4 GI/L, about ≦3.0 GI/L, about ≦2.6 GI/L, about ≦2.2 GI/L, about ≦1.8 GI/L, about ≦1.4 GI/L, about ≦1.0 GI/L, or about ≦0.8 GI/L In other embodiments the WBC level is about ≦3.0 GI/L or about ≦1.1 GI/L. In another embodiment, the WBC levels is about ≦5.0 GI/L, about ≦5.9 GI/L, about ≦7.2 GI/L, about ≦8.6 GI/L or about ≦10.4 GI/L. These levels may be particularly associated with patients with RCC. 
     These WBC levels are reported in connection with an RCC patient population, but the levels or their equivalents in relation to other patient populations may be generally applicable to the field of immunotherapy. 
     Reference ranges for WBCs in a normal patient population have been reported as 0.8-10.8 GI/L (18+ years). 
     Combinations 
     We have found that if a patient has two or more of the afore-mentioned favourable factors or biomarkers then the beneficial effect to the patient of immunotherapy is greater than if the patient only has one of the favourable factors. 
     Thus, the present invention provides a further method for determining a prognosis for benefit for a cancer patient receiving immunotherapy involving (a) measuring levels of one or more, and preferably two or more of the following biomarkers: monocytes, platelets, haemoglobin and WBCs, and (b) comparing the level of the one or more selected biomarkers in the sample to a reference level of the one or more selected biomarkers, wherein a low level of monocytes, WBCs and/or platelets and a high level of any of haemoglobin (as appropriate), in said sample correlates with increased benefit to said patient. 
     In a particularly preferred embodiment we have found that platelet, monocyte and haemoglobin levels impact the efficacy of treatment versus placebo. In particular, abnormal haematological levels, and particularly platelet, monocyte and haemoglobin levels are associated with reduced efficacy of treatment. In other words there is a survival advantage to treatment in patients with normal haematological levels. 
     We have found that in addition, to afore-mentioned factors or biomarkers, immunotherapy may form perform differently in cancer patients with additional baseline characteristics. The factors which may be beneficial to cancer treatment can be summarised as follows: 
     
       
         
           
               
               
               
             
               
                   
                   
               
               
                   
                 High Levels 
                 Low Levels 
               
               
                   
                   
               
             
            
               
                   
                 Chloride 
                 Basophils 
               
               
                   
                 Creatinine 
                 Corrected Calcium 
               
               
                   
                 Eosinophils 
                 Serum Calcium 
               
               
                   
                 Haematocrit 
                 Monocytes 
               
               
                   
                 Haemoglobin 
                 Neutrophils 
               
               
                   
                 Sodium 
                 Platelets 
               
               
                   
                   
                 White blood cells 
               
               
                   
                   
                 (WBCs) 
               
               
                   
                   
               
            
           
         
       
     
     Thus, another method for determining a prognosis for benefit for a cancer patient receiving immunotherapy involving (a) measuring levels of platelets, haemoglobin, monocytes and/or WBCs and one or more biomarkers selected from the group consisting of: corrected calcium, creatinine, chloride, eosinophils, haematocrit, sodium, basophils, serum calcium, and neutrophils and (b) comparing the level of platelets, haemoglobin, monocytes and/or WBCs and the one or more selected biomarkers in the sample to a reference level of platelets, haemoglobin, monocytes and/or WBCs and the one or more selected biomarkers, wherein a low level of platelets, monocytes and/or WBCs, a high level of haemoglobin, and a high level of any of creatnine, chloride, eosinophils, haematocrit, sodium and/or a low level of any corrected calcium, basophils, serum calcium, and neutrophils in said sample correlates with increased benefit to said patient. 
     In particular in relation to corrected calcium we have found the following levels to be indicative of an effect: 
     Corrected Calcium Levels 
     We have identified that immunotherapy performs better in cancer patients with a lower baseline corrected calcium level. 
     Thus, in one aspect the invention provides a method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring a level of corrected calcium in a sample from the cancer patient, and (b) comparing the level of corrected calcium in the sample to a reference level of corrected calcium, wherein a lower level of corrected calcium in the sample correlates with increased benefit to the patient. 
     By “lower level” we include patients who have a level of baseline corrected calcium below the median for a patient in need of immunotherapy. 
     A further method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involves (a) measuring a level of corrected calcium in a sample from the cancer patient, and (b) classifying the patient as belonging to either a first or second group of patients, wherein the first group of patients having low levels of corrected calcium is classified as having an increased likelihood of benefit than the second group of patients having high levels of corrected calcium. 
     The invention also provides a method for monitoring the effectiveness of a course of treatment for a patient with cancer. The method involves (a) determining a level of a corrected calcium in a sample from the cancer patient prior to immunotherapy treatment, and (b) determining the level of corrected calcium in a sample from the patient after treatment, whereby comparison of the corrected calcium level prior to treatment with the corrected calcium level after treatment indicates the effectiveness of the treatment. 
     By “receiving immunotherapy” we also include patients who are being assessed for immunotherapy, i.e. patients who could potentially benefit from treatment for cancer. 
     In other words the present invention provides a method of predicting the responsiveness of a patient or patient population with cancer to treatment with immunotherapy, or for selecting patients or patient populations that may respond to immunotherapy, comprising comparing the differential levels of corrected calcium wherein a corrected calcium level below a reference level is associated with benefit. 
     By “lower level” we include a patient or patient population who have a level of corrected calcium either below a reference level for a patient or patient population who have been diagnosed with cancer and are therefore in need of treatment, such as immunotherapy, or below a reference level for a normal individual or population. By “reference level” we include a level which represents a level below which the administration of immunotherapy will confer a clinical benefit to the patient or patient population, such as improved overall survival, increased progression-free survival, decreased risk of tumour recurrence or spread. 
     In one embodiment the lower level will include a patient or patient population who have a level of corrected calcium below the median for a patient or patient population who have been diagnosed with cancer and are therefore in need of treatment, such as immunotherapy; it will also include a patient or patient population who have a level of corrected calcium which is below the median for a normal individual or patient population. 
     In one embodiment, the corrected calcium level associated with a more favourable outcome is about ≦12.0 mg/dL or about ≦11.0 mg/dL, or more preferably about ≦10.0 mg/dL, about ≦9.6 mg/dL, or about ≦9.4 mg/dL. Even more particularly, the corrected calcium level associated with a more favourable outcome is about ≦9.3 mg/dL. In other embodiments the corrected calcium level is about ≦9.2 mg/dL, about ≦9.1 mg/dL, about ≦9.0 mg/dL, about ≦8.8 mg/dL, about ≦8.7 mg/dL or about ≦8.6 mg/dL. Especially preferred are corrected calcium levels of about ≦9.3 mg/dL, about ≦9.2 mg/dL or about ≦9.1 mg/dL. These levels may be particularly associated with patients with RCC or CRC. 
     More particularly, in one embodiment, the corrected calcium level associated with a more favourable outcome in RCC is about ≦12.0 mg/dL or about ≦11.0 mg/dL, or more preferably about ≦10.0 mg/dL about ≦9.6 mg/dL, or about ≦9.4 mg/dL. Even more particularly, the corrected calcium level associated with a more favourable outcome in RCC is about ≦9.3 mg/dL. In other embodiments the corrected calcium level associated with RCC is about ≦9.2 mg/dL, about ≦9.1 mg/dL, about ≦9.0 mg/dL, about ≦8.8 mg/dL, about ≦8.7 mg/dL or about ≦8.6 mg/dL. Especially preferred are corrected calcium levels associated with RCC of about ≦9.3 mg/dL, about ≦9.2 mg/dL or about ≦9.1 mg/dL. These corrected calcium levels are reported in connection with an RCC patient population in which the corrected calcium levels ranged from 6.8 to 15.4 mg/dL and a median corrected calcium level of 9.3 mg/dL, but the levels or their equivalents in relation to other patient populations may be generally applicable to the field of immunotherapy. 
     In normal populations the serum level of calcium is closely regulated with a normal total calcium of 2.2-2.6 mmol/L (9-10.5 mg/dL) and a normal ionized calcium of 1.1-1.4 mmol/L (4.5-5.6 mg/dL). 
     The amount of total calcium varies with the level of serum albumin, a protein to which calcium is bound. The biologic effect of calcium is determined by the amount of ionized calcium, rather than the total calcium. Ionized calcium does not vary with the albumin level, and therefore it is useful to measure the ionized calcium level when the serum albumin is not within normal ranges, or when a calcium disorder is suspected despite a normal total calcium level. 
     One can derive a corrected calcium level when the albumin is abnormal. This is to correct for the change in total calcium due to the change in albumin-bound calcium, and gives an estimate of what the calcium level would be if the albumin were within normal ranges. 
       Corrected calcium (mg/dL)=measured total Ca (mg/dL)+0.8(4.0−serum albumin [g/dL]), where 4.0 represents the average albumin level.
 
     When there is hypoalbuminemia (a lower than normal albumin), the corrected calcium level is higher than the total calcium. 
     Reference ranges for corrected calcium in a normal patient population have been reported as 2.12-2.56 mmol/L (3+ years) [8.48-10.24 mg/dL]. 
     In respect of creatinine we have found the following levels to be associated with an effect: 
     Creatinine Levels 
     We have identified that immunotherapy performs better in cancer patients with a higher baseline creatinine level. 
     Thus, in one aspect the invention provides a method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring a level of creatinine in a sample from the cancer patient, and (b) comparing the level of creatinine in the sample to a reference level of creatinine, wherein a higher level of creatinine in the sample correlates with increased benefit to the patient. 
     By “higher level” we include patients who have a level of baseline creatinine above the median for a patient in need of immunotherapy. 
     A further method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involves (a) measuring a level of creatinine in a sample from the cancer patient, and (b) classifying the patient as belonging to either a first or second group of patients, wherein the first group of patients having high levels of creatinine is classified as having an increased likelihood of benefit than the second group of patients having low levels of creatinine. 
     The invention also provides a method for monitoring the effectiveness of a course of treatment for a patient with cancer. The method involves (a) determining a level of a creatinine in a sample from the cancer patient prior to immunotherapy treatment, and (b) determining the level of creatinine in a sample from the patient after treatment, whereby comparison of the creatinine level prior to treatment with the creatinine level after treatment indicates the effectiveness of the treatment. 
     By “receiving immunotherapy” we also include patients who are being assessed for immunotherapy, i.e. patients who could potentially benefit from treatment for cancer. 
     In other words the present invention provides a method of predicting the responsiveness of a patient or patient population with cancer to treatment with immunotherapy, or for selecting patients or patient populations that may respond to immunotherapy comprising comparing the differential levels of creatinine wherein a creatinine level above a reference level is associated with benefit. 
     By “higher level” we include a patient or patient population who have a level of creatinine either above a reference level for a patient or patient population who have been diagnosed with cancer and are therefore in need of treatment, such as immunotherapy; or above a reference level for a normal individual or population. By “reference level” we include a level which represents a level above which the administration of immunotherapy will confer a clinical benefit to the patient or patient population such as overall survival, increased progression-free survival decreased risk of tumour recurrence or spread. 
     In one embodiment the higher level will include a patient or patient population who have a level of creatinine above the median for a patient or patient population who have been diagnosed with cancer and are therefore in need of treatment, such as immunotherapy; or it will also include a patient or patient population who have a level of creatinine which is above the median for a normal individual or patient population. 
     In one embodiment, the creatinine level associated with a more favourable outcome is about ≧100 μmol/L, or about ≧110 μmol, more preferably about ≧120 μmol/L. In one even more preferred embodiment, the creatinine level associated with a more favourable outcome is greater than about the normal level in a population. The normal range of creatinine level in a normal population has been reported as about 44 to 124 μmol/L. Thus in one even more preferred embodiment the creatinine level is about 124 μmol/L. In a particularly, preferred embodiment, the creatinine level associated with a more favourable outcome is about ≧130 μmol/L, or about ≧135 μmol/L. In an especially preferred embodiment, the creatinine level associated with a more favourable outcome is about ≧145 μmol/L. These levels may be particularly associated with patients with RCC or CRC. 
     In one embodiment, the creatinine level associated with a more favourable outcome in RCC is about ≧100 μmol/L, or about ≧110 μmol, more preferably about ≧120 μmol/L. In one even more preferred embodiment, the creatinine level associated with a more favourable outcome in RCC is greater than about the normal level in a population. The normal range of creatinine level in a normal population has been reported as about 44 to 124 μmol/L. Thus in one even more preferred embodiment the creatinine level in RCC is about ≧124 μmol/L. In a particularly, preferred embodiment, the creatinine level associated with a more favourable outcome in RCC is about ≧130 μmol/L, or about ≧135 μmol/L. In an especially preferred embodiment, the creatinine level associated with a more favourable outcome in RCC is about ≧145 μmol/L. These creatinine levels are reported in connection with an RCC patient population in which the creatinine levels ranged from 58-268 μmol/L and a median creatinine level of 111 μmol/L, but the levels or their equivalents in other patient populations may be generally applicable to the field of immunotherapy. 
     Eosinophil Levels 
     In relation to eosinophils, the eosinophil level (ABS) in a normal patient population has been reported as 0.05-0.55 GI/L (0+ years), and also as 0.0-7.0% (18+ years), and references to a high or higher amount can be determined accordingly and with reference to the afore-mentioned definitions. 
     Haematocrit Levels 
     In relation to haematocrit, the haematocrit levels in a normal patient population has been reported (given as a percentage of 1.0) as 0.410-0.500 (males 18-64 years), 0.360-0.490 (males 65+ years), 0.350-0.460 (females 18-64 years), and 0.330-0.460 (65+ years), and references to a high or higher amount can be determined accordingly and with reference to the afore-mentioned definitions. In one embodiment for a male (18-64 years) the level should be ≧0.201 and ≦0.599. 
     Sodium Levels 
     In relation to sodium, the sodium levels in a normal patient population has been reported as 136 to 145 milliequivalents per liter (mEq/L) of blood. References to a high or higher amount can be determined accordingly and with reference to the afore-mentioned definitions. 
     Basophil Levels 
     In relation to basophils, the basophil level (ABS) in a normal patient population has been reported as 0.00-0.20 GI/L (1+ years), and also as 0.0-2.0% (0+ years), and references to a low or lower amount can be determined accordingly and with reference to the afore-mentioned definitions. 
     Neutrophil Levels 
     The primary criterion for classification of neutrophils as either segmented (mature) or non-segmented (younger stages including band neutrophils, metamyelocytes, and myelocytes) is the shape of the nucleus. In relation to neutrophils, the neutrophil level (Segmented) in a normal patient population has been reported as 40.0-75.0% (18+ years), and (ABS) as 1.80-8.00 GI/L (1+ years). The neutrophil level (Bands) in a normal patient population has been reported as 0.0-8.0% (18+ years), and (ABS) as 0.00-0.86 GI/L (18+ years). The neutrophil level (total) in a normal patient population has been reported as 40.0-75.0% (18+ years), and (ABS) as 1.80-8.00 GI/L (1+ years). References to a low or lower amount can be determined accordingly and with reference to the afore-mentioned definitions. 
     In addition to the foregoing, the invention includes, as an additional aspect, all embodiments of the invention narrower in scope in any way than the variations specifically mentioned above. For example, although aspects of the invention may have been described by reference to a genus or a range of values for brevity, it should be understood that each member of the genus and each value or sub-range within the range is intended as an aspect of the invention. Likewise, various aspects and features of the invention can be combined, creating additional aspects which are intended to be within the scope of the invention. Although the applicant(s) invented the full scope of the claims appended hereto, the claims appended hereto are not intended to encompass within their scope the prior art work of others. Therefore, in the event that statutory prior art within the scope of a claim is brought to the attention of the applicants by a Patent Office or other entity or individual, the applicant(s) reserve the right to exercise amendment rights under applicable patent laws to redefine the subject matter of such a claim to specifically exclude such statutory prior art or obvious variations of statutory prior art from the scope of such a claim. Variations of the invention defined by such amended claims also are intended as aspects of the invention. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1 : Shows the effect of baseline corrected calcium on patient survival in a renal cancer (TRIST) study, and in particular the survival of TRIST patients stratified by above median vs below median baseline corrected calcium. 
         FIG. 2 : Shows the effect of baseline corrected calcium on patient survival in a renal cancer (TRIST) study, and in particular the survival of TRIST patients over a range of different corrected calcium levels. 
         FIG. 3 : Shows the effect of baseline corrected calcium on patient survival in a renal cancer (TRIST) study, and in particular the survival of TRIST patients over a range of different corrected calcium levels. 
         FIG. 4 : Shows the effect of baseline platelets on patient survival in a renal cancer (TRIST) study, and in particular the survival of TRIST patients stratified by above median vs below median baseline platelets. 
         FIG. 5 : Shows the effect of baseline platelets on patient survival in a renal cancer (TRIST) study, and in particular the survival of TRIST patients over a range of different platelet levels. 
         FIG. 6 : Shows the effect of baseline haemoglobin on patient survival in a renal cancer (TRIST) study, and in particular the survival of TRIST patients over a range of different haemoglobin levels. 
         FIG. 7 : Shows the effect of baseline creatinine on patient survival in a renal cancer (TRIST) study, and in particular the survival of TRIST patients over a range of different creatinine levels. 
         FIG. 8 : Shows the effect of particular baseline corrected calcium, creatinine, haemoglobin and platelets on patient survival in a renal cancer (TRIST) study. 
         FIG. 9 : Shows the effect of zero baseline inclusion factors vs one or more than one of the inclusion factors: corrected calcium, creatinine, haemoglobin and platelets on patient survival in a renal cancer (TRIST) study. 
         FIG. 10 : Shows the effect of particular baseline corrected calcium, creatinine, haemoglobin and platelets on patient survival in a renal cancer (TRIST) study, and in particular the more preferred baseline variables. 
         FIG. 11 : Shows the effect of baseline platelets on patient survival in four colorectal cancer studies, and in particular the survival of CRC patients stratified by above median vs below median baseline platelets. 
         FIG. 12 : Shows the effect of baseline platelets on patient survival in four colorectal cancer studies, and in particular the survival of CRC patients stratified by above vs below a preferred baseline platelet level. 
         FIG. 13 : Shows the effect of baseline platelets on patient survival in four colorectal cancer and two renal cancer studies, and in particular the survival of the patients stratified by above median vs below median baseline platelets. 
         FIG. 14 : Shows the effect of baseline platelets on patient survival in renal cancer studies at a later stage than in  FIG. 13 , and in particular the survival of the patients stratified by above normal, normal vs below normal baseline platelets. 
         FIG. 15 : Shows the effect of baseline haemoglobin on patient survival in four colorectal cancer studies, and in particular the survival of CRC patients stratified by above median vs below median baseline haemoglobin levels. 
         FIG. 16 : Shows the effect of baseline creatinine on patient survival in four colorectal cancer studies, and in particular the survival of CRC patients stratified by above median vs below median baseline creatinine levels. 
         FIG. 17 : Shows the effect of baseline monocytes on patient survival in renal cancer studies, and in particular the survival of the patients stratified by above normal, normal vs below normal baseline platelets. 
         FIG. 18 : Shows the effect of normal haematology on patient survival in renal cancer studies, and in particular the survival of the patients with normal haematology in terms of normal baseline levels of monocytes, platelets and haemoglobin associated with survival benefit trend. 
         FIG. 19 : Shows adjusted Hazard ratio (±95% CI) plotted as a function of the baseline platelet concentration. Baseline platelet levels have been segregated into percentiles and the respective platelet levels noted (×10 9 /L). The number of patients falling into each category is noted along the x axis with the number of events in parentheses. 
         FIG. 20 : Shows adjusted Hazard ratio plotted as a function of the baseline monocyte concentration. Baseline monocyte levels have been segregated into percentiles and the respective monocyte levels noted (×10 9 /L). The number of patients falling into each category is noted on the x axis along with the number of events in parentheses. 
         FIG. 21 : Shows adjusted Hazard ratio plotted as a function of the baseline white blood cell (WBC) concentration. Baseline WBC levels have been segregated into percentiles (bottom 10 th , 25 th  and 50 th  percentile and top 50 th , 25 th  and 10 th  percentile) and the respective WBC levels noted. The number of patients falling into each category is noted on the x axis along with the number of events in parentheses. 
         FIG. 22 : Shows adjusted Hazard ratio plotted as a function of the baseline haemoglobin concentration. Baseline haemoglobin levels have been segregated into percentiles (bottom 10 th , 25 th  and 50 th  percentile and top 50 th , 25 th  and 10 th  percentile) and the respective haemoglobin levels noted (g/dL). The number of patients falling into each category is noted on the x axis along with the number of events in parentheses. 
     
    
    
     DETAILED DESCRIPTION 
     Immunotherapy 
     It is contemplated that the methods of the invention are suitable and applicable for all viral vectors and non-viral vectors adaptable for delivery of an exogenous gene to a mammalian cell for expression of the gene in the cell. A variety of viral vectors may be employed as disclosed herein. In some preferred aspects, viral vectors are replication deficient. Furthermore, as detailed above, a viral vector may preferably comprise poxvirus such as a vaccinia viral vector. A variety of vaccinia viral vectors are known in the art in certain aspects a vaccinia viral vector for use herein may be a modified vaccinia Ankara (MVA) virus. Other exemplary immunotherapies include compositions that include the protein antigen itself; or fragments or epitopes of the antigen; or vectors for delivering a transgene that encodes the antigen (e.g., plasmid or liposomal vectors). 
     In other aspects the immunotherapy may comprise a viral vector which can be either the same as the original vector or a different viral vector such as a heterologous prime-boost vaccination regimen. 
     In some aspects immunotherapeutic methods concern a maintenance immunotherapy that does not comprise the viral vector. For instance, the maintenance immunotherapy comprises a composition comprising the antigen, or at least one epitope thereof, and an adjuvant or carrier. For example, a maintenance immunotherapy may comprise a plasmid that contains a nucleotide sequence that encodes the antigen, operably linked to an expression control sequence to permit expression of the antigen in cells of the mammalian subject. Such a method may, optionally, further comprise (d) immunizing the subject having a measurable immune response to the antigen with a maintenance immunotherapy that is free from the viral vector. Exemplary maintenance immunotherapies include compositions that include the protein antigen itself; or fragments or epitopes of the antigen; or vectors for delivering a transgene that encodes the antigen (e.g., plasmid or liposomal vectors). 
     In other aspects the maintenance immunotherapy may comprise a viral vector which can be either the same as the original vector or a different viral vector such as a heterologous prime-boost vaccination regimen. 
     Likewise, methods disclosed herein are applicable to immunotherapy utilizing a variety of antigens. In certain aspects, an antigen as defined herein comprises at least one tumor antigen such as the tumor antigens listed in the detailed description below. For example, the tumor antigen may comprise a 5T4 antigen. 5T4 antigen and viral vectors comprising 5T4 have been previously described for examples in U.S. Pat. No. 7,148,035, incorporated herein by reference. 
     In one embodiment the invention is intended to be applicable to immunotherapies directed against malignancies. Thus, in some variations, the mammalian subject for immunotherapy is a subject having a cancer such as a cancer that expresses a least one tumor antigen (tumor associated antigen). Preferably, a subject having cancer comprises a cancer which expresses the same antigen that is comprised in the viral vector used for immunotherapy. In some cases a subject comprising a cancer may be a subject with a renal cell or a colorectal cancer. Preferably a mammalian subject is a human subject. 
     In addition to the immunotherapy methods described herein subjects may further be treated with one or more additional therapies such as a therapy considered the standard of care for a particular disease such as cancer. For example, the additional therapy or standard of care therapy may be chemotherapy, radiation therapy, surgery or cytokine therapy. 
     Generally, an immunotherapy for use herein will be formulated in a pharmaceutically acceptable carrier, and may additionally comprise preservatives, salts and/or adjuvants. 
     I. Tumor-associated antigens (TAAs) 
     In certain aspects the application concerns a tumor associated antigen. A suitable tumor associated antigen (TAA) or tumor antigens includes 5T4. As used herein the terms tumor associated antigen and tumor antigen are used interchangeably. Other suitable antigens include TAAs in the following classes: cancer testis antigens (e.g., HOM-MEL-40), differentiation antigens (e.g., HOM-MEL-55), overexpressed gene products (HOM-MD-21), mutated gene products (NY-COL-2), splice variants (HOM-MD-397), gene amplification products (HOM-NSCLC-11) and cancer related autoantigens (HOM-MEL-2.4) as reviewed in Cancer Vaccines and Immunotherapy (2000) Eds Stern, Beverley and Carroll, Cambridge University Press, Cambridge. Further examples include, MART-1 (Melanoma Antigen Recognized by T-cells-1) MAGE-A (MAGE-A1, MAGE-A2, MAGE-A3, MAGE-A4, MAGE-A6, MAGE-A8, MAGE-A10, MAGE-A12), MAGE B (MAGE-B1-MAGE-B24), MAGE-C(MAGE-C1/CT7, CT10), GAGE (GAGE-1, GAGE-8, PAGE-1, PAGE-4, XAGE-1, XAGE-3), LAGE (LAGE-1a(1S), -1b(1L), NY-ESO-1), SSX (SSX1-SSX-5), BAGE, SCP-1, PRAME (MAPE), SART-1, SART-3, CTpl 1, TSP50, CT9/BRDT, gp100, MART-1, TRP-1, TRP-2, MELAN-A/MART-1, Carcinoembryonic antigen (CEA), prostate-specific antigen (PSA), MUCIN (MUC-1) and Tyrosinase. TAAs are reviewed in Cancer Immunology (2001) Kluwer Academic Publishers, The Netherlands. Additional tumor associated antigens include Her 2, survivin and TERT. 
     The term “antigen” refers to protein or peptide to be introduced into a subject. As described herein, an antigen may be provided through delivering a peptide or protein or through delivering a nucleic acid encoding a peptide or protein. 
     By “antigen” in the context of the present invention it is also meant to incorporate an antigenic peptide derived from an antigen. In particular, “tumor associated antigen” is intended to encompass a peptide derived from a tumor associated antigen. 
     An antigen such as a tumor associated antigen can be provided for use as a medicament in a number of different ways. It can be administered as part of a viral vector. A number of suitable viral vectors will be familiar to those skilled in the art and include a number of vectors described herein. 
     II. TroVax® Vaccine 
     TroVax® consists of a highly attenuated strain of vaccinia virus (W), termed Modified Vaccinia Ankara, (MVA), and contains the human TAA 5T4 glycoprotein gene under regulatory control of a modified promoter, mH5. Thus, by “TroVax®” we include Modified Vaccinia Ankara, (MVA), that contains the human TAA 5T4 glycoprotein gene, and preferably under regulatory control of a modified promoter, mH5 
     MVA was developed as a safe vaccine for smallpox and MVA was derived from the W Ankara strain by passaging in primary chick embryo fibroblasts (CEF), after which it was found to be replication defective in all mammalian cell lines tested, except Baby Hamster Kidney cells (BHK-21). Molecular genetic analysis of MVA has revealed substantial differences from the replication competent vaccinia virus which indicate that reversion of attenuation is highly unlikely. MVA is non-pathogenic in mammals including suckling mice, rabbits and primates. Importantly, no complications were reported when MVA was administered to over 120,000 subjects, many of whom were at risk from vaccine complications. Replication of competent strains of W are handled in a Biosafety level II environment; however, MVA has been assigned Biosafety level I status by the National Institutes of Health Intramural Biosafety Committee in the US, the UK Health and Safety Executive and the biosafety authorities in Germany. 
     5T4 is a 72 kDa oncofoetal glycoprotein that is expressed on over 70% of carcinomas of the kidney, breast, gastrointestinal tract, colon and ovaries. Unlike other self-antigen TAAs such as CEA, 5T4 expression as detected by histochemical staining appears to be tumor specific with only low level sporadic staining observed in the gut and pituitary. However this level of staining is so low that it is difficult to determine if it is specific. 5T4-positive tumors include invasive carcinoma of the Ampulla of Vater, breast, colon, endometrium, pancreas, or stomach; a squamous carcinoma of the bladder, cervix, lung or oesophagus; a tubulovillous adenoma of the colon; a malignant mixed Mullerian tumour of the endometirem; a clear cell carcinoma of the kidney; a lung cancer (large cell undifferentiated, giant cell carcinoma, broncho-alveolar carcinoma, metastatic leiomyosarcoma); an ovarian cancer (a Brenner tumour, cystadenocarcinoma, solid teratoma); a cancer of the testis (seminoma, mature cystic teratoma); a soft tissue fibrosarcoma; a teratoma (anaplastic germ cell tumours); or a trophoblast cancer (choriocarcimoma (e.g. in uterus, lung or brain), tumour of placental site, hydatidiform mole). Immunohistochemical analysis indicates that 5T4 expression is an indicator of poor prognosis in colorectal cancer. Additionally, when tumor cells are transfected with the cDNA encoding 5T4, they display increased motility suggesting that expression of this molecule may induce metastatic properties in a tumor. 
     TroVax® is able to induce an anti-5T4 antibody response in mice. Additionally, such a response is able to prevent the establishment of syngeneic tumor cells expressing human 5T4 in two murine tumor models. To model more accurately the possible anti-tumor effects of TroVax® in humans, MVA recombinants were constructed expressing the murine homologue of 5T4 (m5T4). In this self-antigen model MVA-m5T4 induction of an m5T4 antibody response was observed. Furthermore such a response is able to retard or prevent the establishment of syngeneic tumor cells expressing m5T4. Mice have been vaccinated on four occasions with MVA-m5T4 and there have been no reports of toxicity. In addition a number of studies have explored the toxicological consequences of immunization with TroVax®. Mice have been immunized with up to 12 repeated administrations of TroVax®. There were no TroVax® related deaths or adverse effects on clinical signs, body weight, food consumption, organ weights or clinical pathology. There were no macroscopic or microscopic findings suggestive of systemic toxicity due to the test articles. 
     Because 5T4 is an oncofoetal antigen, mice, previously vaccinated with MVA-m5T4, were used for breeding. It was found that immunity to m5T4 did not have a detrimental effect on the ability of mice to become pregnant or give birth to healthy progeny. In a more detailed study, female mice were administered with approx 107 pfu of TroVax® or MVA-m5T4 or placebo at 21 and 14 days prior to pairing with untreated males and, for the pregnant females, on Day 6 of gestation. The pregnant females were maintained to Day 18 of gestation then the injected animals and their respective foetuses analysed macroscopically at necropsy. All clinical observations and necropsy findings were unremarkable. The pregnancy rate was slightly lower in the groups given both TroVax® and MVA-m5T4 compared to control. The toxicological significance of this finding is uncertain but may reflect a treatment impact on mating behavior. There was no adverse effect of treatment with either TroVax® or MVA-m5T4 on the uterine/implantation or foetal data. In summary, there was no female or maternal toxicity and no embryo-foetal toxicity in either group. Histological examination of the tissues from the MVA-m5T4 animals revealed no adverse microscopic findings. 
     It is apparent from pre-clinical studies that TroVax® has little potential to induce toxicity but is likely to induce an efficacious immune response to 5T4. In vivo studies suggest that such an immune response will have anti-tumor activity. 
     TroVax® has been administered to over 400 patients with metastatic colorectal or renal cancer. Over 3000 doses have been administered. No serious adverse event attributed to TroVax® by investigators or the sponsor has been reported. Mild transient injection site reactions are reported in the majority of patients together with mild transient pyrexia. No other notable, common or serious adverse events have been reported in studies using TroVax® as a single agent in heavily pretreated patients or in studies combining TroVax® with chemotherapy, (5FU and leucovorin combined with either oxaliplatin or irinotecan), interferon-α, IL-2 (high dose intravenous regimen or low dose subcutaneous injections) or with sunitinib. 
     Cancer Treatment 
     The present invention is particularly suitable for use in predicting the response to the aforementioned immunotherapeutic agents in patients or patient population with a cancer. Such cancers include, for example, non-solid tumours such as leukaemia, multiple myeloma or lymphoma, and also solid tumours, for example bile duct, bone, bladder, brain/CNS, breast, colorectal, cervical, endometrial, gastric, head and neck, hepatic, lung, muscle, neuronal, oesophageal, ovarian, pancreatic, pleural/peritoneal membranes, prostate, renal, skin, testicular, thyroid, placental, uterine and vulval tumours. 
     The present invention is particularly suitable for identifying those patients with renal, colorectal, breast, prostate or ovarian cancer, more particularly renal or colorectal cancer that will respond to treatment with immunotherapeutic agents, such as TROVAX® as hereinbefore defined. 
     Sample 
     As used herein, the term “sample” is intended to mean any biological fluid, cell, tissue, organ or portion thereof. The term includes samples present in an individual as well as samples obtained or derived from the individual. For example, a sample can be a histologic section of a specimen obtained by biopsy, or samples that are placed in or adapted to tissue culture. Furthermore a sample can be a subcellular fraction or extract, or a crude or substantially pure protein preparation. 
     In the methods of the invention, a sample can be, for example, a cell or tissue obtained using a biopsy procedure or can be a fluid sample containing cells, such as blood, serum, semen, urine, or stool. Those skilled in the art will be able to determine an appropriate sample, which will depend on cancer type, and an appropriate method for obtaining a biopsy sample, if necessary. When possible, it can be preferable to obtain a sample from a patient using the least invasive collection means. For example, obtaining a fluid sample from a patient, such as blood, saliva, serum, semen, urine or stool, is less invasive than collecting a tissue sample. 
     Reference Level 
     As used herein, the term “reference level” refers to a control level of expression of a factor or biomarker used to evaluate a test level of expression of a factor or biomarker in a sample of a patient. For example, when the level of corrected calcium in the patient is higher than the reference level of corrected calcium, the patient will be considered to have a high level of corrected calcium. Conversely, when the level of corrected calcium in the patient is lower than the reference level, the patient will be considered to have a low level of corrected calcium. In another example, when the level of platelets in the patient is higher than the reference level of platelets, the patient will be considered to have a high level of platelets. Conversely, when the level of platelets in the patient is lower than the reference level, the patient will be considered to have a low level of platelets. In a further example, when the level of haemoglobin in the patient is higher than the reference level of haemoglobin, the patient will be considered to have a high level of platelets. Conversely, when the level of haemoglobin in the patient is lower than the reference level, the patient will be considered to have a low level of haemoglobin. Similarly, when the level of creatinine in the patient is higher than the reference level of creatinine, the patient will be considered to have a high level of creatinine. Conversely, when the level of creatine in the patient is lower than the reference level, the patient will be considered to have a low level of creatinine. Similarly, when the level of monocytes in the patient is higher than the reference level of monocytes, the patient will be considered to have a high level of monocytes. Conversely, when the level of monocytes in the patient is lower than the reference level, the patient will be considered to have a low level of monocytes. Furthermore, when the level of WBCs in the patient is higher than the reference level of WBCs, the patient will be considered to have a high level of WBCs. Conversely, when the level of WBCs in the patient is lower than the reference level, the patient will be considered to have a low level of WBCs. 
     In some variations, the reference level may be a range or an average or median measurement of a biomarker calculated from a plurality mammalian subjects that are proposed for the immunotherapy or are not in need of immunotherapy. Where the reference is an average or median, a measurement for the biomarker level above the reference measurement is scored as elevated and a measurement below the reference measurement is scored as reduced. When the reference is a range a measurement for the biomarker around or above the top level for the reference measurement is scored as elevated and a measurement around or below the bottom level for the reference measurement is scored as reduced. In other variations, a measurement that statistically varies from the median or mean by a suitable significant amount (e.g., 1 or 1.5 or 2 standard deviations; or by a “p-value” or other statistical measure of significance) is scored as elevated or reduced. 
     In other variations, a reference level may be a baseline measurement or any other absolute measurement for a particular assay tool. In such variations, an elevated level or a reduced level may represent values that are a certain multiple or fraction of the reference value. 
     Some aspects of the invention involve screening for or determining the presence of a measurable difference from the reference level. Measurable may be defined as a level greater or lower than a baseline response, and more preferably at least about 2, 5, 10, 50, 100 or 1000 fold over or below a baseline response. In cases where there is no measurable baseline response, a baseline response may be defined as the lower detection limit of the assay used to measure the level. 
     The reference level can be determined by a plurality of methods, provided that the resulting reference level accurately provides a level of a biomarker above which exists a first group of patients having a different probability of survival than that of a second group of patients having levels of the biomarker below the reference level. The reference level can be determined by, for example, measuring the level of a biomarker in a non-tumorous sample as the sample of the patient to be tested. The reference level can also be a level of a biomarker of in vitro cultured cells which can be manipulated to simulate tumour cells, or can be manipulated in any other manner which yields levels of the biomarker which accurately determine the reference level. 
     The reference level can also be determined by comparison of the level of a biomarker, such as monocytes, WBCs, corrected calcium, platelet count, haemoglobin or creatinine, in populations of patients having the same cancer. This can be accomplished, for example, by histogram analysis, in which an entire cohort of patients are graphically presented, wherein a first axis represents the level of the biomarker, and a second axis represents the number of patients in the cohort whose samples contain the biomarker at a given level. Two or more separate groups of patients can be determined by identification of subsets populations of the cohort which have the same or similar levels of the biomarker. Determination of the reference level can then be made based on a level which best distinguishes these separate groups. A reference level also can represent the levels of two or more markers. Two or more markers can be represented, for example, by a ratio of values for levels of each biomarker. 
     The reference level can be a single number, equally applicable to every patient, or the reference level can vary, according to specific subpopulations of patients. For example, older men might have a different reference level than younger men for the same cancer, and women might have a different reference level than men for the same cancer. Furthermore, the reference level can be some level determined for each patient individually. For example, the reference level might be a certain ratio of a biomarker in the neoplastic cells of a patient relative to the biomarker levels in non-tumour cells within the same patient. Thus the reference level for each patient can be proscribed by a reference ratio of one or more biomarkers, such as corrected calcium or platelet count, wherein the reference ratio can be determined by any of the methods for determining the reference levels described herein. 
     The reference level may be determined by measuring the baseline level of a biomarker prior to the commencement of immunotherapy 
     A high level of a biomarker, such as corrected calcium, platelet levels haemoglobin or creatinine can be related to a level of the biomarker above a determined reference level. Thus, a reference or basal level of a biomarker, such as corrected calcium, platelet levels, haemoglobin or creatinine in a sample is identified as a “cutoff” value, above which there is a significant correlation between the presence of the biomarker and increased or decreased tumour recurrence or spread. Those of skill in the art will recognize that some “cutoff” values are not sharp in that clinical correlations are still significant over a range of values on either side of the cutoff; however, it is possible to select an optimal cutoff value (for example varying H-scores, and the like) of a level of a biomarker for a cancer cell type. It is understood that improvements in optimal cutoff values could be determined, depending on the sophistication of statistical methods used and on the number and source of samples used to determine reference or basal values. 
     Verification that the reference level distinguishes the likelihood of tumour recurrence or spread in cancer patients expressing below-reference biomarker levels versus cancer patients expressing above-reference biomarker levels can be carried out using single variable or multi-variable analysis. These methods determine the likelihood of a correlation between one or more variables and a given outcome. In the specific case, the methods will determine the likelihood of a correlation between a biomarker level, or the levels of more than one biomarker (or a biomarker level coupled with another variable) and disease-free or overall survival of cancer patients. Any one of a plurality of methods well known to those of ordinary skill in the art for carrying out these analyses can be used. Examples of single variable analysis are the Kaplan-Meir method or the log-rank test. An example of multi-variable analysis is the Cox proportional-hazards regression model. 
     The Kaplan-Meier estimator used in the Examples (also known as the product limit estimator) estimates the survival function from life-time data. In medical research, it might be used to measure the fraction of patients living for a certain amount of time after treatment. The survival function, also known as a survivor function or reliability function, is a property of any random variable that maps a set of events, usually associated with mortality or failure of some system, onto time. It captures the probability that the system will survive beyond a specified time. The term reliability function is common in engineering while the term survival function is used in a broader range of applications, including human mortality. 
     Population-based determination of reference levels, for example, by histogram analysis can be carried out using a cohort of patients sufficient in size in order to determine two or more separate groups of patients having different biomarker levels. Typically, such a cohort comprises at least 25 patients, such as at least 50 patients, including at least 75 patients, and at least 100 patients. Similarly, verification of determined reference levels can also comprise at least 25 patients, such as at least 50 patients, including at least 75 patients, and at least 100 patients. 
     Further, while a reference level can separate two groups of patients, it is within the scope of the invention that numerous reference values might exist which separate a plurality of populations. For example, two reference values can separate a first group of patients with high levels of a biomarker from a second group of patients with intermediate levels the biomarker, and from a third group of patients with low levels of the biomarker. The number of different reference levels can be sufficient to proscribe a curve, such as a continuous line, which describes the likelihood of disease-free or overall survival in a patient as a function of the biomarker level in that patient. Such a curve will constitute a “continuous” biomarker level, where the likelihood of disease-free or overall survival in a patient is proportional to the biomarker level in that patient. Two or more biomarker levels can also be represented by such a curve. 
     Further Combinations 
     The reference level of a biomarker, such as moncytes, platelet count, haemoglobin or WBCs, can further be used in conjunction with another variable found to be a statistically significant indicator of the likelihood of disease-free or overall survival for cancer. Such indicators include the presence or levels of known cancer markers, or can be clinical or pathological indicators (for example, age, tumour size, tumour histology, clinical stage, family history and the like). For example, clinical stage of the cancer is also a statistically significant indicator of disease-free or overall survival, wherein the reference level of a biomarker can vary according to the clinical stage of the cancer. For example, the level of a biomarker, such as a low level of monocytes, platelet count, and/or WBCs, and/or a high level of haemoglobin in conjunction with clinical stage II of a cancer for a given patient, together are indicators for increased likelihood of disease free or overall survival. Hence, the reference level of a biomarker can vary as a function of another statistically significant indicator of disease-free or overall survival for cancer. 
     The use of two or more biomarkers can provide increased confidence in prognostic outcome. For example, as disclosed herein, combinations of low monocytes and low platelet count were correlated with increased disease-free survival. Thus, combinations of biomarkers useful in the prognostic methods of the invention include, for example, monocytes, WBCs, platelet count, haemoglobin, and a multiplicity of other combinations with biomarkers such as corrected calcium, chloride, creatinine, eosinophils, haematocrit, sodium, basophils, serum calcium, and neutrophils and a variety of other general and tumour-specific biomarkers, such as commercially available diagnostic markers. 
     Survival 
     One aspect of the present invention is seeking to achieve improved patient survival including progression-free survival, disease free-survival and overall survival, and also reducing the risk of recurrence and/or metastases. As used herein, the term “disease-free survival” includes the lack of tumour recurrence and/or spread and the fate of a patient after diagnosis, for example, a patient who is alive without tumour recurrence. The phrase “overall survival” refers to the fate of the patient after diagnosis, regardless of whether the patient has a recurrence of the tumour. 
     As used herein, the term “risk of recurrence” refers to the probability of tumour recurrence or spread in a patient subsequent to diagnosis of cancer, wherein the probability is determined according to the process of the invention. 
     Tumour recurrence refers to further growth of neoplastic or cancerous cells after diagnosis of cancer. Particularly, recurrence can occur when further cancerous cell growth occurs in the cancerous tissue. Tumour spread refers to dissemination of cancer cells into local or distant tissues and organs, for example during tumour metastasis. Tumour recurrence, in particular, metastasis, is a significant cause of mortality among patients who have undergone surgical treatment for cancer. Therefore, tumour recurrence or spread is correlated with progression-free survival, disease-free and overall patient survival. 
     Progression-free survival denotes the chances of staying free of disease progression after a particular treatment. 
     Benefit 
     As used in the context of a course of treatment, “benefit” refers to the ability of the course of treatment to decrease the risk of tumour recurrence or spread and therefore to increase the likelihood of disease-free, progression-free, or overall survival of the patient. 
     The methods of the invention for determining a prognosis for survival for a cancer patient are applicable to patients at any stage of tumour progression, and further can be used to determine a stage of tumour progress. A stage of a tumour refers to the degree of progression of a tumour. Various stages of tumour development are well known to those of skill in the art, as exemplified in Markman, “Basic Cancer Medicine,” Saunders, (ed. Zorab, R.) (1997). For example, cancers can be staged into three general stages—localized, regional spread, and distant spread. Cancers also can be staged using the TNM system, which considers the extent of direct spread within affected and nearby tissues, the extent of spread to nearby lymph nodes, and the extent of spread to distant organs. Based on these features, spread of cancers can be summarized by assigning Roman numerals from 0 through IV. Those skilled in the art can select an appropriate staging system for a particular type of cancer. 
     In particular, colon cancer can be staged using the Dukes, Astler-Coller and AJCC/TNM systems, which describe the spread of the cancer in relation to the layers of the wall of the colon or rectum, organs next to the colon and rectum, and other organs farther away. Dukes stage A is equivalent to AJCC/TNM stage I and Astler-Coller stage A, BI; Duke&#39;s stage B is equivalent to AJCC/TNM stage II and Astler-Coller stage B2, B3. Dukes stage C is equivalent to AJCC/TNM stage III and Astler-Coller stage C1, C2, C3. AJCC/TNM stages of colorectal cancer are as follow: Stage 0: the cancer has not grown beyond the inner layer (mucosa) of the colon or rectum. This stage is also known as carcinoma in situ or intramucosal carcinoma; Stage I: the cancer has grown through the mucosa into the submucosa, or can also have grown into the muscularis propria, but it has not spread outside the wall itself into nearby tissue such as lymph nodes; Stage II: the cancer has grown through the wall of the colon or rectum, into the outermost layers and may have invaded other nearby tissues, but has not yet spread to the nearby lymph nodes; Stage III: the cancer can be of any size, but has spread to 3 or fewer nearby lymph nodes, or has spread to 4 or more nodes but it has not spread to other parts of the body; Stage IV: the cancer has spread to distant organs such as the liver, lung, peritoneum or ovary. 
     The staging system for renal cell cancer is based on the degree of tumour spread beyond the kidney. Involvement of blood vessels may not be a poor prognostic sign if the tumour is otherwise confined to the substance of the kidney. Abnormal liver function test results may be due to a paraneoplastic syndrome that is reversible with tumour removal and do not necessarily represent metastatic disease. Except when computed tomography (CT) examination is equivocal or when iodinated contrast material is contraindicated, CT scanning is as good as or better than magnetic resonance imaging (MRI) for detecting renal masses. 
     The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification. 
     TNM Definitions 
     Primary Tumour (T)
         TX: Primary tumour cannot be assessed   T0: No evidence of primary tumour   T1: Tumour 7 cm or less in greatest dimension limited to the kidney   T2: Tumour more than 7 cm in greatest dimension limited to the kidney   T3: Tumour extends into major veins or invades adrenal gland or perinephric tissues but not beyond Gerota&#39;s fascia   T3a: Tumour invades adrenal gland or perinephric tissues but not beyond Gerota&#39;s fascia   T3b: Tumour grossly extends into the renal vein(s) or vena cava below the diaphragm   T3c: Tumour grossly extends into the renal vein(s) or vena cava above the diaphragm   T4: Tumour invades beyond Gerota&#39;s fascia       

     Regional Lymph Nodes (N)
         NX: Regional lymph nodes cannot be assessed   N0: No regional lymph node metastasis   N1: Metastasis in a single regional lymph node   N2: Metastasis in more than 1 regional lymph node   [Note: Laterality does not affect the N classification.]       

     Distant Metastasis (M)
         MX: Distant metastasis cannot be assessed   M0: No distant metastasis   M1: Distant metastasis       

     AJCC Stage Groupings 
     Stage I
         T1, N0, M0       

     Stage II
         T2, N0, M0       

     Stage III
         T1, N1, M0   T2, N1, M0   T3a, N0, M0   T3a, N1, M0   T3b, N0, M0   T3b, N1, M0   T3c, N0, M0   T3c, N1, M0       

     Stage IV
         T4, N0, M0   T4, N1, M0   Any T, N2, M0   Any T, Any N, M1       

     Early stages of tumour development shall be understood to refer to stages in tumour development in which the tumour has detectably spread no further than the lymph nodes local to the organ of the primary tumour. Typically, early stages will be considered to be stages I and II. 
     Analytical Methods 
     The following analytical methods were used in the following Examples, and may be usefully used to determine the appropriate levels of the biomarkers in the present invention: 
     
       
         
           
               
               
               
             
               
                   
                   
               
               
                   
                 ASSAY 
                 METHOD/INSTRUMENT 
               
               
                   
                   
               
             
            
               
                   
                 Creatinine in Serum 
                 Olympus AU640/2700/5400 
               
               
                   
                   
               
            
           
         
       
     
     Analytical Principle: 
     This procedure employs a kinetic modification of the classical Jaffe method which was first described in 1886. It involves the reaction of creatinine and an alkaline picrate solution to produce a red tautometer of creatinine picrate of which the absorbance is measured bichromatically at 520 nm/660 nm. The following reaction occurs at 37° C.: 
       Creatinine+Alkaline Picrate→Creatinine-Picrate
 
     The method measures the absorbance of the sample at a primary wavelength of 520 nm and compares it to the absorbance produced by a known calibrator. The result is then printed out directly in mg/dL. 
     
       
         
           
               
               
             
               
                   
               
               
                 ASSAY 
                 METHOD/INSTRUMENT 
               
               
                   
               
             
            
               
                 COMPLETE BLOOD 
                 BECKMAN Version: 7 
               
               
                 COUNT 
                 COULTER 
               
               
                 (includes Haemoglobin 
                 GENS/LH750/LH780 
               
               
                 measurement and monocyte, WBC and 
               
               
                 platelet count) 
               
               
                   
               
            
           
         
       
     
     The Coulter employs electronic counting and sizing of particles to quantitate and evaluate blood cells. Gen S/LH750/LH780 WBC Differential analysis and classification are based on simultaneous measuring of cell volume, high frequency conductivity and laser light scatter. Hemoglobin, released by hemolysis to either a stable cyanide containing pigment or oxyhemoglobin-based hemachromagen, is measured by photometric absorbance. 
     
       
         
           
               
               
               
             
               
                   
                   
               
               
                   
                 ASSAY 
                 METHOD/INSTRUMENT 
               
               
                   
                   
               
             
            
               
                   
                 Corrected calcium 
                 calculated using the formula: 
               
               
                   
                   
                 [(4 - serum albumin g/dL) * 0.8 + serum 
               
               
                   
                   
                 calcium mg/dL] 
               
               
                   
                   
               
            
           
         
       
     
     Serum albumin and calcium is measured. 
     
       
         
           
               
               
               
             
               
                   
                   
               
               
                   
                 ASSAY 
                 METHOD/INSTRUMENT 
               
               
                   
                   
               
             
            
               
                   
                 Albumin in Serum 
                 Olympus AU640/2700/5400 
               
               
                   
                   
               
            
           
         
       
     
     Analytical Principle: 
     This procedure is based on the dye-binding capability of albumin. Albumin reacts with bromocresol green at pH 4.0 to form a green color. The increase in color is measured bichromatically (600/800 nm) and is proportional to the amount of albumin present. The Olympus method measures the absorbance of the sample at a primary wavelength of 600 nm and compares it to the absorbance produced by known calibrators. The result is then printed out directly in g/dL. 
     
       
         
           
               
               
               
             
               
                   
                   
               
               
                   
                 ASSAY 
                 METHOD/INSTRUMENT 
               
               
                   
                   
               
             
            
               
                   
                 Calcium in Serum 
                 Olympus AU640/2700/5400 
               
               
                   
                   
               
            
           
         
       
     
     Analytical Principle: 
     This Olympus Calcium procedure is based on Calcium ions (Ca2+) reacting with Arsenazo III (2,2′-[1,8-Dihydroxy-3,6-disulphonaphthylene-2,7-bisazo]-bisbenzenear-sonic acid) to form an intense purple colored complex. Magnesium does not significantly interfere in calcium determination using Arsenazo Ill. In this method the absorbance of the Ca-Arsenazo III complex is measured bichromatically at 660/700 nm. The resulting increase in absorbance of the reaction mixture is directly proportional to the calcium concentration in the sample. 
     
       
         
         
             
             
         
       
     
     EXAMPLES 
     Example 1 
     Study Details—TRIST 
     The study was termed TRIST: TroVax® Renal Immunotherapy Survival Trial. An international Phase III, randomized, double blind, placebo controlled, parallel group study to investigate whether TroVax® added to first-line standard of care therapy, prolongs the survival of patients with locally advanced or metastatic renal clear cell adenocarcinoma. 
     The primary purpose of this trial is to demonstrate the effect of TroVax® on survival in patients with locally advanced or metastatic renal clear cell adenocarcinomas. Clear cell adenocarcinomas of the kidney uniformly express 5T4 at high concentrations (80-90% of tumors examined) and are therefore an obvious candidate for treatment with a 5T4 vaccine. 
     Reported median survival times for this indication vary between studies but are generally in the range of 6 to 18 months depending on patient&#39;s status at entry and to a lesser extent on treatment. Novel forms of treatment are urgently needed. 
     This study will assess the impact on survival of adding TroVax® to the first-line standard of care for renal cancer. The current standard of care varies between countries and institutions and is influenced by the patient&#39;s status, the national regulatory status of different treatments and local reimbursement considerations. Commonly accepted standards of care for renal cancer include IL-2, IFNα, or a receptor tyrosine kinase inhibitor such as sunitinib. 
     The use and availability of these treatments varies geographically. 
     High dose IL-2, although approved for the treatment of renal cancer is not included in this study as the high incidence of serious adverse events and need for intensive care limit its application and would complicate the safety evaluation of TroVax®. 
     The rationale for the potential concurrent use of IL-2 is that this compound is believed to act as an adjuvant. IL-2 is currently one of the standards of care regimens for the first line treatment of advanced and metastatic renal cancer. The dose schedule of IL-2 chosen is well recognised by the oncology community and has been validated in large scale phase Ill clinical trials. Over 30 patients treated with a combination of TroVax® and IL-2 (high dose intravenous or low dose subcutaneous regimens) have been assessed in phase II studies in patients with renal cancer. The combination was well tolerated. Compared with the historical adverse event profile of IL-2 alone the only additional adverse events reported were minor local reactions at the site of TroVax® injection and mild transient pyrexia. Humoral and/or cellular immune responses to 5T4 were induced in almost all patients and objective responses by RECIST have been reported. 
     Although it is not clear whether the biologic effects of IFNα occur entirely or in part via immunostimulation, there is evidence to show that it does have a modest clinical effect in renal cancer patients with an objective response rate of approximately 7.5-15%. Studies to determine whether IFNα increases survival in patients with renal cancer have produced inconsistent results. Given the immunological mechanism of action of IFNα, it is reasonable to evaluate the effect of TroVax® on survival in patients receiving this common standard of care. An ongoing study has not indicated any untoward safety impact resulting from co-administration of IFNα and TroVax®. 
     Phase II studies including over 20 patients treated with a combination of TroVax® and IFNα (three times weekly subcutaneous regimen) are ongoing in patients with renal cancer. Developing data indicate the combination to be well tolerated. Compared with the historical adverse event profile of IFNα alone the only additional adverse events reported are minor local reactions at the site of TroVax® injection and mild transient pyrexia. The expected humoral and/or cellular immune responses to 5T4 will be confirmed. Interim study reports will be available for review by regulatory authorities, IRB/Ethics Committees and investigators as part of the approval process of this study. 
     Recently developed oral kinase inhibitors, such as sorafenib and sunitinib, are becoming increasingly important in the management of advanced or metastatic renal cell carcinoma. Safety and immunology data necessary to support coadministration of sorafenib and TroVax® are not available. In view of this and the higher overall response rate reported with sunitinib the latter will be included in this study as an example of a kinase inhibitor used in the treatment of renal cancer. 
     Therefore, in regions where this treatment is approved, sunitinib may be used as the standard of care alongside TroVax®/placebo in this study. A phase II study of patients treated with a combination of TroVax® and sunitinib (50 mg oral dose taken once daily, on a schedule of 4 weeks on treatment followed by 2 weeks off) is ongoing in patients with renal cancer. Developing data indicate the combination to be well tolerated. Compared with the reported data on sunitinib alone the only additional adverse events reported are minor local reactions at the site of TroVax® injection and mild transient pyrexia. The expected humoral and/or cellular immunes response to 5T4 are to be confirmed. An interim study report will be available for review by regulatory authorities, IRB/Ethics Committees and investigators as part of the approval process of this study. 
     A cancer vaccine is intended to prolong survival by inducing an immune response to a tumor associated antigen. Preclinical models indicate that cancer vaccines may delay tumor growth and reduce the number of new metastases. It is not yet known whether a cancer vaccine must produce a high objective tumor response rate (by RECIST) in order to have clinically useful effect on prolonging survival. This will only be determined by a randomised survival study in patients receiving adequate vaccination to reliably induce an efficacious immune response. To date, both disease stabilization and late tumor responses have been reported with various cancer vaccines. 
     The maximum immunological response to TroVax® dose not usually occur until the patient has received a minimum of three injections and it is not yet established whether continuing TroVax® despite early progression will confer therapeutic benefit. Therefore, in this study, if tumor progression is observed but the patient is tolerating TroVax®/placebo and their performance status remains at a Karnofsky score &gt;60%, they should be requested to continue on study receiving TroVax®/placebo until they have received a minimum of eight injections of the study preparation. Continuation on study beyond this point to receive all TroVax®/placebo injections is permitted for such patients but is at the discretion of the investigator or patient. 
     A randomized, parallel group, double blind design is standard in phase III efficacy studies. Interim statistical analyses conducted by an independent Data Safety Monitoring Board according to a pre-specified charter will be based on these interim analyses of safety and efficacy. The DSMB may recommend continuation of the study, stopping the study or stopping enrolment of patients of a specific treatment cell. The DSMB will also assess whether the frequency of events in the control arm matches the predictions used to determine the sample size of the study and may recommend changes to the number of events (deaths) triggering the final analysis. 
     TroVax® is a vaccine against a tumor-associated antigen. The assessment of such tumor vaccines for patients with solid tumors is complicated by a number of factors which influence the definition of the objectives, the route to achieving the objectives and the ongoing management of patients in the study. 
     Special Features of Tumor Vaccines that are Relevant to the Objectives are Listed Below:
         Vaccine-mediated immunotherapy requires repeated administration and time for the patient to develop an immune response to the vaccine antigen. In previous phase II studies it was shown that at least three administrations of TroVax® were required to generate a significant immune response. This means that patients who are removed from the study medication before receiving three injections of TroVax® due to death or rapidly progressive renal cancer, do not allow assessment of the potential of a TroVax®-induced immune response to provide benefit to patients treated for a longer period.   Cancer vaccines such as TroVax® may exert beneficial effects in delaying tumor growth and metastasis that do not manifest as RECIST responses but may prolong survival. This has implications for the management of patients because patients with a RECIST classification of progressive disease may still benefit from continuing with TroVax.   It is not yet known whether tumor shrinkage predicts survival advantage. This means that the definitive efficacy endpoint is survival.       

     Objectives 
     Primary Efficacy Objective 
     To assess whether the addition of TroVax® to first line standard of care, will prolong survival of patients with locally advanced or metastatic clear cell renal adenocarcinoma when compared to placebo. 
     Analysis will occur after a predetermined number of deaths have occurred necessary to trigger the primary endpoint analysis or when specified by an independent Data Safety Monitoring Board based on analyses of interim data. 
     The analysis will be based on the Intent to Treat (ITT) population, composed of all patients. 
     Primary Safety Objective 
     To assess whether the addition of TroVax® to first line standard of care alters the profile of serious and non-serious adverse events, when compared to placebo, in patients with locally advanced or metastatic clear cell renal adenocarcinoma. This will be assessed in the Intent to Treat (ITT) population. 
     Secondary Efficacy Objectives
         To compare the proportion of patients with progression free survival at 26 weeks (+/−1 week) in the TroVax® versus placebo arms based on radiological data. Data will be analysed using the ITT population and adjudicated (blinded peer review) baseline and week 26 radiological data.   To compare the tumor response rates, time to response and duration of response between patients treated with TroVax® versus placebo. This will be analysed in the Intent to Treat (ITT) population.       

     To assess whether the addition of a minimum of three doses of TroVax® to first line standard of care, will prolong survival of patients with locally advanced or metastatic clear cell renal adenocarcinoma when compared to placebo. This will be an exploratory analysis in the Modified Intent to Treat (MITT) population. 
     To assess whether TroVax® has an impact on the quality of life as measured by QLQ30 and EuroQOL questionnaires when compared to placebo. This will be analysed in the Intent to Treat (ITT) population. 
     Endpoints 
     Primary Efficacy Endpoint 
     The survival event rate ratio in the TroVax® arm versus the placebo in the Intent to Treat (ITT) population based on the log of the hazard ratio derived from the Cox Proportional Hazards regression model. A frequentist monitoring approach will be used for evaluating the event ratio. 
     The key objective of this study is to determine whether TroVax® is able to prolong survival in patients receiving first line standard of care. 
     Analysis is triggered by a predetermined number of deaths in the study population or when specified by an independent Data Safety Monitoring Board based on analyses of interim data. 
     Primary Safety Endpoints 
     The number of adverse events (serious and non-serious) in the Intent to Treat population in the TroVax® versus the placebo arm. 
     The laboratory variables (complete blood count and chemistry panel) in the Intent to Treat (ITT) population in the TroVax® versus the placebo arm. 
     Secondary Efficacy Endpoints 
     The proportion of patients in the TroVax® versus placebo arms in the Intent to Treat (ITT) population with progression free survival at 26 weeks based on a comparison of baseline and week 26 (+/−1 week) radiological data and using RECIST criteria. Data will be adjudicated (blinded peer review). 
     Tumor response rates according to the investigator&#39;s reported interpretation of the radiological reports based on RECIST criteria observed in the Intent to Treat (ITT) population. 
     The survival event rate ratio in the TroVax® arm versus the placebo in the Modified Intent to Treat (MITT) population based on the log of the hazard ratio derived from the Cox Proportional Hazards regression model. A frequentist monitoring approach will be used for evaluating the event ratio. 
     The quality of Life score for TroVax® versus placebo as measured by QLQ30 and EuroQOL questionnaires in the Intent to Treat (ITT) and Per Protocol populations. 
     Immunology Endpoint 
     Anti-5T4 antibody levels (additional measures of immune response including specific measures of cellular response will be investigated at some centres. Each will be the subject of a separate related protocol and informed consent for specific study sites and will be conditional upon regulatory and IRB/ethics committee approval before implementation.) 
     Metastatic renal cancer has a poor prognosis. The median survival overall has been reported to be as low as 6 months and five year survival is &lt;5%. Conventional systemic cytotoxic chemotherapeutic agents and hormonal therapies have little impact on survival and response rates are usually &lt;10%. The wide variations in the natural history of the disease and spontaneous regression rates of up to 6% have led to the investigation of immune mechanisms as a factor influencing responses and outcomes. Biological and immunologic therapies have demonstrated the best response rates with some impact on overall survival. However the management of metastatic renal cancer remains a therapeutic challenge. 
     Interferon alpha (IFNα) has demonstrated response rates of 8-26% with median survivals of 13 months. Interleukin-2 (IL-2) induces responses in 7-23% of patients with a median survival of 12 months. The benefit of biologic agents has been confirmed by randomised controlled trials, which have shown modest survival benefits with IFNα compared with medroxprogesterone or vinblastine. Motzer (2004) “Prognostic factors for survival of patients with stage IV renal cell carcinoma: Memorial Sloan-Kettering Cancer Center experience.” Clin Cancer Res 10 (18 Pt 2): 6302S-3S, in a retrospective analysis of 670 patients in 24 trials of systemic chemotherapy or cytokine therapies, demonstrated longer survival times with cytokine therapy. In the group who were long term survivors, 70% were in trials that involved IFNα and/or IL-2 and 30% had been treated with hormonal or cytotoxic agents. 
     The initial studies with IL-2 used protocols based on the principles of chemotherapy, using maximum tolerated doses. This was associated with significant renal, cardiac, pulmonary and haemodynamic toxicity, often requiring admission to intensive care wards and limiting utility to a selected subsection of the patient group. Subsequent studies of IL-2 have demonstrated similar efficacy, but with significantly less toxicity, using lower doses administered subcutaneously on an outpatient basis. In a study, comparing high and low-dose IL-2, there was a higher response rate with high dose treatment but this did not translate into survival benefit. 
     Negrier et al. “Recombinant human interleukin-2, recombinant human interferon alfa-2a, or both, in metastatic renal-cell carcinoma. Groupe Francaise d&#39;Immunotherapie. N Engl J Med 1998; 338; 1272-8 assessed the use of these biologic agents as single agent therapy or combination therapy. They demonstrated response rates of 6.5%, 7.5% and 18.6% for IFNα, IL-2 or the combination, respectively. Although there was a difference in progression free survival, this did not translate into a survival advantage. The rationale for the combination of these agents is that, in vitro, IFNα enhances cell membrane expression of major histocompatibility antigens to which IL-2 activated T-cells can respond. 
     There is well-documented evidence to suggest that selection and prognostic factors significantly influence outcomes and responses to cytokine therapies. Motzer has assessed the prognostic value of a number of variables in patients with advanced or metatstic renal cell carcinoma. In these patients, low Karnofsky performance status, low haemoglobin level and high corrected serum calcium level indicated a poor prognosis. The median time to death in patients with zero risk factors was 22 months. The median survival in patients with one of these risk factors was 11.9 months and patients with 2-3 risk factors had a median survival of 5.4 months. 
     Two new drugs have recently been developed for the management of renal cancer: sunitinib and sorafenib. Both function by inhibiting multiple receptor kinases. Overall (complete and partial) response rates reported with sunitinib are substantially higher (25.5-36.5%) than reported with sorafenib (2%) though information on time to tumor progression and survival is still maturing. 
     Safety and immunology data necessary to support coadministration of sorafenib and TroVax® are not available. In view of this and the higher overall response rate reported with sunitinib the latter will be included in this study as an example of a receptor tyrosine kinase inhibitor used in the treatment of renal cancer. 
     Sunitinib malate is a small molecule that inhibits multiple receptor tyrosine kinase (RTKs), some of which are implicated in tumor growth, pathologic angiogenesis, and metastatic progression of cancer. Sunitinib was evaluated for its inhibitory activity against a variety of kinases (&gt;80 kinases) and was identified as an inhibitor of platelet-derived growth factor receptors (PDGFRα and PDGFRβ), vascular endothelial growth factor receptors (VEGFR1, VEGFR2 and VEGFR3), stem cell factor receptor (KIT), Fms-like tyrosine kinase-3 (FLT3), colony stimulating factor receptor Type 1 (CSF-1R), and the glial cell-line derived neurotrophic factor receptor (RET). Sunitinib inhibition of the activity of these receptor tyrosine kinase (RTKs) has been demonstrated in biochemical and cellular assays, and inhibition of function has been demonstrated in cell proliferation assays. The primary metabolite exhibits similar potency to sunitinib when compared in biochemical and cellular assays. 
     The use of single agent sunitinib in the treatment of cytokine-refractory MRCC was investigated in two single-arm, multi-centre studies. All patients enrolled into these studies experienced failure of prior cytokine-based therapy. The primary endpoint for both studies was overall response rate (ORR). Duration of response (DR) was also evaluated. 
     One hundred and six patients were enrolled into Study 1, and 63 patients were enrolled into Study 2. Across the two studies, 95% of the pooled population of patients had at least some component of clear-cell histology. Patients received 50 mg sunitinib in cycles with 4 weeks on and 2 weeks off. Therapy was continued until the patients met withdrawal criteria or had progressive disease. There were 27 PRs in Study 1 as assessed by a core radiology laboratory for an ORR of 25.5% (95% CI 17.5, 34.9). There were 23 PRs in Study 2 as assessed by the investigators for an ORR of 36.5% (95% CI 24.7-49.6). The majority (&gt;90%) of objective disease responses were observed during the first four cycles; the latest reported response was observed in cycle 10. DR data from Study 1 is premature as only 4 of 27 patients (15%) responding to treatment had experienced disease progression. At the time of the data cut-off, Study 1 was ongoing with 44 of 106 patients (41.5%) continuing treatment, and 11 of the 63 patients (17.5%) enrolled on Study 2 continued to receive sunitinib on continuation protocols. 
     As of March 2006 no data are available to determine whether sunitinib (or sorafenib) prolongs survival in patients with renal cancer. 
     Despite recent development of the kinase inhibitors, stage IV renal cell carcinoma is an area of high unmet medical need. The use of vaccines in this area is novel but capitalises on the accepted opinion that immunologic mechanisms may have a part to play in the treatment of this disease. 
     Primary Efficacy Objective 
     To assess whether the addition of TroVax® to first line standard of care, will prolong survival of patients with locally advanced or metastatic clear cell renal adenocarcinoma when compared to placebo. This will be assessed in the Intent to Treat (ITT) population. 
     Primary Safety Objective 
     To assess whether the addition of TroVax® to first line standard of care alters the profile of serious and non-serious adverse events, when compared to placebo, in patients with locally advanced or metastatic clear cell renal adenocarcinoma. This will be assessed in the Intent to Treat (ITT) population. 
     Secondary Efficacy Objectives 
     To compare the proportion of patients with progression free survival at 26 weeks in the TroVax® versus placebo arms. This will be assessed in the Intent to Treat, (ITT) population. 
     To compare the tumor response rates, time to response and duration of response between patients treated with TroVax® versus placebo. This will be analysed in the Intent to Treat (ITT) population. 
     To assess whether the addition of a minimum of three doses of TroVax® to first line standard of care will prolong survival of patients with locally advanced or metastatic clear cell renal adenocarcinoma when compared to placebo. This will be an exploratory analysis in the Modified Intent to Treat (MITT) population. 
     To assess whether TroVax® has an impact on the quality of life as measured by QLQ30 and EuroQOL questionnaires when compared to placebo. This will be analysed in the Intent to Treat (ITT) population. 
     Study Endpoints 
     Primary Efficacy Endpoint 
     The survival event rate ratio in the TroVax® arm versus the placebo in the Intent to Treat (ITT) population based on the log of the hazard ratio derived from the Cox Proportional Hazards regression model. A frequentist monitoring approach will be used for evaluating the event ratio. 
     Primary Safety Endpoints 
     The number of adverse events (serious and non-serious) in the Intent to Treat population in the TroVax® versus the placebo arm. 
     The laboratory variables (complete blood count and chemistry panel) in the Intent to Treat (ITT) population in the TroVax® versus the placebo arm. 
     Secondary Efficacy Endpoints 
     The proportion of patients in the TroVax® versus placebo arms in the Intent to Treat (ITT) population with progression free survival at 26 weeks based on a comparison of baseline and week 26 (+/−1 week) radiological data and using RECIST criteria. Data will be adjudicated (blinded peer review). 
     Tumor response rates according to the investigator&#39;s reported interpretation of the radiological reports based on RECIST criteria observed in the Intent to Treat (ITT) population. 
     The survival event rate ratio in the TroVax® arm versus the placebo in the Modified Intent to Treat (MITT) population based on the log of the hazard ratio derived from the Cox Proportional Hazards regression model. A frequentist monitoring approach will be used for evaluating the event ratio. 
     The Quality of Life score for TroVax® versus placebo as measured by QLQ30 and EuroQOL questionnaires in the Intent to Treat (ITT) and Per Protocol populations. 
     Immunology Endpoint 
     Anti-5T4 antibody levels (additional measures of immune response including specific measures of cellular response will be investigated at some centers. Each will be the subject of a separate related protocol and informed consent for specific study sites and will be conditional upon regulatory and IRB/ethics committee approval before implementation.) 
     Study Population 
     Patients of any ethnic group with histologically proven clear cell renal adenocarcinoma who have had their primary tumor surgically removed and require treatment for locally advanced or metastatic disease. The intent is to include 700 patients split equally between the TroVax® and placebo arms. 
     Study Design 
     This is an international, randomized, double blind, placebo controlled, parallel group study to investigate whether a minimum of three doses of TroVax® added to first-line standard of care therapy, prolongs the survival of patients with locally advanced or metastatic renal clear cell adenocarcinoma. 
     The primary endpoint is survival. The study is designed to be pragmatic, limiting additional study related investigations to a minimum. Protocol mandated scans and X-rays are limited to two time points (baseline and week 26) to permit comparison of the percentage of patients with progressive disease at 6 months as a secondary efficacy endpoint. Six months was selected based on review of published literature indicating that progressive disease was commonly observed by 26 weeks in patients with renal cancer. Endpoints such as tumor response by RECIST are considered of secondary importance to survival and will be determined by radiological examinations ordered at the discretion of the investigator based on the clinical status of the patient and will be based the interpretation of the patient&#39;s care-team (investigator and local radiologist). 
     Study enrolment will only commence at each centre once ethics and regulatory approval have been obtained from the relevant authorities. 
     After signing the study informed consent form and meeting the baseline enrolment criteria patients will be assigned by the investigator (their physician) to one of the following defined first-line standard of care regimens based on what is best for the patient and consistent with local practice:
         1. subcutaneous low dose IL-2   2. interferon alpha (excluding pegylated IFNalpha)   3. sunitinib       

     Only after the standard of care therapy has been decided should the investigator telephone the Interactive Voice Recognition Service (IVRS). Randomization to TroVax® or placebo will be stratified based on the standard of care chosen by the investigator, study prognostic indicators (Motzer score) and geography. 
     TroVax® is administered at a dose of 1×10 9 TCID50/ml in 1 ml by injection into the deltoid muscle of the upper arm at regular intervals up to 8 weeks apart up to a maximum of 13 doses. 
     An independent Data Safety Monitoring Board will be responsible for preparing the formal monitoring rules for this study. This parallel-designed study contains a series of planned interim assessments for futility, and to ensure that the planning elements relative to attrition and the primary endpoint remain consistent. A frequentist monitoring approach will be used for evaluating the event rate ratio to ensure that the assumptions are accurate and the sample size continues to be appropriate for assessing superiority. The DSMB may recommend changes to the enrollment target if pretrial assumptions prove inaccurate. These DSMB reviews will be conducted confidentially. Data analysis will not be shared with the sponsor, investigators or any other participant in the study. 
     Study Design 
     Type of Study 
     This is an international, randomised, double blind, placebo controlled, parallel group study designed to assess whether, when added to first-line standard of care, TroVax® prolongs survival in patients with locally advanced or metastatic renal carcinoma. 
     The primary endpoint is survival. The study is designed to be pragmatic, limiting additional study related investigations to a minimum. Protocol mandated scans and X-rays are limited to two time points (baseline and week 26) to permit comparison of the percentage of patients with progressive disease at 6 months as a secondary efficacy endpoint. Six months was selected based on review of published literature indicating that progressive disease was commonly observed by 26 weeks in patients with renal cancer. Endpoints such as tumor response by RECIST are considered of secondary importance to survival and will be determined by radiological examinations ordered at the discretion of the investigator based on the clinical status of the patient and will be based the interpretation of the patient&#39;s care-team (investigator and local radiologist). 
     Study enrolment of 700 patients will only commence once ethics and regulatory approval has been obtained from the relevant authorities. 
     After signing the study informed consent form and meeting the baseline enrolment criteria patients will be assigned by the investigator (their physician) to one of the following defined standard of care regimens based on what is best for the patient and consistent with local practice:
         1. subcutaneous low dose IL-2   2. interferon-α (excluding pegylated IFNα)   3. sunitinib       

     Only after the standard of care therapy has been decided should the investigator telephone the Interactive Voice Randomisation Service (IVRS). Randomisation to TroVax® or placebo will be stratified based on the standard of care chosen by the investigator, the study site and prognostic indicators. 
     An independent Data Safety Monitoring Board will periodically review emerging data. These reviews will be conducted confidentially. Data analysis will not be shared with the sponsor, investigators or any other participant in the study. A frequentist monitoring approach will be used for evaluating the event rate ratio to ensure that the assumptions are accurate and the sample size continues to be appropriate for assessing superiority. The DSMB may recommend changes to the enrollment target if pretrial assumptions prove inaccurate. 
     Rationale for Study Design 
     A randomised, parallel group, double blind design is standard in phase III efficacy studies. Interim statistical analyses conducted by an independent Data Safety Monitoring Board will ensure that the trial can be closed if shown to be futile or resized if it turns out that the assumptions made about the primary endpoint in the control group are inaccurate. 
     Study sites, duration and recruitment rates 
     This is an international trial with recruitment across approximately 100 sites. The recruitment rates are estimated to be approximately 0.5 to 4 patients per site per month. Since this is a survival study patients are expected to be on study for a median time of 12 months. 
     Justification of the Proposed Dosing Regimen 
     In the TroVax® phase I study four dose levels were studied (1×10 8  TCID50/ml, 2×10 8 TCID50/ml, 5×10 8  TCID50/ml, and 1×10 9  TCID50/ml) and two different routes of administration, intramuscular and intradermal, were compared. There was no clinically or statistically significant difference in peak immune response though the highest dose produced a slightly earlier antibody response. No difference was observed between the routes of administration in terms of antibody response. All doses and routes were well tolerated with only local injection site reactions which were of similar frequency. In view of a trend to an earlier antibody response the dose of 1×10 9  TCID50/ml was selected. 
     In subsequent phase II studies involving &gt;70 patients, a dose level of 1×10 9 TCID50/ml was used and safety, tolerability and immunogenicity were confirmed. 
     In this study, TroVax®/placebo is administered at weeks 1, 3, 6, 9, 13, 17, 21, 25, 33, 41, 49, 57 and 65. This frequency is influenced by experience gained in phase II studies in patients with renal or colorectal cancer where TroVax® was co-administered with either combination chemotherapy, IL-2 or IFNα. 
     Study Population 
     Patient Recruitment 
     A total of 700 patients with clear cell renal carcinoma will be enrolled in the study. 
     Eligible patients will have had the primary tumor surgically removed. 
     Patients will receive one of the following defined standards of care:
         subcutaneous low dose IL-2   interferon alpha (excluding pegylated IFNα)   sunitinib       

     The choice of first-line standard of care for each patient will be made by the patient&#39;s physician based on normal clinical criteria, local standard of care, and local regulatory and reimbursement status or economic availability. Once treatment is selected, patients will be randomised to TroVax® or placebo. 
     Patients will be recruited internationally. Patients of all ethnic groups are eligible for the study. 
     Entry Criteria 
     Patients who meet the following inclusion criteria and none of the exclusion criteria will be included in this study. 
     Inclusion Criteria 
     Signed informed consent. The patient must be competent to give written informed consent and comply with the protocol requirements. 
     Locally advanced or metastatic, histologically proven clear cell renal carcinoma. 
     Primary tumor surgically removed (some residual advanced primary tumor may remain). 
     At least four weeks post surgery or radiotherapy (defined from time of randomisation.) 
     First-line. No prior therapy for renal cancer except surgery or radiotherapy. 
     Measurable disease. 
     Aged 18 years or more. 
     Patient expected to survive a minimum of 12 weeks (i.e. in the opinion of the investigator there is a &gt;90% probability that the patient will survive &gt;12 weeks if treated with the selected standard of care). 
     Free of clinically apparent autoimmune disease (including no prior confirmed diagnosis or treatment for autoimmune disease including Systemic Lupus Erythematosis, Grave&#39;s disease, Hashimoto&#39;s thyroiditis, multiple sclerosis, insulin dependant diabetes mellitus or systemic (non-joint) manifestations of rheumatoid disease). 
     Total white cell count ≧3×109/L and lymphocyte count ≧1×109/L. 
     Serum creatinine ≦1.5 times the upper limit of normal. 
     Bilirubin ≦2 times the upper limit of normal and an SGPT of ≦4 times the upper limit of normal. 
     Women must be either post menopausal, or rendered surgically sterile or, if of child bearing potential, must have been practising a reliable form of contraception (oral contraception+a barrier method) for at least three months prior to the first dose of TroVax® and must continue while they are being treated with TroVax®. Men must practise a reliable form of contraception (barrier or vasectomy) while they are being treated with TroVax®. 
     No acute changes on 12-lead ECG. 
     Ejection fraction documented as not less than 45% or no clinical suspicion that cardiac ejection fraction is less than 45%. (If clinical suspicion exists the ejection fraction should be measured according to local site procedures). 
     Karnofsky performance status of &gt;80%. 
     Exclusion Criteria 
     Cerebral metastases. (Known from previous investigations or clinically detectable). 
     Previous exposure to TroVax®. 
     Serious infections within the 28 days prior to entry to the trial. 
     Known to test positive for HIV or hepatitis B or C. 
     Life threatening illness unrelated to cancer. 
     History of allergic response to previous vaccinia vaccinations. 
     Known allergy to egg proteins. 
     Known hypersensitivity to neomycin. 
     Participation in any other clinical trial of a licensed or unlicensed drug within the previous 30 days or during the course of this trial. 
     Previous malignancies within the last 10 years other than successfully treated squamous carcinoma of the skin or in situ carcinoma of the cervix treated with cone biopsy. 
     Previous history of major psychiatric disorder requiring hospitalization or any current psychiatric disorder that would impede the patient&#39;s ability to provide informed consent or to comply with the protocol. 
     Oral corticosteroid use unless prescribed as replacement therapy in the case of adrenal insufficiency. 
     Ongoing use of agents listed in locally approved prescribing information as causing immunosuppression. 
     Prior history of organ transplantation. 
     Pregnancy or lactation. 
     Withdrawal Criteria 
     In accordance with applicable regulations, a patient has the right to withdraw from the study at any time and for any reason without prejudice to his or her future medical care by the physician or at the institution. 
     If a patient is withdrawn from treatment with TroVax®/placebo because of an adverse event (AE), the event will be followed up until it has resolved or has stabilized. Because this is a survival study patients should continue to be followed until death to document subsequent treatment and survival status 
     In addition to AEs, other reasons for removal of patients from the study would be the patient&#39;s withdrawal of consent. Should this happen, since this is a survival study, the patient&#39;s physician must request consent from the patient for survival follow up. 
     Withdrawal from the study, and reason for withdrawal, must be documented in the CRF. 
     Because the primary endpoint of this study is survival and all randomised patients will be included in the primary or secondary endpoint analysis patients who wish to withdraw from all other study related procedures for any reason should be asked whether they would consent to follow up limited to documenting their subsequent management and survival status. If they agree, a new informed consent form should be used to document consent to such follow up treatment plan and methods. The Study Schedule is set out below: 
     
       
         
           
               
               
               
               
               
               
               
               
               
               
               
               
             
               
                   
                   
               
             
            
               
                   
                 Base 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
               
               
                   
                 line 
                 1 
                 2 
                 3 
                 4 
                 5 
                 6 
                 7 
                 8 
                 9 
                 10 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
               
               
               
            
               
                 TroVax ®/Placebo day 1/wk 
                 X 
                   
                 X 
                   
                 X 
                   
                 X 
                   
               
            
           
           
               
               
               
            
               
                 Patients only 
                   
                 Patients receive only one of the following treatments 
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
               
            
               
                 receive one 
                 IL-2 Treatment 
                   
                 X 
                 X 
                 X 
                 X 
                 X 
                 X 
                   
                   
                 Continue with 6 weeks sub- 
               
               
                 of these 
                 days 1-5 each wk 
                   
                   
                   
                   
                   
                   
                   
                   
                   
                 cutaneous IL-2 followed by 2 
               
               
                 treatments 
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                 weeks without IL-2 every 8 
               
               
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                 weeks until tumor progression 
               
               
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                 or week 46 (whichever is first) 
               
            
           
           
               
               
            
               
                   
                 OR 
               
            
           
           
               
               
               
               
            
               
                   
                 IFNα 
                   
                 Subcutaneous IFNα day 1, 3 and 5 of each week until tumor 
               
               
                   
                   
                   
                 progression (refer to nationally approved prescribing information 
               
               
                   
                   
                   
                 or institutional guidelines of use of IFNα for renal cancer). 
               
            
           
           
               
               
            
               
                   
                 OR 
               
            
           
           
               
               
               
               
               
               
               
               
               
               
            
               
                   
                 sunitinib 
                   
                 X 
                 X 
                 X 
                 X 
                   
                   
                 Continue with 4 weeks on sunitinib then 2 
               
               
                   
                   
                   
                   
                   
                   
                   
                   
                   
                 weeks without sunitinib every 6 weeks until 
               
               
                   
                   
                   
                   
                   
                   
                   
                   
                   
                 tumor progression. (see nationally approved 
               
               
                   
                   
                   
                   
                   
                   
                   
                   
                   
                 sunitinib prescribing information) 
               
            
           
           
               
               
            
               
                   
                 Patients receive all the following procedures 
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
               
            
               
                 Consent form 
                 X 
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                 Randomisation 
                   
                 X 
               
               
                 Medical History 
                 X 
               
               
                 Physical examination 
                 X 
                   
                   
                   
                   
                   
                 X 
               
               
                 Blood for Immuno (10 ml) 
                 X 
                   
                   
                   
                   
                   
                   
                 X 
                   
                   
                 X 
               
               
                 Weight, BP, Pulse, Temp 
                 X 
                 X 
                   
                 X 
                   
                   
                 X 
                   
                   
                 X 
               
               
                 CBC/Diff/Plts 
                 X 
                 X 
                   
                 X 
                   
                   
                 X 
                   
                   
                 X 
               
               
                 Chemistry Panel 
                   X * 
                 X 
                   
                 X 
                   
                   
                 X 
                   
                   
                 X 
               
               
                 CT or MRI Chest, Abd, 
                 X 
               
               
                 Pelvis 
               
               
                 12 lead ECG 
                 X 
               
               
                 Echocardiogram+ 
                 X 
               
               
                 Karnofsky 
                 X 
                   
                   
                 X 
                   
                   
                 X 
                   
                   
                 X 
               
               
                 Tumor histopathology 
                 X 
               
            
           
           
               
               
               
            
               
                 Pregnancy Test (if 
                 X 
                 Prior to TroVax ®/placebo if any possibility of pregnancy 
               
               
                 applicable) 
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
               
            
               
                 QOL 
                 X 
                   
                   
                   
                   
                   
                 X 
                   
                   
                 X 
                   
               
            
           
           
               
               
            
               
                 Concomitant Therapy 
                 Record on each visit that patient receives TroVax ®/placebo 
               
               
                 AEs 
                 Throughout the study while patient receiving TroVax ®/placebo and 30 days after 
               
               
                 Subsequent renal cancer 
                 Record other renal cancer treatment once patient is not receiving TroVax ®/placebo 
               
               
                 Rx 
               
               
                 Survival status/date of 
                 Record on each visit that patient receives TroVax ®/placebo and every 
               
               
                 death 
                 12 weeks thereafter. If patient does not return to clinic seek 
               
               
                   
                 survival status and date of death as permitted by patient consent 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
               
               
            
               
                   
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
               
               
                   
                 11 
                 12 
                 13 
                 14 
                 15 
                 16 
                 17 
                 18 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
            
               
                   
                 TroVax ®/Placebo day 1/wk 
                 X 
                   
                 X 
                   
               
            
           
           
               
               
               
               
            
               
                   
                 Patients only 
                   
                 Patients receive only one of the following treatments 
               
               
                   
                 receive one 
                 IL-2 Treatment 
                 Continue with 6 weeks sub- 
               
               
                   
                 of these 
                 days 1-5 each wk 
                 cutaneous IL-2 followed by 2 
               
               
                   
                 treatments 
                   
                 weeks without IL-2 every 8 
               
               
                   
                   
                   
                 weeks until tumor progression 
               
               
                   
                   
                   
                 or week 46 (whichever is first) 
               
               
                   
                   
                   
                 OR 
               
               
                   
                   
                 IFNα 
                 Subcutaneous IFNα day 1, 3 and 5 of each week until tumor 
               
               
                   
                   
                   
                 progression (refer to nationally approved prescribing information 
               
               
                   
                   
                   
                 or institutional guidelines of use of IFNα for renal cancer). 
               
               
                   
                   
                   
                 OR 
               
               
                   
                   
                 sunitinib 
                 Continue with 4 weeks on sunitinib then 2 
               
               
                   
                   
                   
                 weeks without sunitinib every 6 weeks until 
               
               
                   
                   
                   
                 tumor progression. (see nationally approved 
               
               
                   
                   
                   
                 sunitinib prescribing information) 
               
            
           
           
               
               
            
               
                   
                 Patients receive all the following procedures 
               
            
           
           
               
               
               
               
               
               
               
               
               
               
            
               
                   
                 Consent form 
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                   
                 Randomisation 
               
               
                   
                 Medical History 
               
               
                   
                 Physical examination 
                   
                   
                 X 
               
               
                   
                 Blood for Immuno (10 ml) 
               
               
                   
                 Weight, BP, Pulse, Temp 
                   
                   
                 X 
                   
                   
                   
                 X 
               
               
                   
                 CBC/Diff/Plts 
                   
                   
                 X 
                   
                   
                   
                 X 
               
               
                   
                 Chemistry Panel 
                   
                   
                 X 
                   
                   
                   
                 X 
               
               
                   
                 CT or MRI Chest, Abd, 
               
               
                   
                 Pelvis 
               
               
                   
                 12 lead ECG 
               
               
                   
                 Echocardiogram+ 
               
               
                   
                 Karnofsky 
                   
                   
                 X 
                   
                   
                   
                 X 
               
               
                   
                 Tumor histopathology 
               
            
           
           
               
               
               
            
               
                   
                 Pregnancy Test (if 
                 Prior to TroVax ®/placebo if any possibility of pregnancy 
               
               
                   
                 applicable) 
               
            
           
           
               
               
               
               
               
               
               
               
               
               
            
               
                   
                 QOL 
                   
                   
                 X 
                   
                   
                   
                 X 
                   
               
            
           
           
               
               
               
            
               
                   
                 Concomitant Therapy 
                 Record on each visit that patient receives TroVax ®/placebo 
               
               
                   
                 AEs 
                 Throughout the study while patient receiving TroVax ®/placebo and 30 days after 
               
               
                   
                 Subsequent renal cancer 
                 Record other renal cancer treatment once patient is not receiving TroVax ®/placebo 
               
               
                   
                 Rx 
               
               
                   
                 Survival status/date of 
                 Record on each visit that patient receives TroVax ®/placebo and every 
               
               
                   
                 death 
                 12 weeks thereafter. If patient does not return to clinic seek 
               
               
                   
                   
                 survival status and date of death as permitted by patient consent 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
            
               
                   
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
               
               
                   
                 19 
                 20 
                 21 
                 22 
                 23 
                 24 
                 25 
                 26 
                 27 
                 28 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                 TroVax ®/Placebo day 1 
                 X 
                   
                 X 
                   
                   
                   
               
            
           
           
               
               
               
            
               
                 Patient   
                   
                 Patients receive only one of the following treatments 
               
               
                   
                 IL-2 Treatment 
                 Continue with 6 weeks sub- 
               
               
                   
                 days 1-5 each wk 
                 cutaneous IL-2 followed by 2 
               
               
                   
                   
                 weeks without IL-2 every 8 
               
               
                   
                   
                 weeks until tumor progression 
               
               
                   
                   
                 or week 46 (whichever is first) 
               
            
           
           
               
               
            
               
                   
                 OR 
               
            
           
           
               
               
               
            
               
                   
                 IFNα 
                 Subcutaneous IFNα day 1, 3 and 5 of each week until tumor 
               
               
                   
                   
                 progression (refer to nationally approved prescribing information 
               
               
                   
                   
                 or institutional guidelines of use of IFNα for renal cancer). 
               
            
           
           
               
               
            
               
                   
                 OR 
               
            
           
           
               
               
               
            
               
                   
                 sunitinib 
                 Continue with 4 weeks on sunitinib then 2 
               
               
                   
                   
                 weeks without sunitinib every 6 weeks until 
               
               
                   
                   
                 tumor progression. (see nationally approved 
               
               
                   
                   
                 sunitinib prescribing information) 
               
            
           
           
               
               
            
               
                   
                 Patients receive all the following procedures 
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
            
               
                 Physical examination 
                   
                   
                   
                   
                   
                   
                   
                 X 
                   
                   
               
               
                 Weight, BP, Pulse, Temp 
                   
                   
                 X 
                   
                   
                   
                 X 
               
               
                 CBC/Diff/Plts 
                   
                   
                 X 
                   
                   
                   
                 X 
               
               
                 Chemistry Panel 
                   
                   
                 X 
                   
                   
                   
                 X 
               
               
                 CT or MRI Chest Abd, 
                   
                   
                   
                   
                   
                   
                   
                 X 
               
               
                 Pelvis 
               
               
                 Karnofsky 
                   
                   
                 X 
                   
                   
                   
                 X 
               
               
                 QOL 
                   
                   
                 X 
                   
                   
                   
                 X 
               
            
           
           
               
               
            
               
                 Pregnancy Test (if 
                 Prior to TroVax ®/placebo if any possibility of pregnancy 
               
               
                 applicable) 
               
               
                 Concomitant Therapy 
                 Record on each visit that patient receives TroVax ®/placebo 
               
               
                 AEs 
                 Throughout the study while patient receiving TroVax ®/placebo and 30 days after 
               
               
                 Subsequent renal cancer 
                 Record other renal cancer treatment once patient is not receiving TroVax ®/placebo 
               
               
                 Rx 
               
               
                 Survival status/date of 
                 Record on each visit that patient receives TroVax ®/placebo and every 
               
               
                 death 
                 12 weeks thereafter. If patient does not return to clinic seek 
               
               
                   
                 survival status and date of death as permitted by patient consent 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
               
               
               
            
               
                   
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
               
               
                   
                 29 
                 30 
                 31 
                 32 
                 33 
                 34 
                 35 
                 36 
                 37 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
               
            
               
                   
                 TroVax ®/Placebo day 1 
                 X 
                   
                   
                   
                   
               
            
           
           
               
               
               
               
            
               
                   
                 Patient   
                   
                 Patients receive only one of the following treatments 
               
               
                   
                   
                 IL-2 Treatment 
                 Continue with 6 weeks sub- 
               
               
                   
                   
                 days 1-5 each wk 
                 cutaneous IL-2 followed by 2 
               
               
                   
                   
                   
                 weeks without IL-2 every 8 
               
               
                   
                   
                   
                 weeks until tumor progression 
               
               
                   
                   
                   
                 or week 46 (whichever is first) 
               
            
           
           
               
               
            
               
                   
                 OR 
               
            
           
           
               
               
               
            
               
                   
                 IFNα 
                 Subcutaneous IFNα day 1, 3 and 5 of each week until tumor 
               
               
                   
                   
                 progression (refer to nationally approved prescribing information 
               
               
                   
                   
                 or institutional guidelines of use of IFNα for renal cancer). 
               
            
           
           
               
               
            
               
                   
                 OR 
               
            
           
           
               
               
               
            
               
                   
                 sunitinib 
                 Continue with 4 weeks on sunitinib then 2 
               
               
                   
                   
                 weeks without sunitinib every 6 weeks until 
               
               
                   
                   
                 tumor progression. (see nationally approved 
               
               
                   
                   
                 sunitinib prescribing information) 
               
            
           
           
               
               
            
               
                   
                 Patients receive all the following procedures 
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
            
               
                   
                 Physical examination 
                   
                   
                   
                   
                 X 
                   
                   
                   
                   
               
               
                   
                 Weight, BP, Pulse, Temp 
                 X 
                   
                   
                   
                 X 
               
               
                   
                 CBC/Diff/Plts 
                 X 
                   
                   
                   
                 X 
               
               
                   
                 Chemistry Panel 
                 X 
                   
                   
                   
                 X 
               
               
                   
                 CT or MRI Chest Abd, 
               
               
                   
                 Pelvis 
               
               
                   
                 Karnofsky 
                 X 
                   
                   
                   
                 X 
               
               
                   
                 QOL 
                 X 
                   
                   
                   
                 X 
               
            
           
           
               
               
               
            
               
                   
                 Pregnancy Test (if 
                 Prior to TroVax ®/placebo if any possibility of pregnancy 
               
               
                   
                 applicable) 
               
               
                   
                 Concomitant Therapy 
                 Record on each visit that patient receives TroVax ®/placebo 
               
               
                   
                 AEs 
                 Throughout the study while patient receiving TroVax ®/placebo and 30 days after 
               
               
                   
                 Subsequent renal cancer 
                 Record other renal cancer treatment once patient is not receiving TroVax ®/placebo 
               
               
                   
                 Rx 
               
               
                   
                 Survival status/date of 
                 Record on each visit that patient receives TroVax ®/placebo and every 
               
               
                   
                 death 
                 12 weeks thereafter. If patient does not return to clinic seek 
               
               
                   
                   
                 survival status and date of death as permitted by patient consent 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
            
               
                   
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
               
               
                   
                 38 
                 39 
                 40 
                 41 
                 42 
                 43 
                 44 
                 45 
                 46 
                 47 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
               
               
            
               
                 TroVax ®/Placebo day 1 
                 X 
                   
                   
                   
                   
                   
                   
               
            
           
           
               
               
               
            
               
                 Patients only 
                   
                 Patients receive only one of the following treatments 
               
            
           
           
               
               
               
               
            
               
                 receive one 
                 IL-2 Treatment 
                 Continue with 6 weeks sub- 
                 No further IL-2 
               
               
                 of these 
                 days 1-5 each wk 
                 cutaneous IL-2 followed by 2 
               
               
                 treatments 
                   
                 weeks without IL-2 every 8 
               
               
                   
                   
                 weeks until tumor progression 
               
               
                   
                   
                 or week 46 (whichever is first) 
               
            
           
           
               
               
            
               
                   
                 OR 
               
            
           
           
               
               
               
            
               
                   
                 IFNα 
                 Subcutaneous IFNα day 1, 3 and 5 of each week until tumor 
               
               
                   
                   
                 progression (refer to nationally approved prescribing information 
               
               
                   
                   
                 or institutional guidelines of use of IFNα for renal cancer). 
               
            
           
           
               
               
            
               
                   
                 OR 
               
            
           
           
               
               
               
            
               
                   
                 sunitinib 
                 Continue with 4 weeks on sunitinib then 2 
               
               
                   
                   
                 weeks off sunitinib every six weeks until 
               
               
                   
                   
                 tumor progression. (see nationally approved 
               
               
                   
                   
                 sunitinib prescribing information) 
               
            
           
           
               
               
            
               
                   
                 Patients receive all the following procedures 
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
            
               
                 Physical examination 
                   
                   
                   
                 X 
                   
                   
                   
                   
                   
                   
               
               
                 Weight, BP, Pulse, Temp 
                   
                   
                   
                 X 
               
               
                 CBC/Diff/Plts 
                   
                   
                   
                 X 
               
               
                 Chemistry Panel 
                   
                   
                   
                 X 
               
               
                 Karnofsky 
                   
                   
                   
                 X 
               
               
                 QOL 
                   
                   
                   
                 X 
               
            
           
           
               
               
            
               
                 Pregnancy Test (if 
                 Prior to TroVax ®/placebo if any possibility of pregnancy 
               
               
                 applicable) 
               
               
                 Concomitant Therapy 
                 Record on each visit that patient receives TroVax ®/placebo 
               
               
                 AEs 
                 Throughout the study while patient receiving TroVax ®/placebo and 30 days after 
               
               
                 Subsequent renal cancer 
                 Record other renal cancer treatment once patient is not receiving TroVax ®/placebo 
               
               
                 Rx 
               
               
                 Survival status/date of 
                 Record on each visit that patient receives TroVax ®/placebo and every 
               
               
                 death 
                 12 weeks thereafter. If patient does not return to clinic seek 
               
               
                   
                 survival status and date of death as permitted by patient consent 
               
               
                   
               
            
           
           
               
               
               
               
               
               
               
               
               
               
            
               
                   
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
               
               
                   
                 48 
                 49 
                 50 
                 51 
                 52 
                 53 
                 54 
                 55 
                 56 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
               
               
               
               
            
               
                   
                 TroVax ®/Placebo day 1 
                 X 
                   
                   
                   
                   
                   
                   
                   
               
            
           
           
               
               
               
               
            
               
                   
                 Patients only 
                   
                 Patients receive only one of the following treatments 
               
               
                   
                 receive one 
                 IL-2 Treatment 
                 No further IL-2 
               
               
                   
                 of these 
                 days 1-5 each wk 
               
            
           
           
               
               
               
            
               
                   
                 treatments 
                 OR 
               
            
           
           
               
               
               
            
               
                   
                 IFNα 
                 Subcutaneous IFNα day 1, 3 and 5 of each week until tumor 
               
               
                   
                   
                 progression (refer to nationally approved prescribing information 
               
               
                   
                   
                 or institutional guidelines of use of IFNα for renal cancer). 
               
            
           
           
               
               
            
               
                   
                 OR 
               
            
           
           
               
               
               
            
               
                   
                 sunitinib 
                 Continue with 4 weeks on sunitinib then 2 
               
               
                   
                   
                 weeks off sunitinib every six weeks until 
               
               
                   
                   
                 tumor progression. (see nationally approved 
               
               
                   
                   
                 sunitinib prescribing information) 
               
            
           
           
               
               
            
               
                   
                 Patients receive all the following procedures 
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
            
               
                   
                 Physical examination 
                   
                 X 
                   
                   
                   
                   
                   
                   
                   
               
               
                   
                 Weight, BP, Pulse, Temp 
                   
                 X 
               
               
                   
                 CBC/Diff/Plts 
                   
                 X 
               
               
                   
                 Chemistry Panel 
                   
                 X 
               
               
                   
                 Karnofsky 
                   
                 X 
               
               
                   
                 QOL 
                   
                 X 
               
            
           
           
               
               
               
            
               
                   
                 Pregnancy Test (if 
                 Prior to TroVax ®/placebo if any possibility of pregnancy 
               
               
                   
                 applicable) 
               
               
                   
                 Concomitant Therapy 
                 Record on each visit that patient receives TroVax ®/placebo 
               
               
                   
                 AEs 
                 Throughout the study while patient receiving TroVax ®/placebo and 30 days after 
               
               
                   
                 Subsequent renal cancer 
                 Record other renal cancer treatment once patient is not receiving TroVax ®/placebo 
               
               
                   
                 Rx 
               
               
                   
                 Survival status/date of 
                 Record on each visit that patient receives TroVax ®/placebo and every 
               
               
                   
                 death 
                 12 weeks thereafter. If patient does not return to clinic seek 
               
               
                   
                   
                 survival status and date of death as permitted by patient consent 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
               
            
               
                   
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                 Wk 
                   
               
               
                   
                 57 
                 58 
                 59 
                 60 
                 61 
                 62 
                 63 
                 64 
                 65 
                 66 
                 Subsequent weeks 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
               
            
               
                 TroVax ®/Placebo day 1 
                 X 
                   
                 X 
                   
                   
               
            
           
           
               
               
               
            
               
                 Patients only 
                   
                 Patients receive only one of the following treatments 
               
               
                 receive one 
                 IL-2 Treatment 
                 No further IL2 
               
               
                 of these 
                 days 1-5 each wk 
               
            
           
           
               
               
            
               
                 treatments 
                 OR 
               
            
           
           
               
               
               
            
               
                   
                 IFNα 
                 Subcutaneous IFNα day 1, 3 and 5 of each week until tumor 
               
               
                   
                   
                 progression (refer to nationally approved prescribing information 
               
               
                   
                   
                 or institutional guidelines of use of IFNα for renal cancer). 
               
            
           
           
               
               
            
               
                   
                 OR 
               
            
           
           
               
               
               
            
               
                   
                 sunitinib 
                 Continue with 4 weeks on sunitinib then 2 
               
               
                   
                   
                 weeks off sunitinib every six weeks until 
               
               
                   
                   
                 tumor progression. (see nationally approved 
               
               
                   
                   
                 sunitinib prescribing information) 
               
               
                   
                   
                 Patients receive all the following procedures 
               
            
           
           
               
               
               
               
               
               
               
               
               
               
               
               
            
               
                 Physical examination 
                 X 
                   
                   
                   
                   
                   
                   
                   
                 X 
                   
                 Continue follow-up for survival 
               
               
                 Weight, BP, Pulse, Temp 
                 X 
                   
                   
                   
                   
                   
                   
                   
                 X 
                   
                 Record subsequent therapy for renal cancer 
               
               
                 CBC/Diff/Plts 
                 X 
                   
                   
                   
                   
                   
                   
                   
                 X 
               
               
                 Chemistry Panel 
                 X 
                   
                   
                   
                   
                   
                   
                   
                 X 
               
               
                 Karnofsky 
                 X 
                   
                   
                   
                   
                   
                   
                   
                 X 
               
               
                 QOL 
                 X 
                   
                   
                   
                   
                   
                   
                   
                 X 
               
            
           
           
               
               
            
               
                 Pregnancy Test (if 
                 Prior to TroVax ®/placebo if any possibility of pregnancy 
               
               
                 applicable) 
               
               
                 Concomitant therapy 
                 Record on each visit that patient receives TroVax ®/placebo 
               
               
                 AEs 
                 Throughout the study while patient receiving TroVax ®/placebo and 30 days after 
               
               
                 Subsequent renal cancer 
                 Record other renal cancer treatment once patient is not receiving TroVax ®/placebo 
               
               
                 Rx 
               
               
                 Survival status/date of 
                 Record on each visit that patient receives TroVax ®/placebo and every 
               
               
                 death 
                 12 weeks thereafter. If patient does not return to clinic seek 
               
               
                   
                 survival status and date of death as permitted by patient consent 
               
               
                   
               
               
                 If clinically indicated * including LDH at baseline 
               
               
                 Timing of all TroVax ® injections +/−3 days. Timing of all laboratory and clinical observations must remain the same relative to TroVax ®. Week 26 scan may vary by +/−7 days. 
               
               
                     indicates data missing or illegible when filed 
               
            
           
         
       
     
     Allocation of Treatments and Randomisation Procedures 
     Treatment (TroVax® or placebo) will be allocated based on stratified randomisation. The primary objective of stratification will be to ensure that the distribution of first-line standard of care treatment is balanced between the two study arms. Secondary objectives of stratification will be to establish balance between the treatment arms with regard to a prognostic index (Motzer score) and geography. 
     Motzer et al demonstrated in a series of 670 patients with advanced renal cell carcinoma that survival correlated with five prognostic factors: Karnofsky performance status (&lt;80%), high lactate dehydrogenase (LDH) level (&gt;1.5 times the upper limit of normal), low haemoglobin level (less than the lower limit of the gender normal), high corrected serum calcium level (&gt;10 mg/dL), and absence of nephrectomy. The higher the number of positive factors the worse the prognosis. Inclusion criteria for this study require a baseline Karnofsky performance status &gt;80% and prior excision of the primary tumor. During the randomisation procedure the patient&#39;s haemoglobin level (plus gender), LDH and serum calcium will be requested to ensure that the treatment arms are balanced with regard to these prognostic variables. 
     A telephone based interactive voice responsive system will be used. Patients will be registered into the study using an Interactive Voice Responsive System (IVRS). Treatment allocation (TroVax® or placebo) and patient registration will only occur after the Investigator has registered the standard of care therapy allocated to the patients and confirmed that the patient meets all inclusion/exclusion criteria. All randomised patients will be included in Intent to Treat (ITT) analyses. 
     Instruction on access and use of the IVRS service including local telephone access number, script of the randomisation questions in local language and help desk numbers will be issued separate from the protocol. 
     Study Medication Administration 
     Patients included in this trial should receive TroVax® or placebo plus one of the following first-line standards of care treatment options: IL-2 (low dose), interferon α or sunitinib. No other form of immunotherapy, chemotherapy, or radiotherapy should be administered between entering the study and tumor progression. Other concurrent medication may be used as detailed in “Other Concurrent Treatments” below. Following tumor progression patients may receive whatever chemotherapy, radiotherapy, cytokine therapy or other therapy is indicated for further management or palliation of the tumor. All such therapy should be recorded on the patient&#39;s case report form as the patient continues to be followed for survival. 
     Administration of TroVax®/Placebo 
     Prior to administering the vaccine, obtain the prospective patient&#39;s vaccination history and determine whether the individual had any previous reactions to any vaccine including TroVax®. 
     All immunisations of TroVax®/placebo will be given by intramuscular injection into the deltoid muscle of the upper arm. 
     All patients will receive the treatment in a side-room away from contact with other patients. The formulation will be delivered to this side-room. TroVax®/Placebo are presented as lyophilised material. Detailed instructions will be provided to the pharmacist for reconstitution. TroVax® must be re-suspended by adding 1.2 mL of water for injection. The resulting solution will appear opalescent. One mL volume of the solution is then withdrawn into a syringe and injected into the patient. The injection will either be drawn up at the bedside by the person administering the dose, or in the pharmacy and delivered to the bedside in a syringe depending upon local circumstances. Prior to injection the check number of the dose must be confirmed, using IVRS, by either the pharmacist or another responsible individual. 
     Under no circumstances must the reconstituted material be allowed to stand for more than two hours at room temperature. If this does occur, the material must be rejected and IVRS notified. 
     The skin will be swabbed with ethanol and the injection will be given intramuscularly. Following this, the injection site will be covered with an occlusive bandage. This bandage will be removed before the patient is discharged from hospital. 
     Please note: The maximum immunological response to TroVax® dose not usually occur until the patient has received at least three injections. Disease stabilisation or late tumor responses have been reported with various cancer vaccines. It is not established whether continuing TroVax® despite early progression will confer therapeutic benefit. If tumor progression is observed but the patient is tolerating TroVax®/placebo and their performance status remains at a Karnofsky score &gt;60% they should be requested to continue receiving TroVax®/placebo until they have received a minimum of eight injections. Continuation beyond this point is permitted at the discretion of the investigator and patient. 
     Patients should remain under medical observation for one hour following injection with TroVax®/placebo. 
     Adequate treatment provisions, including epinephrine injection (1:1000), should be available for immediate use should an anaphylactic reaction occur. 
     All healthcare staff handling TroVax® or materials contaminated by it must wear an apron, gloves, mask, and protective goggles. All materials potentially contaminated with TroVax® e.g. syringes, swabs, bandages, must be destroyed by incineration, or local equivalent, in accordance with hospital policy on genetically modified materials. Certificates of Destruction, or equivalent, must be completed for the used and unused vials, and copies maintained in the Trial File. 
     Administration of IL-2 
     IL-2 (Chiron or locally approved manufacturer) will be given by subcutaneous injection. The lyophilised material (22 million units) must be reconstituted in 1.2 mL of diluent after which it will have a shelf life of 48 hours when kept refrigerated at 2-8° C. The dosage schedule will be an initial dose of 250,000 U/Kg/dose (with an upper limit of 22 million units/dose) for 5 days out of 7 in week 1 of each cycle followed by 125,000 U/kg/dose (with an upper limit of 11 million units/dose) for 5 days in each of weeks 2-6 of each cycle. There will then be a two week recovery period before the next cycle of IL-2 commences. Once reconstituted a vial may be used for two injections when these are given on consecutive days. The dose used should be recorded in the Case Report Form. 
     Administration of IFNα 
     IFNα will be administered once a day as a subcutaneous injection three times per week on days 1, 3 and 5 of each week. (Note: Pegylated IFNα is not included as a standard of care option in this protocol. No safety or immunological activity data are currently available on the concomitant use of TroVax® and pegylated IFNα). 
     Unless tumor progression is noted the patient should be treated for a minimum of 12 weeks. Treatment may be continued until tumor progression at the discretion of the investigator. 
     Doses of IFNα used by different treatment centres depend on local Regulatory Authority approved label text, and manufacturer. The dose used in this study should reflect local standard of care but should be targeted between 9 million International Units (IU) and 18 million IU three times per week. Lower doses should be used during the first (and depending on final target dose) the second week. The actual schedule used will be recorded on the Case Report Form. 
     For further information on IFNα please refer to the nationally approved Package Insert or Summary of Product Characteristics produced by the local license holder. 
     For evaluation of patients for clinical benefit from the treatment please see study schedule. Patients who are benefiting from treatment are eligible for further treatment. Thereafter, therapy will continue until criteria for progressive disease are met or up to an additional 12 months. 
     Administration of Sunitinib 
     Sunitinib capsules are supplied as printed hard shell capsules containing sunitinib malate equivalent to 12.5 mg, 25 mg or 50 mg of sunitinib and should be handled according to the manufacturers instructions. The recommended dose of sunitinib for advanced Renal Cell Cancer is one 50 mg oral dose taken once daily, on a schedule of 4 weeks on treatment followed by 2 weeks off. Sunitinib may be taken with or without food. The schedule used should be recorded in the Case Report Form. 
     Treatment should continue until tumor progression or until unacceptable toxicity occurs. 
     Administration of Other Concurrent Treatments 
     All other concurrent medications will be recorded in detail in the CRF during the treatment. This information may be used to assist interpretation of any report adverse events. If a patient has discontinued TroVax®/placebo and other renal cancer treatments are used, then a simple checklist in the CRF will be used to record the type of treatment; this information may be used to assist interpretation of survival data and management of the patient following the selected standard of care therapy. 
     Medication intended to relieve symptoms will be prescribed at the discretion of the Investigator and recorded in the Case Report Form (CRF). Medications prescribed by the patient&#39;s family practitioner will also be noted in the CRF. The patients should also keep a record of any over the counter medicines consumed and these should be noted in the CRF. 
     Therapies considered necessary for the subject&#39;s well being may be administered at the discretion of the investigator. These will be recorded in the Case Report Form. 
     Supportive care to mitigate known adverse events or complications of concomitant standard of care may be administered at the physician&#39;s discretion including antipyretics, non-steroidal anti-inflammatories, anti-emetics etc. Oral, intramuscular or intravenous steroids should not be used except where required to manage life threatening emergencies. Supportive care will be reported in the Case Report Form. 
     Management of Disease Progression 
     If disease progression is noted during the study, and other anticancer medications are required, the IL-2, IFNα, or sunitinib should be stopped. The selection of subsequent antitumor therapy is not specified by this protocol and is at the discretion of the patient and his or her physician. 
     In the event of tumor progression the patients should remain within the study (unless they request to withdraw). This is for two reasons: 
     This is a survival study and patients need to be followed for survival data. 
     The maximum immunological response to TroVax® does not usually occur until the patient has received at least three injections. Disease stabilisation or late tumor responses have been reported with various cancer vaccines. It is not established whether continuing TroVax® despite early progression will confer therapeutic benefit. Therefore if tumor progression is observed but the patient is tolerating TroVax®/placebo and their performance status remains at a Karnofsky score &gt;60% they should be requested to continue receiving TroVax®/placebo until they have received a minimum of eight injections of the study preparation. Continuation on study beyond this point to receive all TroVax®/placebo injections is permitted at the discretion of the investigator or patient. 
     Specific Procedures 
     Screening and Selection Procedures 
     A screening log must be maintained for all patients screened for entry to the study including, if applicable, the reason for not entering the study. 
     Inclusion/exclusion criteria are listed in the section titled Entry Criteria (above) and the study schedule. 
     Imaging/Diagnostic 
     Within 2 weeks of screening, and prior to receiving study drug metastases will be documented using chest, abdominal and pelvic CT scans according to defined guidelines contained in a Site Operations Manual. This will enable a possible independent review at a later time. An MRI or CT scan of the brain will also be obtained if there is a clinical suspicion of cerebral metastases. 
     Clinical and Laboratory/Diagnostic 
     For screening, these are required within 14 days before the first TroVax®/Placebo injection:
         History and physical examination, including height, weight, and vital signs.   Karnofsky performance status.   Quality of life (QLQ30,EuroQOL) will be evaluated.   12 lead EGC (for all patients) and Echocardiogram only if clinically indicated   Clinical pathology tests (Full blood count with differential white cell and platelet counts, urea and electrolytes, liver function tests (total bilirubin, AST, ALT, alkaline phosphatase), serum proteins, calcium, phosphate, uric acid and creatinine). In addition, at baseline LDH must be measured.   Pregnancy test (for women of reproductive potential—including those whose last menstrual period was within the last two years). At screening this will be a serum test but at all other time points this will be a urine test.   If available, tumor tissue from earlier biopsies will be obtained. (To be batched and tested at a later date for the presence of tumor antigens.)       

     All clinical laboratory tests will be conducted by a suitably qualified central laboratory. 
     Samples for Immunology 
     10 mL blood samples will be required. These samples are to be placed in a heparinised blood collection tube and are to be processed immediately by a suitably qualified central laboratory. The samples will then be analysed by Oxford BioMedica, or designee, according to their SOPs. 
     Study Materials 
     TroVax®/Placebo 
     TroVax®/Placebo will be supplied by Oxford BioMedica Ltd. 
     Packaging and labelling and additional information. Packaging and labelling will be in accordance with Good Manufacturing Practice (GMP) for clinical trials. Each vial will bear a label conforming to national regulations for an Investigational Medicinal Product. The outer carton labelling will also bear a label conforming to national regulations for an Investigational Medicinal Product. 
     Investigators and pharmacists should note that the clinical trial supplies may only be used for the clinical trial for which they are indicated. They must not be employed for any other trial, whether of TroVax® or not, or for any other clinical use. 
     Additional information may be found in the current version of the Investigators Brochure. 
     Storage and Disposition of Study Medications 
     TroVax®/placebo must be stored in a locked fridge between 2° C. to 8° C. (36° F. to 46° F.) in the hospital pharmacy, or other comparable secure location. It must be stored in such a way that it cannot be mixed up or confused with other medications, be they clinical trial supplies or medicines for routine clinical use. 
     Dispensing will be documented by completing a log with the date of dispensing and the patient details. Used vials should be stored in labelled biohazard bags or containers prior to reconciliation by the trial monitor. 
     At each visit, the clinical trial monitor will review the drug-dispensing log and reconcile it with the unused vials (if available due to local procedures). All unused vials will be destroyed on site in accordance with procedures for destruction of genetically modified waste and destruction will be documented appropriately. A copy of the Certificate of Destruction will be lodged in the site Trial File. 
     Precautions/Overdose 
     TroVax® is contraindicated in patients who have previously had hypersensitive reactions to TroVax®, vaccinia vaccinations, egg proteins or neomycin. Patients should remain under medical observation for one hour following injection with TroVax. Adequate treatment provisions, including epinephrine injection (1:1000), should be available for immediate use should an anaphylactic reaction occur. TroVax® is also contraindicated in patients who are pregnant or lactating. 
     Although highly unlikely, it is possible that an autoimmune response against the pituitary or gut might occur since these organs showed sporadic low level staining for 5T4 in in vitro experiments. Studies in over 100 patients receiving approximately 450 doses of TroVax® have not indicated any laboratory or clinical signs or symptoms suggestive of compromised pituitary function. However, the Investigators should be aware of the preclinical finding. 
     All healthcare staff handling TroVax® or materials contaminated by it must wear an apron, gloves, a mask and protective goggles. Pregnant healthcare staff must not handle either TroVax® or materials contaminated with TroVax®. 
     No cases of TroVax® overdose have been reported. No active medical intervention is know to be required in the event of overdose. The patient should be observed for as long as is considered appropriate by the investigator/physician based on the patient&#39;s clinical condition and supportive care given if required. 
     IL-2 
     Il-2 is available commercially from Chiron or a local manufacturer. The lyophilised material (22 million units) must be reconstituted in 1.2 mL of diluent after which it will have a shelf life of 48 hours when kept refrigerated. 
     Current prescribing information should be reviewed prior to administering IL-2. IFNα 
     IFNα is available commercially from a number of manufactures. Only commercially available material approved by the competent national regulatory authority should be used in this study 
     IFNα may be supplied in single use prefilled syringes or in multiuse prefilled “pens”. Patients will be instructed to self administer the IFNα in accord with approved package insert and patient information leaflet by appropriately qualified medical, nursing or pharmacy staff. Reconstitution is not required. 
     IFNα should be stored at 2° to 8° C. (36° F. to 46° F.). 
     Current prescribing information should be reviewed prior to administering IFNα. 
     Sunitinib 
     Sunitinib is supplied as 12.5 mg, 25 mg and 50 mg capsules which should be administered according to the manufacturer&#39;s instructions (Pfizer). 
     Other Study Supplies 
     Case report forms (CRFs) will be used in this study (see Data Collection section below). Quality of life questionnaires EuroQOL and QLQ30 and laboratory kits will also be supplied. The Principal Clinical Investigator and Co-Investigators must keep all CRF supplies, both completed and blank, in a secure place. 
     Adverse Events 
     Adverse Event Definition 
     An adverse event is any untoward medical occurrence in a patient or clinical investigation subject administered a pharmaceutical product and which does not necessarily have to have a causal relationship with the treatment. All adverse events must be described in the appropriate section of the CRF and their severity and putative relationship to the study medication noted. Definitions of severity are as follows:
         Mild: does not interfere with the conduct of the study, resolves spontaneously, does not need medication or any other therapy.   Moderate: requires treatment, interferes temporarily with the conduct of the study.   Severe: forces withdrawal from the study   Serious: death, life threatening, requires or prolongs hospitalisation, results in persistent or significant disability/incapacity, overdose, or is a congenital anomaly/birth defect       

     Definitions of relationship to study medication are as follows:
         Unrelated: bears no relation to timing of medication, similar to symptoms or signs expected in the disease process, does not recur on re-challenge.   Possibly: bears relation to timing of medication, similar to symptoms or signs expected in the disease process, does not recur on re-challenge.   Probably: bears clear relation to timing of medication, distinct from symptoms or signs expected in the disease process, does not recur on re-challenge.   Definitely: bears clear relation to timing of medication, distinct from symptoms or signs expected in the disease process, recurs on re-challenge.       

     Adverse events may also be expected or unexpected. Adverse events are to be considered expected if listed in the Investigator Brochure. 
     Serious Adverse Event (SAE) and Serious Adverse Reaction (SAR) Definition Investigators are required to notify Oxford BioMedica&#39;s pharmacovigilance service provider (PAREXEL) immediately if a patient has a reportable serious adverse event. A serious adverse event (SAE) is defined by ICH-GCP as: 
     Death (death due to progressive renal cancer is the primary endpoint of this study and should not be reported as an adverse event unless in the opinion of the investigator the study medication (TroVax®/placebo) may possibly, probably or definitely have contributed to or hastened death) 
     Life Threatening 
     Requires or prolongs hospitalisation 
     Results in persistent or significant disability/incapacity 
     Congenital anomaly/birth defect 
     Other medically important condition starting or worsening during the study. 
     The investigator must also complete as much as possible of the serious adverse event form in the Case Report Form (CRF) and transfer it to Oxford BioMedica&#39;s pharmacvigilance service provider (PAREXEL) not later than 24 hours after the even becomes known to the investigator or his/her staff. 
     As further information or follow up information becomes available the investigator should document this and amend any previous report if appropriate. This information should be transferred to Oxford BioMedica&#39;s pharmacovigilance service provider (PAREXEL) using the serious adverse event form in the CRF. 
     PAREXEL will report all serious, related, and unexpected adverse events to all relevant Regulatory Authorities in accordance with local regulations. 
     Further instructions on the documentation and transfer of information to permit full compliance with national and international pharmacovigilance requirements and Good Clinical Practice together with training for investigator staff will be provided separate to this protocol. 
     General Requirements 
     This study will utilize the Common Terminology Criteria for Adverse Events Version 3 to determine the severity of the reaction for adverse event reporting. 
     Reporting requirements and procedures depend upon:
         whether agents are suspected of causing the adverse event,   whether the possibility of such an adverse event was reported in the protocol, consent form, or manufacturer&#39;s literature (expected or unexpected adverse event),   the severity or grade of the adverse event.       

     Withdrawals due to Adverse Events 
     If a patient is withdrawn from treatment because of an adverse event (AE), the patient will be followed up until the AE is resolved or has stabilised. Because the primary endpoint of this study is survival the patient will continue to be followed for survival status even if trial therapy was withdrawn. 
     Withdrawal from the study, and reason for withdrawal, must be documented in the CRF. 
     Since the primary endpoint of this study is survival and all randomised patients will be included in the analysis of the primary endpoint. Patients who wish to withdraw from all other study related procedures should be asked whether they would consent to allow follow up limited to establishing their survival status. If they agree, a new consent form to document this consent but withdrawal from all other study procedures should be completed. 
     Pregnancy 
     Patients should be advised that they or their partner should avoid becoming pregnant during the study. 
     Patients of reproductive potential should be taking contraceptive measures as required by the relevant inclusion criterion (as stated above). 
     If a patient does become pregnant she should immediately inform the investigator who should document this on the adverse events page of the CRF. The Investigator should provide necessary counselling for the patient. The Investigator should follow the pregnancy to its conclusion. Spontaneous abortion or foetal abnormality or abnormal birth should be reported as serious adverse events as described above. 
     Management of Toxicity 
     The NCI Common Terminology Criteria for Adverse Events v3.0 (CTCAE) will be utilized (see Appendix A). Toxicity will be evaluated on every patient visit. 
     All toxic events should be managed with optimal supportive care, including transfer to the Intensive Care Unit if appropriate. 
     TroVax®/Placebo management of toxicity 
     No dose reductions of TroVax®/placebo are permitted. Paracetamol/acetaminophen may be used to manage transient pyrexia or local discomfort following injection If the patient is unable to tolerate TroVax®/placebo at the protocol dose TroVax®/placebo should be discontinued but the patient should continue to be followed for survival data. 
     Standard of Care Management of Toxicity 
     Toxicity associated with standard of care therapy should be managed according the nationally approved Package Insert or Summary of Product Characteristics and accepted medical practice. Dosage may be reduced or withdrawn at the discretion of the Investigator. 
     Data Management and Statistical Analysis 
     Overview of the Study Design 
     The DSMB will be responsible for preparing the formal monitoring rules for this study; a general overview of the monitoring program is described in this section of the protocol. Oxford BioMedica will provide guidance to the DSMB, however the Board is an independent body and will be charged with preparing the formal monitoring and stopping rules for the study. This parallel-designed study contains a series of planned interim assessments for futility, and to ensure the planning elements relative to attrition and the primary endpoint remain consistent. The initial interim assessment will take place after 50 patients (25 patients per arm or ˜7% of the target population) have been randomised and followed for 8 weeks when the blood sampling for 5T4 antibodies following the third dose of TroVax® is scheduled to be performed. The intra-treatment group adverse event profiles, rates of attrition, and antibody response will be evaluated by the DSMB. Sample size estimates for this study are predicated on a one year survival. 
     Sample Size Estimates 
     Estimates were prepared to detect an absolute difference of ˜11% in survival at 1-year (base proportions: 50% to 61%); estimates are presented below in Table A. 
     
       
         
           
               
             
               
                 TABLE A 
               
             
            
               
                   
               
               
                 Estimates Based on Overall Survival 
               
            
           
           
               
               
               
               
               
               
               
               
            
               
                   
                 Total 
                 Total 
                   
                   
                 Propor- 
                 Propor- 
                 Haz- 
               
               
                 Pow- 
                 Sample 
                 Required 
                 Al- 
                 Be- 
                 tion 
                 tion 
                 ard 
               
               
                 er 
                 Size (N) 
                 Events 
                 pha 
                 ta 
                 Surv. (S1) 
                 Surv. (S2) 
                 Ratio 
               
               
                   
               
               
                 0.80 
                 691 
                 309 
                 0.05 
                 0.2 
                 0.500 
                 0.605 
                 0.725 
               
               
                   
               
            
           
         
       
     
     A total sample size of ˜700 patients (split equally between the two groups), or 309 events, achieves 80% power to detect a hazard rate of 0.725 when the proportions surviving in each group are 0.500 and 0.605 at a significance level of 0.05 using a two-sided test. These estimates represent the initial framework for monitoring based on the log of the hazard ratio from the Cox Proportional Hazards regression model without adjusting for covariates. 
     Report Definitions 
     Power is the probability of rejecting a false null hypothesis. 
     Events are the number of deaths (from whatever cause) that must occur in each group. 
     Alpha is the probability of rejecting a true null hypothesis. 
     Beta is the probability of accepting a false null hypothesis. 
     S1 is the proportion surviving in group 1, S2 is the proportion surviving in group 2. 
     HR is the hazard ratio. It is calculated using Log(S2)/Log(S1). 
     This sample size would also be appropriate for detecting a minimum difference in median survival of ˜11.3 weeks, based on exponential survival times (Table B). Details used in preparing this estimate are presented below. 
     
       
         
           
               
             
               
                 TABLE B 
               
             
            
               
                   
               
               
                 Comparing Median Survival (H0: Theta1 = Theta2. Ha: Theta1 &lt;&gt; Theta2) 
               
            
           
           
               
               
               
               
               
               
               
               
               
            
               
                   
                   
                   
                 Allocation 
                   
                   
                   
                   
                 Theta1/ 
               
               
                 Power 
                 N1 
                 N2 
                 Ratio 
                 Alpha 
                 Beta 
                 Theta1 
                 Theta2 
                 Theta2 
               
               
                   
               
               
                 0.80000 
                 350 
                 350 
                 1.00000 
                 0.05000 
                 0.20000 
                 48.0 
                 59.3 
                 0.80902 
               
               
                   
               
            
           
         
       
     
     Report Definitions 
     Power is the probability of rejecting a false null hypothesis. 
     N1 is the number of failures needed in Group 1, N2 is the number of failures needed in Group 2. 
     Alpha is the probability of rejecting a true null hypothesis. 
     Beta is the probability of accepting a false null hypothesis. 
     Theta1 is the Mean Life in Group 1, Theta2 is the Mean Life in Group 2. 
     Patient Populations 
     The Intent to Treat (ITT) population will include all patients who are randomised. 
     The Modified Intent to Treat (MITT) population, will include all patients who receive three or more injections, or experience an adverse event directly attributable to the study medication resulting in discontinuation, prior to the third injection. Patients who fail to successfully receive three injections for reasons not directly associated with the study medication will not be included in this population. 
     The Per Protocol (PP) population includes only patients who met the inclusion and exclusion criteria and were treated in accord with the protocol requirements. 
     The primary efficacy analysis will be carried out using the ITT population. However, an exploratory analysis of the primary efficacy parameter will also be carried out using MITT population and the PP population. All safety analyses will be carried out using the Intent to Treat population. 
     Monitoring of the Primary Endpoint 
     The DSMB may recommend stopping the trial early if presented with overwhelming evidence of efficacy. 
     Evidence would be deemed “overwhelming” if the one-sided P-value in favour of the active treatment derived from the Cox Proportional Hazards time-to-death model is less than 0.01%. The overall effect of treatment must also be considered clinically plausible by the DSMB. 
     P-values will be adjusted to maintain an overall one-sided P-value of 2.5% using the alpha-spending approach of Lan and Demets (Lan K K G and DeMets D L (1983) Discrete sequential boundaries for clinical trials. Biometrika 70: 659-663). 
     The DSMB will review at each meeting the number of patients lost to follow-up. If the number of patient lost to follow-up is high enough to compromise the objectives of the study the DSMB may either recommend terminating the study on the grounds that it will not effectively address its objective or alternatively resizing the study to permit the objective of the study to be appropriately address. 
     The DSMB may also recommend stopping the trial early if presented with evidence of futility. At each interim analysis the conditional power will be calculated. If, taking into account the whole clinical context, the DSMB considers the prospect of achieving a statistically significant result within a reasonable sample size to be unacceptably low, then the DSMB may recommend stopping the trial. 
     The methodology for study re-sizing will follow that of Li, Shih, Xie and Lu (Li G, Shih W J, Xie T and Lu J (2002) A sample size adjustment procedure for clinical trials based on conditional power. Biostatistics 3: 277-287). 
     Statistical Analyses 
     Unless otherwise stated, all statistical tests will be performed using 2-sided tests at the 5% significance level. Baseline is defined as the last observation before the initiation of the study related treatment. Continuous demographic parameters, such as the patient&#39;s age at the time of enrolment, will be summarised for the ITT population using descriptive statistics (N, mean, median, standard deviation, minimum and maximum value, and 95% 2-sided confidence limits) and compared between groups using a 2-sample t-test. Categorical parameters will be summarised as a proportion of the ITT population and compared using a 2-tailed Fisher&#39;s Exact test. Co-morbid risk factors will be summarised for the ITT population by treatment assignment and according to the type of variable (categorical, continuous) and compared between groups. Kaplan-Meier estimates for the time to death will be prepared based on the ITT population. Event rates at 12- and 24-months will be derived from the Kaplan-Meier estimates. The number and proportion of patients alive after each treatment cycle will be tabulated and summarised using 95% confidence intervals. Separate tables containing patient counts, percentages, and 95% binomial confidence intervals will be prepared based on risk factors. No data will be imputed for patients who withdrew prematurely from the study, or have missing values for specific parameters. 
     Univariate analyses will be prepared for each laboratory parameter and compared between groups using a 2-sample t-test. The proportion of patients found to have abnormal values considered clinically significant will be compared between treatment groups using a 2-tailed Fisher&#39;s Exact test. Laboratory shift tables containing patient counts and percentages will be prepared by treatment assignment, laboratory parameter, and time. 
     Demography 
     Patient demographic data will be summarised by type of variable; categorical data by counts and percentages and continuous variable by means, standard deviations, medians, minimum, maximum and numbers of patients. 
     Analysis of Efficacy Data 
     The standard covariates for the efficacy analyses are: 
     Geographical region (three groups: USA, European Union, Eastern Europe excluding European Union). 
     First line of standard care (three groups: IL-2, interferon-α, sunitinib) 
     Prognostic index (Motzer score). (Motzer score classifies patients into three prognostic groups: “favorable”, “intermediate” and “poor” based on an algorithm which considers pre-treatment performance status, LDH, hemoglobin, and corrected serum calcium. The inclusion and exclusion criteria preclude enrolment of the “poor” prognostic group. All eligible patients will be covered in the remaining two groups) 
     Primary 
     The primary endpoint is time to death. Time to death will be analyzed in the ITT population using a Cox Proportional Hazards regression model with terms for treatment and the standard efficacy covariates. 
     Secondary 
     The secondary efficacy endpoints will be analysed following the statistical procedures presented below. 
     Endpoint: The proportion of patients with progression free survival at 26 weeks (+/−1 week) based on radiological data in the ITT population. 
     The proportion of patients with progression free survival at 26 weeks (+/−1 week) relative to baseline will be analysed using a logistic regression model with terms for treatment and the standard efficacy covariates. Data will be analysed using the ITT population and adjudicated (blinded peer review). 
     Endpoint: Tumor response rates based on RECIST according to the investigator&#39;s reported interpretation of the radiological reports observed in the ITT population. 
     Both the rate and duration of tumor response will be compared between treatment groups. Response rates will be compared between treatment groups and analysed using a logistic regression model with terms for treatment and the standard efficacy covariates. The duration of response will be analysed using a Cox Proportional Hazards regression model with terms for treatment and the standard efficacy covariates. 
     Endpoint: The survival event rate ratio in the TroVax® arm versus the placebo arm in the MITT population, based on the log of the hazard ratio. 
     Time to death will be analysed using a Cox Proportional Hazards regression model with terms for treatment and the standard efficacy covariates. Survival curves for the proportion of patients remaining event-free will be estimated using the Kaplan-Meier method 
     Endpoint: Anti-5T4 serum antibody levels (additional measures of immune response including specific measures of cellular response will be investigated at some centres). 
     Qualitative antibody response to 5T4 within the active treatment group will be analysed as a main effect using a logistic regression model with terms for the standard efficacy covariates. 
     The analysis of the Quality of Life (QOL) parameters is discussed below. 
     Analysis of Adverse Event Data 
     Safety will be assessed using the Intent to Treat population. Adverse events will be coded using the MedDRA classification to give a preferred term and organ class for each event. Proportions of patients with adverse events will be presented. Tables of adverse events will be presented by organ class and also by organ class and preferred term. These tables will also include overall totals for adverse events within each body system and organ class. The number of patients with an event in each classification of severity and relationship to treatment within each treatment group will be tabulated. Serious adverse events and adverse events leading to withdrawal will be listed separately. 
     Treatment emergent and non-emergent events will be presented separately. Treatment emergent adverse events are defined as adverse events that had an onset day on or after the day of the first dose of study medication. Adverse events that have missing onset dates will be considered to be treatment emergent. 
     Adverse events will be listed by patient within groups showing time of onset, period of event, severity, relationship to disease and outcome. 
     QOL Parameters 
     Results from the QOL questionnaire (EuroQoL and QLQ30) will be presented for the ITT and Per-Protocol populations. Results from the QOL questionnaire will be analyzed using a generalised linear modelling approach based on maximum likelihood, treating patients as a random effect in the model. Terms will be included for the standard efficacy covariates. 
     Concomitant Medication 
     Concomitant medication will be listed by patient, treatment assignment, and study visit. 
     Vital Signs 
     Vital signs to be collected throughout the course of the study include systolic and diastolic blood pressures (mmHg), heart rate (bpm), body temperature (° C./° F.), and weight (kg). Vital signs will be summarised using univariate statistics (N, arithmetic average, standard deviation, median, and range) for each clinical assessment and presented for the cohort of patients who have data at the initial baseline visit and at least one the specific follow-up visits. In addition to the univariate statistics, the changes from baseline to each follow-up assessment visit will be analysed using a paired-difference t-test for the within-group mean change from baseline. Additionally, 95% confidence interval limits for the mean change from baseline will also be reported. 
     The incidence rates of clinically notable vital sign changes, including the criteria for clinically notable, will be summarized and presented in a Patient Data Listing. Vital signs and body weight abnormalities of potential clinical significance will be defined as follows:
         Systolic blood pressure change ≧20 mmHg and a systolic blood pressure value that was ≧180 or ≦90 mmHg   Diastolic blood pressure change ≧15 mmHg and a diastolic blood pressure value that was ≧105 or ≦50 mmHg   Pulse change of ≧15 bpm and a pulse value that was ≧120 or ≦50 bpm   Temperature change of ≧1° C./2° F. and a temperature value that was ≧38° C./101° F.   Body weight decrease ≧5%   Clinically significant abnormal vital signs will be flagged and presented using counts by study visit.       

     An additional listing will be provided for those patients who have clinically significant vital sign abnormalities. 
     Other Safety Parameters 
     All other safety parameters will be listed by patient, treatment assignment, and study treatment period. 
     Laboratory Parameters 
     Haematology, biochemistry and other laboratory data will be listed at each time point by treatment group and, for appropriate values, will be flagged using the signed laboratory ranges as High/Low/Within laboratory normal range (H, L). 
     Changes from baseline will also be listed and abnormal changes from baseline will be flagged. 
     An additional listing will be provided for those patients who have laboratory values that are abnormal and considered to be clinically significant. 
     Withdrawals 
     The number (%) of patients who withdraw from the study over time, along with their reasons for withdrawal, will be tabulated. 
     Deaths 
     All deaths occurring during the treatment period of study and its follow up period will be listed. 
     Determination of Treatment Group Comparability 
     Patient demographics and disease histories will be summarised for each treatment group and compared between treatment groups. 
     Treatment Assignment 
     Patients will be randomised using a stratified central randomisation scheme. Given the initial target enrolment and the proposed number of clinical sites, attempting to balance the enrolment on an intra-centre basis was not considered feasible using a deterministic randomisation scheme. For example, if patients were to be randomised intra-centre using randomised blocks of 4, and 50% of the sites failed to fill a complete block, an enrolment imbalance could develop between the 2 groups resulting in a loss of statistical power. To eliminate this potential imbalance, a central randomisation scheme will be used, balancing on blocks of 4 within geographical areas (usually countries) involving multiple sites. 
     Stratification 
     Patients will be stratified by selected standard of care, prognostic indicator (Motzer score), geographical area, and institution. The stratification will be performed by IVRS. 
     Results 
     Following the announced ending of the trial, immunological and clinical response data were un-blinded. An exploratory analysis was undertaken with the primary aim of identifying potential correlates between parameters and enhanced patient survival. 
     The analyses have focused solely on the biomarkers detected in patients known to have received TroVax®. The magnitude of the biomarker level has been analyzed. Each patient was then categorized into “above median” or “below median” category or low or high level category. The survival of patients in each category was compared by plotting Kaplan-Meier curves. 
       FIG. 1  illustrates “above median” and “below median” corrected calcium effects on patient survival in TroVax®-treated TRIST patients. 
     The data summarized in  FIG. 1  suggest that patients with lower (below median) corrected calcium levels survive for longer than those with above median corrected calcium levels.  FIGS. 2 and 3  confirm that this effect and in particular that it continues as the corrected calcium level is further reduced below median. 
       FIG. 4  illustrates “above median” and “below median” platelet level effects on patient survival in TroVax®-treated TRIST patients. 
     The data summarized in  FIG. 4  suggest that patients with lower (below median) platelet levels survive for longer than those with above median platelet levels.  FIG. 5  confirms that this effect continues as the platelet level is further reduced below median. 
       FIG. 6  illustrates haemoglobin level effects on patient survival in TroVax®-treated TRIST patients. The data summarized in  FIG. 6  suggest that patients with higher haemoglobin levels survive for longer than those with lower haemoglobin levels. 
       FIG. 7  illustrates creatinine level effects on patient survival in TroVax®-treated TRIST patients. The data summarized in  FIG. 7  suggest that patients with higher creatinine levels survive for longer than those with lower creatinine levels. 
     The overall effect of baseline corrected calcium, creatinine, haemoglobin and platelets on patient survival in TroVax®-treated TRIST patients is summarised in  FIGS. 8 to 10 . 
     Example 2 
     Phase II Survival Analysis (CRC) Patients—Effect of Factors on Patient Survival 
     The results of the trials described in the following papers were analysed: 
     Vaccination of colorectal cancer patients with modified vaccinia Ankara delivering the tumor antigen 5T4 (TroVax) induces immune responses which correlate with disease control: a phase I/II trial. Harrop R, Connolly N, Redchenko I, Valle J, Saunders M, Ryan M G, Myers K A, Drury N, Kingsman S M, Hawkins R E, Carroll M W. Clin Cancer Res. 2006 Jun. 1; 12(11 Pt 1):3416-24. 
     An MVA-based vaccine targeting the oncofetal antigen 5T4 in patients undergoing surgical resection of colorectal cancer liver metastases. Elkord E, Dangoor A, Drury N L, Harrop R, Burt D J, Drijfhout J W, Hamer C, 
     Andrews D, Naylor S, Sherlock D, Hawkins R E, Stern P L. J Immunother. 2008 November-December; 31(9):820-9. 
     Vaccination of colorectal cancer patients with TroVax given alongside chemotherapy (5-fluorouracil, leukovorin and irinotecan) is safe and induces potent immune responses. Harrop R, Drury N, Shingler W, Chikoti P, Redchenko I, Carroll M W, Kingsman S M, Naylor S, Griffiths R, Steven N, Hawkins R E. Cancer Immunol Immunother. 2008 July; 57(7):977-86. 
     Vaccination of colorectal cancer patients with modified vaccinia ankara encoding the tumor antigen 5T4 (TroVax) given alongside chemotherapy induces potent immune responses. Harrop R, Drury N, Shingler W, Chikoti P, Redchenko I, Carroll M W, Kingsman S M, Naylor S, Melcher A, Nicholls J, Wassan H, Habib N, Anthoney A. Clin Cancer Res. 2007 Aug. 1; 13(15 Pt 1):4487-94. 
     An exploratory analysis was undertaken with the primary aim of identifying potential correlates between parameters and enhanced patient survival. 
     The analyses have focused solely on the biomarkers detected in patients known to have received TroVax®. The magnitude of the biomarker level has been analyzed. Each patient was then categorized into “above median” or “below median” category or low or high level category. The survival of patients in each category was compared by plotting Kaplan-Meier curves. 
       FIG. 11  illustrates “above median” and “below median” platelet level effects on patient survival in TroVax®-treated CRC patients. 
     The data summarized in  FIG. 12  suggest that patients with lower platelet levels survive for longer than those with higher platelet levels. This effect is confirmed in  FIG. 13  which also includes the results of two RRC trials, namely:
         Clinical trial phase II (single centre study) A prelimiary study of the safety, immunogencity and clinical efficacy of TroVax® given in conjunction with interleukin 2 (IL-2) in the treatment of stage IV renal cell cancer, IND Number 11433; and   A phase I/II feasibility trial to assess the safety, immunological activity and efficacy of TroVax® plus interferon α (IFN-α) in patients with advanced or metastatic renal cell cancer. EudraCT Number: 2006-000753-22. GTAC Number: 117.       

     Details of these trials can be found on www.clinicaltrials.gov. 
       FIG. 14  shows the influence of baseline platelet levels on patient survival at a later stage than  FIG. 13 . It can be seen that lower normal range platelet levels are associated with improved survival in favour of TroVax® versus placebo. 
       FIG. 15  illustrates “above median” and “below median” haemoglobin level effects on patient survival in TroVax®-treated CRC patients in the four above-mentioned CRC trials. The data summarized in  FIG. 15  suggest that patients with higher haemoglobin levels survive for longer than those with lower haemoglobin levels. 
       FIG. 16  illustrates “above median” and “below median” creatinine level effects on patient survival in TroVax®-treated CRC patients in the four above-mentioned CRC trials. The data summarized in  FIG. 16  suggest that patients with higher creatinine levels survive for longer than those with lower creatinine levels. 
       FIG. 17  shows the influence of baseline monocyte levels on patient survival at the same stage as  FIG. 14 . It can be seen that lower normal range platelet levels are associated with improved survival in favour of TroVax® versus placebo. 
       FIG. 18  shows that patients with a normal haematology show a survival benefit rend. Thus, baseline levels of monocytes, platelets and haemoglobin within normal baseline levels are associated with a reduced hazard ratio in favour of TroVax® 
     Example 3 
     Survival Analysis 
     From previous analysis reported above, four variables (platelets, monocytes, white blood cells (WBC) and haemoglobin) were selected to be examined in more detail. In this analysis, the change in treatment effect across subsets of patients defined by baseline values of platelets, monocytes, WBC and haemoglobin was examined. 
     Objective &amp; Methods 
     Objective 
     To estimate and plot the adjusted hazard ratio across changing baseline levels of platelets, monocytes, white blood cells and haemoglobin. 
     Methods 
     Subsets of patient variables were created using cut points defined by the 10 th , 25 th , 50 th , 75 th  and 90 th  percentile for each of the four factors. For each subset, the adjusted hazard ratio (which adjusted for imbalances in prognostic factors between the two treatment arms) was estimated using a Cox proportional hazards model. As there were a limited number of patients and events in the subsets, it was not possible to include all known prognostic variables, as a consequence, prognostic variables to be included in the model were selected using a backwards selection procedure with a 10% selection criterion. The adjusted hazard ratio and 95% confidence intervals were plotted by decreasing and increasing values of baseline concentration. 
     This analysis was performed on mature survival data censored 13 Mar. 2009 (downloaded on 1 Jun. 2009) 
     Table 1 lists the prognostic variables included in the baseline model prior to the selection procedure. The specific factor being investigated was not included in the model as a confounder (for example when estimating the hazard ratio for subsets defined by baseline levels of monocytes, monocytes was not included as a confounder in the model). When the subsets were defined by WBC, then in addition to WBC not being included in the model, monocytes, neutrophils and lymphocytes were also not being included. 
     
       
         
           
               
             
               
                 TABLE 1 
               
               
                   
               
               
                 Known prognostic factors identified from the 
               
               
                 literature included in the baseline model 
               
               
                   
               
             
            
               
                   
               
            
           
           
               
               
            
               
                   
                 prognostic factors * 
               
               
                   
                 Patient variables 
               
               
                   
                 Age 
               
               
                   
                 Gender 
               
               
                   
                 Body Mass Index (BMI) 
               
               
                   
                 Karnofsky score 
               
               
                   
                 Blood biochemistry variables 
               
               
                   
                 Alkaline Phosphatase 
               
               
                   
                 Corrected Calcium 
               
               
                   
                 Haemoglobin 
               
               
                   
                 LDH 
               
               
                   
                 Sodium 
               
               
                   
                 Lymphocytes 
               
               
                   
                 Monocytes 
               
               
                   
                 Neutrophils 
               
               
                   
                 Platelets 
               
               
                   
                 Tumour variables 
               
               
                   
                 Total number of metastatic sites 
               
               
                   
                 Number of bone lesions 
               
               
                   
                 Number of liver lesions 
               
               
                   
                 Number of lymph node lesions 
               
               
                   
                   
               
               
                   
                 * Model also included Standard of care (INF-alpha, IL-2, sutent), and treatment arm (TroVax, placebo). Variables listed are known prognostic factors in renal cell carcinoma obtained from a literature search. 
               
            
           
         
       
     
     Results 
     Platelets 
     It can be seen from Table 2 and  FIG. 19 , that the hazard ratio differed across subsets of patients define by platelet concentration. In patients with platelets ≦232, the hazard ratio was 0.52 (95% CI 0.29, 0.93), so the hazard of dying was approximately 50% less in TroVax compared to placebo. Conversely, it was found that the hazard was higher in Trovax compared to placebo for patients who had platelets &gt;288, however this result was not significant at the 5% level. 
     
       
         
           
               
             
               
                 TABLE 2 
               
             
            
               
                   
               
               
                 Adjusted hazard ratio and 95% CI for subsets 
               
               
                 defined by baseline levels of platelets 
               
            
           
           
               
               
               
               
               
               
            
               
                   
                 platelet 
                   
                 Hazard 
                   
                 p- 
               
               
                 percentile 
                 level 
                 n (events) 
                 ratio 
                 95% CI 
                 value 
               
               
                   
               
               
                 10% 
                 ≦196 
                 73 (20) 
                 0.24 
                 (0.07, 0.77) 
                 0.017 
               
               
                 25% 
                 ≦232 
                 182 (55)  
                 0.52 
                 (0.29, 0.93) 
                 0.032 
               
               
                 90% 
                 ≧492 
                 74 (59) 
                 1.74 
                 (0.98, 3.09) 
                 0.058 
               
               
                   
               
            
           
         
       
     
     Monocytes 
     It can be seen from Table 3 and  FIG. 20 , that the hazard ratio differed across subsets of patients define by monocyte level. In patients with monocytes ≦0.30, the hazard ratio was 0.59 (95% CI 0.37, 0.97), so the hazard of dying was approximately 40% less in TroVax compared to placebo. Conversely, in patients with monocytes &gt;0.42, the hazard ratio was 1.41 (95% CI 1.02, 1.94). 
     
       
         
           
               
             
               
                 TABLE 3 
               
             
            
               
                   
               
               
                 Adjusted hazard ratio and 95% CI for subsets 
               
               
                 defined by baseline levels of monocytes 
               
            
           
           
               
               
               
               
               
               
            
               
                   
                 monocyte 
                   
                 Hazard 
                   
                 p- 
               
               
                 percentile 
                 level 
                 n (events) 
                 ratio 
                 95% CI 
                 value 
               
               
                   
               
               
                 25% 
                 ≦0.30 
                 190 (79)  
                 0.59 
                 (0.37, 0.97) 
                 0.038 
               
               
                 50% 
                 &gt;0.42 
                 347 (164) 
                 1.41 
                 (1.02, 1.94) 
                 0.035 
               
               
                   
               
            
           
         
       
     
     White Blood Cells (WBC) 
     It can be seen from Table 4 and  FIG. 21 , that the hazard ratio differed across subsets of patients define by WBC level. In patients with WBC ≦5.9, the hazard ratio was 0.72 (95% CI 0.44, 1.18). Conversely, in patients with WBC&gt;7.2, the hazard ratio was 1.12 (95% CI 0.82, 1.52). 
     
       
         
           
               
             
               
                 TABLE 4 
               
             
            
               
                   
               
               
                 Adjusted hazard ratio and 95% CI for subsets 
               
               
                 defined by baseline levels of WBC 
               
            
           
           
               
               
               
               
               
               
            
               
                   
                   
                   
                 Hazard 
                   
                 p- 
               
               
                 percentile 
                 wbc 
                 n (events) 
                 ratio 
                 95% CI 
                 value 
               
               
                   
               
            
           
           
               
               
               
               
               
               
            
               
                 10% 
                 ≦5.0 
                 74 (24) 
                 0.63 
                 (0.26, 1.53) 
                 0.308 
               
               
                 25% 
                 ≦5.9 
                 195 (68)  
                 0.72 
                 (0.44, 1.18) 
                 0.194 
               
               
                 50% 
                 ≦7.2 
                 377 (144) 
                 0.99 
                 (0.70, 1.38) 
                 0.942 
               
               
                 50% 
                 &gt;7.2 
                 354 (186) 
                 1.12 
                 (0.82, 1.52) 
                 0.469 
               
               
                 75% 
                 ≧8.6 
                 184 (110) 
                 1.2 
                 (0.81, 1.78) 
                 0.357 
               
               
                 90% 
                 ≧10.4 
                 76 (54) 
                 1.3 
                 (0.74, 2.27) 
                 0.355 
               
               
                   
               
            
           
         
       
     
     Haemoglobin 
     It can be seen from Table 5 and  FIG. 22 , that the hazard ratio differed across subsets of patients defined by haemoglobin level. In patients with haemoglobin ≦13.2, the hazard ratio was 1.24 (95% CI 0.93, 1.64). Conversely, in patients with haemoglobin &gt;15.2, the hazard ratio was 0.26 (95% CI 0.10, 0.68). 
     
       
         
           
               
             
               
                 TABLE 5 
               
             
            
               
                   
               
               
                 Adjusted hazard ratio and 95% CI for subsets 
               
               
                 defined by baseline levels of haemoglobin 
               
            
           
           
               
               
               
               
               
               
            
               
                   
                   
                   
                 Hazard 
                   
                 p- 
               
               
                 percentile 
                 haemoglobin 
                 n (events) 
                 ratio 
                 95% CI 
                 value 
               
               
                   
               
               
                 10% 
                 ≦10.4 
                 76 (63) 
                 0.81 
                 (0.47, 1.38) 
                 0.430 
               
               
                 25% 
                 ≦11.6 
                 186 (139) 
                 1.01 
                 (0.71, 1.44) 
                 0.936 
               
               
                 50% 
                 ≦13.2 
                 368 (215) 
                 1.24 
                 (0.93, 1.64) 
                 0.141 
               
               
                 50% 
                 &gt;13.2 
                 363 (115) 
                 0.82 
                 (0.57, 1.18) 
                 0.292 
               
               
                 75% 
                 ≧14.4 
                 187 (55)  
                 0.78 
                 (0.40, 1.23) 
                 0.219 
               
               
                 90% 
                 ≧15.2 
                 83 (25) 
                 0.26 
                 (0.10, 0.68) 
                 0.006 
               
               
                   
               
            
           
         
       
     
     CONCLUSIONS 
     These data suggest that there is differential risk-benefit to patient survival dependent on the relative levels of certain biomarkers. These data can be used to plan treatment strategies to maximize the survival advantage of 5T4 targeted immunotherapies including identifying patient characteristics that would predict this type of response through assessment of baseline status. 
     Various features of the invention will also now be described with reference to the following numbered paragraphs: 
     1. A method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring a level of corrected calcium in a sample from the cancer patient, and (b) comparing the level of corrected calcium in the sample to a reference level of corrected calcium, wherein a lower level of corrected calcium in the sample correlates with increased benefit to the patient.
 
2. A method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring a level of corrected calcium in a sample from the cancer patient, and (b) classifying the patient as belonging to either a first or second group of patients, wherein the first group of patients having low levels of corrected calcium is classified as having an increased likelihood of benefit than the second group of patients having high levels of corrected calcium.
 
3. A method for monitoring the effectiveness of a course of treatment for a patient with cancer involving (a) determining a level of a corrected calcium in a sample from the cancer patient prior to immunotherapy treatment, and (b) determining the level of corrected calcium in a sample from the patient after treatment, whereby comparison of the corrected calcium level prior to treatment with the corrected calcium level after treatment indicates the effectiveness of the treatment.
 
4. A method of predicting the responsiveness of a patient or patient population with cancer to treatment with immunotherapy, or for selecting patients or patient populations that will respond to immunotherapy comprising comparing the differential levels of corrected calcium.
 
5. A method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring a level of platelets in a sample from the cancer patient, and (b) comparing the level of platelets in the sample to a reference level of platelets, wherein a lower level of platelets in the sample correlates with increased benefit to the patient.
 
6. A method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring a level of platelets in a sample from the cancer patient, and (b) classifying the patient as belonging to either a first or second group of patients, wherein the first group of patients having low levels of platelets is classified as having an increased likelihood of benefit than the second group of patients having high levels of platelets.
 
7. A method for monitoring the effectiveness of a course of treatment for a patient with cancer involving (a) determining a level of platelets in a sample from the cancer patient prior to immunotherapy treatment, and (b) determining the level of platelets in a sample from the patient after treatment, whereby comparison of the platelet level prior to treatment with the platelet level after treatment indicates the effectiveness of the treatment.
 
8. A method of predicting the responsiveness of a patient or patient population with cancer to treatment with immunotherapy, or for selecting patients or patient populations that will respond to immunotherapy, comprising comparing the differential levels of platelets.
 
9. A method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring a level of haemoglobin in a sample from the cancer patient, and (b) comparing the level of haemoglobin in the sample to a reference level of haemoglobin, wherein a higher level of haemoglobin in the sample correlates with increased benefit to the patient.
 
10. A method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring a level of haemoglobin in a sample from the cancer patient, and (b) classifying the patient as belonging to either a first or second group of patients, wherein the first group of patients having high levels of platelets is classified as having an increased likelihood of benefit than the second group of patients having low levels of haemoglobin.
 
11. A method for monitoring the effectiveness of a course of treatment for a patient with cancer involving (a) determining a level of haemoglobin in a sample from the cancer patient prior to immunotherapy treatment, and (b) determining the level of haemoglobin in a sample from the patient after treatment, whereby comparison of the haemoglobin level prior to treatment with the haemoglobin level after treatment indicates the effectiveness of the treatment.
 
12. A method of predicting the responsiveness of a patient or patient population with cancer to treatment with immunotherapy, or for selecting patients or patient populations that will respond to immunotherapy, comprising comparing the differential levels of haemoglobin.
 
13. A method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring a level of creatinine in a sample from the cancer patient, and (b) comparing the level of creatinine in the sample to a reference level of creatinine, wherein a higher level of creatinine in the sample correlates with increased benefit to the patient.
 
14. A method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring a level of creatinine in a sample from the cancer patient, and (b) classifying the patient as belonging to either a first or second group of patients, wherein the first group of patients having high levels of platelets is classified as having an increased likelihood of benefit than the second group of patients having low levels of creatinine.
 
15. A method for monitoring the effectiveness of a course of treatment for a patient with cancer involving (a) determining a level of creatinine in a sample from the cancer patient prior to immunotherapy treatment, and (b) determining the level of creatinine in a sample from the patient after treatment, whereby comparison of the creatinine level prior to treatment with the creatinine level after treatment indicates the effectiveness of the treatment.
 
16. A method of predicting the responsiveness of a patient or patient population with cancer to treatment with immunotherapy, or for selecting patients or patient populations that will respond to immunotherapy, comprising comparing the differential levels of creatinine.
 
17. A method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring levels of one or more of corrected calcium, platelets, haemoglobin and creatinine and (b) comparing the level of corrected calcium, platelets, haemoglobin and creatinine in the sample to a reference level of corrected calcium, platelets, haemoglobin and creatinine, as appropriate, wherein a low level of corrected calcium or a low level of platelets, and/or a high level of haemoglobin or a high level of creatinine in said sample correlates with increased benefit to said patient.
 
18. A method for determining a prognosis for benefit for a cancer patient receiving immunotherapy treatment involving (a) measuring levels of corrected calcium, platelets, haemoglobin and/or creatinine and one or more factors selected from the group consisting of: chloride, eosinophils, haematocrit, sodium, basophils, serum calcium, monocytes, neutrophils and WBCs and (b) comparing the level of corrected calcium, platelets, haemoglobin and/or creatinine and the one or more selected biomarkers in the sample to a reference level of corrected calcium, platelets, haemoglobin and/or creatinine and the one or more selected biomarkers, wherein a low level of corrected calcium and/or platelets, a high level of haemoglobin and/or creatinine, and a high level of any of chloride, eosinophils, haematocrit, sodium and/or a low level of any basophils, serum calcium, monocytes, neutrophils and WBCs in said sample correlates with increased benefit to said patient.
 
19. The method according to any one of the preceding paragraphs wherein the cancer is invasive carcinoma of the Ampulla of Vater, breast, colon, endometrium, pancreas, or stomach; a squamous carcinoma of the bladder, cervix, lung or oesophagus; a tubulovillous adenoma of the colon; a malignant mixed Mullerian tumour of the endometrium; a clear cell carcinoma of the kidney; a lung cancer (large cell undifferentiated, giant cell carcinoma, broncho-alveolar carcinoma, metastatic leiomyosarcoma); an ovarian cancer (a Brenner tumour, cystadenocarcinoma, solid teratoma); a cancer of the testis (seminoma, mature cystic teratoma); a soft tissue fibrosarcoma; a teratoma (anaplastic germ cell tumours); or a trophoblast cancer (choriocarcimoma (e.g. in uterus, lung or brain), tumour of placental site, hydatidiform mole).
 
20. The method according to any one of the preceding paragraphs. wherein the cancer is renal or colorectal cancer.
 
21. The method according to any one of the preceding paragraphs. wherein the immunotherapy comprises use of 5T4.
 
22. The method according to paragraph. 21 wherein the immunotherapy comprises use of a viral vector expressing 5T4.
 
23. The method according to paragraph. 22 wherein the immunotherapy comprises use of a Modified Vaccinia Ankara viral vector expressing 5T4.
 
24. The method according to paragraph 23 wherein the immunotherapy comprises use of a Modified Vaccinia Ankara viral vector expressing the human 5T4 gene under regulatory control of a modified mH5 promoter (TroVax®).