Conditions: Colon Cancer Neoadjuvant Therapy
Keywords: colon cancer camrelizumab neoadjuvant therapy chemotherapy apatinib
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 64
Healthy volunteers: no

Brief summary:
To determine the Efficacy and Safety of camrelizumab and apatinib combined with chemotherapy (mFOLFOX6) for MSS/pMMR locally advanced colon cancer.

Detailed description:
To determine the rate of tumor regression grade 2-4 at time of radical resection of MSS/pMMR colon cancer following neoadjuvant treatment.To determine the pathologic downstage rates at time of radical resection of colon cancer following neoadjuvant treatment, pathologic complete response (pCR) rates, R0 resection rate, 2 year Disease free survival, OS(overall survival) and adverse events, including perioperative complication and mortality rate.

To determine the pathologic downstage rates and pCR rate of radical resection of MSI/dMMR colon cancer.

Arms:
arm 1: Participants received 5 preoperative cycles of PD-1 inhibitor and chemotherapy (mFOLFOX6), 2 months of apatinib, followed by surgery. Apatinib,PD-1 inhibitor and chemotherapy needed to be stopped for 4-6 months before operation. 1 month after surgery, 7 cycles of mFOLFOX6 combined with PD-1 monoclonal antibody were performed as adjuvant therapy.

Interventions: intervention 1: Camrelizumab , apatinib and chemotherapy
Intervention descriptions: intervention 1: Camrelizumab 200 mg, IV infusion on Days 1 each 14-day cycle

Apatinib 250mg oral administration once a day, for two months

mFOLFOX6 oxaliplatin 85 mg/m\^2 IV infusion on Day 1 of each14-day cycle. Fluorouracil: 400 mg/m2 as a bolus injection given after a two-hour leucovorin infusion at a dose of 400 mg/m2. The loading dose is then followed by a 46-hour 5-fluorouracil infusion of 2,400 mg/m2 via a pump programmed to provide a constant drug infusion rate.

Protocol document:
Prot_000.pdf: 
Clinical Study Protocol 
 
 
 
 
Title of study 
Neoadjuvant chemotherapy combined with 
camrelizumab and apatinib in patients with 
locally advanced colon cancer: a single-arm, 
prospective study 
NCT number 
NCT04625803 
Institution 
The First Affiliated Hospital, Zhejiang 
University School of Medicine 
major investigators 
Weijia Fang 
Xiangming Xu 
Protocol No. 
Version 
MA-CRC-II-004 
1.3 
Version Date: 
07 November 2021 
 
 
 


PROTOCOL AGREEMENT 
I confirm that I have read this protocol. I will comply with the protocol and the principles of 
Good Clinical Practice (GCP), any applicable laws and regulations, and the study protocol. 
 
 
Protocol: MA-CRC-II-004, Version 1.3 (07 November 2021) 
Protocol Title: Neoadjuvant chemotherapy combined with camrelizumab and apatinib in patients 
with locally advanced colon cancer: a single-arm, prospective study 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigator Signature                Date                     
 
 


Principal investigator protocol signature page 
I will conscientiously perform my duties as a researcher according to ICH-GCP regulations 
and participate in or directly direct this clinical research. I have received the investigator's manual 
for the investigational drug in this clinical trial; I am aware of and have read the preclinical studies 
of the trial drug and the trial protocol. I agree to perform my duties in accordance with the ICH-
GCP, the Declaration of Helsinki, any applicable laws and regulations, and the study protocol. 
Unless measures must be taken to protect the safety, rights, and interests of the subjects, I will 
modify the protocol only after the sponsor has been informed and consent has been obtained, and 
only after the ethics committee has agreed to implement it. I will be responsible for making clinically 
relevant medical decisions to ensure that subjects receive timely and appropriate treatment if adverse 
events occur during the study and that these adverse events are recorded and reported in accordance 
with relevant national regulations. I guarantee that the data will be true, accurate, complete and 
timely recorded. I will accept the monitoring by the sponsor or inspectors and the inspection by the 
drug regulatory department to ensure the quality of the clinical trial. I promise to keep the subject's 
personal information and related matters confidential. I agreed to disclose my full name and 
occupation to the sponsor, to disclose expenditures related to clinical research on request, and to 
prohibit any commercial or financial conduct related to the trial. I agree that the results of the study 
can be used for drug registration and public publication.  
 
 
Institution The First Affiliated Hospital, Zhejiang University School of Medicine 
 
Xiangming Xu 
 
 
Principal Investigator (In print) 
Principal Investigator (Signature) 
Signature Date 
 
Weijia Fang 
 
 
Principal Investigator (In print) 
Principal Investigator (Signature) 
Signature Date 
 
 
 


Neoadjuvant chemotherapy combined with camrelizumab and apatinib in patients with 
locally advanced colon cancer: a single-arm, prospective study 
1.Background 
Colorectal cancer (CRCs) is a heterogeneous disease with complex genetic and epigenetic 
changes. Tumors in different parts of the colon are clinically and molecular heterogeneous. The 
MOSAIC study established FOLFOX4 as an adjunct therapy for stage II and III colon cancer. 
Adjuvant therapy can improve relapse-free survival and overall survival time[1]. 
In the field of esophageal cancer, gastric cancer and rectal cancer, preoperative neoadjuvant 
chemotherapy and radiotherapy are more effective than postoperative treatment[2-4]. On the one hand, 
preoperative treatment can make the tumor shrink and reduce the probability of tumor cells falling 
off and incomplete resection during surgery[3, 5]. A positive surgical margin is strongly associated 
with local recurrence, which means that the tumor is very aggressive and poorly responsive to 
systemic therapy. On the other hand, preoperative treatment has the advantage of minimizing 
surgical procedures and allowing patients to return to normal activities earlier. 
 
In 2012, FOxTROT enrolled 150 patients with T3/4 colon cancer and randomly divided them 
into two groups: one group received 3 cycles of oxaliplatin and fluorouracil-based chemotherapy 
before surgery and 9 cycles of chemotherapy after surgery; the other group received direct surgery 
and completed 12 cycles of chemotherapy after surgery. The results suggested that the rate of tumor 
regression was more significant in the preoperative chemotherapy group (p=0.04) with lower margin 
positive patients (4% vs. 20%) and higher tumor regression rate (31% vs.2%)[6]. The 2019 ASCO 
abstract reported the updated results of FOxTROT, a total of 1052 patients were enrolled. The 
incomplete resection rate of patients with preoperative neoadjuvant chemotherapy was reduced. In 
the neoadjuvant group, the 2-year recurrence rate was improved, although it did not reach statistical 
significance (14% vs 18%, P=0.11). For this reason, the NCCN recommends neoadjuvant therapy 
(FOLFOX or CAPEOX) for colon cancer patients with T4 or high tumor burden. 
 
NCCN guidelines and CSCO guidelines recommend immunotherapy as the first-line treatment 
for patients with advanced MSI-H or dMMR colon cancer. The PICC study[7] published in The 
Lancet Gastroenterology and Hepatology by Professor Yanhong Deng revealed that the pCR rate of 
colon cancer patients with locally advanced MSI-H using immunotherapy reached 76%. 
Immunotherapy has brought light to the treatment of MSI-H patients. Nowadays, everal clinical 
studies are exploring the neoadjuvant study of immunotherapy combined with chemotherapy for 
colon cancer. 
 
The combination of antivascular therapy and immunotherapy has shown advantages in liver 
cancer, kidney cancer and other tumors.Appropriate doses of anti-angiogenic drugs such as apatinib 
(VEGFR2-TKI) can regulate the tumor immunosuppressive microenvironment and alleviate 
resistance to anti-PD-1 /PD-L1 therapy[8]. 
The purpose of this study is to determine the efficacy and safety of camrelizumab and apatinib 
combined with chemotherapy (mFOLFOX6) for MSS/pMMR locally advanced colon cancer. 
 
 
2 Endpoint 
2.1 Primary Endpoint 
Tumor regression rate of MSS/pMMR patients (Pathological response, percentage of TRG2-4 
to all MSS patients, Dworak criteria) 


 
2.2 Secondary Endpoint 
The secondary endpoints included the tumor pathological downstage rate, defined as the 
percentage of patients with a lower postoperative stage than baseline stage, pCR rate, R0 resection 
rate, 2-year DFS, 2-year EFS and OS for MSS/pMMR colon cancer. The pathological response rate 
and pCR rate for MSI-H/dMMR patients. Perioperative complication rate, mortality and Adverse 
events (National Cancer Institute Common Terminology Criteria for Adverse Events [NCI CTCAE], 
version 5.0). 
 
3.1 Experiment Design 
This is a single-institution, single-arm phase II clinical trial. Patients with histopathologically 
or cytologically confirmed colon adenocarcinoma without distant metastases (T4 or T3 with 
extramural depth ≥5 mm, N0-2, M0, AJCC 8th) were enrolled.  
Patients with microsatellite-stable or proficient mismatch repair (pMMR) received 5 cycles of 
mFOLFOX6 and camrelizumab (200 mg intravenously on day 1, every 2 weeks) and apatinib (250 
mg orally once daily, 2 months). mFOLFOX6 consisted of oxaliplatin 85 mg/m2 on day 1, 
leucovorin 400 mg/m2 on day 1, fluorouracil 400 mg/m2 bolus on day 1, followed by fluorouracil 
2,400 mg/m2 continuous infusion over 46 hours, repeated once every 2 weeks. Surgery was 
scheduled within 4-6 weeks after the last cycle of therapy. 7 cycles of adjuvant camrelizumab plus 
mFOLFOX6 were administered after surgery. 
For patients with microsatellite-instability-high (MSI-H) or deficiency in mismatch repair 
(dMMR), 5 cycles of camrelizumab (200 mg intravenously on day 1, every 2 weeks) plus apatinib 
(250 mg orally once daily, 2 months) were given preoperatively and 7 cycles of camrelizumab plus 
apatinib were given postoperatively. 
Tissue samples and peripheral blood samples were collected for further multiomics analysis. 
The sampling points were: (1) Peripheral blood and colonoscopy tumor tissue at baseline; (2) 
Peripheral blood before operation; (3) surgical tumor tissue; (4) Peripheral blood 1 month after 
surgery (5) Peripheral blood after adjuvant chemotherapy 
 
3.2 Sample Size 
To determine the sample size, we used the Simon 2 stage optimum design with unilateral alpha 
0.05 to achieve the power of 0.8, the pathological response rate (TRG 2-4) is expected to increase 
from 22.5% to 40%. Considering a 10% shedding rate, it is estimated that 64 patients will need to 
be enrolled.  
3.3 Surveillance  
Chemotherapy combined with anti-PD-1 antibodies was used every 14 days for 5 cycles, while 
apatinib treatment was used for 2 months. Chemotherapy, immunotherapy, and apatinib need to be 
discontinued for 4-6 weeks before surgery. After surgery, 7 cycles of chemotherapy combined with 
PD-1 antibody were completed. During chemotherapy, patients should be followed up for the quality 
of life and the toxic and side effects of chemotherapy. Imaging examination should be done to 
evaluate the tumor size after 5 courses of treatment. Imaging examinations were required before and 
after postoperative adjuvant chemotherapy.  
Imaging reviews were performed every 12 weeks for 1 year after the end of medication and 
every 6 months after 1 year. Telephone follow-up was conducted every 12 weeks after the end of 


treatment, and the total follow-up time was from enrollment to death. 
 
4. Inclusion and Exclusion Criteria: 
4.1Inclusion Criteria: 
1. Age ≥ 18 years, ≤75 years 
2. Histologically confirmed colon cancer ( tumor penetrated of muscularis propria depth 
≥5mm of T3 , T4, N0-2, M0) without distant metastasis (AJCC 8th). 
3. ECOG 0-1 
4. Surgical treatment is planned after completion of neoadjuvant therapy 
5. Patients can swallow pills normally 
6. Expected overall survival ≥12 months 
7. Blood routine: no blood transfusion or blood products usage within 14 days, G-CSF or 
other hematopoietic stimulator was not used. WBC counts > 3000/µl，Absolute neutrophil 
count (ANC) ≥ 1500 cells/µl，Platelet count ≥ 100,000/µl，Hemoglobin ≥ 9.0 g/dL. 
8. AST, ALT and alkaline phosphatase ≤ 2.5 times the upper limit of normal (ULN)，Serum 
bilirubin ≤ 1.5 x ULN，creatinine<ULN 
9. Prothrombin time (PT), international standard ratio (INR) ≤1.5 × ULN 
10. Patients who have not received systemic chemotherapy or immunotherapy 
11. Women of childbearing age must be willing to use adequate contraceptives during the study 
period of drug treatment; 
12. Informed consent has been signed. 
 
4.2 Exclusion Criteria: 
1. Patients have received any prior systemic antitumor therapy; 
2. Active bleeding within 3 months; Occurrence of arterial/venous thrombosis within 6 
months; Hereditary or acquired bleeding (e.g., clotting dysfunction) or thrombotic 
tendencies; Full dose oral or injectable anticoagulants or thrombolytic drugs for therapeutic 
purposes are currently being used or have been used recently (10 days prior to the 
commencement of study treatment); Surgery (except for biopsy) was performed within 4 
weeks prior to the study or the surgical incision was not fully healed; Aspirin (> 325 mg/ 
day) or dipyridamole, ticlopidine, clopidogrel, and silotazole are currently being used or 
have recently been used (10 days prior to the study). 
3. Systemic corticosteroids or other systemic immunosuppressive drugs were used within 2 
weeks prior to treatment. Immunosuppressive drugs were started or expected to be used 
during the trial. Inhaled corticosteroids, physiologic replacement doses of glucocorticoids 
are allowed. 
4. Certain or suspected distant metastases. 
5. The patient has a history of autoimmune disease. 
6. Serious uncontrolled systemic diseases, such as severe active infections; 
7. A person is known to be infected with the immunodeficiency virus (HIV) or known to be 
HIV-positive; 
8. Patients have suffered from other malignancies in the past 5 years except cervical 
carcinoma in situ or basal cell carcinoma of the skin 
9. Untreated chronic hepatitis B or chronic hepatitis B virus (HBV) carriers (HBV DNA >500 


IU/mL) or active HCV carriers with HCV RNA can be detected. Remarks: Inactive hepatitis 
B surface antigen (HBsAg) carriers, treated and stable hepatitis B patients (HBV DNA < 
500 IU/mL) may be enrolled 
10. Anti-infective therapy was not discontinued 14 days before the study; 
11. A prior history of interstitial lung disease, drug-induced interstitial lung disease, radiation 
pneumonia, and symptomatic interstitial lung disease or the presence of active pneumonia 
on a chest CT scan within 4 weeks prior to the study. 
12. Patients have a history of intestinal obstruction within six months. Patients with incomplete 
obstruction syndrome of ileus at the time of initial diagnosis may be enrolled in the study 
if they have received definitive (surgical) treatment to resolve the symptoms, as assessed 
by the investigator. 
13. Patients have non-resectable factors, including surgical contraindications 
14. Patients Have high blood pressure that cannot be well controlled by antihypertensive 
medication (systolic ≥140 mmHg or diastolic ≥90 mmHg) 
15. Urine routine indicated urinary protein ≥++ and confirmed 24-hour urinary protein >1.0g; 
16. Known to be allergic to any study drug; 
17. Patients have participated in other drug clinical studies within 4 weeks before enrollment; 
18. Lactating women 
19. According to the judgment of the researcher, the patient may have other factors that may 
affect the results of the study or cause the study to be terminated, such as alcohol abuse, 
drug abuse, other serious diseases (including mental diseases) requiring combined 
treatment. Patients have severe laboratory abnormalities, which will affect the safety of the 
patient. 
 
5 Clinical Assessments 
5.1 Evaluation Method  
Full abdominal enhanced CT, chest CT, pathology assessment, tests (blood routine, 
biochemistry, coagulation function, tumor markers, thyroid function, urine stool routine, 
electrocardiogram) 
5.2 Tumor Assessments  
Disease assessments are to be performed as scheduled according to the calendar, regardless of 
treatment delays resulting from toxicity. Care must be taken in scheduling disease assessments to 
prevent the introduction of bias based on treatment delays. 
Disease assessments will be performed at baseline (Screening) and after 5 courses of treatment. 
Imaging studies will include a CT scan of the chest, abdomen, and pelvis. Radiographic 
confirmation of disease progression (appearance of distant metastasis) will be based on RECIST 1.1. 
Pathological assessment was evaluated after operation.  
Imaging examinations were required before and after postoperative adjuvant chemotherapy. 
Imaging reviews were performed every 12 weeks after the end of all treatments and every six months 
after 1 year. 
5.3 Primary Study Endpoint 
Tumor regression rate of MSS/pMMR patients (Pathological response, percentage of TRG2-4 
to all MSS patients, Dworak criteria) 
TRG Dworak criteria: Grade 0: no regression; Grade 1: dominant tumor mass with obvious 


fibrosis and/or vasculopathy; Grade 2: dominantly fibrotic changes with few tumor cells or groups 
(easy to find); Grade 3: very few (difficult to find microscopically) tumor cells in fibrotic tissue with 
or without mucous substance; Grade 4: no tumor cells, only fibrotic mass (total regression or 
response). 
 
5.4 Secondary Study Endpoint 
The secondary endpoints included the tumor pathological downstage rate, defined as the 
percentage of patients with a lower postoperative stage than baseline stage, pCR rate, R0 resection 
rate, 2-year DFS, 2-year EFS and OS for MSS/pMMR colon cancer. The pathological response rate 
and pCR rate for MSI-H/dMMR patients. Perioperative complication rate, mortality and Adverse 
events (National Cancer Institute Common Terminology Criteria for Adverse Events [NCI CTCAE], 
version 5.0). 
 
6. Safety Evaluation 
6.1 Safety Measurements 
6.1.1 Vital Signs 
Body temperature, blood pressure, pulse and respirations will be performed after resting for 
5 minutes at Screening and every subsequent clinic visit. 
 
6.1.2 Performance Status 
The Eastern Cooperative Oncology Group (ECOG) performance status scale will be used 
(Appendix 3) and will be assessed at Screening and every subsequent clinic visit. 
 
6.1.3 Laboratory Measurements 
Blood and urine will be obtained at the time points described in the Schedule of Activities 
and sent to a central lab for hematology, blood chemistry profile, and urinalysis, respectively. 
After enrollment, blood routine, liver function and renal function were reviewed weekly, and blood 
routine, biochemistry, thyroid function, myocardial enzyme profile, troponin and cytokine were 
reviewed every treatment cycle. 
 
6.1.4 Electrocardiogram (ECG) 
A standard12-lead ECG (with a 10-second rhythm strip) will be collected at Screening and as 
clinically indicated. ECG results were recorded during the screening period, before each cycle of 
chemotherapy and before surgical treatment.  
 
6.2 Adverse Events 
6.2.1 Chemotherapy-related Adverse Events 
1) Oxaliplatin 
The most common adverse events observed during the combination of oxaliplatin and 5-
fluorouracil/folin were gastrointestinal (diarrhea, nausea, vomiting, and mucositis), hematological 
(neutropenia, thrombocytopenia), and neurological reactions (acute, dose accumulation, peripheral 
sensory neuropathy). 
2) fluorouracil 
Nausea, loss of appetite or vomiting; oral mucositis or ulcers, abdominal discomfort or diarrhea; 


Leukopenia is common, most of them reach the lowest point within 2-3 weeks after the start of 
treatment, and return to normal within 3-4 weeks. Thrombocytopenia. Rarely cough, shortness of 
breath, or cerebellar ataxia; Hair loss or intravenous hyperpigmentation with drug injection; 
Extravasation at the intravenous drip may cause local pain, necrosis, or cellulitis. Long-term 
application can cause neurological toxicity. Occasionally, myocardial ischemia. 
6.2.2 Camrelizumab-related Adverse Events 
Adverse reactions with an incidence of > 10% included reactive cutaneous capillary endothelial 
proliferation, anemia, fever, weakness, hypothyroidism, proteinuria, cough, and decreased appetite. 
Incidence > 1% included: hyponatremia, pulmonary infection, elevated aspartate aminotransferase, 
elevated γ-glutamyltransferase, elevated blood bilirubin, elevated bound bilirubin, abnormal liver 
function, neutropenia, decreased white blood cell count, thrombocytopenia, decreased lymphocyte 
count, hypokalemia, elevated propionate aminotransferase, and lipase increased. 
6.2.2.1 Suggestions for symptomatic management of common adverse reactions 
The toxicity of immune checkpoint inhibitors (ICPi) is different from other types of 
antineoplastic drugs, and its severity and duration have their particularity. It can be divided into 
infusion reactions and immune-related adverse events (irAE). Camrelizumab belongs to this class 
of drugs, so it is necessary to identify and treat adverse events caused by camrelizumab early to 
reduce the occurrence of serious toxic events.  
Immune-related adverse events are defined as specific events (including pneumonitis, 
diarrhea/colitis, hepatitis, nephritis/renal dysfunction, rash, and endocrine lesions) for which the 
subject requires treatment with an immunosuppressive drug. 
6.2.2.2 Safety management rules  
Safety management rules and relevant guidelines (e.g., ESMO Clinical practice guidelines for 
the diagnosis, treatment, and follow-up of immunotherapy) for similar products on the market 
abroad can be referred to assist investigators in the evaluation and management of adverse events 
in the following systems: gastrointestinal, renal, pulmonary, hepatic, endocrine, cutaneous, and 
neurological.  
The general principle is to first make a differential diagnosis according to standard medical 
practice, then consider a noninflammatory cause and manage it appropriately. After excluding other 
causes (e.g., disease progression, infection, or other medications), immune-related adverse events 
were considered and immunosuppressive agents were used. Testing for autoantibodies is often 
helpful, and the role of tissue biopsies in diagnosing immune-related adverse events is unclear. 
Consultation with a medical or surgical specialist is recommended, especially before invasive 
diagnostic or therapeutic procedures are performed.  
Corticosteroids are the mainstay of treatment. Subjects with low grade toxicity who are 
ambulatory may be considered for the oral equivalent of the recommended intravenous dose. The 
lower bioavailability of oral corticosteroids should be taken into account when changing to an 
equivalent dose of oral corticosteroids. 
6.2.2.3 infusion reaction 
Camrelizumab is a fully human monoclonal antibody, which is less likely to cause infusion 
reactions and generally does not require prophylactic medication before infusion.  
Once the infusion reaction occurs, the infusion should be slowed down or interrupted according 
to the situation, and clinical supportive treatment should be given, and preventive medication should 
be given before future medication.  


Acute infusion reactions usually develop associated symptoms and signs at the time of or shortly 
after drug infusion and usually resolve within 24 hours after completion of the infusion. Signs and 
symptoms include: Anaphylaxis/hypersensitivity (including drug-induced fever), cough, chills, 
chills/chills, dizziness, headache, fatigue (fatigue, lethargy), rash, itchy/itchy skin, joint pain, muscle 
pain, low or high blood pressure, nausea, vomiting, sweating (sweating), tachycardia, urticaria 
(wheals), dyspnea (shortness of breath), or bronchospasm.  
All grade 3-4 infusion reactions were reported according to the SAE if they met the SAE 
criteria. Management of anaphylaxis should be based on institutional medical practice and 
guidelines. Management of delayed anaphylaxis (e.g., pruritus that develops more than 1 week after 
the end of the infusion) should be managed with symptomatic treatment (e.g., oral antihistamines 
or corticosteroids). 
6.2.2.4 Grading criteria and treatment recommendations for reactive cutaneous capillary endothelial 
proliferation (RCCEP) 
Table1 Grading criteria and treatment recommendations for RCCEP 
Grade  
Clinical manifestation 
Recommendations 
Grade 1 
Multiple or single nodules, 
maximum 
diameter 
≤10mm, with or without 
ulceration and hemorrhage 
Study drug was continued, and topical 
treatment was strengthened for those with 
ulceration and bleeding to prevent infection 
Grade 2 
Multiple 
or 
single 
nodules, 
>10mm 
in 
diameter, with or without 
ulceration 
Study drug should be continued, observation 
or local treatment measures should be taken, 
such as laser or surgical resection, and topical 
treatment should be strengthened for those 
with ulceration and bleeding to prevent 
infection 
Grade 3 
Multiple 
nodules 
were 
found throughout the body 
and complicated by skin 
infection 
study drug should be held until the severity of 
the toxicity decreases to Grade 1 or returns to 
baseline. Observation or topical treatment 
measures such as laser or surgical resection 
were taken, and anti-infection treatment 
shouled be given to concurrent infection 
Grade 4 life-threatening and grade 5 deaths have not yet occurred and are therefore not specified 
 
 
6.2.3 Apatinib-related Adverse Events 
Elevated blood pressure: Most patients with elevated blood pressure occur about 2 weeks after 
taking medicine, and most patients can generally be well controlled by combined use of 
antihypertensive drugs. 
Proteinuria: Proteinuria generally occurs about 3 weeks after administration of the drug and 
can be relieved by dose interruption or dose reduction. 
Hand-foot syndrome: Hand-foot syndrome usually occurs about 3 weeks after taking medicine, 
and can be alleviated by symptomatic treatment. 
Bleeding: The observed bleeding symptoms included gastrointestinal bleeding, hematemesis, 
hemoptysis, positive fecal occult blood, positive urinary occult blood, skin bleeding spots, and 


rupture of liver metastases. Patients in whom fecal occult blood developed generally developed 
within the first cycle after taking the drug. 
Cardiotoxicity: electrocardiographic abnormalities, including sinus bradycardia, partial ST-T 
changes, slowing heart rate, QT prolongation, and acute myocardial infarction. 
Liver toxicity: transaminase, bilirubin, alkaline phosphatase, lactate dehydrogenase increased, 
liver enzyme abnormalities mostly occurred at the initial of the second cycle. 
6.3 Dose Modifications 
6.3.1 Recommendations for Chemotherapy Dose Modifications 
During the treatment, the patient's blood routine was monitored. After the first occurrence of 
grade III-IV neutropenia, the use of G-CSF was recommended after active treatment. In cases of 
grade IV neutropenia, grade III neutropenia with fever (>38.5°C) despite prophylactic colony-
stimulating factor treatment, or grade III or higher thrombocytopenia and increased creatinine 
during treatment that could not be tolerated after treatment, each dose reduction of oxaliplatin and 
fluorouracil was allowed at the discretion of the investigator if toxicity occurred. There were two 
levels of dose adjustment. If a reduction of more than two dose levels was required, treatment was 
discontinued. 
Table 2 Dose modifications of oxaliplatin and fluorouracil: hematologic toxicity, 
nonhematologic toxicity 
Dose Level 
 
Drug 
Dose 
0 
- 
Oxaliplatin 
85mg/m2 
Fluorouracil 
400 
mg/m2 
(intravenous 
infusion), 
2400 
mg/m2 
(continuous 
infusion) 
-1 
Grade III and IV 
hematologic toxicity, 
non-hematologic 
toxicity 
(excluding 
peripheral 
neurotoxicity 
Oxaliplatin 
75mg/m2 
Fluorouracil 
0 mg/m2 (intravenous 
infusion), 
1900 
mg/m2 
(continuous 
infusion) 
-2 
Grade IV hematologic 
toxicity after 1 dose 
level 
reduction 
of 
oxaliplatin 
or 
fluorouracil 
Oxaliplatin 
55mg/m2 
Fluorouracil 
0 mg/m2 (intravenous 
infusion), 
1400 
mg/m2 
(continuous 
infusion) 
Peripheral neurotoxicity: As far as possible, the neurological examination of the subjects was 
performed by the same investigator, before each cycle of treatment, and the subjects should be 
reviewed regularly if they develop symptoms or signs of peripheral neurological disease. The 
administration dose was adjusted according to Table 3 
 
 


Table 3 Oxaliplatin dose adjustment: Peripheral neurotoxicit 
AE 
Peripheral neurotoxicity 
time of duration 
≤7 days 
8-13days 
≥14days 
Hypoesthesia 
No change 
No change 
No change 
Hypoesthesia without 
cold pain  
No change 
No change 
After recovery, the 
dose was reduced 1 
dose 
Hypoesthesia 
with 
cold pain  
No change 
1 dose reduction 
2 dose reduction 
Hypoesthesia 
with 
functional 
impairment 
1 dose reduction 
2 dose reduction 
Discontinued 
oxaliplatin 
 
6.3.2 Recommendations for Modifications of Apatinib  
Table 4 Recommendations for modifications of apatinib 


AE 
Grade 
Drug held or 
not 
Drug 
resumed 
modification 
permanently 
discontinued 
Apatini
b 
related 
toxicity
 
 
hematologi
c toxicities 
Grade 1/2  No 
— 
—  
— 
Grade 3  
Yes 
(except a 
decreased 
lymphocy
te count) 
until 
toxicity 
grade 
decreas
es 
to 
Grade 2 
The first time: the 
original 
dose; 
Second time: 5 
days on, 2 days 
off; Third time: 
medication 
on 
alternate days 
Grade 3 or higher 
hematologic toxicity 
after 
two 
dose 
modification   
Grade 4  
Yes 
until the 
severity 
of 
the 
toxicity 
decreas
es 
to 
Grade 2 
The first time: 5 
days on, 2 days off; 
Second 
time: 
medication 
on 
alternate days 
Other 
nonhema
tologic 
toxicities 
* 
Grade 1 
No 
— 
—  
— 
Grade 
2 
(lasting 
more than 
7 days) 
Yes 
until 
toxicity 
grade 
decreases 
to Grade 1 
Original dose 
— 
Grade 3 
Yes 
until 
toxicity 
grade 
decreas
es 
to 
Grade 1 
The first time: 5 
days on, 2 days off; 
Second 
time: 
medication 
on 
alternate days 
Grade 3 or higher 
nonhematologic 
toxicity after two dose 
modification 
hypertensio
n 
Grade 
3 
(after 
treatment) 
Yes 
until 
toxicity 
grade 
decreas
es 
to 
Grade 1 
The first time: 
the original dose; 
Second time: 5 
days on, 2 days 
off; Third time: 
medication 
on 
alternate days 
After 
two  
adjustments, grade 3 
hypertension recurred 
hypertensi
ve crisis 
Yes 
— 
permanently 
discontinued 
permanently 
discontinued 
Proteinuria 
(without a 
significant 
increase in 
serum 
creatinine) 
Grade 3  
Yes 
until 
toxicity 
grade 
decreases 
to Grade 2 
The 
first 
time:5 
days on, 2 days off; 
Second 
time:  
medication 
on 
alternate days 
After 
two 
adjustments, grade 3 
proteinuria recurred 
hand-foot 
Grade 3 
Yes 
until 
 The first time:5 After 
two 


* : In the event of cerebral hemorrhage, ≥ grade 2 pulmonary hemorrhage, ≥ grade 3 other 
hemorrhage, arterial thrombosis, leukoencephalopathy syndrome, gastrointestinal perforation, and 
nephrotic syndrome during the trial, apatinib administration and active symptomatic treatment were 
terminated, and whether to continue camrelizumab treatment was determined depending on the 
recovery of toxicity of the subjects 
6.3.3 Recommendations for Modifications of Camrelizumab 
No dose adjustment is allowed, only suspension of administration is allowed. The withdrawal 
criteria can be referred to the NCCN Guidelines for immune-related Adverse Reactions 
 
7. Adverse Event 
7.1 Definition 
An adverse event (AE) is an adverse medical event that occurs after a clinical trial subject receives 
a drug, but is not necessarily causally related to the treatment. An AE can be any adverse and 
undesired symptom, sign, laboratory abnormality, or disease, including at least the following:  
1) The pre-existing medical condition/disease (prior to entry into the clinical trial) is only recorded 
as an adverse event if it worsens (including worsening of symptoms, signs, and abnormalities in 
laboratory tests) after initiation of the investigational drug;  
2) Any newly occurring AE: any newly occurring adverse medical condition (including symptoms, 
signs, and newly diagnosed diseases);  
3) Abnormal clinically significant laboratory test results.  
Invasive (e.g., surgery), non-invasive procedures that are diagnostic or therapeutic should not 
be reported as AE, but should be reported when the disease conditions that led to the procedure meet 
the definition of AE, such as acute appendicitis that developed during the reporting period of AE 
should be reported as AE, and appendectomy performed as a result should be recorded as the 
treatment for that AE.  
The investigator should record in detail any AE that occurred in the subject, including the name 
of the AE, time of occurrence and end, severity (graded according to NCI CTCAE <5.0>), 
correlation between the AE and the trial drug, duration, measures taken on the trial drug due to the 
AE, outcome of the AE, and whether it was a serious adverse event. 
 
syndrome 
toxicity 
grade 
decreases 
to Grade 1 
days on, 2 days off; 
Second 
time:  
medication 
on 
alternate days 
adjustments, grade 3 
hand-foot 
syndrome 
recurred 
headache 
Grade 2 
headache 
lasting ≥7 
days after 
symptom
atic 
treatment
, or grade 
3 
headache 
Yes 
until 
toxicity 
grade 
decreases 
to Grade 1 
The first time: 5 
days on, 2 days off; 
Second 
time:  
medication 
on 
alternate days 
After 
two 
adjustments, grade 3 
headache recurred 


7.2 Recording and Management 
Researchers should observe any adverse events that occur during the study, and require subjects 
to truthfully report changes in their condition after receiving treatment and avoid leading questions. 
Watch for adverse events or unanticipated clinical manifestations and adverse events (including 
symptoms, signs, and laboratory tests) while observing efficacy. Adverse events, whether related to 
the investigational drug or not, should be recorded in detail in the CRF, and the combination of 
drugs should be recorded in detail to analyze the relevance of adverse events to clinical procedures 
and drugs, and the record should be signed and dated.  
Medical treatment of subjects: When adverse events are found, the investigator may take 
necessary treatment measures according to the condition, such as surgical intervention, adjustment 
of chemotherapy dose, temporary interruption of treatment, etc., and decide whether to terminate 
the trial. In the event of serious adverse events, necessary treatment measures should be taken 
immediately to protect the safety of subjects. 
 
7.3 AE Severity Grading 
 
Table 5 AE Severity Grading 
Severity 
(Toxicity Grade) 
Description 
Grade 1 
Mild; asymptomatic or mild symptoms; 
clinical or diagnostic observations 
only; intervention not indicated 
Grade 2 
Moderate; minimal, local or noninvasive 
intervention indicated; limiting ageappropriate 
instrumental activities of daily living 
(ADL) 
Grade 3 
Severe or medically significant but not 
immediately life-threatening; 
hospitalization 
or 
prolongation 
of 
hospitalization indicated; disabling; limiting 
self-care ADL 
Grade 4 
Life-threatening consequences; urgent 
intervention indicated 
Grade 5 
Death related to AE 
 
7.4 The Relationship Between AEs and Experimental Drugs 
The investigator shall conduct a comprehensive evaluation to determine whether the investigational 
drug has a reasonable probability of causing or contributing to AE, including whether there is a 
reasonable time sequence between the occurrence of AE and the administration of the 
investigational drug, the characteristics of the investigational drug, the toxicological and 
pharmacological effects of the investigational drug, the use of combined drugs, the subject's 
underlying disease, medical history, and other factors. Family history and deactivation and 
reactivation responses. The possible association between adverse events and the investigational drug 
was evaluated according to a five-level classification of "definitely relevant, probably relevant, 


probably irrelevant, definitely irrelevant, and undetermined". 
 
7.5 SAE Reporting 
7.5.1 SAE Definition 
SAE is an adverse event that occurs during the study that meets one or more of the following criteria:  
events leading to death;  
life-threatening (the term "life-threatening" means that the subject is at risk of death at the time of 
the event/reaction; It is not assumed that an increase in illness may lead to death);  
Events requiring hospitalization or prolonged hospitalization;  
events resulting in permanent or serious disability/loss of function;  
congenital abnormalities or birth defects;  
Other medically important events. 
 
7.5.2 SAE Reporting 
In the event of an SAE, whether first report or follow-up report, the investigator must 
immediately complete, sign and date the Serious Adverse Event Report Form and report it to the 
appropriate authorities within 24 hours of the investigator becoming aware of it. If SAE occurs after 
initiation of study drug use, it should also be reported to Hengrui Drug Safety Department 
(hengrui_drug_safety@hrglobe.cn).  
All SAEs should record in detail the symptoms, severity (refer to NCI-CTCAE 5.0), correlation 
with each investigational drug, occurrence time, treatment time, measures taken by SAE for each 
investigational drug, follow-up time and method, and outcome. If the investigator considers an SAE 
unrelated to the investigational drug, but potentially related to study conditions (such as 
discontinuation of the original treatment, or comorbidities during the trial), this relationship should 
be detailed in the narrative section of the SAE report form. If the intensity of an ongoing SAE or its 
relationship to the investigational drug changes, a follow-up report should be submitted immediately. 
If an investigator believes that a previously reported SAE contains false positives, corrections, 
retractions, or downgrades may be made in the follow-up report and reported in accordance with 
SAE reporting procedures.  
Any serious adverse event that occurs during the study, regardless of whether it is related to 
the study, should be dealt with promptly. The researcher should promptly study the serious adverse 
event and take necessary measures to ensure the safety and rights of the subjects. Researchers must 
complete a Serious Adverse Event Reporting Form, which should record in the original data when, 
how, and to whom the serious adverse event was reported.  
Investigators must report all AEs, SAEs, and other safety events that occur after informed 
consent is signed, but before enrollment, if they result in exclusion from the study or are the result 
of protocol-mandated interventions (including, but not limited to, washout or discontinuation of 
usual treatment, diet, or procedures). 
 
7.6 Pregnancy 
If a female subject becomes pregnant during the study, the subject shall immediately terminate 
the use of the experimental drug and be discharged from the group; if a male subject's partner 
becomes pregnant during the clinical study, the subject shall continue the clinical study. 
8 End of Treatment  


A patient may be discontinued from study treatment at any time if the patient, the investigator, 
feels that it is not in the patient’s best interest to continue on study. If a patient’s study treatment 
must be discontinued, this will not result in automatic withdrawal of the patient from the study. 
The following is a list of possible reasons for early discontinuation of study treatment: 
 Disease progression (patients should be highly encouraged to stay on study treatment 
until there is confirmed radiographic progression) 
Any episode of seizure 
Any other adverse event that cannot be adequately managed with dose modifications, including 
dose interruption for ≥ 28 days may require study drug discontinuation, which must be discussed 
with the Sponsor. 
Protocol violation requiring discontinuation of study treatment 
Patient is not compliant with study procedures 
Lost to follow-up 
Patient withdrawal of consent 
 
9 Protocol Violations 
A protocol violation occurs when the patient or Investigator fails to adhere to significant protocol 
requirements affecting the inclusion, exclusion, patient safety and primary endpoint criteria. 
Protocol violations for this study include, but are not limited to, the following: 
l 
Failure to meet inclusion/exclusion criteria [no waivers will be granted to meet the eligibility 
criteria] 
l 
Use of a prohibited concomitant medication 
l 
Dose modifications that are not within the protocol specifications 
l 
Any other deviation that presents significant risk or safety concerns to the patient  
Failure to comply with Good Clinical Practice (GCP) guidelines will also result in a protocol 
violation. The Sponsor, in consultation with the Investigator, will determine if a protocol violation 
should result in withdrawal of a patient. 
 
10 Statistic Method 
10.1 Analysis Set 
Full Analysis Set (FAS) : Patients who met the enrollment criteria and were treated with the study 
protocol.  
Per Protocol Set (PPS) : This analysis set is defined as subjects with no significant protocol 
deviations during the study or no protocol deviations that have a significant impact on the study 
results.  
Safety Set (SS) : Participants enrolled and receiving at least one cycle of treatment with at least one 
safety evaluation record constitute the safety set of the study.  
The efficacy evaluation of this study will be based on FAS and PPS, in which FAS is the main 
analysis set. Secfety analysis will be based on SS. 
 
10.2 Statistic Method 
The statistical analysis plan is determined before the database is locked, and the statistical 
analysis is carried out in strict accordance with the statistical analysis plan.  
All statistical analysis will be calculated using SAS9.4 or above version of statistical analysis 


software. All confidence intervals (CI) are applied with 95% confidence. For measurement data, 
mean ± standard deviation or median (minimum value, maximum value) will be used for statistical 
description; Frequency (rate) was used for statistical description of counting data. The Kaplan-Meier 
method was used to calculate the median value and 95%CI for time event data, and the survival 
curve was plotted. 
10.2.1. Subject Distribution  
Descriptive analysis of subject distribution, including but not limited to enrollment, withdrawal, 
and major protocol violations. The reasons for screening failure and the reasons for quitting the test 
were summarized.  
10.2.2. Demographic and Other Disease Characteristics  
Descriptive statistics were performed on sociodemographic characteristics and other disease 
characteristics. Sociodemographic characteristics include age, sex, etc. Other characteristics include 
tumor history and past medical history.  
10.2.3. Analysis of Primary Study Endpoint  
The primary endpoint of this study is pathological response rate, which will be aggregated and 
its 95%CI.  
10.2.4. Secondary Study Endpoint Analysis  
For the temporal event data (DFS, OS) in the secondary endpoints, Kaplan-Meier was used to 
estimate the median value, estimate the 95%CI of the median DFS/OS, plot a survival curve, and 
estimate the 2-year disease-free survival and its 95%CI.  
Statistical rates and 95%CI were pooled for binary data in secondary endpoints (tumor 
pathological downphase rate, pCR rate, and R0 removal rate).  
10.2.5. Safety Analysis  
10.2.5.1. Adverse event analysis  
Adverse events will be coded using MedDRA (v23.0 or higher) as low-level terms, preferred 
terms, and major System organ Class (SOC).  
An adverse event occurring during treatment (TEAE) is defined as any adverse event that 
occurs after initiation of the investigational drug. Data on AE, SAE, grade ≥3 AE, grade ≥3 SAE, 
drug-related AE, drug-related AE, incidence ≥5%, incidence ≥5%, AE leading to dose adjustment, 
AE leading to termination of treatment, and AE related to surgery were statistically summarized.  
10.2.5.2. Surgical safety  
Perioperative complication rate, mortality rate and 95%CI need to be collected. 
 
 


Reference 
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CLINGAN P, BRIDGEWATER J, RIVERA F, DE GRAMONT A. Improved overall survival with 
oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment in stage II or III colon cancer in the 
MOSAIC trial [J]. J Clin Oncol, 2009, 27(19): 3109-16. 
[2] Surgical resection with or without preoperative chemotherapy in oesophageal cancer: a randomised 
controlled trial [J]. Lancet, 2002, 359(9319): 1727-33. 
[3] CUNNINGHAM D, ALLUM W H, STENNING S P, THOMPSON J N, VAN DE VELDE C J, 
NICOLSON M, SCARFFE J H, LOFTS F J, FALK S J, IVESON T J, SMITH D B, LANGLEY R E, 
VERMA M, WEEDEN S, CHUA Y J, PARTICIPANTS M T. Perioperative chemotherapy versus surgery 
alone for resectable gastroesophageal cancer [J]. N Engl J Med, 2006, 355(1): 11-20. 
[4] SEBAG-MONTEFIORE D, STEPHENS R J, STEELE R, MONSON J, GRIEVE R, KHANNA S, 
QUIRKE P, COUTURE J, DE METZ C, MYINT A S, BESSELL E, GRIFFITHS G, THOMPSON L C, 
PARMAR M. Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients 
with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial [J]. Lancet, 2009, 
373(9666): 811-20. 
[5] NELSON H, PETRELLI N, CARLIN A, COUTURE J, FLESHMAN J, GUILLEM J, MIEDEMA 
B, OTA D, SARGENT D. Guidelines 2000 for colon and rectal cancer surgery [J]. J Natl Cancer Inst, 
2001, 93(8): 583-96. 
[6] FOXTROT COLLABORATIVE G. Feasibility of preoperative chemotherapy for locally advanced, 
operable colon cancer: the pilot phase of a randomised controlled trial [J]. Lancet Oncol, 2012, 13(11): 
1152-60. 
[7] HU H, KANG L, ZHANG J, WU Z, WANG H, HUANG M, LAN P, WU X, WANG C, CAO W, 
HU J, HUANG Y, HUANG L, WANG H, SHI L, CAI Y, SHEN C, LING J, XIE X, CAI Y, HE X, DOU 
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SAP_001.pdf: 
Statistic Analysis Plan 
 
 
 
Title of study 
Neoadjuvant chemotherapy combined with 
camrelizumab and apatinib in patients with 
locally advanced colon cancer: a single-arm, 
prospective study 
NCT number 
NCT04625803 
Institution 
The First Affiliated Hospital, Zhejiang 
University School of Medicine 
major investigators 
Weijia Fang 
Xiangming Xu 
Protocol No. 
Version 
MA-CRC-II-004 
1.3 
Version Date: 
07 November 2021 


1.sample size 
This was a single-arm study, and no randomization was used. To determine the sample size, 
we used the Simon 2-stage optimum design with a unilateral alpha of 0.05 to achieve a power of 
0.8, and the pathological response rate (TRG 2-4) was expected to increase from 22.5% to 40%. 
Considering a 10% shedding rate, it was estimated that 64 patients needed to be enrolled. 
2. Subject Distribution  
Descriptive analysis of subject distribution, including but not limited to enrollment, withdrawal, 
and major protocol violations. The reasons for screening failure and the reasons for quitting the test 
were summarized.  
3. Demographic and Other Disease Characteristics  
Descriptive statistics were performed on sociodemographic characteristics and other disease 
characteristics. Sociodemographic characteristics include age, sex, etc. Other characteristics include 
tumor history and past medical history.  
4. Analysis of Primary Study Endpoint  
The primary endpoint of this study is pathological response rate, which will be aggregated and 
its 95%CI.  
5. Secondary Study Endpoint Analysis  
For the temporal event data (DFS, OS) in the secondary endpoints, Kaplan-Meier was used to 
estimate the median value, estimate the 95%CI of the median DFS/OS, plot a survival curve, and 
estimate the 2-year disease-free survival and its 95%CI.  
Statistical rates and 95%CI were pooled for binary data in secondary endpoints (tumor 
pathological downphase rate, pCR rate, and R0 removal rate).  
6. Safety Analysis  
All the statistical analyses were performed using SPSS Statistics 26 (IBM, Armonk, NY, USA). 
Continuous variables with parametric distributions were evaluated using t tests. Categorical 
variables were evaluated using the chi-square test (or Fisher’s exact test where appropriate). All the 
statistical tests were two-sided, and the significance threshold for all the P values was 0.05. Graphs 
were generated using GraphPad Prism (version 10.1.1).