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6.3.5.1 evaluation of target lesions

Complete Response (CR): Disappearance of all target lesions. Any pathological lymph nodes (whether target or non-target) must have reduction in short axis to <10 mm. Partial Response (PR): At least a 30% decrease in the sum of the diameters of target lesions, taking as reference the baseline sum of diameters. Progressive Disease (PD): At least a 20% increase in the sum of the diameters of target lesions, taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest on study). In addition to the relative increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm. (Note: the appearance of one or more new lesions is also considered progressions). Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, taking as reference the smallest sum of diameters while on study.  
6.3.5.2 Evaluation of Non-Target Lesions Complete Response (CR): Disappearance of all non-target lesions and normalization of tumor marker level. All lymph nodes must be non-pathological in size (<10 mm short axis). Note: If tumor markers are initially above the upper normal limit, they must normalize for a participants to be considered in complete clinical response. Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or maintenance of tumor marker level above the normal limits.  
Progressive Disease (PD): Appearance of one or more new lesions and/or *unequivocal progression* of existing non-target lesions. *Unequivocal progression* should not normally trump target lesion status. It must be representative of overall disease status change, not a single lesion increase. Although a clear progression of "non-target" lesions only is exceptional, the opinion of the treating physician should prevail in such circumstances, and the progression status should be confirmed at a later time by the review panel (or Principal Investigator). 6.3.5.3 Evaluation of Best Overall Response The best overall response is the best response recorded from the start of the treatment until disease progression/recurrence (taking as reference for progressive disease the smallest measurements recorded since the treatment started). The participant's best response assignment will depend on the achievement of both measurement and confirmation criteria.  
| Target    | Non-Target             | New     | Overall                                           | Best Overall Response when   |
|-----------|------------------------|---------|---------------------------------------------------|------------------------------|
| Lesions   | Lesions                | Lesions | Response                                          | Confirmation is Required*    |
| CR        | CR                     | No      | CR                                                | >4 wks. Confirmation**       |
| CR        | Non                        |         |                                                   |                              |
| CR/Non-PD | No                     | PR      |                                                   |                              |
| CR        | Not                    | No      | PR                                                |                              |
| evaluated | >4 wks. Confirmation** |         |                                                   |                              |
| PR        | Non                        |         |                                                   |                              |
| CR/NonPD/not  evaluated           | No                     | PR      |                                                   |                              |
| SD        | Non                        |         |                                                   |                              |
| CR/NonPD/not  evaluated           | No                     | SD      | Documented at least once >4  wks. from baseline** |                              |  
| Target                                                                                                                                                                                                                                                                                                                                  | Non-Target                                                                                                           | New     | Overall               | Best Overall Response when   |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------|---------|-----------------------|------------------------------|
| Lesions                                                                                                                                                                                                                                                                                                                                 | Lesions                                                                                                              | Lesions | Response              | Confirmation is Required*    |
| PD                                                                                                                                                                                                                                                                                                                                      | Any                                                                                                                  | Yes or  | PD                    |                              |
| No                                                                                                                                                                                                                                                                                                                                      |                                                                                                                      |         |                       |                              |
| Any                                                                                                                                                                                                                                                                                                                                     | PD***                                                                                                                | Yes or  | no prior SD, PR or CR |                              |
| PD                                                                                                                                                                                                                                                                                                                                      |                                                                                                                      |         |                       |                              |
| No                                                                                                                                                                                                                                                                                                                                      |                                                                                                                      |         |                       |                              |
| Any                                                                                                                                                                                                                                                                                                                                     | Any                                                                                                                  | Yes     | PD                    |                              |
| *                                                                                                                                                                                                                                                                                                                                       | See RECIST 1.1 manuscript for further details on what is evidence of a  new lesion.                                  |         |                       |                              |
| **                                                                                                                                                                                                                                                                                                                                      | Only for non-randomized trials with response as primary endpoint.                                                    |         |                       |                              |
| ***                                                                                                                                                                                                                                                                                                                                     | In exceptional circumstances, unequivocal progression in non-target  lesions may be accepted as disease progression. |         |                       |                              |
| Note: Participants with a global deterioration of health status requiring  discontinuation of treatment without objective evidence of disease  progression at that time should be reported as "symptomatic  deterioration." Every effort should be made to document the objective  progression even after discontinuation of treatment. |                                                                                                                      |         |                       |                              |  
| Non-Target Lesions                                                                                                                                                                                                                             | New Lesions   | Overall Response   |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------|--------------------|
| CR                                                                                                                                                                                                                                             | No            | CR                 |
| Non-CR/non-PD                                                                                                                                                                                                                                  | No            | Non-CR/non-PD*     |
| Not all evaluated                                                                                                                                                                                                                              | No            | not evaluated      |
| Unequivocal PD                                                                                                                                                                                                                                 | Yes or No     | PD                 |
| Any                                                                                                                                                                                                                                            | Yes           | PD                 |
| * 'Non-CR/non-PD' is preferred over 'stable disease' for non-target disease since  SD is increasingly used as an endpoint for assessment of efficacy in some trials  so to assign this category when no lesions can be measured is not advised |               |                    |  
6.3.5.4 Duration of Response Duration of overall response: The duration of overall response is measured from the time measurement criteria are met for CR or PR (whichever is first recorded) until the first date that recurrent or progressive disease is objectively documented (taking as reference for progressive disease the smallest measurements recorded since the treatment started). The duration of overall CR is measured from the time measurement criteria are first met for CR until the first date that progressive disease is objectively documented.  
Duration of stable disease: Stable disease is measured from the start of the treatment until the criteria for progression are met, taking as reference the smallest measurements recorded since the treatment started, including the baseline measurements. 6.3.5.5 Progression-Free Survival PFS is defined as the duration of time from start of treatment to time of progression or death, whichever occurs first.
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6.4 toxicity criteria

The following adverse event management guidelines are intended to ensure the safety of each participants while on the study. The descriptions and grading scales found in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 will be utilized for AE reporting. All appropriate treatment areas should have access to a copy of the CTCAE version 5.0. A copy of the CTCAE version 5.0 can be downloaded from the CTEP web site (http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm).
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7 nih reporting requirements /

Please refer to definitions provided in Policy 801: Reporting Research Events found at:
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835\#Policies&Guidance800Series-ComplianceandResearchEventReportingRequirements.
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7.2 ohsrp office of compliance

Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy 802 Non-Compliance Human Subjects Research found at:https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835\#Policies&Guidance
-800Series-ComplianceandResearchEventReportingRequirements. Note: Only IND Safety Reports that meet the definition of an unanticipated problem will need to be reported per these policies. 7.2.2 IRB Requirements for PI Reporting at Continuing Review Please refer to the reporting requirements in Policy 801: Reporting Research Events found at:https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835\#Policies&Guidance -800Series-ComplianceandResearchEventReportingRequirements. 7.2.3 NCI Clinical Director Reporting Problems expeditiously reviewed by the OHSRP in the NIH eIRB system will also be reported to the NCI Clinical Director/designee; therefore, a separate submission for these reports is not necessary. In addition to those reports, all deaths that occur within 30 days after receiving a research intervention should be reported via email unless they are due to progressive disease.  
To report these deaths, please send an email describing the circumstances of the death to NCICCRQA@mail.nih.gov within one business day of learning of the death.
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7.3 nih required data and

The clinical research team will meet on a regular basis (approximately weekly) when participants are being actively treated on the trial to discuss each participant. Decisions about dose level enrollment and dose escalation if applicable will be made based on the toxicity data from prior participants. All data will be collected in a timely manner and reviewed by the principal investigator or a lead associate investigator. Events meeting requirements for expedited reporting as described in Section 7.2.2 will be submitted within the appropriate timeline.  
The principal investigator will review adverse event and response data on each participant to ensure safety and data accuracy. The principal investigator will personally conduct or supervise the investigation and provide appropriate delegation of responsibilities to other members of the research staff. 7.3.2 Data Safety Monitoring Board (DSMB) (OSRO) The DSMB is an independent group of at least 3 experts that monitors participant safety and advises The Sponsor. DSMB members will be separate and independent of study staff participating in this trial and should not have scientific, financial, or other conflicts of interest related to this trial. The DSMB will consist of members with appropriate expertise to contribute to the interpretation of data from this trial. A quorum will consist of a simple majority. The DSMB will review cumulative safety data from this trial at least annually. The DSMB will meet as requested by the sponsor or PI.  
The DSMB will have a final review meeting at the end of the study.  
Procedures for DSMB reviews/meetings will be defined in the DSMB charter. The DSMB will review applicable data, including, but not limited to, enrollment, demographics, dosing data, clinical laboratory data, and safety data, at scheduled timepoints during this trial as defined in the DSMB charter. The DSMB will review blinded aggregate data in the open session of the DSMB meetings. Additional data may be requested by the DSMB, and interim statistical reports may be generated as deemed necessary and appropriate by the Sponsor. As an outcome of each review/meeting, the DSMB will make a recommendation as to the advisability of proceeding with study product administration, and to continue, modify, or terminate this trial.
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8 sponsor protocol/safety reporting 8.1

Any untoward medical occurrence in a patient or clinical investigation subject administered a pharmaceutical product and which does not necessarily have a causal relationship with this treatment. An adverse event (AE) can therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal (investigational) product, whether or not related to the medicinal (investigational) product (ICH E6 (R2)). 8.1.2 Adverse Event of Special Interest (AESI) Mucosal bleeding events which are at least possibly related to study drug (M7824) will be captured as AESIs. These events will not require expedited reporting to the study sponsor unless they also meet SAE criteria. 8.1.3 Serious Adverse Event (SAE) An adverse event or suspected adverse reaction is considered serious if in the view of the investigator or the sponsor, it results in any of the following:
- Death;
- A life-threatening adverse event (see Section **8.1.4**);
- Inpatient hospitalization or prolongation of existing hospitalization o A hospitalization/admission that is pre-planned (i.e., elective or scheduled surgery arranged prior to the start of the study), a planned hospitalization for pre-existing condition, or a procedure required by the protocol, without a serious deterioration in health, is not considered a serious adverse event.  
o A hospitalization/admission that is solely driven by non-medical reasons (e.g.,
hospitalization for patient convenience) is not considered a serious adverse event.  
o Emergency room visits or stays in observation units that do not result in admission to the hospital would not be considered a serious adverse event. The reason for seeking medical care should be evaluated for meeting one of the other serious criteria.  
- Persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions;
- A congenital anomaly/birth defect; - Important medical events that may not result in death, be life-threatening, or require hospitalization may be considered a serious adverse drug experience when, based upon appropriate medical judgment, they may jeopardize the patient or subject and may require medical or surgical intervention to prevent one of the outcomes listed in this definition.
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8.1.4 life-threatening

An adverse event or suspected adverse reaction is considered "life-threatening" if, in the view of either the investigator or sponsor, its occurrence places the patient or subject at immediate risk of death. It does not include an adverse event or suspected adverse reaction that, had it occurred in a more severe form, might have caused death (21CFR312.32). 8.1.5 Severity The severity of each Adverse Event will be assessed utilizing the CTCAE version 5.0. 8.1.6 Relationship to Study Product All AEs will have their relationship to study product assessed using the terms: related or not related.  
- Related - There is a reasonable possibility that the study product caused the adverse event.  
Reasonable possibility means that there is evidence to suggest a causal relationship between the study product and the adverse event.  
- Not Related - There is not a reasonable possibility that the administration of the study product caused the event.  
- .
8.1.7 Adverse Events of Special Interest (AESI) An adverse event of special interest (AESI) is one of scientific and medical interest specific to understanding of the Investigational Product(s) and may require close monitoring and rapid communication by the investigator to the sponsor. An AESI may be serious or non-serious. The rapid reporting of AESIs allows ongoing surveillance of these events to characterize and understand them in association with the use of these investigational products. Only AESIs that match the definition of SAE will be reported as other SAEs within 24 hours from the knowledge of event. The following adverse events, regardless of site, will be collected as an AESI to enable evaluation of potential risk factors, such as site/past radiation/associated infection at site/recent instrumentation and other variables such as time to onset, exposure history, grade of bleeding, anatomical sites, etc. can be collected.
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8.2 assessment of safety events

AE information collected will include event description, date of onset, assessment of severity and relationship to study product and alternate etiology (if not related to study product), date of resolution of the event, seriousness and outcome. The assessment of severity and relationship to the study product will be done only by those with the training and authority to make a diagnosis and listed on the Form FDA 1572 as the site principal investigator or sub-investigator. AEs occurring during the collection and reporting period will be documented appropriately regardless of relationship. AEs will be followed through resolution. SAEs will be:  
- Assessed for severity and relationship to study product and alternate etiology (if not related to study product) by a licensed study physician listed on the Form FDA 1572 as the site principal investigator or sub-investigator.  
- Recorded on the appropriate SAE report form, the medical record and captured in the clinical database.  
- Followed through resolution by a licensed study physician listed on the Form FDA 1572 as the site principal investigator or sub-investigator.
For timeframe of recording adverse events, please refer to Section 6.1. All serious adverse events recorded must be reported to the sponsor. All serious adverse events recorded from the time of first investigational product administration must be reported to the sponsor with the exception of any listed in section 8.4.
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8.3 reporting of serious adverse

Any AE that meets protocol-defined serious criteria or meets the definition of Adverse Event of Special Interest that require expedited reporting must be submitted immediately (within 24 hours of awareness) to OSRO Safety using the CCR SAE report form. Any exceptions to the expedited reporting requirements are found in section 8.4. All SAE reporting must include the elements described in Section 8.2.  
SAE reports will be submitted to the Center for Cancer Research (CCR) at: OSROSafety@mail.nih.gov and to the CCR PI and study coordinator. CCR SAE report form and instructions can be found at: https://ccrod.cancer.gov/confluence/display/CCRCRO/Forms+and+Instructions Following the assessment of the SAE by OSRO, other supporting documentation of the event may be requested by the OSRO Safety and should be provided as soon as possible.
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8.4 waiver of expedited reporting

As overall survival, which includes death due to disease progression and hospitalization due to disease progression are part of the study objectives, and captured as an endpoint in this study, death/hospitalization due to disease progression will not be reported in expedited manner to the sponsor. However, if there is evidence suggesting a causal relationship between the study drug and the event, report the event in an expedited manner according to Section 8.3.
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8.6 reporting pregnancy

All required pregnancy reports/follow-up to OSRO will be submitted to: OSROSafety@mail.nih.gov and to the CCR PI and study coordinator. Forms and instructions can be found here: https://ccrod.cancer.gov/confluence/display/CCRCRO/Forms+and+Instructions
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8.6.1 maternal exposure

If a participant becomes pregnant during the course of the study, the study treatment should be discontinued immediately, and the pregnancy reported to the Sponsor. The potential risk of exposure of the fetus to the investigational agent(s) or chemotherapy agents (s) should be documented in box B5 of the MedWatch form "Describe Event or Problem". Pregnancy itself is not regarded as an SAE. However, congenital abnormalities or birth defects and spontaneous miscarriages that meet serious criteria (Section **8.1.3**) should be reported as SAEs.  
The outcome of all pregnancies should be followed up and documented. 8.6.2 Paternal exposure Male participants should refrain from fathering a child or donating sperm during the study and for 2 months after the last dose of M7824.  
Pregnancy of the participant's partner is not considered to be an AE. The outcome of all pregnancies occurring from the date of the first dose until 2 months after the last dose should, if possible, be followed up and documented. Pregnant partners may be offered the opportunity to participate in an institutional pregnancy registry protocol (e.g., the NIH IRP pregnancy registry study) to provide data about the outcome of the pregnancy for safety reporting purposes.
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8.7 regulatory reporting for studies

Following notification from the investigator, CCR, the IND sponsor, will report any suspected adverse reaction that is both serious and unexpected in expedited manner to the FDA in accordance to 21 CFR 31.2.32. CCR will report an AE as a suspected adverse reaction only if there is evidence to suggest a causal relationship between the study product and the adverse event. CCR will notify FDA and all participating investigators (i.e., all investigators to whom the sponsor is providing drug under its INDs or under any investigator's IND) in an IND safety report of potential serious risks from clinical trials or any other source, as soon as possible, in accordance to 21 CFR Part 312.32. All serious events will be reported to the FDA at least annually in a summary format.
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8.8 sponsor protocol deviation reporting

A Protocol Deviation is defined as any non-compliance with the clinical trial Protocol, Manual of Operational Procedures (MOP) and other Sponsor approved study related documents, GCP, or protocol-specific procedural requirements on the part of the participant, the Investigator, or the study site staff inclusive of site personnel performing procedures or providing services in support of the clinical trial. It is the responsibility of the study Staff to document any protocol deviation identified by the Staff or the site Monitor in the CCR Protocol Deviation Tracking System (PDTS) online application. The entries into the PDTS online application should be timely, complete, and maintained per CCR PDTS user requirements. In addition, any deviation to the protocol should be documented in the participant's source records and reported to the reviewing IRB per their guidelines. OSRO required protocol deviation reporting is consistent with E6(R2) GCP: Integrated Addendum to ICH E6(R1): 4.5 Compliance with Protocol; 5.18.3 (a), and 5.20 Noncompliance; and ICH E3 16.2.2 Protocol deviations.
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9 clinical monitoring plan

Clinical site monitoring is conducted to ensure:  
- that the rights of the participants are protected;
- that the study is implemented per the approved protocol, Good Clinical Practice and standard operating procedures; and,
- the quality and integrity of study data and data collection methods are maintained.
Monitoring for this study will be performed by NCI CCR Office of Sponsor and Regulatory Oversight (OSRO) Sponsor and Regulatory Oversight Support (SROS) Services contractor. Clinical site monitoring activities will be based on OSRO standards, FDA Guidance E6(R2) Good Clinical Practice: Integrated Addendum to ICH E6(R1) March 2018, and applicable regulatory requirements. Details of clinical site monitoring will be documented in a Clinical Monitoring Plan (CMP) developed by OSRO. CMPs will be protocol-specific, risk-based and tailored to address human subject protections and integrity of the study data. OSRO will determine the intensity and frequency of monitoring based on several factors, including study type, phase, risk, complexity, expected enrollment rate, and any unique attributes of the study and the site. The Sponsor will conduct a periodic review of the CMP to confirm the plan's continued appropriateness. A change to the protocol, significant or pervasive non-compliance with GCP, or the protocol may trigger CMP updates. OSRO SROS Monitoring visits and related activities will be conducted throughout the life cycle of each protocol. The first activity is before the study starts to conduct a Site Assessment Visit (SAV) (as warranted), followed by a Site Initiation Visit (SIV), Interim Monitoring Visit(s) (IMVs), and a study Close-Out Visit (COV). Some monitoring activities may be performed remotely, while others will occur at the study site. Monitoring visit reports will describe visit activities, observations, and associated action items or follow-up required for resolution of any issues, discrepancies, or deviations. Monitoring reports will be distributed to the study PI, NCI CCR QA, CCR Protocol Support Office, coordinating center (if applicable), and the OSRO regulatory file. The site Monitor will inform the study team of any deviations observed during monitoring visits. If unresolved, the Monitor will request that the site Staff enter the deviations in the CCR Protocol Deviation Tracking System (PDTS) for deviation reporting to the Sponsor and as applicable per institutional and IRB guidance.
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10 statistical considerations 10.1 statistical

The primary objective of this trial is to determine the objective response rate of combination immunotherapy in participants with HPV associated malignancies. A secondary hypothesis (objective) will be to obtain preliminary data on duration of response, PFS, OS and ratio of participants that are hospitalized because of adverse events attributed to disease progression. An exploratory hypothesis (objective) will be to evaluate exploratory immunologic studies to understand and improve the administered treatment. In patients with cervical cancer with prior pelvic radiation and boost brachytherapy, a key secondary objective is to evaluate the safety of the combination at a reduced dose level in these patients where a potential higher risk of grade 3 hematuria may exist with the full starting doses of M7824 at 1200 mg and NHS-IL12 at 16.8 mcg/kg.
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10.2 sample size determination

Data from the ongoing trial indicates that a response rate for M7824 may be approximately 30%. In the main study cohort (Cohort 1), this trial will try to demonstrate if the proposed combination therapies may be associated with an improved response rate.  
The trial will treat participants with HPV related cancers with HPV vaccine + M7824 + NHSIL12. The objective is to determine if this treatment can be associated with an acceptable response rate. To establish the efficacy of this combination treatment, the primary objective would be to determine if using the proposed agents would rule out a 30% response rate and result in a response rate consistent with 60%. As such, this trial in participants with HPV associated malignancies will be conducted using a Simon optimal two-stage phase II trial design (Simon R, Controlled Clinical Trials 10:1-10, 1989) to rule out an unacceptably low PR+CR rate of 30% (p0=0.30) in favor of an improved response rate of 60% (p1=0.60). With alpha=0.10 (probability of accepting a poor treatment=0.10) and beta = 0.10 (probability of rejecting a good treatment=0.10), the first stage will enroll 8 evaluable checkpoint naïve participants, and if 0 to 2 of the 8 have a clinical response, then no further participants will be accrued. If 3 or more of the first 8 checkpoint naïve participants have a response, then accrual would continue until a total of 20 evaluable checkpoint naïve participants have been treated. As it may take up to several months to determine if a patient has experienced a response, a temporary pause in the accrual may be necessary to ensure that enrollment to the second stage is warranted. If there are 3 to 8 checkpoint naïve participants with a response out of 20 participants, this would be an uninterestingly low response rate. If there were 9 or more of 20 (45.0%) checkpoint naïve patients who experienced a response, this would be sufficiently interesting to warrant possible further study of the combination in later trials in this disease type; decisions about future use of the combination will incorporate response as well as toxicity profile information. Under the null hypothesis (30% response rate), the probability of early termination is 55.2%. In the cohort with patients with cervical cancer with prior pelvic radiation and boost brachytherapy where a potential higher risk of grade 3 hematuria may exist with the full starting doses of M7824 at 1200 mg and NHS-IL12 at 16.8 mcg/kg, the safety evaluation may require up to 12 patients as outlined in Section **3.4.3**, and if there are preliminary hints of efficacy within these 12 patients, up to 12 additional patients may be enrolled at the dose found to be safe for these patients to further explore the safety as well as the potential response rate in a small number of patients. It is expected that if 2 participants per month enroll on the trial, in order to enroll up to a total of 20 evaluable participants with checkpoint naïve disease in the main cohort, and 12+12=24 maximum in the patients in cohort 2, up to 3 years may be required. To allow for several inevaluable participants for the primary objective and potential replacements based on HPV status the accrual ceiling will be set at 56 participants. If additional patients are required to enroll on the trial to account for screen failures and inevaluable patients, the ceiling increase will be incorporated in an amendment.
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10.3 populations for analyses

All participants who receive any investigational treatment will be evaluable for safety and toxicity evaluations. All participants will be evaluable for toxicity from the time of their first treatment with any agent. For efficacy, a modified intention to treat population will be used. Only those participants who have measurable disease present at baseline and have had their disease re-evaluated will be considered evaluable for response. (Note: Participants who exhibit objective disease progression prior to the end of cycle 1 will also be considered evaluable.)
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10.4 statistical analyses 10.4.1 general

Participants will be evaluated with respect to the grades and types of toxicities obtained. The results will be presented descriptively and tabled if appropriate. Further planned analyses are described below. 10.4.2 Analysis of the Primary Endpoints The percentage of checkpoint naïve subjects whose initial doses of study drugs are not modified that achieve an objective confirmed complete or partial overall tumor response using RECIST Version 1.1 will be evaluated. If anti-tumor responses are observed, the 95% confidence interval of the response rate will be evaluated.
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10.4.3 analysis of the secondary

Data will be obtained on duration of response, PFS, OS and ratio of participants that are hospitalized because of adverse events attributed to disease progression. In addition, patients in cohort 2 will have their safety evaluated based on the description in Section **3.4.3**.
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10.4.3.1 duration of response

The duration of overall response is measured from the time measurement criteria are met for CR or PR (whichever is first recorded) until the first date that PD is objectively documented and is evaluated using the Kaplan-Meier method. 10.4.3.2 Progression-Free Survival PFS will be evaluated using Kaplan-Meier methods. PFS will be defined as the time from the date of first treatment to the date of disease progression or death (any cause) whichever occurs first. Subjects who do not have disease progression or have not died at the end of follow up will be censored at the last known date the subject was progression free.
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10.4.3.3 objective response

Objective response is a complete or partial radiographic response as defined by RECIST 1.1
(Section 6.3.5).
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10.4.3.4 overall survival

OS will be evaluated using Kaplan-Meier methods. OS will be defined as the time from the date of first treatment to the date of death (any cause). Subjects who are alive at the end of follow up will be censored at the last known date alive.
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10.4.4 safety analyses

Safety endpoints will be analyzed as summary statistics during treatment and/or as change scores from baseline assessments. AEs will be coded as defined in the Medical Dictionary for Regulatory Activities (MedDRA). All AEs will be recorded and tabulated following each treatment. AEs will be recorded by severity, frequency, and relationship to the study intervention and will be presented by System Organ Class (SOC) designations and preferred term groupings. Information on each AE will include start date, stop date, severity, relationship, expectedness, outcome, and duration.  
Adverse events leading to premature discontinuation from the study intervention and serious treatment-emergent AEs will be presented either in a Table or a Listing. In addition, overall safety will be assessed by descriptive analyses using tabulated frequencies of AEs by grade using CTCAE Version 5 within dose cohorts and for the overall study population in terms of treatment-emergent AEs, SAEs, and clinically significant changes in safety laboratory tests, physical examinations, ECGs, and vital signs. Patients in cohort 2 will have their safety evaluated as detailed in Section 3.4.3, with up to 12 patients, with further evaluation focusing on bleeding events in the maximum of 12 patients enrolled at the dose considered safe among the patients in this cohort also being enrolled for an exploratory evaluation of efficacy. 10.4.5 Baseline Descriptive Statistics Baseline Characteristics will be described. 10.4.6 Planned Interim Analyses Interim assessment of efficacy will be made according to the Simon two stage phase II designs of each cohort described in Section **10.4.6.**
10.4.7 Tabulation of Individual Participant Data Individual responses in a cohort may be depicted within a larger group using a waterfall plot or spider diagram. 10.4.8 Exploratory Analyses
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10.4.8.1 exploratory analyses immune responses

Where feasible exploratory immune analyses will be conducted to evaluate anti-tumor immune responses. Immune response will be assessed among all subjects treated in each cohort. The magnitude of immune responses will be described. A subject will be considered evaluable for immune response if they receive at least one dose of treatment. The percentage of subjects with a positive immune response will be evaluated by cohort. For flow cytometry analyses on PBMC samples, Student T tests or Kruskal-Wallis and Wilcoxon rank sum tests as appropriate will be performed on percentages of TNF-α and/or IFN-γ expressing cells among the different cohorts to determine any significant differences in cell populations. For antigen specific T cell responses, a positive immune response is defined by CMI reactivity in *ex vivo* stimulation using a flow cytometric readout (cytokine production or CD107 expression). Antigen-specific peptide challenge assays require a readout of >250 reactive T-cells/million cells above the background [38]. 10.4.8.2 Exploratory Analyses: Preliminary Activity in Patients Receiving Lower Doses In patients who receive reduced initial doses of therapy as per Section 3.4.3, both in the dose seeking portion as well as in a small group of patients treated at the safe dose, the percentage of subjects who achieve an objective confirmed complete or partial overall tumor response using RECIST Version 1.1 for a specific initial dose will be evaluated. If anti-tumor responses are observed, the 95% confidence interval of the response rate will be evaluated.
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11 collaborative agreements

11.1 COOPERATIVE RESEARCH AND DEVELOPMENT AGREEMENT **(CRADA)** A CRADA (02666) is in place with EMD Serono for the supply of M7824 and NHS-IL12. A CRADA (03279) is in place with PDS Biotechnology for the supply of PDS0101.
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12 human subjects protections 12.1

Subjects from all racial/ethnic groups are eligible for this study if they meet the eligibility criteria. Efforts will be made to extend accrual to a representative population. Due to impaired cellular immunity which may affect the efficacy of treatment, patients with poorly controlled HIV as well as patents with detectable viral loads of hepatitis B and C will be excluded. Participants who do not accept blood transfusions will be excluded. As there is a risk of severe bleeding with this study drug, participants must be willing to receive blood transfusions if medically necessary for their own safety.  
.
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12.2 participation of children

Individuals under the age of 18 will not be eligible to participate in this study because of unknown toxicities in pediatric patients.
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12.3 participation of subjects unable

Adults unable to provide consent are excluded from enrolling in the protocol. However, it is possible that subjects enrolled in the protocol may permanently lose the capacity to consent for themselves during the course of this study. In the event this occurs, the subjects will remain in the study because there is a prospect of direct benefit from research participation. All subjects ≥ age 18 will be offered the opportunity to fill in their wishes for research and care, and assign a substitute decision maker on the "NIH Advance Directive for Health Care and Medical Research Participation" form so that another person can make decisions about their medical care in the event that they become incapacitated or cognitively impaired during the course of the study. Note: The PI or AI will contact the NIH Ability to Consent Assessment Team (ACAT) for evaluation to assess ongoing capacity of the subjects and to identify an LAR, as needed.  
Please see Section **12.5.1** for consent procedure.
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12.4 risks/benefit assessment

Participants will receive evaluation of their disease at the National Cancer Institute's Clinical Center. The potential benefit to a participant that goes onto study is a reduction in the bulk of their tumor which may or may not have a favorable impact on symptoms and/or survival. Potential adverse reactions attributable to the administration of the study drug utilized in this trial are discussed in Section 14. All care will be taken to minimize side effects, but they can be unpredictable in nature and severity. Participants will be examined and evaluated prior to enrollment. All evaluations to monitor the treatment of participants will be recorded in the medical record. If participants suffer any physical injury as a result of the participation in this study, immediate medical treatment is available at the Clinical Center, National Cancer Institute, Bethesda, Maryland. Although no compensation is available, any injury will be evaluated and treated in keeping with the benefits or care to which participants are entitled under applicable regulations.
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12.4.1 risks

Some of the procedures performed on this study are not known to be associated with risk. These include urine tests and EKGs. Below are a list of procedures and study interventions that are associated with risk.
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12.4.1.1 study drug risks

Risks include the possible occurrence of any of a range of side effects which are listed in the Consent Document. Participants may be harmed from being in this study by toxicity due to the drug or combination of drugs given during this study. M7824 is similar to immune check point inhibitors. There are preliminary data to suggest that not all patients benefit from immune check point inhibitors nor M7824. Additionally, there are preliminary data to suggest that an unexpectedly rapid progression of disease occurs in some patients receiving immunotherapy such as immune checkpoint inhibitors.
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12.4.1.2 risk of optional biopsies

All care will be taken to minimize risks that may be incurred by tumor sampling. However, there are procedure-related risks (such as bleeding, infection and visceral injury) that will be explained fully during informed consent. 12.4.1.3 Risks of Exposure to Ionizing Radiation This research study involves the possibility of 7 CT CAP scans, 1 brain CT scan, and 2 CT guided biopsies collected for research purposes. The amount of radiation exposure you will receive from these procedures is equal to approximately 9.4 rem. The CT scans and CT guided biopsies in this study will expose the research participant to 31.3 years' worth of background radiation. This level of exposure results in an increased risk of cancer.
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12.4.1.4 additional risks of ct

In addition to the radiation risks addressed above, CT scans that employ contrast may cause allergic reactions, injection site reactions abdominal discomfort and fainting.  
12.4.1.5 Research Blood Collection Risks Risks of blood draws include pain and bruising in the area where the needle is placed, lightheadedness, and rarely, fainting. When large amounts of blood are collected, low red blood cell count (anemia) can develop.
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12.4.1.6 other risks

Risks include the possible occurrence of any of a range of side effects which are listed in the Consent Document or this protocol document. Frequent monitoring for adverse effects will help to minimize the risks associated with administration of the study agents.
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12.4.2 benefits

The potential benefit to a patient that goes onto study is a reduction in the bulk of their tumor which may or may not have favorable impact on symptoms and/or survival. 12.4.3 Assessment of Potential Risks and Benefits Metastatic or refractory/recurrent HPV associated malignancies (cervical, anal, oropharyngeal cancers, etc.) are in need of improved therapy options. Preclinical studies suggest that the use of a combination of multiple immunotherapy agents may have improved anti-tumor efficacy. A number of clinically appropriate strategies to minimize risks to participants have been built into the protocol through the means of inclusion/exclusion criteria, monitoring strategies, and management guidelines. Overall, there is direct potential benefit of the combination of a therapeutic vaccine against HPV positive cancers (PDS0101), a tumor targeted immunocytokine (NHS-IL12) and a bifunctional fusion protein targeting PD-L1 and TGF beta (M7824) in subjects with advanced HPV associated malignancies for participants retaining the ability to consent and those who lose capacity to consent during the course of the trial with this combination immunotherapy proposed in this study.  
The potential benefit to a participant that goes onto this study is a reduction in the bulk of their tumor which may or may not have favorable impact on symptoms and/or survival. Potential adverse reactions attributable to the administration of the study drug utilized in this trial are discussed in Section 14. All care will be taken to minimize side effects, but they can be unpredictable in nature and severity.
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12.5 consent process and documentation

The informed consent document will be provided as a physical or electronic document to the participant or consent designee(s) as applicable for review prior to consenting. A designated study investigator will carefully explain the procedures and tests involved in this study, and the associated risks, discomforts and benefits. In order to minimize potential coercion, as much time as is needed to review the document will be given, including an opportunity to discuss it with friends, family members and/or other advisors, and to ask questions of any designated study investigator. A signed informed consent document will be obtained prior to entry onto the study. The initial consent process as well as re-consent, when required, may take place in person or remotely (e.g., via telephone or other NIH approved remote platforms used in compliance with policy, including HRPP Policy 303) per discretion of the designated study investigator and with the agreement of the participant/consent designee(s). Whether in person or remote, the privacy of the subject will be maintained. Consenting investigators (and participant/consent designee, when in person) will be located in a private area (e.g., clinic consult room). When consent is conducted remotely, the participant/consent designee will be informed of the private nature of the discussion and will be encouraged to relocate to a more private setting if needed. Consent will be documented with required signatures on the physical document (which includes the printout of an electronic document sent to participant) or as described below, with a manual (non-electronic) signature on the electronic document. When required, witness signature will be obtained similarly as described for the investigator and participant.
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manual (non-electronic) signature on electronic

When a manual signature on an electronic document is used for the documentation of consent at the NIH Clinical Center, this study will use the following to obtain the required signatures:  
- Adobe platform (which is not 21 CFR Part 11 compliant); or,
- iMedConsent platform (which is 21 CFR Part 11 compliant)
During the consent process, participants and investigators will view individual copies of the approved consent document on screens at their respective locations (if remote consent); the same screen may be used when at the same location, but is not required. Both the investigator and the subject will sign the document using a finger, stylus or mouse.  
Note: Refer to the CCR SOP PM-2, Obtaining and Documenting the Informed Consent Process for additional information (e.g., verification of participant identity when obtaining consent remotely) found at https://ccrod.cancer.gov/confluence/pages/viewpage.action?pageId=73203825.  
As there is an optional biopsy for research in this protocol, the participant will be asked to sign a separate consent at the time of the procedure. If the participant refuses the optional biopsy at that time, the refusal will be documented in the medical record and in the research record. 12.5.1 Consent Process for Participants Who Decline Other Treatment Options Participants who are eligible because they decline the treatment options described in the eligibility criteria (see Section 2.1) will have consent obtained in the presence of an independent consent monitor from the Bioethics department or Human Subjects Protection Unit (HSPU). 12.5.2 Consent Process for Adults Who Lack Capacity to Consent to Research Participation For participants addressed in Section **12.3**, an LAR will be identified consistent with Policy 403 and informed consent obtained from the LAR, as described in Section 12.5.
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13 regulatory and operational considerations

This study may be temporarily suspended or prematurely terminated if there is sufficient reasonable cause. Written notification, documenting the reason for study suspension or termination, will be provided by the suspending or terminating party to study participants, investigator, the Investigational New Drug (IND) and regulatory authorities. If the study is prematurely terminated or suspended, the Principal Investigator (PI) will promptly inform study participants, the Institutional Review Board (IRB), and sponsor and will provide the reason(s) for the termination or suspension. Study participants will be contacted, as applicable, and be informed of changes to study visit schedule. Circumstances that may warrant termination or suspension include, but are not limited to:  
- Determination of unexpected, significant, or unacceptable risk to participants
- Demonstration of efficacy that would warrant stopping
- Insufficient compliance to protocol requirements
- Data that are not sufficiently complete and/or evaluable - Determination that the primary endpoint has been met - Determination of futility
Study may resume once concerns about safety, protocol compliance, and data quality are addressed, and satisfy the sponsor, IRB and as applicable, Food and Drug Administration (FDA).
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13.2 quality assurance and quality

Each clinical site will perform internal quality management of study conduct, data and biological specimen collection, documentation and completion. An individualized quality management plan will be developed to describe a site's quality management. Quality control (QC) procedures will be implemented beginning with the data entry system and data QC checks that will be run on the database will be generated. Any missing data or data anomalies will be communicated to the site(s) for clarification/resolution. Following written Standard Operating Procedures (SOPs), the monitors will verify that the clinical trial is conducted, and data are generated and biological specimens are collected, documented (recorded), and reported in compliance with the protocol, International Conference on Harmonisation Good Clinical Practice (ICH GCP), and applicable regulatory requirements (e.g., Good Laboratory Practices (GLP), Good Manufacturing Practices (GMP)). The investigational site will provide direct access to all trial related sites, source data/documents, and reports for the purpose of monitoring and auditing by the sponsor, and inspection by local and regulatory authorities.
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13.3 conflict of interest policy

The independence of this study from any actual or perceived influence, such as by the pharmaceutical industry, is critical. Therefore, any actual conflict of interest of persons who have a role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed and managed. Furthermore, persons who have a perceived conflict of interest will be required to have such conflicts managed in a way that is appropriate to their participation in the design and conduct of this trial. The study leadership in conjunction with the National Cancer Institute has established policies and procedures for all study group members to disclose all conflicts of interest and will establish a mechanism for the management of all reported dualities of interest.
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13.4 confidentiality and privacy

Participant confidentiality and privacy is strictly held in trust by the participating investigators, their staff, and the sponsor(s). This confidentiality is extended to cover testing of biological samples and genetic tests in addition to the clinical information relating to participants. Therefore, the study protocol, documentation, data, and all other information generated will be held in strict confidence. No information concerning the study or the data will be released to any unauthorized third party without prior written approval of the sponsor. All research activities will be conducted in as private a setting as possible. The study monitor, other authorized representatives of the sponsor, representatives of the Institutional Review Board (IRB), and/or regulatory agencies may inspect all documents and records required to be maintained by the investigator, including but not limited to, medical records (office, clinic, or hospital) and pharmacy records for the participants in this study. The clinical study site will permit access to such records. The study participant's contact information will be securely stored at the clinical site for internal use during the study. At the end of the study, all records will continue to be kept in a secure location for as long a period as dictated by the reviewing IRB, Institutional policies, or sponsor requirements. Study participant research data, which is for purposes of statistical analysis and scientific reporting, will be stored at the NCI CCR. This will not include the participant's contact or identifying information. Rather, individual participants and their research data will be identified by a unique study identification number. The study data entry and study management systems used by the clinical site and by NCI CCR research staff will be secured and password protected. At the end of the study, all study databases will be archived at the NIH. To further protect the privacy of study participants, a Certificate of Confidentiality has been issued by the National Institutes of Health (NIH). This certificate protects identifiable research information from forced disclosure. It allows the investigator and others who have access to research records to refuse to disclose identifying information on research participation in any civil, criminal, administrative, legislative, or other proceeding, whether at the federal, state, or local level. By protecting researchers and institutions from being compelled to disclose information that would identify research participants, Certificates of Confidentiality help achieve the research objectives and promote participation in studies by helping assure confidentiality and privacy to participants.
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14 pharmaceutical information 14.1 pds0101

14.1.1 Source / Acquisition and Accountability PDS0101 will be provided by PDS Biotechnology through a CRADA. R-DOTAP and HPVmix will be provided to the clinical trial site by the manufacturer. The investigator or designee (e.g., pharmacist) will maintain an ongoing inventory of the investigational product supply according to standard site procedures. The investigational product will be dispensed at the direction of an investigator for administration to a study participant enrolled on the clinical trial. Disposal of expired or unused product will be returned to the manufacturer or disposed of according to standard site procedures based on agreement between the manufacturer and the site.
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14.1.2 toxicity

In 2014-2016, a Phase I/IIA human clinical trial was performed at 3 sites in the US in 12 subjects with high-risk HPV infection and biopsy-proven CIN1 to study the safety and immunogenicity of PDS0101. Administration of PDS0101 was well tolerated. The majority of AEs were due to administration site reactions. Most administration site reactions were mild or moderate in severity.  
Some more severe administration site reactions including swelling and redness were reported in the 3- and 10-mg R-DOTAP cohorts. Most administration site reactions resolved the same day or within a few days. Per the subject symptom diary, administration site reactions were more severe and of longer duration in subjects in the 10-mg R-DOTAP cohort. No clinically significant differences in the types and pattern of TEAEs were observed between Vaccinations 1, 2, or 3. No DLTs were observed; thus, the MTD was the 10-mg R-DOTAP dose. No serious adverse events (SAEs), study discontinuations due to adverse events, or deaths occurred. No clinically relevant abnormal hematology, blood chemistry, urinalysis, or physical findings were observed. 14.1.3 Formulation and Preparation PDS0101 is a 2-vial formulation which is mixed 1:1 v/v just prior to administration. Vial \#1 (ImmunoMAPK-RDOTAP): is a sterile, turbid pharmaceutical suspension of liposomal nanoparticles composed of the pure R-enantiomer of the cationic (positively charged) lipid DOTAP (dioleoyl-trimethylammonium propane). The particle size is between 100-200nm. RDOTAP is a novel immune modulator which induces the production of important cytokines and chemokines and also enhances the cytolytic T-Lymphocyte response when combined with the antigenic peptides. ImmunoMAPK-RDOTAP is has been evaluated at 3 dose levels, 1.0, 3.0 and 10.0mg. Vial \#2 (HPVmix): is a sterile, clear and slightly viscous suspension consisting of 6 nononcogenic lipidated peptides selected from immunogenic regions of the human papillomavirus strain 16 E6 and E7 proteins. The peptides exist in a mixed micellar particulate state. The HPVmix formulation contains 20% by volume of dimethyl sulfoxide (DMSO). HPVmix is being evaluated at a single dose level of 2.7 mg. The 1:1 mixture of R-DOTAP and HPVmix (antigens) yields a mixture of liposomes and peptide mixed micelles in 10% DMSO. The nanoparticulate vaccine induces antigen specific T-cell therapeutic responses. 14.1.4 Stability and Storage
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immunomapk-rdotap (vial #1) and hpv

Storage: Store at -70oC ± 10oC.  
Shipping: Shipped on dry ice in insulated container. Always check the temperature monitoring device to ensure maintenance of required storage condition during shipment.  
R-DOTAP Thawing: Place at room temperature for a minimum of 90 minutes (1.5 hours)
prior to mixing with HPVmix.  
HPVmix Thawing: Remove from freezer at least 60 minutes (1 hour) after removal of RDOTAP. Place at room temperature for a minimum of 30 minutes (0.5 hours) and a maximum of 90 minutes (1.5 hours) prior to mixing with RDOTAP.
Mixture: PDS0101 should not be administered if held in vial for more than 120 minutes (2 hours) at ambient temperature after mixing.  
14.1.5 Administration Procedures Subcutaneous administration in a limb. Each subsequent vaccination should preferably be administered alternating between limbs (e.g., L arm  R arm).  
Two separate 0.5mL injections preferably ~ 6 cm apart of vaccine in the same extremity Total Dose: 3.0mg R-DOTAP/2.7 mg HPV Peptides 14.1.6 Incompatibilities Not available.
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14.2 m7824 (msb0011359c) (ind #

14.2.1 Source / Acquisition and Accountability M7824 is manufactured and supplied for the trial by EMD Serono Research and Development Institute. M7824 will be provided to the clinical trial site by the manufacturer. The investigator or designee (e.g., pharmacist) will maintain an ongoing inventory of the investigational product supply according to standard site procedures. The investigational product will be dispensed at the direction of an investigator for administration to a study participant enrolled on the clinical trial. Disposal of expired or unused product will be returned to the manufacturer or disposed of according to standard site procedures based on agreement between the manufacturer and the site. 14.2.2 Toxicity The immunoglobulin portion of M7824 molecule is identical to avelumab (Bavencio). Respective warnings and precautions for grade 2 or higher immune-mediated pneumonitis, immune-mediated colitis, immune-mediated endocrinopathies, immune-mediated hepatitis) and infusion reactions are included in the prescribing for Bavencio (bavencio.com). Participants will be pre-medicated to prophylax against infusions reactions. The following additionally significant immune-mediated adverse reactions have occurred in less than 1% of 1738 participants treated with BAVENCIO: myocarditis with fatal cases, myositis, psoriasis, arthritis, exfoliative dermatitis, erythema multiforme, pemphigoid, hypopituitarism, uveitis, Guillain-Barré syndrome, and systemic inflammatory response. The above irAEs are all considered an anticipated risk of treatment with M7824 and thus will not be considered DLTs.  
In a phase 1, open-label 3+3 dose-escalation study of M7824 in 16 participants, 3 participants experienced grade 3 drug-related adverse events including skin infection secondary to grade 2 bullous pemphigoid, lipase increased, and colitis with associated anemia. There were no grade 4 - 5 treatment related adverse events. Please see table below for details.  
| Treatment-related adverse events 3 mg/kg (n =  3)                                       | 10 mg/kg (n = 3)   | 20 mg/kg (n = 7)   | Total (n = 16)   |         |        |        |       |
|-----------------------------------------------------------------------------------------|--------------------|--------------------|------------------|---------|--------|--------|-------|
| Any                                                                                     | Grade              | Any                | Grade            | Any     | Grade  | Any    | Grade |
| Grade                                                                                   | 3                  | Grade              | 3                | Grade   | 3      | Grade  | 3     |
| Participants with                                                                       | 2                  | 1                  | (33.3)           | 0 (0.0) | 4      |        |       |
| 1                                                                                       | 2                  | 7                  | 3                |         |        |        |       |
| any event**                                                                             | (66.7)             | (33.3)             | (57.1)           | (28.6)  | (43.8) | (18.8) |       |
| Anemia                                                                                  | 1                  | 1                  |                  |         |        |        |       |
| (14.3)                                                                                  | 1 (6.3)            | 1 (6.3)            |                  |         |        |        |       |
| (14.3)                                                                                  |                    |                    |                  |         |        |        |       |
| Bullous                                                                                 | 1                  |                    |                  |         |        |        |       |
| (33.3)                                                                                  | 1 (6.3)            |                    |                  |         |        |        |       |
| pemphigoid  Colitis                                                                     | 1                  | 1                  |                  |         |        |        |       |
| (14.3)                                                                                  | 1 (6.3)            | 1 (6.3)            |                  |         |        |        |       |
| (14.3)                                                                                  |                    |                    |                  |         |        |        |       |
| Dermatitis                                                                              | 1                  |                    |                  |         |        |        |       |
| (33.3)                                                                                  | 1 (6.3)            |                    |                  |         |        |        |       |
| acneiform Dyspnea                                                                       | 1                  |                    |                  |         |        |        |       |
| (14.3)                                                                                  | 1 (6.3)            |                    |                  |         |        |        |       |
| exertional*** Hyperthyroidism                                                           | 1                  |                    |                  |         |        |        |       |
| (14.3)                                                                                  | 1 (6.3)            |                    |                  |         |        |        |       |
| Hypophosphatemia                                                                        | 1                  |                    |                  |         |        |        |       |
| (14.3)                                                                                  | 1 (6.3)            |                    |                  |         |        |        |       |
| Hypothyroidism                                                                          | 1                  | 1                  | 2                |         |        |        |       |
| (33.3)                                                                                  | (14.3)             | (12.5)             |                  |         |        |        |       |
| Infusion-related                                                                        | 1                  |                    |                  |         |        |        |       |
| (14.3)                                                                                  | 1 (6.3)            |                    |                  |         |        |        |       |
| reaction Keratoacanthoma                                                                | 1                  |                    |                  |         |        |        |       |
| (14.3)                                                                                  | 1 (6.3)            |                    |                  |         |        |        |       |
| Lipase increase                                                                         | 1                  | 1                  |                  |         |        |        |       |
| (14.3)                                                                                  | 1 (6.3)            | 1 (6.3)            |                  |         |        |        |       |
| (14.3)                                                                                  |                    |                    |                  |         |        |        |       |
| Nausea                                                                                  | 1                  |                    |                  |         |        |        |       |
| (33.3)                                                                                  | 1 (6.3)            |                    |                  |         |        |        |       |
| Pruritus                                                                                | 1                  |                    |                  |         |        |        |       |
| (33.3)                                                                                  | 1 (6.3)            |                    |                  |         |        |        |       |
| Rash maculopapular                                                                                         | 1                  | 1                  | 2                |         |        |        |       |
| (33.3)                                                                                  | (33.3)             | (12.5)             |                  |         |        |        |       |
| Skin infection                                                                          | 1                  | 1                  |                  |         |        |        |       |
| (33.3)                                                                                  | 1 (6.3)            | 1 (6.3)            |                  |         |        |        |       |
| (33.3)                                                                                  |                    |                    |                  |         |        |        |       |
| Vomiting                                                                                | 1                  |                    |                  |         |        |        |       |
| (33.3)                                                                                  | 1 (6.3)            |                    |                  |         |        |        |       |
| **There were no treatment-related AEs in the 3 participants treated with 1 mg/kg M7824. |                    |                    |                  |         |        |        |       |  
***The differential for this dyspnea was pneumonitis vs. lymphangitic spread of disease (disease progression). As of August 2017, > 500 participants have been treated with M7824 across multiple solid tumor  
 expansion cohorts. The safety profile is consistent with other monotherapy checkpoint inhibitors, with the exception of keratoacanthomas and cutaneous squamous cell carcinomas which have occurred in approximately 3-5% of participants and are well managed with surgical excision. These lesions have not been a criterion for treatment discontinuation, but thus far have all spontaneously regressed following treatment discontinuation. At least 2 instances of nodular regenerative hyperplasia have been observed with the use of this agent. 14.2.2.1 Hemophagocytic lymphohistiocytosis (HLH) HLH/MAS is an inflammatory response which may be related to immune therapy, but the mechanism is poorly understood. This may present with liver function test abnormalities, low blood cell counts, fevers, elevated ferritin and/or elevated triglycerides. HLH may be acquired (secondary), but in the setting of immune therapy we believe it is acquired. This can spontaneously resolve or be treated with steroids or other immune suppressive therapies. 14.2.3 Formulation and Preparation M7824 is provided as a sterile liquid formulation and packaged at a 10 mg/mL concentration in USP/ Ph Eur type I 50R vials that are filled with drug product solution to allow an extractable volume of 60 mL (600 mg/60 mL). The vials are closed with rubber stoppers in serum format complying with USP and Ph Eur with an aluminum crimp seal closure. Each single-use vial contains 600mg of M7824, formulated as 10mg/mL of active, 6% (w/v) Trehalose, 40 mM NaCl, 5 mM Methionine, 0.05% (w/v) Tween 20, 10 mM L-Histidine at pH 5.5. The liquid formulation is diluted directly with 0.9% sodium chloride solution for injection. The estimated volumes of delivery are anticipated to be no more than 250mL. The verified concentration range in the infusion solution is 0.16 mg/mL to 9.6 mg/mL. 14.2.4 Stability and Storage M7824 must be stored at 2℃ to 8℃ until use. Product stored at room temperature for extended periods of time might be subject to degradation. M7824 must not be frozen. Rough shaking of the reconstituted solution must be avoided. The chemical and physical in-use stability for the infusion solution of M7824 in 0.9% sodium chloride for injection has been demonstrated for a total of 72 hours at room temperature; however, from a microbiological point of view, the diluted solution should be used immediately and is not intended to be stored unless dilution has taken place in controlled and validated aseptic conditions. No other drugs should be added to the infusion containers containing M7824. See Manual of Preparation of approved ancillary supplies. 14.2.5 Administration Procedures See Section 3.2.  
14.2.6 Incompatibilities Not available.
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14.3 nhs-il12 (ind # 019267)

14.3.1 Source / Acquisition and Accountability NHS-IL12 is manufactured and supplied by EMD Serono. NHS-IL12 will be provided to the clinical trial site by the manufacturer. The investigator or designee (e.g., pharmacist) will maintain an ongoing inventory of the investigational product supply according to standard site procedures. The investigational product will be dispensed at the direction of an investigator for administration to a study participant enrolled on the clinical trial. Disposal of expired or unused product will be returned to the manufacturer or disposed of according to standard site procedures based on agreement between the manufacturer and the site.
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14.3.2 toxicity

Subjects (n=59) were treated subcutaneously with NHS-IL12 in a single ascending dose cohort followed by a multiple ascending dose cohort (n=37 with every 4-week dosing). The primary objective of this trial was to determine MTD as defined by the number of DLTs. None of the subjects treated with single or multiple doses up to 12.0 µg/kg experienced a DLT. At 16.8 µg/kg, 1/6 subjects had a DLT (grade 3 increase in alanine transaminase [ALT]). At 21.8 µg/kg, 2/6 subjects had a DLT (grade 3 increase in aspartate transaminase [AST] and ALT; grade 3 increase in lipase without clinical signs of pancreatitis). MTD was 16.8 µg/kg. The most frequently observed treatment-related adverse event (TRAE) was decreased lymphocyte count (27/59 subjects; 45.8%). Other TRAEs included decreased white blood cells (WBCs) (24/59; 40.7%), fever and elevated AST (21 each; 35.6%), elevated ALT (20; 3.9%), and anemia and flu-like symptoms (18 each; 30.5%) (Table 2; Supplemental Figure 5). Among the cohort receiving 16.8 µg/kg, the most frequently reported TRAEs were elevated AST (75%), decreased WBCs and elevated ALT (68.8% each), and decreased lymphocyte count and fever (62.5% each). At least one grade ≥ 3 TRAE was seen in 12/59 subjects (20.3%). These included decreased lymphocyte count (5; 8.5%), decreased neutrophil count (4; 6.8%), elevated ALT (3; 5.1%), decreased WBCs (2; 3.4%), and hypokalemia, hyperhidrosis, elevated alkaline phosphatase, AST, and lipase (1 each; 1.7%). All grade ≥ 3 TRAEs were transient; only hyperhidrosis was symptomatic. One grade 4 TRAE was observed (asymptomatic decreased lymphocyte count); no grade 5 TRAE was observed. 14.3.3 Formulation and Preparation NHS-IL12 is formulated as a 1.5 mg/mL solution and is supplied by the Sponsor in single-use glass vials with a rubber stopper and sealed with an aluminum Flip Off® crimp seal closure. The contents of the NHS-IL12 vials are sterile and nonpyrogenic, and do not contain bacteriostatic preservatives. Any spills that occur should be cleaned up using the facility's standard cleanup procedures for biologic products. Rough shaking of the solution must be avoided. NHS-IL12 drug product will be administered undiluted (1500mcg/mL) for doses ≥ 300mcg.  
However, for doses below 300 µg, NHS-IL12 drug product must be diluted with 0.9% saline solution (sodium chloride injection). Doses 100 to 299 mcg will be administered as a 500mcg/mL solution and doses 30 to 99 mcg will be administered as a 150 mcg/mL solution. Detailed information on medical devices to be used for the preparation and administration of NHS-IL12 will be provided in the Investigator Brochure. Any unused portion of the solution should be discarded in biohazard waste disposal with final disposal by accepted local and national standards of incineration. 14.3.4 Stability and Storage NHS-IL12 drug product must be stored at 2°C to 8°C until use, with a temperature log maintained daily. All medication boxes supplied to the study site must be stored carefully, safely, and separately from other drugs. The chemical and physical in-use stability of NHS-IL12 diluted and undiluted solution in syringes has been demonstrated for 24 hours at 25°C. However, to reduce the risk of microbial contamination, the solution should be used immediately unless medication preparation has been performed in controlled and validated aseptic conditions. Rough shaking of the solution must be avoided. 14.3.5 Administration Procedures NHS-IL12 is administered subcutaneously. It can be given in the arm, leg or abdomen. Where feasible it should be given in a different limb than the vaccine. 14.3.6 Incompatibilities Not available.
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15 references

10. Grohmann U, Belladonna ML, Bianchi R, Orabona C, Ayroldi E, Fioretti MC, Puccetti P:
IL-12 acts directly on DC to promote nuclear localization of NF-kappaB and primes DC for IL-12 production. *Immunity* 1998, 9(3):315-323.
11. Del Vecchio M, Bajetta E, Canova S, Lotze MT, Wesa A, Parmiani G, Anichini A:
Interleukin-12: biological properties and clinical application. *Clin Cancer Res* 2007, 13(16):4677-4685.  
12. Massarelli E, William W, Johnson F, Kies M, Ferrarotto R, Guo M, Feng L, Lee JJ, Tran H, Kim YU *et al*: Combining Immune Checkpoint Blockade and Tumor-Specific 1. Viens LJ, Henley SJ, Watson M, Markowitz LE, Thomas CC, Thompson TD, Razzaghi H, Saraiya M: **Human Papillomavirus-Associated Cancers - United States, 2008-** 2012. *MMWR Morb Mortal Wkly Rep* 2016, 65(26):661-666.  
2. Long HJ, 3rd, Bundy BN, Grendys EC, Jr., Benda JA, McMeekin DS, Sorosky J, Miller DS, Eaton LA, Fiorica JV, Gynecologic Oncology Group S: **Randomized phase III trial**
of cisplatin with or without topotecan in carcinoma of the uterine cervix: a Gynecologic Oncology Group Study. *J Clin Oncol* 2005, 23(21):4626-4633.  
3. Vermorken JB, Mesia R, Rivera F, Remenar E, Kawecki A, Rottey S, Erfan J,
Zabolotnyy D, Kienzer HR, Cupissol D *et al*: Platinum-based chemotherapy plus cetuximab in head and neck cancer. *N Engl J Med* 2008, 359(11):1116-1127.
4. Long HJ, 3rd: **Management of metastatic cervical cancer: review of the literature**. J
Clin Oncol 2007, 25(20):2966-2974.  
5. Eng C, Chang GJ, You YN, Das P, Rodriguez-Bigas M, Xing Y, Vauthey JN, Rogers JE,
Ohinata A, Pathak P *et al*: **The role of systemic chemotherapy and multidisciplinary**
management in improving the overall survival of patients with metastatic squamous cell carcinoma of the anal canal. *Oncotarget* 2014, 5(22):11133-11142.  
6. Monk BJ, Sill MW, McMeekin DS, Cohn DE, Ramondetta LM, Boardman CH, Benda J,
Cella D: **Phase III trial of four cisplatin-containing doublet combinations in stage**
IVB, recurrent, or persistent cervical carcinoma: a Gynecologic Oncology Group study. *J Clin Oncol* 2009, 27(28):4649-4655.  
7. Tewari KS, Sill MW, Long HJ, 3rd, Penson RT, Huang H, Ramondetta LM, Landrum LM, Oaknin A, Reid TJ, Leitao MM *et al*: **Improved survival with bevacizumab in**
advanced cervical cancer. *N Engl J Med* 2014, 370(8):734-743.  
8. Monk BJ, Sill MW, Burger RA, Gray HJ, Buekers TE, Roman LD: Phase II trial of bevacizumab in the treatment of persistent or recurrent squamous cell carcinoma of the cervix: a gynecologic oncology group study. *J Clin Oncol* 2009, 27(7):1069-1074.  
9. van Herpen CM, van der Voort R, van der Laak JA, Klasen IS, de Graaf AO, van Kempen LC, de Vries IJ, Boer TD, Dolstra H, Torensma R *et al*: **Intratumoral rhIL-12**
administration in head and neck squamous cell carcinoma patients induces B cell activation. *Int J Cancer* 2008, 123(10):2354-2361.  
Vaccine for Patients With Incurable Human Papillomavirus 16-Related Cancer: A
Phase 2 Clinical Trial. *JAMA Oncol* 2019, 5(1):67-73.  
13. Lonez C, Vandenbranden M, Ruysschaert JM: **Cationic liposomal lipids: from gene**
carriers to cell signaling. *Prog Lipid Res* 2008, 47(5):340-347.  
14. Wood L, et al.: In: *Society for Immunotherapy of Cancer (SITC): November 8, 2019* 2019; National Harbor, MD.  
15. Boyerinas B, Jochems C, Fantini M, Heery CR, Gulley JL, Tsang KY, Schlom J:
Antibody-Dependent Cellular Cytotoxicity Activity of a Novel Anti-PD-L1 Antibody Avelumab (MSB0010718C) on Human Tumor Cells. *Cancer Immunol Res* 2015, 3(10):1148-1157.  
16. Heery CR, O'Sullivan-Coyne G, Madan RA, Cordes L, Rajan A, Rauckhorst M, Lamping E, Oyelakin I, Marte JL, Lepone LM *et al*: **Avelumab for metastatic or locally**
advanced previously treated solid tumours (JAVELIN Solid Tumor): a phase 1a, multicohort, dose-escalation trial. *Lancet Oncol* 2017, 18(5):587-598.  
17. Donahue RN, Lepone LM, Grenga I, Jochems C, Fantini M, Madan RA, Heery CR,
Gulley JL, Schlom J: Analyses of the peripheral immunome following multiple administrations of avelumab, a human IgG1 anti-PD-L1 monoclonal antibody. J Immunother Cancer 2017, 5:20.  
18. Blobe GC, Schiemann WP, Lodish HF: **Role of transforming growth factor beta in**
human disease. *N Engl J Med* 2000, 342(18):1350-1358.  
19. Dumont N, Arteaga CL: **Transforming growth factor-beta and breast cancer: Tumor**
promoting effects of transforming growth factor-beta. *Breast Cancer Res* 2000, 2(2):125-132.  
20. Formenti SC, Lee P, Adams S, Goldberg JD, Li X, Xie MW, Ratikan JA, Felix C, Hwang L, Faull KF *et al*: **Focal Irradiation and Systemic TGFbeta Blockade in Metastatic** Breast Cancer. *Clin Cancer Res* 2018, 24(11):2493-2504.  
21. Ivanovic V, Melman A, Davis-Joseph B, Valcic M, Geliebter J: Elevated plasma levels of TGF-beta 1 in patients with invasive prostate cancer. *Nat Med* 1995, 1(4):282-284.  
22. Shen M, Tsai Y, Zhu R, Keng PC, Chen Y, Chen Y, Lee SO: **FASN-TGF-beta1-PD-L1**
axis contributes to the development of resistance to NK cell cytotoxicity of cisplatinresistant lung cancer cells. *Biochim Biophys Acta Mol Cell Biol Lipids* 2018, 1863(3):313-322.  
23. Tsushima H, Kawata S, Tamura S, Ito N, Shirai Y, Kiso S, Imai Y, Shimomukai H,
Nomura Y, Matsuda Y *et al*: **High levels of transforming growth factor beta 1 in** patients with colorectal cancer: association with disease progression. Gastroenterology 1996, 110(2):375-382.  
24. Terabe M, Robertson FC, Clark K, De Ravin E, Bloom A, Venzon DJ, Kato S, Mirza A,
Berzofsky JA: Blockade of only TGF-beta 1 and 2 is sufficient to enhance the efficacy of vaccine and PD-1 checkpoint blockade immunotherapy. *Oncoimmunology* 2017, 6(5):e1308616.  
25. Vanpouille-Box C, Formenti SC: Dual Transforming Growth Factor-beta and Programmed Death-1 Blockade: A Strategy for Immune-Excluded Tumors? Trends Immunol 2018, 39(6):435-437.  
26. Grenga I, Donahue RN, Gargulak ML, Lepone LM, Roselli M, Bilusic M, Schlom J:
Anti-PD-L1/TGFbetaR2 (M7824) fusion protein induces immunogenic modulation of human urothelial carcinoma cell lines, rendering them more susceptible to immune-mediated recognition and lysis. *Urol Oncol* 2018, 36(3):93 e91-93 e11.  
27. Jochems C, Tritsch SR, Pellom ST, Su Z, Soon-Shiong P, Wong HC, Gulley JL, Schlom J: **Analyses of functions of an anti-PD-L1/TGFbetaR2 bispecific fusion protein** (M7824). *Oncotarget* 2017, 8(43):75217-75231.  
28. Knudson KM, Hicks KC, Luo X, Chen JQ, Schlom J, Gameiro SR: **M7824, a novel**
bifunctional anti-PD-L1/TGFbeta Trap fusion protein, promotes anti-tumor efficacy as monotherapy and in combination with vaccine. *Oncoimmunology* 2018, 7(5):e1426519.  
29. Lan Y, Zhang D, Xu C, Hance KW, Marelli B, Qi J, Yu H, Qin G, Sircar A, Hernandez VM *et al*: **Enhanced preclinical antitumor activity of M7824, a bifunctional fusion**
protein simultaneously targeting PD-L1 and TGF-beta. *Sci Transl Med* 2018, 10(424).  
30. Ravi R, Noonan KA, Pham V, Bedi R, Zhavoronkov A, Ozerov IV, Makarev E, A VA,
Wysocki PT, Mehra R *et al*: Bifunctional immune checkpoint-targeted antibodyligand traps that simultaneously disable TGFbeta enhance the efficacy of cancer immunotherapy. *Nat Commun* 2018, 9(1):741.  
31. David JM, Dominguez C, McCampbell KK, Gulley JL, Schlom J, Palena C: **A novel**
bifunctional anti-PD-L1/TGF-beta Trap fusion protein (M7824) efficiently reverts mesenchymalization of human lung cancer cells. *Oncoimmunology* 2017, 6(10):e1349589.  
32. Strauss J, Heery C, Schlom J, Madan RA, Cao L, Kang Z, Lamping E, Marte JL,
Donahue RN, Grenga I *et al*: **Phase 1 trial of M7824 (MSB0011359C), a bifunctional**
fusion protein targeting PD-L1 and TGF-beta, in advanced solid tumors. Clin Cancer Res 2018.  
33. Fallon J, Tighe R, Kradjian G, Guzman W, Bernhardt A, Neuteboom B, Lan Y,
Sabzevari H, Schlom J, Greiner JW: The immunocytokine NHS-IL12 as a potential cancer therapeutic. *Oncotarget* 2014, 5(7):1869-1884.  
34. Strauss J, Heery CR, Kim JW, Jochems C, Donahue RN, Montgomery AS, McMahon S,
Lamping E, Marte JL, Madan RA *et al*: **First-in-Human Phase I Trial of a TumorTargeted Cytokine (NHS-IL12) in Subjects with Metastatic Solid Tumors**. *Clin* Cancer Res 2019, 25(1):99-109.  
35. Lepone LM, Donahue RN, Grenga I, Metenou S, Richards J, Heery CR, Madan RA,
Gulley JL, Schlom J: **Analyses of 123 Peripheral Human Immune Cell Subsets:**
Defining Differences with Age and between Healthy Donors and Cancer Patients Not Detected in Analysis of Standard Immune Cell Types. *J Circ Biomark* 2016, 5:5. Version Date: *05.12.2023* 36. Eisenhauer EA, Therasse P, Bogaerts J, Schwartz LH, Sargent D, Ford R, Dancey J,
Arbuck S, Gwyther S, Mooney M *et al*: **New response evaluation criteria in solid** tumours: revised RECIST guideline (version 1.1). *Eur J Cancer* 2009, 45(2):228-247.  
37. Seymour L, Bogaerts J, Perrone A, Ford R, Schwartz LH, Mandrekar S, Lin NU, Litiere S, Dancey J, Chen A *et al*: **iRECIST: guidelines for response criteria for use in trials** testing immunotherapeutics. *Lancet Oncol* 2017, 18(3):e143-e152.  
38. Zhestianikov VD, Savel'eva GE, Kalinin VL: **[The adaptive response to mitomycin C**
exposure in the hyper-radioresistant mutant Escherichia coli Gamr444].  
Adaptivnyi otvet na vozdeistvie mitomitsinom C u giperradiorezistentnogo mutanta Escherichia coli Gamr444. *Tsitologiia* 1991, 33(1):88-96.
untitled h1
16 appendicies

| 16.1                                                                                                                                                                                       | APPENDIX A PERFORMANCE STATUS CRITERIA ECOG Performance Status Scale   | Karnofsky Performance Scale                                  |             |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------|--------------------------------------------------------------|-------------|
| Grade                                                                                                                                                                                      | Descriptions                                                           | Percent                                                      | Description |
| 100                                                                                                                                                                                        | Normal, no complaints, no  evidence of disease.                        |                                                              |             |
| Normal activity. Fully active,                                                                                                                                                             |                                                                        |                                                              |             |
| 0                                                                                                                                                                                          | able to carry on all pre-disease  performance without restriction.     | Able to carry on normal activity;                            |             |
| 90                                                                                                                                                                                         | minor signs or symptoms of  disease. Normal activity with effort;      |                                                              |             |
| 80                                                                                                                                                                                         | some signs or symptoms of  disease.                                    |                                                              |             |
| Symptoms, but ambulatory.  Restricted in physically strenuous  activity, but ambulatory and able  to carry out work of a light or  sedentary nature (e.g., light  housework, office work). |                                                                        |                                                              |             |
| 1                                                                                                                                                                                          | Cares for self, unable to carry on                                     |                                                              |             |
| 70                                                                                                                                                                                         | normal activity or to do active  work.                                 |                                                              |             |
| In bed <50% of the time.  Ambulatory and capable of all  self-care, but unable to carry out  any work activities. Up and  about more than 50% of waking  hours.                            | Requires occasional assistance,                                        |                                                              |             |
| 60                                                                                                                                                                                         | but is able to care for most of  his/her needs.                        |                                                              |             |
| 2                                                                                                                                                                                          | 50                                                                     | Requires considerable assistance  and frequent medical care. |             |
| 40                                                                                                                                                                                         | Disabled, requires special care  and assistance.                       |                                                              |             |
| In bed >50% of the time.  Capable of only limited self-care,  confined to bed or chair more  than 50% of waking hours.                                                                     |                                                                        |                                                              |             |
| 3                                                                                                                                                                                          | Severely disabled,                                                     |                                                              |             |
| 30                                                                                                                                                                                         | hospitalization indicated. Death  not imminent.                        |                                                              |             |
| 20                                                                                                                                                                                         | Very sick, hospitalization  indicated. Death not imminent.             |                                                              |             |
| 100% bedridden. Completely  disabled. Cannot carry on any  self-care. Totally confined to bed  or chair.                                                                                   |                                                                        |                                                              |             |
| 4                                                                                                                                                                                          | 10                                                                     | Moribund, fatal processes  progressing rapidly.              |             |
| 5                                                                                                                                                                                          | Dead.                                                                  | 0                                                            | Dead.       |