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1 Version Date:10*.30.2019* Abbreviated Title: Chemo+antiPDL1+ vaccine in CRC CC **Protocol \#:** 17C0057 H IBC \# RD-16-XI-10 OSP \# 1707-1636 Version Date: October 30, 2019 NCT Number: NCT03050814 Title: A Randomized Phase II trial of Standard of Care Alone or in Combination with Ad-CEA
vaccine and Avelumab in Patients with Previously Untreated Metastatic or Unresectable Colorectal Cancer  
NCI **Principal Investigator:** Julius Strauss, MD  
Laboratory of Tumor Immunology and Biology (LTIB) Center for Cancer Research (CCR) National Cancer Institute (NCI) Building 10, Room 13N240 9000 Rockville Pike Bethesda, MD 20892 301-480-0202  
julius.strauss@nih.gov
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commercial agents

| Drug Name:       | avelumab; anti-PD-L1 antibody;   | ETBX-011; adenoviral CEA   |
|------------------|----------------------------------|----------------------------|
| MSB0010718C      | vaccine                          |                            |
| BB IND           | 17056                            | 17056                      |
| Number: Sponsor: | Center for Cancer Research       | Center for Cancer Research |
| Manufacturer:    | EMD Serono, Inc.                 | Etubics Corporation        |  
bevacizumab, 5-FU, leucovorin, oxaliplatin, and capecitabine will be purchased by the pharmacy at each participating institution
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precis background primary objective

- Colorectal cancer (CRC) is the fourth most common cancer diagnosis in the United States and accounts for the second most cancer-related deaths.  
- Programmed death ligand 1 (PD-L1) is a transmembrane protein that was first identified for its role in the maintenance of self-tolerance and prevention of autoimmunity. Blockade of the interaction between PD-L1 on tumor cells and PD-1 on T cells is expected to reverse T cell suppression within tumors. These agents are dependent on underlying T cell activation against the tumor cell to be effective.  
- Avelumab is a fully human IgG1 anti-PDL1 antibody that selectively binds to PD-L1 and competitively blocks its interaction with PD-1.  
- In ongoing phase 1 trials of avelumab, the agent has been well tolerated and has shown clinical activity.  
- Clinical trials with anti-PD-1/L1 agents in colorectal cancer have resulted in minimal activity in patients who do not have mismatch repair deficiency (MMR-D).  
- Therapeutic cancer vaccines targeting overexpressed proteins offer a potential method to activate T cells against tumors.  
- A novel adenovirus based, CEA-targeting vaccine has demonstrated cytolytic T cell responses in patients with metastatic colorectal cancer.  
- Standard of care agents in first line metastatic CRC have properties been associated with improved immune response via immunologic cell death and immunogenic modulation.  
- To determine if there is an improvement progression free survival among patients with metastatic or unresectable colorectal cancer who are treated with standard of care + antiPDL1 monoclonal antibody + Ad-CEA therapeutic cancer vaccine compared with standard of care alone.  
- Subjects age 18 and older with previously untreated pathologically confirmed metastatic or unresectable colorectal cancer; prior adjuvant therapy is acceptable.  
- ECOG performance status < 2. - Normal organ and bone marrow function. - Subjects with active autoimmune diseases requiring treatment and subjects requiring system steroids (except for physiologic doses for steroid replacement) are not allowed.  
- Tumor sample and whole blood sample must be available for proteomics, genomics and transcriptomics analyses.  
- Subjects with metastatic or unresectable colorectal cancer with mismatch repair deficiency
(MMR-D or MSI-High) will not be eligible.  
Eligibility:
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design

- This is a randomized, multicenter phase II clinical trial designed to evaluate the potential improvement in progression free survival (PFS) when Avelumab and Ad-CEA vaccine are used in combination with standard of care therapy in metastatic or unresectable colorectal cancer when compared with standard of care alone (FOLFOX-A).  
- A lead in cohort, comprising the first 6 evaluable subjects enrolled, will be treated with avelumab + Ad-CEA vaccine + standard of care in order to assess the safety of the combination.  
- If no more than 1 subject in the lead in cohort experiences a dose limiting toxicity attributable to the IND agents, 70 evaluable subjects will be randomized on a 1:1 basis to receive either Avelumab + Ad-CEA vaccine + standard of care (Arm B) or standard of care alone (Arm A)
- Standard of care therapy consists of 6 - 12 two week cycles of bevacizumab + FOLFOX
(5-FU, leucovorin, oxaliplatin) followed by two week cycles of bevacizumab + capecitabine/5-FU until disease progression
- Subjects assigned to Arm A that have progressive disease will be offered Avelumab + AdCEA vaccine in combination with a standard chemotherapy regimen
- Kaplan-Meier curves and a two-tailed log-rank test will be the primary analysis methods.  
- The accrual ceiling for the study is set at 97 Abbreviated Title: Chemo+antiPDL1+ vaccine in CRC
Version Date:10.30.2019  
| TABLE OF CONTENTS                                                                                                                            |                                                                                                                                                   |
|----------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------|
| PRÉCIS .                                                                                                                                     |                                                                                                                                                   |
| TABLE OF CONTENTS..........................................................................................................................4 |                                                                                                                                                   |
| l                                                                                                                                            | INTRODUCTION                                                                                                                                      |
| 1.1                                                                                                                                          | Study Objectives .                                                                                                                                |
| 1.2                                                                                                                                          | Background and Rationale ...................................................................................................................... 8 |
| 2                                                                                                                                            | ELIGIBILITY ASSESSMENT AND ENROLLMENT ............................................................36                                              |
| 2.1                                                                                                                                          | Eligibility Criteria                                                                                                                              |
| 2.2                                                                                                                                          | Screening Evaluation                                                                                                                              |
| Registration Procedures ......................................................................................................39             |                                                                                                                                                   |
| 2.3                                                                                                                                          |                                                                                                                                                   |
| 3                                                                                                                                            | STUDY IMPLEMENTATION ............................................................................................................41               |
| 3.1                                                                                                                                          | Study Design                                                                                                                                      |
| 3.2                                                                                                                                          | Dose Limiting Toxicity (Lead-In Period Only) .............................................................42                                      |
| 3.3                                                                                                                                          | Study Stopping Rule (Lead-In Period Only) ...................................................................42                                   |
| 3.4                                                                                                                                          | Drug Administration                                                                                                                               |
| Dose Delays/Modifications ...............................................................................................46                  |                                                                                                                                                   |
| 3.5                                                                                                                                          | Study Calendar .............................................................................................................................61    |
| 3.6                                                                                                                                          |                                                                                                                                                   |
| 3.7                                                                                                                                          | Criteria for Removal from Protocol Therapy and Off Study Criteria ..........................65                                                    |
| 3.8                                                                                                                                          | Cost and Compensation                                                                                                                             |
| 4                                                                                                                                            | CONCOMITANT MEDICATIONS/MEASURES ......................................................................66                                         |
| Supportive Care                                                                                                                              |                                                                                                                                                   |
| 4.1                                                                                                                                          |                                                                                                                                                   |
| s                                                                                                                                            | BIOSPECIMEN COLLECTION                                                                                                                            |
| Correlative Studies for Research/Pharmacokinetic Studies .........................................68                                         |                                                                                                                                                   |
| 5.1                                                                                                                                          | Immunological studies ..............................................................................................................68            |
| 5.1.1                                                                                                                                        |                                                                                                                                                   |
| 5.2                                                                                                                                          | Sample Collection Summary ...............................................................................................................72       |
| 5.3                                                                                                                                          | Sample Storage, Tracking, Disposition (Clinical Services Program [CSP])..............73                                                           |
| 5.4                                                                                                                                          | Samples for Genetic/Genomic Analysis .......................................................................................74                    |
| 6                                                                                                                                            | DATA COLLECTION AND EVALUATION                                                                                                                    |
| 6.1                                                                                                                                          | DATA COLLECTION                                                                                                                                   |
| 6.2                                                                                                                                          | DATA SHARING PLANS .........................................................................................................................76    |
| Genomic Data Sharing P lan ......................................................................................................76          |                                                                                                                                                   |
| 6.3                                                                                                                                          |                                                                                                                                                   |
| 6.4                                                                                                                                          | Response Criteria .......................................................................................................................76       |  
4  
5  
Version Date:10*.30.2019*  
| Version Date:10.30.2019 6.5 Toxicity Criteria 83 7 NIHREPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN 83 7.1 Definitions 83 7.2 OHSRP Office of Compliance and Training IRB Reporting 83 7.3 NCI Clinical Director Reporting 84 7.4 .NCI Guidance for Reporting Expedited Adverse Events for Multi-Center Trials 84 7.5 Institutional Biosafety Committee (IBC) Reporting Criteria 84 7.6 NIH REQUIRED Data and Safety Monitoring Plan 85 8 SPONSOR SAFETY REPORTING 86 8.1 Definitions 86 8.2 Assessment of Safety Events 87 8.3 Reporting of Serious Adverse Events 88 8.4 Waiver of expedited reporting to CCR 88 8.5 Safety Reporting Criteria to the Pharmaceutical Collaborators 88 8.6 Regulatory Reporting for Studies Conducted Under CCR-Sponsored IND 90 9 CLINICAL MONITORING 90 10 STATISTICAL CONSIDERATIONS 91 11 COLLABORATIVE AGREEMENTS 92 11.1 CRADA 92 11.2 MTA 92 11.3 Multi-Institutional Guidelines 92 12 HUMAN SUBJECTS PROTECTIONS 92 12.1 Rationale For Subject Selection 92 12.2 Participation of Children 92 12.3 Participation of subjects unable to give consent 92 12.4 Evaluation of Benefits and Risks/Discomforts 93 12.5 Consent and Assent Process and Documentation 93 13 PHARMACEUTICAL INFORMATION 94 13.1 Avelumab (BB IND# 17056) 94 13.2 Ad-CEA Vaccine (BB IND# 17056) 98 13.3 Bevacizumab (Avastin) 101 13.4 Capecitabine 104   |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|  
| 6                                                                                                                    |                                                                                                                                             |
|----------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------|
| Abbreviated Title: Chemo+antiPDL1+ vaccine in CRC                                                                    |                                                                                                                                             |
| Version Date:10.30.2019                                                                                              |                                                                                                                                             |
| 13.5                                                                                                                 | 5-Fluorouracil (5-FU) ..................................................................................................................107 |
| 13.6                                                                                                                 | LEUCOVOR IN                                                                                                                                 |
| OXALiPlatin                                                                                                          |                                                                                                                                             |
| 13.7                                                                                                                 |                                                                                                                                             |
| 15                                                                                                                   |                                                                                                                                             |
| 15 APPENDICES                                                                                                        |                                                                                                                                             |
| Appendix A: Preclinical model evaluation of the combination of FOLFOX with anti¬                                     |                                                                                                                                             |
| 15.1                                                                                                                 | PD-L1.                                                                                                                                      |
| 15.2                                                                                                                 | Appendix B-Performance Status Criteria ..................................................................................122                |
| Appendix C: CCR Problem Report Form..............................................................................123 |                                                                                                                                             |
| 15.3                                                                                                                 |                                                                                                                                             |
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1 introduction 1.1 study objectives

- To determine if there is an improvement in progression free survival among patients with metastatic or unresectable colorectal cancer who are treated with standard of care + AdCEA vaccine + Avelumab compared with standard of care alone
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1.1.2 secondary objective

- To determine the ratio of patients that are hospitalized because of adverse events attributed to disease progression
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1.1.3 exploratory objective(s)

- Safety of the combination versus standard of care alone
- **Immunologic** effects of the combination compared with standard of care o **Peripheral**
Quantitate T cell responses against CEA, and other tumor associated antigens using methods such as intracellular cytokine staining, ELIspot, and/or others Flow-based assay for analysis of PBMC subsets  
T-cell clonal expansion assay Serum cytokine and soluble factor analysis Neutrophil lymphocyte ratio at baseline and change during treatment HLA subtype correlation with clinical outcomes ELISA for antibody generation against CEA
o **Tumoral**
Immunohistochemistry analysis of T cell infiltrate (may include CD3, CD4, CD8, FoxP3 and others), immune regulatory markers (may include IDO, LAG3, TIM3, PD-1, PD-L1 and others)
RNA and proteomic analysis for:
- immune signature changes  
- KRAS mutation status relationship to IL10 and TGF-beta tumor expression
- Tumor subtyping into accepted molecular patterns - TLR4 loss of function polymorphisms and relationship to outcomes Determine the genomic and proteomic profile of subjects' tumors to identify gene mutations, gene amplifications, RNA-expression levels, and protein-
8 Version Date:10*.30.2019* expression levels. Correlations between genome/proteomic profiles and efficacy outcomes will be assessed.  
- Correlative analysis of immune endpoints with clinical outcomes - Overall response rate (CR+PR by RECIST 1.1) - Overall survival
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1.2 background and rationale 1.2.1

Colorectal cancer (CRC) is the third most common cancer diagnosis in the United States with a projected 132,700 new cases diagnosed in 2015. However, this disease accounts for the second most cancer-related deaths, projected to be 49,700 in 2015.1
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1.2.2 early stage colorectal cancer

Extensive work by the Galon, Pages, and Fridman group has identified, in retrospective analyses, immune cell tumor infiltrate signatures to be predictive of prognosis in early stage colorectal cancer at the time of diagnosis. Pages et al.2 showed that signs of an immune response within colorectal cancers were associated with the absence of pathological evidence of early metastatic invasion and that an increased density of CD45RO+ memory T-cells was an independent predictor of increased overall survival (n = 490, P, 0.05). Five-year overall survival and disease-free survival were 46.3% and 43.1%, respectively, for tumors with a high density of CD45RO+ cells compared with 23.7% and 21.5% for tumors with a low density. Tumors without signs of early metastatic invasion had increased infiltrates of immune cells and increased levels of mRNA for products of TH1 effector cells, but not increased levels of inflammatory mediators or immunosuppress ive molecules. Markers of T-cell migration, activation and differentiation were also increased, as well as the numbers of CD8+ T-cells. In addition, Galon et al.3 further characterized the tumor infiltrating immune cells in the same cohort of colorectal cancer patients, and found that the type, density and location of the immune cells were a predictor of survival superior to the histopathological methods currently used, and independent of the tumor node metastasis (TNM)
system (**Figure 1**). By conducting genomic and in situ immunostaining on resected tumors from patients with colorectal cancer, they found that TH1 adaptive immunity had a beneficial effect on clinical outcome. Tumors from patients without recurrence had significantly higher immune cell densities within both the center of the tumor (CT) and the invasive margin (IM). There was a statistically significant correlation between the immune cell density and patient outcome (n = 490, P, 0.05). They looked at all T-lymphocytes (CD3+), CD8+ T-cell effectors and memory T-cells (CD45RO+). Further investigation of the primary tumor microenvironment showed a correlation between the absence of metastasis to lymph nodes or distant organs and markers of innate immune cells (macrophages, dendritic cells, natural killer [NK] cells and NK T-cells) and activated Tcells.4 The co-expression of genes for cytotoxicity and TH1 predicted patient survival independently of metastatic status (n = 142, P, 0.05). Pages et al.5 recently published a study in which they classified early stage colorectal cancer patients (TNM I–II) into four different prognostic groups based on the density of CD45RO+ and CD8+ cells in different tumor regions. Six hundred and two tumors from two independent cohorts were investigated, and they found dramatic differences in disease-free, disease-specific and overall survival (**Figure 2**). Five-year survival in patients with high densities of both CD8+ and CD45RO+ cells was 86.2%, and only 9
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4.8% of the patients had tumor recurrence, whereas in the group with low densities of these cells, 75% had tumor recurrence, and only 27.5% survived. The immune criteria were found to be independent prognostic factors in multivariate analysis (n = 602, P, 0.0001).  
Figure 1. Disease free survival according to tumor histopathology (TNM staging), versus tumor infiltrating immune  
  
cell density (CD3+ and CD45RO+) in two separate tumor regions.  
(A) Kaplan-Meier curves illustrate   
| (B) Kaplan-Meier curves illustrate  the duration of disease-free  survival according to the UICCTNM stages (as in [a]) and  according to the density of CD3+ cells in combined tumor regions  (CD3CT LoCD3IMLo, thick lines,  n=93 patients; CD3CTHiCD3IMHi ,  thin lines, n = 109). The  subgroup of patients w ho did not  appear to have a coordinated in  situ immune reaction in tumor  regions (Hi/Lo or Lo/Hi for CD3+ cell densities) presented KaplanMeier curves similar to those in  the entire cohort. (C) Kaplan-Meier curves illustrate  the duration of disease-free  survival according to the UICCTNM stages and to the density of  CD3+ and CD45RO+ cells in  combined tumor regions (CD3CT LoCD3IMLo plus  CD45ROCTLoCD45ROIMLo, thick  lines n = 16 patients;  CD3CTHiCD3IMHi plus  CD45ROCTHiCD45ROIMHi , thin  lines, n = 88). Cutoff values  w ere 250, 640, 60 and 190 for  CD3CT, CD3IM, CD45ROCT and  CD45IM, respectively. In (b and  c), log-rank statistical test, **p <  10 4; ns, not significant; CT,  center of the tumor; IM invasive  margin.   |
|---|  
10 Version Date:10*.30.2019* Figure 2. Overall survival in Stage I and II CRC patients according to CD8+ and CD45RO+ cell densities.  
  
While early stage disease appears to be immunologically relevant, the underlying immune response in advanced colorectal cancer appears to be very poor in the majority of patients with advanced colorectal cancer. This is indicated by a low number of PD-L1+ tumor cells despite the presence of CD8+PD-1+ T cells found in the intratumoral space in metastatic colorectal cancer cases.6,7 This tumor microenvironment phenotype has been associated with a low likelihood of anti-tumor effect when treated with PD-1/L1 blocking agents.7 It has been hypothesized that a tumor microenvironment without PD-L1 expression indicates a poor T cell response against the tumor and that specific T-cell activation against target antigens in the tumor could lead to increased T cell infiltration with PD-1 expression and result in PD-L1 upregulation, which would make PD1/L1 inhibition a viable anti-tumor strategy.  
8 Previous work from our group has indicated that vaccination against target antigens overexpressed in the tumor can lead to significant infiltration of T cells in patients with prostate cancer.  
9 Addition of therapeutic cancer vaccine capable of driving a specific T cell response to the tumor may overcome the poor immunogenicity of advanced colorectal cancer.
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1.2.4 ad5 [e1- e2b-]-cea(6d) vaccine

Overcoming the problem of pre-existing anti-vector immunity has been a subject of intense investigation. Investigations using other Ad subtypes or even non-human forms of Ad have been examined. Even if these approaches succeed in an initial immunization, subsequent vaccinations may be problematic due to immune responses generated against the differing Ad subtype. To overcome the Ad immunization barrier, and circumvent the adverse conditions for Ad5 [E1-] vectors, Etubics has constructed an advanced generation Ad vector. The new Ad5 [E1-, E2b-]- based vectors have additional deletions in the E2b region, removing the DNA polymerase and the preterminal protein genes. These vectors essentially do not replicate in cells, normal or transformed. These replication-defective vectors can only be propagated in the newly engineered, proprietary human 293 cell line (E.C7) that supplies the E1 and E2b gene functions *in trans* required for vector production.  
10-12 Deletion of the E2b region also confers advantageous immune properties on the novel Ad vectors. The deletion of E2b region sequences has the beneficial effect of markedly reducing residual late viral gene expression (>10,000 fold reduction in Ad-fiber protein levels).10 This minimizes induction of anti-viral immune responses and allows for greater persistence of transduced cells. This enables more potent immune responses to specific, non-viral antigens while minimizing the immune responses to Ad viral proteins. Importantly, Ad5 [E1-, E2b-]-based vector vaccines can be injected multiple times in homologous immunization regimens designed to induce and increase specific immune responses to tumor antigens.13-21 Ad-CEA is an Ad5 [E1-, E2b-]-based vector vaccine that contains the insertion of a modified CEA gene (CEA(6D)) designed to increase cell mediated immune (CMI) responses to CEA in immunized patients.22-24
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1.2.4.2 preclinical data

In pre-clinical studies,16 the immunogenicity of Ad5 [E1-, E2b-]-CEA(6D) vaccine was tested in an Ad5 naïve and an Ad5 immune murine model. To assess the induction of cellular meditated immunity following immunization, Ad5 naïve C57Bl/6 mice were immunized three times subcutaneously (SQ) with 1010 VP of Ad5 [E1-]-CEA(6D) at weekly intervals. Three immunizations were used because our prior studies in an HIV-1 model demonstrated that the Ad5
[E1-, E2b-] vector induced a maximum immune boost after three immunizations.17,18 Fourteen days after the final immunization, CEA-specific CMI responses were determined by IFN-γ and IL2 ELISpot assays. Mice immunized with Ad5 [E1-, E2b-]-CEA(6D) induced a significantly greater number of IFN-γ (p<0.01) and IL-2 (p<0.01) secreting splenocytes than mice immunized with Ad5
[E1-]-CEA(6D) (Figure 3 **A, B**). Splenocytes from vaccinated mice and controls were assessed 12
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for non-specific cytokine secretion following stimulation with HIV-1 Gag and β-galactosidase.  
Non-specific IFN-γ or IL-2 secretion was not detected in T-cells from the spleens of mice vaccinated with either CEA expressing vector (**Figure 3**). Splenocytes were also stimulated with Ad5-null to confirm positive vaccination against Ad5 and splenocytes derived from all such immunized mice harbored Ad5 specific T-cells (**Figure 3**). Elevated levels of CEA specific IgG
antibody were detected after immunizations and these levels were comparable for both Ad5-CEA vectors.  
  
To test the hypothesis that Ad5 [E1-, E2b-]-CE(6D) is more effective than Ad5 [E1-]-CEA(6D) in the presence of Ad5 immunity, Ad5 naive C57Bl/6 mice were immunized twice with 1010 VP of Ad5 [E1-]-null to induce Ad5 immunity. The presence of anti-Ad5 IgG antibody was confirmed 13 Version Date:10*.30.2019* by ELISA as 0.028 ± 0.028 ng Equivalents of IgG antibody for baseline samples versus 39.50 ±
3.78 ng Equivalents of IgG antibody in samples after Ad5-null immunizations (p<0.0001). Ad5 immune mice were then immunized three times at weekly intervals with 1010 VP of Ad5 [E1-]-
CEA(6D) or Ad5 [E1-, E2b-]-CEA(6D). Splenocytes were collected 14 days after the final immunization and assessed by IFN-γ and IL-2 ELISpot. Ad5-immune mice immunized with Ad5 [E1-, E2b-]-CEA(6D) exhibited significantly higher levels of IFN-γ (p=0.04) and IL-2 (p<0.01)
secreting splenocytes as compared to Ad5 immune mice immunized with Ad5 [E1-]-CEA(6D)
(**Figure 4**). When compared to the results for naïve mice above, levels of CEA specific IgG
antibody generated after immunizations were greatly reduced.  
  
14 Version Date:10*.30.2019* Having immunologically compared the two Ad5-CEA(6D) vectors, a study was then performed to determine if the Ad5 [E1-, E2b-]-CEA(6D) vector could break tolerance in the more stringent CEA transgenic mouse model in which CEA is a self-antigen. Mice were immunized once with 2.6 X
1010 VP of Ad5 [E1-, E2b-]-CEA(6D) and 14 days later, their splenocytes were assessed for CMI
responses by IFN-γ ELISpot assays. As presented in **Figure 5**, elevated numbers of IFN-γ secreting splenocytes were observed after only one injection with the vector platform. ELISpot studies employing Cytomegalovirus (CMVpp65) and HIV-gag antigens demonstrated that the response was specific to CEA.  
  
C57Bl/6 mice transgenic for CEA were immunized once with Ad5 [E1-, E2-]-CEA(6D) and tested for CMI
response activity to CEA. Note the elevated levels of IFN-γ secreting splenocytes specific for CEA and not for irrelevant antigens such as CMV or HIV-1 Gag. The error bars depict the SEM.  
The efficacy of immunizations with Ad5 [E1-, E2b-]-CEA(6D) was evaluated by the treatment of CEA expressing MC-38 tumors that were growing in Ad5 naïve and Ad5 immune mice. A group of C57Bl/6 mice (n=7) were implanted SQ with 106 CEA expressing MC-38 tumor cells (MC38-
CEA). Six days later, when tumors were palpable (3-5mm), the mice were treated with three SQ
injections of 1010 VP of Ad5 [E1-, E2b-]-CEA(6D) on days 7, 13 and 19. Untreated C57Bl/6 mice (n=7) implanted with 106 MC38-CEA cells and injected at the same time points with injection buffer alone served as controls. Tumor volumes were measured and reported as previously described.16 The sizes of treated and control tumors are presented in **Figure 6A** as a function of time. At Day 20 post implant the tumors in mice treated with Ad5 [E1-, E2b-]-CEA(6D) were significantly (p<0.05) smaller as compared to controls (**Figure 6A**). Tumors were excised and weighed at the termination of the study. Tumors from mice treated with Ad5 [E1-, E2b-]-CEA(6D)
weighed significantly (p<0.05) less than tumors from control mice (**Figure 6B**). Splenocytes from both groups of mice were assessed for the number of CEA stimulated IFN-γ secreting T cells by ELISpot. Mice immunized with Ad5 [E1-, E2b-]-CEA(6D) had a significantly (p<0.05) greater number of INF-γ secreting T-cells in their spleens as compared to control mice (**Figure 6C**).  
  
To determine if Ad5 immune MC38-CEA tumor bearing mice could be treated with Ad5 [E1-,
E2b-]-CEA(6D), C57Bl/6 mice (n=7) were immunized two times at a two-week interval with 1010 VP of Ad5 [E1-]-null. Two weeks after the second Ad5 [E1-]-null immunization, mice were implanted SQ with 106 CEA expressing MC-38 tumor cells. Six days later tumors were measurable (3-5mm) and the mice were treated with three SQ injections of 1010 VP of Ad5 [E1-, E2b-]-
CEA(6D) at weekly intervals. C57Bl/6 mice (n=7) which were immunized twice with Ad5 [E1-]-
null, inoculated with 106 MC38-CEA cells and injected three times SQ with injection buffer alone served as controls. All mice were monitored for tumor growth and tumor volumes are reported using previously described methods.16 Evaluation was over a 21-day period and the size of MC38-
CEA tumors was determined as a function of time. At day 19 the tumors in mice treated with Ad5
[E1-, E2b-]-CEA(6D) were significantly smaller as compared to the controls (**Figure 7A**). At the 16  
end of the study all mice were sacrificed and the tumors were excised and weighed. Tumors from the mice treated with Ad5 [E1-, E2b-]-CEA(6D) weighed significantly less than the tumors from controls (**Figure 7B**). The number of CEA stimulated T-cells in the spleen which secreted IFN-γ was determined by ELISpot assay. As presented in **Figure 7C**, mice immunized with Ad5 [E1-,
E2b-]-CEA(6D) had a significantly greater number of IFN-γ secreting T-cells than did control  
  
In summary, Ad5 [E1-, E2b-]-CEA(6D) is a therapeutic vaccine targeting CEA that induces robust immune responses, even in the presence of pre-existing Ad5 immunity. When compared directly with a conventional Ad5 [E1-]-CEA(6D) vector, the Ad5 [E1-, E2b-]-CEA(6D) platform induced superior cellular mediated immune responses in both Ad5 naïve and Ad5 immune animals. In therapeutic efficacy studies, treatment with Ad5 [E1-, E2b-]-CEA(6D) resulted in significantly decreased established MC38-CEA tumor growth even in mice which had been pre-immunized against Ad5. Treatment with Ad5 [E1-, E2b-]-CEA(6D) did not result in any adverse effects in pre-clinical studies. Our goal is to further develop this therapeutic vaccine against CEA and utilize this novel Ad5 vector system that overcomes barriers found with other Ad5 systems. The results of these pre-clinical studies establish the technical and immunological merit of using the Ad5 [E1-, E2b-]-CEA(6D) vaccine as a therapeutic agent.
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1.2.4.3 clinical safety

Etubics Corporation has performed a Phase I/II clinical trial of Ad-CEA (Ad5 [E1-, E2b-]-
CEA(6D)) (IND\#14325).13,19 The Phase I/II study consisted of a dose-escalation study of four dosage levels (1x109, 1x1010, 1x1011, 5x1011 VP/dose) of ETBX-011 (Phase I component), and the maximally tolerated dose of ETBX-011 (Phase II and 5x1011 VP/dose components). Ad-CEA was administered by SQ injection every 3 weeks. Thirty-two patients with metastatic colorectal cancer, median age 57.5 (range 38–77) who had failed a median of three prior chemotherapeutic regimens (range 2–5), had a performance status of 90 % (range 70–100 %), and had three sites of metastatic disease (range 1–4), were enrolled. The majority of patients were able to receive all three immunizations. Four patients who stopped immunizations early did so due to significant disease progression.  
A total of 94 immunization treatments were administered to all patients. There was no doselimiting toxicity and no serious adverse effects (SAE) that resulted in treatment discontinuation at any vaccine dose level. The most common toxicity was a self-limited, injection site reaction. Other reactions occurred with less than a 10% incidence of all adverse effects (AE) reported and included fever, flu-like symptoms, anorexia, chills, nausea, and headache. These symptoms were also selflimiting and did not require intervention other than symptomatic measures such as acetaminophen.13,19
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1.2.4.4 clinical immune response

A secondary objective was to evaluate CEA specific immune responses following immunization treatments with the product candidate. As determined by an ELISA technique,13,19 we observed no antibody activity directed against CEA. We assessed CMI responses in colorectal cancer patients treated in cohort 1, cohort 2, cohort 3/Phase II, and cohort 5. PBMCs were isolated prior to immunotherapy treatment and after all treatments as well as three weeks following the last treatment from patients. CEA specific ELISpot assays were performed on PBMC as previously described13,16,19 to determine the numbers of interferon gamma (IFN-γ) secreting lymphocytes
(SFC) after exposure to CEA peptides *in vitro*. We determined the highest CMI responses during immunizations, regardless of time point (weeks 3, 6, or 9) in the patients treated in cohort 1, cohort 2, cohort 3/Phase II, and cohort 5. This analysis revealed a dose response to increasing levels of product (**Figure 8**). The highest CMI levels occurred in patients that received the highest dose of 5x1011 VP (Cohort 5). In a preliminary study, we observed a population of polyfunctional CD8+
T cells (those that secrete more than 1 cytokine when activated) after immunizations that secreted multiple cytokines, a sign of greater functionality of T cells induced by the vaccine. In further 18 Version Date:10*.30.2019* follow-up analysis of a few patient blood samples, we noted a decrease in CEA directed immune responses after immunizations were stopped (**Figure 9**). This observation supports a rationale for booster immunizations.  
  
Figure 8. CMI responses in treated patients. CMI (IFN-γ secretion) was assessed at baseline (Pre) and after administrations of Ad5 [E1-, E2b-]-CEA(6D) (Post). The highest CMI responses (regardless of time point) observed in the patients after treatment revealed a dose response. The highest CMI levels occurred in patients that received the highest dose of 5x1011 VP (Cohort 5). The CMI responses for Cohort 3/Phase II and Cohort 5 were significantly elevated (P=0.0002 and P=0.0317, respectively; *Mann-Whitney test*) as compared to their baseline (Pre) values. Specificity of the responses was demonstrated by the lack of reactivity with the irrelevant antigens β-galactosidase and HIV-gag (data not shown). For positive controls, PBMCs were exposed to concanavalin A (data not shown). SFC: spot forming cells. Values = Mean ± SEM for each Cohort.  
  
We also measured Ad5 NAb and CMI against Ad5 and correlated it with CEA-specific CMI. Each patient had their serum and PBMC sample tested at baseline (prior to treatment) and at 9 weeks after completion of 3 treatments. Nineteen of 31 colorectal cancer patients (61%) tested in this study had Ad5 neutralizing activity in serum samples prior to the onset of treatment with Ad5 [E1- , E2b-]-CEA(6D). The mean pre-treatment Ad5 NAb titer value obtained among all patients was 1:189 ±1:71 SEM and the mean pre-treatment Ad5 NAb titer among seropositive patients was 1:308 ± 1:108. Analysis of serum samples from patients who received 3 immunizations revealed Ad5 NAb titers that were significantly increased (P<0.0001, *Mann-Whitney test*) by week 9 (mean 1:4767 ± 1:1225 SEM) when compared with their respective baseline values. Analysis of PBMC
for CMI responses to Ad5 also revealed a significant increase (P<0.01, Mann-Whitney test) in Ad5 directed CMI responses after immunizations with Ad5 [E1-, E2b-]-CEA(6D) (22.6 ± 9.3 SEM IFN-γ secreting SFC at week 0 versus 191.1 ± 83.7 IFN-γ SFC at week 9).  
1.2.4.5 Clinical evidence of activity The Ad-CEA treated colorectal cancer patients (total=32) were followed for survival and KaplanMeier plots and survival proportions performed (PRISM software).13,19 Events were determined by information from the social security death index (SSDI) database, clinical charts and telephone calls (**Figure 10**).  
  
The seven patients in cohorts 1 and 2 experienced a 12-month survival proportion of 29%. The 21 patients in cohort 3 and Phase II experienced a 12-month survival proportion of 48%. The six patients in cohort 5 experienced a 12-month survival proportion of 50%. Twenty-nine month overall survival of the intent-to-treat population (32 patients) was 20% (**Figure 10A**) with a median survival time of 11 months from informed consent/first injection. For the subset of 28 patients that received all 3 immunizations, the 29-month survival was 23% (**Figure 10B**) with a median survival time of 13 months. For the 22 patients optimally dosed with the two highest doses of vaccine (1 and 5 x 1011) and receiving all 3 immunizations, the 28-month overall survival was 19% (**Figure 10C**). Median overall survival was 13 months in the optimally treated patients. Since there was no active control group in the study, comparisons for significance in survival time cannot be made. There were 3 stable disease events observed immediately after completion of treatment.  
1.2.4.6 Evidence of an Ad5 [E1-, E2b-]-based vaccine driving T cell infiltration and PD-L1 upregulation High-risk human papillomavirus (HPV) such as HPV type-16 is associated with the etiology of cervical and more than 90% of HPV-related head and neck squamous cell carcinomas (HNSCC).2527 Preventive vaccines such as Human Papillomavirus Bivalent [Types 16 and 18] Vaccine and Human Papillomavirus Quadrivalent [Types 6, 11, 16, and 18] Vaccine are currently being used as a primary defense against HPV associated cancers by preventing infection with the virus but reports indicate that they are not effective for active immunotherapy of established disease.28 Immunotherapeutic treatment of HPV induced malignances has been investigated by us and others. The HPV early 6 (E6) and early 7 (E7) genes are expressed at high levels in HPV-induced cancers and are involved in the immortalization of primary human epidermal cells.26,28-32 Thus, these are ideal targets for tumor-specific immunotherapy because unlike many other tumor-associated antigens these viral antigens are "non-self" and thus do not have the potential to induce autoimmunity.21,28-33 Using the Ad5 [E1-, E2b-]-based vector platform, we investigated in a murine model of HPVassociated E6/E7 expressing cancer if immunotherapy against human papilloma virus (HPV) using a viral gene delivery platform to immunize against HPV 16 genes E6 and E7 (Ad5 [E1-, E2b-]- E6/E7) combined with programmed death-ligand 1 (PD-1) blockade could increase therapeutic 21 Version Date:10*.30.2019* effect as compared to the vaccine alone.33 Ad5 [E1-, E2b-]-E6/E7 as a single agent induced HPVE6/E7 cell-mediated immunity. Immunotherapy using Ad5 [E1-, E2b-]-E6/E7 resulted in clearance of small tumors and an overall survival benefit in mice with larger established tumors. When immunotherapy was combined with immune checkpoint blockade, an increased level of anti-tumor activity against large tumors was observed (**Figure 11**). Analysis of the tumor microenvironment in Ad5 [E1-, E2b-]-E6/E7 treated mice revealed elevated CD8+ tumor infiltrating lymphocytes (TILs); however, we observed induction of suppressive mechanisms such as programmed death-ligand 1 (PD-L1) expression on tumor cells and an increase in PD-1+ TILs.  
When Ad5 [E1-, E2b-]-E6/E7 immunotherapy was combined with anti-PD-1 antibody, we observed CD8+ TILs at the same level but a reduction in tumor PD-L1 expression on tumor cells and reduced PD-1+ TILs providing a mechanism by which combination therapy favors a tumor clearance state and a rationale for pairing antigen-specific vaccines with checkpoint inhibitors in future clinical trials.  
  
1.2.4.7 Rationale for combining chemotherapy treatment with Ad5 [E1-, E2b-]-based vaccine immunotherapy
Using the same murine model of HPV-associated E6/E7 expressing cancer described above (see section **1.2.4.6**), we investigated if immunotherapy using Ad5 [E1-, E2b-]-E6/E7 could be combined with cisplatin/radiation treatment that is utilized to treat HNSCC.21 We observed that when immunotherapy was combined with cisplatin/radiation treatment, a significant increase in survival time demonstrated in tumor bearing mice treated with the combination of immunotherapy 23 Version Date:10*.30.2019* Figure 12.Immunotherapy combined with chemotherapy/ radiation treatment of established HPV-E6/E7 expressing tumors. Established HPV-E6/E7 expressing tumors were treated by immunotherapy on days 7, 14, & 21 combined with cisplatin/radiation treatment on days 13, 20, & 27. Control tumor bearing mice were treated by injections with Ad-null combined with cisplatin/radiation treatment.  
In light of the above results, we then investigated the effects of combining immunizations with Ad5 [E1-, E2b-]-E6/E7 with cisplatin/radiation treatment versus cisplatin/radiation treatment alone in a murine model. We observed that the combination of Ad5 [E1-, E2b-]-E6/E7 immunizations plus cisplatin/radiation treatment resulted in the induction greater CMI responses as compared to immunizations with Ad5 [E1-, E2b-]-E6/E7 alone (**Figure 13**). These results provide us with a rationale for combining immunotherapy with chemotherapy treatment in order to achieve greater anti-tumor CMI responses.  
  
Figure 13. Non-tumor bearing mice were treated as described in **Figure 11**
above. Two weeks after the last treatment, mice were assessed for CMI activity as determined by ELISpot assays for IFN-γ secreting splenocytes. Note the increased CMI responses in mice treated with combination therapy (Ad5 [E1-, E2b-]-mE6/E7/CRT).  
and cisplatin/radiation treatment as compared to control mice receiving cisplatin/radiation  
  
treatment alone (**Figure 12**).
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1.2.5 anti-pd-l1 monoclonal antibody avelumab

Programmed death ligand 1 (PD-L1) is a transmembrane protein that was first identified for its role in the maintenance of self-tolerance and prevention of autoimmunity.  
34 Engagement of PDL1 on dendritic cells with the programmed death 1 (PD-1) receptor on T cells delivers an inhibitory signal that promotes T cell anergy or apoptosis.  
35 This immunoinhibitory checkpoint is often subverted by tumor cells that over-express PD-L1 in order to escape immunosurveillance in the tumor microenvironment. Indeed, there is a strong correlation between PD-L1 expression and prognosis in cancer. Blockade of the interaction between PD-L1 on tumor cells and PD-1 on T
cells is expected to reverse T cell suppression within tumors, thereby promoting effective antitumor immune responses.  
Several antibodies directed against the PD-L1 / PD-1 pathway are in clinical development for cancer treatment.36 Compared with anti-PD-1 antibodies that target T-cells, anti-PDL1 antibodies that target tumor cells are expected to have less side effects, including a lower risk of autoimmunerelated safety issues, as blockade of PD-L1 leaves the PD-L2 / PD-1 pathway intact to promote peripheral self-tolerance.  
37 To this end, avelumab, a fully human IgG1 anti-PDL1 antibody (drug code MSB0010718C) has been produced. Avelumab selectively binds to PD-L1 and competitively blocks its interaction with PD-1. Avelumab is also cross-reactive with murine PD-L1, thus allowing in vivo pharmacology studies to be conducted in normal laboratory mice. However, due to immunogenicity directed against the fully human avelumab molecule, the dosing regimen was limited to three doses given within a week. The key preclinical pharmacology findings for avelumab are summarized below.  
- Functional enhancement of primary T cell activation in vitro in response to antigenspecific and antigen non-specific stimuli.  
- Significant inhibition of in vivo tumor growth (PD-L1 expressing MC38 colon carcinoma) as a monotherapy.  
- In vivo efficacy is driven by CD8+ T cells, as evidenced by complete abrogation of antitumor activity when this cell type was systemically depleted.  
- Combination with localized, fractionated radiotherapy resulted in complete regression of established tumors with generation of anti-tumor immune memory.  
- Chemotherapy combinations also showed promising activity:
o Additive combination effect when partnered with oxaliplatin and 5-fluorouracil
(5-FU) (core components of FOLFOX [oxaliplatin, 5-FU, and folinic acid]) against MC38 colon tumors. (Summarized in section 2.5)
o Significant increase in survival when partnered with gemcitabine against PANC02 pancreatic tumors.  
- Antibody-dependent cell-mediated cytotoxicity (ADCC) was demonstrated against human tumor cells in vitro; furthermore, studies in ADCC deficient settings in vivo support a contribution of ADCC to anti-tumor efficacy.  
- No complement-dependent cytotoxicity was observed in vitro. - Immunomonitoring assays with translational relevance for the clinic further support an immunological mechanism of action:
o Consistent increases in CD8+PD-1+ T cells and CD8+ effector memory T cells as measured by fluorescence-activated cell sorter (FACS).  
25 Version Date:10*.30.2019* o Enhanced tumor-antigen specific CD8+ T cell responses as measured by pentamer staining and enzyme-linked immunosorbent spot (ELISPOT) assays.  
1.2.5.1 Outcomes in colorectal cancer in trials using agents blocking PD-1 - PD-L1 interaction Despite reports indicating that anti-tumor radiographic responses were unlikely using agents that interfere with PD-1 -- PD-L1 binding in colorectal cancer, 38 there have been reports of radiographic responses.  
39-41 Additionally, a correlation has been demonstrated in multiple clinical trials indicating that PD-L1 expression levels on tumor tissue predict the likelihood of radiographic response.38,40 However, it has become clear that PD-L1 expression, as it is currently measured, is not a definitive requirement for anti-tumor efficacy.39,40 It has been noted that colorectal tumors rarely express PD-L1 compared with other tumors that are more likely to respond to PD-1 - PDL1 blockade.38 However, it is known that a strong anti-tumor T cell response, producing IFNgamma, will induce PD-L1 expression. Together, this data strongly supports the conclusion that an underlying immune response is necessary for PD-1 - PD-L1 blockade to have an anti-tumor effect. This is part of the rationale for this combination with the standard therapy and Ad-CEA
vaccine that may be capable of induction of PD-L1 expression (described in section **1.2.8** below)
and thereby increase the anti-tumor activity of PD-1 - PD-L1 blockade.
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1.2.5.2 avelumab phase i (13-c-0063)

We have recently completed the dose escalation portion of clinical trial 13-C-0063 (NCT01772004). 4, 14 (1 withdrew before treatment), 12 and 21 patients, respectively, were enrolled into 4 escalating dose levels: 1 mg/kg, 3 mg/kg, 10 mg/kg, and 20 mg/kg. The maximum tolerated dose was not exceeded. At the 20 mg/kg dose level, 1 dose limiting toxicity was experienced out of 6 patients treated. This DLT was associated with a significant anti-tumor response and was attributed to drug because of the possibility that it was an immune-related adverse event (with transient elevated creatine kinase, muscle weakness, myalgia, transaminitis, myocarditis with elevated troponin and inferiolateral ST-elevation on ECG). To date, 80 patients have been enrolled. 55pts (71.2%) have come off-study: 43 (53.7%) for progression and 6 (7.5 %) for toxicity. Grade 3 AEs attributable to drug comprised of 7 laboratory abnormalities (4 increased liver transaminases, 1 decreased lymphocytes,1 elevated creatine kinase and 1 elevated lipase) in 5 patients and symptomatic myositis requiring intervention in 2 other patients
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1.2.5.3 pharmacokinetics and receptor occupancy

Data from 25 patients was evaluable for PK and RO analysis. Median time to maximum concentration was approximately 1.5 to 2 hours after infusion (for all doses with a linear PK). Half-life was 63.4, 80.7, 93.9 and 115.1 hours for dose levels 1, 2, 3 and 4 respectively, measured by ELISA. Target RO data was available for 13 patients, measured by PD-L1 binding on peripheral leucocytes via flow cytometry. Mean RO was 75.7, 93.8 and 93.2% for dose levels 1, 2 and 3 respectively.
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1.2.5.4 clinical outcomes in patients

At the time of the writing of this document, 18 patients have enrolled on the single-agent phase I study of avelumab with mCRC at the 10mg/kg dose level. Of these 18, 14 had reached the first restaging for evaluation. Of the 14 evaluable patients, 3 remain on study without evidence of progression for >100 days. Two of these patients have had stable disease for >200 days. The patient to be detailed in section **1.2.5.4.2** with a significant fall in CEA has remained on study with stable disease through day 350. Of the remaining evaluable patients (n = 11), 9 have had disease progression within 85 days of initial treatment. The remaining 2 patients came off study for adverse events (transaminase elevation and infusion reaction, respectively). **Figure 14** illustrates the outcomes to date for patients with CRC treated with avelumab (MSB0010718C) by Response Evaluation Criteria for Solid Tumors (RECIST) criteria.  
Figure 14. Observed changes in target lesions by size (RECIST)
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1.2.5.4.2 cea response

One patient with mCRC on the phase I study had a remarkable decrease in serum CEA. At baseline his CEA was 267. After starting avelumab, he had a rapid and consistent fall in CEA over the following 5 months with stable disease on scans. He has now been on study for over 11 months with stable disease on scans. Notably, a biopsy of one of his retroperitoneal lymph nodes, being followed as measurable disease on CT scan, revealed "fibroadipose tissue with focal chronic inflammation. No tumor seen." This patient still has elevated CEA in the range of 22-41 that has been holding in this range for 5 months. **Figure 15** demonstrates the change in this patient's CEA.
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1.2.5.4.3 immune data 1.2.6 colorectal

27  
  
Version Date:10*.30.2019* Figure 15. CEA change in patient with mCRC receiving single agent avelumab (MSB0010718C)
An analysis of immune cell subset changes from baseline to day 15 and day 43 was performed on PBMC samples from the first 23 patients enrolled on the phase I study of avelumab on clinical trial 13-C-0063 (NCT01772004), which included patients at 4 dose levels (1, 3, 10, and 20mg/kg).  
There was no clear pattern of change (defined as 20% increase or decrease) pre- versus posttreatment in absolute lymphocyte count. A panel of markers was used to define >50 immune cell subsets by flow-cytometry at the same intervals. There were no significant changes in any of the immune cell subsets. Notably, there was no decrease in the number of circulating immune cells expressing PD-L1 (including B lymphocytes and dendritic cells). A randomized trial comparing irinotecan and bolus fluorouracil plus leucovorin (IFL, control combination), oxaliplatin and infused fluorouracil plus leucovorin (FOLFOX), or irinotecan and oxaliplatin (IROX) established the FOLFOX combination, given for a total of 6 months, as the standard of care for first line treatment in patients with metastatic colorectal cancer (mCRC).42 Though multiple infusion schedules of FOLFOX have been validated, typically denominated as 'modified FOLFOX, there are no essential changes in the constituent cytotoxic agents of the regimen. Of these, mFOLFOX6 is one of the most widely used. Oxaliplatin, however, is very difficult for patients to receive for greater than 6 months (12 cycles) due to progressive neurotoxicity. Though 6 months of combination therapy remains the standard of care in mCRC, clinical judgment may influence the decision to limit the number of oxaliplatincontaining cycles towards the end of treatment Other trials, including the CAIRO3 study, have demonstrated the feasibility and benefit of discontinuation of oxaliplatin after a 3 month
"induction" period with continuation of 5-FU and leucovorin as "maintenance" therapy.43
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1.2.6.2 bevacizumab (avastin)

Addition of bevacizumab to first-line 5-FU and Oxaliplatin containing regimens was demonstrated to increase time to progression in mCRC patients with a manageable side effect profile and nonoverlapping toxicities.44,45 Later trials indicated that continuing bevacizumab beyond first progression (in combination with subsequent chemotherapy) improved overall survival in an unselected group of patients by KRAS mutational status, which has led to its approved use in the maintenance setting.46,47
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1.2.6.3 capecitabine

This agent is a prodrug that is enzymatically converted to 5-fluorouracil by 3 enzymatic steps following oral ingestion. As an orally active fluoropyrimidine, capecitabine has been approved for use in the adjuvant setting.48 In the advanced colon cancer setting, it has been shown to be equally efficacious as 5-fluorouracil, though with more reported rates of hand-foot syndrome.49 This agent offers the convenience of the oral route with its benefits of reducing infusion commitments for patients in the maintenance setting, while achieving high concentrations intratumorally, given the higher concentrations of thymidine phosphorylase in tumor as compared to normal tissues.50
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1.2.6.4 population expected outcomes

Using the above noted standard of care, the expected radiographic progression free survival is approximately 10 months in patients with metastatic colorectal adenocarcinoma.46,47 At the time of progression, patients will typically be treated with a similar regimen, using 5-FU, leucovorin, and irinotecan (FOLFIRI). Unfortunately, that therapy also has a limited duration of benefit and patients have very few choices in the third line setting. Clearly, there is a significant need to improve outcomes in patients overall with metastatic colorectal cancer. Combining agents with non-overlapping toxicity and different mechanisms of action in the front line setting may be an excellent way to improve short and long term clinical outcomes.
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1.2.7 rationale for combination of

As previously noted, PD-1/L1 blockade has had minimal effect in the majority of patients with advanced colorectal cancer. The notable exception has been patients with microsatalite instability
(MSI-Hi, also called MisMatch Repair Deficiency, MMR-D).51 It has been hypothesized that the increased mutation burden in these tumors provides a greater number of potential neo-epitopes for T-cell receptors to recognize and bind, resulting in killing.52,53 Combining anti-PD-L1 antibody with a therapeutic cancer vaccine capable of inducing CEA-specific T cell immune responses plus the standard of care creates multiple advantages that may allow for improved clinical outcomes. As previously discussed, advanced colorectal cancer appears to be weakly immunogenic. Therapeutic cancer vaccines are designed to drive T cell activation against a tumor-associated antigen. The Ad-CEA vaccine targets CEA, an antigen overexpressed universally in colorectal cancer. T cell activation against the target antigen should result in greater trafficking and infiltration of T cells in to the tumor microenvironment. When combined with Avelumab, a PDL1 inhibitor, those activated T cells are more likely to have a direct anti-tumor effect, resulting in radiographic tumor response and delayed time to progression. Both 5-FU and oxaliplatin have been identified as agents which can induce immunogenic cell death and/or decrease the number of regulatory T cells 54, which increases the antigen targets available to active T cells and T cell activation and killing of tumor cells. This effect is known to be capable of inducing an anti-tumor immune response.54-58 There is also evidence that immunotherapy in combination with 5-FU is capable of increasing the immune response against tumor cells. As has been discussed, an underlying anti-tumor T cell response appears to be necessary for PD-L1 induction in the tumor tissue. PD-L1 expression has been correlated with the likelihood of PD-1 - PD-L1 blockade to induce anti-tumor immune response and cause tumor volume reduction and clinical benefit. Another mechanism by which the underlying anti-tumor immune response may be improved when patients are exposed to the standard of care regimen is through a process known as immunogenic modulation. Hodge and colleagues in the LTIB have demonstrated repeatedly the potential improvement in antigen presentation, FAS upregulation, and T cell mediated killing in combination with chemotherapeutics, including 5-FU and oxaliplatin.59 Decreased tumor burden induced by standard of care therapy may allow better immune response by debulking the tumor and improving the microenvironment for immunologic killing.60-65 The addition of standard of care therapy also provides ample time for an immune response to occur, which may be important considering the occasional delayed responses and prolonged stable disease findings that have been described with anti-PD-1 and anti-PD-L1 targeting agents. Given the findings with ipilimumab improving overall survival while not necessarily improving PFS66, it may be that delayed immunologic effects create long term clinical benefit in some populations despite lack of immediate tumor volume reduction. By using a therapy in combination with standard agents known to induce tumor volume reduction, we may be able to capture that long term benefit. Preclinical evidence indicates that vascular endothelial growth factor (VEGF) signaling in the tumor microenvironment causes disorganized perfusion, resulting in poor T cell trafficking to the tumor site, increased hypoxia, and an immunosuppressive microenvironment. Rakesh Jain's group has demonstrated significant improvement in T cell infiltration with the addition of VEGF
inhibition in preclinical models.67 In this study, VEGF inhibition increased the efficacy of a vaccine to induce T cell infiltration into the tumor, resulting in better anti-tumor effect. Similarly, Dr. Hwu's group has found VEFG blockade to result in greater T cell infiltration in adoptively transferred T cells in a murine model.68 Alfaro, et al., found VEGF inhibition to be valuable for dendtritic cell differentiation and T cell activation.69 Taken together, these data indicate a potential synergy between VEGF inhibition and immunotherapy, supportive of combining these agents in patients.  
1.2.7.1 Rationale for exclusion of MSI-high mCRC
While PD-1/L1 blockade has resulted in objective tumor responses in patients with microsatellite instability, there is an unmet need for better therapeutic interventions for patients who have microsatellite stable colorectal cancer. In these patients, who make up the large majority of patients with metastatic colorectal cancer (>90%), there has been little or no evidence of clinical benefit with PD-1/L1 blockade. Our hypothesis is that the combination of the agents comprising FOLFOX-bevacizumab and Ad-CEA vaccine will increase specific T cell activation, which will result in PD-1/L1 blockade allowing T cell mediated killing of tumor cells. As a result, patients who are known to respond to PD-1/L1 blockade are excluded from this study as they may not need chemotherapy at all. Ongoing studies in the population of MSI-Hi colorectal cancer are 30 Version Date:10*.30.2019* ongoing to answer this question and we would not want to confound our study by including patients in the MSI-Hi population.
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1.2.7.2 preclinical data support

Our CRADA partner, EMD-Serono, has already performed a preclinical model evaluation of the combination of FOLFOX with anti-PD-L1. The study was conducted in compliance with GLP and the global policy "Quality management system (QMS) for Merck Serono research (MSR)" of Merck KGaA. Materials and methods and additional data available in **Appendix A**.  
The study investigated the potential of combining avelumab with the core components of FOLFOX (5-fluorouracil and oxaliplatin) in two separate studies (TI10-079 & TI11-001) conducted in mice bearing subcutaneous MC38 tumors. The therapeutic combination of oxaliplatin/5-FU and anti-PD-L1 blockade using avelumab in  
 MC38 tumor-bearing mice yielded superior tumor growth inhibition relative to control mice and either form of monotherapy (**Figure 16**). Additionally, the avelumab and oxaliplatin/5-FU
combination significantly extended survival compared to mice receiving either vehicle control or monotherapy (**Figure 17**).  
Figure 16. MC 38 Tumor Growth Inhibition in Mice Receiving Avelumab (Anti-PD-L1) in Combination with Oxaliplatin and 5-FU
Female C57BL/6 mice w ere inoculated in the right subcutaneous flank w ith 1x106 MC38 colon carcinoma cells. When tumors reached a mean volume of ~50 mm3, mice w ere sorted into treatment groups (N=10). 5-FU (60 mg/kg by i.v. injection) and OX (5 mg/kg by i.p.  
injection) w ere administered on days 0 and 14. MSB0010718C (400 μg by i.v. injection) w as given on days 3, 6, and 9. Tumor volumes w ere measured tw ice w eekly via calipers. Data are mean ± SEM.  
31  
  
Version Date:10*.30.2019* Figure 17. Survival of MC38 Tumor-Bearing Mice Receiving Avelumab (Anti-PD-L1) in Combination with Oxaliplatin and 5-FU
Female C57BL/6 mice w ere inoculated in the right subcutaneous flank w ith 1x106 MC38 colon carcinoma cells. When tumors reached a mean volume of ~50 mm3, mice w ere sorted into treatment groups (N=10). 5- FU (60 mg/kg by i.v. injection)
and OX (5 mg/kg by i.p. injection) w ere administered on days 0 and 14.  
MSB0010718C (400 μg by i.v.  
injection) w as given on days 3, 6, and 9. Kaplan-Meier plots and Log Rank statistics w ere used to calculate survival differences betw een groups. Survival w as censored at the time tumor volumes reached 2000 mm3. Data are expressed as median survival time in days.  
In both *in vivo* studies (TI10-079 and TI11-001), a subset of mice in each treatment group was sacrificed to evaluate trends in immune phenotype in the spleen and tumor tissues. Using a pentamer analysis of splenic tissue, the avelumab and oxaliplatin/5-FU combination was shown to significantly elevate the precursor frequency of tumor-reactive P15E-specific CD8+ T cells
(P15E is a known tumor antigen expressed in MC38 colorectal cancer tumor lines,70 (**Figure 18**).  
Additionally, avelumab therapy was shown to consistently and significantly increase the percentage of splenic CD8+ T cells expressing the PD-1 receptor (**Figure 19**).  
32  
  
Version Date:10*.30.2019* Figure 18. Pentamer Analysis of Tumor-Antigen Specific T Cells Subsets of 5 animals from each study group w ere sacrificed on study day 21 for FACS-based detection of p15Especific T cells using a fluorescently-labeled synthetic MHC class I pentamer loaded w ith a p15E-derived antigenic peptide epitope. The spleen from each animal w as dissociated into single cell suspensions and subsequently stained w ith an anti-CD8 antibody and the p15E pentamer. From the total splenocyte gate, the percentage of cells positive for both CD8 and the pentamer w as determined. Data w ere acquired using a BD LSR II flow cytometer.  
  
33  
  
Version Date:10*.30.2019* Figure 20. CD8+ Tumor-Infiltrating Lymphocyte Levels Subsets of 5 animals from each group w ere sacrificed for FACS-based immunophenotyping analysis on day 21 follow ing the start of treatment. Tumors w ere harvested and dissociated into single cell suspensions by enzymatic digestion (collagenase) and mechanical disruption. Suspensions w ere then stained w ith a fluorescentlylabeled antibodies specific for the NK1.1 surface marker and data w ere acquired using a BD LSR II flow cytometer.  
  
Subsets of 5 animals from each group w ere sacrificed for FACSbased immunophenotyping analysis on day 21 follow ing the start of treatment. Tumors w ere harvested and dissociated into  
 enzymatic digestion (collagenase) Suspensions w ere then stained antibodies specific for the NK1.1 surface marker and data w ere acquired using a BD LSR II flow
34  
  
Version Date:10*.30.2019* Figure 22. Combination of Avelumab (MSB0010718C) with 5-FU and Oxaliplatin: ELISPOT Measurement of Tumor Antigen Specific CD8+ T cells For the ELISPOT assay, spleens from treated animals w ere harvested on day 21 after the start of treatment and processed into single cells suspensions (splenocytes from 5 mice from each group w ere pooled). The splenocytes w ere cultured for six days in the presence of a p15E-derived peptide antigen epitope (amino acid sequence KSPWFTTL) in order to stimulate expansion of antigen-specific CD8+ T cells. As a control for non-specific activation, the assay w as run in parallel using an irrelevant peptide derived from chicken ovalbumin (OVA). Follow ing the six day period of *in vitro* antigen stimulation, the CD8+ T cells w ere isolated from the cultures and placed in co-culture w ith antigen presenting cells (APCs) loaded w ith the same p15E antigenic peptide or OVA as a control. The cocultures w ere prepared in ELISPOT assay plates coated w ith an antibody that captured secreted IFN-γ. Follow ing assay plate development, each IFN-γ positive "spot" represented a CD8+ T cell that had become activated by p15Especific stimulation.  
One interpretation of this data is that chemotherapy initiates a cascading sequence in which tumor cell destruction and the shedding of tumor antigen in the tumor microenvironment activates innate and adaptive immune responses to the tumor. In this scenario, PD-L1 blockade is thought to potentiate the adaptive immune response, which may indirectly activate innate effector cells such as NK cells. By blocking negative costimulation of tumor-reactive T cells mediated by the PD-1/PD-L1 interaction, avelumab may be employed in a variety of settings and indications to maximize the potential efficacy of standard of care cytotoxic therapies as well as immunotherapy combinations.  
1.2.7.3 Clinical data support We have looked into the use of standard chemotherapy in patients with previously untreated metastatic colorectal cancer and have found no difference in the number of 40+ different immune cell subsets pre- versus post-treatment with standard therapy (5-FU based chemotherapy71). This was done in collaboration with Dr. John Marshall at Georgetown, who assisted with collecting clinical samples from 6 patients pre- and post-standard therapy. Thus, chemotherapy should not diminish the potential immune benefits of anti-PD-L1 therapy.  
1.2.7.4 Clinical safety data combining FOLFOX + PD-1/PD-L1+ Bevacizumab therapy The first patient enrolled on this trial developed febrile neutropenia and shortly thereafter passed away from a grade 5 bowel perforation event attributed to bevacizumab. Data from a phase II
trial of a mFOLFOX6 + bevacizumab + a PD-L1 inhibitor 72 showed no reported episodes of bowel perforation among 30 patients with colorectal cancer enrolled on this combination. Given this data and the fact that the episode of bowel perforation on this study is a solo event, we think it is appropriate to continue with bevacizumab on the combined chemotherapy/ immunotherapy arm (Arm B) of the study for now. Should any similar events of bowel perforation occur we will plan on discontinuing bevacizumab from this arm of the study. In addition, in the phase II trial of mFOLFOX6 + bevacizumab + a PD-L1 inhibitor cited above there was an unexpectedly high percentage of grade ≥ 3 neutropenia (43%) in patients receiving this combination. In addition, a second phase II trial 73 evaluating mFOLFOX6 + pembrolizumab had an unexpectedly high rate of febrile neutropenia (3/6 pts) in their safety lead in cohort. As it is generally standard clinical practice to first remove the 5-FU bolus infusion in the setting of neutropenia and based upon the expected high rate of neutropenia with this combination, we are prophylactically removing the 5-FU bolus infusion from the chemotherapy/ immunotherapy arm (Arm B) of the study.
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1.2.8 summary

- Colorectal cancer (CRC) is the fourth most common cancer diagnosis in the United States and accounts for the second most cancer-related deaths.  
- Programmed death ligand 1 (PD-L1) is a transmembrane protein that was first identified for its role in the maintenance of self-tolerance and prevention of autoimmunity. Blockade of the interaction between PD-L1 on tumor cells and PD-1 on T cells is expected to reverse T cell suppression within tumors. These agents are dependent on underlying T cell activation against the tumor cell to be effective.  
- Avelumab is a fully human IgG1 anti-PDL1 antibody that selectively binds to PD-L1 and competitively blocks its interaction with PD-1.  
- In ongoing phase 1 trials of avelumab, the agent has been well tolerated and has shown clinical activity.  
- Clinical trials with anti-PD-1/L1 agents in colorectal cancer have resulted in minimal activity in patients who do not have mismatch repair deficiency (MMR-D)
- Therapeutic cancer vaccines targeting overexpressed proteins offer a potential method to activate T cells against tumors.  
- A novel adenovirus based, CEA-targeting vaccine has demonstrated cytolytic T cell responses in patients with metastatic colorectal cancer.  
- Standard of care agents in first line metastatic CRC have properties been associated with improved immune response via immunologic cell death and immunogenic modulation
- A preclinical model combining 5-FU and oxaliplatin plus avelumab has demonstrated potential synergy of this combination
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2 eligibility assessment and enrollment

2.1.1.1 Subjects must have previously untreated metastatic or unresectable colorectal cancer and have no contraindications to treatment with the standard of care regimen (as defined in section **3.4.1**) as determined by the investigator. Prior adjuvant therapy for surgically resectable disease (including oligometastatic disease) is acceptable (including immunotherapy), but must have been completed at least 6 months prior to enrollment.  
2.1.1.2 Patients should not be eligible for potentially curative surgical intervention in the case of oligometastic disease at the time of enrollment or must have actively refused after explicit discussion of potential benefit of this intervention with multidisciplinary team.
2.1.1.3 Histologically confirmed colorectal cancer. 2.1.1.4 Patients must have measurable disease by RECIST criteria as defined in section 6.4. 2.1.1.5 Age ≥18 years. Because safety data is not known with this agent in patients less than 18 years old, children are excluded from this study.  
2.1.1.6 ECOG performance status ≤ 2 (see **Appendix B**). 2.1.1.7 Patients must have normal organ and marrow function as defined below:
- Creatinine clearance (Per Institutional standard or 24-hour urine) ≥ 30 mL/min.  
- Adequate hepatic function defined by a total bilirubin level ≤ 1.5 × the upper limit of normal range (ULN), an aspartate aminotransferase (AST), level ≤ 2.5 × ULN, and an alanine aminotransferase (ALT) level ≤ 2.5 × ULN or, for subjects with documented metastatic disease to the liver, AST and ALT levels ≤ 5 × ULN
- Hematological eligibility parameters (within16 days of enrollment):
o Granulocyte count ≥ 1,500/mm3
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o platelet count >=100000/mm3

o Hemoglobin ≥ 9 g/dL
2.1.1.8 The effects of Ad-CEA vaccine and avelumab on the developing human fetus are unknown. For this reason and because Ad-CEA vaccine and avelumab as well as other therapeutic agents used in this trial are known to be teratogenic, women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation and for a period of 4 months after the last treatment with avelumab or 6 months after the last administration of bevacizumab, whichever occurs later. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately.  
2.1.1.9 Ability of subject to understand and the willingness to sign a written informed consent document.
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2.1.2 exclusion criteria

2.1.2.1 Metastatic or unresectable colorectal cancer with mismatch repair deficiency (MMR-D
or MSI-High).  
2.1.2.2 Concurrent treatment for cancer except agents specified within the treatment protocol. 2.1.2.3 Prior major surgery or gastrointestinal perforation within 28 days of enrollment. 2.1.2.4 Persisting toxicity related to prior therapy (NCI CTCAE v5.0 Grade > 1); however alopecia, sensory neuropathy Grade <=2, or other Grade <=2 AEs not constituting a safety risk based on investigator's judgment are acceptable.  
2.1.2.5 Known history of testing positive for HIV or known acquired immunodeficiency syndrome.  
2.1.2.6 Hepatitis B virus (HBV) or hepatitis C virus (HCV) infection at screening (positive HBV surface antigen or HCV RNA if anti-HCV antibody screening test positive).  
2.1.2.7 Any significant disease that, in the opinion of the investigator, may impair the patient's tolerance of study treatment.  
2.1.2.8 Active autoimmune disease that might deteriorate when receiving an immuno-stimulatory agent. Patients with diabetes type I, vitiligo, psoriasis, or hypo- or hyperthyroid diseases not requiring immunosuppressive treatment are eligible.  
2.1.2.9 Current use of immunosuppressive medication, EXCEPT for the following: a. intranasal, inhaled, topical steroids, or local steroid injection (e.g., intra-articular injection); b. Systemic corticosteroids at physiologic doses ≤ 10 mg/day of prednisone or equivalent; c. Steroids as premedication for hypersensitivity reactions (e.g., CT scan premedication).  
2.1.2.10 Patients who are receiving any other investigational agents within 28 days before start of study treatment.  
2.1.2.11 Prior organ transplantation including allogenic stem-cell transplantation.  
2.1.2.12 Subjects with active central nervous system (CNS) metastases causing clinical symptoms or metastases that require therapeutic intervention are excluded. Subjects with a history of treated CNS metastases (by surgery or radiation therapy) are not eligible unless they have fully recovered from treatment, demonstrated no progression for at least 2 months, and do not require continued steroid therapy. Subjects with CNS metastases incidentally detected during Screening which do not cause clinical symptoms and for which standard of care suggests no therapeutic intervention is needed are eligible.  
2.1.2.13 Active infection, requiring systemic therapy. 2.1.2.14 Clinically significant (i.e., active) cardiovascular disease: cerebral vascular accident/stroke (< 3 months prior to enrollment), myocardial infarction (< 3 months prior to enrollment), unstable angina, congestive heart failure (≥ New York Heart Association Classification Class II), or uncontrolled arrhythmias.  
2.1.2.15 Other severe acute or chronic medical conditions including immune colitis, inflammatory bowel disease, immune pneumonitis, pulmonary fibrosis or psychiatric conditions including recent (within the past year) or active suicidal ideation or behavior; or laboratory abnormalities that may increase the risk associated with study 38 Version Date:10*.30.2019* participation or study treatment administration or may interfere with the interpretation of study results and, in the judgment of the investigator, would make the patient inappropriate for entry into this study.  
2.1.2.16 Pregnant women and breastfeeding mothers are excluded due to unknown impact on embryos or infants.  
2.1.2.17 Known alcohol or drug abuse. 2.1.2.18 "Known prior severe hypersensitivity to investigational product or any component in its formulations, including known severe hypersensitivity reactions to monoclonal antibodies (NCI CTCAE v5.0 Grade ≥ 3).  
2.1.2.19 Patients with a known hypersensitivity/allergy to any of the standard of care agents used in this study or related compounds (e.g. platinum compounds) are excluded.  
2.1.2.20 Prior history of hypertensive emergency or hypertensive encephalopathy (for those expected to receive bevacizumab).  
2.1.2.21 Serious, non-healing wound, active ulcer, or untreated bone fracture, including tumorrelated pathological fracture.  
2.1.2.22 Evidence of bleeding diathesis or significant coagulopathy (in the absence of therapeutic anticoagulation).  
2.1.2.23 Patients being treated with medications with drug-drug interactions with study agents will require evaluation by to determine if full doses of all study treatments can be given safely. Significant drug-drug interactions will need to be addressed prior to enrollment. Alternatively, the patient will not be eligible.  
2.1.2.24 Vaccination within 4 weeks of the first dose of avelumab and while on trials is prohibited except for administration of inactivated vaccines.
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2.1.3 recruitment strategies 2.2 this

Minimal risk activities that may be performed before the subject has signed a consent include the following:
- Email, written, in person or telephone communications with prospective subjects - Review of existing medical records to include H&P, laboratory studies, etc.  
- Review of existing MRI, x-ray, or CT images
- Review of existing photographs or videos - Review of existing pathology specimens/reports from a specimen obtained for diagnostic purposes A waiver of consent for these activities has been requested in section 12.5.2
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2.2.2 screening activities performed after

The following activities will be performed only after the subject has signed the consent for this study for screening. Assessments performed at outside facilities or on another NIH protocol within the timeframes below may also be used to determine eligibility once a patient has signed the consent. Studies should be done within 16 days prior to treatment unless otherwise noted below.  
- History and physical exam including performance status and vital signs
- Scans (within 28 days prior to treatment)  
o CT CAP (chest abdomen and pelvis) with oral and IV contrast (MRI
abdomen/pelvis with contrast + chest CT without contrast if IV contrast is contraindicated or CT CAP is inadequate)
o Brain MRI - if clinically indicated
- Hepatic Panel (Alkaline Phosphatase, ALT/GPT, AST/GOT, Total Bilirubin, Direct Bilirubin)  
- Acute Care Panel (Sodium [NA], Potassium [K], Chloride [CL] Total CO2
[Bicarbonate], Creatinine, Glucose, Urea nitrogen, eGFR)
- CBC with differential
- Serum or urine HCG in women of childbearing potential - HBV (HBsAg), HCV (anti-HCV), HIV (anti-HIV) screening (within 3 months prior to treatment)
- Urine dipstick - PT/INR, PTT - Histologic confirmation of diagnosis (including MSI or MMR status; any time prior to treatment)
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2.3 registration procedures 2.3.1 registration

Registration will be a two-part process as patients are screened on this protocol. Authorized staff must register an eligible candidate with NCI Central Registration Office (CRO) within 24 hours of signing consent. To initially register a subject after the participant has signed the consent, complete the top portion of the registration Eligibility Checklist from the website
(http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) indicating that the patient is being registered for screening and send via encrypted email to: NCI Central Registration Office ncicentralregistration-l@mail.nih.gov. Once eligibility is confirmed after completion of screening studies, complete the remainder of the form which is the eligibility checklist, indicating that the patient is being registered for treatment and email the completed registration checklist to the CRO at NCI Central Registration Office ncicentralregistration40 Version Date:10*.30.2019* l@mail.nih.gov. After confirmation of eligibility at Central Registration Office, CRO staff will call pharmacy to advise them of the acceptance of the patient on the protocol prior to the release of any investigational agents. Verification of Registration will be forwarded electronically via email to the research team. A recorder is available during non-working hours.  
Subjects that do not meet screening criteria should be removed from the study following the procedure in section **3.7.2**.
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2.3.2 for participating site registration

Registration will be a two-part process as patients are screened on this protocol. A protocol registration form will be supplied by the CCR study coordinator and updates will be provided as needed. To initially register a subject, after the participant has signed consent, complete the top portion of the form and send to CCR study coordinator. Once eligibility is confirmed, after completion of screening studies, complete the remainder of the form which is the eligibility checklist, indicating that the patient is being registered for treatment and send to CCR study coordinator. In addition, source documents supporting the eligibility criteria must be sent to the CCR study coordinator. The CCR study coordinator will notify you either by e-mail or fax that the protocol registration form has been received which will include the unique patient/subject ID number. Questions about eligibility should be directed to the CCR study coordinator or PI. Questions related to registration should be directed to the CCR study coordinator. Subjects that do not meet screening criteria should be removed from the study following the procedure in section **3.7.4**.
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2.3.3 treatment assignment and randomization

| Number   | Name              | Description                                                                                                       |
|----------|-------------------|-------------------------------------------------------------------------------------------------------------------|
| 1        | Lead in, Cohort 1 | Patients with Previously Untreated Metastatic or Unresectable  Colorectal Cancer enrolled for safety assessment   |
| 2        | Cohort 2          | Patients with Previously Untreated Metastatic or Unresectable  Colorectal Cancer enrolled for efficacy assessment |  
Arms  
| Number           | Name                | Description                                                                                                                                                            |
|------------------|---------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| A                | FOLFOX-A alone      | Subjects will receive FOLFOX + bevacizumab for up to 12 2-week  cycles followed by maintenance therapy with bevacizumab +  capecitabine/5-FUuntil disease progression. |
| B                | Lead in, FOLFOX-A + | Subjects will receive FOLFOX + bevacizumab + avelumab + AdCEA vaccine (given weeks 0, 2, 4, 8, 12, 16, and then every 12                                                                                                                                                                        |
| Avelumab +Ad-CEA | weeks) for up to 12 2-week cycles followed by maintenance  therapy with bevacizumab + capecitabine/5-FU+ avelumab + AdCEA vaccine (following every 12 weeks dosing schedule per  schema in 3.1.1.2) until disease progression.                     |                                                                                                                                                                        |
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randomization and arm assignment

Randomization will be performed at study entry by the NCI Central Registration Office. The first 6 evaluable subjects (Cohort 1) will be assigned to the Arm B regimen. Thereafter, if the study proceeds, subjects in Cohort 2 will be randomized on a 1:1 basis to Arm A and Arm B.
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3 study implementation 3.1 study

This is an open-label, randomized, multicenter phase 2.5 clinical trial designed to evaluate the potential improvement in progression free survival (PFS) when avelumab is used in combination with standard of care therapy and Ad-CEA vaccine in metastatic or unresectable colorectal cancer when compared with standard of care alone. Patients in the standard of care alone arm will be offered the opportunity to cross-over and receive avelumab + Ad-CEA vaccine in combination with any combination of the Arm A standard of care deemed appropriate by the investigator after disease progression (as defined by RECIST 1.1. in section 6.4). Cross-over will not be offered in the case of rapid or symptomatic progression due to the need for implementation of a standard option with known efficacy. Other clinical and immunologic endpoints will be captured with the goal of establishing correlative data that can later be prospectively tested in a larger phase 3 study. Initially, we will enroll 6 patients assigned to receive the combination of chemotherapy, Ad-CEA vaccine and avelumab to evaluate safety and feasibility of this treatment schedule. These patients will be enrolled at NCI only. Patients will be enrolled in a staggered fashion with 5 days minimum between each patient enrolled. If there are no dose limiting toxicities, as defined in section 3.2, we will proceed to the phase 2.5 portion of the trial. If > 1/6 patients experience a DLT attributable to the IND agents, we will not proceed with the phase 2.5 portion of the trial.
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3.1.1 study schema

3.1.1.1 Randomization  
  
Note: 5-FU bolus is not given in the FOLFOX-A + Avelumab +Ad-CEA vaccine Arm B Note: 5-FU may be substituted for capecitabine in the maintenance phase Version Date:10.30.2019  
  
Dosing
Note : 5-FU may be substituted for capecitabine in the maintenance phase
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dose limiting toxicity (lead-in period

The DLT evaluation period will be defined as the period from the first dose of avelumab until 28 days have passed. DLT will be assessed in the first 6 patients enrolled. Patients will be enrolled at least 5 days from each other to allow  adequate assessment of acute toxicity  for each patient prior to enrolment of the next patient. If > 1/6 patients experience a DLT, with the combination, the study will be stopped and will not proceed to the randomized phase 2 portion of the study. Subjects who do not complete the DLT observation period for reasons other than a DLT will be replaced.  
The goal of the safety evaluation for the combination is to determine if there are any increased or unexpected toxicities  due to the combination  of therapies that would not be expected with either regimen alone (FOLFOX-A or avelumab). As such, a DLT for the combination  will be defined as any adverse event that is unexpected relative to the known safety profile of the standard and investigational agents in the opinion of the investigator. The phase 2.5 portion of the study will not proceed until the DLT evaluation period for 6 patients has been completed.
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3.3 study stopping rule (lead-in

Any adverse event meeting criteria for DLT and any death within 30 days of receiving investigational agents, regardless of attribution, will result in the study halting enrollment until an 43 Version Date:10*.30.2019* expedited safety report has been sent to the FDA and the SAE has been evaluated by the investigators.
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3.4 drug administration 3.4.1 all

During the course of the study subjects in study Arm A will receive intravenous (IV) bevacizumab plus FOLFOX (first line therapy) on Days 1 and 2 of a 2 weeks cycle as tolerated per investigator discretion for up to a total of 12 cycles in keeping with standard of care treatment guidelines. Subjects in study Arm B will receive bevacizumab plus FOLFOX (first line therapy) on Days 2 and 3. After completion of first-line induction therapy, both study arm subjects will continue treatment with capecitabine/5-FU plus bevacizumab on a 2-week cycle in the maintenance period. Body surface area (BSA) and dosing will be calculated based on the weight recorded within 2 days prior to avelumab dosing.  
3.4.1.1 Administration of Bevacizumab plus FOLFOX (Induction Therapy) 45,46 Arm A:  
- Bevacizumab 5 mg/kg IV over 30 - 90 min on day 1 (infusion rate will be dependent on rate escalation tolerance, section **3.4.1.3**),
- Oxaliplatin 85mg/m2 IV over 2 hours on day 1 (infusion rate may be adjusted based on tolerance as described in section **3.4.1.4**),
- Leucovorin* 400mg/m2 IV over 2 hours on day 1,
- 5-FU* 400 mg/m2 IV bolus on day 1, - 5-FU* 2400 mg/m2 IV over 46 hours (+/- 2 hours) to start on day 1.
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arm b

- Bevacizumab 5 mg/kg IV over 30 - 90 min on day 2 (infusion rate will be dependent on rate escalation tolerance, section **3.4.1.3**),
- Oxaliplatin 85mg/m2 IV over 2 hours on day 2 (infusion rate may be adjusted based on tolerance as described in section **3.4.1.4**),
- Leucovorin* 400mg/m2 IV over 2 hours on day 2, - 5-FU* 2400 mg/m2 IV over 46 hours (+/- 2 hours) to start on day 2.
* 5-Fluorouracil and leucovorin should be administered separately to avoid the formation of a precipitate. Per package insert, leucovorin is administered first.  
* **Note:** Same dose of chemotherapy may be used from previous cycle if patients weight has not changed by more than 10%.  
See section **1.2.7.4** for rationale for the removal of 5-FU bolus infusion in Arm B.  
44 Version Date:10.30.2019 3.4.1.2 Administration of Capecitabine plus Bevacizumab (Maintenance Therapy)43  
- Capecitabine 625 mg/m2 twice a day every day by mouth. Patients should be instructed to take capecitabine with water within 30 minutes after a meal. Doses should be rounded to the nearest dose achievable without splitting pills.  
- Bevacizumab 5 mg/kg IV over 30 - 90 min on day 1, repeat every 14 days (infusion rate will be dependent on rate escalation tolerance, section **3.4.1.3**).  
- 5-FU (+/- leucovorin) may be substituted for capecitabine in the maintenance phase. 5FU
(+/- leucovorin) dosing during the maintenance phase will be the same as the induction phase (see section **3.4.1.1**).  
- **Note:** Same dose of chemotherapy may be used from previous cycle if patient's weight has not changed by more than 10%.
3.4.1.3 Bevacizumab rate escalation The first dose of bevacizumab will be given over 90 minutes. If the dose is well tolerated with no infusion reactions, the rate will be increased for the second dose, which will be given over 60 minutes. If the second dose is well tolerated, the third dose and all subsequent doses will be given over 30 minutes. If there is an initial infusion reaction at 90 or 60 minute infusion times, but subsequent doses are well-tolerated, the rate may be escalated at the investigator's discretion. Bevacizumab will be permanently discontinued in subjects who experience a grade 3 or 4 infusion reaction suspected to be related to bevacizumab.
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3.4.1.4 oxaliplatin rate

Subjects who experience a grade 1 or 2 hypersensitivity reaction suspected to be related to oxaliplatin, may continue treatment with oxaliplatin at the investigator's discretion. Subsequent infusions must be administered at a slower rate (i.e. over 4 to 6 hours) in addition to premedication (e.g. dexamethasone, ranitidine, and diphenhydramine) 30-60 minutes prior to oxaliplatin. Subjects who experience a grade 3 or 4 hypersensitivity reaction suspected to be related to oxaliplatin, may continue treatment with oxaliplatin if in the investigator's discretion benefits of continuing therapy outweigh risks. In this situation, the allergy team must be consulted and be in agreement with the plan of care. Skin test and desensitization protocols may be used. However, patients who experience anaphylactic shock or severe immune thrombocytopenia should discontinue oxaliplatin.
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3.4.2 lead-in arm a crossovers

Subjects in the lead in portion of the study and subjects in Arm B will additionally receive the study drugs, avelumab and Ad-CEA vaccine, during the induction treatment period as well as during the maintenance phase of therapy. Avelumab and Ad-CEA vaccine will be given on day 1 and FOLFOX + bevacizumab will be given on day 2. Subjects in arm A that progress will be offered the opportunity to receive Ad-CEA vaccine and avelumab in combination with a standard chemotherapy regimen as described in section **3.4.2.4**.  
45 Version Date:10.30.2019 3.4.2.1 Avelumab administration As a routine precaution, subjects enrolled in this trial must be observed for 30 minutes post infusion, in an area with resuscitation equipment and emergency agents. At all times during avelumab treatment, immediate emergency treatment of an infusion-related reaction or a severe hypersensitivity reaction according to institutional standards must be assured. In order to treat possible anaphylactic reactions, dexamethasone 10 mg and epinephrine in a 1:1000 dilution or equivalents should always be available along with equipment for assisted ventilation. Subjects will receive intravenous infusion of avelumab over 1 hour (-10 minutes / +20 minutes, i.e., 50 to 80 minutes) according to the schedule in sections 3.4.2.3 or **3.4.2.4** as applicable at a dose of 10 mg/kg. Modifications of the infusion rate due to infusion-related reactions are described in section **3.5.1**.  
Premedication with an antihistamine and with acetaminophen approximately 30 to 60 minutes prior to the first 4 infusions of avelumab is mandatory (for example, 25-50 mg diphenhydramine and 500-650 mg acetaminophen I.V or oral equivalent). Premedication should be administered for subsequent avelumab infusions based upon clinical judgment and presence/severity of prior infusion reactions. This regimen may be modified based on local treatment standards and guidelines, as appropriate. The dose of avelumab will be calculated based on the weight of the subject obtained within 2 days prior to avelumab administration. Subjects will receive avelumab at the appropriate schedule until confirmed progression, unacceptable toxicity, or any criterion for withdrawal from the therapy. Avelumab should be given prior to IV chemotherapy during each cycle, when possible.  
Note: Same dose of avelumab may be used from previous cycle if patients weight has not changed by more than 10%. 3.4.2.2 Ad-CEA vaccine administration Ad-CEA vaccine will be administered as subcutaneous injection in the thigh on Day 1 of specific cycles, prior to avelumab. Ad-CEA will be administered on cycles 1, 2, and 3; 5, 7, and 9; and every 6 cycles thereafter. Ad-CEA will be provided in a frozen state in a 2 ml vial with a fill volume of 1 ml of extractable vaccine which contains 5x1011 total virus particles. The product should be stored at –20°C until used and immediately thawed before use.
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to administer 5x1011 virus particles

Withdraw 1.0 mL of contents from the previously thawed, supplied Ad-CEA from the vial and administer subcutaneously to the patient without any further manipulation.  
3.4.2.3 Lead-in and Arm B Induction and Maintenance During the induction and maintenance phases (FOLFOX plus bevacizumab, and capecitabine plus bevacizumab, respectively), avelumab should be given on day 1 of each cycle. In addition, D1 of each cycle of treatment may be moved +/- 2 days for logistical reasons.  
46 Version Date:10.30.2019 3.4.2.4 Crossovers from Arm A
Subjects that have progressed during the induction phase on Arm A will be given the option to cross over to avelumab + Ad-CEA vaccine in combination FOLFOX in order to exploit the synergistic effects of the combination therapy. Subjects on Arm A who have progressed during the maintenance phase will be given the option to cross over to avelumab + Ad-CEA vaccine in combination with either capecitabine/5-FU + bevacizumab or capecitabine/5- FU+bevacizumab+oxaliplatin based on investigator choice. Subjects that cross over will be treated on a 2 week cycle. Avelumab should be given on day 1 of each cycle and prior to the other agents to avoid giving steroids prior to avelumab. In addition, D1 of each cycle of treatment may be moved +/- 2 days for logistical reasons. Cross-over will not be offered in the case of rapid or symptomatic progression due to the need for implementation of a standard option with known efficacy. Definitions:  
1. Rapid or symptomatic progression is defined by clinical context including what is commonly termed a "visceral crisis." In these cases, there are increased symptoms of disease progression, laboratory abnormalities due to disease progression, or a combination of both.  
2. Radiographic disease progression that is not felt to put a patient in imminent danger by the investigator would meet criteria for standard progression with eligibility for crossover.
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3.5 dose delays/modifications 3.5.1 avelumab

Note: standard of care therapy will be continued during any AE related delay or discontinuation of avelumab.  
3.5.1.1 Treatment Modification for Symptoms of avelumab infusion related reactions.  
Note: These are just guidelines for consideration and may be deviated from on a case by case basis at the investigator's discretion. When deviating from the below guidelines the investigator should document the reason in the medical record.  
| NCI-CTCAE Grade                                                                            | Treatment Modification for Avelumab                                                |
|--------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------|
| Grade 1 - mild                                                                             | Decrease the avelumab infusion rate by 50% and  monitor closely for any worsening. |
| Mild transient reaction; infusion interruption not  indicated; intervention not indicated. |                                                                                    |  
47  
Version Date:10*.30.2019*  
| Version Date:10.30.2019 NCI-CTCAE Grade                                                                                                                                                                                       | Treatment Modification for Avelumab                                                                                                                                         |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Grade 2 - moderate                                                                                                                                                                                                            | Temporarily discontinue avelumab infusion.                                                                                                                                  |
| Therapy or infusion interruption indicated but  responds promptly to symptomatic treatment (e.g.,  antihistamines, NSAIDs, narcotics, i.v. fluids);  prophylactic medications indicated for ≤ 24 hours.                       | Resume infusion at 50% of previous rate once  infusion related reaction has resolved or decreased  to at least Grade 1 in severity, and monitor closely  for any worsening. |
| Grade 3 or Grade 4 - severe or life-threatening                                                                                                                                                                               | Stop the avelumab infusion immediately and  disconnect infusion tubing from the subject.                                                                                    |
| Grade 3: Prolonged (e.g., not rapidly responsive  to symptomatic medication and/or brief  interruption of infusion); recurrence of symptoms  following initial improvement; hospitalization  indicated for clinical sequelae. | Subjects have to be withdrawn immediately from  avelumab treatment and must not receive any  further avelumab treatment.                                                    |
| Grade 4: Life-threatening consequences; urgent  intervention indicated.                                                                                                                                                       |                                                                                                                                                                             |  
If avelumab infusion rate has been decreased by 50% or interrupted due to an infusion reaction, it must remain decreased for the next scheduled infusion. If no infusion reaction is observed in the next scheduled infusion, the infusion rate may be returned to baseline at the subsequent infusions based on investigator's medical judgment. If hypersensitivity reaction occurs, the subject must be treated according to the best available medical practice.  
3.5.1.2 Management of Immune-mediated Adverse Reactions Note: These are just guidelines for consideration and may be deviated from on a case by case basis at the investigator's discretion. When deviating from the below guidelines the investigator should document the reason in the medical record.  
| Gastrointestinal irAEs                                                |                                                                    |                                                                                                                               |
|-----------------------------------------------------------------------|--------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------|
| Severity of Diarrhea/Colitis (NCI-CTCAE v5)                           | Initial Management                                                 | Follow-up Management                                                                                                          |
| Grade 1 Diarrhea: < 4 stools/day over  Baseline Colitis: asymptomatic | Continue avelumab therapy Symptomatic treatment (e.g.  loperamide) | Close monitoring for worsening symptoms Educate subject to report worsening immediately If worsens: Treat as Grade 2, 3 or 4. |  
48  
Version Date:10*.30.2019*  
| Version Date:10.30.2019 Grade 2  Diarrhea: 4 to 6 stools per day over  Baseline; IV fluids indicated < 24  hours; not interfering with ADL Colitis: abdominal pain; blood in  stool                                                                                                                                                                                 | Withhold avelumab therapy                                                                                                                                                                                                                                                                                                                                | If improves to Grade ≤ 1:                                                                                                                                                                                                                                                                                                                                        |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Symptomatic treatment                                                                                                                                                                                                                                                                                                                                               | Resume avelumab therapy If persists > 5-7 days or recurs: Treat as Grade 3 or 4.                                                                                                                                                                                                                                                                         |                                                                                                                                                                                                                                                                                                                                                                  |
| Grade 3 to 4 Diarrhea (Grade 3): ≥ 7 stools per  day over Baseline; incontinence; IV  fluids ≥ 24 h; interfering with ADL Colitis (Grade 3): severe abdominal  pain, medical intervention indicated,  peritoneal signs Grade 4: life-threatening,  perforation Withhold avelumab for  Grade 3. Permanently discontinue  avelumab for Grade 4 or  recurrent Grade 3. | If improves:  Continue steroids until Grade ≤ 1, then taper over at least  1 month; resume avelumab therapy following steroids  taper (for initial Grade 3).  If worsens, persists > 3 to 5 days, or recurs after  improvement: Add infliximab 5mg/kg (if no contraindication). Note:  infliximab should not be used in cases of perforation or  sepsis. |                                                                                                                                                                                                                                                                                                                                                                  |
| 1.0 to 2.0 mg/kg/day  prednisone IV or equivalent Add prophylactic antibiotics  for opportunistic infections  Consider lower endoscopy Dermatological irAEs                                                                                                                                                                                                         |                                                                                                                                                                                                                                                                                                                                                          |                                                                                                                                                                                                                                                                                                                                                                  |
| Grade of Rash                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                          |                                                                                                                                                                                                                                                                                                                                                                  |
| (NCI-CTCAE v5)                                                                                                                                                                                                                                                                                                                                                      | Initial Management                                                                                                                                                                                                                                                                                                                                       | Follow-up Management                                                                                                                                                                                                                                                                                                                                             |
| Grade 1 to 2                                                                                                                                                                                                                                                                                                                                                        | Continue avelumab therapy  Symptomatic therapy (for                                                                                                                                                                                                                                                                                                      |                                                                                                                                                                                                                                                                                                                                                                  |
| Covering ≤ 30% body surface area                                                                                                                                                                                                                                                                                                                                    | example, antihistamines,  topical steroids)                                                                                                                                                                                                                                                                                                              | If persists > 1 to 2 weeks or recurs:  Withhold avelumab therapy  Consider skin biopsy  Consider 0.5-1.0 mg/kg/day prednisone or equivalent.  Once improving, taper steroids over at least 1 month,  consider prophylactic antibiotics for opportunistic  infections, and resume avelumab therapy following  steroids taper. If worsens:  Treat as Grade 3 to 4. |
| Grade 3 to 4 Grade 3: Covering > 30% body  surface area;  Grade 4: Life threatening  consequences                                                                                                                                                                                                                                                                   | Withhold avelumab for  Grade 3. Permanently discontinue for  Grade 4 or recurrent Grade 3.  Consider skin biopsy  Dermatology consult  1.0 to 2.0 mg/kg/day  prednisone or equivalent Add prophylactic antibiotics  for opportunistic infections                                                                                                         | If improves to Grade ≤ 1:  Taper steroids over at least 1 month; resume avelumab  therapy following steroids taper (for initial Grade 3).                                                                                                                                                                                                                        |  
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| Pulmonary irAEs                                                                              |                                                                                                                                                                                                                                                    |                                                                                                                                                                                                                                                       |
|----------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Grade of Pneumonitis (NCI-CTCAE v5)                                                          | Initial Management                                                                                                                                                                                                                                 | Follow-up Management                                                                                                                                                                                                                                  |
| Grade 1                                                                                      | Consider withholding                                                                                                                                                                                                                               |                                                                                                                                                                                                                                                       |
| Radiographic changes only                                                                    | avelumab therapy  Monitor for symptoms every  2 to 3 days  Consider Pulmonary and  Infectious Disease consults                                                                                                                                     | Re-assess at least every 3 weeks If worsens:  Treat as Grade 2 or Grade 3 to 4.                                                                                                                                                                       |
| Grade 2                                                                                      | Withhold avelumab therapy                                                                                                                                                                                                                          |                                                                                                                                                                                                                                                       |
| Mild to moderate new symptoms                                                                | Pulmonary and Infectious  Disease consults Monitor symptoms daily;  consider hospitalization  1.0 to 2.0 mg/kg/day  prednisone or equivalent Add prophylactic antibiotics  for opportunistic infections  Consider bronchoscopy, lung  biopsy       | Re-assess every 1 to 3 days  If improves:  When symptoms return to Grade ≤ 1, taper steroids over  at least 1 month, and then resume avelumab therapy  following steroids taper  If not improving after 2 weeks or worsening:  Treat as Grade 3 to 4. |
| Grade 3 to 4 Grade 3: Severe new symptoms;  New/worsening hypoxia; Grade 4: Life-threatening | Permanently discontinue  avelumab therapy. Hospitalize. Pulmonary and Infectious  Disease consults. 1.0 to 2.0 mg/kg/day prednisone or equivalent  Add prophylactic antibiotics  for opportunistic infections  Consider bronchoscopy, lung  biopsy | If improves to Grade ≤ 1:  Taper steroids over at least 1 month  If not improving after 48 hours or worsening:  Add additional immunosuppression (for example,  infliximab, cyclophosphamide, IV immunoglobulin, or  mycophenolate mofetil)           |
| Hepatic irAEs                                                                                |                                                                                                                                                                                                                                                    |                                                                                                                                                                                                                                                       |
| Grade of Liver Test Elevation (NCI-CTCAE v5)                                                 | Initial Management                                                                                                                                                                                                                                 | Follow-up Management                                                                                                                                                                                                                                  |
| Grade 1 Grade 1 AST or ALT > ULN to 3.0  x ULN and/or Total bilirubin >  ULN to 1.5 x ULN    | Continue avelumab therapy                                                                                                                                                                                                                          | Continue liver function monitoring  If worsens:  Treat as Grade 2 or 3 to 4.                                                                                                                                                                          |
| Grade 2 AST or ALT > 3.0 to ≤ 5 x ULN  and/or total bilirubin > 1.5 to ≤ 3 x  ULN            | Withhold avelumab therapy Increase frequency of  monitoring to every 3 days.                                                                                                                                                                       | If returns to Grade ≤ 1: Resume routine monitoring; resume avelumab therapy. If elevation persists > 5 to 7 days or worsens:  Treat as Grade 3 to 4.                                                                                                  |  
50  
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| Version Date:10.30.2019 Grade 3 to 4 AST or ALT > 5 x ULN and/or total  bilirubin > 3 x ULN  Permanently discontinue  avelumab therapy  Increase frequency of  monitoring to every 1 to  2 days  1.0 to 2.0 mg/kg/day  prednisone or equivalent Add prophylactic antibiotics  for opportunistic infections  Consult gastroenterologist/  hepatologist Consider obtaining MRI/CT  scan of liver and liver biopsy  if clinically warranted   | If returns to Grade ≤ 1:  Taper steroids over at least 1 month  If does not improve in > 3 to 5 days, worsens or  rebounds:  Add mycophenolate mofetil 1 gram (g) twice daily  If no response within an additional 3 to 5 days, consider  other immunosuppressants per local guidelines.   |                                                                                                                                                     |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------|
| Renal irAEs                                                                                                                                                                                                                                                                                                                                                                                                                                |                                                                                                                                                                                                                                                                                            |                                                                                                                                                     |
| Grade of Creatinine Increased  (NCI-CTCAE v5)                                                                                                                                                                                                                                                                                                                                                                                              | Initial Management                                                                                                                                                                                                                                                                         | Follow-up Management                                                                                                                                |
| Continue renal function monitoring                                                                                                                                                                                                                                                                                                                                                                                                         |                                                                                                                                                                                                                                                                                            |                                                                                                                                                     |
| Grade 1 Creatinine increased > ULN to 1.5 x                                                                                                                                                                                                                                                                                                                                                                                                | Continue avelumab therapy                                                                                                                                                                                                                                                                  | If worsens:                                                                                                                                         |
| ULN                                                                                                                                                                                                                                                                                                                                                                                                                                        | Treat as Grade 2 to 3 or 4.                                                                                                                                                                                                                                                                |                                                                                                                                                     |
| Grade 2 to 3 Creatinine increased > 1.5 and ≤ 6 x  ULN                                                                                                                                                                                                                                                                                                                                                                                     | Withhold avelumab therapy Increase frequency ofmonitoring to  every 3 days 1.0 to 2.0 mg/kg/day prednisone or  equivalent. Add prophylactic antibiotics for  opportunistic infections Consider renal biopsy                                                                                | If returns to Grade ≤1: Taper steroids over at least 1 month, and resume  avelumab therapy following steroids taper. If worsens:  Treat as Grade 4. |
| Grade 4 Creatinine increased > 6 x ULN                                                                                                                                                                                                                                                                                                                                                                                                     | Permanently discontinue avelumab  therapy Monitor creatinine daily 1.0 to 2.0 mg/kg/day prednisone or  equivalent. Add prophylactic antibiotics for  opportunistic infections Consider renal biopsy Nephrology consult                                                                     | If returns to Grade ≤1: Taper steroids over at least 1 month.                                                                                       |  
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| Cardiac irAEs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |                                                                                                                                                                                                                               |                                                                                                                                                                      |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Myocarditis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           | Initial Management                                                                                                                                                                                                            | Follow-up Management                                                                                                                                                 |
| New onset of cardiac signs or  symptoms and / or new laboratory  cardiac biomarker elevations (e.g.  troponin, CK-MB, BNP) or cardiac  imaging abnormalities suggestive  of myocarditis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | Withhold avelumab therapy.                                                                                                                                                                                                    | If symptoms improve and immune-mediated  etiology is ruled out, re-start avelumab therapy.                                                                           |
| Hospitalize. In the presence of life threatening cardiac  decompensation, consider transfer to a  facility experienced in advanced heart  failure and arrhythmia management. Cardiology consult to establish etiology  and rule-out immune-mediated  myocarditis.  Guideline based supportive treatment as  per cardiology consult.* If symptoms do not improve/worsen, viral  myocarditis is excluded, and immune-mediated  etiology is suspected or confirmed following  cardiology consult, manage as immunemediated myocarditis. Consider myocardial biopsy if  recommended per cardiology consult.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                               |                                                                                                                                                                      |
| Immune-mediated myocarditis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           | Permanently discontinue avelumab. Guideline based supportive treatment as  appropriate as per cardiology consult.* 1.0 to 2.0 mg/kg/day prednisone or  equivalent Add prophylactic antibiotics for  opportunistic infections. | Once improving, taper steroids over at least 1  month. If no improvement or worsening, consider  additional immunosuppressants (e.g.  azathioprine, cyclosporine A). |
| *Local guidelines, or e.g.ESC or AHA guidelines  ESC guidelines website:https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines AHA guidelines website: http://professional.heart.org/professional/GuidelinesStatements/searchresults.jsp?q=&y=&t=1001 Endocrine irAEs Endocrine Disorder Initial Management Follow-up Management Grade 1 or Grade 2  endocrinopathies  (hypothyroidism,  hyperthyroidism, adrenal  insufficiency, type I diabetes  mellitus) Continue avelumab therapy Endocrinology consult if needed Continue hormone replacement/suppression  and monitoring of endocrine function as  appropriate.Start thyroid hormone replacement  therapy (for hypothyroidism),  anti-thyroid treatment (for  hyperthyroidism), corticosteroids (for  adrenal insufficiency) or insulin (for  Type I diabetes mellitus) as  appropriate.  Rule-out secondary endocrinopathies  (i.e. hypopituitarism / hypophysitis) |                                                                                                                                                                                                                               |                                                                                                                                                                      |  
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| Version Date:10.30.2019 Grade 3 or Grade 4  endocrinopathies  (hypothyroidism,  hyperthyroidism, adrenal  insufficiency, type I diabetes  mellitus)                                                                                                                                                                                                                                                                                                                                      | Withhold avelumab therapy Consider hospitalization Endocrinology consult                                                                                                                                                                                                                                                                                                                                                                            | Resume avelumab once symptoms and/or  laboratory tests improve to Grade ≤ 1 (with or  without hormone replacement/suppression). Continue hormone replacement/suppression  and monitoring of endocrine function as  appropriate.                                                                                               |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Start thyroid hormone replacement  therapy (for hypothyroidism),  anti-thyroid treatment (for  hyperthyroidism), corticosteroids (for  adrenal insufficiency) or insulin (for  type I diabetes mellitus) as  appropriate.  Rule-out secondary endocrinopathies  (i.e. hypopituitarism / hypophysitis)                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                     |                                                                                                                                                                                                                                                                                                                               |
| Hypopituitarism/Hypophysitis                                                                                                                                                                                                                                                                                                                                                                                                                                                             | If secondary thyroid and/or adrenal                                                                                                                                                                                                                                                                                                                                                                                                                 |                                                                                                                                                                                                                                                                                                                               |
| (secondary endocrinopathies)                                                                                                                                                                                                                                                                                                                                                                                                                                                             | insufficiency is confirmed (i.e.  subnormal serum FT4 with  inappropriately low TSH and/or low  serum cortisol with inappropriately  low ACTH): - Refer to endocrinologist for  dynamic testing as indicated and  measurement of other hormones  (FSH, LH, GH/IGF-1, PRL, testosterone in men, estrogens in  women)  - Hormone  replacement/suppressive therapy  as appropriate  - Perform pituitary MRI and visual  field examination as indicated | Resume avelumab once symptoms and  hormone tests improve to Grade ≤ 1 (with or  without hormone replacement). In addition, for hypophysitis with abnormal  MRI, resume avelumab only once shrinkage of  the pituitary gland on MRI/CT scan is  documented.  Continue hormone replacement/suppression  therapy as appropriate. |
| If hypophysitis confirmed: - Continue avelumab if mild  symptoms with normal MRI.  Repeat the MRI in 1 month - Withhold avelumab if moderate,  severe or life-threatening  symptoms of hypophysitis and/or  abnormal MRI. Consider  hospitalization. Initiate  corticosteroids (1 to 2 mg/kg/day  prednisone or equivalent)  followed by corticosteroids taper  during at least 1 month. - Add prophylactic antibiotics for  opportunistic infections. Other irAEs (not described above) |                                                                                                                                                                                                                                                                                                                                                                                                                                                     |                                                                                                                                                                                                                                                                                                                               |  
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| Version Date:10.30.2019 Grade of other irAEs                                                                                                                        | Initial Management                                                                                                                                                                                               | Follow-up Management                                                                                                   |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------|
| (NCI-CTCAE v5)                                                                                                                                                      |                                                                                                                                                                                                                  |                                                                                                                        |
| Grade 2 or Grade 3 clinical signs  or symptoms suggestive of a  potential irAE                                                                                      | Withhold avelumab therapy pending                                                                                                                                                                                | If irAE is ruled out, manage as appropriate                                                                            |
| clinical investigation                                                                                                                                              | according to the diagnosis and consider restarting avelumab therapy If irAE is confirmed, treat as Grade 2 or 3 irAE.                                                                                                                                                                                                                  |                                                                                                                        |
| Grade 2 irAEor first occurrence                                                                                                                                     | Withhold avelumab therapy                                                                                                                                                                                        |                                                                                                                        |
| of Grade 3 irAE                                                                                                                                                     | 1.0 to 2.0 mg/kg/day prednisone or  equivalent  Add prophylactic antibiotics for  opportunistic infections  Specialty consult as appropriate                                                                     | If improves to Grade ≤ 1:  Taper steroids over at least 1 month and resume  avelumab therapy following steroids taper. |
| Recurrence of same Grade 3                                                                                                                                          | Permanently discontinue avelumab                                                                                                                                                                                 |                                                                                                                        |
| irAEs                                                                                                                                                               | therapy 1.0 to 2.0 mg/kg/day prednisone or equivalent Add prophylactic antibiotics for  opportunistic infections  Specialty consult as appropriate                                                               | If improves to Grade ≤ 1:  Taper steroids over at least 1 month.                                                       |
| Grade 4                                                                                                                                                             | Permanently discontinue avelumab  therapy 1.0 to 2.0 mg/kg/day prednisone or equivalent and/or other  immunosuppressant as needed Add prophylactic antibiotics for  opportunistic infections  Specialty consult. | If improves to Grade ≤ 1:  Taper steroids over at least 1 month                                                        |
| Requirement for 10 mg per day  or greater prednisone or  equivalent for more than 12  weeks for reasons other than  hormonal replacement for  adrenal insufficiency | Permanently discontinue avelumab  therapy Specialty consult                                                                                                                                                      |                                                                                                                        |
| Persistent Grade 2 or 3 irAE  lasting 12 weeks or longer Abbreviations: ACTH=adrenocorticotropic hormone; ADL=activities of daily living; BNP=Btype natriuretic peptide; CK-MB=creatine kinase MB; FSH=follicle-stimulating hormone;                                                                                                                                                                     |                                                                                                                                                                                                                  |                                                                                                                        |  
Abbreviations: ACTH=adrenocorticotropic hormone; ADL=activities of daily living; BNP=Btype natriuretic peptide; CK-MB=creatine kinase MB; FSH=follicle-stimulating hormone;  
GH=growth hormone; IGF-1=insulin-like growth factor 1; LH=luteinizing hormone; PRL=prolactin.  
54 Version Date:10*.30.2019* 3.5.2 **Active Immunotherapy with Ad-CEA vaccine will be discontinued for:**  
3.5.2.1 Life-threatening anaphylactic reactions related to the Ad-CEA vaccine.  
3.5.2.2 DLT related to active immunotherapy with Ad-CEA as follows: If one or more patients develop a Grade 4 allergic reaction without a clear attributable cause, other than study vaccine.
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3.5.3 bevacizumab

Note: These are just guidelines for consideration and may be deviated from on a case by case basis at the investigator's discretion. When deviating from the below guidelines the investigator should document the reason in the medical record.  
3.5.3.1 Hypertension 3.5.3.1.1 Bevacizumab should not be administered unless SBP< 150 and DBP < 90. Management of hypertension is outlined below.  
3.5.3.1.2 Mild/Moderate Hypertension
For SBP > 140 and < 210 mm Hg or DBP > 90 and < 120 mm Hg that is sustained over at least a two week period, initiate or adjust anti-hypertensive therapy. Bevacizumab should be delayed until the blood SBP< 150 and DBP < 90.
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3.5.3.1.3 severe hypertension

For SBP ≥ 210 mm Hg or DBP ≥ 120 mm Hg but without end organ damage, begin antihypertensive therapy. Bevacizumab should be delayed until blood SBP< 150 and DBP < 90.  
3.5.3.1.4 Hypertensive Urgency or Emergency Bevacizumab therapy should be permanently discontinued in the presence of hypertensive urgency (DBP >120 with evidence of optic disc edema or progressive end-organ complications) or hypertensive emergency (SBP > 210 and DBP > 120 presenting with headaches, blurred vision, or focal neurological symptoms, or papilledema). .  
3.5.3.2 Thrombotic Events 3.5.3.2.1 Deep Vein Thrombosis Bevacizumab should not be administered in the presence of deep vein thrombosis or pulmonary embolism. Anticoagulation may be used and bevacizumab may be restarted when thrombosis is resolved. 3.5.3.2.2 Arterial Thromboembolic Events Bevacizumab should be permanently discontinued in the presence of new arterial thrombotic disease, including but not limited to, myocardial infarct due to coronary thrombosis and ischemic stroke.
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3.5.3.3 neutropenia

Bevacizumab should be held if the absolute neutrophil count (ANC) is less than 750 cells/µL until ANC is again above 750 cells/µL.  
55 Version Date:10.30.2019
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3.5.3.4 hemorrhage

3.5.3.4.1 Life Threatening In the case of hemoptysis, hematemesis, hematochezia, intracranial hemorrhage or any significant blood loss, bevacizumab should not be administered.
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3.5.3.5 proteinuria

If urine dipstick indicates ≥2+ proteinuria, bevacizumab administration should be delayed pending the results of a 24-hour urine collection for protein. If the 24-hour urine protein is ≥2 grams, bevacizumab will be delayed for up to 6 weeks, until the proteinuria is <2+ or the 24-hour urine protein is < 1 grams/24 hr.
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3.5.3.6 liver function abnormalities

Bevacizumab should be withheld in the event of ≥ Grade 3 LFT elevations attributed to bevacizumab and should not resume until the abnormalities have recovered to ≤ Grade 1.
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3.5.3.7 allergic reaction

In case of flushing, shortness of breath, facial edema, headache, chills, back pain, tightness of the chest and throat, and/or hypotension, fever or rash, the infusion should be suspended until the patient is assessed until the events have subsided. For grade 3 or 4 allergic reactions, bevacizumab should be permanently discontinued.  
3.5.3.8 Surgical or periodontal procedures If there is need for an elective major surgical or periodontal procedure, bevacizumab should be held beginning at least 6 weeks prior to the procedure and must not be resumed before 4 weeks after the surgical procedure. For urgent or emergent surgery or endoscopic procedures, bevacizumab should be held for 4 weeks after the procedure. Longer delays may be necessary, if clinically indicated, in order to ensure that adequate healing has taken place prior to bevacizumab resumption. For minor procedures (i.e. interventional radiology diagnostic procedures), bevacizumab will be held only if there is evidence that healing is compromised.  
3.5.3.9 Reversible Posterior Leukoencephalopathy Syndrome (RPLS)
Bevacizumab should not be administered to patients with signs or symptoms of RPLS. Evaluation should include neurologic evaluation, ocular examination, head MRI, and blood pressure assessment. If these clinical criteria are consistent with the diagnosis of RPLS, bevacizumab will be permanently discontinued.  
3.5.3.10 Gastrointestinal Perforations and Fistula Formation Bevacizumab should be discontinued in the event of a gastrointestinal perforation or the formation of a fistula.
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3.5.3.11 miscellaneous

Bevacizumab may be held at any point when in the opinion of the investigator the risks of giving bevacizumab outweigh the potential benefit.  
56 Version Date:10*.30.2019*
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3.5.4 capecitabine

Dose adjustments for toxicities per CTCAE as per table.  
Note: These are just guidelines for consideration and may be deviated from on a case by case basis at the investigator's discretion. When deviating from the below guidelines the investigator should document the reason in the medical record.  
| Summary of management of common Capecitabine toxicities  Toxicity Capecitabine dose modification   |                                                                                                                                                                                                                                                                                                                 |
|----------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Grade 2 hand foot syndrome                                                                         | Interrupt until ≤ grade 1. May then restart  capecitabine at full dose. For second occurrence,  hold capecitabine until ≤ grade 1, then restart  capecitabine one dose level lower (75% of starting  dose first occurrence, 50% of the starting dose the  second occurrence, discontinue the third occurrence). |
| Grade 3 hand foot syndrome                                                                         | Interrupt until ≤ grade 1. Then restart capecitabine  one dose level lower (75% of starting dose first  occurrence, 50% of the starting dose the second  occurrence, discontinue the third occurrence).                                                                                                         |
| Grade 2 Nausea/Vomiting                                                                            | Continue at current dose, modify anti-emetic  regimen                                                                                                                                                                                                                                                           |
| Grade 3 Nausea/Vomiting                                                                            | Hold until recovery to grade 1 (or grade 2 if present  at baseline) then resume one dose level lower*                                                                                                                                                                                                           |
| Grade 2 Diarrhea                                                                                   | Continue current dose, add optimal anti-diarrheal  therapy                                                                                                                                                                                                                                                      |
| Grade 3 (or greater) Diarrhea                                                                      | Hold until recovery to grade 1 (or grade 2 if present  at baseline) then resume one dose level lower*                                                                                                                                                                                                           |
| Grade 3 (or greater) fatigue                                                                       | Hold until recovery to grade 1 (or grade 2 if present  at baseline) then resume one dose level lower*                                                                                                                                                                                                           |
| Grade 3 (or greater) mucositis                                                                     | Hold until recovery to grade 1 (or grade 2 if present  at baseline) then resume one dose level lower*                                                                                                                                                                                                           |
| Grade 2 thrombocytopenia                                                                           | Continue at current dose                                                                                                                                                                                                                                                                                        |
| Grade 3 thrombocytopenia                                                                           | Hold until recovery until < grade 1 then resume one  dose level lower*                                                                                                                                                                                                                                          |  
57 Version Date:10*.30.2019*  
| Summary of management of common Capecitabine toxicities  Toxicity Capecitabine dose modification                                                                                                                                                                                           |                                                                                                |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------|
| Grade 4 thrombocytopenia                                                                                                                                                                                                                                                                   | Hold until recovery until < grade 1 then resume one  dose level lower*                         |
| Grade 3 neutropenia                                                                                                                                                                                                                                                                        | Hold until recovery until < grade 1 then resume one  dose level lower*                         |
| Grade 4 neutropenia                                                                                                                                                                                                                                                                        | Hold until recovery until < grade 1 then resume one  dose level lower*                         |
| > Grade 3 febrile neutropenia                                                                                                                                                                                                                                                              | Hold until resolution of fever and neutropenia to <  grade 1. Then resume on dose level lower* |
| *Dose reductions for capecitabine 1. Starting dose: 625 mg/m2 BID continuously 2. DL -1: 470 mg/m2 BID continuously 3. DL -2: 310 mg/m2 BID continuously 4. Discontinuation of capecitabine. Capecitabine may be held in the maintenance setting (i.e., chemo holiday) when in the opinion |                                                                                                |  
Capecitabine may be held in the maintenance setting (i.e., chemo holiday) when in the opinion of the investigator the risks of giving capecitabine outweigh the potential benefit. The same is true for 5-FU when given as an alternative in the maintenance setting.  
58 Version Date:10*.30.2019*
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3.5.5 folfox dose adjustment

Note: These are just guidelines for consideration and may be deviated from on a case by case basis at the investigator's discretion. When deviating from the below guidelines the investigator should document the reason in the medical record.
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for arm a

| For Arm A Adverse Event                                             | First Occurrence                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               | Second Occurrence                                                                                                                                                                                                                                                                                                                                                                                    | Third Occurrence                                                                                                                                                                                       | Fourth Occurrence   |
|---------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------|
| ANC <1000/mL OR Platelets <75000/mL  OR Any Febrile Neutropenia     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |                                                                                                                                                                                                                                                                                                                                                                                                      |                                                                                                                                                                                                        |                     |
| Hematologic Toxicity                                                | 1. Hold all therapy and check CBC weekly until recovery to: ANC ≥1000/mLand Platelets ≥75000/mL AND 2. Discontinue 5-FU bolus on Day 1 at the next  cy cle and consider adding growth factor  support for neutropenia  1. Hold all therapy and check CBC weekly until recovery to: ANC ≥1000/mLand Platelets ≥75000/mL AND 2. Decrease Oxaliplatin to 65mg/m2 on Day 1 at the next cycle 1. Hold all therapy and check CBC weekly until recovery to: ANC ≥1000/mLand Platelets ≥75000/mL AND 2. Decrease 5-FU continuous infusion to 1800mg/m2 and decrease Oxaliplatin to 50mg/m2  on Day 1 at the next cycle | 1. Hold all therapy and check CBC weekly until recovery to: ANC ≥1000/mLand Platelets ≥75000/mL AND 2. Decrease 5-FU continuous infusion to 1200mg/m2 and discontinue Oxaliplatin on Day 1 at the next cycle                                                                                                                                                                                         |                                                                                                                                                                                                        |                     |
| ANC ≥1000/ml but <1500/mL                                           | OR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |                                                                                                                                                                                                                                                                                                                                                                                                      |                                                                                                                                                                                                        |                     |
| Platelets ≥75000/ml but  <100000/mL                                 | 1. Discontinue 5-FU bolus on Day 1 at the next cy cle and consider adding growth factor  support for neutropenia  1. Decrease Oxaliplatin to 65mg/m2 on Day 1 at 1. Decrease Oxaliplatin to 50mg/m2 on Day 1 at                                                                                                                                                                                                                                                                                                                                                                                                | 1. Decrease 5-FU continuous infusion to                                                                                                                                                                                                                                                                                                                                                              |                                                                                                                                                                                                        |                     |
| the next cycle                                                      | the next cycle                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | 1800mg/m2 on Day 1 at the next cycle                                                                                                                                                                                                                                                                                                                                                                 |                                                                                                                                                                                                        |                     |
| Any other CTC ≥ Grade 3 hematologic toxicity , (e.g.  HgB <8.0g/dL) | 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Discontinue 5-FU bolus on Day 1 at the next  cycle 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Decrease Oxaliplatin to 65mg/m2 on Day 1 at the next cycle 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Decrease Oxaliplatin to 50mg/m2 on Day 1 at the next cycle                                                                                                                                       | 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Decrease 5-FU continuous infusion to 1800mg/m2 on Day 1 at the next cycle                                                                                                                                                                                                                            |                                                                                                                                                                                                        |                     |
| Nausea/Vomiting CTC ≥                                               | 1. Hold all therapy until recovery to Grade 1 (or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              |                                                                                                                                                                                                                                                                                                                                                                                                      |                                                                                                                                                                                                        |                     |
| Grade 3                                                             | Grade 2 level, if present at baseline) AND 2. Add a aprepitant if not already receiving .                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |                                                                                                                                                                                                                                                                                                                                                                                                      |                                                                                                                                                                                                        |                     |
| Non-Hema tolo gic Toxicity                                          | If already receiving, consider addin g  olanzapine and/or administerin g  dexamethasone 4mg PO 24 and 48 hrs after  oxaliplatin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                | 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Discontinue 5-FU bolus and reduce  oxaliplatin to 65mg/m2 on Day 1 at the next  cycle 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Decrease 5-FU continuous infusion to 1800mg/m2 and decrease Oxaliplatin to 50mg/m2  on Day 1 at the next cycle | 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Decrease 5-FU continuous infusion to 1200mg/m2 and discontinue Oxaliplatin on Day 1  at the next cycle |                     |
| Diarrhea CTC ≥ Grade 3, despite optimal antidiarrheal therapy       | 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Discontinue 5-FU bolus at the next cycle 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Decrease 5-FU continuous infusion to 1800mg/m2 on Day 1 at the next cycle 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Decrease 5-FU continuous infusion to 1200mg/m2 at the next cycle                                                                                                                            | 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Decrease Oxaliplatin to 65mg/m2 on Day 1 at the next cycle                                                                                                                                                                                                                                           |                                                                                                                                                                                                        |                     |
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59 version date10.30.2019

| Fatigue CTC ≥ Grade 3 OR Mucositis CTC ≥ Grade 3  OR Other Toxicity Not  Defined Herein CTC ≥ Grade 3 despite optimal supportive care 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Discontinue 5-FU bolus on Day 1 at the next  cycle 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Decrease Oxaliplatin to 65mg/m2 on Day 1 at the next cycle 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Decrease 5-FU continuous infusion to 1800mg/m2 on Day 1 at the next cycle   | 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Decrease 5-FU continuous infusion to 1200mg/m2 and decrease Oxaliplatin to 50mg/m2  on Day 1 at the next cycle   |                                                                                                                                                                                                                              |     |
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| Peripheral Neuropathy CTC 1. Hold all therapy until recovery to Grade ≤ 2 ≥ Grade 2  AND 2. Decrease Oxaliplatin to 65mg/m2 on Day 1 at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |                                                                                                                                                                                                                  |                                                                                                                                                                                                                              |     |
| FOLFOX-Specific Toxicities                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      | the next cycle                                                                                                                                                                                                   | 1. Hold all therapy until recovery to Grade ≤ 2 AND 2. Decrease Oxaliplatin to 50mg/m2 on Day 1 at the next cycle 1. Hold all therapy until recovery to Grade ≤ 2 AND 2. Discontinue Oxaliplatin on Day 1 at the next  cycle | N/A |
| Hand-Foot sy ndrome CTC 1. Hold all therapy until recovery to Grade 1 (or  ≥ Grade 3  Grade 2 level, if present at baseline) AND 2. Decrease 5-FU continuous infusion to 1800mg/m2 on Day 1 at the next cycle 1. Hold all therapy until recovery to Grade 1 (or Grade 2 level, if present at baseline) AND 2. Discontinue 5-FU bolus on Day 1 at the next  cycle 1. Hold all therapy until recovery to Grade 1 (or  Grade 2 level, if present at baseline) AND 2. Decrease 5-FU continuous infusion to 1200mg/m2 at the next cycle                                                                                              | 1. Hold all therapy until recovery to Grade 1 (or  Grade 2 level, if present at baseline) AND 2. Decrease Oxaliplatin to 65mg/m2 on Day 1 at the next cycle                                                      |                                                                                                                                                                                                                              |     |