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for participants with measurable disease

| Version Date: 05.10.2022 Target  Non-Target   | New                                                                                                                                                                                                                                                                                                                               | Overall   | Best Overall Response when                        |                           |
|-----------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------|---------------------------------------------------|---------------------------|
| Lesions                                       | Lesions                                                                                                                                                                                                                                                                                                                           | Lesions   | Response                                          | Confirmation is Required* |
| CR                                            | CR                                                                                                                                                                                                                                                                                                                                | No        | CR                                                | >4 wks. Confirmation**    |
| CR                                            | Non                                                                                                                                                                                                                                                                                                                                   |           |                                                   |                           |
| CR/Non-PD                                     | No                                                                                                                                                                                                                                                                                                                                | PR        |                                                   |                           |
| CR                                            | Not                                                                                                                                                                                                                                                                                                                               | No        | PR                                                |                           |
| evaluated                                     | >4 wks. Confirmation**                                                                                                                                                                                                                                                                                                            |           |                                                   |                           |
| PR                                            | Non                                                                                                                                                                                                                                                                                                                                   |           |                                                   |                           |
| CR/NonPD/not  evaluated                                               | No                                                                                                                                                                                                                                                                                                                                | PR        |                                                   |                           |
| SD                                            | Non                                                                                                                                                                                                                                                                                                                                   |           |                                                   |                           |
| CR/NonPD/not  evaluated                                               | No                                                                                                                                                                                                                                                                                                                                | SD        | Documented at least once >4  wks. from baseline** |                           |
| PD                                            | Any                                                                                                                                                                                                                                                                                                                               | Yes or    | PD                                                |                           |
| No                                            |                                                                                                                                                                                                                                                                                                                                   |           |                                                   |                           |
| Any                                           | PD***                                                                                                                                                                                                                                                                                                                             | Yes or    | PD                                                |                           |
| No                                            | no prior SD, PR or CR                                                                                                                                                                                                                                                                                                             |           |                                                   |                           |
| Any                                           | Any                                                                                                                                                                                                                                                                                                                               | Yes       | PD                                                |                           |
| *                                             | See RECIST 1.1 manuscript for further details on what is evidence of a  new lesion.                                                                                                                                                                                                                                               |           |                                                   |                           |
| **                                            | Only for non-randomized trials with response as primary endpoint.                                                                                                                                                                                                                                                                 |           |                                                   |                           |
| ***                                           | In exceptional circumstances, unequivocal progression in non-target  lesions may be accepted as disease progression.                                                                                                                                                                                                              |           |                                                   |                           |
| Note:                                         | Participants with a global deterioration of health status requiring  discontinuation of treatment without objective evidence of disease  progression at that time should be reported as "symptomatic  deterioration." Every effort should be made to document the objective  progression even after discontinuation of treatment. |           |                                                   |                           |  
| Non-Target Lesions                                                                                                                                                                                                                             | New Lesions   | Overall Response   |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------|--------------------|
| CR                                                                                                                                                                                                                                             | No            | CR                 |
| Non-CR/non-PD                                                                                                                                                                                                                                  | No            | Non-CR/non-PD*     |
| Not all evaluated                                                                                                                                                                                                                              | No            | not evaluated      |
| Unequivocal PD                                                                                                                                                                                                                                 | Yes or No     | PD                 |
| Any                                                                                                                                                                                                                                            | Yes           | PD                 |
| * 'Non-CR/non-PD' is preferred over 'stable disease' for non-target disease since  SD is increasingly used as an endpoint for assessment of efficacy in some trials  so to assign this category when no lesions can be measured is not advised |               |                    |
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6.3.5.4 duration of response

Duration of overall response: The duration of overall response is measured from the time measurement criteria are met for CR or PR (whichever is first recorded) until the first date that recurrent or progressive disease is objectively documented (taking as reference for progressive disease the smallest measurements recorded since the treatment started). The duration of overall CR is measured from the time measurement criteria are first met for CR until the first date that progressive disease is objectively documented. Duration of stable disease: Stable disease is measured from the start of the treatment until the criteria for progression are met, taking as reference the smallest measurements recorded since the treatment started, including the baseline measurements. 6.3.5.5 Progression-Free Survival PFS is defined as the duration of time from start of treatment to time of progression or death, whichever occurs first.
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6.4 toxicity criteria

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

Please refer to definitions provided in Policy 801: Reporting Research Events found at: https://irbo.nih.gov/confluence/display/IRBO/Policies+and+SOPs. Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy 802 Non-Compliance Human Subjects Research found at: https://irbo.nih.gov/confluence/display/IRBO/Policies+and+SOPs. Note: Only IND Safety Reports that meet the definition of an unanticipated problem will need to be reported per these policies. 7.2.2 IRB Requirements for PI Reporting at Continuing Review Please refer to the reporting requirements in Policy 801: Reporting Research Events found at: https://irbo.nih.gov/confluence/display/IRBO/Policies+and+SOPs. Problems expeditiously reported to the OHSRP in iRIS will also be reported to the NCI Clinical Director. A separate submission is not necessary as reports in iRIS will be available to the Clinical Director. In addition to those reports, all deaths that occur within 30 days after receiving a research intervention should be reported via email to the Clinical Director unless they are due to progressive disease. To report these deaths, please send an email describing the circumstances of the death to the Clinical Director/designee at NCICCRQA@mail.nih.gov within one business day of learning of the death. The Principal Investigator (or delegate) will notify IBC of any unexpected fatal or life-threatening experience associated with the use of CV301 vaccine as soon as possible but in no event later than 7 calendar days of initial receipt of the information. Serious adverse events that are unexpected and associated with the use of CV301 vaccine but are not fatal or life-threatening, much be reported to the NIH IBC as soon as possible, but not later than 15 calendar days after the investigator's initial receipt of the information. Adverse events may be reported by using the FDA Form 3500a. Within 60 days after the one-year anniversary of the date on which the IBC approved the initial protocol, and after each subsequent anniversary until the trial is completed, the Principal Investigator (or delegate) shall submit the information described below. Alternatively, the IRB continuing review report can be sent to the IBC in lieu of a separate report. Please include the IBC protocol number on the report. 7.4.2.1 Clinical Trial Information A brief summary of the status of the trial in progress or completed during the previous year. The summary is required to include the following information:
the title and purpose of the trial;  
clinical site;
the Principal Investigator;  
clinical protocol identifiers; participant population (such as disease indication and general age group, e.g., adult or pediatric);
the total number of participants planned for inclusion in the trial; the number entered into the trial to date whose participation in the trial was completed; and the number who dropped out of the trial with a brief description of the reasons; the status of the trial, e.g., open to accrual of subjects, closed but data collection ongoing, or fully completed; and if the trial has been completed, a brief description of any study results.
7.4.2.2 Progress Report and Data Analysis Information obtained during the previous year's clinical and non-clinical investigations, including:  
a narrative or tabular summary showing the most frequent and most serious adverse experiences by body system; a summary of all serious adverse events submitted during the past year; a summary of serious adverse events that were expected or considered to have causes not associated with the use of the gene transfer product such as disease progression or concurrent medications; if any deaths have occurred, the number of participants who died during participation in the investigation and causes of death; and a brief description of any information obtained that is pertinent to an understanding of the gene transfer product's actions, including, for example, information about dose-response, information from controlled trials, and information about bioavailability.
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7.5 nih required data and

The clinical research team will meet on a regular basis (approximately weekly) when participants are being actively treated on the trial to discuss each participant. Decisions about dose level enrollment and dose escalation will be made based on the toxicity data from prior participants. All data will be collected in a timely manner and reviewed by the principal investigator or a lead associate investigator. Events meeting requirements for expedited reporting as described in Section 7.2.1 will be submitted within the appropriate timelines. The principal investigator will review adverse event and response data on each participant to ensure safety and data accuracy. The principal investigator will personally conduct or supervise the investigation and provide appropriate delegation of responsibilities to other members of the research staff.
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7.5.2 data safety monitoring board

The DSMB is an independent group of at least 3 experts that monitors participant safety and advises the Sponsor. DSMB members will be separate and independent of study staff participating in this trial and should not have scientific, financial, or other conflicts of interest related to this trial. The DSMB will consist of members with appropriate expertise to contribute to the interpretation of data from this trial. A quorum will consist of a simple majority. The DSMB will review cumulative safety data from this trial at least annually. The DSMB will meet when trial halting criteria (see Section **3.4.3)** are met, or as requested by the sponsor or PI. The DSMB will have a final review meeting at the end of the study. Procedures for DSMB reviews/meetings will be defined in the DSMB charter. The DSMB will review applicable data, including, but not limited to, enrollment, demographics, dosing data, clinical laboratory data, and safety data, at scheduled timepoints during this trial as defined in the DSMB charter. The DSMB will review blinded aggregate data in the open session of the DSMB meetings. Additional data may be requested by the DSMB, and interim statistical reports may be generated as deemed necessary and appropriate by the Sponsor. As an outcome of each review/meeting, the DSMB will make a recommendation as to the advisability of proceeding with study product administration, and to continue, modify, or terminate this trial.
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8 sponsor/protocol safety reporting 8.1

Any untoward medical occurrence in a participant or clinical investigation subject administered a pharmaceutical product and which does not necessarily have a causal relationship with this treatment. An adverse event (AE) can therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal (investigational) product, whether or not related to the medicinal (investigational) product (ICH E6 (R2)). 8.1.2 Adverse Event of Special Interest (AESI) Mucosal bleeding events which are at least possibly related to study drug (M7824) will be captured as AESIs. These events will not require expedited reporting to the study sponsor unless they also meet SAE criteria.
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8.1.3 serious adverse event (sae)

An adverse event or suspected adverse reaction is considered serious if in the view of the investigator or the sponsor, it results in any of the following:
Death; A life-threatening adverse event (see Section **8.1.4**); Inpatient hospitalization or prolongation of existing hospitalization  
o A hospitalization/admission that is pre-planned (i.e., elective or scheduled surgery arranged prior to the start of the study), a planned hospitalization for pre-existing condition, or a procedure required by the protocol, without a serious deterioration in health, is not considered a serious adverse event.  
o A hospitalization/admission that is solely driven by non-medical reasons (e.g.,
hospitalization for participant convenience) is not considered a serious adverse event.  
o Emergency room visits or stays in observation units that do not result in admission to the hospital would not be considered a serious adverse event. The reason for seeking medical care should be evaluated for meeting one of the other serious criteria.  
Persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions; A congenital anomaly/birth defect; Important medical events that may not result in death, be life-threatening, or require hospitalization may be considered a serious adverse drug experience when, based upon appropriate medical judgment, they may jeopardize the participant or subject and may require medical or surgical intervention to prevent one of the outcomes listed in this definition.
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8.1.4 life-threatening

An adverse event or suspected adverse reaction is considered "life-threatening" if, in the view of either the investigator or sponsor, its occurrence places the participant or subject at immediate risk of death. It does not include an adverse event or suspected adverse reaction that, had it occurred in a more severe form, might have caused death (21CFR312.32).
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8.1.5 severity

The severity of each Adverse Event will be assessed utilizing the CTCAE version 5.0. 8.1.6 Relationship to Study Product All AEs will have their relationship to study product assessed using the terms: related or not related.  
Related - There is a reasonable possibility that the study product caused the adverse event.  
Reasonable possibility means that there is evidence to suggest a causal relationship between the study product and the adverse event.  
Not Related - There is not a reasonable possibility that the administration of the study product caused the event.
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8.2 assessment of safety events

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

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

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

All required pregnancy reports/follow-up to OSRO will be submitted to: OSROSafety@mail.nih.gov and to the CCR PI and study coordinator. Forms and instructions can be found here: https://ccrod.cancer.gov/confluence/display/CCRCRO/Forms+and+Instructions 8.6.1 Maternal Exposure If a participant becomes pregnant during the course of the study, the study treatment should be discontinued immediately and the pregnancy reported to the Sponsor no later than 24 hours of when the Investigator becomes aware of it. The Investigator should notify the Sponsor no later than 24 hours of when the outcome of the Pregnancy becomes known. Pregnancy itself is not regarded as an SAE. However, congenital abnormalities or birth defects and spontaneous miscarriages that meet serious criteria (Section **8.1.3**) should be reported as SAEs. The outcome of all pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, normal birth, or congenital abnormality) should be followed up and documented. 8.6.2 Paternal Exposure Male participant should refrain from fathering a child or donating sperm during the study and for 2 months after the last dose of M7824. Pregnancy of the participant's partner is not considered to be an AE. However, the outcome of all pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, normal birth, or congenital abnormality) occurring from the date of the first dose until 2 months after the last dose should, if possible, be followed up and documented.
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8.7 regulatory reporting for studies

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

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

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

The primary objectives of this trial are to determine the objective response rate of combination immunotherapy in two separate arms evaluating triple or quadruple therapy in participants with checkpoint naïve MSS small bowel or colorectal cancer. A secondary hypothesis (objective) will be to obtain preliminary data on duration of response, PFS, OS and ratio of participants that are hospitalized because of adverse events attributed to disease progression for each of these arms. An exploratory hypothesis (objective) will be to evaluate exploratory immunologic studies to understand and improve the administered treatment.
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10.2 sample size determination

Initially, Arm 1 will be conducted using the phase II design described below. Upon its completion, a dose level escalation of NHS-IL12 will be conducted, called Arm 2A. This arm will enroll up to 18 participants in the three dose levels and the participants at the highest safe dose level (or MTD) will be included in the first stage of the phase II evaluation of the quadruple therapy (Arm 2B) as described below. In participants with microsatellite stable small bowel or colon cancer, the clinical response rate to current single agent therapies is very low (<5%). It would be desirable if by using a combination of multiple agents, the response rate would be improved. To establish the efficacy of each of the proposed combinations (triple or quadruple therapy), the primary objective would be to determine if the proposed combination would rule out a 10% response rate and result in a response rate consistent with 40%. As such, participants on each arm (Arm 1 or 2B) will be treated in a trial conducted using a Simon optimal two-stage phase II trial design (Simon R, Controlled Clinical Trials 10:1-10, 1989) to rule out an unacceptably low PR+CR rate of 10% (p0=0.10) in favor of an improved response rate of 40% (p1=0.40). With alpha=0.05 (probability of accepting a poor treatment=0.05) and beta = 0.10 (probability of rejecting a good treatment=0.10), the first stage for each arm will enroll 9 evaluable participants, and if 0 to 1 of the 9 have a clinical response, then no further participants will be accrued in that cohort. For evaluation of the quadruple therapy, the first 6 participants may include those at the MTD from Arm 2A, assuming they are fully evaluable for response. For simplicity, once these participants are included in the Phase II evaluation, they will be considered as if they were in Arm 2B in the descriptions below. If 2 or more of the first 9 participants have a response, then accrual would continue until a total of 20 evaluable participants have been treated on that arm. As it may take up to several months to determine if a participant has experienced a response, a temporary pause in the accrual may be necessary to ensure that enrollment to the second stage is warranted. If there are 2 to 4 participants with a response out of 20 participants in a given arm, this would be an uninterestingly low response rate. If there were 5 or more of 20 (25.0%) who experienced a response, this would be sufficiently interesting to warrant further study in later trials in this disease type. Under the null hypothesis (10% response rate), the probability of early termination is 77.5%. It is anticipated that 2-3 participants per month may enroll onto this trial. Thus, it is expected that the trial can enroll up to 46 evaluable participants (up to 12 for safety evaluation during dose escalation in Arm 2A, 40 for primary efficacy analyses in Arm 1 and Arm 2B together, minus 6 included from the dose escalation Arm 2A) in approximately two years. To allow for a small number of screen failures and participants who will be inevaluable for the primary objective analysis (e.g., checkpoint refractory), the accrual ceiling will be set at 80 participants.
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10.3 populations for analyses

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

The fraction of participants with response to the triple or quadruple therapy will be reported. For those enrolled during the first 6 participants on Arm 1 or during the dose escalation for NHS-IL12 (Arm 2A), the participants will be evaluated with respect to the grades and types of toxicities obtained. The results will be presented descriptively and tabled if appropriate. 10.4.2 Analysis of the Primary Endpoints The percentage of subjects that achieve an objective confirmed complete or partial overall tumor response using RECIST Version 1.1 will be evaluated per arm (Arm 1 and 2B). If anti-tumor responses are observed, the 95% confidence interval of the response rate will be evaluated. It is possible that the response rates observed with combination immunotherapy will be less in participants whom have previously received checkpoint therapy and not be truly reflective of a population of participants whom have not had prior checkpoint therapy. While checkpoint experienced participants will not be excluded from enrollment, the primary efficacy analyses will be limited to checkpoint naïve participants with MSS colon cancer and efficacy analyses in the checkpoint refractory. 10.4.3 Analysis of the Secondary Endpoints Data will be obtained on duration of response, PFS, OS and ratio of participants that are hospitalized because of adverse events attributed to disease progression.
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10.4.3.1 duration of response

The duration of overall response will be evaluated by arm for those with a PR or greater in Arm 1 and Arm 2B. The duration of overall response is measured from the time measurement criteria are met for CR or PR (whichever is first recorded) until the first date that PD is objectively documented and is evaluated using the Kaplan-Meier method.
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10.4.3.2 progression-free survival

PFS will be evaluated by arm using Kaplan-Meier methods. PFS will be defined as the time from the date of first treatment to the date of disease progression or death (any cause) whichever occurs first. Subjects who do not have disease progression or have not died at the end of follow up will be censored at the last known date the subject was progression free.  
10.4.3.3 Objective Response Objective response is a complete or partial radiographic response as defined by RECIST 1.1 (Section **6.3.5**).
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10.4.3.4 overall survival

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

Safety endpoints will be analyzed as summary statistics during treatment and/or as change scores from baseline assessments. AEs will be coded as defined in the Medical Dictionary for Regulatory Activities (MedDRA). All AEs will be recorded and tabulated following each treatment. AEs will be recorded by severity, frequency, and relationship to the study intervention and will be presented by System Organ Class (SOC) designations and preferred term groupings. Information on each AE will include start date, stop date, severity, relationship, expectedness, outcome, and duration. Adverse events leading to premature discontinuation from the study intervention and serious treatment-emergent AEs will be presented either in a Table or a Listing. In addition, overall safety will be assessed by descriptive analyses using tabulated frequencies of AEs by grade using CTCAE Version 5 within dose cohorts and for the overall study population in terms of treatment-emergent AEs, SAEs, and clinically significant changes in safety laboratory tests, physical examinations, ECGs, and vital signs. 10.4.5 Baseline Descriptive Statistics Baseline Characteristics will be described. 10.4.6 Planned Interim Analyses Interim assessment of efficacy will be made according to the Simon two stage Phase II designs of each arm described. 10.4.7 Tabulation of Individual Participant Data Individual responses in a cohort may be depicted within a larger group using a waterfall plot or spider diagram. 10.4.8 Exploratory Analyses The following are the planned exploratory objectives and endpoints: To conduct exploratory immunologic studies to understand and improve the administered treatment, including:
peripheral immune subset analysis before and on treatment; soluble factors circulation (e.g., sCD27 and sCD40 ligand) before and on treatment; tumor tissue PD-L1 expression and immune infiltration before and after treatment.  
Where feasible, exploratory immune analyses will be conducted to evaluate anti-tumor immune responses. Immune response will be assessed among all subjects treated in each phase II cohort. The magnitude of immune responses will be described. A subject will be considered evaluable for immune response if they receive at least one dose of treatment. The percentage of subjects with a positive immune response will be evaluated separately by arm. For flow cytometry analyses on PBMC samples, Student t-tests or Wilcoxon rank sum tests as appropriate will be performed on percentages of TNF- and/or IFN- expressing cells among the different cohorts to determine any significant differences in cell populations between arms For antigen specific T cell responses, a positive immune response is defined by CMI reactivity in ex vivo stimulation using a flow cytometric readout (cytokine production or CD107 expression). Antigen-specific peptide challenge assays require a readout of >250 reactive T-cells/million cells above the background [46]. In general, evaluations of soluble factors and tumor tissue immune infiltration will be compared before vs. after treatment using appropriate paired tests. Any statistical analyses performed on these exploratory endpoints will be done without formal adjustment for multiple comparisons but in the context of the number of tests performed [46]. To assess responses to therapy using iRECIST per treatment assignment (three or four drug combination). To assess response to therapy using RECIST and iRECIST in checkpoint refractory participants (including participants with MSI disease). To assess responses to therapy by RAS mutation status.
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11 collaborative agreements 11.1 cooperative

A CRADA (02666) is in place with EMD Serono for the supply of M7824 and NHS-IL12. A CRADA (02561) is in place with Bavarian Nordic for the supply of CV301 (MVA-BN-CV301 and FPV-CV-301). A CRADA (03058) is in place with ImmunityBio, Inc. for the supply of N-803.
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12 human subjects protections 12.1

Subjects from all racial/ethnic groups are eligible for this study if they meet the eligibility criteria. Efforts will be made to extend accrual to a representative population. Due to impaired cellular immunity which may affect the efficacy of treatment, participants with poorly controlled HIV as well as patents with detectable viral loads of hepatitis B and C will be excluded. As there is a risk of severe bleeding with this study drug, participants must be willing to receive blood transfusions if medically necessary for their own safety. Participants must be able to receive blood transfusions in order to minimize the risks of receiving M7824.
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12.2 participation of children

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

Adults unable to provide consent are excluded from enrolling in the protocol. However, it is possible that subjects enrolled in the protocol may permanently lose the capacity to consent for themselves during the course of this study. In the event this occurs, the subjects will remain in the study because there is a prospect of direct benefit from research participation. All subjects ≥ age 18 will be offered the opportunity to fill in their wishes for research and care, and assign a substitute decision maker on the "NIH Advance Directive for Health Care and Medical Research Participation" form so that another person can make decisions about their medical care in the event that they become incapacitated or cognitively impaired during the course of the study. Note: The PI or AI will contact the NIH Ability to Consent Assessment Team (ACAT) for evaluation to assess ongoing capacity of the subjects and to identify an LAR, as needed. Please see Section **12.5.1** for consent procedure.
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12.4 risk/benefit assessment 12.4.1 known

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

Risks include the possible occurrence of any of a range of side effects which are listed in Sections **14.1.2, 14.2.2, 14.3.2** and **14.4.2**. Participants may be harmed from being in this study by toxicity due to the drug or combination of drugs given during this study. M7824 is similar to immune check point inhibitors. There are preliminary data to suggest that not all patients benefit from immune check point inhibitors nor M7824. Additionally, there are preliminary data to suggest that an unexpectedly rapid progression of disease occurs in some patients receiving immunotherapy such as immune checkpoint inhibitors.
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12.4.1.2 risk of optional biopsies

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

CT scans create low levels of radiation, which has a small potential to cause cancer and other defects. However, the risk associated with scan is small. 12.4.1.5 Risks Due to Contrast Agents for CT Contrast agents can cause allergic reactions and kidney damage. Allergic reactions can include mild itching associated with hives but can also result in a serious life-threatening emergency from difficulty breathing. If this occurs, it is treatable.
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12.4.1.6 risk of mri

People are at risk for injury from the MRI magnet if they have some kinds of metal in their body. People with fear of confined spaces may become anxious during an MRI. Those with back problems may have back pain or discomfort from lying in the scanner. The noise from the scanner is loud enough to damage hearing, especially in people who already have hearing loss. There are no known long-term risks of MRI scans. 12.4.1.7 Risk of Gadolinium Enhanced MRI The gadolinium infusion may cause mild symptoms such as coldness in the arm during the injection, a metallic taste, headache, and nausea. There are risks of an IV catheter include bleeding, infection, or inflammation of the skin and vein with pain and swelling. Procedure-related risks from MRI and gadolinium enhanced MRI will be explained fully during informed consent.  
12.4.1.8 Risks of Blood Collection Risks of blood draws include pain and bruising in the area where the needle is placed, lightheadedness, and rarely, fainting. When large amounts of blood are collected, low red blood cell count (anemia) can develop. The amount of blood that may be drawn from adult participants for research purposes shall not exceed 10.5 mL/kg or 550 mL, whichever is smaller, over any eight-week period. Specific volumes are also listed in table in Section 5.1.
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12.4.1.9 other risks

Risks include the possible occurrence of any of a range of side effects which are listed in the Consent Document or this protocol document. Frequent monitoring for adverse effects will help to minimize the risks associated with administration of the study agents. 12.4.2 Known Potential Benefits The potential benefit to a participant that goes onto study is a reduction in the bulk of their tumor which may or may not have favorable impact on symptoms and/or survival. 12.4.3 Assessment of Potential Risks and Benefits Advanced small bowel and colorectal cancers are in need of improved therapy options. Preclinical studies suggest that the use of a combination of multiple immunotherapy agents may have improved anti-tumor efficacy. A number of clinically appropriate strategies to minimize risks to participants have been built into the protocol through the means of inclusion/exclusion criteria, monitoring strategies, and management guidelines. Overall, the potential benefits of the combination of a vaccine targeting tumor associated antigens (CV301), a bifunctional fusion protein targeting PD-L1 and TGF beta (M7824), an IL-15 superagonist (N-803), and a tumor targeted immunocytokine (NHS-IL12) in subjects with advanced small bowel and colorectal malignancies for participants retaining the ability to consent and those who lose capacity to consent during the course of the trial outweigh the risks associated with this combination immunotherapy proposed in this study.
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12.5 consent process and documentation

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

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

This study may be temporarily suspended or prematurely terminated if there is sufficient reasonable cause. Written notification, documenting the reason for study suspension or termination, will be provided by the suspending or terminating party to study participants, investigator, the Investigational New Drug (IND) sponsor and regulatory authorities. If the study is prematurely terminated or suspended, the Principal Investigator (PI) will promptly inform study participants, the Institutional Review Board (IRB), and sponsor and will provide the reason(s) for the termination or suspension. Study participants will be contacted, as applicable, and be informed of changes to study visit schedule. Circumstances that may warrant termination or suspension include, but are not limited to:  
Determination of unexpected, significant, or unacceptable risk to participants Demonstration of efficacy that would warrant stopping Insufficient compliance to protocol requirements Data that are not sufficiently complete and/or evaluable Determination that the primary endpoint has been met Determination of futility Participant death at least possibly attributed to study treatment
A higher than expected rate (>15-20%) of grade 3 or greater bleeding events due to study treatment or the occurrence of a grade 5 bleeding event due to study treatment.  
Study may resume once concerns about safety, protocol compliance, and data quality are addressed, and satisfy the sponsor, IRB andas applicable, Food and Drug Administration (FDA).
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13.2 quality assurance and quality

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

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

Participant confidentiality and privacy is strictly held in trust by the participating investigators, their staff, and the sponsor(s). This confidentiality is extended to cover testing of biological samples and genetic tests in addition to the clinical information relating to participants. Therefore, the study protocol, documentation, data, and all other information generated will be held in strict confidence. No information concerning the study or the data will be released to any unauthorized third party without prior written approval of the sponsor. All research activities will be conducted in as private a setting as possible. The study monitor, other authorized representatives of the sponsor, representatives of the Institutional Review Board (IRB), and/or regulatory agencies may inspect all documents and records required to be maintained by the investigator, including but not limited to, medical records (office, clinic, or hospital) and pharmacy records for the participants in this study. The clinical study site will permit access to such records. The study participant's contact information will be securely stored at the/each clinical site for internal use during the study. At the end of the study, all records will continue to be kept in a secure location for as long a period as dictated by the reviewing IRB, Institutional policies, or sponsor requirements. Study participant research data, which is for purposes of statistical analysis and scientific reporting, will be transmitted to and stored at the NCI CCR. This will not include the participant's contact or identifying information. Rather, individual participants and their research data will be identified by a unique study identification number. The study data entry and study management systems used by the clinical site and by NCI CCR research staff will be secured and password protected. At the end of the study, all study databases will be archived at the NIH.  
To further protect the privacy of study participants, a Certificate of Confidentiality has been issued by the National Institutes of Health (NIH). This certificate protects identifiable research information from forced disclosure. It allows the investigator and others who have access to research records to refuse to disclose identifying information on research participation in any civil, criminal, administrative, legislative, or other proceeding, whether at the federal, state, or local level. By protecting researchers and institutions from being compelled to disclose information that would identify research participants, Certificates of Confidentiality help achieve the research objectives and promote participation in studies by helping assure confidentiality and privacy to participants.
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14 pharmaceutical information 14.1 cv301

CV301 (MVA-BN-CV301 and FPV-CV-301) will be supplied by the manufacturer, Bavarian Nordic. 14.1.2 Toxicity A phase I study was just completed at the NCI with no dose limiting toxicities (unpublished). As expected, CV-301 was well tolerated in all 12 participants with no DLT noted. The only attributable toxicities were grade 1 and 2, and primarily injections site reactions and flu-like symptoms, with other rare toxicities such as headache and nausea (also grade 2 or less) also reported. There were no grade 3 or greater toxicities reported in the study. Initial safety data show that the most frequently occurring treatment-related AEs were temporary and self-limiting, grade 1 or 2 in severity and included injection site reactions (injection site erythema, pruritus, pain, induration and swelling) and general symptoms including fever/chills, flu-like symptoms, headache, fatigue/weakness, nausea/vomiting, myalgia and arthralgia. There was no occurrence of any of the pre-specified adverse events of special interest (immune-related events and cardiac events). There were no related SAEs. There were no dose limiting toxicities. MVA-BN-CV301 (Prime Vaccine) The most common side effects associated with MVA-BN and other MVA-BN-derived vaccines include mild to moderate flu-like symptoms such as: fever, chills, muscle or joint ache, and tiredness (fatigue). In addition, some localized reactions at the site where the vaccine is injected under skin (subcutaneously). These injection site reactions may include any or all of the following:
swelling, localized pain, hardness of a small area of skin around the injection site induration), and redness.
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fpv-cv301 (boost vaccine)

The most common side effects from the use of fowlpox vaccines are mild and may include the following: fever, tiredness (fatigue), muscle or joint ache, headache, and flu-like symptoms. In addition, some localized reactions at the site where the vaccine is injected under skin (subcutaneously). These injection site reactions may include any or all of the following: swelling, localized pain, hardness of a small area of skin around the injection site induration), and redness.
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pooled adr data of all

The following two tables from the CV301 Investigator Brochure (IB) v5 summarize the pooled ADR data of all completed MVA-BN trials. The safety profile of each of the trials with recombinant MVA-BN based vaccines is comparable to the safety profile as displayed in the table, as the occurrence of the ADRs is considered to be a reaction to the vector rather than the insert based on previous experience with recombinant  
Suspected Adverse Drug Reactions Reported by ≥ 1% of Subjects in the Completed MVA-BN Clinical Trials* (N=7863**)  
| Clinical Trials* (N=7863**)                                                                                                                                    | No. of reports by   | Frequency   |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------|-------------|
| Preferred Term (PT)                                                                                                                                            | subjects            | %           |
| Injection site pain                                                                                                                                            | 6385                | 81.2        |
| Injection site erythema                                                                                                                                        | 5049                | 64.2        |
| Injection site swelling                                                                                                                                        | 3804                | 48.4        |
| Injection site induration                                                                                                                                      | 3315                | 42.2        |
| Injection site pruritus                                                                                                                                        | 2935                | 37.3        |
| Myalgia                                                                                                                                                        | 2524                | 32.1        |
| Fatigue                                                                                                                                                        | 2425                | 30.8        |
| Headache                                                                                                                                                       | 2274                | 28.9        |
| Nausea                                                                                                                                                         | 1102                | 14.0        |
| Rigors/chills                                                                                                                                                  | 684                 | 8.7         |
| Body temperature increased                                                                                                                                     | 269                 | 3.4         |
| Appetite disorder                                                                                                                                              | 218                 | 2.8         |
| Arthralgia                                                                                                                                                     | 206                 | 2.6         |
| Injection site nodule                                                                                                                                          | 195                 | 2.5         |
| Injection site discolouration                                                                                                                                  | 191                 | 2.4         |
| Pain in extremity                                                                                                                                              | 147                 | 1.9         |
| Injection site haematoma                                                                                                                                       | 107                 | 1.4         |
| Pyrexia                                                                                                                                                        | 99                  | 1.3         |
| Axillary pain                                                                                                                                                  | 91                  | 1.2         |
| Injection site warmth                                                                                                                                          | 85                  | 1.1         |
| * POX-MVA-001, -002, -004, -005, -006, -007, -008, -009, -010, -011, -013, -023, -024, -027, -028, -029, -030, - 036, -037, -03X, HIV-NEF-004 and HIV-POL-002. |                     |             |  
** 8 subjects exposed but not included in analysis. 7 subjects in POX-MVA-009 received Dryvax either on the same day or within 7 days after MVA-BN administration and were therefore not included to avoid a potential bias in the adverse event reporting. 1 subject in POX-MVA-029 was not vaccinated according to the randomization, therefore removed from analysis set. Source: MVA-BN IB Ed. 24.0
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adrs for fpv (originating from

Additional safety information on vaccinia and FPV can be found in the PROSTVAC Investigator's Brochures.
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14.1.3 formulation and preparation

MVA-BN-CV301 and FPV-CV301 encode the human MUC-1 and the human CEA gene in combination with human TRICOM. No marker gene is present in both recombinant viruses. MVA-BN-CV301 is a liquid-frozen, highly attenuated, live recombinant virus based on the viral vector MVA-BN. It is administered as s.c. injection. Packaging and vials will be labeled according to the respective product specifications.  
One MVA-BN-CV301 vaccine vial has a nominal titer of 4 x 108 infectious units (Inf.U) in 0.5 mL of the drug product. FPV-CV301 is a liquid-frozen, highly attenuated, live recombinant virus. It is administered as s.c. injection. The packages and vials will be labeled according to the respective product specifications.  
One FPV-CV301 vaccine vial has a nominal virus titer of 1 x 109 Inf.U in 0.5 mL of the drug product.  
MVA-BN-CV301 and FPV-CV301 are each supplied in 2 mL type I borosilicate glass vials closed with sterile bromobutyl rubber stoppers, crimped with aluminum caps and covered with polypropylene closures. 14.1.4 Stability and Storage Supplies of both the MVA-BN-CV301 and the FPV-CV301 vaccines will be shipped temperature controlled and monitored to the clinical trial site. Once at the site, the package should be handed over to personnel in charge of vaccine preparation (e.g., the pharmacist or representative). Site personnel are responsible for proper storage of vaccine upon receipt. Both the MVA-BN-CV301 and the FPV-CV301 vaccines must be shipped to site and stored at a temperature of -20℃ +/- 5℃) or -80℃ +/- 5℃, avoiding direct light. A vial must not be re-frozen once it has been thawed. A provisional shelf life of 2 years at -80°C ± 10°C has been given. Expiry date may be extended due to real time stability data. Storage at -20°C ± 5°C is limited to 12 months after moving from -80°C ± 10°C to -20°C ± 5°C. 14.1.5 Administration Procedures Each dose of MVA-BN-CV301 consists of 4 injections administered subcutaneously (one in each arm and one in each leg). Each dose of FPV-CV301 consists of 1 injection administered subcutaneously (preferably in the non-dominant arm). 14.1.6 Incompatibilities Not available.
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14.2 m7824 (msb0011359c) (ind #

14.2.1 Source / Acquisition and Accountability M7824 is manufactured and supplied for the trial by EMD Serono Research and Development Institute. M7824 will be provided to the clinical trial site by the manufacturer. The investigator or designee (e.g., pharmacist) will maintain an ongoing inventory of the investigational product supply according to standard site procedures. The investigational product will be dispensed at the direction of an investigator for administration to a study participant enrolled on the clinical trial. Disposal of expired or unused product will be returned to the manufacturer or disposed of according to standard site procedures based on agreement between the manufacturer and the site. 14.2.2 Toxicity The immunoglobulin portion of M7824 molecule is identical to avelumab (Bavencio). Respective warnings and precautions for grade 2 or higher immune-mediated pneumonitis, immune-mediated colitis, immune-mediated endocrinopathies, immune-mediated hepatitis) and infusion reactions are included in the prescribing for Bavencio (bavencio.com). Participants will be pre-medicated to prophylax against infusions reactions. The following additionally significant immune-mediated adverse reactions have occurred in less than 1% of 1738 participants treated with BAVENCIO:
myocarditis with fatal cases, myositis, psoriasis, arthritis, exfoliative dermatitis, erythema multiforme, pemphigoid, hypopituitarism, uveitis, Guillain-Barré syndrome, and systemic inflammatory response. The above irAEs are all considered an anticipated risk of treatment with M7824 and thus will not be considered DLTs. In a phase 1, open-label 3+3 dose-escalation study of M7824 in 16 participants, 3 participants experienced grade 3 drug-related adverse events including skin infection secondary to grade 2 bullous pemphigoid, lipase increased, and colitis with associated anemia. There were no grade 4 - 5 treatment related adverse events. Please see table below for details.  
| 3 mg/kg (n =  3)   | 10 mg/kg (n = 3)   | 20 mg/kg (n = 7)   | Total (n = 16)   |       |       |       |       |
|--------------------|--------------------|--------------------|------------------|-------|-------|-------|-------|
| Any                | Grade              | Any                | Grade            | Any   | Grade | Any   | Grade |
| Grade              | 3                  | Grade              | 3                | Grade | 3     | Grade | 3     |  
| Version Date: 05.10.2022                                                                | 3 mg/kg (n =  3)   | 10 mg/kg (n = 3)   | 20 mg/kg (n = 7)   | Total (n = 16)   |        |        |
|-----------------------------------------------------------------------------------------|--------------------|--------------------|--------------------|------------------|--------|--------|
| Participants with                                                                       | 2                  | 1                  | (33.3)             | 0 (0.0)          | 4      |        |
| 1                                                                                       | 2                  | 7                  | 3                  |                  |        |        |
| any event**                                                                             | (66.7)             | (33.3)             | (57.1)             | (28.6)           | (43.8) | (18.8) |
| Anemia                                                                                  | 1                  | 1                  |                    |                  |        |        |
| (14.3)                                                                                  | 1 (6.3)            | 1 (6.3)            |                    |                  |        |        |
| (14.3)                                                                                  |                    |                    |                    |                  |        |        |
| Bullous                                                                                 | 1                  |                    |                    |                  |        |        |
| (33.3)                                                                                  | 1 (6.3)            |                    |                    |                  |        |        |
| pemphigoid  Colitis                                                                     | 1                  | 1                  |                    |                  |        |        |
| (14.3)                                                                                  | 1 (6.3)            | 1 (6.3)            |                    |                  |        |        |
| (14.3)                                                                                  |                    |                    |                    |                  |        |        |
| Dermatitis                                                                              | 1                  |                    |                    |                  |        |        |
| (33.3)                                                                                  | 1 (6.3)            |                    |                    |                  |        |        |
| acneiform Dyspnea                                                                       | 1                  |                    |                    |                  |        |        |
| (14.3)                                                                                  | 1 (6.3)            |                    |                    |                  |        |        |
| exertional*** Hyperthyroidism                                                           | 1                  |                    |                    |                  |        |        |
| (14.3)                                                                                  | 1 (6.3)            |                    |                    |                  |        |        |
| Hypophosphatemia                                                                        | 1                  |                    |                    |                  |        |        |
| (14.3)                                                                                  | 1 (6.3)            |                    |                    |                  |        |        |
| Hypothyroidism                                                                          | 1                  | 1                  | 2                  |                  |        |        |
| (33.3)                                                                                  | (14.3)             | (12.5)             |                    |                  |        |        |
| Infusion-related                                                                        | 1                  |                    |                    |                  |        |        |
| (14.3)                                                                                  | 1 (6.3)            |                    |                    |                  |        |        |
| reaction Keratoacanthoma                                                                | 1                  |                    |                    |                  |        |        |
| (14.3)                                                                                  | 1 (6.3)            |                    |                    |                  |        |        |
| Lipase increase                                                                         | 1                  | 1                  |                    |                  |        |        |
| (14.3)                                                                                  | 1 (6.3)            | 1 (6.3)            |                    |                  |        |        |
| (14.3)                                                                                  |                    |                    |                    |                  |        |        |
| Nausea                                                                                  | 1                  |                    |                    |                  |        |        |
| (33.3)                                                                                  | 1 (6.3)            |                    |                    |                  |        |        |
| Pruritus                                                                                | 1                  |                    |                    |                  |        |        |
| (33.3)                                                                                  | 1 (6.3)            |                    |                    |                  |        |        |
| Rash maculopapular                                                                                         | 1                  | 1                  | 2                  |                  |        |        |
| (33.3)                                                                                  | (33.3)             | (12.5)             |                    |                  |        |        |
| Skin infection                                                                          | 1                  | 1                  |                    |                  |        |        |
| (33.3)                                                                                  | 1 (6.3)            | 1 (6.3)            |                    |                  |        |        |
| (33.3)                                                                                  |                    |                    |                    |                  |        |        |
| Vomiting                                                                                | 1                  |                    |                    |                  |        |        |
| (33.3)                                                                                  | 1 (6.3)            |                    |                    |                  |        |        |
| **There were no treatment-related AEs in the 3 participants treated with 1 mg/kg M7824. |                    |                    |                    |                  |        |        |  
***The differential for this dyspnea was pneumonitis vs. lymphangitic spread of disease (disease progression). As of August 2017, > 500 participants have been treated with M7824 across multiple solid tumor expansion cohorts. The safety profile is consistent with other monotherapy checkpoint inhibitors, with the exception of keratoacanthomas and cutaneous squamous cell carcinomas which have occurred in approximately 3-5% of participants, and are well managed with surgical excision. These lesions have not been a criterion for treatment discontinuation, but thus far have all spontaneously regressed following treatment discontinuation. In addition, after discussion among NCI investigators on multiple protocols using M7824, multiple bleeding events ranging from low grade gingival bleeding and epistaxis to more serious hemoptysis, GI bleeding and hematuria have been observed. Some of these events can be attributed to bleeding events related to cancer directly and others bleeding events can be attributed to colitis or cystitis which is a known toxicity of anti-PD-L1 agents including M7824. However, there remains the possibility that M7824 may increase the overall risk of bleeding in ways that may not be directly related to direct tumor bleeding or inflammatory bleeding events described with checkpoint inhibitors like M7824. It is hypothesized that this possible increased bleeding risk may be due to TGF beta inhibition which has an effect on angiogenesis; bleeding has also been observed in participants receiving M7824 and may be drug-related (e.g., gum bleeding, nose bleeds, coughing up blood, blood in their urine, or blood in the stool). Accordingly, participants will be notified of the same possible risk in the informed consent document for this study (e.g., gum bleeding, nose bleeds, coughing up blood, blood in their urine, or blood in the stool). At least 2 instances of nodular regenerative hyperplasia have been observed with the use of this agent. 14.2.3 Formulation and Preparation M7824 is provided as a sterile liquid formulation and packaged at a 10 mg/mL concentration in USP/ Ph Eur type I 50R vials that are filled with drug product solution to allow an extractable volume of 60 mL (600 mg/60 mL). The vials are closed with rubber stoppers in serum format complying with USP and Ph Eur with an aluminum crimp seal closure. Each single-use vial contains 600mg of M7824, formulated as 10mg/mL of active, 6% (w/v) Trehalose, 40 mM NaCl, 5 mM Methionine, 0.05% (w/v) Tween 20, 10 mM LHistidine at pH 5.5. The liquid formulation is diluted directly with 0.9% sodium chloride solution for injection. The estimated volumes of delivery are anticipated to be no more than 250mL. The verified concentration range in the infusion solution is 0.16 mg/mL to 9.6 mg/mL.
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14.2.4 stability and storage

M7824 must be stored at 2℃ to 8℃ until use. Product stored at room temperature for extended periods of time might be subject to degradation. M7824 must not be frozen. Rough shaking of the reconstituted solution must be avoided. The chemical and physical in-use stability for the infusion solution of M7824 in 0.9% sodium chloride for injection has been demonstrated for a total of 72 hours at room temperature; however, from a microbiological point of view, the diluted solution should be used immediately and is not intended to be stored unless dilution has taken place in controlled and validated aseptic conditions. No other drugs should be added to the infusion containers containing M7824. See Manual of Preparation of approved ancillary supplies. 14.2.5 Administration Procedures See Section 3.2. 14.2.6 Incompatibilities Not available.
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14.3 n-803 (ind # 19660)

14.3.1 Source / Acquisition and Accountability N-803 is manufactured and supplied by ImmunityBio, Inc. N-803 will be provided to the clinical trial site by the manufacturer. The investigator or designee (e.g., pharmacist) will maintain an ongoing inventory of the investigational product supply according to standard site procedures. The investigational product will be dispensed at the direction of an investigator for administration to a study participant enrolled on the clinical trial. Disposal of expired or unused product will be returned to the manufacturer or disposed of according to standard site procedures based on agreement between the manufacturer and the site.
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14.3.2 toxicity

In participants receiving the 10 mcg/kg subcutaneous injection, the following were reported grade 1 and 2 toxicities: worsening anemia, nausea/vomiting, constipation, fatigue, fever, peripheral IV infiltration, injection site reactions, pain/aches, sinusitis, hypoalbuminemia, hypocalcemia, hypophosphatemia, decreased iron, headaches, dysgeusia, and cough. Grade 3 hypertension and decreased lymphocyte count were also reported. Atrial fibrillation, neutropenia and febrile neutropenia have also been reported as potential risks of N-803. N-803 has been tested in combination with the anti-PD-1 agent, nivolumab at a dose of 240 mg i.v. every 4 weeks, in a phase 1 dose expansion study (n=21) with N-803 given weekly for 5 weeks on, 1 week off, for up to 5-6 months for pre-treated, advanced/metastatic NSCLC (NCT02523469). Fifteen participants received higher N-803 dosing: 15 mcg/kg (n=6) and 20 mcg/kg (n=9). Among all doses, there were no DLTs and no Grade 4 or 5 adverse events. Grade 3 adverse events were fever (n=1), flu-like illness (n=2), lymphopenia (n=2), fatigue (n=2), back pain (n=1), and dizziness (n=1). Grade 1 or 2 large injection site reactions were observed in 14 participants.
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14.3.3 formulation and preparation

N-803 is a soluble complex consisting of two protein subunits of a human IL-15 variant associated with high affinity to a dimeric human IL-15 receptor α (IL-15Rα) sushi domain/human IgG1 Fc fusion protein. The IL-15 variant is a 114 aa polypeptide comprising the mature human IL-15 cytokine sequence with an Asn to Asp substitution at position 72 of helix C (N72D). The human IL-15Rα sushi domain/human IgG1 Fc fusion protein comprises the sushi domain of the human IL-15 receptor α subunit (IL-15Rα) (aa 1-65 of the mature human IL-15Rα protein) linked with the human IgG1 CH2-CH3 region containing the Fc domain (232 amino acids). Aside from the N72D substitution, all of the protein sequences are human. Based on the amino acid sequence of the subunits, calculated molecular weight of complex comprising two IL-15N72D polypeptides and a disulfide linked homodimeric IL-15RαSu/IgG1 Fc protein is 92.4 kilodaltons (kDa). Each IL-15N72D polypeptide has a calculated molecular weight of approximately 12.8 kDa and the IL-15RαSu/IgG1 Fc fusion protein has a calculated molecular weight of approximately 33.4 kDa.  
Both the IL-15N72D and IL-15RαSu/IgG1 Fc proteins are glycosylated resulting in an apparent molecular weight of N-803 as approximately 113 kDa by size exclusion chromatography. The isoelectric point (pI) determined for N-803 ranges from approximately 5.5 to 6.5. Thus, the fusion protein is negatively charged at pH 7. The calculated molar extinction coefficient at A280 for N803 is 116,540 M-1, or 1.26 OD280 for a 1 mg/mL solution of N-803, or one OD280 is equivalent to 0.79 mg/mL solution of N-803. The biological drug product, N-803, is formulated in a phosphate buffered saline solution. The drug substance is produced by a recombinant mammalian cell line and is manufactured using protein-free media. N-803 is supplied at a concentration of 2 mg/mL and lot FG-16-0182-2 is administered undiluted. For lots other than FG-16-0182-2, the manufacturer will provide additional preparation instructions. 14.3.4 Stability and Storage Study medication is provided in a 2mL vial containing 0.6 mL of N-803 at a concentration of 2 mg/mL. Study medication must be maintained at a temperature between 2℃ and 8℃. The duration of time during which the product remains stable at room temperature will be obtained from Altor. 14.3.5 Administration Procedures N-803 is administered subcutaneously. 14.3.6 Incompatibilities Not available.
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14.4 nhs-il12 (ind # 19660)

14.4.1 Source / Acquisition and Accountability NHS-IL12 is manufactured and supplied by EMD Serono. NHS-IL12 will be provided to the clinical trial site by the manufacturer. The investigator or designee (e.g., pharmacist) will maintain an ongoing inventory of the investigational product supply according to standard site procedures. The investigational product will be dispensed at the direction of an investigator for administration to a study participant enrolled on the clinical trial. Disposal of expired or unused product will be returned to the manufacturer or disposed of according to standard site procedures based on agreement between the manufacturer and the site. 14.4.2 Toxicity Subjects (n=59) were treated subcutaneously with NHS-IL12 in a single ascending dose cohort followed by a multiple ascending dose cohort (n=37 with every 4-week dosing). The primary objective of this trial was to determine MTD as defined by the number of DLTs. None of the subjects treated with single or multiple doses up to 12.0 µg/kg experienced a DLT. At 16.8 µg/kg, 1/6 subjects had a DLT (grade 3 increase in alanine transaminase [ALT]). At 21.8 µg/kg, 2/6 subjects had a DLT (grade 3 increase in aspartate transaminase [AST] and ALT; grade 3 increase in lipase without clinical signs of pancreatitis). MTD was 16.8 µg/kg. The most frequently observed treatment-related adverse event (TRAE) was decreased lymphocyte count (27/59 subjects; 45.8%). Other TRAEs included decreased white blood cells (WBCs) (24/59; 40.7%), fever and elevated AST (21 each; 35.6%), elevated ALT (20; 3.9%), and anemia and flu-like symptoms (18 each; 30.5%) (Tab. Among the cohort receiving 16.8 µg/kg, the most frequently reported TRAEs were elevated AST (75%), decreased WBCs and elevated ALT (68.8% each), and decreased lymphocyte count and fever (62.5% each). At least one grade ≥ 3 TRAE was seen in 12/59 subjects (20.3%). These included decreased lymphocyte count (5; 8.5%), decreased neutrophil count (4; 6.8%), elevated ALT (3; 5.1%), decreased WBCs (2; 3.4%), and hypokalemia, hyperhidrosis, elevated alkaline phosphatase, AST, and lipase (1 each; 1.7%). All grade ≥ 3 TRAEs were transient; only hyperhidrosis was symptomatic. One grade 4 TRAE was observed (asymptomatic decreased lymphocyte count); no grade 5 TRAE was observed. 14.4.3 Formulation and Preparation NHS-IL12 is formulated as a 1.5 mg/mL solution and is supplied by the Sponsor in single-use glass vials with a rubber stopper and sealed with an aluminum Flip Off® crimp seal closure. The contents of the NHS-IL12 vials are sterile and nonpyrogenic, and do not contain bacteriostatic preservatives. Any spills that occur should be cleaned up using the facility's standard cleanup procedures for biologic products.  
Rough shaking of the solution must be avoided.  
NHS-IL12 drug product is ready-to-use. However, for doses below 300 g, NHS-IL12 drug product must be diluted with 0.9% saline solution (sodium chloride injection). Detailed information on medical devices to be used for the preparation and administration of NHS-IL12 will be provided in the Manual of Operations. Any unused portion of the solution should be discarded in biohazard waste disposal with final disposal by accepted local and national standards of incineration. 14.4.4 Stability and Storage NHS-IL12 drug product must be stored at 2°C to 8°C until use, with a temperature log maintained daily. All medication boxes supplied to the study site must be stored carefully, safely, and separately from other drugs. The chemical and physical in-use stability of NHS-IL12 diluted and undiluted solution in syringes has been demonstrated for 24hours at 25°C. However, to reduce the risk of microbial contamination, the solution should be used immediately unless medication preparation has been performed in controlled and validated aseptic conditions. Rough shaking of the solution must be avoided. 14.4.5 Administration Procedures NHS-IL12 is administered subcutaneously. 14.4.6 Incompatibilities Not available.
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15 references

5. Le DT, Uram JN, Wang H, Bartlett BR, Kemberling H, Eyring AD, Skora AD, Luber BS, Azad NS, Laheru D *et al*: **PD-1 Blockade in Tumors with Mismatch-Repair** Deficiency. *N Engl J Med* 2015, 372(26):2509-2520.
11. Dumont N, Arteaga CL: Transforming growth factor-beta and breast cancer: Tumor promoting effects of transforming growth factor-beta. *Breast Cancer Res* 2000, 2(2):125-132.  
12. Formenti SC, Lee P, Adams S, Goldberg JD, Li X, Xie MW, Ratikan JA, Felix C, Hwang L, Faull KF *et al*: Focal Irradiation and Systemic TGFbeta Blockade in Metastatic Breast Cancer. *Clin Cancer Res* 2018, 24(11):2493-2504.  
1. Grothey A: **VEGF inhibition beyond tumour progression**. *Lancet Oncol* 2013, 14(1):2-3.  
2. Mayer RJ, Van Cutsem E, Falcone A, Yoshino T, Garcia-Carbonero R, Mizunuma N,
Yamazaki K, Shimada Y, Tabernero J, Komatsu Y *et al*: **Randomized trial of TAS-102** for refractory metastatic colorectal cancer. *N Engl J Med* 2015, 372(20):1909-1919.  
3. Yoshino T, Mizunuma N, Yamazaki K, Nishina T, Komatsu Y, Baba H, Tsuji A,
Yamaguchi K, Muro K, Sugimoto N *et al*: **TAS-102 monotherapy for pretreated** metastatic colorectal cancer: a double-blind, randomised, placebo-controlled phase 2 trial. *Lancet Oncol* 2012, 13(10):993-1001.  
4. Herbst RS GM, Fine GD, et al: **A study of MPDL3280A, an engineered PD-L1**
antibody in patients with locally advanced or metastatic tumors. Journal of Clinical Oncology 2013, 31:3000-3000.  
6. O'Neil BH, Wallmark JM, Lorente D, Elez E, Raimbourg J, Gomez-Roca C, Ejadi S,
Piha-Paul SA, Stein MN, Abdul Razak AR *et al*: **Safety and antitumor activity of the** anti-PD-1 antibody pembrolizumab in patients with advanced colorectal carcinoma. PLoS One 2017, 12(12):e0189848.  
7. Boyerinas B, Jochems C, Fantini M, Heery CR, Gulley JL, Tsang KY, Schlom J:
Antibody-Dependent Cellular Cytotoxicity Activity of a Novel Anti-PD-L1 Antibody Avelumab (MSB0010718C) on Human Tumor Cells. *Cancer Immunol Res* 2015, 3(10):1148-1157.  
8. Heery CR, O'Sullivan-Coyne G, Madan RA, Cordes L, Rajan A, Rauckhorst M, Lamping E, Oyelakin I, Marte JL, Lepone LM *et al*: Avelumab for metastatic or locally advanced previously treated solid tumours (JAVELIN Solid Tumor): a phase 1a, multicohort, dose-escalation trial. *Lancet Oncol* 2017, 18(5):587-598.  
9. Donahue RN, Lepone LM, Grenga I, Jochems C, Fantini M, Madan RA, Heery CR,
Gulley JL, Schlom J: Analyses of the peripheral immunome following multiple administrations of avelumab, a human IgG1 anti-PD-L1 monoclonal antibody. J Immunother Cancer 2017, 5:20.  
10. Blobe GC, Schiemann WP, Lodish HF: **Role of transforming growth factor beta in**
human disease. *N Engl J Med* 2000, 342(18):1350-1358.  
13. Ivanovic V, Melman A, Davis-Joseph B, Valcic M, Geliebter J: Elevated plasma levels of TGF-beta 1 in patients with invasive prostate cancer. *Nat Med* 1995, 1(4):282-284.  
14. Shen M, Tsai Y, Zhu R, Keng PC, Chen Y, Chen Y, Lee SO: **FASN-TGF-beta1-PD-L1**
axis contributes to the development of resistance to NK cell cytotoxicity of cisplatinresistant lung cancer cells. *Biochim Biophys Acta Mol Cell Biol Lipids* 2018, 1863(3):313-322.  
15. Tsushima H, Kawata S, Tamura S, Ito N, Shirai Y, Kiso S, Imai Y, Shimomukai H,
Nomura Y, Matsuda Y *et al*: High levels of transforming growth factor beta 1 in patients with colorectal cancer: association with disease progression. Gastroenterology 1996, 110(2):375-382.  
16. Terabe M, Robertson FC, Clark K, De Ravin E, Bloom A, Venzon DJ, Kato S, Mirza A,
Berzofsky JA: Blockade of only TGF-beta 1 and 2 is sufficient to enhance the efficacy of vaccine and PD-1 checkpoint blockade immunotherapy. *Oncoimmunology* 2017, 6(5):e1308616.  
17. Vanpouille-Box C, Formenti SC: Dual Transforming Growth Factor-beta and Programmed Death-1 Blockade: A Strategy for Immune-Excluded Tumors? *Trends* Immunol 2018, 39(6):435-437.  
18. Grenga I, Donahue RN, Gargulak ML, Lepone LM, Roselli M, Bilusic M, Schlom J:
Anti-PD-L1/TGFbetaR2 (M7824) fusion protein induces immunogenic modulation of human urothelial carcinoma cell lines, rendering them more susceptible to immune-mediated recognition and lysis. *Urol Oncol* 2018, 36(3):93 e91-93 e11.  
19. Jochems C, Tritsch SR, Pellom ST, Su Z, Soon-Shiong P, Wong HC, Gulley JL, Schlom J: **Analyses of functions of an anti-PD-L1/TGFbetaR2 bispecific fusion protein** (M7824). *Oncotarget* 2017, 8(43):75217-75231.  
20. Knudson KM, Hicks KC, Luo X, Chen JQ, Schlom J, Gameiro SR: M7824, a novel bifunctional anti-PD-L1/TGFbeta Trap fusion protein, promotes anti-tumor efficacy as monotherapy and in combination with vaccine. *Oncoimmunology* 2018, 7(5):e1426519.  
21. Lan Y, Zhang D, Xu C, Hance KW, Marelli B, Qi J, Yu H, Qin G, Sircar A, Hernandez VM *et al*: Enhanced preclinical antitumor activity of M7824, a bifunctional fusion protein simultaneously targeting PD-L1 and TGF-beta. *Sci Transl Med* 2018, 10(424).  
22. Ravi R, Noonan KA, Pham V, Bedi R, Zhavoronkov A, Ozerov IV, Makarev E, A VA,
Wysocki PT, Mehra R *et al*: Bifunctional immune checkpoint-targeted antibodyligand traps that simultaneously disable TGFbeta enhance the efficacy of cancer immunotherapy. *Nat Commun* 2018, 9(1):741.  
23. David JM, Dominguez C, McCampbell KK, Gulley JL, Schlom J, Palena C: **A novel**
bifunctional anti-PD-L1/TGF-beta Trap fusion protein (M7824) efficiently reverts mesenchymalization of human lung cancer cells. *Oncoimmunology* 2017, 6(10):e1349589.  
24. Strauss J, Heery CR, Schlom J, Madan RA, Cao L, Kang Z, Lamping E, Marte JL,
Donahue RN, Grenga I *et al*: Phase I Trial of M7824 (MSB0011359C), a Bifunctional Fusion Protein Targeting PD-L1 and TGFbeta, in Advanced Solid Tumors. *Clin* Cancer Res 2018, 24(6):1287-1295.  
25. Conlon KC, Lugli E, Welles HC, Rosenberg SA, Fojo AT, Morris JC, Fleisher TA,
Dubois SP, Perera LP, Stewart DM *et al*: **Redistribution, hyperproliferation,** activation of natural killer cells and CD8 T cells, and cytokine production during first-in-human clinical trial of recombinant human interleukin-15 in patients with cancer. *J Clin Oncol* 2015, 33(1):74-82.  
26. Kobayashi H, Carrasquillo JA, Paik CH, Waldmann TA, Tagaya Y: Differences of biodistribution, pharmacokinetics, and tumor targeting between interleukins 2 and 15. *Cancer Res* 2000, 60(13):3577-3583.  
27. Miller JS, Morishima C, McNeel DG, Patel MR, Kohrt HEK, Thompson JA, Sondel PM,
Wakelee HA, Disis ML, Kaiser JC *et al*: **A First-in-Human Phase I Study of** Subcutaneous Outpatient Recombinant Human IL15 (rhIL15) in Adults with Advanced Solid Tumors. *Clin Cancer Res* 2018, 24(7):1525-1535.
28. Romee R, Cooley S, Berrien-Elliott MM, Westervelt P, Verneris MR, Wagner JE,
Weisdorf DJ, Blazar BR, Ustun C, DeFor TE *et al*: First-in-human phase 1 clinical study of the IL-15 superagonist complex ALT-803 to treat relapse after transplantation. *Blood* 2018, 131(23):2515-2527.  
29. Fujii R, Jochems C, Tritsch SR, Wong HC, Schlom J, Hodge JW: **An IL-15**
superagonist/IL-15Ralpha fusion complex protects and rescues NK cell-cytotoxic function from TGF-beta1-mediated immunosuppression. Cancer Immunol Immunother 2018, 67(4):675-689.
30. Kim PS, Kwilas AR, Xu W, Alter S, Jeng EK, Wong HC, Schlom J, Hodge JW: IL-15 superagonist/IL-15RalphaSushi-Fc fusion complex (IL-15SA/IL-15RalphaSu-Fc; ALT-803) markedly enhances specific subpopulations of NK and memory CD8+ T cells, and mediates potent anti-tumor activity against murine breast and colon carcinomas. *Oncotarget* 2016, 7(13):16130-16145.  
31. Wrangle JM, Velcheti V, Patel MR, Garrett-Mayer E, Hill EG, Ravenel JG, Miller JS,
Farhad M, Anderton K, Lindsey K *et al*: **ALT-803, an IL-15 superagonist, in** combination with nivolumab in patients with metastatic non-small cell lung cancer: a non-randomised, open-label, phase 1b trial. *Lancet Oncol* 2018, 19(5):694-704.
32. Tsang KY, Palena C, Yokokawa J, Arlen PM, Gulley JL, Mazzara GP, Gritz L, Yafal AG, Ogueta S, Greenhalgh P *et al*: **Analyses of recombinant vaccinia and fowlpox** vaccine vectors expressing transgenes for two human tumor antigens and three human costimulatory molecules. *Clin Cancer Res* 2005, 11(4):1597-1607.  
33. Mohebtash M, Tsang KY, Madan RA, Huen NY, Poole DJ, Jochems C, Jones J, Ferrara T, Heery CR, Arlen PM *et al*: **A pilot study of MUC-1/CEA/TRICOM poxviral-based** vaccine in patients with metastatic breast and ovarian cancer. *Clin Cancer Res* 2011, 17(22):7164-7173.  
34. Morse MA, Niedzwiecki D, Marshall JL, Garrett C, Chang DZ, Aklilu M, Crocenzi TS,
Cole DJ, Dessureault S, Hobeika AC *et al*: **A randomized phase II study of** immunization with dendritic cells modified with poxvectors encoding CEA and MUC1 compared with the same poxvectors plus GM-CSF for resected metastatic colorectal cancer. *Ann Surg* 2013, 258(6):879-886.  
35. Gatti-Mays ME, Strauss J, Donahue RN, Palena C, Del Rivero J, Redman JM, Madan RA, Marte JL, Cordes LM, Lamping E *et al*: A Phase I Dose-Escalation Trial of BNCV301, a Recombinant Poxviral Vaccine Targeting MUC1 and CEA with Costimulatory Molecules. *Clin Cancer Res* 2019, 25(16):4933-4944.  
36. Strauss J, Heery CR, Kim JW, Jochems C, Donahue RN, Montgomery AS, McMahon S,
Lamping E, Marte JL, Madan RA *et al*: **First-in-Human Phase I Trial of a TumorTargeted Cytokine (NHS-IL12) in Subjects with Metastatic Solid Tumors**. *Clin* Cancer Res 2019, 25(1):99-109.  
37. Vandeveer AJ, Fallon JK, Tighe R, Sabzevari H, Schlom J, Greiner JW: **Systemic**
Immunotherapy of Non-Muscle Invasive Mouse Bladder Cancer with Avelumab, an Anti-PD-L1 Immune Checkpoint Inhibitor. *Cancer Immunol Res* 2016, 4(5):452-462.  
38. Fallon J, Tighe R, Kradjian G, Guzman W, Bernhardt A, Neuteboom B, Lan Y,
Sabzevari H, Schlom J, Greiner JW: The immunocytokine NHS-IL12 as a potential cancer therapeutic. *Oncotarget* 2014, 5(7):1869-1884.  
39. Brahmer JR, Tykodi SS, Chow LQ, Hwu WJ, Topalian SL, Hwu P, Drake CG, Camacho LH, Kauh J, Odunsi K *et al*: **Safety and activity of anti-PD-L1 antibody in patients** with advanced cancer. *N Engl J Med* 2012, 366(26):2455-2465.  
40. Wrangle JM, Velcheti V, Patel MR, Garrett-Mayer E, Hill EG, Ravenel JG, Miller JS,
Farhad M, Anderton K, Lindsey K *et al*: ALT-803, an IL-15 superagonist, in combination with nivolumab in patients with metastatic non-small cell lung cancer: a non-randomised, open-label, phase 1b trial. *Lancet Oncol* 2018.  
41. Strauss J G-MM, Redman J, et al. : **Safety and activity of M7824, a bifunctional**
fusion protein targeting PD-L1 and TGF-β, **in patients with HPV associated cancers.** ASCO Annual Meeting June 1-5, 2018: Chicago, IL 2018.  
42. Merck KGaA D, Germany presented updated clinical results for bifunctional immunotherapy at ASCO 2018 [press release]. Darmstadt, Germany: Merck KGaA; June 4, 2018. prnewswire.com/news-releases/ merck-kgaa-darmstadt-germany-presentsupdated-clin: 2018:prnewswire.com/news-releases/ merck-kgaa-darmstadt-germanypresents-updated-clinical-results-for-bi- functional-immunotherapy-m7824-at-asco-2018684461311.html 43. Lepone LM, Donahue RN, Grenga I, Metenou S, Richards J, Heery CR, Madan RA,
Gulley JL, Schlom J: **Analyses of 123 Peripheral Human Immune Cell Subsets:** Defining Differences with Age and between Healthy Donors and Cancer Patients Not Detected in Analysis of Standard Immune Cell Types. *J Circ Biomark* 2016, 5:5.  
44. Eisenhauer EA, Therasse P, Bogaerts J, Schwartz LH, Sargent D, Ford R, Dancey J,
Arbuck S, Gwyther S, Mooney M *et al*: **New response evaluation criteria in solid** tumours: revised RECIST guideline (version 1.1). *Eur J Cancer* 2009, 45(2):228-247.  
45. Zhestianikov VD, Savel'eva GE, Kalinin VL: **[The adaptive response to mitomycin C**
exposure in the hyper-radioresistant mutant Escherichia coli Gamr444]. *Tsitologiia* 1991, 33(1):88-96.  
46. Heery CR, Singh BH, Rauckhorst M, Marte JL, Donahue RN, Grenga I, Rodell TC,
Dahut W, Arlen PM, Madan RA *et al*: **Phase I Trial of a Yeast-Based Therapeutic** Cancer Vaccine (GI-6301) Targeting the Transcription Factor Brachyury. *Cancer* Immunol Res 2015, 3(11):1248-1256.
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16 appendices

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