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untitled h2

Modification (Pembrolizumab, Vorinostat, Tamoxifen)  
Protocol Number: CC \#147523
Study Drugs: pembrolizumab, vorinostat, tamoxifen, Version Number: 3.0 Version Date: 07/28/2016 IND Number: Exempt Principal Investigator (Sponsor-Investigator)  
  
Pamela N. Munster, MD
UCSF Helen Diller Family Comprehensive Cancer Center  
  
  
Amy Jo Chien, MD
Michelle Melisko, MD
Mark Moasser, MD
John Park, MD
Anne Reinert, MD
Hope Rugo, MD
Melanie Majure, MD  
Statistician  
  
Lead Clinical Research Coordinator Amy Deluca Revision History  
  
Proprietary and Confidential The information in this document is considered privileged and confidential, and may not be disclosed to others except to the extent necessary to obtain Institutional Review Board approval and informed consent, or as required by Federal and State laws. Persons to whom this information is disclosed should be informed that this information is privileged and confidential and that it should not be further disclosed.  
| Version 3.0 Version 2.0 Version 1.3 Version 1.2 Version 1.1 Version 1.0   | 07/28/16 07/07/16 01/23/15 11/17/14 8/11/14   |
|---------------------------------------------------------------------------|-----------------------------------------------|
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protocol signature page

Protocol No.: 3.0  Version Date: 07/28/16  
1. I agree to follow this protocol version as approved by the UCSF Protocol Review Committee (PRC), Committee on Human Research (CHR), and Data Safety Monitoring Committee (DSMC).  
2. I will conduct the study in accordance with applicable CHR requirements, Federal regulations, and state and local laws to maintain the protection of the rights and welfare of study participants.  
3. I certify that I, and the study staff, have received the requisite training to conduct this research protocol.  
4. I have read and understand the information in the Investigators' Brochure (or Manufacturer's Brochure) regarding the risks and potential benefits. I agree to conduct the protocol in accordance with Good Clinical Practices (ICH-GCP), the applicable ethical principles, the Statement of Investigator (Form FDA 1572), and with local regulatory requirements. In accordance with the FDA Modernization Act, I will ensure the registration of the trial on the www.clinicaltrials.gov website.  
5. I agree to maintain adequate and accurate records in accordance with CHR policies, Federal, state and local laws and regulations.
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ucsf principal investigator / study

Printed Name  
| Signature              | Date   |
|------------------------|--------|
| Principal Investigator | Site   |
| Printed Name Signature | Date   |
nct # 02395627 reversing therapy
abstract title

Reversing therapy resistance with epigenetic-immune modification: phase II trial of Vorinostat, Tamoxifen and Pembrolizumab in hormone receptor expressing advanced breast cancer.
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patient population

Patients with ER+ hormone therapy resistant (HRT) and ER-negative breast cancer
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rationale for study background

More than two thirds of all advanced breast cancers are dependent on estrogen, and the introduction of selective estrogen receptor modulators (SERMs) has dramatically improved the survival of women with breast cancer. Unfortunately, the development of hormone therapy resistance in breast cancer is one of the most frequent causes of cancer death in women worldwide. This proposal is focused on the potential role of epigenetic immune priming to reverse therapy resistance in pre and postmenopausal breast cancer. Initially focused on hormone therapy positive tumors, recent preclinical studies have further suggested that epigenetic priming may be even more effective in ER-negative tumors that do not respond to Immune check point inhibitors or have low PD-1/PD-L1 expression. The goal of this study is to demonstrate that Vorinostat can increase PD-1 and PD-L1 expression. The goal of immune priming is to increase the number and composition of tumor infiltrating lymphocytes, which renders this a relevant approach to therapy resistant TNBC or ER-negative HER2-positive tumors
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the role of hdac inhibitors

The role of epigenetic modulation has been studied extensively in breast cancer therapy. We have previously shown that epigenetic modulation with an HDAC inhibitor can reverse hormone therapy resistance and force cells into programmed cell death1. Based on these preclinical studies, we had proposed two clinical trials testing HDAC inhibitors with hormonal therapy in ER+ breast cancer. In a first clinical trial, we evaluated the role of vorinostat (VOR) in reversing therapy resistance in advanced breast cancer2. The objective response rate by RECIST criteria was 19%, the clinical benefit rate (response or stable disease >24 weeks) was 40%, and the median response duration was 10.3 months (confidence interval: 8.1–12.4). A second trial (ENCORE 301) evaluated entinostat and exemestane. The median overall survival in the combination arm was 28.1 months compared to 19.8 months in the exemestane only arm (HR = 0.59; P = 0.036).
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programmed cell death 1 (pd-1)

Inhibition of the PD-L1/PD-1 axis has been a major milestone in many cancer types. Clinically, epigenetic immune regulation has been implicated in priming lung cancer cells to PD-1 inhibitors, which resulted in prolonged responses3,4. Increased PD-L1 expression has been observed in hormone therapy resistance, frequently reported with loss of progesterone receptor
(PR) expression, a measure of hormone therapy resistance5. Hence, PD-1 inhibitors may have a role in hormone therapy resistant breast cancer, and PD-1 inhibitors may be more effective after epigenetic immune priming. Several investigators have shown that HDAC inhibitors have immune modulatory functions, including modulation of Tregs, FoxP3 expression, changes in tumor-infiltrating lymphocytes (TILs), induction of PD-L1 expression and blockage of PD-1 signaling. Hence, the combination of HDAC inhibitors may potentiate the efficacy of PD-1 inhibitors6.
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optimal epigenetic immune priming (eip)

Based on the established role of HDAC inhibitors in reversing hormone therapy resistance to antiestrogens and aromatase inhibitors and therapy resistance in ER-negative tumors , and the provocative role of HDAC inhibitors in modulating tumor immunity, we propose to test the role of epigenetic immune priming (EIP) in acquired therapy resistance. In a three-arm Phase II trial, we will explore concurrent and sequential EIP, testing two principles:  
Sequential priming with optimal immune activation (Arm B and C) and, Concurrent priming with maximal dosing of both epigenetic and immune modulators (Arm A).
nct # 02395627 reversing therapy
primary objective

a) To define the optimal approach for epigenetic immune priming in breast cancer on the basis of overall response rate (ORR: CR+PR+SD at 24 weeks).  
b) Safety and tolerability of vorinostat, tamoxifen and pembrolizumab
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secondary objectives

a) To define the optimal approach for epigenetic immune priming in therapy –resistant breast cancer b) Determine the impact of vorinostat on PD-L1 expression in ER-positive tumors and ERnegative tumors c) To assess duration of response (DOR) 24 week landmark progression free survival
(PFS:24)
d) Median PFS and overall survival (OS) e) Tumor responses will also be calculated by Immune Related Response-Criteria (irRC).
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exploratory objectives

a) To evaluate changes in expression of immune checkpoint receptors / ligands
(programmed death receptor-1 [PD-1]/programmed death ligand-1 [PD-L1]) in tumor biopsies pre- and post-therapy in tumor and immune cells.  
b) To assess the ratio of effector T cells: regulatory T cells in blood and tumor biopsies pre- and post-therapy.  
c) To evaluate inflammatory T cell signature changes in blood and tumor biopsies pre- and post-therapy.  
d) To evaluate changes in number of myeloid-derived suppressor cells (MDSCs) in peripheral blood and tumor biopsies pre- and post-therapy.  
e) To evaluate changes in histone acetylation in peripheral blood cells and tumor biopsies pre- and post-therapy f) Initial comparison to vorinostat induced PD-1 in lymphocytes, PD-L1 modulation in ERpositive and ER-negative tumors
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study design

We propose a randomized two-arm trial, using Simon's 2-stage design, in ER+ patients with therapy resistant breast cancer to test the optimal sequence and dosing of epigenetic immune priming in hormone therapy resistant breast cancer. A third arm (Arm C) will include ERnegative patients who will follow the concurrent priming, but exclude tamoxifen.  
The two arms all include vorinostat, TAM and pembrolizumab to evaluate  
Sequential priming - begin pembrolizumab in Cycle 1 (**Arm B and Arm C**) and, Concurrent priming with maximal dosing of both epigenetic and immune modulators–
begin pembrolizumab on day 1 in Cycle 2 (Arm A)
Drug combination: We propose an exploratory biomarker study to test the combination of pembrolizumab and vorinostat.
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population

We will test this combination in patients with tumors that may have unknown or low PD-L1 expression by prior testing (e.g. prior Keynote study screen failures). Patients may have progressed on prior PD-1/PD-L1 checkpoint inhibitors. Tumor must have less than 1% ER expression (HER2 positive or negative)
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duration of therapy

Patients may continue treatment for 24 months from the time of study entry, and longer with permission of the sponsor and Merck.
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duration of follow up

Patients will be followed for 30 days after completion of treatment or removal from study, and serious adverse events will be collected for 30 days after the end of treatment.
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duration of study

The study will conclude when all enrolled patients have been followed for more than 30 days following completion of therapy. The estimated duration of study, from start of enrollment to final study report is 4 years.
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study drugs

Tamoxifen (generic) is a non-steroidal selective estrogen receptor modulator (SERM) currently used in the prevention of breast cancer, for ductal carcinoma in situ, in women with early stage breast cancer and for those with metastatic cancer. It is extensively metabolized after oral administration, with N-desmethyl tamoxifen the major metabolite found in patients' plasma. Vorinostat (Suberoylanilide hydroxamic acid, SAHA; Merck) is a small molecule inhibitor of histone deacetylases (HDACs) that binds directly in the enzyme's active site in the presence of a zinc ion. It targets most human Class 1 (related to the yeast transcriptional regulator Rpd3) and Class 2 (similar to the yeast Hda1) enzymes. It causes G1 or G2 phase cell-cycle arrest, apoptosis or differentiation in cultured transformed cells. Vorinostat is the most potent HDAC inhibitor that can be administered orally with excellent bioavailability. Pembrolizumab (Merck) is a potent and highly selective humanized monoclonal antibody of the IgG4/kappa isotype designed to directly block the interaction between PD-1 and its ligands, PDL1 and PD-L2. This blockade enhances functional activity of the target lymphocytes to facilitate tumor regression and ultimately immune rejection. Pembrolizumab is currently under clinical investigation.
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safety assessments

Safety will be assessed by reviewing adverse events (AEs), laboratory evaluations, physical examination, and spontaneous reports. Each patient will be assessed periodically for the development of any toxicity according to the MCI CTCAE v4.0. All AEs and serious AEs (SAEs) will be documented and reported. We will also pay particular attention to pembrolizumab adverse events of clinical interest, which will predominantly be of immune origin.
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efficacy assessments

For the primary endpoint, patients will be assessed for objective responses by RECIST criteria 1.1. Secondary endpoints include immune response, progression free survival, and overall survival. Monitoring of secondary endpoints will be performed via serial imaging and follow up for survival. Correlative endpoints include epigenetic modulation and immune modulation as well as their interaction.
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unique aspects of this study

This is the first study to look at the response of hormone therapy resistant breast cancer to epigenetic immune priming. It is also the first study to look at the combination of an HDAC inhibitor (vorinostat), an anti-estrogen (tamoxifen) and a PD-1 inhibitor (pembrolizumab) in pre or postmenopausal patients with ER+ advanced breast cancer with progression on multiple prior therapies.
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recent preclinical studies have further

In a third arm the study will evaluated the role of epigenetic priming in tumors that are ERnegative.
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list of abbreviations

| AE     | adverse event                                           |
|--------|---------------------------------------------------------|
| ALP    | alkaline phosphatase                                    |
| ALT    | alanine aminotransferase                                |
| ANC    | absolute neutrophil count                               |
| AST    | aspartate aminotransferase                              |
| ATC    | Anatomical Therapeutic Chemical (Classification System) |
| AUC    | area under the curve                                    |
| BUN    | blood urea nitrogen                                     |
| CBC    | complete blood cell (count)                             |
| CHR    | Committee on Human Research (UCSF IRB)                  |
| CR     | complete response                                       |
| CRC    | Clinical Research Coordinator                           |
| CRF    | case report form                                        |
| CSF    | cerebral spinal fluid                                   |
| CT     | computerized tomography                                 |
| CTCEA  | Common Terminology Criteria for Adverse Events          |
| CTEP   | Cancer Therapy Evaluation Program                       |
| CTMS   | Clinical Trial Management System                        |
| DFS    | disease-free survival                                   |
| DLT    | dose limiting toxicity                                  |
| DSMC   | Data and Safety Monitoring Committee                    |
| DSMP   | Data and Safety Monitoring Plan                         |
| ECOG   | Eastern Cooperative Oncology Group                      |
| ECI    | event of clinical interest                              |
| FCBP   | female of childbearing potential                        |
| FDA    | Food and Drug Administration                            |
| GCP    | Good Clinical Practice                                  |
| HBeAg  | Hepatitis B "e" antigen                                 |
| HBV    | hepatitis B virus                                       |
| HCT    | hematocrit                                              |
| HCV    | hepatitis C virus                                       |
| HDFCCC | Helen Diller Family Comprehensive Cancer Center         |
| HGB    | hemoglobin                                              |
| HIV    | human immunodeficiency virus                            |
| ICH    | International Conference on Harmonization               |
| IND    | investigational new drug application                    |
| IP     | investigational product                                 |
| IRB    | Institutional Review Board                              |  
| iwCLL   | International Workshop on Chronic Lymphocytic Leukemia   |
|---------|----------------------------------------------------------|
| IV      | intravenous                                              |
| LDH     | lactate dehydrogenase                                    |
| LFT     | liver function test                                      |
| MedDRA  | Medical Dictionary for Regulatory Activities             |
| MRI     | magnetic resonance imaging                               |
| MTD     | maximum tolerated dose                                   |
| NCI     | National Cancer Institute                                |
| NHL     | non-Hodgkin's lymphoma                                   |
| ORR     | overall response rate                                    |
| PD      | disease progression                                      |
| PD-1    | Programmed cell death 1                                  |
| PK      | pharmacokinetics                                         |
| PO      | Per os (by mouth, orally)                                |
| PR      | partial response                                         |
| PRC     | Protocol Review Committee (UCSF)                         |
| QOL     | Quality of Life                                          |
| RBC     | red blood cell (count)                                   |
| SD      | stable disease                                           |
| SD      | standard deviation                                       |
| SGOT    | serum glutamic oxaloacetic transaminase                  |
| SGPT    | serum glutamic pyruvic transaminase                      |
| TIL     | Tumor-infiltrating lymphocytes                           |
| ULN     | upper limit of normal                                    |
| WBC     | white blood cell (count)                                 |
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table of contents

| Protocol Signature Page.                                                                                                                                 |                                                                                                                                                             |
|----------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------|
| L List of Abbreviations                                                                                                                                  |                                                                                                                                                             |
| 1 Introduction                                                                                                                                           |                                                                                                                                                             |
| 1.1                                                                                                                                                      | Background on Indication ................................................................................................................................13 |
| 1.1.1 Introduction to breast cancer ..................................................................................................................13 |                                                                                                                                                             |
| 1.2                                                                                                                                                      | Background on the Compounds..........................................................................................................15                     |
| 1.3                                                                                                                                                      | Rationale for the Proposed Study ....................................................................................................18                     |
| 1.3.1 Rationale for Epigenetic Immune Priming (EIP): ...................................................................18                               |                                                                                                                                                             |
| 2 Objectives of the Study                                                                                                                                |                                                                                                                                                             |
| 2.1                                                                                                                                                      | Primary objective: .                                                                                                                                        |
| Secondary objectives:                                                                                                                                    |                                                                                                                                                             |
| 2.2                                                                                                                                                      |                                                                                                                                                             |
| 2.4                                                                                                                                                      | Endpoints                                                                                                                                                   |
| 2.4.1                                                                                                                                                    | Primary Endpoints                                                                                                                                           |
| a)                                                                                                                                                       | Overall response rate (CR+PR and SD at 24 weeks) ..........................................................................21                               |
| TOXICITY                                                                                                                                                 |                                                                                                                                                             |
| b)                                                                                                                                                       |                                                                                                                                                             |
| 2.4.2                                                                                                                                                    | Secondary Endpoints                                                                                                                                         |
| D Duration of response rate                                                                                                                              |                                                                                                                                                             |
| a)                                                                                                                                                       |                                                                                                                                                             |
| b)                                                                                                                                                       | 24 week landmark progression free survival (PFS:24),.................................................................21                                     |
| c)                                                                                                                                                       | Median PFS and overall survival (OS),.                                                                                                                      |
| d)                                                                                                                                                       | Tumor responses will also be calculated by Immune Related Response-Criteria (irRC)                                                                          |
| 21                                                                                                                                                       |                                                                                                                                                             |
| e)                                                                                                                                                       | To test the response of PD-L1 expression to epigenetic modulation ....................................21                                                    |
| 2.5                                                                                                                                                      | Exploratory Endpoints.                                                                                                                                      |
| 3 Study Design .                                                                                                                                         |                                                                                                                                                             |
| 3.1                                                                                                                                                      | C Conservers                                                                                                                                                |
| 3.2                                                                                                                                                      | Number of Subjects                                                                                                                                          |
| 3.3                                                                                                                                                      | Eligibility Criteria .                                                                                                                                      |
| 3.3.1                                                                                                                                                    | Inclusion Criteria                                                                                                                                          |
| 3.3.2                                                                                                                                                    | Exclusion Criteria .                                                                                                                                        |
| 3.4                                                                                                                                                      | D Duration of Therapy                                                                                                                                       |
| 3.5                                                                                                                                                      | D Duration of Follow Up                                                                                                                                     |
| Phase II - Pembrolizumab, Vorinostat, Tamoxifen,                                                                                                         | Page 10 of 83                                                                                                                                               |  
| 3.6                                                                                                                                            | Randomization Procedures                                                                                                                                             |
|------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Study Timeline                                                                                                                                 |                                                                                                                                                                      |
| 3.7                                                                                                                                            |                                                                                                                                                                      |
| 3.7.1                                                                                                                                          | Clinical Criteria for Early Trial Termination..................................................................26                                                    |
| 4 Study Drugs                                                                                                                                  |                                                                                                                                                                      |
| 4.1                                                                                                                                            | Description, Supply and Storage of Investigational Drugs .................................................27                                                         |
| 4.1.1                                                                                                                                          | Investigational Drug Tamoxifen ........................................................................................................27                            |
| 4.1.2                                                                                                                                          | Investigational Drug Vorinostat (Zolinza, NSC 701852) ...........................................28                                                                  |
| Investigational Drug MK-3475 (Pembrolizumab) ........................................................29                                        |                                                                                                                                                                      |
| 4.1.3                                                                                                                                          |                                                                                                                                                                      |
| 4.2                                                                                                                                            | D Drug Accountability                                                                                                                                                |
| D Drug Ordering                                                                                                                                |                                                                                                                                                                      |
| 4.3                                                                                                                                            |                                                                                                                                                                      |
| 4.4                                                                                                                                            | Packaging and Labeling of Study Drugs .......................................................................................33                                      |
| 5 Treatment Plan .                                                                                                                             |                                                                                                                                                                      |
| 5.1                                                                                                                                            | Dosage and Administration                                                                                                                                            |
| 5.1.1                                                                                                                                          | Dose Modifications and Dosing Delays .............................................................................35                                                 |
| 5.2                                                                                                                                            | Monitoring and Toxicity Management ........................................................................................42                                        |
| 6 Study Procedures and Observations ................................................................................................43         |                                                                                                                                                                      |
| 6.2                                                                                                                                            | Schedule of Procedures and Observations .............................................................................43                                              |
| 6.2.2                                                                                                                                          | Long Term/Survival Follow-up Procedures ...................................................................44                                                        |
| 6.2.3                                                                                                                                          | D Discontinuation of Therapy ............................................................................................................44                          |
| Analysis of Exploratory Endpoints: Tissue based endpoints ...........................................................49                        |                                                                                                                                                                      |
| Analysis of Exploratory Endpoints: Immune endpoints ......................................................................50                   |                                                                                                                                                                      |
| Usage of Concurrent/Concomitant Medications                                                                                                    |                                                                                                                                                                      |
| 6.3                                                                                                                                            |                                                                                                                                                                      |
| 6.3.2                                                                                                                                          | Acceptable Concomitant Medications                                                                                                                                   |
| 6.3.3                                                                                                                                          | Prohibited Concomitant Medications ...............................................................................................52                                 |
| 6.3.4                                                                                                                                          | Rescue Medications & Supportive Care ..................................................................................................53                            |
| Supportive Care Guidelines .                                                                                                                   |                                                                                                                                                                      |
| Contraception                                                                                                                                  |                                                                                                                                                                      |
| 7 Reporting and Documentation of Results .                                                                                                     |                                                                                                                                                                      |
| 7.1 Evaluation of Efficacy (or Activity) .                                                                                                     |                                                                                                                                                                      |
| 7.1.1. Antitumor Effect                                                                                                                        |                                                                                                                                                                      |
| 7.4                                                                                                                                            | Evaluation of Safety .............................................................................................................................................58 |
| 7.5                                                                                                                                            | Adverse Events .                                                                                                                                                     |
| Definition of Adverse Event ................................................................................................................58 |                                                                                                                                                                      |
| 7.5.2                                                                                                                                          |                                                                                                                                                                      |
| Phase II - Pembrolizumab, Vorinostat, Tamoxifen,                                                                                               | Page 11 of 83                                                                                                                                                        |  
| 7.5.3                                                                                                                                                          | Adverse reaction .                                                                                                                                            |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Evaluation of an Adverse Event....................................................................................................60                           |                                                                                                                                                               |
| 7.6                                                                                                                                                            |                                                                                                                                                               |
| 7.7                                                                                                                                                            | Follow-up of Adverse Events ............................................................................................................63                    |
| Adverse Events Reporting ..............................................................................................................63                      |                                                                                                                                                               |
| 7.8                                                                                                                                                            |                                                                                                                                                               |
| 7.8.1                                                                                                                                                          | Definition of an Overdose for This Protocol and Reporting of Overdose to the                                                                                  |
| study PI and Merck..........................................................................................................................................64 |                                                                                                                                                               |
| 7.8.2                                                                                                                                                          | Serious Adverse Events                                                                                                                                        |
| 7.8.3                                                                                                                                                          | Reporting of Pregnancy and Lactation to the Sponsor and to Merck.......................65                                                                     |
| 7.9                                                                                                                                                            | Expedited Reporting ................................................................................................................................65        |
| 8.0 Statistical Considerations and Evaluation of Results ..........................................................................6                           |                                                                                                                                                               |
| 8.1                                                                                                                                                            | Sample Size and Power Estimate .......................................................................................................67                      |
| 8.2                                                                                                                                                            | Interim Analyses                                                                                                                                              |
| 8.3                                                                                                                                                            | Analyses Plans .                                                                                                                                              |
| 8.3.1                                                                                                                                                          | Analysis Population ............................................................................................................................67            |
| 8.4                                                                                                                                                            | Evaluation of Safety.......................................................................................................................................67 |
| 9.0 Study Management .                                                                                                                                         |                                                                                                                                                               |
| Pre-study Documentation ...................................................................................................................68                  |                                                                                                                                                               |
| 9.1                                                                                                                                                            |                                                                                                                                                               |
| 9.2                                                                                                                                                            | Institutional Review Board Approval ........................................................................................68                                |
| 9.3                                                                                                                                                            | Informed Consent ......................................................................................................................................68     |
| 9.4                                                                                                                                                            | Changes in the Protocol ....................................................................................................................68                |
| 9.5                                                                                                                                                            | Handling and Documentation of Clinical Supplies ............................................................68                                                |
| Case Report Forms (CRFs) ................................................................................................................69                    |                                                                                                                                                               |
| 9.6                                                                                                                                                            |                                                                                                                                                               |
| 9.7                                                                                                                                                            | Oversight and Monitoring Plan ........................................................................................................69                      |
| 9.8                                                                                                                                                            | Record Keeping and Record Retention .......................................................................................69                                 |
| 9.9                                                                                                                                                            | Coordinating Center Documentation of Distribution                                                                                                             |
| 10 Protection of Human Subjects ............................................................................................................................70 |                                                                                                                                                               |
| 10.1                                                                                                                                                           | Protection from Unnecessary Harm.................................................................................................70                           |
| 10.2                                                                                                                                                           | Protection of Privacy ...................................................................................................................................70   |
| References .                                                                                                                                                   |                                                                                                                                                               |
| Appendices .                                                                                                                                                   |                                                                                                                                                               |
| Appendix 1: Performance Status Criteria ................................................................................................80                     |                                                                                                                                                               |
| Appendix 3: UCSF Policy/Procedure for Required Regulatory Documents for UCSF                                                                                   |                                                                                                                                                               |  
Investigator-Initiated Oncology Clinical Trials with an Investigator held Investigational New Drug (IND)
Phase II - Pembrolizumab. Vorinostat. Tamoxifen.  
Appendix 4 **Multicenter Institutional Studies**..................................................................................85 4.1Data and Safety Monitoring Plan for Multicenter Study (Phase 2 or 3 Institutional Study) .....85
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1 introduction 1.1 background on

Breast cancer is one of the most common cancers in the western hemisphere and the second most common cause of cancer death in women7. Endocrine therapy (including ovarian ablation, estrogen administration, and more recently, antiestrogen administration) has been a major component of antitumor therapy in breast cancer for more than a century8. Hormone sensitive metastatic breast cancer remains a therapeutic challenge despite the many recent advances in therapy as these tumors are frequently less sensitive to chemotherapy9. Barring a few exceptions, cure is not achieved in this disease. While hormonal interventions have clearly been shown to decrease tumor burden and to prolong life, the majority of patients eventually succumb to their disease due to disease recurrence. More than two thirds of all advanced breast cancers are dependent on estrogen. Estrogen withdrawal by physical removal of the ovaries or inhibition of their function has been one of the earliest successful interventions against breast cancer; however this intervention was limited to premenopausal women. The introduction of the SERMS (selective estrogen receptor modulators) has dramatically improved the survival of women with breast cancer, both pre and postmenopausal. The most prominent SERM is tamoxifen, which until recently has been the gold standard for first-line therapy in women with advanced hormone-sensitive breast cancer. The production of estrogen in postmenopausal women requires an enzyme called aromatase, which can be successfully blocked chemically. The introduction of several aromatase inhibitors (AIs) has added greatly to the arsenal against breast cancer and they have replaced tamoxifen as first-line therapy in the postmenopausal setting. The most commonly used aromatase inhibitors include letrozole, anastrozole and exemestane. However, the AIs are reserved for women who have naturally entered menopause or have their ovarian function suppressed. For premenopausal women or women who are unable to tolerate AIs, tamoxifen remains the gold standard. The response rate to first line hormonal therapy, determined from four pivotal randomized Phase III trials, ranges from 20-33%10,11,12,13. The response rate to second line hormonal therapy is considerably less (10-20%)10, suggesting a clear need for more effective therapy.14,15,16 Breast cancer has now been subclassified into several major subgroups: hormone therapy sensitive, hormone therapy resistant (HTR), HER2 positive (HER2+) and triple negative (TN). The treatment approaches to these clinical subtypes vastly differ. Hormone resistance has been attributed to a number of different mechanisms, namely loss of ER expression, alterations in apoptosis and cell signaling pathways, changes in ER coregulators, and the development of escape pathways17. Therefore, these women receive minimal benefit from endocrine therapy.  
The development of hormone therapy resistance is one of the most frequent causes of cancer death in women worldwide. The importance of intact immune surveillance in controlling outgrowth of neoplastic transformation has been known for decades18. Accumulating evidence shows a correlation between tumor-infiltrating lymphocytes (TILs) in cancer tissue and favorable prognosis in
Page 14 of 83 various malignancies19,20,21,22. In particular, the presence of CD8+ T-cells and the ratio of CD8+
effector T-cells / FoxP3+ regulatory T-cells correlates with improved prognosis and long-term survival in many solid tumors.  
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress immune control. The normal function of PD-1, expressed on the cell surface of activated T-cells under healthy conditions, is to down-modulate unwanted or excessive immune responses, including autoimmune reactions. PD-1 (encoded by the gene Pdcd1) is an Ig superfamily member related to CD28 and CTLA-4, which has been shown to negatively regulate antigen receptor signaling upon engagement of its ligands (PD-L1 and/or PDL2)23,24. The structure of murine PD-1 has been resolved25. PD-1 and its family members are type I transmembrane glycoproteins containing an Ig Variable-type (V-type) domain responsible for ligand binding and a cytoplasmic tail, which is responsible for the binding of signaling molecules. The cytoplasmic tail of PD-1 contains 2 tyrosine-based signaling motifs, an immunoreceptor tyrosine-based inhibition motif (ITIM) and an immunoreceptor tyrosine-based switch motif (ITSM). Following Tcell stimulation, PD1 recruits the tyrosine phosphatases SHP-1 and SHP-2 to the ITSM motif within its cytoplasmic tail, leading to the dephosphorylation of effector molecules such as CD3ζ, PKCθ and ZAP70, which are involved in the CD3 T-cell signaling cascade14,15,16,23. The mechanism by which PD-1 down modulates T-cell responses is similar to, but distinct from that of CTLA-4 as both molecules regulate an overlapping set of signaling proteins26,27. PD-1 was shown to be expressed on activated lymphocytes including peripheral CD4+ and CD8+ T-cells, B-cells, T regs and Natural Killer cells28,29. Expression has also been shown during thymic development on CD4-CD8- (double negative) T-cells, as well as subsets of macrophages and dendritic cells30. The ligands for PD-1 (PD-L1 and PD-L2) are constitutively expressed or can be induced in a variety of cell types, including non-hematopoietic tissues, as well as in various tumors26,31,32,33. Both ligands are type I transmembrane receptors containing both IgV- and IgClike domains in the extracellular region and contain short cytoplasmic regions with no known signaling motifs. Binding of either PD-1 ligand to PD-1 inhibits T-cell activation triggered through the T-cell receptor. PD-L1 is expressed at low levels on various non-hematopoietic tissues, most notably on vascular endothelium, whereas PD-L2 protein is only detectably expressed on antigen-presenting cells found in lymphoid tissue or chronic inflammatory environments. PD-L2 is thought to control immune T-cell activation in lymphoid organs, whereas PD-L1 serves to dampen unwarranted T-cell function in peripheral tissues26. Although healthy organs express little (if any) PD-L1, a variety of cancers were demonstrated to express abundant levels of this T-cell inhibitor. PD-1 has been suggested to regulate tumor-specific T-cell expansion in subjects with melanoma (MEL)34. This suggests that the PD-1/PD-L1 pathway plays a critical role in tumor immune evasion and should be considered an attractive target for therapeutic intervention.
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1.1.5 pd-1 and pd-l1 in

Inhibition of the PD-L1/PD-1 axis has been a major milestone in many cancer types. However, its relevance in breast cancer remains less clear. Expression and upregulation of PD-L1 is variable in breast cancer, and found to be high in TN and HER2+ disease. Increased PD-L1 expression has been observed in hormone therapy resistance, frequently reported with loss of the progesterone receptor (PR), a measure of hormone therapy resistance5. Hence, PD-1 inhibitors may have a role in hormone therapy resistant breast cancer. However, PD-1 inhibitors may be more effective after epigenetic immune priming. This proposal is focused on the potential role of epigenetic immune priming to reverse hormone therapy resistance (HTR) in pre and postmenopausal breast cancer. Recent data suggests that PD-L1 expression is low in a majority of patients, which may confer poor response to PD-1 or PD-L1 check point inhibitors. Preclinical in vitro and in vivo studies, including ours, suggests that HDAC inhibition using vorinostat increases PD-L1 transcription
Page 15 of 83 and cellular expression in breast cancer cells, including ER+ hormone sensitive and resistant as well as TN cells.
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1.2 background on the compounds

Tamoxifen is the most commonly used anti-estrogen or SERM. It is currently being used for the prevention of breast cancer, for ductal carcinoma in situ, in women with early stage breast cancer and for those with metastatic cancer. It is generally well tolerated and due to its extensive use, its toxicities and long-term sequelae are well characterized. Women being treated with tamoxifen may experience flushing (similar to the flushing women experience during menopause), vaginal dryness and vaginal discharge. The most serious side effect is the slightly increased risk of thromboembolic events. In a trial involving 900 women treated with either tamoxifen or letrozole, 9 out of 455 patients experienced a thromboembolic event (2%), compared to 3 patients out of 455 in the group treated with letrozole (<1%). Other side effects included hot flashes (25%), headaches (5%), fatigue (5%) and nausea (8%)13. The observation of endometrial cancer (<0.5%) has been predominantly observed when used in the preventive or adjuvant setting35. Hence, the cumulative administration of tamoxifen is rarely hampered by toxicity, but rather by the emergence of resistance suggested by clinical progression while on the drug.
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1.2.2 histone deacetylases (hdac) and

A promising new class of drugs showing activity in cancer is the histone deacetylase inhibitors
(HDACi)36,37. While these agents may have single agent activity in cancer, they may also sensitize certain cancers to other types of therapeutic agents or overcome resistance. Histone deacetylases (HDAC) function to modulate gene expression by the removal of acetyl groups from histones38,39. The addition of acetyl groups to lysine residues on the N-terminal tail of histones by histone acetyl transferases (HAT) results in the weakening of the bond between histones and DNA39. In contrast, removal of acetyl groups by HDACs results in the condensation of the nucleosomes and has been correlated with gene silencing39. HDACs can be divided into at least three different classes, I-III. Each class contains several members of structurally and functionally variable HDACs40,41. Alterations in the regulatory function of HATs and HDACs have been associated with the development of certain cancers42. For example, mutations in the HAT gene CBP have been correlated with the development of certain colorectal and gastric cancers43, whereas altered HDAC function has been associated with the onset of acute promyelocytic leukemia (APL)42. There are several inhibitors of HDACs that show anticancer activity in vitro and in vivo44. These include the short-chain fatty acids (sodium butyrate, valproic acid (VPA)), the hydroxamic acids (suberoylanilide hydroxamic acid (SAHA), trichostatin A), the cyclic tetrapeptides (depsipeptide (FK-228)) and the benzamides (MS-275). Vorinostat, FK-228, MS-275 and others are currently undergoing early clinical testing.
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1.2.3 suberoylanilide hydroxamic acid (vorinostat

Vorinostat (Suberoylanilide hydroxamic acid, SAHA; NSC 701852) is a small molecule inhibitor of histone deacetylase (HDAC) that binds directly in the enzyme's active site in the presence of a zinc ion45. Because aberrant HDAC activity has been implicated in a variety of cancers, development of HDAC inhibitors is a rational approach to the design of targeted anticancer therapeutics. Several HDAC inhibitors from multiple chemical classes have been developed and are currently in clinical trials. Trichostatin A and butyric acid were among the first HDAC inhibitors to be administered to patients, but these were found to be clinically unsuitable due to potency and formulation issues46,47. Depsipeptide was originally selected for clinical study based on its antiproliferative effects; subsequently it was discovered to antagonize HDACs and was the first HDAC inhibitor to demonstrate clinical efficacy48. Of the three classes of HDACs, vorinostat targets most human Class 1 (related to the yeast transcriptional regulator Rpd3) and Class 2 (similar to the yeast Hda1) enzymes37,49. The third class of HDACs (homologues of yeast sir2) requires NAD+ for activity and is not inhibited by vorinostat. Among those currently in clinical trials, vorinostat is the most potent HDAC inhibitor that can be administered orally with excellent bioavailability. Vorinostat was the first HDAC approved for CTCL in 2006. Vorinostat was identified originally by its ability to induce differentiation of murine erythroleukemia cells at micromolar concentrations50. Subsequently, it was found to induce differentiation or arrest growth of a wide variety of human carcinoma cells. To date, vorinostat activity has been reported in transformed hematopoietic cells, including multiple myeloma (MM), acute promyelocytic leukemia (APL), acute lymphocytic leukemia, chronic myelogenous leukemia, Waldenstrom's macroglobulinemia, and cutaneous T-cell lymphoma (CTCL)51-55.  
Activity has also been reported in cell lines representing other tumor types including bladder transitional cell carcinoma, breast cancer, prostate cancer, head and neck squamous carcinoma, and colon carcinoma56-61.  
The antitumor activity of vorinostat was demonstrated in several in vivo models of cancer, including a xenograft model of human CWR22 prostate cancer cells57, a mouse model of APL
containing the promyelocytic leukemia zinc-finger-retinoic acid receptor α fusion gene (PLZF-RARα)62, and an N-methylnitrosourea-induced mammary tumor model in rodents63. Vorinostat has also showed activity when administered daily by intraperitoneal (IP) injections in the CWR22 and PLZF-RARα models and by oral (PO) administration in the carcinogen-induced mammary tumor model.
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1.2.4 pembrolizumab/mk-3475

Refer to the Investigator's Brochure (IB) for detailed background information on MK-3475. Pembrolizumab (previously known as SCH 900475) is a potent and highly selective humanized monoclonal antibody (mAb) of the IgG4/kappa isotype designed to directly block the interaction between PD-1 and its ligands, PD-L1 and PD-L2.
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1.2.4.1 pharmaceutical and therapeutic background

The importance of intact immune surveillance in controlling outgrowth of neoplastic transformation has been known for decades [1]. Accumulating evidence shows a correlation between tumor-infiltrating lymphocytes (TILs) in cancer tissue and favorable prognosis in various malignancies [2; 3; 4; 5; 6]. In particular, the presence of CD8+ T-cells and the ratio of CD8+ effector T-cells / FoxP3+ regulatory T-cells correlates with improved prognosis and longterm survival in many solid tumors.  
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress immune control. The normal function of PD-1, expressed on the cell surface of activated T-cells under healthy conditions, is to down-modulate unwanted or excessive immune responses, including autoimmune reactions. PD-1 (encoded by the gene Pdcd1) is an Ig superfamily member related to CD28 and CTLA-4 which has been shown to negatively regulate antigen receptor signaling upon engagement of its ligands (PD-L1 and/or PD L2) [7; 8]. The structure of murine PD-1 has been resolved [9]. PD-1 and family members are type I transmembrane glycoproteins containing an Ig Variable-type (V-type) domain responsible for ligand binding and a cytoplasmic tail which is responsible for the binding of signaling molecules. The cytoplasmic tail of PD-1 contains 2 tyrosine-based signaling motifs, an immunoreceptor tyrosine-based inhibition motif (ITIM) and an immunoreceptor tyrosine-based switch motif (ITSM). Following Tcell stimulation, PD 1 recruits the tyrosine phosphatases SHP-1 and SHP-2 to the ITSM motif within its cytoplasmic tail, leading to the dephosphorylation of effector molecules such as CD3ζ, P K C θ a n d Z A P 7 0 w hi c h ar e i n v ol v e d i n t h e C D 3 T- c ell si g n ali n g c a s c a d e [ 7; 1 0; 1 1; 1 2]. T h e m e c h a ni s m b y w hi c h P D- 1 d o w n m o d ul at e s T- c ell r e s p o n s e s i s si mil ar t o, b ut di sti n ct fr o m t h at of C T L A- 4 a s b ot h m ol e c ul e s r e g ul at e a n o v erl a p pi n g s et of si g n ali n g pr ot ei n s [ 1 3; 1 4]. P D- 1 w a s s h o w n t o b e e x pr e s s e d o n a cti v at e d l y m p h o c yt e s i n cl u di n g p eri p h er al C D 4 + a n d C D 8 + Tc ell s, B- c ell s, T r e g s a n d N at ur al Kill er c ell s [ 1 5; 1 6]. E x pr e s si o n h a s al s o b e e n s h o w n d uri n g t h y mi c d e v el o p m e nt o n C D 4- C D 8- ( d o u bl e n e g ati v e) T- c ell s a s w ell a s s u b s et s of m a cr o p h a g e s a n d d e n driti c c ell s [ 1 7]. T h e li g a n d s f or P D- 1 ( P D- L 1 a n d P D- L 2) ar e c o n stit uti v el y e x pr e s s e d or c a n b e i n d u c e d i n a v ari et y of c ell t y p e s, i n cl u di n g n o n- h e m at o p oi eti c ti s s u e s a s w ell a s i n v ari o u s t u m or s [ 1 3; 1 8; 1 9; 2 0]. B ot h li g a n d s ar e t y p e I tr a n s m e m br a n e r e c e pt or s c o nt ai ni n g b ot h I g V- a n d I g C-li k e d o m ai n s i n t h e e xtr a c ell ul ar r e gi o n a n d c o nt ai n s h ort c yt o pl a s mi c r e gi o n s wit h n o k n o w n si g n ali n g m otif s. Bi n di n g of eit h er P D- 1 li g a n d t o P D- 1 i n hi bit s T- c ell a cti v ati o n tri g g er e d t hr o u g h t h e T- c ell r e c e pt or. P D- L 1 i s e x pr e s s e d at l o w l e v el s o n v ari o u s n o nh e m at o p oi eti c ti s s u e s, m o st n ot a bl y o n v a s c ul ar e n d ot h eli u m, w h er e a s P D- L 2 pr ot ei n i s o nl y d et e ct a bl y e x pr e s s e d o n a nti g e n- pr e s e nti n g c ell s f o u n d i n l y m p h oi d ti s s u e or c hr o ni c i nfl a m m at or y e n vir o n m e nt s. P D- L 2 i s t h o u g ht t o c o ntr ol i m m u n e T- c ell a cti v ati o n i n l y m p h oi d or g a n s, w h er e a s P D- L 1 s er v e s t o d a m p e n u n w arr a nt e d T- c ell f u n cti o n i n p eri p h er al ti s s u e s [ 1 3].  
Alt h o u g h h e alt h y or g a n s e x pr e s s littl e (if a n y) P D- L 1, a v ari et y of c a n c er s w er e d e m o n str at e d t o e x pr e s s a b u n d a nt l e v el s of t hi s T- c ell i n hi bit or. P D- 1 h a s b e e n s u g g e st e d t o r e g ul at e t u m ors p e cifi c T- c ell e x p a n si o n i n s u bj e ct s wit h m el a n o m a ( M E L)[ 2 1]. T hi s s u g g e st s t h at t h e P D1/ P D- L 1 p at h w a y pl a y s a criti c al r ol e i n t u m or i m m u n e e v a si o n a n d s h o ul d b e c o n si d er e d a s a n attr a cti v e t ar g et f or t h er a p e uti c i nt er v e nti o n.  
M K- 3 4 7 5 ( pr e vi o u sl y k n o w n a s S C H 9 0 0 4 7 5) i s a p ot e nt a n d hi g hl y s el e cti v e h u m a ni z e d m o n o cl o n al a nti b o d y ( m A b) of t h e I g G 4/ k a p p a i s ot y p e d e si g n e d t o dir e ctl y bl o c k t h e i nt er a cti o n b et w e e n P D- 1 a n d it s li g a n d s, P D- L 1 a n d P D- L 2 wit h o ut A D C C or C D C a cti vit y.
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1. 2. 4. 2 pr

T h er a p e uti c st u di e s i n m o u s e m o d el s h a v e s h o w n t h at a d mi ni str ati o n of a nti b o di e s bl o c ki n g P D1/ P D- L 1 i nt er a cti o n e n h a n c e s i nfiltr ati o n of t u m or- s p e cifi c C D 8 + T- c ell s a n d l e a d s ulti m at el y t o t u m or r ej e cti o n, eit h er a s a m o n o-t h er a p y or i n c o m bi n ati o n wit h ot h er tr e at m e nt m o d aliti e s.  
A nti- m o u s e P D- 1 or a nti- m o u s e P D- L 1 a nti b o di e s h a v e d e m o n str at e d a nti-t u m or r e s p o n s e s a s a m o n o-t h er a p y i n m o d el s of s q u a m o u s c ell c ar ci n o m a, p a n cr e ati c c ar ci n o m a, M E L a n d c ol or e ct al c ar ci n o m a. Bl o c k a d e of t h e P D- 1 p at h w a y eff e cti v el y pr o m ot e d C D 8 + T- c ell i nfiltr ati o n i nt o t h e t u m or a n d t h e pr e s e n c e of I F N- , gr a n z y m e B, a n d p erf ori n, i n di c ati n g t h at t h e m e c h a ni s m of a cti o n i n v ol v e d l o c al i nfiltr ati o n a n d a cti v ati o n of eff e ct or T- c ell f u n cti o n i n vi v o  
[ 2 2; 2 3; 2 4; 2 5; 2 6; 2 7]. E x p eri m e nt s h a v e c o nfir m e d t h e i n vi v o effi c a c y of P D- 1 bl o c k a d e a s a m o n o-t h er a p y a s w ell a s i n c o m bi n ati o n wit h c h e m ot h er a p y i n s y n g e n ei c m o u s e t u m or m o d el s  
( s e e t h e I n v e sti g at or' s Br o c h ur e [I B]).
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1. 2. 4. 3 pr

O n g oi n g cli ni c al tri al s ar e b ei n g c o n d u ct e d i n a d v a n c e d m el a n o m a, n o n- s m all c ell l u n g c a n c er, h e a d a n d n e c k c a n c er, ur ot h eli al tr a ct c a n c er, tri pl e n e g ati v e br e a st c a n c er, g a stri c c a n c er, a n d h e m at ol o gi c m ali g n a n ci e s. F or tri al d et ail s pl e a s e r ef er t o t h e I n v e sti g at or' s Br o c h ur e.  
P e m br oli z u m a b h a s b e e n a p pr o v e d i n m el a n o m a a n d l u n g c a n c er.
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1. 3. 1 r ati

Cli ni c all y, e pi g e n eti c i m m u n e r e g ul ati o n h a s b e e n i m pli c at e d i n pri mi n g l u n g c a n c er c ell s t o P D1 i n hi bit or s w hi c h r e s ult e d i n pr ol o n g e d r e s p o n s e s 3, 4
. T h e effi c a c y of P D- 1 i n hi bit or s h a s n ot b e e n e st a bli s h e d; h o w e v er t h e e x pr e s si o n of P D- L 1 i n E R + br e a st c a n c er i s l o w. P D- L 1 expression however has been shown to be a poor predictor of survival and PD-L1 expression has been suggested to increase as ER+ tumors become resistant to therapy. The role of epigenetic modulation has been studied extensively in breast cancer therapy.  
Several investigators have shown that HDAC inhibitors have immune modulatory functions, including modulation of Tregs, FoxP3 expression, changes in TIL expression, induction of PDL1 expression and blockage of PD-1. We have previously shown that epigenetic modulation with an HDAC inhibitor can reverse hormone therapy resistance and force cells into programmed cell death1. Based on these preclinical studies, we had proposed two clinical trials testing HDAC inhibitors with hormonal therapy in ER+ breast cancer. We hypothesize that pre-exposure of breast cancer cells to the HDAC inhibitor vorinostat (i.e., Arm A, sequential treatment) will result in down regulation of T-regulatory cells (Tregs) and FoxP3, which will increase the efficacy of PD-1 inhibitors, as measured by ORR, and prime cells to increased immune response. We therefore anticipate the schedule of administration may play an important role in the administration of this combination strategy.
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recent preclinical studies have further

In a Phase II clinical trial, we evaluated the role of vorinostat (VOR) in reversing hormone therapy resistance in advanced breast cancer2. In a single arm study, 43 patients (median age 56 years (31–71)) were treated. A total of 25 patients (58%) received prior adjuvant tamoxifen (TAM), 29 (67%) progressed on at least one prior chemotherapy regimen, 42 (98%) progressed after one, and 23 (54%) after two aromatase inhibitors. The objective response rate by RECIST criteria was 19% and the clinical benefit rate (response or stable disease >24 weeks) was 40%. The median response duration was 10.3 months (confidence interval: 8.1–12.4). Histone hyperacetylation and higher baseline HDAC2 levels correlated with response and responses were mainly seen in the 56% of patients who had a meaningful change in acetylation with vorinostat. Preclinical studies have further suggested that hormonal therapy must be continued even in the presence of an HDAC inhibitor.
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1.3.1.2 prior studies with other

A second phase II (ENCORE 301) trial evaluated entinostat and exemestane, and treated patients with advanced estrogen receptor (ER)-positive breast cancer66. This study recently received Breakthrough Therapy designation from the FDA for its potential to reverse resistance to hormonal therapies. The median PFS was 4.3 months versus 2.3 months, for entinostat and placebo, respectively (HR = 0.73; P = 0.06). The median overall survival in the combination arm was 28.1 m compared to 19.8 m in the exemestane arm (HR = 0.59; P = 0.036). The objective response rate to the combination was 6.3%, while to exemestane alone was 4.6% (P = 0.58). While these two studies cannot be compared directly, the preclinical studies and the clinical studies, as well as the current landscape of standard of care, will make the combination with tamoxifen more likely effective. The combination with tamoxifen will also allow enrollment of premenopausal women. Hence the combination of HDAC inhibitors and PD-1 inhibitors may further result in an enhancement of anti-tumor efficacy of PD-1 inhibitors6,67. Based on the established role of HDAC inhibitors in reversing hormone therapy resistance to antiestrogens and aromatase inhibitors and the provocative role of HDAC inhibitors in modulating tumor immunity, we propose to test the role of epigenetic immune priming (EIP) in acquired hormone therapy resistance.  
In a two arm Phase II trial, we will explore concurrent and sequential EIP testing two principles: Sequential priming with optimal immune activation (Arm A) and concurrent priming with maximal dosing of both epigenetic and immune modulators (Arm B).
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2.1 primary objective

a) To define the optimal approach for epigenetic immune priming in hormone refractory breast cancer on the basis of overall response rate (ORR: CR+PR+SD at 24 weeks).  
b) Safety and tolerability of vorinostat, tamoxifen and pembrolizumab
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2.2 secondary objectives

a) To define the optimal approach for epigenetic immune priming in hormone –resistant breast cancer and ER-negative tumors b) To assess duration of response (DOR) 24 week landmark progression free survival
(PFS:24)
c) Median PFS and overall survival (OS) d) Tumor responses will also be calculated by Immune Related Response-Criteria (irRC). e) To test the response of tumor PD-L1 expression to epigenetic modulation
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2.3 exploratory objectives

a) To assess for post-treatment changes in tumor-infiltrating lymphocyte (TIL) populations, PD-L1 expression and potential indicators of response. If tumor samples demonstrate that epigenetic therapy converts tumors from a low (baseline) to high TIL (posttreatment) but without a corresponding increase in ORR, then we can confidently reject our hypothesis that enhancing TILs will increase pembrolizumab efficacy in this tumor type.  
b) Acetylation of histones in PBMCs as a pharmacodynamics response marker for vorinostat.
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2.4 endpoints

Two arm study to determine the role of sequential versus epigenetic priming of ER+ breast cancer cells. A comparator arm in ER-negative tumors with biomarker endpoints
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2.4.1 primary endpoints

a) Overall response rate (CR+PR and SD at 24 weeks) b) Toxicity
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2.4.2 secondary endpoints

a) Duration of response rate b) 24 week landmark progression free survival (PFS:24), c) Median PFS and overall survival (OS), d) Tumor responses will also be calculated by Immune Related Response-Criteria (irRC) e) To test the response of PD-L1 expression to epigenetic modulation
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2.5 exploratory endpoints

To assess for post-treatment changes in TIL population, PD-L1 expression and potential indicators of response. If tumor samples demonstrate that the combination therapy converts tumors from a low (baseline) to high TIL (post-treatment) but without a corresponding increase in ORR, then we can confidently reject our hypothesis that enhancing TILs will increase pembrolizumab efficacy. Acetylation of histones in PBMCs as a response marker for vorinostat.
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3 study design 3.1 characteristics

We propose a three arm, 20-87 patient trial in patients with hormone therapy resistant breast cancer to test the optimal sequence and dosing of epigenetic immune priming in hormone therapy resistant breast cancer. The two arms all include vorinostat, TAM and pembrolizumab to evaluate either sequential priming (Arm A) or, concurrent priming with maximal dosing of both epigenetic and immune modulators in ER+ (Arm B) and ER- (Arm C?) disease. Stage 1 of the trial will evaluate 20 patients, 10 in each arm and randomly assigned. If the response rates are adequate, the trial will proceed to Stage 2 in order to evaluate 58 patients, 29 in each arm. Given the absence of responses in PD-L1 low patients to pembrolizumab, we will determine the benefits for vorinostat in reversing therapy resistance to pembrolizumab in ER-negative breast cancers (HER2-positive or negative) Patients will be evaluated for response at 12 weeks by RECIST1.1 (using IR-RECIST) and will continue on therapy if they have stable disease or response at the time of disease evaluations. Patients with progression on imaging, but are clinically stable, may stay on study but will require follow up staging after 4-6 weeks. Patients will be assessed continually for safety and tolerability as well as for any adverse events. If progression on therapy with pembrolizumab, patient may continue if clinical indicated and be re-evaluated after 4-8 weeks. We will follow AEs of clinical interest as defined by Merck and will dose modify pembrolizumab as per Merck guidelines. We have significant prior experience with vorinostat as an agent and are familiar with managing drug toxicities. In addition, we are experienced with immune-related toxicities as well. Tissue biopsies of all patients will be collected prior to enrollment to assess for pre-treatment TIL and PD-L-1 expression. A limited number of patients with disease unamenable to biopsy will be allowed to enroll in the trial with prior approval from study PI. Follow up biopsies and peripheral blood collection will be taken from all patients post-treatment, prior to starting cycle 4, to characterize changes in local tissue effects and antigen-specific cellular and humoral immune responses in peripheral blood.
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3.2 number of subjects 20-87

Patients must have baseline evaluations performed prior to the first dose of study drug and must meet all inclusion and exclusion criteria. In addition, the patient must be thoroughly informed about all aspects of the study, including the study visit schedule and required evaluations and all regulatory requirements for informed consent. The written informed consent must be obtained from the patient prior to enrollment. The following criteria apply to all patients enrolled onto the study *unless otherwise specified.*
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3.3.1 inclusion criteria

1. Pre and postmenopausal women or men with stage IV ER+ breast cancer histological or cytological confirmation
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er-positive tumors

a. Progressed after at least one line of hormonal therapy  
b. Any number of prior chemotherapy in the metastatic setting c. Any number of prior hormonal therapies. d. HER2 positive or negative
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er-negative tumors

e. PD-L1 low, high or unknown  
f. Progression after prior PD-1 or PD-L1 inhibitors allowed g. HER2 positive or negative
2. 18 years or older.  
3. Eastern Cooperative Oncology Group (ECOG) Performance Status of ≤ 2. 4. Understand and voluntarily sign an informed consent prior to any study-related assessments or procedures are conducted and are able adhere to the study visit schedule and other protocol requirements.  
5. Consent to paired tumor biopsy, for accessible tumors 6. Measureable tumor by RECIST criteria v.1.1 7. Per Good Clinical Practice, any toxicity related to prior therapies that, in the opinion of the investigator, would potentially be worsened with anti-PD1 therapy should be resolved to less than Grade 1 8. Adequate organ function within 14 days of study start:
o Absolute neutrophil count (ANC) ≥ 1.5 X 109/L
o Hemoglobin (Hgb) ≥9g/dL (may transfuse if clinically indicated) o Platelets (plt) ≥ 100 x 109/L
o Potassium within normal range, or correctable with supplements; o AST and ALT ≤2.5 x Upper Limit Normal (ULN) or ≤5.0 x ULN if liver tumor is present; o Serum total bilirubin ≤ 1.5 x ULN
o Serum creatinine ≤ 1.5 x ULN, or 24-hr clearance ≥ 60ml/min; and 9. Females of child-bearing potential (defined as a sexually mature women who):
o Has not undergone a hysterectomy (the surgical removal of the uterus) or bilateral oophorectomy (the surgical removal of both ovaries) or, o Has not been naturally postmenopausal for at least 24 consecutive months (i.e.,
has had menses at any time during the preceding 24 consecutive months).
Must have negative serum pregnancy test within 7 days before starting study treatment in females of childbearing potential (FCBP) and willingness to adhere to acceptable forms or birth control (a physician- approved contraceptive method (oral, injectable, or implantable hormonal contraceptive; tubal ligation; intra-uterine device; barrier contraceptive with spermicide; or vasectomized partner).  
10. Male subjects with female partner of childbearing potential must agree to the use of a physician-approved contraceptive method throughout the course of the study
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3.3.2 exclusion criteria

1. Any significant medical condition, laboratory abnormalities, which places the subject at unacceptable risk if he/she were to participate in the study.  
2. Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy within 2 weeks prior to study Day 1 or who has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to a previously administered agent.  
a. Note: Subjects with ≤ Grade 2 neuropathy are an exception to this criterion and may qualify for the study.  
b. Note: If subject received major surgery, they must have recovered adequately from the toxicity and/or complications from the intervention prior to starting therapy.  
c. Patients may continue on ovarian suppression 3. Has a known additional malignancy that is progressing or requires active treatment.  
Exceptions include basal cell carcinoma of the skin, squamous cell carcinoma of the skin, or in situ cervical cancer that has undergone potentially curative therapy.  
4. Any condition that confounds the ability to interpret data from the study. 5. Symptomatic central nervous system metastases. Subjects with brain metastases that have been previously treated with WBXRT and are stable for 6 weeks are allowed. Gamma or cyber knife treated lesions may enroll 2 weeks after completion if toxicities are resolved and no longer requiring steroids, patients with asymptomatic brain metastases are allowed after discussion with the study sponsor.)
6. Persistent diarrhea or malabsorption ≥ NCI CTCAE grade 2, despite medical management.  
7. Unstable angina, significant cardiac arrhythmia, or New York Heart Association (NYHA)
class 3 or 4 congestive heart failure.  
8. Prior systemic cancer-directed treatments or investigational modalities ≤ 5 half-lives or 3 weeks, whichever is shorter, prior to starting study drug or who have not recovered from side effects of such therapy (except alopecia).  
9. Has an active auto-immune disease requiring systemic treatment within the past 3 months or a documented history of clinical autoimmune disease in the past, or a syndrome that requires systemic steroids or immunosuppressive agents. Subjects with vitiligo or resolved childhood asthma/atopia would be an exception to this rule. Subjects that require intermittent use of bronchodilators or local steroid injections would not be excluded from the study. Subjects with hypothyroidism stable on hormone replacement or Sjorgen's syndrome will not be excluded from the study.  
10. Has evidence of interstitial lung disease or active, non-infectious pneumonitis. 11. Has an active infection requiring systemic therapy. 12. Has a history or current evidence of any condition, therapy, or laboratory abnormality that might confound the results of the trial, interfere with the subject's participation for the full duration of the trial, or is not in the best interest of the subject to participate, in the opinion of the treating investigator.  
13. Has known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the trial.  
14. Is pregnant or breastfeeding, or expecting to conceive or father children within the projected duration of the trial, starting with the pre-screening or screening visit through 120 days after the last dose of trial treatment. Pregnant women are excluded from this study because vorinostat, tamoxifen and PD-1 are drug classes with the potential for teratogenic or abortifacient effects. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother, breastfeeding should be discontinued if the mother is treated with vorinostat, tamoxifen and PD-1 inhibitors.  
15. Active and ongoing steroid use, except for non-systemically absorbed treatments (such as inhaled or topical steroid therapy for asthma, COPD, allergic rhinitis).  
16. Major surgery ≤ 2 weeks prior to starting a study drug or who have not recovered from side effects of such therapy.  
17. Known hypersensitivity to pembrolizumab or any of its insipients. 18. Has received a live vaccine within 30 days prior to the first dose of trial treatment.
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3.4 duration of therapy

In the absence of treatment delays due to adverse events, treatment may continue for 24 months or until:
Clearly documented disease progression Inter-current illness that prevents further administration of treatment Unacceptable adverse event(s) Patients decides to withdraw from the study Significant patient non-compliance with protocol General or specific changes in the patients' condition render the patient unacceptable for further treatment in the judgment of the investigator.  
Patients may receive palliative radiation therapy for isolated symptomatic lesions A subject must be discontinued from the trial for any of the following reasons:
· The subject or legal representative (such as a parent or legal guardian) withdraws consent.  
· Confirmed radiographic disease progression
Note: For unconfirmed radiographic disease progression, but clear clinical progression in the opinion of the treating physician or investigator, the patient should be withdrawn from study for progression. Note: A subject may be granted an exception to continue on treatment with confirmed radiographic progression if clinically stable or clinically improving by symptoms or tumor markers. Unacceptable adverse experiences as described in Section 7.4
· Intercurrent illness that prevents further administration of treatment  
· Investigator's decision to withdraw the subject · The subject has a confirmed positive serum pregnancy test · Noncompliance with trial treatment or procedure requirements · The subject is lost to follow-up
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3.5 duration of follow up

Patients will be followed for 30 days after completion of treatment or removal from study Patients removed from study for unacceptable treatment related adverse event(s) will be followed until resolution or stabilization of all treatment related adverse events to Grade 2 or lower. Subjects who discontinue for reasons other than progressive disease will have post-treatment follow-up for disease status until disease progression, initiating a non-study cancer treatment, withdrawing consent or becoming lost to follow-up. After documented disease progression each subject will be followed by telephone for overall survival until death, withdrawal of consent, or the end of the study, whichever occurs first. Subjects may withdraw consent at any time for any reason or be dropped from the trial at the discretion of the investigator should any untoward effect occur. In addition, a subject may be withdrawn by the investigator or the Sponsor if enrollment into the trial is inappropriate, the trial plan is violated, or for administrative and/or other safety reasons. Specific details regarding discontinuation or withdrawal are provided in Section 6.2.7
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3.6 randomization procedures

This is an open-label randomized trial; therefore, the Sponsor, investigator and subject will know the treatment administered. Two arms will be tested, with each independent assessment. Patients will be randomized to either arm using a computerized randomization program by Dr. Scott Thomas. Patients will be further stratified by prior number of chemo- and hormonal therapies. No randomization is required for ER-negative patients (patients must have biopsiable disease)
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3.7 study timeline

Trial treatment should be administered on Day 1 of each cycle after all procedures/assessments have been completed as detailed on the Trial Flow Chart (Section 5.1). Trial treatment may be administered up to 3 days before or after the scheduled Day 1 of each cycle due to administrative reasons. All trial treatments will be administered on an outpatient basis. pembrolizumab will be administered as a 30 minute IV infusion (treatment cycle intervals may be increased due to toxicity as described in Section 5.2.1.2). Sites should make every effort to target infusion timing to be as close to 30 minutes as possible. However, given the variability of infusion pumps from site to site, a window of -5 minutes and +10 minutes is permitted (i.e., infusion time is 30 minutes: -5 min/+10 min) .
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3.7.1 clinical criteria for early

Early trial termination will be the result of the criteria specified below:  
1. Quality or quantity of data recording is inaccurate or incomplete 2. Poor adherence to protocol and regulatory requirements 3. Incidence or severity of adverse drug reaction in this or other studies indicates a potential health hazard to subjects 4. Plans to modify or discontinue the development of the study drug
In the event of Merck decision to no longer supply study drug, ample notification will be provided so that appropriate adjustments to subject treatment can be made.
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4 study drugs 4.1 description

Tamoxifen is available in the following doses for oral administration.  
· 10 mg Tablets. Each tablet contains 15.2 mg of tamoxifen citrate, which is equivalent to 10 mg of tamoxifen.  
· 20 mg Tablets. Each tablet contains 30.4 mg of tamoxifen citrate, which is equivalent to 20 mg of tamoxifen.
The administered dose will be 20 mg daily. Classification Non-steroidal anti-estrogen
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mechanism of action

Following a single oral dose of 20 mg tamoxifen, an average peak plasma concentration of 40 ng/mL (range 35 to 45 ng/mL) occurred approximately 5 hours after dosing. The decline in plasma concentrations of tamoxifen is biphasic with a terminal elimination half-life of about 5 to 7 days. The average peak plasma concentration of N-desmethyl tamoxifen is 15 ng/mL (range 10 to 20 ng/mL). Chronic administration of 10 mg tamoxifen given twice daily for 3 months to patients results in average steady-state plasma concentrations of 120 ng/mL (range 67-183 ng/mL) for tamoxifen and 336 ng/mL (range 148-654 ng/mL) for N-desmethyl tamoxifen. The average steady-state plasma concentrations of tamoxifen and N-desmethyl tamoxifen after administration of 20 mg tamoxifen once daily for 3 months are 122 ng/mL (range 71-183 ng/mL) and 353ng/mL (range 152-706 ng/mL), respectively. After initiation of therapy, steady state concentrations for tamoxifen are achieved in about 4 weeks and steady-state concentrations for N-desmethyl tamoxifen are achieved in about 8 weeks, suggesting a half-life of approximately 14 days for this metabolite. In a steady state, crossover study of 10 mg NOLVADEX tablets given twice a day vs. a 20 mg NOLVADEX tablet given once daily, the 20 mg NOLVADEX tablet was bioequivalent to the 10 mg NOLVADEX tablets.
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metabolism

Tamoxifen is extensively metabolized after oral administration. N-desmethyl tamoxifen is the major metabolite found in patients' plasma. The biological activity of N-desmethyl tamoxifen appears to be similar to that of tamoxifen. 4-Hydroxytamoxifen and a side chain primary alcohol derivative of tamoxifen have been identified as minor metabolites in plasma. Tamoxifen is a substrate of cytochrome P-450 3A, 2C9 and 2D6, and an inhibitor of P-glycoprotein.
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excretion

Studies in women receiving 20 mg of 14C tamoxifen have shown that approximately 65% of the administered dose was excreted from the body over a period of 2 weeks with fecal excretion as the primary route of elimination. The drug is excreted mainly as polar conjugates, with unchanged drug and unconjugated metabolites accounting for less than 30% of the total fecal radioactivity. Drug-drug Interactions: In vitro studies showed that erythromycin, cyclosporin, nifedipine and diltiazem competitively inhibited formation of N-desmethyl tamoxifen with apparent K1 of 20, 1, 45 and 30 μM, respectively. The clinical significance of these in vitro studies is unknown.
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how supplied

Tamoxifen (generic) is commercially available. (AstraZeneca has discontinued the commercial manufacture and distribution of branded NOLVADEX® tablets in the United States as of June 2006) Contraindications: Tamoxifen is contraindicated in patients with known hypersensitivity to the drug or any of its ingredients. Complete and updated adverse event information is available in the Investigational Drug Brochure and product package insert.
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4.1.2 investigational drug vorinostat (zolinza

Vorinostat is available in size 3 capsules containing 100 mg of Vorinostat for administration. Classification Antineoplastic Mechanism of Action Vorinostat, a histone deacetylase (HDAC) inhibitor. Histone deacetylases (HDACs) are a family of enzymes that regulate chromatin remodeling and gene transcription via the dynamic process of acetylation and deacetylation of core histones. Vorinostat, a potent inhibitor of HDAC activity, binds directly to the catalytic pocket of HDAC enzymes. It causes G1 or G2 phase cell-cycle arrest, apoptosis, or differentiation in cultured transformed cells
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storage

Store vorinostat capsules at room temperature, 15 to 30 .C (59 to 86 .F). Do not store above 30.C. Avoid exposure to excessive moisture.
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method of administration

Unless otherwise stated in the protocol, vorinostat capsules must be administered whole. Administer doses of vorinostat with food, if possible.
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potential drug interactions

The major pathways of vorinostat metabolism involve glucuronidation and β-oxidation. As vorinostat is not eliminated via CYP450 pathways, no drug-drug interactions are expected with known CYP450 inhibitors or inducers. Although vorinostat was not a potent reversible CYP450 inhibitor, studies performed to monitor gene expression changes indicated some potential for CYP2C9 and CYP3A4 activity suppression. However, these changes were observed at concentrations higher than the pharmacologically relevant concentration of 2 μM (Cmax). Prothrombin time and INR prolongations have been reported in patients taking vorinostat concomitantly with coumarin derivative anticoagulants. Monitor these patients more frequently for alterations in their coagulation parameters. Special Handling: Vorinostat is an anticancer drug. If clean powder is spilt from broken or damaged vorinostat capsules care should be taken to minimize inhalation or direct contact with skin. Wash spill area at least 3 times with ethyl alcohol, followed by water.
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patient care implications

Because vorinostat's dose limiting toxicities are anorexia, dehydration, diarrhea, and fatigue, patients should maintain adequate fluid and food intake. Encourage patients to seek a nutritional consult. Treat diarrhea promptly with appropriate supportive care, including loperamide. Instruct patients to begin taking loperamide at the first signs of: 1) poorly formed or loose stool, 2) occurrence of more bowel movements than usual in one day, or 3) unusually high volume of stool. Loperamide should be taken in the following manner: 4 mg at first onset of diarrhea, then 2 mg after each unformed stool. Daily dose should not exceed 16 mg/day. Loperamide should not be taken prophylactically. Advise patients to drink plenty of clear fluids to help prevent dehydration caused by diarrhea. Avoid loperamide if there is the presence of blood or mucus in the stool or if diarrhea is accompanied by fever. If grade 3 or 4 diarrhea develops, discontinue further treatment with vorinostat. Patients should not have taken valproic acid, another histone deacetylase inhibitor, for at least 2 weeks prior to study enrollment.
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how supplied

Vorinostat is supplied by Merck & Co., Inc. Vorinostat will be provided in a 100-120 tablet bottle. For the purpose of this study, vorinostat will be given at 400 mg per day (4x 100 mg tablets), 5 of 7 days. Please refer to complete prescribing information in the FDA packet insert for storage and handling.
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4.1.3 investigational drug mk-3475 (pembrolizumab)

Pembrolizumab will be available in 100mg solution in a single use-vial for intravenous administration. Classification Antineoplastic
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mechanism of action

Pembrolizumab (previously known as SCH 900475) is a potent and highly selective humanized monoclonal antibody (mAb) of the IgG4/kappa isotype designed to directly block the interaction between PD-1 and its ligands, PD-L1 and PD-L2. This blockade enhances functional activity of the target lymphocytes to facilitate tumor regression and ultimately immune rejection.
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contraindications none availability

Pembrolizumab is an investigational agent supplied by Merck, for storage and application please refer to lab manual.
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summary

The programmed cell death 1 (PD-1) pathway represents a major immune control switch which may be engaged by tumor cells to overcome active T-cell immune surveillance. MK-3475 (Pembrolizumab, previously known as SCH 900475) is a potent and highly selective humanized monoclonal antibody (mAb) of the IgG4/kappa isotype designed to directly block the interaction between PD-1 and its ligands, PD-L1 and PD-L2. This blockade enhances functional activity of the target lymphocytes to facilitate tumor regression and ultimately immune rejection.  
Page 29 of 83 Merck is studying pembrolizumab for various oncology indications. An open-label Phase I study is being conducted to evaluate the safety and clinical activity of pembrolizumab when administered as monotherapy. The dose escalation portion of this study evaluated three dose levels of single agent pembrolizumab (1 mg/kg, 3 mg/kg, and 10 mg/kg), in patients with advanced solid tumors. All three dose levels were well tolerated and no dose-limiting toxicities (DLTs) were observed, therefore the maximum tolerated dose (MTD) has not been determined. The ongoing expansion part of this study is evaluating pembrolizumab in patients with melanoma (MEL) and non-small cell lung cancer (NSCLC). In a Phase II study, is also being conducted to evaluate the safety and clinical activity of pembrolizumab relative to standard of care chemotherapy in melanoma. In a randomized, controlled, open-label, three-arm Phase III pivotal study is being conducted to evaluate two dosing regimens of pembrolizumab versus ipilimumab (IPI) in patients with unresectable or metastatic MEL who have not received IPI treatment. Protocol 010 (PN010), a randomized, adaptively designed Phase II/III trial is being conducted to evaluate two dosing schedules of pembrolizumab (10 mg/kg Q3W or 2 mg/kg Q3W) versus docetaxel in patients with NSCLC with PD-L1 positive tumors who have experienced disease progression after platinum-containing systemic therapy. In an open-label, non-randomized, Phase I study is evaluating pembrolizumab alone in Japanese patients with advanced solid tumors and in combination with cisplatin/pemetrexed and carboplatin/paclitaxel in patients with advanced NSCLC. The combination therapy portion of the trial had not yet initiated as of 18-Oct-2013. In a nonrandomized, multi-cohort trial is evaluating pembrolizumab 10 mg/kg Q2W in patients with PD-L1 positive advanced solid tumors. Cohort A is enrolling patients with triple negative breast cancer, Cohort B is enrolling patients with squamous cell carcinoma of the head and neck, Cohort C is enrolling patients with urothelial tract cancer of the renal pelvis, ureter, bladder, or urethra. As of the cut-off date of 18-Oct-2013, Cohort D which will enroll patients with adenocarcinoma of the stomach or gastroesophageal junction had not yet initiated. Safety data are continuing to accumulate in the clinical development program across multiple indications; immune-related adverse events (irAEs) are expected based on the nature of the compound, its mechanism of action and reported experience with immunotherapies that have a similar mechanism of action.
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nonclinical pharmacology

Pembrolizumab strongly enhances T-lymphocyte immune responses in cultured blood cells from healthy human donors, cancer patients, and primates. In T-cell activation assays using human donor blood cells, the EC50 (concentration where 50% of the maximum effect is achieved) has been ~0.1 to 0.3 nM. In addition to interleukin-2 (IL-2), tumor necrosis factor alpha (TNFα), interferon gamma (IFNΩ), and levels of other cytokines were modulated by pembrolizumab. The antibody potentiates existing immune responses only in the presence of antigen and does not nonspecifically activate T-cells. Using an anti-murine PD-1 analog antibody, PD-1 blockade has been shown to significantly inhibit tumor growth in a variety of syngeneic murine tumor models. In these experiments in mice, anti-PD-1 therapy is synergistic with chemotherapeutic agents such as gemcitabine and 5-fluorouracil (5-FU) and combination therapy results in increased complete tumor regression rates in vivo.
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nonclinical pharmacokinetics

After intravenous (IV) administration of pembrolizumab to cynomolgus monkeys, systemic exposure to pembrolizumab independent of sex, increased with increasing dose. Systemic exposure for the 7-day dosing interval increased after repeated dosing from 40 to 200 mg/kg. Area under the concentration-time curve (AUC) for the 7-day dosing interval (AUC[0-7 days])
after one dose appeared to be dose-proportional from 0.3 to 200 mg/kg, suggesting doseindependent pharmacokinetics (PK). Terminal half-life (t½) values from individual animals after repeated IV dosing ranged from 11.8 to 23.7 days (mean values ranged from 15.7 to 22.3 days) across the doses tested. Safety Pharmacology/Toxicology The potential for systemic toxicity of pembrolizumab was assessed in a 1-month repeat-dose toxicity study with a 4-month recovery in cynomolgus monkeys and in a 6-month repeat dose toxicity study with a 4-month recovery period in cynomolgus monkeys. In the 1- month toxicity study, cynomolgus monkeys were administered an IV dose of 6, 40, or 200 mg/kg once weekly for a total of five doses. Four monkeys/sex/group were euthanized during Week 5. The remaining two monkeys/sex/group were euthanized during Week 23, after a four-month postdose period. In this study, pembrolizumab was well tolerated in monkeys with the systemic exposure (AUC) up to approximately 170,000 μg/ day/mL over the course of the study. There was no test article-related mortality, and test article-related changes were limited to an increased incidence of inguinal swelling, and increased splenic weights in males receiving 200 mg/kg. Both of these findings were not considered adverse and there was no histopathologic correlation. Splenic weights were normal at the post-dose necropsy. Anti-pembrolizumab antibodies were detected in seven (out of eight) animals in the 6 mg/kg dose group and one (out of eight) animal in the 40 mg/kg dose group, and were associated with an apparent increase in clearance of pembrolizumab. The presence of anti-drug antibodies (ADA) in monkeys in the low-dose group and in one monkey in the mid-dose group did not impact the pharmacodynamic response as sufficient target engagement was demonstrated for the duration of the study (with the exception of one low-dose monkey). Additionally, anti-pembrolizumab antibodies were not detected in any monkeys in the high-dose group, suggesting that potential toxicity has been evaluated at the highest exposure levels in the study. Based on the lack of adverse test articlerelated findings in this study, the No Observable Adverse Effect Level (NOAEL) was ≥200 mg/kg. In the 6-month toxicity study, the potential for systemic toxicity was assessed in cynomolgus monkeys administered an IV dose of 6, 40, or 200 mg/kg once every other week for approximately 6 months (a total of 12 doses) followed by a 4-month treatment free period. Three animals/sex/group were designated for interim necropsy at the end of the 6-month dosing phase (3 days after receiving the last dose in Study Week 23); and the remaining monkeys were designated for final necropsy following the 4-month treatment-free period. Pembrolizumab was well tolerated at all dose levels. There were no test article-related antemortem findings. There were no test article-related electrocardiographic or ophthalmic findings. There were no test article-related changes at injection sites. There were no test article-related gross observations or organ weight changes at the interim or final necropsy. Since there were no test article-related histomorphologic findings at interim necropsy, histomorphologic evaluation of tissues collected at final necropsy were not conducted. The presence of ADA was observed in five out of ten animals at 6 mg/kg/dose during the dosing phase, which correlated with an apparent increased rate of elimination of pembrolizumab in these animals. No anti-pembrolizumab antibodies were detected at 40 or 200 mg/kg/dose during the dosing phase, and no MK-3475 serum concentration profiles in these two groups suggested an effect of ADA on pembrolizumab elimination rate. During the treatment-free period, anti-pembrolizumab antibodies were detected in two animals at 6 mg/kg/dose, which already had ADA present during the dosing phase, and in two additional animals (one at 6 mg/kg/dose and one at 200 mg/kg/dose), which were ADA negative during the dosing phase. The detection of anti-pembrolizumab antibodies had a minimal effect on the mean group systemic exposure to pembrolizumab during the study and
Page 31 of 83 did not impact the evaluation of potential toxicity of MK- 3475 for the duration of the 6-month study as there were no test article-related effects on any of the parameters examined and as no monkey in the mid- and high-dose groups developed ADA during the dosing phase. In conclusion, pembrolizumab administered once every other week over a 6-month duration to cynomolgus monkeys was well tolerated and the no observed effect level (NOEL) was ≥200 mg/kg/dose (the highest dose tested). In addition, tissue cross-reactivity studies using monkey and human specimens were conducted to evaluate the potential cross reactivity of pembrolizumab with cryosections of cynomolgus monkey tissues and normal human tissues. Results demonstrated the expected on-target staining of the membranes of mononuclear leukocytes in both species. The off-target staining (cytoplasmic and stromal) that occurred in many tissues of both species was considered spurious binding inherent to the experimental conditions of the in vitro tissue cross reactivity studies with no *in vivo* toxicological significance. Clinical Development Clinical data from PN001 is presented in ths report with a visit cut-off date of 26-Jul-2013. As of 26-Jul-2013, there have been 789 patients treated in PN001 with pembrolizumab as a 30minute IV infusion. Of these 789 patients, preliminary data are presented in this report from 479 patients. Data from 200 patients in Part B3 and 110 patients in Part F that were treated as of the cut-off data were not included in the analyses yet. Based upon this safety database consisting of patients treated up to 10 mg/kg once every two to three weeks, pembrolizumab has been generally well-tolerated at doses up to 10 mg/kg every other week without DLTs. One (0.002%) patient assayed to date had samples confirmed positive for ADA, but no impact on safety has been observed. Five other clinical studies (PN002, PN006, PN010, PN011, and PN012) are ongoing however preliminary data analyses are not yet available. Important safety findings from these studies will be discussed in Section 5 of this report. For these 5 studies, the number of treated patients indicated in this report is based on a visit cut-off date of 18-Oct-2013 to allow for more mature enrollment data and align with the Development Safety Update Report data cutoff date. Pembrolizumab PK results have been obtained from PN001 following the first dose at 1, 3 and 10 mg/kg IV of pembrolizumab administered to 17 patients with solid tumors. The observed pharmacokinetic profile of pembrolizumab was typical of other IgG mAbs with a half-life (t½) of approximately 2 to 3 weeks. There was no indication of dose dependency of half-life in the 3 dose groups and a dose related increase in exposure was observed from 1 to 10 mg/kg. The long half-life supports a dosing interval of every 2 or 3 weeks. Exposure obtained with sparse sampling after dosing melanoma and non-small cell lung cancer (NSCLC) patients at 2 and 10 mg/kg, every 2 or 3 weeks, is consistent with this profile. As of 18-Oct-2013, PN002 has randomized 497 patients with metastatic melanoma (495 patients were treated) across 3 treatment groups as follows, pembrolizumab 2 mg/kg Q3W, pembrolizumab 10 mg/kg Q3W, and chemotherapy (investigator choice of treatment) in a 1:1:1 ratio. PN006 has randomized 68 IPI-naïve patients with unresectable or metastatic melanoma across the 3 treatment groups: 10 mg/kg Q2W, 10 mg/kg Q3W, and ipilimumab in a 1:1:1 ratio. PN010 has randomized three patients with NSCLC across the 3 treatment groups: 10 mg/kg Q3W, 2 mg/kg Q3W, and docetaxel 75 mg/m2 Q3W in a 1:1:1 ratio. In PN011 10 patients have been treated. In PN012, 109 patients have been treated across the three cohorts as of 18-Oct2013.
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4.3 drug ordering

UCSF will obtain pembrolizumab (MK-3475) directly from Merck as study supply.
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4.4 packaging and labeling of

Drugs will be packaged and labeled per UCSF institutional standards, adhering to applicable local and federal laws.
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5 treatment plan 5.1 dosage

The dose regimen of 200 mg Q3W of pembrolizumab is planned for all urothelial cancer trials. Available PK results in subjects with melanoma, NSCLC, and other solid tumor types support a lack of meaningful difference in PK exposures obtained at a given dose among tumor types. An open-label Phase 1 trial (PN001) in melanoma subjects is being conducted to evaluate the safety and clinical activity of single agent pembrolizumab. The dose escalation portion of this trial evaluated three dose levels, 1 mg/kg, 3 mg/kg, and 10 mg/kg, administered every 2 weeks (Q2W) in subjects with advanced solid tumors. All three dose levels were well tolerated and no dose-limiting toxicities were observed. This first in human study of pembrolizumab showed evidence of target engagement and objective evidence of tumor size reduction at all dose levels (1 mg/kg, 3 mg/kg and 10 mg/kg Q2W). No maximum tolerated dose (MTD) has been identified. In KEYNOTE-001, two randomized cohort evaluations of melanoma subjects receiving pembrolizumab at a dose of 2 mg/kg versus 10 mg/kg Q3W have been completed. The clinical efficacy and safety data demonstrate a lack of clinically important differences in efficacy response or safety profile at these doses. For example, in Cohort B2, advanced melanoma subjects who had received prior ipilimumab therapy were randomized to receive pembrolizumab at 2 mg/kg versus 10 mg/kg Q3W. The overall response rate (ORR) was 26% (21/81) in the 2mg/kg group and 26% (25/79) in the 10 mg/kg group (full analysis set (FAS)). The proportion of subjects with drug-related adverse events (AEs), grade 3-5 drug-related AEs, serious drugrelated AEs, death or discontinuation due to an AE was comparable between groups or lower in the 10 mg/kg group. Available pharmacokinetic results in subjects with melanoma, NSCLC, and other solid tumor types support a lack of meaningful difference in pharmacokinetic exposures obtained at a given dose among tumor types. Population PK analysis has been performed and has confirmed the expectation that intrinsic factors do not affect exposure to pembrolizumab to a clinically meaningful extent. Taken together, these data support the use of lower doses (with similar exposure to 2 mg/kg Q3W) in all solid tumor indications. 2 mg/kg Q3W is being evaluated in NSCLC in PN001, Cohort F30 and PN010, and 200 mg Q3W is being evaluated in head and neck cancer in PN012, which are expected to provide additional data supporting the dose selection. Selection of 200 mg as the appropriate dose for a switch to fixed dosing is based on simulation results indicating that 200 mg will provide exposures that are reasonably consistent with those obtained with 2 mg/kg dose and importantly will maintain individual patient exposures within the exposure range established in melanoma as associated with maximal clinical response. A population PK model, which characterized the influence of body weight and other patient covariates on exposure, has been developed using available data from 476 subjects from PN001. The distribution of exposures from the 200 mg fixed dose are predicted to considerably overlap those obtained with the 2 mg/kg dose, with some tendency for individual values to range slightly higher with the 200 mg fixed dose. The slight increase in PK variability predicted for the fixed dose relative to weight-based dosing is not expected to be clinically important given that the range of individual exposures is well contained within the range of exposures shown in the melanoma studies of 2 and 10 mg/kg to provide similar efficacy and safety. The population PK evaluation revealed that there was no significant impact of tumor burden on exposure. In addition, exposure was similar between the NSCLC and melanoma indications. Therefore, there are no anticipated changes in exposure between different tumor types and indication settings.
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table 5.1 regimen description arm

| Study Drug           | Dose                  | Route   | Schedule            | Cycle Length      |
|----------------------|-----------------------|---------|---------------------|-------------------|
| Tamoxifen            | 20                    | mg      |                     |                   |
| Tablets              | Oral                  | daily   | continuous          | All               |
| cycles               |                       |         |                     |                   |
| Vorinostat           | 400 mg                | Oral    | Days 5/7 All cycles | 3 weeks (21 days) |
| Day 1, week 1        |                       |         |                     |                   |
| Pembrolizumab 200 mg | Intravenous Cycles 1+ |         |                     |                   |
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arm b (figure 1)

| Study Drug          | Dose              | Route                        | Schedule            | Cycle Length      |
|---------------------|-------------------|------------------------------|---------------------|-------------------|
| Tamoxifen           | 20mg Tablets Oral | daily continuous  All cycles |                     |                   |
| Vorinostat          | 400mg             | Oral                         | Days 5/7 All cycles | 3 weeks (21 days) |
| Pembrolizumab 200mg | Intravenous       | Day 1, week 1 Cycles 2+      |                     |                   |
| Arm C (Figure 1)    |                   |                              |                     |                   |  
| Study Drug           | Dose                  | Route   | Schedule            | Cycle Length      |
|----------------------|-----------------------|---------|---------------------|-------------------|
| Vorinostat           | 400 mg                | Oral    | Days 5/7 All cycles | 3 weeks (21 days) |
| Day 1, week 1        |                       |         |                     |                   |
| Pembrolizumab 200 mg | Intravenous Cycles 1+ |         |                     |                   |
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5.1.1 dose modifications and dosing

The following dose modification rules will be used with respect to potential toxicity. Toxicity will be assessed continuously according to the NCI Common Terminology Criteria for Adverse Events Version 4.0 (CTCAE v4.0) The following dose modifications should be made for febrile neutropenia, and blood counts obtained on day one of each cycle. If more than one of these conditions applies, use the most stringent (i.e., the greatest dose reduction). The AE may be due to pembrolizumab or
Page 34 of 83 vorinostat alone in which case the respective agent should be reduced. If overlapping toxicity is suspected both drugs may be reduced with the potential to re-escalate the non-offending agent. Given the very different nature of pembrolizumab and vorinostat/tamoxifen toxicities, separate tables are shown for individual agents. No dose modification will be pursued for tamoxifen.
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5.1.1.1 dose modifications and dosing

Hematologic toxicity  
| Neutropenia: Neutropenia                                                                                                                                  | Vorinostat                       | Tamoxifen   |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------|-------------|
| Febrile neutropenia ANC >1000                                                                                                                             | 100%                             | 100%        |
| ANC: 500-1000                                                                                                                                             | Hold for until <grade 2 # ,      | 100%        |
| Restart at 75%: 300 mg qd for all  subsequent cycles Second occurrence resume at 200 mg  qd for all subsequent cycles Third occurrence: remove from study |                                  |             |
| ANC: 0-500                                                                                                                                                | Hold for until <grade 2 or less# | 100%        |
| Restart at 75%: 300 mg qd for all  subsequent cycles Second occurrence resume at 200 mg  qd for all subsequent cycles Third occurrence: remove from study |                                  |             |  
\#Patient with a dose delay for more than 3 weeks in the first 2 cycles will need to be replaced for toxicity and efficacy assessments. Patients who developed a second episode of **febrile neutropenia** despite a dose modification will be removed from study. Anemia  
| Hemoglobin   | Vorinostat       | Tamoxifen   |
|--------------|------------------|-------------|
| >8 mg/dl     | 100 %: 400 mg qd | 100%        |  
6.5-8 mg/dl 75 %: 300 mg qd 100%  
<6.5 mg/dl 50 %: 200 mg qd 100%  
An alternative to dose modification would be the use of PRBC transfusion. This is not allowed in cycle one, but may be used at the discretion of the treating physician for subsequent cycles.
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thrombocytopenia non-hematological toxicities

Laboratory abnormalities must be clinically relevant and dose and drug related to prompt dose modifications.  
| Thrombocytopenia Platelets                                                                                                                                  | Vorinostat                  | Tamoxifen   |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------|-------------|
| >75'000                                                                                                                                                     | 100 %: 400 mg qd            | 100%        |
| <75'000                                                                                                                                                     | 100 %: 400 mg qd            | 100%        |
| ≤50'000/mm3                                                                                                                                                 | Hold until <grade 2 or less | 100%        |
| Restart at 75%: 300 mg qd for all  subsequent cycles Second occurrence resume at  200 mg qd for all subsequent  cycles Third occurrence: remove from  study |                             |             |
| ≤25'000/mm3                                                                                                                                                 | Hold until <grade 2 or less | 100%        |
| Restart at 75%: 300 mg qd for all  subsequent cycles Second occurrence resume at  200 mg qd for all subsequent  cycles Third occurrence: remove from  study |                             |             |  
Page 36 of 83  
| Bilirubin       | Vorinostat       | Tamoxifen   |
|-----------------|------------------|-------------|
| ≤1.5 mg/dl      | 100 %: 400 mg qd | 100%        |
| 1.6  3.0 mg/dl | 75 %: 300 mg qd  | 100%        |  
| >3.0 mg/dl                                                                                          | First occurrence: hold until <grade 2, 75 %:  300 mg qd  100%  Second occurrence: Hold until grade 2 or  less, 50 %: 200 mg qd   |             |      |       |        |    |
|-----------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------|-------------|------|-------|--------|----|
| AST/ALT                                                                                             | Vorinostat                                                                                                                       | Tamoxifen   |      |       |        |    |
| ≤2.5 x ULN                                                                                          | 100 %: 400 mg qd                                                                                                                 | 100%        |      |       |        |    |
| 2.5-5 x ULN                                                                                         | First occurrence: 75 %: 300 mg qd                                                                                                | 100%        |      |       |        |    |
| Second occurrence: 50 %: 200 mg qd                                                                  |                                                                                                                                  |             |      |       |        |    |
| > 5 x ULN                                                                                           | First                                                                                                                            | occurrence: | hold | until | <grade | 2, |
| resume at 75 %: 300 mg qd                                                                           | 100%                                                                                                                             |             |      |       |        |    |
| Second occurrence: Hold until grade 2 or  less, 50 %: 200 mg qd Third occurrence: remove from study |                                                                                                                                  |             |      |       |        |    |
| Hepatic Dysfunction: Any new increase in LFTs should raise the concern to rule out                  |                                                                                                                                  |             |      |       |        |    |  
Hepatic Dysfunction: Any new increase in LFTs should raise the concern to rule out progressive metastatic disease. If the rise is not due to progressive metastatic disease, give the following dose based on lab values obtained on day 1 of each cycle: Effects on the liver: Tamoxifen has been associated with changes in liver enzyme levels, and on rare occasions, a spectrum of more severe liver abnormalities including fatty liver, cholestasis, hepatitis and hepatic necrosis. A few of these serious cases included fatalities. In most reported cases, the relationship to tamoxifen was uncertain. However, some positive rechallenges and dechallenges have been reported. If grade 3 or 4 liver toxicity is maintained after a temporary stopping of vorinostat, both drugs should be stopped. Any rechallenge should be discussed with the study chair. **If treatment is delayed for more than 3 weeks, contact the** Principle Investigator.
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gastrointestinal toxicity

Nausea/Vomiting/Dehydration: In this protocol, the routine use of any and all anti-emetics is allowed as clinically appropriate; these include the use of dexamethasone and 5-HT3 receptor antagonists. Patients should maintain adequate fluid and food intake because vorinostat's dose-limiting toxicities are anorexia, dehydration, diarrhea, and fatigue. In the setting of dysgeusia, popsicles and Gatorade have been found to be useful by some investigators to maintain adequate hydration. Patients should also be encouraged to seek a nutritional consult. Diarrhea: Treat diarrhea promptly with appropriate supportive care, including loperamide. Instruct patients to begin taking loperamide at the first signs of: 1) poorly formed or loose stool, 2) occurrence of more bowel movements than usual in one day, or 3) unusually high volume of stool. Loperamide should be taken in the following manner: 4 mg at first onset of diarrhea then 2 mg after each unformed stool. The daily dose should not exceed 16 mg. Loperamide should not be taken prophylactically. Advise patients to drink plenty of clear fluids to help prevent dehydration caused by diarrhea. Avoid loperamide if there is the presence of blood or mucus in the stool or if diarrhea is accompanied by fever. If diarrhea is suspected to be linked to pembrolizumab and is ≥ grade 3, hold dose until toxicity resolves to ≤ grade 1, then resume at dose given in prior cycle.
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other non-hematological toxicities

Laboratory abnormalities must be clinically relevant and dose and drug related to prompt dose modifications. Give the following dose based on the worst toxicity encountered during the previous cycle:  
| Fatigue                                      | Vorinostat                                                                                                                                                                              | Tamoxifen   |          |        |         |      |
|----------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------|----------|--------|---------|------|
| Grade 1                                      | 100%                                                                                                                                                                                    | 100%        |          |        |         |      |
| Grade 2                                      | Hold until toxicity is ≤grade 1, then resume at                                                                                                                                         | 100%        |          |        |         |      |
| dose given in prior cycle.                   |                                                                                                                                                                                         |             |          |        |         |      |
| Grade 3, 4                                   | Hold until toxicity is ≤ grade 1, then resume at  75% (or less) of dose given in the prior cycle.                                                                                       | 100%.       |          |        |         |      |
| If                                           | grade                                                                                                                                                                                   | 3           | toxicity | recurs | despite | dose |
| reduction, decrease to 50 % of initial dose. |                                                                                                                                                                                         |             |          |        |         |      |
| Other                                        | Vorinostat                                                                                                                                                                              | Tamoxifen   |          |        |         |      |
| Grade 1                                      | 100%                                                                                                                                                                                    | 100%        |          |        |         |      |
| Grade 2                                      | Hold until toxicity is ≤grade 1, then resume at                                                                                                                                         | 100%        |          |        |         |      |
| dose given in prior cycle.                   |                                                                                                                                                                                         |             |          |        |         |      |
| Grade 3                                      | Hold until toxicity is ≤grade 1, then resume at  75% (or less) of dose given in the prior cycle. If  grade 3 toxicity recurs despite dose reduction,  decrease to 50 % of initial dose. | 100%        |          |        |         |      |
| Grade 4                                      | Discontinue protocol therapy.                                                                                                                                                           | 100%        |          |        |         |      |
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vorinostat may be reduced for

Effects on the Eye: Ocular disturbances, including corneal changes, decrement in color vision perception, retinal vein thrombosis, and retinopathy has been reported in patients receiving tamoxifen. An increased incidence of cataracts and the need for cataract surgery have been reported in patients receiving tamoxifen. If grade 3 or 4 ocular toxicities occur, both drugs should be stopped. Any rechallenge should be discussed with the study chair.
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5.1.1.2 dose modifications and dosing

Subjects should receive appropriate supportive care measures as deemed necessary by the treating investigator including but not limited to the items outlined below:
**Diarrhea:** Subjects should be carefully monitored for signs and symptoms of enterocolitis (such as diarrhea, abdominal pain, blood or mucus in stool, with or without fever) and of bowel perforation (such as peritoneal signs and ileus). In symptomatic subjects, infectious etiologies should be ruled out, and if symptoms are persistent and/or severe, endoscopic evaluation should be considered.  
o In subjects with severe enterocolitis (Grade 3), pembrolizumab will be permanently discontinued and treatment with systemic corticosteroids should be initiated at a dose of 1 to 2 mg/kg/day of prednisone or equivalent. When symptoms improve to Grade 1 or less, corticosteroid taper should be started and continued over at least 1 month.  
o In subjects with moderate enterocolitis (Grade 2), pembrolizumab should be withheld and anti-diarrheal treatment should be started. If symptoms are persistent for more than one week, systemic corticosteroids should be initiated (e.g., 0.5 mg/kg/day of prednisone or equivalent). When symptoms improve to Grade 1 or less, corticosteroid taper should be started and continued over at least 1 month. Regarding guidelines for continuing treatment with pembrolizumab, see Section 5.2.  
o All subjects who experience diarrhea should be advised to drink liberal quantities of clear fluids. If sufficient oral fluid intake is not feasible, fluid and electrolytes should be substituted via IV infusion.  
**Nausea/vomiting:** Nausea and vomiting should be treated aggressively, and consideration should be given in subsequent cycles to the administration of prophylactic antiemetic therapy according to standard institutional practice. Subjects should be strongly encouraged to maintain liberal oral fluid intake.  
**Anti-infectives**: Subjects with a documented infectious complication should receive oral or IV antibiotics or other anti-infective agents as considered appropriate by the treating investigator for a given infectious condition, according to standard institutional practice.  
**Immune-related adverse events:** Please see Section 5.2.2 below and the separate guidance document in the administrative binder regarding diagnosis and management of adverse experiences of a potential immunologic etiology. Specific immune-related adverse events (irAEs) will be collected and designated as immune-related events of clinical interest (ECIs) as described in Section 5.2.2.
**Management of Infusion Reactions:** Acute infusion reactions (which can include cytokine release syndrome, angioedema, or anaphylaxis) are different from allergic/hypersensitive reactions, although some of the manifestations are common to both AEs. Signs and symptoms usually develop during or shortly after drug infusion and generally resolve completely within 24 hours of completion of infusion. Signs/symptoms may include: Allergic reaction/hypersensitivity (including drug fever); Arthralgia (joint pain); Bronchospasm; Cough; Dizziness; Dyspnea (shortness of breath); Fatigue (asthenia, lethargy, malaise); Headache; Hypertension; Hypotension; Myalgia (muscle pain); Nausea; Pruritis/itching; Rash/desquamation; Rigors/chills; Sweating (diaphoresis); Tachycardia; Tumor pain (onset or exacerbation of tumor pain due to treatment); Urticaria (hives, welts, wheals); Vomiting.  
Table 5.1 below shows treatment guidelines for subjects who experience an infusion reaction associated with administration of pembrolizumab.
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table 5.1 infusion reaction treatment

| NCI CTCAE Grade                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               | Treatment                                                                                                                                      | Premedication        | at   |         |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------|----------------------|------|---------|
| subsequent dosing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |                                                                                                                                                |                      |      |         |
| Grade 1 Mild reaction;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        | infusion                                                                                                                                       |                      |      |         |
| interruption not indicated;  intervention not indicated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       | Increase monitoring of vital signs  as medically indicated until the  subject is deemed medically  stable in the opinion of the  investigator. | None                 |      |         |
| Grade 2 Requires                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | infusion                                                                                                                                       |                      |      |         |
| interruption but responds  promptly to symptomatic  treatment (e.g.,  antihistamines, NSAIDS,  narcotics, IV fluids);  prophylactic medications  indicated for < =24 hrs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      | Stop                                                                                                                                           | Infusion             | and  | monitor |
| symptoms. Additional appropriate medical  therapy may include but is not  limited to: IV fluids Antihistamines NSAIDS Acetaminophen Narcotics Increase monitoring of vital signs  as medically indicated until the  subject is deemed medically  stable in the opinion of the  investigator. If symptoms resolve within one  hour of stopping drug infusion,  the infusion may be restarted at  50% of the original infusion rate  (e.g. from 100 mL/hr to 50  mL/hr). Otherwise dosing will be  held until symptoms resolve and  the subject should be  premedicated for the next  scheduled dose. Subjects who develop Grade 2  toxicity despite adequate  premedication should be  permanently discontinued  from further trial treatment  administration. | Subject                                                                                                                                        | may                  | be   |         |
| premedicated 1.5h (±  30 minutes) prior to  infusion of  pembrolizumab with: Diphenhydramine 50  mg po (or equivalent  dose of antihistamine). Acetaminophen 500- 1000 mg po (or  equivalent dose of  antipyretic).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           |                                                                                                                                                |                      |      |         |
| Grades 3 or 4 Grade 3: Prolonged (i.e.,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       | not                                                                                                                                            |                      |      |         |
| rapidly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       | responsive                                                                                                                                     | to                   |      |         |
| symptomatic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   | medication                                                                                                                                     |                      |      |         |
| and/or brief interruption  of infusion); recurrence of  symptoms following initial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            | Stop Infusion. Additional appropriate medical  therapy may include but is not  limited to: IV fluids Antihistamines NSAIDS                     | No subsequent dosing |      |         |  
| NCI CTCAE Grade                                                                                                                                                                                                                                                                      | Treatment                                                                                                                                                                                                                                                            | Premedication   | at   |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------|------|
| subsequent dosing                                                                                                                                                                                                                                                                    |                                                                                                                                                                                                                                                                      |                 |      |
| improvement;  hospitalization                                                                                                                                                                                                                                                        | indicated                                                                                                                                                                                                                                                            |                 |      |
| for other clinical sequelae  (e.g., renal impairment,  pulmonary infiltrates)                                                                                                                                                                                                        | Acetaminophen Narcotics Oxygen Pressors Corticosteroids Epinephrine                                                                                                                                                                                                  |                 |      |
| Grade 4: Life-threatening; pressor  or ventilatory support  indicated                                                                                                                                                                                                                | Increase monitoring of vital signs  as medically indicated until the  subject is deemed medically  stable in the opinion of the  investigator. Hospitalization may be  indicated. Subject is permanently  discontinued from further trial  treatment administration. |                 |      |
| Appropriate resuscitation equipment should be available in the room and a physician  readily available during the period of drug administration. For Further information, please refer to the Common Terminology Criteria for Adverse  Events v4.0 (CTCAE) at http://ctep.cancer.gov |                                                                                                                                                                                                                                                                      |                 |      |
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5.1.1.3 supportive care guidelines for

Subjects with symptomatic pneumonitis should immediately stop receiving pembrolizumab and have an evaluation. The evaluation may include bronchoscopy and pulmonary function tests to rule out other causes such as infection. If the subject is determined to have study drug associated pneumonitis, the suggested treatment plan is detailed in Table 5.12.
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table 5.12 recommended approach to

| Study drug  associated  pneumonitis                                       | Withhold/Discontinue                                         | Supportive Care                                                                                                                                                                       |                            |
|---------------------------------------------------------------------------|--------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------|
| pembrolizumab?                                                            |                                                              |                                                                                                                                                                                       |                            |
| Grade                                                                     | 1                                                            | No action                                                                                                                                                                             | Intervention not indicated |
| (asymptomatic) Grade 2                                                    | Withhold  pembrolizumab,                                     | may                                                                                                                                                                                   |                            |
| return to treatment if  improves to Grade 1 or  resolves within 12  weeks | Systemic corticosteroids are indicated.  Taper if necessary. |                                                                                                                                                                                       |                            |
| Grade 3 and Grade                                                         | Discontinue                                                  | Systemic corticosteroids are indicated.                                                                                                                                               |                            |
| 4                                                                         | pembrolizumab                                                | The use of infliximab may be indicated  as appropriate. Refer to the Event of  Clinical Interest and Immune-related  Adverse Event Guidance Document  for additional recommendations. |                            |  
For Grade 2 pneumonitis that improves to ≤ Grade 1 within 12 weeks, the following rules should apply:  
First episode of pneumonitis o May increase dosing interval by one week in subsequent cycles Second episode of pneumonitis - permanently discontinue pembrolizumab if upon rechallenge subject develops pneumonitis  Grade 2
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5.2 monitoring and toxicity management

Each patient receiving pembrolizumab in combination with Tamoxifen and Vorinostat will be evaluable for safety. The safety parameters include all laboratory tests and hematological abnormalities, physical findings, and spontaneous reports of adverse events reported to the investigator by patients. Each patient will be assessed periodically for the development of any toxicity as outlined in Section 6 Study Procedures and Observations. Toxicity will be assessed according to the NCI CTCAE v4.0. Dose adjustments will be made according to the system showing the greatest degree of toxicity.
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5.2.2 events of clinical interest

Selected non-serious and serious adverse events are also known as Events of Clinical Interest (ECI) and must be reported to the Sponsor. For the time period beginning when the consent form is signed until treatment allocation/randomization, any ECI, or follow up to an ECI, that occurs to any subject must be reported within 24 hours to the Sponsor if it causes the subject to be excluded from the trial, or is the result of a protocol-specified intervention, including but not limited to washout or discontinuation of usual therapy, diet, placebo treatment or a procedure. For the time period beginning at treatment allocation/randomization through 30 days following cessation of treatment if the subject initiates new anticancer therapy, whichever is earlier, any ECI, or follow up to an ECI, whether or not related to the Sponsor's product, must be reported within 24 hours to the Sponsor, either by electronic media or paper. Electronic reporting procedures can be found in the EDC data entry guidelines. Paper reporting procedures can be found in the Investigator Trial File Binder (or equivalent). Events of Clinical Interest for this trial include: 1. an overdose of Sponsor's product, as defined in Section 7.8.1 - Definition of an Overdose for This Protocol and Reporting of Overdose to the Sponsor, that is not associated with clinical symptoms or abnormal laboratory results. 2. an elevated AST or ALT lab value that is greater than or equal to 3X the upper limit of normal and an elevated total bilirubin lab value that is greater than or equal to 2X the upper limit of normal and, at the same time, an alkaline phosphatase lab value that is less than 2X the upper limit of normal, as determined by way of protocol-specified laboratory testing or unscheduled laboratory testing.* *Note: These criteria are based upon available regulatory guidance documents. The purpose of the criteria is to specify a threshold of abnormal hepatic tests that may require an additional evaluation for an underlying etiology. The trial site guidance for assessment and follow up of these criteria can be found in the Investigator Trial File Binder (or equivalent).
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6 study procedures and observations

Eligible patients will receive treatment as described above, in consecutive 3-week cycles, until progression of disease or unacceptable toxicity. Patients are expected to receive treatment for at least 3 cycles, at which time the first evaluation for efficacy will occur. If there is continued safety and tolerability, treatment may continue. For Arm A: After the initial treatment with vorinostat and tamoxifen, regardless of response of the staging studies, PD-1 will be added to all patients. For Arm B: patients may remain on study if there is radiological progression however the clinical presentation shows improvement or benefit.  
All patients will be restaged during week 9 and 18 via imaging scans, staging will then be continued every 3 cycles until 6 months. After 6 months staging may be spaced out to 6 cycles if clinically indicated. Patients will be followed for evaluation of safety for at least 30 days after the last dose of study drug. Any study drug-related serious adverse events will be followed until resolution, return to baseline grade, or deemed irreversible by the Investigator. Subjects who experience a recurrence of the same severe or life-threatening event at the same grade or greater with re-challenge of pembrolizumab should be discontinued from trial treatment.
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6.2 schedule of procedures and

The study-specific assessments are detailed in this section and outlined in Section 6 Schedule of Study Procedures and Assessments. Screening assessments must be performed within 28 days prior to the first dose of investigational product. Any results falling outside of the reference ranges may be repeated at the discretion of the investigator. All on-study visit procedures are allowed a window of ± 5 days unless otherwise noted. Treatment or visit delays for public holidays or weather conditions, or patient's personal reasons that do not compromise safety do not constitute a protocol violation. Treatment delays may not exceed 3 weeks, unless discussed with the study team for patients with documented benefit. Patients with proven systemic benefit, who have localized progression in the sanctuary site, may receive localized treatment to that site, including but not limited to radiation therapy, gamma knife or surgery. A written, signed, informed consent form (ICF) and a Health Insurance Portability and Accountability Act (HIPAA) authorization must be obtained before any study-specific assessments are initiated. A copy of the signed ICF will be given to the subject and a copy will be filed in the medical record. The original will be kept on file with the study records.  
All patients who are consented will be registered in OnCore®, the UCSF Helen Diller Family Comprehensive Cancer Center Clinical Trial Management System (CTMS). The system is password protected and meets HIPAA requirements.
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6.2.2 long term/survival follow-up procedures

The mandatory Safety Follow-Up Visit should be conducted approximately 30 days after the last dose of trial treatment or before the initiation of a new anti-cancer treatment, whichever comes first. All AEs that occur prior to the Safety Follow-Up Visit should be recorded. Subjects with an AE of Grade > 1 deemed related to study drug, will be followed until the resolution of the AE to Grade 0-1, baseline or until the beginning of a new anti-neoplastic therapy.
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follow-up visits

Subjects who discontinue trial treatment for a reason other than disease progression will move into the follow-up phase and should be assessed every 12 weeks (± 7 days) by radiologic imaging to monitor disease status. Every effort should be made to collect information regarding disease status until the start of new anti-neoplastic therapy, disease progression, death, end of the study or if the subject begins retreatment with pembrolizumab. Information regarding poststudy anti-neoplastic treatment will be collected if new treatment is initiated.
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survival follow-up

Once a subject experiences confirmed disease progression or starts a new anti-cancer therapy, the subject moves into the survival follow-up phase and should be contacted by telephone every 12 weeks to assess for survival status until death, withdrawal of consent, or the end of the study, whichever occurs first.
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6.2.3 discontinuation of therapy

The Investigator will withdraw a patient whenever continued participation is no longer in the patient's best interests. Reasons for withdrawing a patient include, but are not limited to, disease progression, the occurrence of an adverse event or a concurrent illness, a patient's request to end participation, or simply significant uncertainty on the part of the Investigator that continued participation is prudent. There may also be administrative reasons to terminate participation, such as concern about a patient's compliance with the prescribed treatment regimen. When a subject discontinues/withdraws prior to trial completion, all applicable activities scheduled for the final trial visit should be performed at the time of discontinuation. Any adverse events which are present at the time of discontinuation/withdrawal should be followed in accordance with the safety requirements outlined in Section 7.2 - Assessing and Recording Adverse Events. Subjects who a) attain a CR or b) complete 24 months of treatment with combination of vorinostat, tamoxifen or pembrolizumab may discontinue treatment with the option of restarting treatment if they may derive further benefit in the opinion of the study team. Tamoxifen should be continued. After discontinuing treatment following assessment of CR, these subjects should return to the site for a Follow-up Visit every 12 weeks with staging studies as described for patients on active treatment.  
| Table 6.                            | Study Calendar                                                                                  |         |                |            |              |    |    |
|-------------------------------------|-------------------------------------------------------------------------------------------------|---------|----------------|------------|--------------|----|----|
| Test/Study                          | Baselinea screening                                                                             | Cycle 1 | Cycle 2        | Subsequent | Restaging or |    |    |
| cyclesg                             | off study                                                                                       |         |                |            |              |    |    |
| D10                                 |                                                                                                 |         |                |            |              |    |    |
| D1                                  | D8                                                                                              | -12     | D15            | D1         |              |    |    |
| History                             | X                                                                                               | X       | X              | X          | X            | X  |    |
| Concomitant  medication             | X                                                                                               | X       | X              | X          | X            | X  |    |
| Physical                            | Exam,                                                                                           |         |                |            |              |    |    |
| Vitals & ECOG                       | X                                                                                               | X       | X              | X          | X            | X  |    |
| Height                              | and                                                                                             |         |                |            |              |    |    |
| weight                              | X                                                                                               | X       | X              | X          | X            | X  |    |
| Toxicity  Assessment                | X                                                                                               | X       | X              | X          | X            | X  | Xb |
| PK sample                           | X or D1f                                                                                        | Xh      | Xf             | (end       | of           |    |    |
| cycle 3)                            |                                                                                                 |         |                |            |              |    |    |
| Tumor  FNA/Biopsy                   | X or D1f                                                                                        | Xf      | (end           | of         |              |    |    |
| cycle 3)                            |                                                                                                 |         |                |            |              |    |    |
| PBMC                                | X or D1f                                                                                        | Xh      | Xf             | (end       | of           |    |    |
| cycle 3)                            |                                                                                                 |         |                |            |              |    |    |
| Lymphocyte  Subset                  | X or D1 f                                                                                       | Xh      | Xf             | (end       | of           |    |    |
| cycle 3)                            |                                                                                                 |         |                |            |              |    |    |
| CBC w/diff                          | X                                                                                               | X       | X              | X          | X            | X  |    |
| Comprehensive  metabolic paneli     | X                                                                                               | X       | X              | X          | X            | Xc |    |
| Thyroid Function                    | X                                                                                               | X       | X(odd  cycles) |            |              |    |    |
| CEA, Ca15-3, Ca  125 (If clinically | X                                                                                               | X       | X              | Xc         |              |    |    |
| indicated) Pregnancy Test           | Xd                                                                                              | Xd      |                |            |              |    |    |
| Radiology (CT scans, MRI)           | Xe                                                                                              | Xe      | Xe             |            |              |    |    |
| Documentation of  Response          | X                                                                                               |         |                |            |              |    |    |
| Vorinostat                          | 400 mg once a day, 5 days on, 2 days off, weekly every cycle                                    |         |                |            |              |    |    |
| Tamoxifen                           | 20 mg once a day continuously (for ER+ disease only)                                            |         |                |            |              |    |    |
| Pembrolizumab                       | 200 mg q every three weeks                                                                      |         |                |            |              |    |    |
| Arm A)                              | start on day 1 of cycle 1                                                                       |         |                |            |              |    |    |
| Pembrolizumab                       | 200 mg q every three weeks                                                                      |         |                |            |              |    |    |
| Arm B)                              | start on day 1 of cycle 2                                                                       |         |                |            |              |    |    |
| a)                                  | All screening procedures must be performed within 28 days unless otherwise indicated. Pre-study |         |                |            |              |    |    |  
a) All screening procedures must be performed within 28 days unless otherwise indicated. Pre-study  
tests, History and Physical may be used for Day 1 tests if within 2 weeks  
b) Toxicity assessment must be performed until all treatment-related toxicities have been resolved or decreased to grade 1. Adverse events must be recorded up to 30 days after termination on study c) Every month for the first 6 cycles, then at least every 3 cycles thereafter, more frequently if clinically indicated d) For women of childbearing potential, performed within 7 days of starting treatment. Pregnancy test will be repeated if clinically indicated.  
e) Staging studies within 30 days prior to day of start, restaging after cycle 3 (week9), 6 (week 18),
then 9, 12, then every 6 cycles if clinically indicated. Partial and complete responses must be confirmed at least one month apart from the first documentation of objective response. Scans may be performed more frequently if clinically indicated.  
f) Pre-study within 14 days, and end of cycle 3 (preferably day 17-19) prior to cycle 4 day 1 pembrolizumab infusion.  
g) Cycle delays up to 5 days for non-medical reason (e.g. holidays) are acceptable without notification of regulatory agencies.  
h) On day 10-12 pre-dose. i) Sodium, Potassium, Chloride, blood urea nitrogen, Creatinine, Non-fasting glucose, Calcium, Magnesium, Phosphorus, ALT, AST, Alkaline Phosphatase, Albumin, Total Bilirubin, Total Protein j) Therapy delay for palliative radiation should be based on discussion with the study sponsor and the treating physician, every effort should be made not to hold therapy, patients where vorinostat is being held for more than 4 weeks may stay on study if there is felt to be a benefit
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6.2.4 logistics for correlative studies

Labeling:  
1. Preprinted bar-coded PK sample labels with patient's allocation number and prescribed collection time for the collection tubes.  
2. Labels should be attached to the red-top Vacutainer tube and NUNC™ tube before the blood is collected.  
Procedures:
1. Label red-top Vacutainer tube (no anticoagulant) with preprinted bar-coded PK
sample labels.  
2. Collect 5.0 mL whole blood in the labeled red-top vacutainer tube. If blood is being collected from a central or PIC line, collect a 10 mL discard sample first before collecting the actual PK samples.  
3. Invert the tube several times and allow the blood sample to clot at room temperature for 30 minutes.  
4. Centrifuge the clotted sample at 2,000 x g for 15 minutes at 4°C. 5. Transfer the serum to 3.6 mL NUNC internal thread round bottom cryotubes (NUNC
366524) with the bar-coded PK sample **label** attached.  
6. Samples will be stored at -70°C until processing
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6.2.4.2 histone acetylation in peripheral

Exposure to HDAC inhibitors results in inhibition of histone deacetylation. Histone acetylation (mainly histone H3) has been used as a biological marker of HDAC inhibitor activity. H3 acetylation has been measured successfully in PBMCs in clinical trials using vorinostat and other HDAC inhibitors. We will therefore measure H3 and H4 acetylation in peripheral blood mononuclear cells and in tumor samples of patients before and after treatment with vorinostat. Mononuclear cells will be obtained prior to treatment initiation and repeated on day 10 (+2) and at the end of cycle 3 (day 17-19). Cells will be isolated from patient blood by centrifugation at 400 x g (Sorvall, HS4 rotor) for 30 min using a Ficoll-Paque gradient (Sigma, St. Louis, MO) as described by Sandor et al. Histone acetylation will be quantified by WB analysis of PBMCs using an acid extraction method to collect nuclear histone proteins.
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6.2.4.3 evaluation of vorinostat effects

Post-treatment tumor samples and PBMCs (as well as the vorinostat PK samples) will be obtained on cycle 3 (days 17-19) after the vorinostat morning dose. Fine needle aspirations (FNA) and core biopsies will be obtained either by an interventional radiologist (visceral disease, lymph node) or a cytopathologist (subcutaneous and skin lesions). Diff-Quick air-dry method (FNA) or touch prep analysis (core biopsies) at time of biopsy will be used to confirm the presence of tumor. Tumor samples will be divided and processed for specific techniques as listed below. An attempt for three cores will be made using the appropriate needle. Tissues will be evaluated for the effects of vorinostat on histone acetylation and estrogen expression (by IHC). For IHC, tumors will be fixed in formalin (1 hour/mm thickness), dehydrated, blocked in paraffin. Five-micron sections will be stained with the appropriate antibodies and visualized by light microscopy. Staining will be evaluated using Adobe Photoshop. As the tumor biopsies may contain a mixture of tumor and surrounding cells, cells will be stained (in addition to ER and H3) with specific antibodies used to distinguish tumor versus non-tumor tissues (e.g. cytokeratin (Keratin (5D3)) for breast cancers. PBMCs histone acetylation and ER expression will be quantified by Western blot.
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6.2.4.4 logistics on immune modulation

For immune assays we will collect 60cc of blood in green top tubes at baseline and day 10-12 in cycle 1 and on day 17-18 in cycle 3, at the time points specified above for tumor biopsies, FFPE for immune cell infiltrate and a frozen section will be obtained for TCR sequencing.
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exploratory objectives

1. To define the treatment-induced effects on circulating immune cells.  
2. To assess the presence of antigen-specific immune responses to a broad panel of candidate tumor antigens.  
At the prespecified endpoints: we will obtain Immunohistochemistry and gene expression analysis for immune cell subset quantification and localization within tumors Flow cytometry to evaluate changes in intra-tumoral and circulating immune cells T cell receptor (TCR) deep sequencing of tissue samples from pre-treatment biopsies and post-treatment biopsies, and post-treatment circulating T cells.  
Immune response mRNA expression analysis to derive signatures associated with tumor response Identification of genomic mutations and gene copy aberrations associated with response and resistance to therapy Antigen array-base detection of circulating antibody responses
These assays will be obtained in conjuction with Dr. Michael Rosenblum's lab.  
lJCsF Helen Diller Family  
  
  
Comprehensive Cancer Center
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6.3 usage of concurrent/concomitant medications

All treatments that the investigator considers necessary for a subject's welfare may be administered at the discretion of the investigator in keeping with the community standards of medical care. All concomitant medication will be recorded on the case report form (CRF) including all prescription, over-the-counter (OTC), herbal supplements, and IV medications and fluids. If changes occur during the trial period, documentation of drug dosage, frequency, route, and date may also be included on the CRF. All concomitant medications received within 28 days before the first dose of trial treatment and 30 days after the last dose of trial treatment should be recorded. Concomitant medications administered after 30 days after the last dose of trial treatment should be recorded for SAEs and ECIs as defined in Section 7.2. Anti-diarrheal and anti-emetic treatment may be given as required, either therapeutically or prophylactically, after such events have occurred in conjunction with a prior dose given without anti-diarrheals or anti-emetics. If needed, efforts will be made to standardize such supportive regimens in agreement with participating Investigators. Other examples of supportive care medications include prophylactic or therapeutic use of erythropoietin for anemia and bisphosphonates (e.g., pamidronate).
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6.3.3 prohibited concomitant medications

Subjects are prohibited from receiving the following therapies during the Screening and Treatment Phase (including retreatment for post-complete response relapse) of this trial:
Anti-cancer systemic chemotherapy or biological therapy  
Immunotherapy not specified in this protocol Chemotherapy not specified in this protocol Investigational agents other than Pembrolizumab Radiation therapy o Note: Radiation therapy to a symptomatic solitary lesion or to the brain may be allowed after consultation with the study PI and Merck.  
Live vaccines within 30 days prior to the first dose of trial treatment and while participating in the trial. Examples of live vaccines include, but are not limited to, the following: measles, mumps, rubella, chicken pox, yellow fever, rabies, BCG, and typhoid (oral) vaccine. Seasonal influenza vaccines for injection are generally killed virus vaccines and are allowed; however intranasal influenza vaccines (e.g. Flu-Mist®) are live attenuated vaccines, and are not allowed.  
Glucocorticoids for any purpose other than to modulate symptoms from an event of clinical interest of suspected immunologic etiology. The use of physiologic doses of corticosteroids may be approved after consultation with the study PI and Merck.
Subjects who, in the assessment by the investigator, require the use of any of the aforementioned treatments for clinical management should be removed from the trial. Subjects may receive other medications that the investigator deems to be medically necessary.  
The Exclusion Criteria describes other medications which are prohibited in this trial.  
There are no prohibited therapies during the Post-Treatment Follow-up Phase.
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6.3.4 rescue medications & supportive

Subjects should receive appropriate supportive care measures as deemed necessary by the treating investigator including but not limited to the items outlined below:  
Diarrhea: Subjects should be carefully monitored for signs and symptoms of enterocolitis
(such as diarrhea, abdominal pain, blood or mucus in stool, with or without fever) and of bowel perforation (such as peritoneal signs and ileus). In symptomatic subjects, infectious etiologies should be ruled out, and if symptoms are persistent and/or severe, endoscopic evaluation should be considered.  
o In subjects with severe enterocolitis (Grade 3), pembrolizumab will be permanently discontinued and treatment with systemic corticosteroids should be initiated at a dose of 1 to 2 mg/kg/day of prednisone or equivalent. When symptoms improve to Grade 1 or less, corticosteroid taper should be started and continued over at least 1 month.  
o In subjects with moderate enterocolitis (Grade 2), pembrolizumab should be withheld and anti-diarrheal treatment should be started. If symptoms are persistent for more than one week, systemic corticosteroids should be initiated (e.g., 0.5 mg/kg/day of prednisone or equivalent). When symptoms improve to Grade 1 or less, corticosteroid taper should be started and continued over at least 1 month. Regarding guidelines for continuing treatment with pembrolizumab, see Section 5.2.  
o All subjects who experience diarrhea should be advised to drink liberal quantities of clear fluids. If sufficient oral fluid intake is not feasible, fluid and electrolytes should be substituted via IV infusion.  
Nausea/vomiting: Nausea and vomiting should be treated aggressively, and consideration should be given in subsequent cycles to the administration of prophylactic antiemetic therapy according to standard institutional practice. Subjects should be strongly encouraged to maintain liberal oral fluid intake.  
Anti-infectives: Subjects with a documented infectious complication should receive oral or IV antibiotics or other anti-infective agents as considered appropriate by the treating investigator for a given infectious condition, according to standard institutional practice.  
Immune-related adverse events: Please see Section 5.6.1.1 below and the separate guidance document in the administrative binder regarding diagnosis and management of adverse experiences of a potential immunologic etiology.
Management of Infusion Reactions: Acute infusion reactions (which can include cytokine release syndrome, angioedema, or anaphylaxis) are different from allergic/hypersensitive reactions, although some of the manifestations are common to both AEs. Signs and symptoms usually develop during or shortly after drug infusion and generally resolve completely within 24 hours of completion of infusion. Signs/symptoms may include: Allergic reaction/hypersensitivity (including drug fever); Arthralgia (joint pain); Bronchospasm; Cough; Dizziness; Dyspnea (shortness of breath); Fatigue (asthenia, lethargy, malaise); Headache; Hypertension; Hypotension; Myalgia (muscle pain); Nausea; Pruritis/itching; Rash/desquamation; Rigors/chills; Sweating (diaphoresis); Tachycardia; Tumor pain (onset or exacerbation of tumor pain due to treatment); Urticaria (hives, welts, wheals); Vomiting.
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contraception

Pembrolizumab, tamoxifen and vorinostat may have adverse effects on a fetus in utero. Furthermore, it is not known if pembrolizumab has transient adverse effects on the composition of sperm. Non-pregnant, non-breast-feeding women may be enrolled if they are willing to use 2 methods of birth control or are considered highly unlikely to conceive. Highly unlikely to conceive is defined as 1) surgically sterilized, or 2) postmenopausal (a woman who is ≥45 years of age and has not had menses for greater than 1 year will be considered postmenopausal), or 3) not heterosexually active for the duration of the study. The two birth control methods can be either two barrier methods or a barrier method plus a hormonal method to prevent pregnancy. Subjects should start using birth control from study Visit 1 throughout the study period up to 120 days after the last dose of study therapy. The following are considered adequate barrier methods of contraception: diaphragm, condom (by the partner), intrauterine device, sponge, or spermicide. Appropriate hormonal contraceptives will include any registered and marketed contraceptive agent that contains an estrogen and/or a progestational agent (including oral, subcutaneous, intrauterine, or intramuscular agents). Subjects should be informed that taking the study medication may involve unknown risks to the fetus (unborn baby) if pregnancy were to occur during the study. In order to participate in the study they must adhere to the contraception requirement (described above) for the duration of the study and during the follow-up period defined in section 7.2.2-Reporting of Pregnancy and Lactation to the regulatory agencies and to Merck. If there is any question that a subject will not reliably comply with the requirements for contraception, that subject should not be entered into the study.
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7 reporting and documentation of

Response and progression in this study will be evaluated using the new international criteria proposed by the Response Evaluation Criteria in Solid Tumors (RECIST) Committee [JNCI 92(3):205-216, 2000] as well as Immune Related Response-Criteria (irRC).]. Changes in only the largest diameter (unidimensional measurement) of the tumor lesions are used in the RECIST v1.1 criteria (or International Workshop on Chronic Lymphocytic Leukemia [IWCLL]).
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7.1.2 definitions

Evaluable for toxicity All patients will be evaluable for toxicity from the time of their first treatment with the study drug. Evaluable for objective response Only those patients who have measurable disease present at baseline, have received at least one cycle of therapy, and have had their disease re-evaluated will be considered evaluable for response. These patients will have their response classified according to the definitions stated below. (Note: Patients who exhibit objective disease progression prior to the end of Cycle 1 will also be considered evaluable.)
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7.1.3 disease parameters measurable disease

Measurable disease is defined as lesions (or tumors) that can be accurately measured in at least one dimension (longest diameter to be recorded) with a minimum size of 10mm by CT scan (irrespective of scanner type) and MRI (no less than double the slice thickness and a minimum of 10mm), 10mm caliper measurement by clinical exam (when superficial), and/or 20mm by chest X-ray (if clearly defined and surrounded by aerated lung). All tumor measurements will be recorded in millimeters or decimal fractions of centimeters. Previously irradiated lesions are considered non-measurable except in cases of documented progression of the lesion since the completion of radiation therapy.
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target lesions

All measurable lesions up to a maximum of 5 lesions total (and a maximum of two lesions per organ) representative of all involved organs should be identified as target lesions and recorded and measured at baseline. Target lesions will be selected on the basis of their size (lesions with the longest diameter) and their suitability for accurate repeated measurements (either by imaging techniques or clinically). A sum of the longest diameter (LD) for all target lesions will be calculated and reported as the baseline sum LD. The baseline sum LD will be used as reference by which to characterize the objective tumor response.
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non-target lesions

All other lesions (or sites of disease) including any measurable lesions over and above the 5 target lesions should be identified as non-target lesions and should also be recorded at baseline. It is possible to record multiple non-target lesions involving the same organ as a single item on the case record form (e.g. "multiple enlarged pelvic lymph nodes" or "multiple liver metastases"). Bone lesions may be measureable if ≥ 1 cm on MRI. Measurements of these lesions are not required, but the presence or absence of each will be noted throughout follow-up.
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non-measurable disease (tumor markers)

Non-measurable disease is all other lesions (or sites of disease), including small lesions (longest diameter < 20 mm with conventional techniques or < 10 mm using spiral CT scan). Leptomeningeal disease, ascites, pleural or pericardial effusion, inflammatory breast disease, lymphangitic involvement of skin or lung, abdominal masses/abdominal organomegaly identified by physical exam that is not measurable by reproducible imaging techniques are all nonmeasurable. (e.g., PSA, CA-125, CA19-9, CEA)
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7.2.1 methods for evaluation of

All measurements will be taken and recorded in metric notation using a ruler or calipers. All baseline evaluations will be performed as closely as possible to the beginning of treatment and never more than 28 days before the beginning of the treatment.  
The same method of assessment and the same technique will be used to characterize each identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is preferred to evaluation by clinical examination when both methods have been used to assess the antitumor effect of a treatment.
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7.2.2 clinical lesions

Lesions will only be considered measurable when they are superficial (e.g., skin nodules, palpable lymph nodes). For the case of skin lesions, documentation by color photography including a ruler to estimate the size of the lesion is recommended. If measured by calipers, measurements have to be confirmed by two independent health care professionals.
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7.2.3 chest x-ray

Lesions on chest X-ray are acceptable as measurable lesions when they are clearly defined and surrounded by aerated lung. However, CT is preferable.
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7.2.4 conventional ct and mri

Imaging should be performed with cuts of 10 mm or less in slice thickness contiguously. Spiral CT should be performed using a 5 mm contiguous reconstruction algorithm. This applies to the chest, abdomen, and pelvis.
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7.3 response criteria evaluation of

Disappearance of all target lesions, determined by two separate observations conducted not less than 4 weeks apart. Any pathological lymph nodes (whether target or non-target) must have reduction in short axis to <10 mm (the sum may not be "0" if there are target nodes). There can be no appearance of new lesions.
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partial response (pr)

At least a 30% decrease in the sum of the longest diameter (LD) of target lesions, taking as reference the baseline sum LD. There can be no appearance of new lesions. Progressive Disease (PD) At least a 20% increase in the sum of the SLD of target lesions, taking as reference the smallest sum SLD recorded since the treatment started and minimum 5 mm increase over the nadir, or the appearance of one or more new lesions.