64 16 APPENDICES ..................................................................................................................... 67 CONFIDENTIAL CRUKD/17/003 Protocol Final 5.0 dated 08Jun2021 Page 6 of 72 EudraCT number : 2016 -002577 -35 Cancer Research UK 16.1 APPENDIX 1: WHO PERFORMANCE STATUS SCALE .................................................... 67 16.2 APPENDIX 2: NEW YORK HEART ASSOCIATION (NYHA) SCALE ................................. 68 16.3 APPENDIX 3: MEASUREMENT OF DISEASE ................................................................... 69 CONFIDENTIAL CRUKD/17/003 Protocol Final 5.0 dated 08Jun2021 Page 10 of 72 EudraCT number : 2016 -002577 -35 Cancer Research UK PROTOCOL SIGNATURES Sponsor Signature: The Sponsor has read and agrees to the protocol, as detailed in this document. I am aware of my responsibilities as the Sponsor under the UK Clinical Trials Regulations1, the guidelines of Good Clinical Practice (GCP)2, the Declaration of Helsinki3, the applicable regulations of UK law and the trial protocol. The Sponsor agrees to conduct the trial according to these regulations and guidelines and to appropriately direct and assist Sponsor’s staff who will be involved in the trial, and ensure that all staff members are aware of their clinical trial responsibilities . Name: Title: Signature: Date: 1 The Medicines for Human Use (Clinical Trials) Regulations (S.I. 2004/1031) and any subsequent amendments to it. 2 ICH Harmonised Tripartite Guideline E6 (R1): Note for Guidance on Good Clinical Practice (CPMP/ICH/135/95) Step 5, adopted by CPMP July 1996. 3 WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964 and all subsequent amendments including Oct 2013. CONFIDENTIAL CRUKD/17/003 Protocol Final 5.0 dated 08Jun2021 Page 11 of 72 EudraCT number : 2016 -002577 -35 Cancer Research UK PROTOCOL SIGNATURES Investigator Signature: I have read and agree to the protocol, as detailed in this document. I am aware of my responsibilities as an Investigator under the UK Clinical Trials Regulations1, the guidelines of Good Clinical Practice (GCP)2, the Declaration of Helsinki3, the applicable regulations of the relevant NHS Trusts and the trial protocol. I agree to conduct the trial according to these regulations and guidelines and to appropriately direct and assist the staff under my control, who will be involved in the trial , and ensure that all staff members are aware of their clinical trial responsibilities. Investigator's Name: Name of site: Signature: Date: 1 The Medicines for Human Use (Clinical Trials) Regulations (S.I. 2004/1031) and any subsequent amendments to it. 2 ICH Harmonised Tripartite Guideline E6 (R1): Note for Guidance on Good Clinical Practice (CPMP/ICH/135/95) Step 5, adopted by CPMP July 1996. 3 WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964 and all subsequent amendments including Oct 2013. CONFIDENTIAL CRUKD/17/003 Protocol Final 5.0 dated 08Jun2021 Page 12 of 72 EudraCT number : 2016 -002577 -35 Cancer Research UK 1 PROTOCOL S YNOPSIS 1.1 Full t itle: A Cancer Research UK Phase I trial of AST-VAC2 ( allogeneic dendritic cell vaccine) administered weekly via intradermal injection in patients with advanced non- small cell lung cancer (NSCLC). 1.2 Short title : A Phase I trial of AST-VAC2 vaccine in patients with non- small cell lung cancer. 1.3 Clinical trial objectives and endpoints : Primary objective Endpoint To assess the safety and tolerability of the target dose of AST-VAC2 given as six intradermal (id) injections at Weeks 1, 2, 3, 4, 5 and 6 in patients with advanced NSCLC. Determining frequency and causality of each adverse event (AE) to AST -VAC2 and grading severity according to the National Cancer Institute (NCI) Common Terminology Criteria for Adve rse Events (CTCAE) Version 4.02 or protocol specific grading system for injection site reactions (ISRs) . The secondary and tertiary objectives and endpoints of the trial can be found in Section 3.1. 1.4 Trial Design : This is a first in man, open label, multi -centre Phase I trial to investigate the safety, immunogenicity and patient survival following administration of the dendritic cell ( DC) vaccin e AST -VAC2 in patients with advanced NSCLC (metastatic or locally advanced). All enrolled patients will receive AST -VAC2. Safety review and stopping rule criteria are detailed in Section 3.3 . If stopping criteria are met as per protocol, this will trigger an independent review of the data. Pharmacodynamic data will also be reviewed as available. All potential trial patients will be asked to consent to a pre- screening assessment of Human Leucocyte Antigen ( HLA) typing. Once the HLA result is known, patients who are HLA A *02:01 positive will be asked to consent to participate in the main trial. Patients who are HLA A*02:01 negative will not be eligible for the trial. Patients receiving AST -VAC2 will be followed up for safety (primary endpoint) , pharmacodynamic analyses in blood samples (secondary endpoint) . All patients will be followed up for up to two years post first vaccination for overall survival and for five years post first vaccination for safety. 1.5 Trial treatment: Patients will receive AST-VAC2 vaccinations , administered by i d injection at six time points over a period of six weeks (Figure 1) . An interval of 7 days (+/ - 1 day) should occur between each of the vaccination days. Two intradermal injections (totalling 1x10 7 cells of AST -VAC2 ) will be administered on each vaccinati on day. The target administered dose of vaccine is 1x107 cells of AST -VAC2. CONFIDENTIAL CRUKD/17/003 Protocol Final 5.0 dated 08Jun2021 Page 18 of 72 EudraCT number : 2016 -002577 -35 Cancer Research UK myelogenous leukaemia (see Section 2.4 and IB Section 5.1.2.1). In this trial, a target dose of 1x 107 cells has been proposed based on the tolerability of this dose in the AST -VAC1 trial discussed in Section 2.4 and IB Section 5.1.2.1. Each patient will receive a maximum of six vaccinations based on previous clinical experience with AST - VAC1 in prostate cancer patients, where six vaccinations were found to induce the highest levels of anti- hTERT immune responses. Based on the vaccination regimens used for AST-VAC1, AST -VAC2 will be given at Weeks 1, 2, 3, 4, 5 and 6, 7 days apart (+/ - 1 day). CONFIDENTIAL CRUKD/17/003 Protocol Final 5.0 dated 08Jun2021 Page 22 of 72 EudraCT number : 2016 -002577 -35 Cancer Research UK All potential patients will be asked to consent to a pre- screening assessment of HLA typing. Only patients who are screened and found to be HLA A *02:01 positive will be asked to consent to the main trial and continue into screening to establish eligibility for trial treatment. It is expected that up to eight patients will be recruited, t he final number depending on the emerging safety data, patient replacement and vaccine availability. Patients will receive six AST -VAC2 vaccinations (administered by two id injections for each vaccination) , once a week (every 7 days +/ - 1 day) for six weeks. Only one target dose of AST -VAC2 will be explored i.e. 1x 107 cells. A reduced dose of AST -VAC2 or a reduction in number of vaccinations administered, may be considered following observation of unacceptable toxicity at this dose level. Any modi fication to the vaccination dose/schedule will be determined and agreed by the Sponsor & Chief Investigator based on emerging data as the trial progresses. The ‘End of Trial’ will be declared once all patients have either withdrawn (see Section 11.0) from the trial or died, or the last patient has completed their final safety follow -up visit (5 years post the first vaccination), whichever is the latter. 3.3 Safety Review 3.3.1 Safety considerations AST-VAC2 has never been investigated in the clinic so no clinical safety data are available. Based upon experience with other autologous and allogeneic DC vaccines, including AST -VAC1, the potential toxicities of AST -VAC2 are expected to be minimal. Severe AEs related to AST -VAC1 (related autologous DC cell therapy , Section 2.4 and IB section 5. 1.2.1) have not been observed in Phase I and II clinical trials with the possible exception of an occurrence of thrombocytopenia in one patient with acute myeloid leukaemia (AML) . The principal potential toxicity of AST -VAC2 is likely to be related to the allogeneic nature of the AST-VAC2 vaccine which could lead to injection site inflammation. However, it is noted that the mixed leucocyte reaction could elicit an adjuvant effect which may be beneficial in the context of this trial. Systemic inflammatory responses associated with cytokine release have not been demonstrated in dendritic cell vaccines to date and therefore are not considered to be a significant risk for AST -VAC2. Chroni c toxicities, particularly related to unintended proliferation of A ST-VAC2, are not anticipated. AST-VAC2 is derived from a hESC line. The cells are terminally differentiated during manufacture to generate cells with a phenotype comparable to that of autologous dendritic cells, which are known to have a low proliferative potential and a short biological half -life. Furthermore, these cells are irradiated post-cryopreservation to minimise the risk of any cells with proliferative potential remaining in the I MP. Finally, AST -VAC2 is only partially haplotyped to the recipient therefore the recipient may also induce a rejection reaction to the cells causing rapid elimination. Overall, the drug product is therefore expected to have no proliferative potential in vivo and the potential for tumour genicity/ectopic growth is considered to be remote. All AEs observed during this trial will be assessed using NCI CTCAE Version 4.02, with the exception of Injection Site Reactions (ISR) which are defined using the protocol specific grading system detailed in Section 9.8 . The risk of developing any of the AEs noted above and in Section 3.3.3 is low and largely theoretical however if any of the above is seen or suspected during the vaccination schedule or follow up period, investigators should investigate as per standard clinical practice and may include assessments as appropriate. If any of these AEs meet the stopping rule criteria as set out in Section 3.3.3 , this will trigger an independent review as stated. 3.3.2 Safety Evaluation Only one target dose level is being explored in this trial . CONFIDENTIAL CRUKD/17/003 Protocol Final 5.0 dated 08Jun2021 Page 23 of 72 EudraCT number : 2016 -002577 -35 Cancer Research UK Safety evaluations by the Sponsor and collaborating Investigators will be conducted after the first patient has received AST -VAC2 and then again after the second and third patients have been treated, Figure 4. Once open recruitment has been initiated, safety review will be per formed at regular intervals (as required) . Figure 3. Safety Evaluation A safety review committee, consisting of all Investigators , representatives of the Sponsor and representatives of the drug company (observers only) , will review emerging study data (to include all clinical data, safety data listings and applicable PD data) on an ongoing basis, with particular reference to ensuring that patients are able to complete the vaccination schedule without AST-VAC2 toxicity -related delays. Should the committee have significant concerns about toxicity seen during the trial they will have the authority to suspend or terminate the trial and/or make recommendations to the Sponsor to modify the vaccination administration. Pending discussions between the Sponsor and CI and based on vaccine availability, the following options may be considered during the trial : • Reduced dose and/or • Modified number of vaccinations, e.g. if plateaued immune responses are observed with fewer vaccinations in those patients already treated. 3.3.2.1 Data to be discussed at safety review meetings. Data which should be discussed at the safety review meeting will include: • Patients treated since the last safety review meeting including vaccine related adverse events noted and duration of treatment. • Assessment and agreement on any related adverse events that may have occurred and resulting actions. • Relevant PD data availabl e since the last meeting. • Any additional relevant information relating to adverse events or patient safety which may have arisen following distribution of listings for the meeting and will therefore not be documented in the listings. • Any possible concern after the review of cumulative data e.g. toxicities. • Assessment and agreement on continuation of patient enrolment to the study. 3.3.3 Stopping rule criteria. On observation of any of the following related adverse events, the study data (defined above) will be reviewed by the independent Protocol Safety and Review Board (PSRB) for an opinion. • ISR Grade 3 or 4 (as per protocol specific grading system) . • Clinically significant systemic allergic reaction (in the judgement of the investigator) • Evidence of clinically significant a utoimmunity (in the judgement of the investigator) • Cytokine release syndrome Grade 3 or 4. • Evidence of tumorgenicity/ectopic growth (including teratoma formation) . • Any other clinically significant toxicity (in the judgement of the investigator) CONFIDENTIAL CRUKD/17/003 Protocol Final 5.0 dated 08Jun2021 Page 26 of 72 EudraCT number : 2016 -002577 -35 Cancer Research UK 3. Systemic steroids or other drugs with a likely effect on immune competence are forbidden during the trial with the exception of replacement treatment. Inhaled and topical steroids are permitted . The predictable need of their use will preclude the patient from trial entry. 4. Female patients who are able to become pregnant (or are alre ady pregnant or lactating). However, those patients who have a negative serum or urine pregnancy test before enrolment and agree to use two forms of contraception (one effective form plus a barrier method) [oral, injected or implanted hormonal contraception and condom; intra- uterine device and condom; diaphragm with spermicidal gel and condom] or agree to sexual abstinence*, effective from the first administration of AST -VAC2 throughout the trial and for six months afterwards are considered eligible. 5. Male patients with partners of child- bearing potential (unless they agree to take measures not to father children by using a barrier method of contraception [condom plus spermicide] or to sexual abstinence * effective from the first administration of AST -VAC2, throughout the trial and for six months afterwards. Men with partners of child- bearing potential must also be willing to ensure that their partner uses an effective method of contraception for the same duration for example, hormonal contraception, intraut erine device, diaphragm with spermicidal gel or sexual abstinence). Men with pregnant or lactating partners must be advised to use barrier method contraception (for example, condom plus spermicidal gel) to prevent exposure of the foetus or neonate . 6.