Examples of ECOG Phase II Studies - Dana-Farber/Harvard Cancer ...

Examples of ECOG Phase II Studies

4. Administer doses with food.E12025. Diarrhea should be treated with diphenoxalate or loperamide in appropriatedosage.8.112 ReferencesPerifosine investigator drug brochure. ASTA Medica, 1998.Crul M, Rosing H, de Klerk GJ et al. Phase I and pharmacological study of daily oraladministration of perifosine (D-21266) in patients with advanced solid tumours. Eur JCancer 381615-1621, 2002.Hilgard P, Klenner T, Stekar J et al. D-21266 a new heterocyclic alkylphospholipidwith antitumour activity. Eur J Cancer 33442-446, 1997.9.0 STATISTICAL CONSIDERATIONS9.1 Primary Objective9.2 ToxicityThe primary goal for this Phase II study is to evaluate the objective response rate in patientswith locally advanced, unresectable or metastatic pancreatic adenocarcinoma treated withperifosine. A true response rate of 20% or more will be taken as evidence of activity in thispatient population.The null hypothesis to be tested is that the true response rate is 9% or lower. A two-stagedesign will be utilized in this study where a total of 84 patients will be accrued (76 eligiblepatients). During stage one, 35 patients will be accrued to the study, assuming 32 will beeligible. If there are 4 or more responses (CR+PR) observed, we will continue to the secondstage of accrual (90% CI for 4 responses: [4%, 26%]). Forty-nine patients will be accrued tothe second stage, assuming 44 will be eligible. If there are 11 or more responses, thetreatment will be considered promising (90% two stage CI for 11 responses: [9%, 27%]). Thistest has 86% power under the alternative hypothesis if the true response rate is 20%.The probability of stopping early if the true response rate is 9% is 0.68 and is 0.09 if the trueresponse rate is 20%. The probability of concluding that the treatment is effective if the trueresponse rate is 9% is 0.06.The toxicity rate is not expected to be extensive due to the dose modification schema that hasbeen built into the protocol as outlined in section 5.3. However, all toxicities will be closelymonitored throughout the study through the adverse event reporting system and the standardECOG toxicity analyses. A grade 3 or higher true toxicity rate of 25% or greater at the initialmaintenance dose level of perifosine may lead to a suspension of the study for toxicity review.If 7 or more grade 3 or higher toxicities are observed in the first stage of accrual (N=35), theprobability of suspending the trial is 81% and 94% if the true toxicity rate is 0.25 and 0.30respectively.9.3 Secondary ObjectivesThe secondary endpoints of this study are progression free survival, overall survival, durationof response and toxicity. With 1 year of follow up the 90% confidence interval for 1 year overallsurvival will be no wider than 20% assuming a median of 1 year (exponential distribution). The90% confidence interval for 1 year progression free survival rate will be no wider than 17%assuming a median of 6 months (exponential distribution) with one year of follow up. Overallsurvival and progression free survival will be estimated using the method of Kaplan-Meier.Duration of response will also be analyzed in an exploratory fashion.The toxicity profile in these patients will be tabulated and analyzed in an exploratory fashion.The maximum width of the 90% toxicity confidence interval will be approximately 0.20 (±0.10).18

9.4 AccrualE1202The accrual time is expected to be about 21 months (approximately 4 patients per month).9.5 Safety MonitoringInterim analyses of toxicity are performed twice yearly for all ECOG studies. Reports of theseanalyses are sent to the ECOG Principal Investigator or Senior Investigator at the participatinginstitutions. Expedited reporting of certain adverse events is required, as described in Section5.2.9.6 Gender and EthnicityThis study is open to both men and women and to all racial/ethnic groups. The patientenrollment pattern is expected to be similar to that of typical ECOG gastrointestinal cancerstudies. According to the most recent ECOG experience, there is no evidence for outcometo be affected by neither race nor gender. Thus, the study will not have separate accrualtargets for different subgroups. We will however, conduct subset analyses to assess genderand racial/ethnic effects when possible. According to historic data for ECOG gastrointestinalstudies, the table below illustrates the ethnic, race and gender breakdown that we areexpecting:Ethnic CategorySex/GenderMales Females Unknown TotalHispanic or Latino 0 0 0 0Not Hispanic or Latino 38 46 0 84Ethnic Category: Total of allsubjects38 46 0 84Racial CategoryAmerican Indian or Alaskan Native 0 0 0 0Asian 0 0 0 0Black or African American 3 3 0 6Native Hawaiian or other PacificIslander0 0 0 0White 35 43 0 78More than one race 0 0 0 0Unknown 0 0 0 0Racial Category: Total of allsubjects38 46 0 8410.0 PATHOLOGY REVIEW10.1 Upon the development of AML/MDS representative AML/MDS diagnostic material is to besubmitted for review and classification. Materials will be reviewed by John Bennett, M.D.The clinical investigator and the submitting pathologist have the responsibility for submittingrepresentative diagnostic materials. When a patient is registered to receive protocol therapy,the submitting pathologist and clinical research associate should refer to Appendix III(Pathology Submission Guidelines) which provides the following:10.11 Instruction Sheet from ECOG Pathology Coordinating Office providing details for theSubmission of Pathology Materials.19

Eastern Coope rativeE1603Oncology Group September 16, 20038.1.11 Side EffectsCardiovascular: Arrhythmia (asymptomatic ST- and T-wave changes on EKGtracings), Supraventricular arrhythmias (SVT/atrial fibrillation/flutter), hypotension,myocardial ischemia, increased cardiac troponin I, increased QTc interval,hemolysis, hemorrhageCNS: Syncope, confusionGastrointestinal: Nausea, vomiting, anorexia, gastritis, abdominal pain, melena/GIbleedBlood/bone marrow: Decreased hemoglobin, leukopenia, neutropenia,thrombocytopeniaMetabolic/laboratory: Increased CPK, hypocalcemia, hyperglycemia, fever,dehydration, weight loss, hypophosphatemia, hyponatremia, hypokalemia,hypomagnesemia, increased creatinine, increased PTConstitutional Symptoms: Fatigue (lethargy, malaise, asthenia)Hepatic: Increased SGOT and SGPT, hypoalbuminemia, hyperbilirubinemiaPulmonary: Hypoxia, pleural effusionRenal: HyperuricemiaWhole body: Tumor lysis syndrome, infectionOther: Injection site reaction, vaginal bleedingDose-limiting toxicities reported for the two DCTD, NCI-sponsored clinical trialsinclude fatigue, leukopenia, thrombocytopenia, and weight loss.8.1.12 Nursing/Patient ImplicationsMonitor for signs and symptoms of infection.Monitor liver function tests and metabolic profiles routinely.8.1.13 ReferencesDepsipeptide drug information sheet. Pharmaceutical Management Branch, CTEP,NCI 5/03.Depsipeptide Clinical Investigator Brochure. Fujisawa Pharmaceuticals/ Division ofCancer Treatment and Diagnosis (DCTD) National Cancer Institute (NCI).9. Statistical Considerations9.1 Accrual: A maximum of 30 eligible patients will be registered with a two-stage accrualdesign. To allow for ineligibility, 33 patients will be accrued. We expect to accrue 33 patientsin one year.9.2 Primary EndpointThe primary objective of this study is to evaluate the response rate of Depsipeptide inpatients with malignant melanoma. If Depsipeptide shows evidence of at least a 20%29

Eastern Coope rativeE1603Oncology Group September 16, 2003response rate, we would consider this a promising drug for a further study. However toconserve patient resources, we wish to minimize accrual if the response rate is less than2%. Therefore, a two-stage design will be used with a first stage accrual goal of 14 (for 12eligible) patients. If at least one response is seen in the first 14 (assuming 12 eligible)patients, additional 19 patients (assuming 18 eligible) will be entered. If 3 or more responsesare seen in 30 eligible patients, this will be considered evidence of a promising responserate.The table below summarizes operating characteristics of the two-stage design. If the trueresponse rate is 2%, there is a 78% chance of stopping the study early. If the true responserate is 20%, there is a 91% chance of concluding this is a promising regimen.Prob. stopping early (< 1 response in 12eligible patients)Overall prob. (> 3 responses in 30 eligiblepatients)Operating CharacteristicsTrue Response Rate2% 20%0.78 0.070.02 0.919.3 Secondary EndpointsIn addition, progression-free survival, overall survival will be evaluated. The data will besummarized using the method of Kaplan and Meier. The toxicity profile of Depsipeptide willbe evaluated in all treated patients. The proportion of patients experiencing grade 3 or highertoxicities will be estimated and summarized with a 90% confidence interval(CI). With asample size of 33 patients, the width of the 90% CI will not be wider than 31%.Biopsy samples will be collected at three time points: baseline, 1 day and 18 days post initialtreatment. When possible, biopsies will also be collected from patients who initially respondat the time of subsequent progression. The changes in the molecular expression pathwaywill be evaluated using the biopsy samples collected at different time points. These resultswill be correlated with the clinical outcome. Given the exploratory nature of the laboratorycorollary, the analysis of the laboratory data will be mainly descriptive.9.4 Safety MonitoringInterim analyses of toxicity are performed twice yearly for all ECOG studies. Reports ofthese analyses are sent to the ECOG Principal Investigator or Senior Investigator at theparticipating institutions. Expedited reporting of certain adverse events is required, asdescribed in section 5.2.30

Eastern Coope rativeE1603Oncology Group September 16, 20039.5 Gender and EthnicityBased on previous data from E1696 and E3695, the anticipated accrual in subgroupsdefined by gender and race is:Ethnic CategoryGenderFemales Males TotalHispanic or Latino 0 0 0Not Hispanic or Latino 11 22 33Ethnic Category: Total of all subjects 11 22 33Racial CategoryAmerican Indian or Alaskan Native 0 0 0Asian 0 0 0Black or African American 0 0 0Native Hawaiian or other Pacific Islander 0 0 0White 11 22 33Racial Category: Total of all subjects 11 22 33The accrual targets in individual cells are not large enough for definitive subgroup analyses.Therefore, overall accrual to the study will not be extended to meet individual subgroupaccrual targets.31

E6800SCHEMAREClassification Factor:• No prior immunotherapy/biologic therapy• Prior immunotherapy/biologic therapyEGISAtrasentan 10 mgorally daily.VALUContinue until evidence ofdisease progression orunacceptable toxicity.Note: Prior treatment w/ granulocytemacrophagecolony stimulating factor(GM-CSF) will not be counted as priorbiological therapy. If a patient receivesless than 4 weeks of biological therapy,they are still eligible and should beclassified as "no prior immunotherapy/biologic therapy".TERATE 1Accrual Objective: 90 (45 to each stratum)1. Evaluate for response every 2 cycles (8 weeks).

9.0 STATISTICAL CONSIDERATIONSE68009.1 Primary ObjectiveThe primary objective of the study is to determine the proportion of patients who are aliveand free from progression of disease at 6 months. Patients with prior immunotherapy andthose with no prior immunotherapy will be accrued separately. The target accrual is 90patients (45 each with and without prior therapy), and assumes that 5 patients in eachgroup will be ineligible. The sample size calculations are thus based on 40 eligiblepatients per group.9.2 Patients with Prior Immunotherapy9.21 Patients who have been treated with prior immunotherapy will be similar to thoseaccrued to E4896, phase II study of carboxyamidotriazole (CAI). While the datafrom E4896 are not mature enough to use for designing this study, theassumptions that guided that study will be employed here. A drug with minimalactivity would be expected to have a progression-free survival rate at 6 months of10%. Alternatively, atrasentan will be considered worthy of further study if its trueprogression-free survival rate at 6 months is 25% or better.9.22 A single-stage accrual plan will be employed. All 40 eligible patients will beenrolled and observed through their 6-month evaluations. If 7 or more of the 40eligible patients are alive and progression-free at 6 months, we will conclude thatthe regimen warrants further study. The probability of concluding that thetreatment is effective is 90% if the true rate at 6 months is 25%. The probabilityof concluding that the treatment is effective if the true rate is 10% is about 10%. If8 out of 40 eligible patients are alive and progression-free at 6 months, the 90%confidence interval will be approximately 10% to 33%.9.3 Patients with No Prior Therapy9.31 In patients with no prior immunotherapy, a drug with minimal activity mightdemonstrate a 6-month progression-free survival rate of 25%. To be worthy offurther study, atrasentan should have a true 6-month progression-free survivalrate of 45%, which is what might be expected using interferon (22). Because thetreatment choices for patients with no prior therapy are more extensive, it will bedesirable to stop early if the agent is not demonstrating efficacy. Therefore, atwo-stage accrual plan will be employed. First, 18 patients will be enrolled andobserved through their 6-month evaluations. Accrual to this arm will halt untilthese patients are assessed. Upon assessment, if 5 or more of 18 eligiblepatients per arm are alive and progression-free at 6 months, accrual will continueto 40 eligible patients. If 4 or fewer patients among the first 18 eligible patients arealive and progression free at 6 months, the study will halt and the agent will bedeclared ineffective for patients with no prior therapy.If 14 or more of the 40 eligible patients are alive and progression-free at 6months, we will conclude that the regimen warrants further study. As shown inthe following table, the probability of concluding that the treatment is effective is9% if the true rate at 6 months is 25%. The probability of stopping early if thetreatment is ineffective (true 6-month-progression-free survival rate of 25%) is52%. The probability of concluding that the treatment is effective is 90% if thetrue rate at 6 months is 45%. If 15 patients are alive and progression-free at 6months out of 40 eligible patients, the two-stage 90% confidence interval will beapproximately 25% to 52%.22

Probability stoppingearly (< 5 responses)Probability > 4responses duringStage 1 and rejectingthe treatmentOverall probability ofrejecting thetreatmentExpected samplesizeTrue Probability Progression Free at 6 Months0.2 0.25 0.3 0.35 0.4 0.45E68000.7164 0.5187 0.3327 0.1886 0.0942 0.040.266 0.3864 0.3907 0.282 0.1466 0.050.9823 0.9051 0.7234 0.4706 0.2407 0.124.24 28.159 32.68 35.85 37.93 39.19.4 ToxicityAll patients who receive treatment, regardless of eligibility, will be evaluated for toxicity.Patients with and without prior immunotherapy will be considered together whenassessing toxicity. Assuming that toxicity data is available on all 90 patients, the 90%confidence interval for the true probability of observing a toxicity of Grade 4 or higher willbe no wider than 18%. The study will have excellent probability of detecting raretoxicities. The probability of observing one or more toxicities with a true rate of 1% is60%.9.5 Accrual Rate and DurationThe most recently completed ECOG study in renal carcinoma was E4896, Phase II Studyof CAI (NSC #609974) in Patients with Advanced Renal Cell Carcinoma Refractory toImmunotherapy. The study, which was restricted to patients with one or two priorimmunotherapy regimens, accrued 57 patients in 6 months, an average of almost 10patients per month. Accrual among patients with no prior immunotherapy is expected tobe about 7 patients per month. Total duration of accrual should be about 6 months whilethe study is open to accrual, or up to 15 months total.9.6 Safety MonitoringInterim analyses of toxicity are performed twice yearly for all ECOG studies. Reports ofthese analyses are sent to the ECOG Principal Investigator or Senior Investigator at theparticipating institutions. Expedited reporting of certain adverse events is required, asdescribed in Section 5.2.9.7 Gender and EthnicityBased on previous data from E4896 the anticipated accrual in subgroups defined bygender and race is:23

Gender and Minority Accrual Estimates for Proposed Study (Accrual Goal = 90)E6800Ethnic CategorySex/GenderFemales Males Unknown TotalHispanic or Latino 0 2 0 2Not Hispanic or Latino 32 56 0 88Unknown 0 0 0 0Ethnic Category: Total of all32 58 0 90subjects 1Racial CategoryAmerican Indian or Alaskan Native 0 0 0 0Asian 0 0 0 0Black or African American 0 6 0 6Native Hawaiian or other PacificIslander0 0 0 0White 32 52 0 84More than one race 0 0 0 0Unknown 0 0 0 0Racial Category: Total of all subjects 32 58 0 90The accrual targets in individual cells are not large enough for definitive treatmentcomparisons to be made within subgroup accrual targets.10.0 PATHOLOGY REVIEW10.1 Upon the development of AML/MDS, representative AML/MDS diagnostic material is tobe submitted for review and classification. Materials will be reviewed by John Bennett,M.D.The clinical investigator and the submitting pathologist have the responsibility forsubmitting representative diagnostic materials. Refer to Appendix VI (PathologySubmission Guidelines) which provides the following:10.11 Instruction Sheet from ECOG Pathology Coordinating Office providing details forthe Submission of Pathology Materials.10.12 Memorandum to the submitting pathologist from Stanley Hamilton, M.D.,chair,ECOG Pathology Committee, providing details for the Submission of PathologyMaterials.10.13 A list of required materials.10.14 An ECOG Pathology Material Submission Form (#638).24

E4999Revised 2/01, Addendum #18.712 ReferencesAnon. American Society of Clinical Oncology recommendations for the use ofhematopoietic colony-stimulating factors: Evidence-based, clinical practiceguidelines. J. Clin Oncol 1994;12:2471-2508.Grant SM, Heel RC. Recombinant granulocyte-macrophage colony-stimulating factor(rGM-CSF): a review of its pharmacological properties and prospective role on themanagement of myelosuppression. Drugs 1992; 43:516-60.Investigational Drug Brochure: Leukine, Immunex Research and DevelopmentCorporation. Revised November, 1993.Personal correspondence: Kim Murray, Pharm.D., Inimunex Corporation, April 5, 1996.Louie SG. Jung B. Clinical effects of biologic response modifiers. Am J Hosp Pharm1993;50:(Suppl 3):S10-S18.9.0 STATISTICAL CONSIDERATIONS9.1 AccrualThe primary objective of this study is to evaluate the response (complete response pluscomplete response without full platelet recovery) rate for each treatment in relapsed orrefractory AML patients. In addition, toxicity will be evaluated.A maximum of 150 eligible patients will be randomized to one of the three treatment arms(50 to each treatment arm). To allow for 10% ineligibility, 165 patients will be entered. Basedon the ECOG experience with E2995, it is expected to accrue 8 patients per month.Therefore, we expect to complete the accrual within 2 years.32c

E49999.2 ResponseAll of the three treatment arms have the same study design described in this section.If the treatment demonstrates at least a 40% response rate, we would consider this apromising regimen for further study. However, we wish to minimize accrual if the CR rate isless than 25%.Therefore, the two-stage design will first accrue 26 patients (assuming 24 eligible). If at least7 responses are seen among 24 eligible patients, an additional 29 patients (assuming 26eligible) will be entered. If 17 or more responses are seen in 50 eligible patients, this will beconsidered evidence of a promising response rate.Using this study design, the chance of concluding that the treatment is active is 0.09 whenthe true response rate is 25%. The chance of concluding the treatment is active is 0.81 whenthe true response rate is 40%. Operating characteristics of the two-stage design aresummarized in Table 1. The 90% confidence interval for the observed response rate of 17/50is (0.24, 0.49), for 20/50 is (0.29, 0.53) and for 23/50 is (0.34, 0.59).Table 1Operating CharacteristicsTrue Response Rate 25% 40%Probability of stopping early(< 7 responses in 24 eligible pts)Overall probability of concluding treatment is active(> 17 responses in 50 eligible pts)0.61 0.100.09 0.819.3 Monitoring For ToxicityTreatment-related toxicities will be monitored closely for all three treatment arms, especiallyfor arm A (IDAC + gemtuzumab ozogamicin) as we do not have much information on thetoxicity of this regimen. Although there is no formal stopping rule based on the toxicity data,we will consider an early stopping of any treatment arms if unacceptable toxicities areobserved. Toxicity will be monitored using ECOG’s standard ADR mechanism.9.4 Cytogenetic StudyOf the 150 eligible patients, we assume that at least 135 patients (90%) will submit samplesfor the cytogenetic study.The karyotype at the time of diagnosis will be compared to the karyotype at the time ofrelapse. The proportion of patients with different karyotypes will be described using theconfidence interval. Based on the sample size of 135 eligible patients, 90% confidenceinterval will not be wider than 0.15.33

Eastern Cooperative E1602Oncology GroupSchemaStratification Factors:1. HLA Status 1• HLA - A1 + only• HLA - A2 + only• HLA - A1 + and HLA - A2 +• Other (HLA - A3 + )2. SIN Biopsy to beperformed• Yes• NoAccrual Goal: 176RANDOMIZATIONARM A - 12MPMulti-epitope Peptide Vaccine 12 MP(12 Melanoma Peptides restricted byClass I MHC) + 110 mcg GMCSF & 1ml Montanide ISA-51 at each of 2sites 2 , day 1 of weeks 1, 2 and 3ARM B - 12MP/TetMulti-epitope Peptide Vaccine 12 MP/Tet (12 Melanoma Peptides restrictedby Class I MHC plus 1 TetanusHelper Peptide) + 110 mcg GMCSF& 1 ml Montanide ISA-51 at each of 2sites 2 , day 1 of weeks 1, 2 and 3ARM C - 12MP/6HPMulti-epitope Peptide Vaccine 12MP/6HP (12 Melanoma Peptidesrestricted by Class I MHC plus 6Melanoma Helper Peptides) + 110mcg GMCSF & 1 ml MontanideISA-51 at each of 2 sites 2 , day 1 ofweeks 1, 2 and 3ARM D - 6HPMulti-epitope Peptide Vaccine 6HP (6Melanoma Helper Peptides) + 110mcg GMCSF & 1 ml Montanide ISA-51 at each of 2 sites 2 , day 1 of weeks1, 2 and 3ARM A - 12MPMulti-epitope Peptide Vaccine 12MP (12 Melanoma Peptidesrestricted by Class I MHC), + 110mcg GM-CSF & 1 ml MontanideISA-51 at 1 site 3 , day 1 of weeks 5,6 and 7ARM B - 12MP/TetMulti-epitope Peptide Vaccine 12MP/Tet (12 Melanoma Peptidesrestricted by Class I MHC plus 1Tetanus Helper Peptide), + 110mcg GM-CSF & 1 ml MontanideISA-51 at 1 site 3 , day 1 of weeks 5,6 and 7ARM C - 12MP/6HPMulti-epitope Peptide Vaccine 12MP/6HP (12 Melanoma Peptidesrestricted by Class I MHC plus 6Melanoma Helper Peptides), + 110mcg GM-CSF & 1 ml MontanideISA-51 at 1 site 3 , day 1 of weeks 5,6 and 7ARM D - 6HPMulti-epitope Peptide Vaccine 6HP(6 Melanom a Helper Peptides), +110 mcg GM-CSF & 1 mlMontanide ISA-51 at 1 site 3 , day 1of weeks 5, 6 and 71. Only patients who are HLA-A1+, HLA-A2+, or HLA-A3+ are eligible for this study.2. Patients will be administered each m ulti-epitope peptide vaccine intradermally (~50%) and subcutaneously (~50%) in two contiguous 1 ml aliquots. Thevaccines will be administered on two extremities.3. Patients will be administered each m ulti-epitope peptide vaccine intradermally (~50%) and subcutaneously (~50%) in two contiguous 1 ml aliquots. The 3vaccines and all subsequent repeat sets of vaccines (booster vaccines) will be administered on a single extremity. That extremity will be the extremity fromwhich the sentinel immunized node was NOT removed.4. All patients will be followed for response until progression, and for survival for 5 years from study entry.HARVESTSINDay 1ofweek 4optionalWeeks8-11RestProtocol treatmentis discontinued ifprogression 4Noprogression ofdisease(as defined bySection 6.0)Reassess onweek 12 forevidence ofanti-tumorresponseRepeat sets of 3weekly booster 3vaccines2 x 9 weeks,2 x 12 weeks2 x 24 weeksor until tumorprogressionNOTE: Submission of peripheral blood for use in ancillary studies described in Section 11.1 is mandatory. Collection time points and submission guidelines aredescribed in Sections 7.2 and 11.1.i

Eastern CooperativeOncology GroupE16028.5.10 Nursing/Patient Implications1. Inform patient of possible side effects. Answer any questions.2. Do not premedicate unless absolutely necessary. Acetaminophen is thepreferred analgesic if needed, but nonsteroidals or aspirin may be used.Diphenhydramine may be used to reduce erythema if needed.3. Monitor for acute reactions. Outpatients may need to be observed for 1 – 2hours after receiving first dose.8.5.11 ReferencesRosenberg, et al. Nature Med 1998; (94)4:321-327.9. Statistical ConsiderationsThe main objective of this randomized phase II study is to evaluate four vaccine regimens that mayinduce anti-melanoma immune responses in patients with advanced melanoma. The four vaccineregimens include (A) 12 peptides, (B) 12 peptides + tetanus helper peptide, (C) 12 peptides + 6helper peptides and (D) 6 helper peptides.A total of 176 patients will be randomized to the four treatment arms. Of 44 patients in each arm, weexpect 40 patients will be eligible and evaluable for immune responses. Based on previous ECOGexperiences, accrual will be completed within 3 years.The immunologic and toxicity data will be closely monitored by the ECOG Data MonitoringCommittee (DMC) as summarized in Section 9.4.9.1 Primary Immunologic Data9.1.1 CTL response in PBLThe primary endpoint is the CTL response assessed in peripheral blood T-celllymphocytes (PBL). Since arms B and C have 12 MP + helper peptides, theexpected CTL response rate is higher in these two arms than in arms A or D. On theother hand, arm D only has helper peptides and thus will be used as a negativecontrol.We expect that the CTL response rate will be less than 10% in arm D and at least40% in arms A, B and C. This study is designed for the main comparisons of theCTL response rates in arms A vs. D, B vs. D and C vs. D. The sample size of 40evaluable patients in each arm will provide at least 85% power to detect a differenceof at least 30% in CTL response rate (from 10% to 40% or higher). This is based ona two-sided type I error of .05.Although this study is not powered for other comparisons, the following exploratoryanalysis will be performed. It will be of interest to compare the CTL response ratesof arms B and C. There will be at least 82% power if the difference in the CTLresponse rate in arms B and C are at least 20%. For example, the CTL responserates in B vs. C are 80% vs. 100%, 70% vs. 95%, 60% vs. 90% vs. 45% vs. 80%,the power will be 83%, 82%, 85% and 87%, respectively. This is based on a two-42

Eastern CooperativeOncology GroupE1602sided type I error of 0.05. If there is no difference in the CTL response rate of arms Band C, the CTL response rate will be compared in arms A vs. B+C. There will be85% power if the difference in the CTL response rate in arms A and B+C is 30%(40% to 70%). This is based on a two-sided type I error of 0.05.The immune CTL response is defined in section 9.3. The CTL response in PBL willbe assessed using the baseline and first 6 weeks samples. In addition to theevaluation of the binary outcome of immune response vs. no response, themagnitude of response in terms of the number of T-cells responding to peptides andpatterns of immune responses over time will be evaluated and summarizeddescriptively.Given the exploratory nature of this study, no adjustments will be made for multiplecomparisons.9.1.2 CTL response in SIN harvestT-lymphocytes from a lymph node draining an immunization site (SIN) will also beevaluated. The data from University of Virginia studies indicate that the CTLresponse in SIN harvest will be higher than the CTL response in PBL. We anticipatethat at least 10 eligible and evaluable patients in each treatment arm will agree toparticipate in SIN harvest.We anticipate that at least 25% of patients will participate in SIN biopsy. This impliesat least 10 evaluable patients in each treatment arm will have SIN biopsy samples.We expect that the CTL response rate in SIN harvest will be 10% in arm D and atleast 80% in arms A, B and C. The sample size of 10 evaluable patients in each armwill provide at least 80% power to detect a difference of at least 70% in CTLresponse rate in SIN biopsy samples (from 10% to 80%) for the comparisons of CTLresponse rates in arm A vs. D, B vs. D, C vs. D.9.1.3 Stopping rule based on clinical and immunologic endpointsAlthough the primary endpoint of this study is CTL response in PBL, this study willbe monitored for clinical and immunologic endpoints. We propose stopping rules forclinical endpoints in section 9.1.3.1 and for the immunologic endpoint in section9.1.3.2. An interim analysis will be performed when the clinical response data areavailable in the first 20 eligible patients and the immunologic response data areavailable in the first 10 eligible patients. Since it takes longer to assess immuneresponses, we expect about 10 patients will have the immune response assessedwhen the response data become available in the first 20 eligible patients. We willassess both clinical and immune responses in arms A-C at the time of the interimanalysis and will consider discontinuing a treatment arm when either the clinical orimmunologic endpoint does not demonstrate efficacy. Since arm D serves as acontrol for immune response to class I MHC-restricted peptides, we will not applythe stopping rules to this arm. However in the event of stopping all three arms A-C,we will consider stopping arm D as well.9.1.3.1 Clinical EndpointsApproved therapy for stage IV melanoma includes cytotoxic chemotherapyand high-dose IL-2. The objective response rates for these therapies arein the range of 9-15%, but prolongation of life has not been proven withexisting approved therapy for stage IV melanoma. Immune therapy, if43

Eastern CooperativeOncology GroupE1602effective, is hoped to induce objective clinical responses in some patients,but another potential benefit is prolongation of survival, which may occurby stabilization of disease. The stopping rules for clinical outcome arebased on these considerations.In a large review of previous ECOG studies (E1675, E1687, E2683,E2685, E3690, E4687, E3695; total n=1710) in stage IV disease, theobjective clinical response rate (CR + PR) was 12%, and the rate ofdisease stabilization (CR+PR+SD) was 28%. This provides reasonablebaseline values to design a stopping rule for the present study. In arecently completed study of a peptide vaccine in stage IV melanoma,E1696, preliminary data on clinical response (data as of July 2003) revealsa lower objective response rate (4.5%), but a higher rate of diseasestabilization (45%). These data suggest that a good clinical outcome maybe manifested either by objective clinical response or by a higher rate ofdisease stabilization. While the primary endpoint in the present study isimmunologic, we will assess the objective response rate and the diseasestabilization rate for each arm after we accrue 22 patients (for 20 eligiblepatients) and consider discontinuing that arm if these rates are low.Specifically, if 0 patients experience an objective response (CR or PR),AND if fewer than 7 patients experience disease stabilization(CR+PR+SD) in the first 20 eligible patients, we will discontinue accrual tothat arm. The following table displays the probability of stopping earlywhen the true response rate ranges from 3% to 10% and the true rate ofdisease stabilization ranges from 15% to 35%. If the true response rate is3% and the rate of disease stabilization is 15%, the probability ofdiscontinuing a treatment arm is .53. On the other hand, if the trueresponse rate is 10% and the rate of disease stabilization is 35%, theprobability of discontinuing a treatment arm is 0.07.PROBABILITY OF EARLY STOPPING FOR CLINICAL ENDPOINTS( 0 response and < 7 SDs in first 20 eligible patients)SD rate \ Response Rate 3% 5% 10%15%.53 .35 .1225%.43 .28 .1035%.33 .22 .079.1.3.2 Immunologic EndpointWe will monitor for the CTL response in arms A-C. We expect that the CTLresponse rate is at least 40% in these arms. We will consider discontinuing atreatment arm if less than 2 CTL responses are observed in the first 10 eligiblepatients. The table below displays the probability of stopping early under a range oftrue CTL response rates.44

Eastern CooperativeOncology GroupE1602PROBABILITY OF EARLY STOPPING FOR CTL RESPONSE(< 2 CTL response in first 10 eligible patients)CTL resp ra 10% 20% 30% 40% 50%.74 .38 .15 .05 .019.1.3.3 First stage stopping rule and accrualThis stopping rule will be assessed when clinical response data becomeavailable in the first 20 eligible patients and CTL response data becomeavailable in the first 10 eligible patients on arms A-C. We will considerdiscontinuing a treatment arm if (0 clinical response and < 7 diseasestabilizations in 20 eligible patients) or (

Eastern CooperativeOncology GroupE16029.3 Definitions of Immune Responses9.3.1 CTL responseAssessment of immunologic response will be based upon a fold-increase in T cellresponse measure by ELIspot (53, 96). The fold-increase will be measured as theratio compared to the pre-vaccine ratio. Observed fold-increases less than one willbe converted to one to indicate no response. When the pre-vaccine PBL value willbe zero, this value will be converted to one, to avoid dividing by zero.Evaluation of T-cell responses will be based on the following definitions: N_vax =number of T-cells responding to peptide in the vaccine. N_neg = number of T-cellsresponding to negative control (maximum of two negative controls (a) C1R-A1, T2,or C1R-A3, alone or (b) C1R-A1, T2, or C1R-A3 pulsed with an irrelevant peptide)R_vax = ratio of Nvax/Nneg.For evaluations of PBL, a patient is considered to have a T-cell response tovaccination only if all of the following criteria have been met:1) N_vax exceeds N_neg by at least 30 cells per 100,000 (corresponds to ~ 0.15%of CD8+ cells)2) R_vax > 2 (fold-increase of at least 2)3) (N_vax - 1 S.D.) > (N_neg + 1 S.D.)4) R_vax after vaccination > 2 x R_vax pre-vaccine.The peak CTL response to any peptide after the first vaccine is reported as a foldincreaseover the negative control, and the increase due to vaccination is reportedas a ratio of the post-vaccine measure to the pre-vaccine measure.9.3.2 Helper T-cell Response9.4 Study MonitoringHelper-T cell responses will be evaluated first by proliferation assay offresh/cryopreserved PBL in the presence of each of the helper peptides. A foldincreasein reactivity of at least 4 from background will be considered as a response.Positive responses will be evaluated further by cytokine production to determine ifthe helper responses included are predominantly of the Th1 or Th2 types.This study will be monitored by the ECOG Data Monitoring Committee (DMC). The DMCmeets twice each year. For each meeting, all monitored studies are reviewed for safety andprogress toward completion. When appropriate, the DMC will also review interim analyses ofoutcome data. Copies of the toxicity reports prepared for the DMC meetings are included inthe study reports prepared for the ECOG group meeting (except that for double blindstudies, the DMC may review unblinded toxicity data, while only pooled or blinded data willbe made public). These group meeting reports are made available to the local investigators,who may provide them to their IRBs. Only the study statistician and the DMC members willhave access to interim analyses of outcome data. Prior to completion of this study, any useof outcome data will require approval of the DMC. Any DMC recommendations for changesto this study will be circulated to the local investigators in the form of addenda to this protocoldocument. A complete copy of the ECOG DMC Policy can be obtained from the ECOGCoordinating Center.46

Eastern CooperativeOncology GroupE16029.5 Gender and EthnicityBased on previous data from E1696, E3695 the anticipated accrual in subgroups defined bygender and race is:Ethnic CategoryGenderFemales Males TotalHispanic or Latino 0 1 1Not Hispanic or Latino 59 116 175Ethnic Category: Total of all subjects 59 117 176Racial CategoryAmerican Indian or Alaskan Native 0 0 0Asian 0 0 0Black or African American 1 0 1Native Hawaiian or other Pacific Islander 0 0 0White 58 117 175Racial Category: Total of all subjects 59 117 17610. Pathology ReviewThe accrual targets in individual cells are not large enough for definitive subgroup analyses.Therefore, overall accrual to the study will not be extended to meet individual subgroupaccrual targets.10.1 Upon the development of AML/MDS, representative AML/MDS diagnostic material is to besubmitted for review and classification. Materials will be reviewed by John Bennett, M.D.The clinical investigator and the submitting pathologist have the responsibility for submittingrepresentative diagnostic materials. Refer to Appendix III (Pathology Submission Guidelines)which provides the following:10.1.1 Instruction Sheet from ECOG Pathology Coordinating Office providing details for theSubmission of Pathology Materials.10.1.2 Memorandum to the submitting pathologist from Stanley Hamilton, M.D.,chair,ECOG Pathology Committee, providing details for the Submission of PathologyMaterials.10.1.3 A list of required materials.10.1.4 An ECOG Pathology Material Submission Form (#638).10.2 The materials required for this protocol (upon the development of AML/MDS) are:10.2.1 ECOG Pathology Material Submission Form (#638), Parts A & B completed. Pleaseidentify the clinical status of the submitted material (i.e., pretreatment as opposed toremission and relapse).47