NCI Consent Form Template for Adult Cancer Trials



Consent Form – Part A-Monotherapy: Dose Finding

Study Title for Study Participants: Finding the best dose of anti-LAG-3 or anti-CD137 in patients with brain cancer.

Official Study Title for Internet Search on : A Phase I Trial of Anti-LAG-3 or Anti-CD137 Alone and in Combination with Anti-PD-1 in Patients with Recurrent GBM

What is the usual approach to my brain cancer?

You are being asked to take part in this study because you have a type of brain cancer called glioblastoma multiforme which has grown or has recurred. You have already been treated with surgery, radiation, and chemotherapy. People who are not in a study are usually treated with more chemotherapy and additional surgery if appropriate. Bevacizumab is also an available and Food and Drug Administration (FDA)-approved treatment for patients with recurrent glioblastoma who have not previously received it, although it does not cure and its effect on survival is unknown. Sometimes, combinations of these are used and your doctor can explain which may be best for you. These treatments can reduce symptoms and may stop the tumor from growing for several months or more.

What are my other choices if I do not take part in this study?

If you decide not to take part in this study, you have other choices. For example:

• you may choose to have the usual approach described above

• you may choose to take part in a different study, if one is available

• you may choose not to be treated for cancer, but you may want to receive comfort care to relieve symptoms.

Why is this study being done?

The purpose of this study is to test the safety of two investigational study drugs called anti-LAG-3 and anti-CD137 when each is given alone. “Investigational” means that the drug is being studied. It also means that the FDA (U.S. Food and Drug Administration) has not approved the drug for use in patients, including people with your type of cancer. Each of these drugs is an antibody (type of protein) that may stimulate the cells in your body, called your immune system, that protect you from infection. These drugs have already been tested in people with other types of cancer but not yet in brain cancer. This study tests doses of each drug to see which dose is safer in people with brain cancer.

There will be between 20 and 36 people taking part in this study.

What are the study groups?

Study participants will be assigned to receive either anti-LAG-3 or anti-CD137. The drug each patient is assigned will alternate between the two drugs: the first person to enroll in the study will be assigned one of the drugs and the next person will be assigned the other drug, and so on.

For participants assigned to receive anti-LAG-3, different doses of anti-LAG-3 will be given to groups of several study participants. The first group of study participants will receive the lowest dose. If the drug does not cause serious side effects, it will be given to a group of several other study participants at a higher dose. There are 3 different doses for anti-LAG- 3. The dose may be lowered if side effects occur that require it. Then no more groups of study participants will be enrolled.

For participants assigned to receive anti-CD137, a dose of anti-CD137 will be given to several study participants. If the drug does not cause serious side effects, it will be given to several other study participants at the same dose. The dose may be lowered if side effects occur that require it. Then no more groups of study participants will be enrolled.

Study participants receiving anti-LAG-3 will be given the drug in the form of an infusion into a vein once every 2 weeks in the outpatient clinic. Participants will return to the clinic every 28 days to see the study doctor.

Study participants receiving anti-CD137 will be given the drug in the form of an infusion into a vein once every 3 weeks in the outpatient clinic. Participants will return to the clinic every 21 days to see the study doctor.

How long will I be in this study?

If you are receiving anti-LAG-3, you will continue to receive your study drug and be in the study for up to 96 weeks (about 22 months) unless your tumor grows, or you have side effects that cause your condition to worsen, or you desire to stop treatment. After you stop the study drug, your doctor will continue to watch you for side effects and follow your condition for at least 100 days.

If you are receiving anti-CD137, you will continue to receive your study drug and be in the study for up to 45 weeks (about 11 months) unless your tumor grows, or you have side effects that cause your condition to worsen, or you desire to stop treatment. After you stop the study drug, your doctor will continue to watch you for side effects and follow your condition for at least 100 days.

Certain patients who have no clinical signs or symptoms of disease progression and are tolerating treatment, but who have an MRI showing apparent progression of their disease while on treatment, may be allowed to continue treatment until another MRI 2-2 ½ months later confirms or rules out progressive disease. These patients will need to sign this consent form again in order to continue treatment.

You will be contacted every 2 months for two years after you stop the study drug to find out how you are doing. After 2 years, you will be contacted every 6 months.

What extra tests and procedures will I have if I take part in this study?

Most of the exams, tests, and procedures you will have are part of the usual approach for your cancer. However, if you choose to take part in the study, then you will need the following extra tests. They are not part of the usual approach for your type of cancer.

During the study:

• Collection of about 78 extra blood samples during the first 4 cycles of treatment for studies of the effects of the study drug:

If you are receiving anti-LAG-3, these samples will be taken at the following times:

• Cycle 1, Day 1: 13-14 samples before you receive your dose

• Cycle 1, Day 15: 13-14 samples before you receive your dose

• Cycle 2, Day 1: 26 samples before you receive your dose

• Cycle 4, Day 1: 26 samples before you receive your dose

If you are receiving anti-CD137, these samples will be taken at the following times:

• Cycle 1, Day 1: 13-14 samples before you receive your dose

• Cycle 2, Day 1: 13-14 samples before you receive your dose

• Cycle 3, Day 1: 26 samples before you receive your dose

• Cycle 4, Day 1: 26 samples before you receive your dose

• Collection of stored pieces of cancer tissue, if available, from your initial surgery at the diagnosis of glioblastoma, to look at certain features of the tumor. The tissue will be requested from the facility where you had your initial surgery to remove the tumor. If you had any additional surgeries for glioblastoma prior to enrolling on this study, this tissue will also be collected when tissue is available.

• If you need further surgery for your brain tumor while you are taking part in this study, pieces of cancer tissue from your tumor will be collected to look at certain features of the tumor. The tissue will be collected during normal surgery to remove the tumor.

These samples are required in order for you to take part in this study because the research on the samples is an important part of the study.

Neither you nor your health care plan/insurance carrier will be billed for the collection or processing of the research blood samples or tumor tissue that will be used for this study.

What possible risks can I expect from taking part in this study?

If you choose to take part in this study, there is a risk that you may:

• Lose time at work or home and spend more time at the hospital or doctor’s office than usual

• You may be asked sensitive or private questions which you normally do not discuss

The medication used in this study may affect how different parts of your body work such as your liver, kidneys, heart, and blood. The study doctor will be testing your blood and will let you know if changes occur that may affect your health.

There is also a risk that you could have side effects from the study drug.

Here are important points about side effects:

• The study doctors do not know who will or will not have side effects.

• Some side effects may go away soon, some may last a long time, or some may never go away.

• Some side effects may interfere with your ability to have children.

• Some side effects may be serious and may even result in death.

Here are important points about how you and the study doctor can make side effects less of a problem:

• Tell the study doctor if you notice or feel anything different so they can see if you are having a side effect.

• The study doctor may be able to treat some side effects.

• The study doctor may adjust the study drugs to try to reduce side effects.

Below are the most common and the most serious side effects that researchers know about. There might be other side effects that researchers do not yet know about. If important new side effects are found, the study doctor will discuss these with you.

Both anti-LAG-3 and anti-CD137 are foreign proteins and could cause an allergic reaction when infused into a vein. Very rarely, the reaction could be severe. The signs of an allergic reaction may be rash, low blood pressure, wheezing and difficulty breathing. This kind of reaction may happen within seconds or hours of receiving the drug. If this happens, your doctor may use several types of medicines to control the reaction.

Potential Risks of Anti-LAG-3:

Side effects include:

• skin reactions

• oral mucositis and

• immune-related side effects that have been seen in participants treated with other immunotherapies and which may or may not be caused by anti-LAG-3, including:

▪ Uveitis – inflammation of the eyes that may cause:

• eye redness

• eye pain

• sensitivity to light

• blurred vision

• decreased vision

• floating spots in your vision

▪ Hypophysitis – inflammation of the pituitary gland that may cause:

• low blood sugar

• dehydration

• weakness

• dizziness

• other symptoms

▪ Hyperthyroidism – overactive thyroid gland activity that may lead to:

• Fatigue

• Weakness

• muscle aches

• anxiety

• weight loss

• intolerance to heat

• other symptoms

▪ Hepatitis – inflammation of the liver that may result in:

• Nausea

• Fatigue

• abdominal pain

• impart a yellowish hue to your skin or eyes

• darkness of your urine

▪ Pancreatitis – inflammation of the pancreas that may lead to:

• high levels of lipase and that may be accompanied by nausea, vomiting, and abdominal pain

▪ Colitis – inflammation of the lining of the colon, sometimes associated with:

• severe diarrhea

▪ Arthritis – painful swelling, inflammation and stiffness of the fingers, wrists, arms and legs

Potential Risks of Anti-CD137:

The following is a list of the side effects occurring in subjects treated with anti-CD137. Most were mild and resolved without treatment.

Likely

• Fatigue

• Liver function test abnormalities

• Rash with or without itching skin

Less Likely

• Fever

• Nausea

• Decreased appetite

• Diarrhea

• Weakness

• Headache

• Vomiting

• Joint pain

• Constipation

• Cough

• Low white blood cells count that may increase your risk of infection. If you develop a fever when your blood count is low, you may need to be hospitalized and treated with intravenous antibiotics

• Low platelet count that may increase your risk of bleeding or require a platelet transfusion

• Anemia that may require a blood transfusion if you have fatigue, shortness of breath or other symptoms that occur with a low red blood cell count

• Skin infection

The severity of side effects was greater in subjects treated with higher doses and included two deaths due to complications of liver failure. The doses of anti-CD137 that will be used in this study are below those that were associated with those deaths. Of the patients previously tested at doses to be used in this study, there was a single patient who had a severe liver function blood test abnormality. The patient showed no symptoms of liver disease (e.g., yellowing of the whites of the eyes or skin, belly pain/itchiness) and the laboratory value resolved rapidly without treatment. Anti-CD137may increase the risk of liver damage associated with the use of other medications or substances that can injure the liver. In particular, it is important that you avoid alcohol ingestion while you are undergoing treatment and limit the use of acetaminophen, another commonly used medication that can cause liver injury.

Rare but Serious

• Increases in liver blood tests that are associated with severe liver damage. Your doctor needs to do other tests to determine the cause of the liver damage. When anti-CD137 is the cause, the liver blood tests usually go back to normal after discontinuation of anti-CD137 and without the use of other medicines within 7-42 days. Less commonly, your doctor may need to use medicines (for example, steroids) to help the liver recover. This event has been serious enough to cause hospitalization and infrequently death. The deaths which have occurred have happened despite treatments with medicines to help the liver recover and other efforts to treat the liver failure.

• A case of fatal sepsis syndrome occurred in one patient

• Other kinds of rare, but severe side effects seen following treatment with anti-CD137 include: abdominal pain, appendicitis, gastrointestinal bleeding, fatigue, renal failure, vaginal bleeding, progression of your cancer, decreased blood oxygen levels, and swelling of the lymphatic vessels (lymphangitis)

Reproductive risks: You should not get pregnant, breastfeed, or father a baby while in this study. Women of childbearing potential must agree to use two methods of contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study treatment, and through at least 23 weeks after the last dose of any study drug. Women of childbearing potential will be required to have a pregnancy test within 24 hours prior to treatment start and then approximately every 8-9 weeks while on study, to ensure that they are not pregnant. Should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately. Sexually active men of reproductive potential who are partners of women with reproductive potential must also agree to use adequate contraception prior to the study, for the duration of study participation, and through at least 32 weeks after the last dose of study drug.The medication used in this study could be very damaging to an unborn baby. Check with the study doctor about what types of birth control, or pregnancy prevention, to use while in this study.

There can also be a risk in finding out new genetic information about you. New health information about inherited traits that might affect you and your blood relatives could be found during a study.

What possible benefits can I expect from taking part in this study?

This study is unlikely to help you. This study may help us learn things that may help people in the future.

Can I stop taking part in this study?

Yes. You can decide to stop at any time. If you decide to stop for any reason, it is important to let the study doctor know as soon as possible so you can stop safely. If you stop, you can decide whether or not to let the study doctor continue to provide your medical information to the organization running the study.

The study doctor will tell you about new information or changes in the study that may affect your health or your willingness to continue in the study.

The study doctor may take you out of the study:

• If your health changes and the study is no longer in your best interest

• If new information becomes available

• If you do not follow the study rules

• If the study is stopped by the sponsor, IRB or FDA.

What are my rights in this study?

Taking part in this study is your choice. No matter what decision you make, and even if your decision changes, there will be no penalty to you. You will not lose medical care or any legal rights.

For questions about your rights while in this study, call the ________________________ (insert name of center) Institutional Review Board at __________________ (insert telephone number).

What are the costs of taking part in this study?

The study drugs, anti-LAG-3 or anti-CD137 , will be supplied at no charge while you take part in this study. The cost of getting the drug ready and giving it to you is also provided at no charge. It is possible that anti-LAG-3 or anti-CD137 may not continue to be supplied while you are on the study. Although not likely, if this occurs, your study doctor will talk to you about your options.

You and/or your health plan/insurance company will need to pay for all of the other costs of treating your cancer while in this study, including the cost of tests, procedures, or medicines to manage any side effects, unless you are told that certain tests are supplied at no charge. Before you decide to be in the study, you should check with your health plan or insurance company to find out exactly what they will pay for.

You will not be paid for taking part in this study.

What happens if I am injured or hurt because I took part in this study?

If you are injured or hurt as a result of taking part in this study and need medical treatment, please tell your study doctor. The study sponsors will not offer to pay for medical treatment for injury. Your insurance company may not be willing to pay for study-related injury. If you have no insurance, you would be responsible for any costs.

If you feel this injury was a result of medical error, you keep all your legal rights to receive payment for this even though you are in a study.

Who will see my medical information?

Your privacy is very important to us and the researchers will make every effort to protect it. Your information may be given out if required by law. For example, certain states require doctors to report to health boards if they find a disease like tuberculosis. However, the researchers will do their best to make sure that any information that is released will not identify you. Some of your health information, and/or information about your specimen, from this study will be kept in a central database for research. Your name or contact information will not be put in the database.

There are organizations that may inspect your records. These organizations are required to make sure your information is kept private, unless required by law to provide information. Some of these organizations are:

• The study sponsor and the drug company supporting this study.

• The Institutional Review Board, IRB, is a group of people who review the research with the goal of protecting the people who take part in the study.

• The Food and Drug Administration and the National Cancer Institute in the U.S., and similar ones if other countries are involved in the study.

Where can I get more information?

You may visit the NCI Web site at for more information about studies or general information about cancer. You may also call the NCI Cancer Information Service to get the same information at: 1-800-4-CANCER (1-800-422-6237).

A description of this clinical trial will be available on , as required by U.S. Law. This Web site will not include information that can identify you. At most, the Web site will include a summary of the results. You can search this Web site at any time.

Who can answer my questions about this study?

You can talk to the study doctor about any questions or concerns you have about this study or to report side effects or injuries. Contact the study doctor __________________ (insert name of study doctor[s]) at __________________ (insert telephone number).

ADDITIONAL STUDIES SECTION

This part of the consent form is about optional studies that you can choose to take part in. You will not get health benefits from any of these studies. The researchers leading these optional studies hope the results will help other people with cancer in the future.

The results will not be added to your medical records and you or your study doctor will not know the results.

You will not be billed for these optional studies. You can still take part in the main study even if you say “no” to these optional studies.

At the end of the Additional Studies Section, circle your choice of “yes” or “no” for the following studies.

Optional Biobanking for Possible Future Studies

Researchers are trying to learn more about cancer. Much of this research is done using samples from your tissue, blood, urine, or other fluids. Through these studies, researchers hope to find new ways to prevent, detect, treat, or cure health problems. Information learned from these studies may help other patients in the future.

Some of these studies may be about genes. Genes carry information about features that are found in you and in people who are related to you. Researchers are interested in the way that genes affect how your body responds to treatment.

If you choose to take part, blood that remains from the research samples collected for the main study will be saved and stored. The researchers ask your permission to store and use your residual blood samples and related health information (for example, your response to cancer treatment, results of study tests and medicines you are given) for medical research. The research that may be done is unknown at this time. Storing samples for future studies is called “biobanking”. The Biobank is being run by the Adult Brain Tumor Consortium at the Johns Hopkins University School of Medicine.

WHAT IS INVOLVED?

If you agree to take part, here is what will happen next:

1) Residual material from the blood that was collected at the time of your research blood draws will be stored in the Biobank.

2) Your sample and some related health information may be stored in the Biobank, along with samples and information from other people who take part. The samples will be kept until they are used up. Information from your medical record will be updated from time to time.

3) Qualified researchers can submit a request to use the materials stored in the Biobank. A science committee at the Adult Brain Tumor Consortium, and/or the National Cancer Institute, will review each request. There will also be an ethics review to ensure that the request is necessary and proper. Researchers will not be given your name or any other information that could directly identify you.

4) Neither you nor your study doctor will be notified when research will be conducted or given reports or other information about any research that is done using your samples.

5) Some of your genetic and health information may be placed in central databases that may be public, along with information from many other people. Information that could directly identify you will not be included.

WHAT ARE THE POSSIBLE RISKS?

1) There is a risk that someone could get access to the personal information in your medical records or other information researchers have stored about you.

2) There is a risk that someone could trace the information in a central database back to you. Even without your name or other identifiers, your genetic information is unique to you. The researchers believe the chance that someone will identify you is very small, but the risk may change in the future as people come up with new ways of tracing information.

3) In some cases, this information could be used to make it harder for you to get or keep a job or insurance. There are laws against the misuse of genetic information, but they may not give full protection. There can also be a risk in knowing genetic information. New health information about inherited traits that might affect you or your blood relatives could be found during a study. The researchers believe the chance these things will happen is very small, but cannot promise that they will not occur.

HOW WILL INFORMATION ABOUT ME BE KEPT PRIVATE?

Your privacy is very important to the researchers and they will make every effort to protect it. Here are just a few of the steps they will take:

1) When your sample(s) is sent to the researchers, no information identifying you (such as your name) will be sent. Samples will be identified by a unique code only.

2) The list that links the unique code to your name will be kept separate from your sample and health information. Any Biobank staff with access to the list must sign an agreement to keep your identity confidential.

3) Researchers to whom the Biobank sends your sample and information will not know who you are. They must also sign an agreement that they will not try to find out who you are.

4) Information that identifies you will not be given to anyone, unless required by law.

5) If research results are published, your name and other personal information will not be used.

WHAT ARE THE POSSIBLE BENEFITS?

You will not benefit from taking part. The researchers, using the samples from you and others, might make discoveries that could help people in the future.

ARE THERE ANY COSTS OR PAYMENTS?

There are no costs to you or your insurance. You will not be paid for taking part. If any of the research leads to new tests, drugs, or other commercial products, you will not share in any profits.

WHAT IF I CHANGE MY MIND?

If you decide you no longer want your samples to be used, you can call the study doctor, _________________, (insert name of study doctor for main trial) at ________________________ (insert telephone number of study doctor for main trial) who will let the researchers know. Then, any sample that remains in the bank will no longer be used and related health information will no longer be collected. Samples or related information that have already been given to or used by researchers will not be returned.

WHAT IF I HAVE MORE QUESTIONS?

If you have questions about the use of your samples for research, contact the study doctor, ________________, (insert name of study doctor for main trial), at _____________________ (insert telephone number of study doctor for main trial).

Please circle your answer to show whether or not you would like to take part in each option:

BLOOD SAMPLES FOR FUTURE RESEARCH STUDIES:

My blood samples and related information may be kept in a Biobank for use in future health research.

YES NO

I agree that my study doctor, or their representative, may contact me or my physician to see if I wish to participate in other research in the future.

YES NO

This is the end of the section about optional studies.

My Signature Agreeing to Take Part in the Main Study

I have read this consent form or had it read to me. I have discussed it with the study doctor and my questions have been answered. I will be given a signed copy of this form. I agree to take part in the study.

Participant’s signature________________________________

Date of signature____________________________________

Re-Consent for Select Patients On Study With Apparent Progressive Disease Who May Be Eligible for Continued Treatment

My Signature Agreeing To Continue on this Study Even Though My MRI Scan Appears Worse at this Time

I understand that my MRI looks worse and that this could be due to either tumor growth or a reaction to the therapy. However, as I remain a good candidate for continued therapy with the study drug/drugs, I agree to continue with this therapy until there is additional information suggesting that this is not an optimal path forward.

Participant’s signature_________________________________

Date of signature_____________________________________

Investigator signature__________________________________ Date____________________

Consent Form – Part B-Combination Therapy

Study Title for Study Participants: Finding the safe dose of anti-LAG-3 or anti-CD137 when combined with anti-PD-1 in patients with brain cancer.

Official Study Title for Internet Search on : A Phase I Trial of Anti-LAG-3 or Anti-CD137 Alone and in Combination with Anti-PD-1 in Patients with Recurrent GBM

What is the usual approach to my brain cancer?

You are being asked to take part in this study because you have a type of brain cancer called glioblastoma multiforme which has grown or has recurred. You have already been treated with surgery, radiation, and chemotherapy. People who are not in a study are usually treated with more chemotherapy and additional surgery if appropriate. Bevacizumab is also an available and Food and Drug Administration (FDA)-approved treatment for patients with recurrent glioblastoma who have not previously received it, although it does not cure and its effect on survival is unknown. Sometimes, combinations of these are used and your doctor can explain which may be best for you. These treatments can reduce symptoms and may stop the tumor from growing for several months or more.

What are my other choices if I do not take part in this study?

If you decide not to take part in this study, you have other choices. For example:

• you may choose to have the usual approach described above

• you may choose to take part in a different study, if one is available

• you may choose not to be treated for cancer, but you may want to receive comfort care to relieve symptoms.

Why is this study being done?

The purpose of this study is to test the safety of the investigational study drugs, anti-LAG-3 or anti-CD137, when each is combined with another study drug, anti-PD-1. “Investigational” means that the drug is being studied. The FDA (U.S. Food and Drug Administration) has not approved anti-LAG-3 or anti-CD137 for use in patients, including people with your type of cancer. Anti-PD-1 (also known as nivolumab) is FDA-approved for use in patients with another type of cancer but is considered investigational for this study.

Each of these drugs is an antibody (type of protein) that may stimulate the cells in your body, called your immune system, that protect you from infection. These drugs have already been tested in people with other types of cancer, but not yet in brain cancer. This study tests doses of anti-LAG-3 or anti-CD137 in combination with a dose of anti-PD-1 to see which dose combination is safer in people with brain cancer.

There will be between 24 and 40 people taking part in this study.

What are the study groups?

Study participants will be assigned to receive either the combination of anti-LAG-3 plus anti-PD-1 or anti-CD137 plus anti-PD-1. The drug combination each patient is assigned will alternate between the two combinations (anti-LAG-3 + anti-PD-1 and anti-CD137 + anti-PD-1): the first person to enroll in the study will be assigned one of the combinations and the next person will be assigned the other combination, and so on.

For participants assigned to receive anti-LAG-3 + anti-PD-1, different doses of anti-LAG-3 combined with a dose of anti-PD-1 will be given to groups of several study participants. The first group of study participants will receive the lowest dose of anti-LAG-3 combined with anti-PD-1. If the drug combination does not cause serious side effects, it will be given to a group of several other study participants at a higher dose. There are 2 different doses for anti-LAG-3 to be tested with one dose of anti-PD-1. The dose may be lowered if side effects occur that require it. Then no more groups of study participants will be enrolled.

For participants assigned to receive anti-CD137 + anti-PD-1, different doses of anti-CD137 combined with a dose of anti-PD-1 will be given to groups of several study participants. The first group of study participants will receive the lowest dose of anti-CD137 combined with anti-PD-1. If the drug combination does not cause serious side effects, it will be given to a group of several other study participants at a higher dose. There are 2 different doses for anti-CD137 to be tested with one dose of anti-PD-1. The dose may be lowered if side effects occur that require it. Then no more groups of study participants will be enrolled.

Participants assigned to receive anti-LAG-3 + anti-PD-1 will be given the study drugs in the form of infusions into a vein once every 2 weeks in the outpatient clinic. Anti-PD-1 will be given first, followed by anti-LAG-3 within 30 minutes of completing the infusion of anti-PD-1. Participants will return to the clinic every 28 days to see the study doctor.

Participants assigned to receive anti-CD137 + anti-PD-1 will be given the study drugs in the form of infusions into a vein in the outpatient clinic: anti-PD-1 will be given once every 2 weeks and anti-CD137 will be given once every 4 weeks. On the days when both study drugs are administered, anti-PD-1 will be given first, followed by anti-CD137 within 30 minutes of completing the infusion of anti-PD-1. Participants will return to the clinic every 28 days to see the study doctor.

How long will I be in this study?

You will continue to receive your study drug combination and be in the study for up to 96 weeks (about 22 months) unless your tumor grows, or you have side effects that cause your condition to worsen, or you desire to stop treatment. After you stop taking the study drugs, your doctor will continue to watch you for side effects and follow your condition for at least 100 days.

Certain patients who have no clinical signs or symptoms of disease progression and are tolerating treatment, but who have an MRI showing apparent progression of their disease while on treatment, may be allowed to continue treatment until another MRI 2-2 ½ months later confirms or rules out progressive disease. These patients will need to sign this consent form again in order to continue treatment.

You will be contacted every 2 months for two years after you stop the study drug to find out how you are doing. After 2 years, you will be contacted every 6 months.

What extra tests and procedures will I have if I take part in this study?

Most of the exams, tests, and procedures you will have are part of the usual approach for your cancer. However, if you choose to take part in the study, then you will need the following extra tests. They are not part of the usual approach for your type of cancer.

During the study:

• Collection of about 78 extra blood samples during the first 4 cycles of treatment for studies of the effects of the study drug:

These samples will be taken at the following times:

• Cycle 1, Day 1: 13-14 samples before you receive your dose

• Cycle 1, Day 15: 13-14 samples before you receive your dose

• Cycle 2, Day 1: 26 samples before you receive your dose

• Cycle 4, Day 1: 26 samples before you receive your dose

• Collection of stored pieces of cancer tissue, if available, from your initial surgery at the diagnosis of glioblastoma, to look at certain features of the tumor. The tissue will be requested from the facility where you had your initial surgery to remove the tumor. If you had any additional surgeries for glioblastoma prior to enrolling on this study, this tissue will also be collected when tissue is available.

• If you need further surgery for your brain tumor while you are on this study, pieces of cancer tissue from your tumor will be collected to look at certain features of the tumor. The tissue will be collected during normal surgery to remove the tumor.

These samples are required in order for you to take part in this study because the research on the samples is an important part of the study.

Neither you nor your health care plan/insurance carrier will be billed for the collection or processing of the research blood samples that will be used for this study.

What possible risks can I expect from taking part in this study?

If you choose to take part in this study, there is a risk that you may:

• Lose time at work or home and spend more time at the hospital or doctor’s office than usual

• You may be asked sensitive or private questions which you normally do not discuss

The medications used in this study may affect how different parts of your body work such as your liver, kidneys, heart, and blood. The study doctor will be testing your blood and will let you know if changes occur that may affect your health.

There is also a risk that you could have side effects from the study drug.

Here are important points about side effects:

• The study doctors do not know who will or will not have side effects.

• Some side effects may go away soon, some may last a long time, or some may never go away.

• Some side effects may interfere with your ability to have children.

• Some side effects may be serious and may even result in death.

Here are important points about how you and the study doctor can make side effects less of a problem:

• Tell the study doctor if you notice or feel anything different so they can see if you are having a side effect.

• The study doctor may be able to treat some side effects.

• The study doctor may adjust the study drugs to try to reduce side effects.

Below are the most common and the most serious side effects that researchers know about. There might be other side effects that researchers do not yet know about. If important new side effects are found, the study doctor will discuss these with you.

Anti-LAG-3, anti-CD137, and anti-PD-1 are foreign proteins and could cause an allergic reaction when infused into a vein. Very rarely, the reaction could be severe. The signs of an allergic reaction may be rash, low blood pressure, wheezing and difficulty breathing. This kind of reaction may happen within seconds or hours of receiving the drug. If this happens, your doctor may use several types of medicines to control the reaction.

Possible Side Effects of Anti-LAG-3:

Side effects include:

• skin reactions

• oral mucositis and

• immune-related side effects that have been seen in participants treated with other immunotherapies and which may or may not be caused by anti-LAG-3, including:

▪ Uveitis – inflammation of the eyes that may cause:

• eye redness

• eye pain

• sensitivity to light

• blurred vision

• decreased vision

• floating spots in your vision

▪ Hypophysitis – inflammation of the pituitary gland that may cause:

• low blood sugar

• dehydration

• weakness

• dizziness

• other symptoms

▪ Hyperthyroidism – overactive thyroid gland activity that may lead to:

• Fatigue

• Weakness

• muscle aches

• anxiety

• weight loss

• intolerance to heat

• other symptoms

▪ Hepatitis – inflammation of the liver that may result in:

• Nausea

• Fatigue

• abdominal pain

• impart a yellowish hue to your skin or eyes

• darkness of your urine

▪ Pancreatitis – inflammation of the pancreas that may lead to:

• high levels of lipase and that may be accompanied by nausea, vomiting, and abdominal pain

▪ Colitis – inflammation of the lining of the colon, sometimes associated with:

• severe diarrhea

▪ Arthritis – painful swelling, inflammation and stiffness of the fingers, wrists, arms and legs

In another study with anti-LAG-3 combined with anti-PD-1 for solid tumors, there was a recent episode of ventricular fibrillation in a participant with known cardiovascular risk factors. Nonetheless, this event was considered as possibly related to the combination therapy regardless, as there is not enough information to determine whether ventricular fibrillation might occur in paients treated in this protocol with anti-LAG-3 alone or in combination with anti-PD-1.

Possible Side Effects of Anti-CD137:

Anti-CD137 (also known as urelumab) is a foreign protein and could cause an allergic reaction when it is infused into the vein. Very rarely, the reaction could be severe. The signs of an allergic reaction may be rash, low blood pressure, wheezing and difficulty breathing. This kind of reaction may happen within seconds or hours of receiving the drug. If this happens, your doctor may use several types of medicines to control the reaction.

The following is a list of the side effects occurring in subjects treated with anti-CD137. Most were mild and resolved without treatment.

Likely

• Fatigue

• Liver function test abnormalities

• Rash with or without itching skin

Less Likely

• Fever

• Nausea

• Decreased appetite

• Diarrhea

• Weakness

• Headache

• Vomiting

• Joint pain

• Constipation

• Cough

• Low white blood cells count that may increase your risk of infection. If you develop a fever when your blood count is low, you may need to be hospitalized and treated with intravenous antibiotics

• Low platelet count that may increase your risk of bleeding or require a platelet transfusion

• Anemia that may require a blood transfusion if you have fatigue, shortness of breath or other symptoms that occur with a low red blood cell count

• Skin infection

The severity of side effects was greater in subjects treated with higher doses and included two deaths due to complications of liver failure. The doses of anti-CD137 that will be used in this study are below those that were associated with those deaths. Of the patients previously tested at doses to be used in this study, there was a single patient who had a severe liver function blood test abnormality. The patient showed no symptoms of liver disease (e.g., yellowing of the whites of the eyes or skin, belly pain/itchiness) and the laboratory value resolved rapidly without treatment. Anti-CD137may increase the risk of liver damage associated with the use of other medications or substances that can injure the liver. In particular, it is important that you avoid alcohol ingestion while you are undergoing treatment and limit the use of acetaminophen, another commonly used medication that can cause liver injury.

Rare but Serious

• Increases in liver blood tests that are associated with severe liver damage. Your doctor needs to do other tests to determine the cause of the liver damage. When anti-CD137 is the cause, the liver blood tests usually go back to normal after discontinuation of anti-CD137 and without the use of other medicines within 7-42 days. Less commonly, your doctor may need to use medicines (for example, steroids) to help the liver recover. This event has been serious enough to cause hospitalization and infrequently death. The deaths which have occurred have happened despite treatments with medicines to help the liver recover and other efforts to treat the liver failure.

• A case of fatal sepsis syndrome occurred in one patient

• Other kinds of rare, but severe side effects seen following treatment with anti-CD137 include: abdominal pain, appendicitis, gastrointestinal bleeding, fatigue, renal failure, vaginal bleeding, progression of your cancer, decreased blood oxygen levels, and swelling of the lymphatic vessels (lymphangitis)

Possible Side Effects of Anti-PD-1:

|COMMON, SOME MAY BE SERIOUS |

|In 100 people receiving anti-PD-1 (BMS-936558), more than 20 and up to 100 may have: |

|Tiredness |

| |

|OCCASIONAL, SOME MAY BE SERIOUS |

|In 100 people receiving anti-PD-1 (BMS-936558), from 4 to 20 may have: |

|Anemia which may require blood transfusion |

|Swelling and redness of the eye which may cause blurred vision with a chance of blindness |

|Pain |

|Diarrhea, nausea |

|Dry mouth |

|Fever |

|Swelling and redness at the site of the medication injection |

|Bruising, bleeding |

|Loss of appetite |

|Fluid in the body |

|Swelling of the body which may cause shortness of breath or headache, tiredness, and nerve pain |

|Itching, rash, skin changes |

| |

|RARE, AND SERIOUS |

|In 100 people receiving anti-PD-1 (BMS-936558), 3 or fewer may have: |

|Damage to organs which may cause weakness or shortness of breath and/or cough |

|Visual disturbances |

|Swelling and pain around the eyes which may lead to vision changes and difficulty closing eyes |

|A tear or hole in the stomach that may require surgery |

|Allergic reaction which may cause rash, low blood pressure, wheezing, shortness of breath, swelling of the face or throat |

|Reaction during or following a drug infusion which may cause fever, chills, rash |

|A condition with high blood sugar which leads to tiredness, frequent urination, excessive thirst, headache, nausea and vomiting, and can|

|result in coma |

|Muscle pain and/or weakness with dark red urine |

|Confusion |

|Abnormal movement of the facial muscles |

|Weakness and paralysis |

|Muscle weakness |

|Numbness, tingling or pain of the arms and legs |

|Kidney damage which may require dialysis |

*Damage to the body by the immune system caused by nivolumab may also include:

Lung problems (pneumonitis). Symptoms of pneumonitis may include:

· New or worsening cough

· Chest pain

· Shortness of breath

Intestinal problems (colitis) that can lead to tears or holes in your intestine.Signs and symptoms of colitis may include:

· Diarrhea (loose stools) or more bowel movements than usual

· Blood in your stools or dark, tarry, sticky stools

· Severe stomach area (abdomen) pain or tenderness

Liver problems (hepatitis). Signs and symptoms of hepatitis may include:

· yellowing of your skin or the whites of your eyes

· Severe nausea or vomiting

Kidney problems, including nephritis and kidney failure. Signs of kidney problems may include:

· Decrease in the amount of urine

· Blood in your urine

· Swelling in your ankles

· Loss of appetite

Hormone gland problems (especially the thyroid and pituitary glands). Signs and symptoms that your hormone glands are not working properly may include:

· Headaches that will not go away or unusual headaches

· Extreme tiredness or changes in mood or behavior decreased sex drive,

· Dizziness or fainting

Problems in other organs.

· Rash

· Changes in eyesight

· Severe or persistent muscle weakness or joint pains

Getting medical treatment right away may keep these problems from becoming more serious.

Reproductive risks: You should not get pregnant, breastfeed, or father a baby while in this study. Women of childbearing potential must agree to use two methods of contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study treatment, and through at least 23 weeks after the last dose of any study drug. Women of childbearing potential will be required to have a pregnancy test within 24 hours prior to treatment start and then approximately every 8-9 weeks while on study, to ensure that they are not pregnant. Should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately. Sexually active men of reproductive potential who are partners of women with reproductive potential must also agree to use adequate contraception prior to the study, for the duration of study participation, and through at least 32 weeks after the last dose of study drug.The medication used in this study could be very damaging to an unborn baby. Check with the study doctor about what types of birth control, or pregnancy prevention, to use while in this study.

There can also be a risk in finding out new genetic information about you. New health information about inherited traits that might affect you and your blood relatives could be found during a study.

What possible benefits can I expect from taking part in this study?

This study is unlikely to help you. This study may help us learn things that may help people in the future.

Can I stop taking part in this study?

Yes. You can decide to stop at any time. If you decide to stop for any reason, it is important to let the study doctor know as soon as possible so you can stop safely. If you stop, you can decide whether or not to let the study doctor continue to provide your medical information to the organization running the study.

The study doctor will tell you about new information or changes in the study that may affect your health or your willingness to continue in the study.

The study doctor may take you out of the study:

• If your health changes and the study is no longer in your best interest

• If new information becomes available

• If you do not follow the study rules

• If the study is stopped by the sponsor, IRB or FDA.

What are my rights in this study?

Taking part in this study is your choice. No matter what decision you make, and even if your decision changes, there will be no penalty to you. You will not lose medical care or any legal rights.

For questions about your rights while in this study, call the ________________________ (insert name of center) Institutional Review Board at __________________ (insert telephone number).

What are the costs of taking part in this study?

The study drugs, anti-LAG-3 or anti-CD137 and anti-PD-1 will be supplied at no charge while you take part in this study. The cost of getting the drug ready and giving it to you is also provided at no charge. It is possible that anti-LAG-3 or anti-CD137 and anti-PD-1 may not continue to be supplied while you are on the study. Although not likely, if this occurs, your study doctor will talk to you about your options.

You and/or your health plan/insurance company will need to pay for all of the other costs of treating your cancer while in this study, including the cost of tests, procedures, or medicines to manage any side effects, unless you are told that certain tests are supplied at no charge. Before you decide to be in the study, you should check with your health plan or insurance company to find out exactly what they will pay for.

You will not be paid for taking part in this study.

What happens if I am injured or hurt because I took part in this study?

If you are injured or hurt as a result of taking part in this study and need medical treatment, please tell your study doctor. The study sponsors will not offer to pay for medical treatment for injury. Your insurance company may not be willing to pay for study-related injury. If you have no insurance, you would be responsible for any costs.

If you feel this injury was a result of medical error, you keep all your legal rights to receive payment for this even though you are in a study.

Who will see my medical information?

Your privacy is very important to us and the researchers will make every effort to protect it. Your information may be given out if required by law. For example, certain states require doctors to report to health boards if they find a disease like tuberculosis. However, the researchers will do their best to make sure that any information that is released will not identify you. Some of your health information, and/or information about your specimen, from this study will be kept in a central database for research. Your name or contact information will not be put in the database.

There are organizations that may inspect your records. These organizations are required to make sure your information is kept private, unless required by law to provide information. Some of these organizations are:

• The study sponsor and the drug company supporting this study.

• The Institutional Review Board, IRB, is a group of people who review the research with the goal of protecting the people who take part in the study.

• The Food and Drug Administration and the National Cancer Institute in the U.S., and similar ones if other countries are involved in the study.

Where can I get more information?

You may visit the NCI Web site at for more information about studies or general information about cancer. You may also call the NCI Cancer Information Service to get the same information at: 1-800-4-CANCER (1-800-422-6237).

A description of this clinical trial will be available on , as required by U.S. Law. This Web site will not include information that can identify you. At most, the Web site will include a summary of the results. You can search this Web site at any time.

Who can answer my questions about this study?

You can talk to the study doctor about any questions or concerns you have about this study or to report side effects or injuries. Contact the study doctor __________________ (insert name of study doctor[s]) at __________________ (insert telephone number).

ADDITIONAL STUDIES SECTION

This part of the consent form is about optional studies that you can choose to take part in. You will not get health benefits from any of these studies. The researchers leading these optional studies hope the results will help other people with cancer in the future.

The results will not be added to your medical records and you or your study doctor will not know the results.

You will not be billed for these optional studies. You can still take part in the main study even if you say “no” to these optional studies.

At the end of the Additional Studies Section, circle your choice of “yes” or “no” for the following studies.

Optional Biobanking for Possible Future Studies

Researchers are trying to learn more about cancer. Much of this research is done using samples from your tissue, blood, urine, or other fluids. Through these studies, researchers hope to find new ways to prevent, detect, treat, or cure health problems. Information learned from these studies may help other patients in the future.

Some of these studies may be about genes. Genes carry information about features that are found in you and in people who are related to you. Researchers are interested in the way that genes affect how your body responds to treatment.

If you choose to take part, blood that remains from the research samples collected for the main study will be saved and stored. The researchers ask your permission to store and use your residual blood samples and related health information (for example, your response to cancer treatment, results of study tests and medicines you are given) for medical research. The research that may be done is unknown at this time. Storing samples for future studies is called “biobanking”. The Biobank is being run by the Adult Brain Tumor Consortium at the Johns Hopkins University School of Medicine.

WHAT IS INVOLVED?

If you agree to take part, here is what will happen next:

1) Residual material from the blood that was collected at the time of your research blood draws will be stored in the Biobank.

2) Your sample and some related health information may be stored in the Biobank, along with samples and information from other people who take part. The samples will be kept until they are used up. Information from your medical record will be updated from time to time.

3) Qualified researchers can submit a request to use the materials stored in the Biobank. A science committee at the Adult Brain Tumor Consortium, and/or the National Cancer Institute, will review each request. There will also be an ethics review to ensure that the request is necessary and proper. Researchers will not be given your name or any other information that could directly identify you.

4) Neither you nor your study doctor will be notified when research will be conducted or given reports or other information about any research that is done using your samples.

5) Some of your genetic and health information may be placed in central databases that may be public, along with information from many other people. Information that could directly identify you will not be included.

WHAT ARE THE POSSIBLE RISKS?

1) There is a risk that someone could get access to the personal information in your medical records or other information researchers have stored about you.

2) There is a risk that someone could trace the information in a central database back to you. Even without your name or other identifiers, your genetic information is unique to you. The researchers believe the chance that someone will identify you is very small, but the risk may change in the future as people come up with new ways of tracing information.

3) In some cases, this information could be used to make it harder for you to get or keep a job or insurance. There are laws against the misuse of genetic information, but they may not give full protection. There can also be a risk in knowing genetic information. New health information about inherited traits that might affect you or your blood relatives could be found during a study. The researchers believe the chance these things will happen is very small, but cannot promise that they will not occur.

HOW WILL INFORMATION ABOUT ME BE KEPT PRIVATE?

Your privacy is very important to the researchers and they will make every effort to protect it. Here are just a few of the steps they will take:

1) When your sample(s) is sent to the researchers, no information identifying you (such as your name) will be sent. Samples will be identified by a unique code only.

2) The list that links the unique code to your name will be kept separate from your sample and health information. Any Biobank staff with access to the list must sign an agreement to keep your identity confidential.

3) Researchers to whom the Biobank sends your sample and information will not know who you are. They must also sign an agreement that they will not try to find out who you are.

4) Information that identifies you will not be given to anyone, unless required by law.

5) If research results are published, your name and other personal information will not be used.

WHAT ARE THE POSSIBLE BENEFITS?

You will not benefit from taking part. The researchers, using the samples from you and others, might make discoveries that could help people in the future.

ARE THERE ANY COSTS OR PAYMENTS?

There are no costs to you or your insurance. You will not be paid for taking part. If any of the research leads to new tests, drugs, or other commercial products, you will not share in any profits.

WHAT IF I CHANGE MY MIND?

If you decide you no longer want your samples to be used, you can call the study doctor, _________________, (insert name of study doctor for main trial) at ________________________ (insert telephone number of study doctor for main trial) who will let the researchers know. Then, any sample that remains in the bank will no longer be used and related health information will no longer be collected. Samples or related information that have already been given to or used by researchers will not be returned.

WHAT IF I HAVE MORE QUESTIONS?

If you have questions about the use of your samples for research, contact the study doctor, ________________, (insert name of study doctor for main trial), at _____________________ (insert telephone number of study doctor for main trial).

Please circle your answer to show whether or not you would like to take part in each option:

BLOOD SAMPLES FOR FUTURE RESEARCH STUDIES:

My blood samples and related information may be kept in a Biobank for use in future health research.

YES NO

I agree that my study doctor, or their representative, may contact me or my physician to see if I wish to participate in other research in the future.

YES NO

This is the end of the section about optional studies.

My Signature Agreeing to Take Part in the Main Study

I have read this consent form or had it read to me. I have discussed it with the study doctor and my questions have been answered. I will be given a signed copy of this form. I agree to take part in the study.

Participant’s signature________________________________

Date of signature_____________________________________

Re-Consent for Select Patients On Study With Apparent Progressive Disease Who May Be Eligible for Continued Treatment

My Signature Agreeing To Continue on this Study Even Though My MRI Scan Appears Worse at this Time

I understand that my MRI looks worse and that this could be due to either tumor growth or a reaction to the therapy. However, as I remain a good candidate for continued therapy with the study drug/drugs, I agree to continue with this therapy until there is additional information suggesting that this is not an optimal path forward.

Participant’s signature_________________________________

Date of signature_____________________________________

Investigator signature__________________________________ Date_____________________

-----------------------

Treatment Assignment:

Patients going on the study will alternately be put on one study drug or the other

Anti-LAG-3

You agree to take part in the study

Anti-CD137

Dose (MTD): 8 mg flat dose

Anti-LAG-3 + Anti-PD-1

Treatment Assignment:

Patients going on the study will alternately be put on one combination treatment or the other

You agree to take part in the study

Anti-CD137 + Anti-PD-1

Dose (MTD): 8 mg flat dose

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download