Open-Label, Phase 1 Study of Nivolumab Combined with Nab-Paclitaxel Plus 2 Gemcitabine in Advanced Pancreatic Cancer

Author Manuscript Published OnlineFirst on June 18, 2020; DOI: 10.1158/1078-0432.CCR-20-0099 Author manuscripts have been peer reviewed and accepted for publication but have not yet been edited.

1 Open-Label, Phase 1 Study of Nivolumab Combined With nab-Paclitaxel Plus 2 Gemcitabine in Advanced Pancreatic Cancer

4 Zev A. Wainberg,1 Howard S. Hochster,2 Edward J. Kim,3 Ben George,4 Aparna Kaylan,5 E. 5 Gabriela Chiorean,6 David M. Waterhouse,7 Martin Guiterrez,8 Aparna Parikh,9 Rishi Jain,10 6 Daniel Ricardo Carrizosa,11 Hatem H. Soliman,12 Thomas Lila,13 David J. Reiss,14 Daniel W. 7 Pierce,13 Rafia Bhore,15 Sibabrata Banerjee,15 Larry Lyons,15 Chrystal U. Louis,15 Teng Jin 8 Ong,15 Peter J. O’Dwyer16

9 10 1Department of Hematology/Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA 11 90095, USA 12 2Department of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 13 08903, USA 14 3Department of Internal Medicine, UC Davis Comprehensive Cancer Center, Sacramento, CA 15 95817, USA 16 4Department of Medical Oncology, Froedtert & the Medical College of Wisconsin, Milwaukee, WI 17 53226, USA 18 5Department of Medicine, Northwestern University, Chicago, IL 60611, USA 19 6Department of GI Oncology & Phase I Programs, University of Washington School of Medicine, 20 Seattle, WA 98109, USA 21 7Department of Medical Oncology and Hematology, Oncology Hematology Care, Inc, Cincinnati, 22 OH 45226, USA 23 8Department of Medical Oncology, John Theurer Cancer Center, Hackensack, NJ 07601, USA 24 9Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA 02114, 25 USA 26 10Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 27 Columbus, OH 43210, USA 28 11Department of Hematology/Oncology, Levine Cancer Institute, Charlotte, NC 28204, USA 29 12Department of Women’s Oncology, University of South Florida, Moffitt Cancer Center, Tampa, 30 FL 33612, USA 31 13Department of Translational Development & Diagnostics, Bristol-Myers Squibb, San 32 Francisco, CA 94063, USA 33 14Department of Informatics & Predictive Sciences, Bristol-Myers Squibb, Seattle, WA 98102, 34 USA

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35 15Department of Medical Affairs Leadership, Bristol-Myers Squibb, Princeton, NJ 08648, USA 36 16Department of Medical Oncology, University of Pennsylvania, Abramson Cancer Center, 37 Philadelphia, PA 19104, USA 38 39 Running title: Nivo plus nab-Pac and Gem in Advanced Pancreatic Cancer

40 Keywords: dose-limiting toxicity, gemcitabine, nab-paclitaxel, nivolumab, pancreatic cancer

41 Correspondence to: Zev A. Wainberg, MD 42 David Geffen School of Medicine at UCLA 43 2020 Santa Monica Blvd, Suite 600 44 Los Angeles, CA 90404 45 Tel: 310-829-5471 46 Email: [email protected] 47

48 Conflict of interest statements

49 ZAW: consulting/advisory: Merck, Lilly, Bristol-Myers Squibb, EMD Serono, Bayer, Celgene (a

50 Bristol-Myers Squibb Company), Five Prime, Ipsen

51 HSH: consulting/advisory: Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb,

52 Genentech, Exelixis

53 EJK: research funding: Celgene (a Bristol-Myers Squibb Company), OncoMed, Halozyme,

54 Merck, Boston Biomedical, EpicentRx, Astellas, Samumed

55 BG: consulting/advisory: Celgene (a Bristol-Myers Squibb Company), Cook Medical, Bristol-

56 Myers Squibb, Foundation Medicine, Ipsen, Exelixis, BTG, Taiho Oncology, Terumo

57 Interventional Systems, Eisai

58 AK: consulting/advisory: Bristol-Myers Squibb, Eisai, Ipsen; research funding: Bristol-Myers

59 Squibb; independent monitor: Samumed

60 EGC: consulting/advisory: AstraZeneca, Five Prime, Vicus, Halozyme, Ipsen, Eisai, Seattle

61 Genetics; research funding: Celgene (a Bristol-Myers Squibb Company), Merck, Halozyme,

62 Incyte, Roche, Stemline, Boehringer Ingelheim

63 DMW: consulting/advisory: AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb; speakers

64 bureau: Bristol-Myers Squibb

65 MG: stock/ownership: Cota; honoraria: Esanex; consulting/advisory: Eli Lilly; speakers bureau:

66 Bristol-Myers Squibb, Merck, Eli Lilly; research funding: Acerta, Bayer, Bristol-Myers Squibb,

67 Celgene (a Bristol-Myers Squibb Company), Checkpoint, Eisai, Eli Lilly, EMD Serono, Esanex,

68 Genentech, Incyte, Infinity, MedImmune, Merck, Mirati, Modern, Regeneron, Sanofi, Seattle

69 Genetics, Silenseed, Spectrum, TESARO

70 AP: consulting/advisory: PureTech Health, Eisai, Foundation Medicine; travel: Eisai

71 RJ: nothing to disclose

72 DRC: research funding: Celgene (a Bristol-Myers Squibb Company), Merck, AstraZeneca,

73 Pfizer

74 HHS: consulting/advisory: Eli Lilly, Novartis, AstraZeneca, Pfizer, Celgene (a Bristol-Myers

75 Squibb Company), Puma Biotechnology

76 TL: employment: Bristol-Myers Squibb Company

77 DJR: employment: Bristol-Myers Squibb Company; stock/ownership: Bristol-Myers Squibb

78 Company

79 DP: employment: Bristol-Myers Squibb Company; stock/ownership: Bristol-Myers Squibb

80 Company

81 RB: employment: Bristol-Myers Squibb Company; stock/ownership: Bristol-Myers Squibb

82 Company

83 SB: employment: Bristol-Myers Squibb Company, Novartis; stock/ownership: Bristol-Myers

84 Squibb Company

85 LL: employment: Bristol-Myers Squibb Company; stock/ownership: Bristol-Myers Squibb

86 Company

87 CUL: employment: Bristol-Myers Squibb Company; stock/ownership: Bristol-Myers Squibb

88 Company; patents/royalties/IP: Cell Medica

89 TJO: employment: Bristol-Myers Squibb Company; stock/ownership: Bristol-Myers Squibb

90 Company

91 PJO: consulting/advisory: Genentech, Bristol-Myers Squibb, Boehringer Ingelheim; research

92 funding: Bristol-Myers Squibb, Pfizer, Novartis, Genentech, Mirati, Celgene (a Bristol-Myers

93 Squibb Company), GlaxoSmithKline, BBI Healthcare, Merck, Pharmacyclics, Bayer, Five Prime,

94 Forty Seven, Amgen

95 96

97 Abstract (249/250 words)

98 Purpose: Assess safety and efficacy of nivolumab plus nab-paclitaxel and gemcitabine in

99 patients with locally advanced/metastatic pancreatic cancer in a 2-part, open-label, phase 1 trial.

100 Patients and Methods: Fifty chemotherapy-naive patients received nab-paclitaxel 125 mg/m2

101 plus gemcitabine 1000 mg/m2 (days 1, 8, and 15) and nivolumab 3 mg/kg (days 1 and 15) in 28-

102 day cycles. The primary endpoints were dose-limiting toxicities (DLTs; part 1) and grade 3/4

103 treatment-emergent adverse events (TEAEs) or treatment discontinuation due to TEAEs (parts

104 1/2). Secondary efficacy endpoints were progression-free survival (PFS), overall survival (OS),

105 and response. Assessment of programmed cell death-ligand 1 (PD-L1) expression was an

106 exploratory endpoint; additional biomarkers were assessed post hoc.

107 Results: One DLT (hepatitis) was reported in part 1 among 6 DLT-evaluable patients; 48/50

108 patients experienced grade 3/4 TEAEs and 18 discontinued treatment due to TEAEs. One

109 grade 5 TEAE (respiratory failure) was reported. Median (95% CI) PFS/OS was 5.5 (3.25-7.20

110 months)/9.9 (6.74-12.16 months) months, respectively (median follow-up for OS, 13.6 months

111 [95% CI, 12.06-23.49 months]). Overall response rate (95% CI) was 18% (8.6%-31.4%). Median

112 PFS/OS was 5.5/9.7 months (PD-L1 <5%) and 6.8/11.6 months (PD-L1 ≥5%), respectively.

113 Proportion of peripheral Ki67+ CD8+/CD4+ cells increased significantly from baseline to cycle 3;

114 median peak on-treatment Ki67+ CD8+ T-cell values were higher in responders than in

115 nonresponders.

116 Conclusions: The safety profile of nivolumab plus nab-paclitaxel and gemcitabine at standard

117 doses in advanced pancreatic cancer was manageable, with no unexpected safety signals.

118 Overall, the clinical results of this study do not support further investigation.

119

120 Funding: This work was supported by Bristol-Myers Squibb Company, Princeton, NJ.

121 Trial Registration: ClinicalTrials.gov identifier, NCT02309177

122 https://clinicaltrials.gov/ct2/show/NCT02309177

123 Statement of translational relevance (139/150 words) 124 nab-Paclitaxel plus gemcitabine is an approved initial treatment option for patients with

125 metastatic pancreatic cancer (PC). The combination of first-line immune checkpoint inhibitors

126 with chemotherapy has demonstrated efficacy in several phase 3 trials in advanced cancers.

127 Here, the safety of nivolumab plus nab-paclitaxel and gemcitabine was assessed in a

128 multicenter, open-label, phase 1 trial. Treatment of 50 patients with advanced PC and no prior

129 therapy resulted in 1 dose-limiting toxicity; 48 patients had grade 3/4 treatment-emergent

130 adverse events (TEAEs) and 18 discontinued treatment due to TEAEs. Median progression-free

131 survival and overall survival were 5.5 and 9.9 months, respectively. The proportion of Ki67+

132 CD8+ cells increased and was higher in responders than in nonresponders. This study

133 established the safety of nivolumab plus nab-paclitaxel and gemcitabine (each at full dose);

134 however, activity beyond historical nab-paclitaxel plus gemcitabine data was not observed.

135

136

137 Introduction

138 Systemic chemotherapy remains the standard treatment for pancreatic cancer (PC). Based on

139 the MPACT and PRODIGE trials, nab-paclitaxel plus gemcitabine or FOLFIRINOX (5-

140 fluorouracil, leucovorin, irinotecan, oxaliplatin) are appropriate initial options for metastatic

141 disease (1-3). Although survival has improved slightly with these treatments, additional

142 treatments for advanced PC (APC) are urgently needed.

143 In APC, results from phase 1/2 trials of immune checkpoint inhibitor (ICI) monotherapy

144 or combinations of 2 ICIs have been discouraging (4-8). The combination of first-line ICIs (eg,

145 atezolizumab, pembrolizumab) with chemotherapy has demonstrated efficacy in several phase

146 3 trials in advanced cancers (9-12). In a small phase 1 study in advanced solid tumors, including

147 PC, nab-paclitaxel and gemcitabine plus pembrolizumab showed promising efficacy and

148 acceptable safety (13).

149 The objective of this study was to evaluate safety and efficacy of nivolumab plus nab-

150 paclitaxel–based regimens in advanced cancers (pancreatic, non-small cell lung [NSCLC], and

151 breast). Here, we report the results in patients with locally advanced or metastatic PC.

152

153 Materials and Methods

154 Study oversight

155 This study (NCT02309177) was approved by the institutional review board and/or independent

156 ethics committee at each study site and conducted in accordance with International Conference

157 on Harmonisation E6 guidelines and the Declaration of Helsinki (14). All patients provided

158 written informed consent before any study procedures. Additional details are provided in the

159 eMethods in the Supplement (protocol and summary of changes are available online). The trial

160 is complete.

161

162 Study design and patients

163 This open-label, multicenter, multicohort, phase 1 study investigated nivolumab plus nab-

164 paclitaxel in patients with PC using a 2-part, 2-arm design (eFigure 1). In part 1, the safety of

165 the regimens was evaluated, and initiation of arms A and B was sequential. In arm A part 1,

166 dose-limiting toxicities (DLTs) with nab-paclitaxel plus nivolumab were assessed. If the regimen

167 was deemed safe in arm A part 1, then arm B part 1 was to be initiated. In arm B part 1, DLTs

168 were evaluated in patients treated with nab-paclitaxel plus gemcitabine and nivolumab. In part

169 2, treatment arms deemed safe in part 1 could be expanded at the recommended part 2 dose to

170 further assess safety and explore anti-tumor activity of the regimens. Arm B could be initiated

171 regardless of whether a decision was made to proceed with arm A part 2. The trial was

172 conducted across 12 sites in the United States.

173 Patients aged ≥18 years with histologically or cytologically confirmed, locally advanced

174 or metastatic pancreatic adenocarcinoma were eligible. In arm A part 1, patients must have

175 received 1 prior systemic chemotherapy regimen for locally advanced or metastatic disease. In

176 arm A part 2 and arm B (parts 1 and 2), no prior systemic chemotherapy or investigational

177 therapy exposure, except as an adjuvant radiosensitizer, was permitted. Other key inclusion

178 criteria were measurable disease per Response Evaluation Criteria in Solid Tumors (RECIST)

179 v1.1, Eastern Cooperative Oncology Group performance status (ECOG PS) of 0 or 1, and

180 adequate organ function (eMethods). Key exclusion criteria included prior ICI therapy and grade

181 ≥2 peripheral neuropathy. Mandatory tumor biopsy was performed prior to treatment (between

182 days −90 to −1) and at cycle 2 (within 24 hours of initial tumor assessment at 6 weeks after

183 cycle 1 day 1, even if the tumor assessment showed disease progression).

184

185 Treatment

186 In arm A, patients received nab-paclitaxel 125 mg/m2 on days 1, 8, and 15 and

187 nivolumab 3 mg/kg on days 1 and 15 of each 28-day cycle by intravenous infusion. In arm B,

188 patients received nab-paclitaxel 125 mg/m2 plus gemcitabine 1000 mg/m2 on days 1, 8, and 15

189 and nivolumab 3 mg/kg (prior to chemotherapy) on days 1 and 15 of 28-day cycles (eFigure 1)

190 by intravenous infusion. Treatment was given until disease progression (per RECIST v1.1) or

191 unacceptable toxicity; patients could continue nivolumab beyond RECIST v1.1-defined

192 progression if certain criteria (eMethods) were met.

193

194 Study endpoints

195 The primary endpoints were safety and tolerability, including rates of DLTs (part 1) and grade

196 3/4 treatment-emergent adverse events (TEAEs) or treatment discontinuation due to TEAEs

197 (parts 1 and 2). Secondary endpoints were TEAEs leading to dose reduction, dose delay, or

198 treatment discontinuation; investigator-assessed progression-free survival (PFS); overall

199 survival (OS); disease control rate (DCR); overall response rate (ORR); and duration of

200 response (DOR). Exploratory endpoints included quantifying immune cells and biomarkers and

201 their correlation with tumor response and efficacy. Evaluation of the impact of baseline tumor

202 cell programmed cell death-ligand 1 (PD-L1) expression on tumor response was a prespecified

203 exploratory endpoint; however, all additional biomarker assessments were post hoc analyses.

204

205 Assessment of safety and efficacy

206 DLT assessment and related definitions are provided in the eMethods. Safety was assessed by

207 TEAEs (Medical Dictionary for Regulatory Activities v21.0) and reported using system organ

208 class and preferred terms at the investigators’ discretion. TEAE severity was graded using

209 National Cancer Institute Common Terminology Criteria for Adverse Events v4.0.

210 Investigators assessed tumor response using computed tomography or magnetic resonance

211 imaging and RECIST v1.1. Additional details, including those for biomarker analyses, are

212 provided in the eMethods and eTables 1 and 2.

213

214 Statistical analyses

215 Laboratory abnormalities and study drug exposure were described using descriptive statistics.

216 PFS, OS, and DOR were summarized by Kaplan-Meier methods with medians and 2-sided 95%

217 CIs. For survival analyses by PD-L1 expression, hazard ratios and 95% CIs were estimated

218 using a Cox proportional hazards regression model adjusted for PD-L1 status. Prespecified PD-

219 L1 cutoffs of 1% and 5% were used to analyze survival data. Response definitions and sample

220 size considerations are provided in the eMethods.

221

222 Results

223 Patient demographics

224 In arm A part 1, 11 patients were enrolled between February 2015 and November 2015; all

225 patients discontinued treatment (Figure 1). The primary reason for treatment discontinuation

226 was disease progression (6 of 11 patients [55%]), followed by adverse events (3 [27%]),

227 symptomatic deterioration (1 [9%]), or other reasons (1 [9%]). The median age was 62.0 years

228 (range, 57-77); most patients were male (6 [55%]) and white (8 [73%]) (eTable 3). Most patients

229 had stage IV disease at primary diagnosis (7 [64%]) and metastatic disease at study entry (10

230 [91%]). Among 6 patients with available tumor tissue, PD-L1 expression was <1% in 4 (36%),

231 ≥1% in 2 (18%), and ≥5% in 1 (9%). The median follow-up time for OS was 35.9 months (95%

232 CI, 1.68-35.88 months).

233 In arm B, 50 patients were enrolled between February 2016 and October 2017 (Figure 1). All

234 patients discontinued treatment mainly due to disease progression (19 of 50 patients [38%]);

235 patients also discontinued due to symptom deterioration (10 [20%]), patient withdrawal (9

236 [18%]), adverse event (7 [14%]), death (2 [4%]), or other reasons (3 [6%]). The median age was

237 67.5 years (range, 43-86); most patients were male (28 [56%]) and white (41 [82%]) (Table 1).

238 Most patients had stage IV disease at primary diagnosis (42 [84%]) and metastatic disease at

239 study entry (48 [96%]). Among 40 patients with available tumor tissue, PD-L1 expression was

240 <1% in 28 (56%), ≥1% in 12 (24%), and ≥5% in 6 (12%). The median follow-up time for OS was

241 13.6 months (95% CI, 12.06-23.49 months).

242

243 Safety

244 In arm A part 1, no DLTs were observed among 7 DLT-evaluable patients. All 11 treated

245 patients experienced ≥1 grade 3/4 TEAE and 3 (27%) discontinued treatment due to TEAEs

246 (summarized in eTable 4). Grade 3/4 TEAEs occurring in >10% of patients were leukopenia (3

247 of 11 patients [27%]), anemia (2 [18%]), neutropenia (2 [18%]), and pulmonary embolism (2

248 [18%]) (eTable 5). Of note, grade 3/4 peripheral neuropathy occurred in 1 patient. At least 1

249 any-grade or grade 3/4 TEAE of special interest attributable to nivolumab was reported in 9

250 (82%) and 3 (27%) patients, respectively. Grade 1/2 hypothyroidism attributable to nivolumab

251 was reported in 1 patient. At least 1 serious TEAE was reported in 9 patients (82%). No grade 5

252 treatment related TEAEs were observed.

253 In arm B part 1, 1 DLT (hepatitis, evidenced by grade 3 elevated liver function tests, suspected

254 to be related to nab-paclitaxel and gemcitabine) was reported among 6 DLT-evaluable patients.

255 Among the 50 treated patients, 49 (98%) either experienced ≥1 grade 3/4 TEAE (48 [96%]) or

256 discontinued treatment due to TEAEs (18 [36%]; summarized in eTable 4). Grade 3/4 TEAEs

257 occurring in >10% of patients were anemia (18 of 50 patients [36%]), neutrophil count

258 decreased (10 [20%]), neutropenia (8 [16%]), peripheral neuropathy (8 [16%]), hypokalemia (7

259 [14%]), and leukopenia (6 [12%]) (Table 2). At least 1 any-grade or grade 3/4 TEAE of special

260 interest attributable to nivolumab was reported in 45 (90%) and 18 (36%) patients, respectively.

261 Grade 1/2 pneumonitis, hypothyroidism, and colitis attributable to nivolumab were reported in 4

262 (8%), 2 (4%), and 2 (4%) patients, respectively. At least 1 serious TEAE was reported in 36

263 patients (72%). One grade 5 TEAE considered related to nivolumab (respiratory failure, likely

264 pneumonitis) was reported.

265

266 Efficacy

267 Upon establishing safety of nab-paclitaxel plus nivolumab in arm A part 1, a decision was made

268 to not pursuit arm A part 2; however, exploratory efficacy data were collected and are

269 summarized in eTables 6 and 7.

270 Except for DOR (which was based on the 9 patients with a response), efficacy analyses in arm

271 B were conducted among the 50 treated patients. The ORR was 18% (95% CI, 8.6%-31.4%; 1

272 confirmed complete response [2%]; 8 confirmed partial responses [16%]; eTable 6). The DCR

273 was 64% (95% CI, 49.2%-77.1%; 23 patients [46%] had stable disease for ≥6 weeks). Median

274 DOR was 17.4 months (95% CI, 2.96-20.70 months). Overall, 7 patients (14%) received

275 nivolumab monotherapy after initial RECIST-defined disease progression (median duration of

276 50 days after stopping chemotherapy); of these, 4 (57%) achieved disease control (95% CI,

277 18.4%-90.1%; as defined above). Median PFS was 5.5 months (95% CI, 3.25-7.20 months;

278 Figure 2A) and the 6-month PFS rate was 47% (95% CI, 31%-62%). Median OS was 9.9

279 months (95% CI, 6.74-12.16 months; Figure 2B) and the 6-month OS rate was 73% (95% CI,

280 58%-84%).

281

282 Treatment exposure and dose modifications

283 Treatment exposure and dose modifications were based on the 50 treated patients. Median

284 treatment duration was 17 weeks (range, 1-103 weeks), and median number of treatment cycles

285 was 4 (range, 1-26 cycles) (eTable 8). Twenty-one patients (42%) received ≥5 treatment cycles.

286 Median dose intensity, relative dose intensity, and cumulative dose of study drugs are reported

287 in eTable 8. For nab-paclitaxel, ≥1 dose reduction or delay was reported in 24 (48%) and 15

288 (30%) patients, respectively; corresponding numbers were 22 (44%) and 16 (32%) for

289 gemcitabine, and 0 (dose reduction was not permitted) and 19 (38%) for nivolumab (eTable 8).

290

291 Exploratory biomarker analyses

292 Baseline tumor PD-L1

293 Median PFS in patients with baseline tumor PD-L1 <1% or ≥1% was 6.1 and 5.4 months,

294 respectively (eFigure 2A); the median OS was 9.7 and 7.1 months, respectively (eFigure 2B).

295 Median PFS in patients with PD-L1 <5% or ≥5% was 5.5 and 6.8 months, respectively (eFigure

296 2C); median OS was 9.7 and 11.6 months, respectively (eFigure 2D).

297

298 Peripheral T-cell proliferation (arm B only; post hoc analyses)

299 In blood lymphocytes, the mean Ki67+ proliferation index for both CD8+ and CD4+ T cells

300 increased with treatment (CD8+: 1.9% [baseline] to 7.3% [cycle 3]; CD4+: 1.7% to 4.1%; P<.001

301 for both; eFigure 3).

302 Both flow cytometry and objective tumor response data were available for 41 patients.

303 For both CD8+ and CD4+ T cells, the peak on-treatment values were higher in clinical

304 responders, most notably for CD8+ cells (P=.03; Figure 3A). The median Ki67+ percentages at

305 baseline were indistinguishable between clinical responders and nonresponders. Consistent

306 with this, median PFS was longer in patients with higher vs lower peak on-treatment Ki67+

307 CD8+ T-cell levels (7.2 vs 3.8 months; P=.04; Figure 3B).

308

309 Tumor T-cell infiltration (arm B only; post hoc analyses)

310 Immunohistochemical assessment of T-cell markers was performed for a limited number of

311 paired baseline and on-treatment tumor samples (CD8+, 6 pairs; CD4+, 5 pairs). No significant

312 differences in T-cell densities were observed between the 2 tumor tissue groups (eFigure 4).

313 However, several significant differences were observed between the baseline metastatic tumor

314 samples analyzed in this study and a set of resected primary PC samples obtained from

315 chemotherapy-naive patients enrolled in a different study using the same immunohistochemistry

316 and image analysis platform. The overall median density of CD8+ cells in the tumor

317 microenvironment (TME) of baseline metastases was significantly lower than that in primary

318 tumors (55/mm2 vs 199/mm2; P<.001; eTable 9), and the median CD4+/CD8+ ratio was

319 significantly greater (7.3 vs 2.4; P<.001; eTable 10). The median ratios of T-cell density in tumor

320 epithelial vs stromal compartments were significantly lower in primary tumors than in baseline

321 metastases (CD8+, 0.2 vs 0.4; P=.10; CD4+, 0.4 vs 1.1; P<.001; eTable 11). The median tumor

322 epithelial/stromal density ratio for CD8+ cells in on-treatment samples (1.1) was numerically

323 greater than that in paired baseline samples (0.4; P=.06) and significantly greater than that in

324 primary tumor samples (0.2; P<.001) (eFigure 5 and eTable 11).

325

326 Serum cytokines (arm B only; post hoc analyses)

327 In a pilot study assessing 14 cytokines (eMethods and eTable 2), 2-fold increases were

328 observed in 2 interferon gamma (IFNγ)-induced cytokines (CXCL10, MIG) and soluble

329 interleukin 2 receptor alpha (sIL2Rα) in 3 of 12 patients. In a follow-up analysis encompassing 8

330 cytokines in 45 patients, baseline levels of IFNγ-responsive markers, including CXCL10, were

331 not significantly different between clinical responders and nonresponders; however, the median

332 value for the highest observed on-treatment CXCL10 concentration was numerically greater in

333 responders (459 vs 265 pg/mL; P=.10; eFigure 6A). Both baseline and peak on-treatment

334 median concentrations of sIL2Rα were greater in clinical responders than in nonresponders;

335 however, the differences were not statistically significant (eFigure 6B). Median PFS was longer

336 in patients with higher vs lower peak on-treatment concentrations of both CXCL10 (7.2 vs 4.3

337 months; eFigure 6C) and sIL2Rα (7.2 vs 3.8 months; eFigure 6D), although the differences were

338 not statistically significant.

339

340 Discussion

341 The results from this phase 1 study suggest that nab-paclitaxel plus gemcitabine can be safely

342 combined with ICIs in patients with APC. One DLT was reported, and all study drugs were

343 tolerable at full dose. The safety profile of the combination was consistent with that of the

344 individual agents. However, the efficacy results do not support further testing.

345 PC is currently the third, and is projected to become the second, leading cause of

346 cancer-related deaths in the United States (15-17). In patients with PC (except those with high

347 microsatellite instability) (18), no responses have been observed with single-agent ICIs (4-7).

348 However, the expanded use of ICIs plus chemotherapy in several malignancies has dramatically

349 changed the way many advanced cancers are treated. To our knowledge, this is the first and

350 largest clinical trial of an ICI plus established chemotherapy regimen in patients with newly

351 diagnosed APC. When this study was launched, the investigators were hopeful that adding an

352 ICI to an established chemotherapy backbone would mirror the findings in other advanced

353 malignancies; however, efficacy beyond the historical control of nab-paclitaxel plus gemcitabine

354 was not observed (2,19).

355 Multiple hypotheses may explain why PC has not responded well to various

356 immunotherapy treatments (20-23). One major hypothesis relates to the dense stroma within

357 the TME (24). Preclinical observations have suggested that due to the presence of a complex

358 desmoplastic stroma, immune cells—particularly T cells—cannot infiltrate the TME (25,26).

359 However, because preclinical evidence suggests that nab-paclitaxel can affect the desmoplastic

360 stroma and increase intratumoral gemcitabine penetration (27), we hypothesized that this may

361 represent an opportunity for immune cells to also access the tumor.

362 Intriguingly, while our observation that T cells are relatively scarce within the epithelial

363 compartment of primary PC was consistent with a previous report (28), the analyses suggest

364 that metastatic tumors may be characterized by less tumoral exclusion or stromal sequestration

365 of T cells. Paired tumor analysis indicates that T-cell distribution may further normalize during

366 treatment. Despite this, overall CD8+ cell densities in metastatic tumors remain low compared

367 with those in primary tumor stromal regions and are accompanied by relatively high densities of

368 CD4+ cells, including CD4+ FoxP3+ Tregs. Both observations could underlie the limitations in

369 immune response.

370 Beneficial outcomes of programmed cell death protein 1–targeted therapy in NSCLC or

371 melanoma are accompanied by activation and proliferation of peripheral blood CD8+ T cells

372 (29,30). Here, robust treatment-associated peripheral CD8+ Ki67+ index increases were

373 correlated with improved tumor response and PFS, suggesting possible impacts of reinvigorated

374 T cells on tumor cells. However, the limited data from paired tumor samples do not allow us to

375 conclude that changes in peripheral T-cell proliferation are accompanied by parallel changes in

376 T cells within the TME.

377 Although pretreatment IFNγ levels are positively associated with clinical responses to

378 immunotherapy in NSCLC and melanoma (31,32), increased levels of the IFNγ-induced

379 cytokine CXCL10 are correlated with poor clinical outcomes in PC (33). Perhaps somewhat

380 analogously, while IL-2 and cognate α/β receptor subunits are required for response to

381 immunotherapy in a mouse melanoma model, shedding of its receptor (sIL2Rα) is negatively

382 correlated with clinical outcome (34). The nominal correlation between serum CXCL10 and

383 sIL2Rα levels with clinical response observed here raises the possibility that these measures

384 reflect a mixture of immune-stimulatory and immune response–limiting feedback into the TME,

385 perhaps via effects on Tregs (34,35).

386 The clinical results presented herein suggest an incomplete understanding of optimal

387 pairing of ICIs with chemotherapy for treating PC and do not support further development of this

388 regimen. However, some immuno-oncology combinations have demonstrated signs of activity in

389 patients with refractory microsatellite-stable PC (36,37). These have primarily included

390 combinations of ICIs and inhibitors of tumor-associated macrophages (TAMs). Among other

391 cells, TAMs have been shown in preclinical studies to be responsible for an inherently immune-

392 resistant TME (38-40). Importantly, some combinations with monoclonal antibodies have shown

393 some response in PC and are being tested in additional combinations (20,22).

394

395 Limitations and conclusions

396 This study was limited by the relatively small sample size and lack of a comparator arm. The

397 biomarker analyses suggest that the combination therapy does elicit immunologic response in

398 patients with APC, which may be associated with more desirable clinical outcomes in some

399 patients. However, possible relationships between changes in peripheral immune-response

400 markers and events within the TME are not well characterized in this study. Although there was

401 no clear correlation between expression of baseline biomarkers, including PD-L1, and clinical

402 benefit, additional work is needed to determine whether specific subsets of patients can benefit

403 from the combination of ICIs and nab-paclitaxel plus gemcitabine in the first-line setting.

404 Additional studies assessing nab-paclitaxel plus gemcitabine as a backbone for combinations

405 with novel immunotherapy agents are needed to address the unmet clinical need in APC.

406

407 Data sharing statement

408 Data requests may be submitted to Celgene, a Bristol-Myers Squibb Company, at

409 https://vivli.org/ourmember/celgene/ and must include a description of the research proposal.

410

411 Acknowledgments

412 The authors thank the patients who participated in the study and their families. This study was

413 supported by Bristol-Myers Squibb Company. Emin Avsar and Amy Hammell of Bristol-Myers

414 Squibb provided substantial feedback and support during the conduct of the study. Writing

415 assistance was provided by Narender Dhingra, MBBS, PhD, CMPP, of MediTech Media, Ltd,

416 and funded by Bristol-Myers Squibb Company. The authors are fully responsible for all content

417 and editorial decisions for this manuscript.

418

419 References

420 1. Conroy T, Desseigne F, Ychou M, Bouche O, Guimbaud R, Becouarn Y, et al. FOLFIRINOX

421 versus gemcitabine for metastatic pancreatic cancer. N Engl J Med 2011;364(19):1817–25.

422 doi 10.1056/NEJMoa1011923.

423 2. Von Hoff DD, Ervin T, Arena FP, Chiorean EG, Infante J, Moore M, et al. Increased survival

424 in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med

425 2013;369(18):1691–703. doi 10.1056/NEJMoa1304369.

426 3. August 19. National Comprehensive Cancer Network. NCCN clinical practice guidelines in

427 oncology. Pancreatic adenocarcinoma. V3.2019.

428 . Accessed August

429 19, 2019.

430 4. Brahmer JR, Tykodi SS, Chow LQ, Hwu WJ, Topalian SL, Hwu P, et al. Safety and activity

431 of anti-PD-L1 antibody in patients with advanced cancer. N Engl J Med 2012;366(26):2455–

432 65. doi 10.1056/NEJMoa1200694.

433 5. Mizugaki H, Yamamoto N, Murakami H, Kenmotsu H, Fujiwara Y, Ishida Y, et al. Phase I

434 dose-finding study of monotherapy with atezolizumab, an engineered immunoglobulin

435 monoclonal antibody targeting PD-L1, in Japanese patients with advanced solid tumors.

436 Invest New Drugs 2016;34(5):596–603. doi 10.1007/s10637-016-0371-6.

437 6. Patnaik A, Kang SP, Rasco D, Papadopoulos KP, Elassaiss-Schaap J, Beeram M, et al.

438 Phase I study of pembrolizumab (MK-3475; anti-PD-1 monoclonal antibody) in patients with

439 advanced solid tumors. Clin Cancer Res 2015;21(19):4286–93. doi 10.1158/1078-

440 0432.CCR-14-2607.

441 7. Royal RE, Levy C, Turner K, Mathur A, Hughes M, Kammula US, et al. Phase 2 trial of

442 single agent ipilimumab (anti-CTLA-4) for locally advanced or metastatic pancreatic

443 adenocarcinoma. J Immunother 2010;33(8):828–33. doi 10.1097/CJI.0b013e3181eec14c.

444 8. O'Reilly EM, Oh DY, Dhani N, Renouf DJ, Lee MA, Sun W, et al. Durvalumab with or without

445 tremelimumab for patients with metastatic pancreatic ductal adenocarcinoma: a phase 2

446 randomized clinical trial. JAMA Oncol. 2019 July 18. [Epub ahead of print]. doi

447 10.1001/jamaoncol.2019.1588.

448 9. Gandhi L, Rodríguez-Abreu D, Gadgeel S, Esteban E, Felip E, De Angelis F, et al.

449 Pembrolizumab plus chemotherapy in metastatic non-small-cell lung cancer. N Engl J Med

450 2018;378(22):2078–92. doi 10.1056/NEJMoa1801005.

451 10. Paz-Ares L, Luft A, Vicente D, Tafreshi A, Gumus M, Mazieres J, et al. Pembrolizumab plus

452 chemotherapy for squamous non-small-cell lung cancer. N Engl J Med 2018;379(21):2040–

453 51. doi 10.1056/NEJMoa1810865.

454 11. Schmid P, Adams S, Rugo HS, Schneeweiss A, Barrios CH, Iwata H, et al. Atezolizumab

455 and nab-paclitaxel in advanced triple-negative breast cancer. N Engl J Med

456 2018;379(22):2108–21. doi 10.1056/NEJMoa1809615.

457 12. Socinski MA, Rittmeyer A, Shapovalov D, Orlandi F, McCleod M, Soo R, et al. IMpower131:

458 progression-free survival (PFS) and overall survival (OS) analysis of a randomised phase III

459 study of atezolizumab + carboplatin + paclitaxel or nab-paclitaxel vs carboplatin + nab-

460 paclitaxel in 1L advanced squamous NSCLC. Poster presented at: ESMO 2018 Congress;

461 October 19-23, 2018; Munich, Germany [abstract 4580].

462 13. Weiss GJ, Waypa J, Blaydorn L, Coats J, McGahey K, Sangal A, et al. A phase Ib study of

463 pembrolizumab plus chemotherapy in patients with advanced cancer (PembroPlus). Br J

464 Cancer 2017;117(1):33–40. doi 10.1038/bjc.2017.145.

465 14. Good clinical practice research guidelines reviewed, emphasis given to responsibilities of

466 investigators: second article in a series. J Oncol Pract 2008;4(5):233–5. doi

467 10.1200/JOP.0854601.

468 15. February 14. American Cancer Society. Cancer facts and figures.

469

470 statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-figures-2019.pdf>.

471 Accessed February 14, 2019.

472 16. Rahib L, Smith BD, Aizenberg R, Rosenzweig AB, Fleshman JM, Matrisian LM. Projecting

473 cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas

474 cancers in the United States. Cancer Res 2014;74(11):2913–21. doi 10.1158/0008-

475 5472.CAN-14-0155.

476 17. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin 2019;69(1):7–34.

477 doi 10.3322/caac.21551.

478 18. March 4. Keytruda (pembrolizumab) for injection, for intravenous use [prescribing

479 information]. Merck & Co., Inc.

480 . Accessed

481 March 4, 2019.

482 19. Goldstein D, El-Maraghi RH, Hammel P, Heinemann V, Kunzmann V, Sastre J, et al. nab-

483 Paclitaxel plus gemcitabine for metastatic pancreatic cancer: long-term survival from a

484 phase III trial. J Natl Cancer Inst 2015;107(2). doi 10.1093/jnci/dju413.

485 20. Wainberg Z, Piha-Paul S, Luke J, Kim E, Thompson J, Pfanzelter N, et al. First-in-human

486 phase 1 dose escalation and expansion of a novel combination, anti–CSF-1 receptor

487 (cabiralizumab) plus anti–PD-1 (nivolumab), in patients with advanced solid tumors. J

488 Immunother Cancer 2017;5(suppl 3) [abstract O42].

489 21. Sharma P, Hu-Lieskovan S, Wargo JA, Ribas A. Primary, adaptive, and acquired resistance

490 to cancer immunotherapy. Cell 2017;168(4):707–23. doi 10.1016/j.cell.2017.01.017.

491 22. Calvo A, Joensuu H, Sebastian M, Naing A, Bang YJ, Martin M, et al. Phase lb/II study of

492 lacnotuzumab (MCS110) combined with spartalizumab (PDR001) in patients (pts) with

493 advanced tumors. J Clin Oncol 2018;36(suppl) [abstract 3014].

494 23. O'Hara MH, O'Reilly EM, Rosemarie M, Varadhachary G, Wainberg ZA, Ko A, et al. A phase

495 Ib study of CD40 agonistic monoclonal antibody APX005M together with gemcitabine (gem)

496 and nab-paclitaxel (NP) with or without nivolumab (nivo) in untreated metastatic ductal

497 pancreatic adenocarcinoma (PDAC) patients. Cancer Res 2019;79(suppl) [abstract CT004].

498 doi 10.1158/1538-7445.AM2019-CT004.

499 24. Hilmi M, Bartholin L, Neuzillet C. Immune therapies in pancreatic ductal adenocarcinoma:

500 where are we now? World J Gastroenterol 2018;24(20):2137–51. doi

501 10.3748/wjg.v24.i20.2137.

502 25. Kanat O, Ertas H. Shattering the castle walls: anti-stromal therapy for pancreatic cancer.

503 World J Gastrointest Oncol 2018;10(8):202–10. doi 10.4251/wjgo.v10.i8.202.

504 26. Ene-Obong A, Clear AJ, Watt J, Wang J, Fatah R, Riches JC, et al. Activated pancreatic

505 stellate cells sequester CD8+ T cells to reduce their infiltration of the juxtatumoral

506 compartment of pancreatic ductal adenocarcinoma. Gastroenterology 2013;145(5):1121–32.

507 doi 10.1053/j.gastro.2013.07.025.

508 27. Von Hoff DD, Ramanathan RK, Borad MJ, Laheru DA, Smith LS, Wood TE, et al.

509 Gemcitabine plus nab-paclitaxel is an active regimen in patients with advanced pancreatic

510 cancer: a phase I/II trial. J Clin Oncol 2011;29(34):4548–54. doi

511 10.1200/JCO.2011.36.5742.

512 28. Blando J, Sharma A, Higa MG, Zhao H, Vence L, Yadav SS, et al. Comparison of immune

513 infiltrates in melanoma and pancreatic cancer highlights VISTA as a potential target in

514 pancreatic cancer. Proc Natl Acad Sci U S A 2019;116(5):1692–7. doi

515 10.1073/pnas.1811067116.

516 29. Huang AC, Postow MA, Orlowski RJ, Mick R, Bengsch B, Manne S, et al. T-cell invigoration

517 to tumour burden ratio associated with anti-PD-1 response. Nature 2017;545(7652):60–5.

518 doi 10.1038/nature22079.

519 30. Kamphorst AO, Pillai RN, Yang S, Nasti TH, Akondy RS, Wieland A, et al. Proliferation of

520 PD-1+ CD8 T cells in peripheral blood after PD-1-targeted therapy in lung cancer patients.

521 Proc Natl Acad Sci U S A 2017;114(19):4993–8. doi 10.1073/pnas.1705327114.

522 31. Karachaliou N, Gonzalez-Cao M, Crespo G, Drozdowskyj A, Aldeguer E, Gimenez-Capitan

523 A, et al. Interferon gamma, an important marker of response to immune checkpoint blockade

524 in non-small cell lung cancer and melanoma patients. Ther Adv Med Oncol

525 2018;10:1758834017749748. doi 10.1177/1758834017749748.

526 32. Yamazaki N, Kiyohara Y, Uhara H, Iizuka H, Uehara J, Otsuka F, et al. Cytokine biomarkers

527 to predict antitumor responses to nivolumab suggested in a phase 2 study for advanced

528 melanoma. Cancer Sci 2017;108(5):1022–31. doi 10.1111/cas.13226.

529 33. Lunardi S, Jamieson NB, Lim SY, Griffiths KL, Carvalho-Gaspar M, Al-Assar O, et al. IP-

530 10/CXCL10 induction in human pancreatic cancer stroma influences lymphocytes

531 recruitment and correlates with poor survival. Oncotarget 2014;5(22):11064–80. doi

532 10.18632/oncotarget.2519.

533 34. Hannani D, Vétizou M, Enot D, Rusakiewicz S, Chaput N, Klatzmann D, et al. Anticancer

534 immunotherapy by CTLA-4 blockade: obligatory contribution of IL-2 receptors and negative

535 prognostic impact of soluble CD25. Cell Res 2015;25(2):208–24. doi 10.1038/cr.2015.3.

536 35. Lunardi S, Lim SY, Muschel RJ, Brunner TB. IP-10/CXCL10 attracts regulatory T cells:

537 implication for pancreatic cancer. Oncoimmunology 2015;4(9):e1027473. doi

538 10.1080/2162402X.2015.1027473.

539 36. Carleton M, Powers J, Phillips P, Beg MS, Lee JJ, Rahma OE, et al. Pharmacodynamics

540 (PD) and genomic profiling of pts treated with cabiralizumab (cabira) + nivolumab (nivo)

541 provide evidence of on-target tumor immune modulations and support future clinical

542 applications. J Clin Oncol 2018;36(15 suppl) [abstract 3020].

543 37. Halama N, Pruefer U, Frömming A, Beyer D, Eulberg D, Jungnelius JU, et al. Evaluation of

544 tumor biomarkers in patients with microsatellite-stable, metastatic colorectal or pancreatic

545 cancer treated with the CXCL12 inhibitor NOX-A12 and preliminary safety in combination

546 with PD-1 checkpoint inhibitor pembrolizumab. J Clin Oncol 2018;36(15 suppl) [abstract

547 e15094].

548 38. Candido JB, Morton JP, Bailey P, Campbell AD, Karim SA, Jamieson T, et al. CSF1R(+)

549 Macrophages sustain pancreatic tumor growth through T cell suppression and maintenance

550 of key gene programs that define the squamous subtype. Cell Rep 2018;23(5):1448–60. doi

551 S2211-1247(18)30519-9.

552 39. Ries CH, Cannarile MA, Hoves S, Benz J, Wartha K, Runza V, et al. Targeting tumor-

553 associated macrophages with anti-CSF-1R antibody reveals a strategy for cancer therapy.

554 Cancer Cell 2014;25(6):846–59. doi 10.1016/j.ccr.2014.05.016.

555 40. Zhu Y, Knolhoff BL, Meyer MA, Nywening TM, West BL, Luo J, et al. CSF1/CSF1R blockade

556 reprograms tumor-infiltrating macrophages and improves response to T-cell checkpoint

557 immunotherapy in pancreatic cancer models. Cancer Res 2014;74(18):5057–69. doi

558 10.1158/0008-5472.CAN-13-3723.

559

560 Table 1. Demographics and Baseline Clinical Characteristics (arm B parts 1 and 2) 561 Characteristic Patients (N=50)562 Age, median (range), years 67.5 (43-86) 563 <65 years, n (%) 19 (38) 564 ≥65 years, n (%) 31 (62) 565 566 Sex, n (%) 567 Male 28 (56) 568 Female 22 (44) 569 Race, n (%) 570 White 41 (82) 571 Black/African American 4 (8) 572 Not collected or reported 5 (10) 573 Body weight, mean (SD), kg 76.5 (16) 574 ECOG PS, n (%) 575 0 19 (38) 576 1 31 (62) 577 Stage at primary diagnosis, n (%) 578 I 0 (0) 579 II 1 (2) 580 III 3 (6) 581 IV 42 (84) Unknown 4 (8) Metastatic disease, n (%) Yes 48 (96) No 2 (4) PD-L1 category, n (%)a <1% 28 (56) ≥1% 12 (24) ≥5% 6 (12) Missing 10 (20) ECOG PS, Eastern Cooperative Oncology Group performance status; PD-L1, programmed cell death-ligand 1. a n=40. PD-L1 was detected by immunohistochemistry using the PD-L1 rabbit monoclonal 28-8 pharmDx kit.

582 Table 2. Safety (arm B parts 1 and 2) 583 Patients (N=50) Parameter, n (%) Any Grade Grade 3/4 Most common TEAEsa Anemia 26 (52) 18 (36) Neutrophil count decreased 15 (30) 10 (20) Neutropenia 9 (18) 8 (16) Peripheral neuropathyb 33 (66) 8 (16) Hypokalemia 18 (36) 7 (14) Leukopenia 9 (18) 6 (12) Nausea 36 (72) 5 (10) Diarrhea 35 (70) 5 (10) Abdominal pain 18 (36) 5 (10) ALT increased 14 (28) 5 (10) AST increased 13 (26) 5 (10) Hyperglycemia 9 (18) 5 (10) Hyponatremia 7 (14) 5 (10) Fatigue 33 (66) 4 (8) Vomiting 26 (52) 3 (6) Dehydration 17 (34) 3 (6) Thrombocytopenia 10 (20) 3 (6) Muscular weakness 8 (16) 3 (6) Platelet count decreased 7 (14) 3 (6) Hypoxia 7 (14) 3 (6) Select TEAEs of special interest attributable to nivolumabc Pneumonitis 4 (8) 0 Hypothyroidism 2 (4) 0 Colitis 2 (4) 0 Note: TEAEs are presented by preferred term and worst NCI CTCAE grade. ALT, alanine aminotransferase; AST, aspartate aminotransferase; CTCAE, Common Terminology Criteria for Adverse Events; NCI, National Cancer Institute; TEAE, treatment- emergent adverse event. a Grade 3/4 TEAEs reported in >5% of patients; presented in descending order of grade 3/4 TEAE incidence. b Reported as a grouped term. c Any grade select TEAEs of special interest reported in ≥2 patients. 584

585 Figure Legends 586 Figure 1. CONSORT diagram. aPatients in both arms A and B (patients were not randomized 587 to arm A and arm B). AE, adverse event. 588 Figure 2. Investigator-Assessed PFS (A) and OS (B) in All Patients (arm B parts 1 and 2). 589 OS, overall survival; PFS, progression-free survival. 590 Figure 3. Peripheral T-cell Proliferation on Treatment (arm B parts 1 and 2). Peak on- 591 treatment proliferative index (Ki67+%) and association with objective tumor response (A) and 592 investigator-assessed PFS (B). HR, hazard ratio; NR, nonresponder; PFS, progression-free 593 survival; R, responder; Tx, treatment. *Wilcoxon P value.

Figure 1 89 Patients screeneda

28 Patients with screen failure

61 Patients treateda

Arm A Arm B Patients treated (n=11) Patients treated (n=50) Part 1 (n=11) Part 1 (n=6) DLT-evaluable patients (n=7) DLT-evaluable patients (n=6) Part 2 (n=14) Part 2 expansion (n=30) Treatment discontinued (n=11) Disease progression (n=6) AE (n=3) Treatment discontinued (n=50) Symptomatic deterioration (n=1) Disease progression (n=19) Other (n=1) Symptomatic deterioration (n=10) Patient withdrawal (n=9) AE (n=7) Continued into follow-up period (n=8) Death (n=2) Alive (n=1) Other (n=3) Dead (n=7)

Continued into follow-up period (n=38) Alive (n=9) Dead (n=29)

a Downloaded from clincancerres.aacrjournals.org on September 25, 2021. © 2020 American Association for Cancer In both Arms A and B. Patients were not randomized to Research.Arm A and Arm B. Author Manuscript Published OnlineFirst on June 18, 2020; DOI: 10.1158/1078-0432.CCR-20-0099 Author manuscripts have been peer reviewed and accepted for publication but have not yet been edited.

Figure 2A

1.0 Investigator-Assessed PFS 0.9 0.8 Median (95% CI) PFS, months 5.5 (3.25-7.20)

0.7 No. of events (n/N): 34/50 0.6 Censored 0.5 0.4

PFS Probability PFS 0.3 0.2 0.1 0.0 0 2 4 6 8 10 12 14 16 18 20 22 24 Months No. of patients at risk 50 32 22 17 8 7 4 3 2 2 2 1 0

Figure 2B

1.0 OS 0.9 0.8 Median (95% CI) OS, months 9.9 (6.74-12.16) 0.7 No. of events (n/N): 31/50 0.6 Censored 0.5 0.4

OS Probability 0.3 0.2 0.1 0.0 0 3 6 9 12 15 18 21 24 27 30 33 Months No. of patients at risk 50 39 31 23 13 5 3 2 1 1 1 0

Figure 3A

CD3+/CD8+ CD3+/CD8+ CD3+/CD4+ CD3+/CD4+

8 7 20 P=.03* 15 6 6 15 5 10 4 4 10 3 Ki67+, % Ki67+, %

2 2 5 5 1 Baseline Max on Tx Baseline Max on Tx NR R NR R NR R NR R n 33 9 32 9 33 9 32 9 Ki67+, median, % 1.43 1.37 6.87 13.86 1.595 1.66 5.76 7.08

NR, nonresponder; R, responder; Tx, treatment. Downloaded from clincancerres.aacrjournals.org on September 25, 2021. © 2020 American Association for Cancer * Wilcoxon P value. Research. Author Manuscript Published OnlineFirst on June 18, 2020; DOI: 10.1158/1078-0432.CCR-20-0099 Author manuscripts have been peer reviewed and accepted for publication but have not yet been edited.

Figure 3B (part 1)

1.0 CD3+/CD8+ Cells Median PFS (95% CI), months 0.8 ≥8.56: 7.2 (4.30-20.24) <8.56: 3.8 (1.41-7.13)

0.6 HR (95% CI): 0.5 (0.21-1.00) Log-rank P=.0429 + Censored 0.4

PFS Probability Probability PFS 0.2

0.0

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Months No. of patients at risk ≥8.56 19 19 17 13 12 11 10 7 4 4 4 3 3 2 2 2 2 2 2 2 2 1 1 0 <8.56 26 23 14 11 9 7 7 6 4 4 3 3 1 1 1 1 0

Figure 3B (part 2)

1.0 CD3+/CD4+ Cells Median PFS (95% CI), months ≥5.79: 6.5 (2.99-12.16) 0.8 <5.79: 6.1 (1.41-7.23)

0.6 HR (95% CI): 0.6 (0.27-1.34) Log-rank P=.2076

0.4 + Censored

PFS Probability Probability PFS 0.2

0.0

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Months No. of patients at risk ≥5.79 24 23 18 14 13 11 10 8 7 7 7 6 4 3 3 3 2 2 2 2 2 1 1 0 <5.79 21 19 13 10 8 7 7 5 1 1 0

Open-Label, Phase 1 Study of Nivolumab Combined With nab -Paclitaxel Plus Gemcitabine in Advanced Pancreatic Cancer

Zev A. Wainberg, Howard S. Hochster, Edward J Kim, et al.

Clin Cancer Res Published OnlineFirst June 18, 2020.

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