Subcutaneous Atezolizumab for the Treatment of Non-small Cell Lung Cancer

Inclusion Criteria:

• Non-small cell lung cancer (NSCLC) patients who are eligible for treatment withatezolizumab for approved indications. These include the following:

• Locally advanced or metastatic 1st line patients whose tumors have high PD-L1expression (PD-L1 stained >= 50% of tumor cells [TC >= 50%] or PD-L1 stainedtumor-infiltrating immune cells [IC] covering >= 10% of the tumor area [IC >= 10%]), as determined by an Food and Drug Administration (FDA) - approved test,with no EGFR or ALK genomic tumor aberrations

• For the treatment of adult patients with metastatic NSCLC who have diseaseprogression during or following platinum-containing chemotherapy. Patients withEGFR or ALK genomic tumor aberrations should have disease progression onFDA-approved therapy for NSCLC harboring these aberrations prior to receiving

• For adjuvant treatment following resection and platinum-based chemotherapy foradult patients with stage II to IIIA NSCLC whose tumors have PD-L1 expressionon >= 1% of tumor cells, as determined by an FDA-approved test

• Be willing and able to provide written informed consent/assent for the trial

• Be at least 18 years of age on day of signing informed consent

• Have detectable disease based on computed tomography (CT) and/or positron emissiontomography (PET) scan

• Have ready access wifi or cellular data plan

• Have a performance status of 0-2 on the Eastern Cooperative Oncology Group (ECOG)performance scale

• Ability to comply with the study protocol, in the investigator's judgment

• Life expectancy >= 3 months

• Absolute neutrophil count (ANC) >= 1.5 x 10^9/L (1500/uL) without granulocytecolony-stimulating factor support (obtained within 14 days prior to initiation ofstudy treatment)

• Lymphocyte count >= 0.5 x 10^9/L (500/uL) (obtained within 14 days prior toinitiation of study treatment)

• Platelet count >= 100 x 10^9/L (100,000/uL) without transfusion (obtained within 14days prior to initiation of study treatment)

• Hemoglobin >= 90 g/L (9 g/dL) (obtained within 14 days prior to initiation of studytreatment)

• Patients may be transfused to meet this criterion

• Aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkalinephosphatase (ALP) =< 2.5 x upper limit of normal (ULN) with the following exceptions (obtained within 14 days prior to initiation of study treatment):

• Patients with documented liver metastases: AST and ALT =< 5 x ULN

• Patients with documented liver or bone metastases: ALP =< 5 x ULN

• Serum bilirubin =< 1.5 x ULN with the following exception (obtained within 14 daysprior to initiation of study treatment)

• Patients with known Gilbert disease: serum bilirubin =< 3 x ULN

• Serum creatinine =< 1.5 x ULN or creatinine clearance >= 30 mL/min (calculated usingthe Cockcroft-Gault formula) (obtained within 14 days prior to initiation of studytreatment)

• Serum albumin >= 25 g/L (2.5 g/dL) (obtained within 14 days prior to initiation ofstudy treatment)

• For patients not receiving therapeutic anticoagulation: International normalizedratio (INR) or activated partial thromboplastin time (aPTT) =< 1.5 x ULN (obtainedwithin 14 days prior to initiation of study treatment)

• For patients receiving therapeutic anticoagulation: stable anticoagulant regimen

• For women of childbearing potential: agreement to remain abstinent (refrain fromheterosexual intercourse) or use contraceptive methods, as defined below:

• Women must remain abstinent or use contraceptive methods with a failure rate of < 1% per year during the treatment period and for 5 months after the final doseof atezolizumab

• A woman is considered to be of childbearing potential if she is postmenarchal,has not reached a postmenopausal state (>= 12 continuous months of amenorrheawith no identified cause other than menopause), and has not undergone surgicalsterilization (removal of ovaries and/or uterus). The definition ofchildbearing potential may be adapted for alignment with local guidelines orrequirements

• Examples of contraceptive methods with a failure rate of < 1% per year includebilateral tubal ligation, male sterilization, hormonal contraceptives thatinhibit ovulation, hormone-releasing intrauterine devices, and copperintrauterine devices

• The reliability of sexual abstinence should be evaluated in relation to theduration of the clinical trial and the preferred and usual lifestyle of thepatient. Periodic abstinence (e.g., calendar, ovulation, symptothermal, orpostovulation methods) and withdrawal are not adequate methods of contraception

Exclusion Criteria:

• History of leptomeningeal disease

• Untreated or treatment refractory brain metastases

• Uncontrolled tumor-related pain

• Patients requiring pain medication must be on a stable regimen at study entry

• Symptomatic lesions (e.g., bone metastases or metastases causing nerveimpingement) amenable to palliative radiotherapy should be treated prior toenrollment. Patients should be recovered from the effects of radiation. Thereis no required minimum recovery period

• Asymptomatic metastatic lesions that would likely cause functional deficits orintractable pain with further growth (e.g., epidural metastasis that is notcurrently associated with spinal cord compression) should be considered forloco-regional therapy if appropriate prior to enrollment

• Uncontrolled pleural effusion, pericardial effusion, or ascites requiring recurrentdrainage procedures (once monthly or more frequently)

• Patients with indwelling catheters (e.g., PleurX) are allowed

• Patients with known HIV test at screening are eligible provided they are stable onanti-retroviral therapy, have a CD4 count >= 200/uL, and have an undetectable viralload

• Uncontrolled or symptomatic hypercalcemia (ionized calcium > 1.5 mmol/L, calcium > 12 mg/dL or corrected serum calcium > ULN)

• Active or history of autoimmune disease or immune deficiency, including, but notlimited to, myasthenia gravis, myositis, autoimmune hepatitis, systemic lupuserythematosus, rheumatoid arthritis, inflammatory bowel disease, antiphospholipidantibody syndrome, Wegener granulomatosis, Sjogren syndrome, Guillain-Barresyndrome, or multiple sclerosis, with the following exceptions:

• Patients with a history of autoimmune-related hypothyroidism who are onthyroid-replacement hormone are eligible for the study

• Patients with controlled type 1 diabetes mellitus who are on an insulin regimenare eligible for the study

• Patients with eczema, psoriasis, lichen simplex chronicus, or vitiligo withdermatologic manifestations only (e.g., patients with psoriatic arthritis areexcluded) are eligible for the study provided all of following conditions aremet:

• Rash must cover < 10% of body surface area

• Disease is well controlled at baseline and requires only low-potencytopical corticosteroids

• No occurrence of acute exacerbations of the underlying condition requiringpsoralen plus ultraviolet A radiation, methotrexate, retinoids, biologicagents, oral calcineurin inhibitors, or high-potency or oralcorticosteroids within the previous 12 months

• History of idiopathic pulmonary fibrosis, organizing pneumonia (e.g., bronchiolitisobliterans), drug-induced pneumonitis, or idiopathic pneumonitis, or evidence ofactive pneumonitis on screening chest CT scan

• History of radiation pneumonitis in the radiation field (fibrosis) is permitted

• Active tuberculosis

• Significant cardiovascular disease (such as New York Heart Association Class II orgreater cardiac disease, myocardial infarction, or cerebrovascular accident) within 3 months prior to initiation of study treatment, unstable arrhythmia, or unstableangina

• Major surgical procedure, other than for diagnosis, within 4 weeks prior toinitiation of study treatment, or anticipation of need for a major surgicalprocedure during the study

• History of malignancy other than lung cancer within 3 years prior to screening, withthe exception of malignancies with a negligible risk of metastasis or death (e.g., 5-year overall survival [OS] rate > 90%), such as adequately treated carcinoma insitu of the cervix or bladder, non-melanoma skin carcinoma, localized prostate orresected differentiated thyroid cancer, ductal or lobular carcinoma in situ, orstage I uterine cancer

• Severe infection within 4 weeks prior to initiation of study treatment, including,but not limited to, hospitalization for complications of infection, bacteremia, orsevere pneumonia

• Treatment with therapeutic IV antibiotics within 2 weeks prior to initiation ofstudy treatment

• Prior allogeneic stem cell or solid organ transplantation

• Any other disease, metabolic dysfunction, physical examination finding, or clinicallaboratory finding that contraindicates the use of an investigational drug, mayaffect the interpretation of the results, or may render the patient at high riskfrom treatment complications

• Treatment with a live, attenuated vaccine within 4 weeks prior to initiation ofstudy treatment, or anticipation of need for such a vaccine during atezolizumabtreatment or within 5 months after the final dose of atezolizumab

• Treatment with investigational therapy within 28 days prior to initiation of studytreatment. However, Covid-19 vaccines administered under an FDA emergency useauthorization are permitted

• Current treatment with anti-viral therapy for hepatitis B virus (HBV)

• Prior treatment with CD137 agonists or immune checkpoint blockade therapies,including anti-CTLA-4, anti-PD-1, and anti-PD-L1 therapeutic antibodies

• Treatment with systemic immunostimulatory agents (including, but not limited to,interferon and interleukin 2 [IL-2]) within 4 weeks or 5 half-lives of the drug (whichever is longer) prior to initiation of study treatment

• Treatment with systemic immunosuppressive medication (including, but not limited to,corticosteroids, cyclophosphamide, azathioprine, methotrexate, thalidomide, andanti-TNF-alpha agents) within 2 weeks prior to initiation of study treatment, oranticipation of need for systemic immunosuppressive medication during studytreatment, with the following exceptions:

• Patients who received acute, low-dose systemic immunosuppressant medication ora one-time pulse dose of systemic immunosuppressant medication (e.g., 48 hoursof corticosteroids for a contrast allergy) are eligible

• Patients who received mineralocorticoids (e.g., fludrocortisone),corticosteroids for chronic obstructive pulmonary disease (COPD) or asthma, orlow-dose corticosteroids for orthostatic hypotension or adrenal insufficiencyare eligible for the study

• History of severe allergic anaphylactic reactions to chimeric or humanizedantibodies or fusion proteins

• Known hypersensitivity to Chinese hamster ovary cell products or to any component ofthe atezolizumab formulation

• Pregnancy or breastfeeding, or intention of becoming pregnant during study treatmentor within 5 months after the final dose of study treatment

• Women of childbearing potential must have a negative serum pregnancy testresult within 14 days prior to initiation of study treatment

• Intact normal skin without potentially obscuring tattoos, pigmentation, or lesionsin the area for intended injection