| E.1 Medical condition or disease under investigation | 
| E.1.1 | Medical condition(s) being investigated  | 
| Metastatic pancreatic cancer | 
 
 
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| E.1.1.1 | Medical condition in easily understood language  | 
| Pancreatic cancer that has spread to other areas of the body | 
 
 
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| E.1.1.2 | Therapeutic area  | Diseases [C] - Cancer [C04] | 
| MedDRA Classification | 
| E.1.2 Medical condition or disease under investigation | 
| E.1.2 | Version  | 14.1 | 
 
| E.1.2 | Level  | LLT | 
 
| E.1.2 | Classification code  | 10033605 | 
 
| E.1.2 | Term  | Pancreatic cancer metastatic | 
 
| E.1.2 | System Organ Class  | 100000004864 | 
 
 
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| E.1.3 | Condition being studied is a rare disease  |  Yes  | 
| E.2 Objective of the trial | 
| E.2.1 | Main objective of the trial  | 
| To compare the efficacy of CO-1.01 and gemcitabine in patients with metastatic pancreatic adenocarcinoma and low human equilibrative nucleoside transporter 1 (hENT1) expression | 
 
 
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| E.2.2 | Secondary objectives of the trial  | 
• To compare the efficacy of CO-1.01 and gemcitabine in patients with metastatic pancreatic adenocarcinoma and known hENT1 status (all patients and high hENT1 expression).
 • To compare the tolerability and toxicity of CO-1.01 with gemcitabine.
 • To compare changes in pain severity in patients receiving CO-1.01 and gemcitabine.
 • To compare changes in health status in patients receiving CO-1.01 and gemcitabine.
 • To perform sparse PK sampling in patients taking CO-1.01 to contribute towards development of a population PK model of CO-1.01.
 • To evaluate the clinical utility of the hENT1 diagnostic test. | 
 
 
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| E.2.3 | Trial contains a sub-study  |  No  | 
| E.3 | Principal inclusion criteria  | 
Patients are eligible for the study if all of the following criteria are met:
 • Metastatic pancreatic ductal adenocarcinoma (i.e., Stage 4).
 • Histological/cytological confirmation of metastatic tissue (not primary tumor) by a central pathology laboratory (H&E stain) to ensure sufficient material is available for later hENT1 analysis.
 − Biopsy from metastases must be obtained ≥3 months after adjuvant chemotherapy (if applicable).
 − Paraffin block or freshly fixed tissue sufficient for preparing ≥6 unstained slides for central storage and subsequent hENT1 analysis is required.
 • Adjuvant chemotherapy/radiotherapy (if administered) ≥6 months prior to randomization.
 • Palliative radiotherapy (if administered) ≥1 month prior to randomization.
 • CT scan ≤30 days prior to randomization.
 • Performance Status (ECOG) 0 or 1.
 • Estimated life expectancy ≥12 weeks.
 • Age ≥18 years.
 • Adequate hematological and biological function, which is defined as the following:
 Bone marrow function
 − Neutrophils ≥1.5 × 10 to the power of 9/L
 − Platelets >100.0 × 10 to the power of 9/L
 − Hemoglobin ≥9 g/dL
 Hepatic function
 − AST ≤2.5 × upper limit of normal (ULN); if liver metastases, ≤5 × ULN
 − Bilirubin ≤1.5 times ULN; if liver metastases, ≤3 × ULN
 − Albumin >3 g/dL
 − PT/PTT within 10% ULN
 Renal function
 − Serum creatinine ≤1.5 × ULN
 • Written consent on an IRB/IEC-approved Informed Consent Form prior to any study-specific evaluation. | 
 
 
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| E.4 | Principal exclusion criteria | 
Patients are excluded from the study if any of the following criteria are met:
 • Prior palliative chemotherapy for pancreatic cancer.
 • Radical pancreatic resections (e.g., Whipple procedure) are not allowed < 6 months prior to randomization. Exploratory laparotomy, palliative (e.g., bypass) surgery, or other procedures (e.g., stents) are not allowed <14 days prior to randomization. In both cases the patient must be sufficiently recovered and stable.
 • Symptomatic brain metastases.
 • Participation in other investigational drug clinical studies ≤30 days prior to randomization.
 • Concomitant treatment with prohibited medications (e.g., concurrent anticancer therapy including other chemotherapy, radiation, hormonal treatment, or immunotherapy) ≤30 days prior to randomization.
 • History of allergy to gemcitabine or eggs.
 • Presence of any serious or unstable concomitant systemic disorder incompatible with the clinical study (e.g., substance abuse, uncontrolled intercurrent illness including active infection, arterial thrombosis, symptomatic pulmonary embolism).
 • Any disorder that would hamper protocol compliance.
 • Prior nonpancreatic malignancy treated with chemotherapy. Prior malignancies treated with surgery or radiotherapy alone must be in remission ≥3 years. Prior malignancies allowed irrespective of when they occurred are in situ carcinoma of the cervix, in situ ductal breast cancer, low-grade local bladder cancer, and nonmelanotic
 skin cancer.
 • Females who are pregnant or breastfeeding.
 • Refusal to use adequate contraception for fertile patients (females and males during the study and for 6 months after the last protocol-specified treatment). Adequate forms of contraception are docuble-barrier methods (condoms or diaphragm with spermicidal jelly or foam); oral, depot, or injectible contraceptives, interuterine devices; tubal ligation.
 • Any other reason the investigator considers the patient should not participate in the study. | 
 
 
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| E.5 End points | 
| E.5.1 | Primary end point(s) | 
The overall survival (OS) in patients with low hENT1 expression
 
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| E.5.1.1 | Timepoint(s) of evaluation of this end point | 
The primary endpoint analysis will take place when 90 events of death
 have been observed in the hENT1-low patients. | 
 
 
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| E.5.2 | Secondary end point(s) | 
• OS in all patients and patients with high hENT1 expression
 • Objective tumor response rate (ORR), duration of response, and progression free survival (PFS) in patients with measurable/evaluable disease, using RECIST 1.1.
 • CA 19-9 velocity and response rate.
 • Drug tolerability and toxicity using clinical AE monitoring, clinical laboratory testing, ECG outcomes, and dose modifications of protocol-specified treatment
 • Change from baseline in pain severity measured by the worst pain on the Brief Pain Inventory (BPI) short form.
 • Change from baseline in health status measured by the European Quality of Life-5 Dimension (EQ-5D) instrument and European Quality Visual Analog Scale (EQ VAS)
 • PK profile of CO-1.01 based on sparse sampling. | 
 
 
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| E.5.2.1 | Timepoint(s) of evaluation of this end point | 
The secondary analyses will occur when 90 events of death have been
 observed in the hENT1-low patients. AEs will be assessed from the time informed consent (IC) is obtained through 28 days after the last
 protocol-specified treatment administration. | 
 
 
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| E.6 and E.7 Scope of the trial | 
| E.6 | Scope of the trial | 
| E.6.1 | Diagnosis |  No  | 
| E.6.2 | Prophylaxis |  No  | 
| E.6.3 | Therapy |  Yes  | 
| E.6.4 | Safety |  Yes  | 
| E.6.5 | Efficacy |  Yes  | 
| E.6.6 | Pharmacokinetic |  Yes  | 
| E.6.7 | Pharmacodynamic |  No  | 
| E.6.8 | Bioequivalence |  No  | 
| E.6.9 | Dose response |  No  | 
| E.6.10 | Pharmacogenetic |  Yes  | 
| E.6.11 | Pharmacogenomic |  Yes  | 
| E.6.12 | Pharmacoeconomic |  No  | 
| E.6.13 | Others |  No  | 
| E.7 | Trial type and phase | 
| E.7.1 | Human pharmacology (Phase I) |  No  | 
| E.7.1.1 | First administration to humans |  No  | 
| E.7.1.2 | Bioequivalence study |  No  | 
| E.7.1.3 | Other |  No  | 
| E.7.1.3.1 | Other trial type description |  | 
| E.7.2 | Therapeutic exploratory (Phase II) |  Yes  | 
| E.7.3 | Therapeutic confirmatory (Phase III) |  No  | 
| E.7.4 | Therapeutic use (Phase IV) |  No  | 
| E.8 Design of the trial | 
| E.8.1 | Controlled |  Yes  | 
| E.8.1.1 | Randomised |  Yes  | 
| E.8.1.2 | Open |  Yes  | 
| E.8.1.3 | Single blind |  No  | 
| E.8.1.4 | Double blind  |  No  | 
| E.8.1.5 | Parallel group |  Yes  | 
| E.8.1.6 | Cross over  |  No  | 
| E.8.1.7 | Other |  No  | 
| E.8.2 |  Comparator of controlled trial | 
| E.8.2.1 | Other medicinal product(s) |  Yes  | 
| E.8.2.2 | Placebo  |  No  | 
| E.8.2.3 | Other |  No  | 
| E.8.2.4 | Number of treatment arms in the trial | 2 | 
| E.8.3 | 
                                The trial involves single site in the Member State concerned
                             |  No  | 
| E.8.4 |  The trial involves multiple sites in the Member State concerned  |  Yes  | 
| E.8.4.1 | Number of sites anticipated in Member State concerned | 3 | 
| E.8.5 | The trial involves multiple Member States |  Yes  | 
| E.8.5.1 | Number of sites anticipated in the EEA | 31 | 
| E.8.6 Trial involving sites outside the EEA | 
| E.8.6.1 | Trial being conducted both within and outside the EEA |  Yes  | 
| E.8.6.2 | Trial being conducted completely outside of the EEA |  No  | 
| E.8.6.3 | If E.8.6.1 or E.8.6.2 are Yes, specify the regions in which trial sites are planned | 
| Argentina | 
 
| Australia | 
 
| Brazil | 
 
| Canada | 
 
| Russian Federation | 
 
| Ukraine | 
 
| United States | 
 
 
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| E.8.7 | Trial has a data monitoring committee |  Yes  | 
| E.8.8 | 
                        Definition of the end of the trial and justification where it is not the last
                        visit of the last subject undergoing the trial
                     | 
| The study will close once all CO-1.01 patients have either completed participation or have transferred to a locally approved treatment access program in accordance with relevant local regulations. | 
 
 
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| E.8.9 Initial estimate of the duration of the trial | 
| E.8.9.1 | In the Member State concerned years | 2 | 
| E.8.9.1 | In the Member State concerned months | 4 | 
| E.8.9.1 | In the Member State concerned days | 0 | 
| E.8.9.2 | In all countries concerned by the trial years | 2 | 
| E.8.9.2 | In all countries concerned by the trial months | 4 | 
| E.8.9.2 | In all countries concerned by the trial days | 0 |