Phase II Trial of Paclitaxel Combined With Trastuzumab and Pertuzumab as Pre-Operative Therapy for Inflammatory Breast Cancer
Phase: PHASE2
Conditions: Breast Cancer
Sponsor: Dana-Farber Cancer Institute

DF/HCC Protocol #: 12-497 
Protocol Version Date: April 23, 2021 
 
 
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Title: Phase II Trial of Paclitaxel Combined with Trastuzumab and Pertuzumab as 
Preoperative Therapy for Inflammatory Breast Cancer 
 
NCT Number: NCT01796197 
 
IRB Approval Date: 04/23/2021 
 
 
 

DF/HCC Protocol #: 12-497 
Protocol Version Date: April 23, 2021 
 
 
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NCI Protocol #: 
 Not Applicable 
 
DF/HCC Protocol #: 12-497 
 
TITLE:  Phase II Trial of Paclitaxel Combined with Trastuzumab and Pertuzumab as 
Preoperative Therapy for Inflammatory Breast Cancer 
 
 
Coordinating Center: 
 
 
Dana Farber Cancer Institute 
 
*Principal Investigator (PI): 
Filipa Lynce, MD 
 
Dana-Farber Cancer Institute 
 
450 Brookline Avenue, YC-1255 
 
Boston, MA 02215 
 
Tel: 617-632-3800 
 
Fax: 617-632-1930 
 
Email: Filipa_Lynce@dfci.harvard.edu 
 
Statistician: 
Meredith Regan, ScD  
 
Department of Biostatistics and Computational Biology 
 
Dana-Farber Cancer Institute 
 
450 Brookline Avenue, (CLS 11007) 
 
Boston, MA 02215 
 
Tel: 617-632-2471 
 
Fax: 617-632-2444 
 
 
 
Data Coordinator:   
Claire Remolano 
Dana-Farber Cancer Institute 
450 Brookline Ave., DA-157 
Boston, MA 02215 
Tel:  617-582-9380 
Fax:  617-632-3550 
Email: marie_remolano@dfci.harvard.edu 
 
 
 
Agent(s):  HERCEPTIN (trastuzumab) [Supplied by Genentech], PERJETA (pertuzumab) 
[Supplied by Genentech], Paclitaxel [Commercial], Doxorubicin [Commercial], 
Cyclophosphamide [Commercial] 
 
IND #:  117932 
IND Sponsor:  Filipa Lynce, MD   
 
 
Protocol Type / Version # / Version Date: Amendment 20 / Protocol Version # 20/ Version 
Date: April 23, 2021 

DF/HCC Protocol #: 12-497 
Protocol Version Date: April 23, 2021 
 
 
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DF/HCC Protocol #: 12-497 
Protocol Version Date: April 23, 2021 
 
 
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SCHEMA 
 
Run-In Phase 
(week 1/Day 1): 
Pertuzumab 
loading dose and 
trastuzumab 
loading dose,
Research Biopsy 
1
Pre-Operative 
Treatment (starting 
week 2/Day 8):
Trastuzumab with 
Paclitaxel weekly x 16,
Research Biopsy 2 on 
Day 8
Starting at Week 4 (Day 
21), add Pertuzumab, 
continue 
q3 weeks until 
completion of 
Trastuzumab and 
Paclitaxel
Surgery: 
Modified 
Radical 
Mastectomy
Option 1: 
AC every 2-3 weeks x 4 
cycles
Followed by 
Trastuzumab loading 
dose, then trastuzumab 
and pertuzumab q3 
weeks to complete 12 
months
Option 2:
Continue trastuzumab 
and pertuzumab q3 
weeks to complete 12 
months
Radiation 
Therapy and 
Endocrine 
Therapy if HR 
Positive
(Can be 
concurrent with 
trastuzumab and 
pertuzumab)
Survival Follow-up:
 every 3 months x 1 year, 
then every 6 months x 4 
years, then annually until 
death or withdrawal
Patients will have 
mammogram/ultrasound 
and MRI done per 
standard practice 
recommendations
R
E
G
I
S
T
E
R
 
AC=Doxorubicin and cyclophosphamide 
 
 
Non-randomized phase II study, N = 30  
Patient Characteristics:  
• Newly diagnosed inflammatory breast cancer 
• HER2+ 
 

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TABLE OF CONTENTS 
 
SCHEMA .........................................................................................................................................4 
1. 
OBJECTIVES ......................................................................................................................8 
1.1 
Study Design ............................................................................................................8 
1.2 
Primary Objectives ...................................................................................................9 
1.3 
Secondary Objectives ...............................................................................................9 
2. 
BACKGROUND .................................................................................................................9 
2.1 
Study Disease(s).....................................................................................................10 
2.2 
Trastuzumab Clinical Experience ..........................................................................11 
2.3 
Pertuzumab Clinical Experience ............................................................................13 
2.4 
Trastuzumab and Pertuzumab Combination Therapy in Patients with 
HER2-positive Metastatic Breast Cancer ..............................................................13 
2.5 
Trastuzumab and Pertuzumab Safety .....................................................................14 
2.6 
Rationale for the Use of Pertuzumab and Trastuzumab in IBC .............................15 
2.7 
Correlative Studies Background ............................................................................15 
3. 
PARTICIPANT SELECTION ...........................................................................................17 
3.1 
Inclusion Criteria ...................................................................................................17 
3.2 
Exclusion Criteria ..................................................................................................19 
3.3 
Inclusion of Women and Minorities ......................................................................20 
4. 
REGISTRATION PROCEDURES ...................................................................................20 
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions ...................................20 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions .................................20 
4.3 
General Guidelines for Other Investigative Sites ..................................................20 
4.4 
Registration Process for Other Investigative Sites .................................................21 
5. 
TREATMENT PLAN ........................................................................................................21 
5.1 
Treatment Regimen ................................................................................................21 
5.2 
Pre-Treatment Criteria ...........................................................................................23 
5.3 
Treatment Administration ......................................................................................24 
5.4 
General Concomitant Medication and Supportive Care Guidelines ......................28 
5.5 
Criteria for Taking a Participant Off Protocol Therapy .........................................29 
5.6 
Duration of Follow Up ...........................................................................................29 
5.7 
Criteria for Taking a Participant Off Study ...........................................................30 
5.8 
Study Discontinuation ............................................................................................30 
6. 
DOSING DELAYS/DOSE MODIFICATIONS................................................................30 
6.1 
Trastuzumab and Pertuzumab Dosage Modification .............................................31 
6.2 
Dose Modifications and Delays for Paclitaxel: .....................................................31 
6.3 
Dose Modifications and Delays for Paclitaxel and 
doxorubicin/cyclophosphamide (AC) ....................................................................33 

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7. 
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS ............................35 
7.1 
Expected Toxicities ................................................................................................35 
7.2 
Adverse Event Characteristics ...............................................................................41 
7.3 
Expedited Adverse Event Reporting ......................................................................42 
7.4 
Expedited Reporting to the Food and Drug Administration (FDA) ......................43 
7.5 
Reporting to Genentech Drug Safety .....................................................................43 
7.6 
Expedited Reporting to Hospital Risk Management .............................................44 
7.7 
Monitoring of Adverse Events and Period of Observation ....................................44 
7.8 
Routine Adverse Event Reporting .........................................................................45 
8. 
PHARMACEUTICAL INFORMATION ..........................................................................45 
8.1 
Pertuzumab ............................................................................................................45 
8.2 
Trastuzumab ...........................................................................................................47 
8.3 
Paclitaxel ................................................................................................................50 
8.4 
Doxorubicin ...........................................................................................................51 
8.5 
Cyclophosphamide .................................................................................................53 
9. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................54 
9.1 
Gene Expression Microarrays ................................ Error! Bookmark not defined. 
9.2 
Circulating Biomarkers ..........................................................................................55 
9.3 
Sample Acquisition ................................................................................................55 
10. 
STUDY CALENDAR .......................................................................................................61 
11. 
MEASUREMENT OF EFFECT........................................................................................64 
11.1 
Antitumor Effect ....................................................................................................64 
12. 
DATA REPORTING / REGULATORY REQUIREMENTS ...........................................65 
12.1 
Data Reporting .......................................................................................................65 
12.2 
Data Safety Monitoring ..........................................................................................66 
12.3 
Multicenter Guidelines ...........................................................................................66 
13. 
STATISTICAL CONSIDERATIONS...............................................................................67 
13.1 
Study Design/Endpoints.........................................................................................67 
13.2 
Design and Sample Size .........................................................................................67 
13.3 
Analysis of Primary Endpoints ..............................................................................68 
13.4 
Analysis of Secondary Endpoints, Reporting and Exclusions ...............................68 
14. 
PUBLICATION PLAN .....................................................................................................69 
REFERENCES ..............................................................................................................................71 
Appendix A.  LVEF ASSESSMENTS ALGORITHM .................................................................75 
Appendix B.  Genentech Safety Reporting Fax Cover Sheet ........................................................76 
Appendix C. DF/HCC Multi-Center Data and Safety Monitoring Plan ........................................77 

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Appendix D 
12-497 DFCI SPECIMEN REQUISITION FORM ...............................................91 
Appendix E 
12-497 Michigan SPECIMEN REQUISITION FORM ........................................92 
 
 
 

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1. OBJECTIVES 
 
1.1 
Study Design 
Patients with untreated inflammatory breast cancer undergo a research breast biopsy and whole 
blood sample for correlative studies at baseline. They then receive both trastuzumab and 
pertuzumab for a loading dose (day 1, week 1). One week later (week 2, day 8), a second 
research biopsy from breast tissue and whole blood sample for correlative studies is obtained.  
On week 2, day 8, patients begin weekly paclitaxel for 16 doses. Weekly trastuzumab continues 
with paclitaxel to complete 16 doses of paclitaxel. Pertuzumab is given every 3 weeks beginning 
on week 1, day 1 and continues until 16 doses of paclitaxel are completed. Following 16 doses of 
paclitaxel, trastuzumab and pertuzumab can continue every 3 weeks until surgery. Four to five 
(5) weeks following the completion of preoperative therapy, patients deemed surgically operable 
proceed to total mastectomy and axillary lymph node dissection, where residual cancer is 
obtained for correlative studies. 
 
Patients have two options for post-operative therapy as determined by treating physician. Option 
1:  Four to five (4-5) weeks following surgery, patients then receive doxorubicin and 
cyclophosphamide every 14-21 days for 4 cycles.  Three to 4 weeks following the completion of 
doxorubicin and cyclophosphamide, trastuzumab and pertuzumab is administered every 3 weeks 
to complete 12 months of HER2-directed therapy.  Option 2: Trastuzumab and pertuzumab is 
administered every 3 weeks to complete 12 months of HER2-directed therapy. 
Radiation is given to the post-surgical chest wall and regional lymph nodes beginning 
approximately 3-6 weeks after surgery or following completion of doxorubicin and 
cyclophosphamide, concurrent with trastuzumab and pertuzumab administration. 
Endocrine therapy with either tamoxifen or an aromatase inhibitor is given in standard fashion 
for hormone receptor positive disease, either beginning with the initiation of radiation therapy, or 
at the completion of radiation therapy.  
Patients with Stage IV disease by virtue of nodal involvement alone will continue on 
trastuzumab and pertuzumab until disease progression.  
Patients whose disease has not achieved the criteria for surgical resection following pre-operative 
study therapy with 16 doses of paclitaxel combined with pertuzumab and trastuzumab, yet the 
disease has not progressed, may receive doxorubicin and cyclophosphamide every 14-21 days 
for 4 cycles. 
Patients whose disease is then deemed surgically resectable may proceed to total mastectomy 
and axillary lymph node dissection 4 to 5 weeks following completion of doxorubicin and 
cyclophosphamide. They may then continue on study treatment as outlined above (i.e., radiation 
therapy and continued pertuzumab and trastuzumab).  
Patients whose disease is not surgically resectable following doxorubicin and cyclophosphamide 
every 14-21 days for 4 cycles, may proceed  to definitive radiation given to the breast and 

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regional lymph nodes beginning approximately 4 to 5 weeks after completion of doxorubicin and 
cyclophosphamide.  
If their disease is then deemed surgically resectable, they may proceed to total mastectomy and 
axillary lymph node dissection 5 – 6 weeks following completion of radiation therapy.  They 
then continue on study treatment as outlined above (i.e., continue on pertuzumab and 
trastuzumab). 
 
CLARIFICATION NOTE:  Patients will only receive doxorubicin and cyclophosphamide and 
radiation therapy once during their course of treatment; either pre- or post-mastectomy.  
 
1.2 
Primary Objectives 
 
• To determine pathologic complete response (pCR) rate after preoperative therapy with 
combination paclitaxel (T), trastuzumab (H) and pertuzumab (P) in HER2+ inflammatory 
breast cancer. 
 
• To assess the residual cancer burden (RCB) after preoperative therapy with combination 
paclitaxel (T), trastuzumab (H) and pertuzumab (P) in HER2+ inflammatory breast 
cancer. 
 
1.3 
Secondary Objectives 
• To assess the toxicity of protocol therapy, including clinically-significant CHF. 
• To determine the efficacy of therapy defined as disease-free survival (DFS), time to 
treatment failure (TTF), and overall survival (OS). 
• To assess microarray analysis on pre-treatment breast cancer biopsy specimens using 
PAM50 to correlate the intrinsic subtype with pCR.  
• To assess microarray analysis on residual disease within the breast accessed at the time of 
mastectomy and by using PAM50 correlate the intrinsic subtype of the resistance clone 
with residual disease.  
• To identify early adaptive responses that are associated with resistance to HER2 directed 
therapies, i.e., trastuzumab and pertuzumab, but analyzing breast tissue specimens 
obtained 8 days after exposure to only HER2 directed treatment.  
• To assess changes in circulating biomarkers, including ctDNA, with pCR. 
• 
To develop patient-derived xenograph (PDX) models of HER2 positive inflammatory 
breast cancer in order to facilitate extensive research on this disease.  
 
2. BACKGROUND 
 

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2.1 
Study Disease(s) 
 
2.1.1 Inflammatory Breast Cancer 
 
Inflammatory breast cancer (IBC) accounts for 2-5% of all invasive breast cancer. IBC is 
classified as a “cliniopathologic” diagnosis, whereby documentation of invasive breast 
carcinoma is established in the setting of unique clinical characteristics including a rapid 
onset of breast enlargement, pain, diffuse erythema and edema (peau d’orange) usually 
occurring within 3-6 months.  The breast cancer often presents without a palpable mass, 
and dermal lymphatic involvement with cancer is demonstrated in approximately 75% of 
the cases.1 It is the effect of dermal lymphatic involvement, not infiltration of 
inflammatory cells that result in the clinical changes observed in IBC.  The median age at 
presentation is less than that seen in non-IBC, and there is a greater incidence of IBC 
among African American women. 2, 3 
 
The intrinsic biology of IBC is such that advanced disease is present at the time of 
diagnosis. Approximately 55-85% of patients present with metastasis to the axillary and / 
or supraclavicular lymph nodes, and distant metastatic disease is present at diagnosis in 
approximately 20-40% of women. 4  Even in the absence of metastatic disease at 
presentation, the likelihood of developing distant metastasis is extremely high, supporting 
a role for chemotherapy as the mainstay of treatment. Historically, surgery and radiation 
therapy alone resulted in a 54% relapse rate within 18 months, translating into a median 
survival of 1.2 years. 5 The addition of chemotherapy to the initial treatment of IBC, i.e. 
trimodality therapy, improved the median overall survival to 3.8 years, translating into an 
approximately 50% 5-year overall survival. 1 
 
The extent of locoregional disease precludes mastectomy as primary treatment for IBC, 
therefore preoperative chemotherapy has become the standard of care; however the 
optimal chemotherapy regimen has yet to be determined. Anthracycline-containing 
regimens employed preoperatively have resulted in 40-45% 5-year overall survival, 
whereas the addition of taxanes to these regimens improved the pathologic complete 
response rate and overall survival. 6-8 The current chemotherapy regimens utilized as pre-
operative treatment for IBC most commonly include anthracyclines and taxanes, yet the 
poor overall survival rates still necessitate ongoing investigation into improved pre-
operative regimens.  
 
High-throughput molecular technologies have identified five intrinsic molecular subtypes of 
breast cancer: luminal A, luminal B, HER2 positive, triple negative, and normal. 9 Molecular 
analysis of IBC demonstrates a tendency for this disease to segregate into the more 
proliferative intrinsic subtypes, i.e. triple negative (estrogen receptor (ER), progesterone 
receptor (PR) and HER2 negative) and HER2 positive. 10 Several studies have shown a 40-
50% incidence of HER2 positive disease among IBC, which is more than 2-fold greater than 
the incidence seen in non-IBC. 11, 12  The prevalence of HER2 positive disease among 
patients with IBC and the recent availability of effective agents targeting the HER2 domain 
support further investigation into the optimal preoperative regimen incorporating HER2 
targeting agents in the treatment of IBC.  

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2.1.2 HER2 and Breast Cancer 
 
Growth factors and their receptors play critical roles in development, cell growth, 
differentiation, and apoptosis.13  Such receptors span the cell membrane, with the 
extracellular domain binding specific growth factors and the intracellular domain 
transmitting growth signals. Interaction of the extracellular domain with its cognate 
ligand often results in intracellular activation of tyrosine kinase activity. Overexpression 
of human epidermal growth factor receptor 2 (HER2, also known as erbB2, neu, and 
p185HER2) is observed in approximately 25-30% of human breast cancers. 14  HER2 
overexpression has been reported to only rarely occur in the absence of gene 
amplification. 15,16  High level of HER2 expression has been correlated with poor clinical 
outcome. 14 
 
Several lines of evidence support a direct role for HER2 overexpression in the 
pathogenesis and poor clinical course of human tumors.17 When the mutated gene is 
transfected into murine fibroblast (NIH 3T3) cells, it causes transformation, and the 
resulting cells are tumorigenic in the nude mice. 18,19 Additionally, transgenic mice that 
overexpress the rodent homolog of the human HER2 gene develop breast cancer. 20 
Finally, specific antibodies to the extracellular domain of HER2 inhibit the experimental 
growth of tumors that overexpress the gene. 21,22 These data suggest a direct role for 
HER2 in both malignant transformation and enhanced tumorigenicity. Therefore a 
strategy to antagonize the abnormal function of overexpressed HER2 was developed to 
improve the course of patients with HER2-overexpressing tumors. Monoclonal antibodies 
directed against the HER2 protein were developed and humanized to minimize the 
likelihood of immunogenicity. One of these antibodies (trastuzumab) was very effective 
in inhibiting both in vitro and in vivo proliferation of human breast cancer tumor cells 
overexpressing the HER2 protein and in mediating antibody-dependent cellular 
cytotoxicity in the presence of human effector cells.23 
 
There is substantial preclinical evidence that inhibition of signal transduction pathways 
can potentiate the cytotoxic activity of chemotherapeutic drugs. Indeed, trastuzumab has 
been shown to have synergy, in vitro and in vivo, with several chemotherapeutic drugs 
including cisplatin, doxorubicin, thiotepa, etoposide, vinorelbine, and 
taxanes.24,25,26,27,28,29  Given this promising preclinical data, trastuzumab was tested in 
the clinic both as a single agent and in combination with chemotherapy. 
 
2.2 
Trastuzumab Clinical Experience 
 
2.2.1 Trastuzumab Clinical Experience in Metastatic Breast Cancer:  
 
The clinical benefit of trastuzumab in women with metastatic breast cancer has been 
demonstrated in two pivotal studies. A large Phase II trial (H0649g) assessed the activity 
of trastuzumab as a single agent in 222 women with HER2 overexpressing metastatic 
breast cancer with progressive disease after one or more chemotherapy regimens.30 A 
blinded, independent response evaluation committee identified 8 complete and 26 partial 

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responses, for an objective response rate of 15% in the intent-to-treat population (95% 
confidence interval, 11% to 21%). The median duration of response was 9.1 months, and 
the median duration of survival was 13 months. The most common adverse events, which 
occurred in approximately 40% of patients, were mild to moderate infusion-associated 
fever and/or chills. These symptoms usually occurred only during the first infusion. The 
most clinically significant event was cardiac dysfunction, which occurred in 4.7% of 
patients. 
 
A large, open-label, randomized Phase III study (H0648g) in 469 patients with HER2-
positive metastatic breast cancer was conducted to evaluate the efficacy of trastuzumab in 
combination with chemotherapy as first-line treatment. Patients who were anthracycline-
naïve were randomized to receive either anthracycline plus cyclophosphamide (AC) or 
trastuzumab plus AC. Patients who had received prior anthracyclines in the adjuvant 
setting were randomized to receive either paclitaxel or trastuzumab plus paclitaxel. 
Patients randomized to trastuzumab and chemotherapy measurably benefited in 
comparison to patients treated with chemotherapy alone in terms of time to disease 
progression, overall response rate, median duration of response, and survival. As 
determined by an independent Response Evaluation Committee (REC), trastuzumab 
prolonged median time to disease progression from 4.6 months to 7.4 months (p<0.001), 
improved the overall response rate (complete and partial responses) from 32% to 50% 
(p<0.001), and increased median duration of response from 6.1 to 9.1 months (p<0.001). 
Compared to chemotherapy alone, the addition of trastuzumab significantly lowered the 
incidence of death at one year from 33% to 22% (p=0.008) and increased median overall 
survival 24% from 20.3 months to 25.1 months (p=0.046). The observed survival 
advantage remained despite crossover of 66% of patients initially randomized to 
chemotherapy alone who elected to receive trastuzumab upon disease progression.31  
Fever/chills were observed with the initial trastuzumab infusion in approximately 25% of 
patients. Class III or IV cardiac dysfunction was observed in 16% of the trastuzumab + 
AC subgroup; increasing age was an associated risk factor for the development of 
cardiotoxicity in this treatment cohort.  
 
Based on these data, trastuzumab was approved by the U.S. Food and Drug 
Administration (FDA) for use in HER2-overexpressing metastatic breast cancer in 
combination with paclitaxel for first-line treatment and as a single agent for patients 
failing prior chemotherapy for metastatic disease. However, current usage patterns of 
trastuzumab indicate that the drug is now being used in a broader array of circumstances 
that in the pivotal clinical trials.  
 
2.2.2 Trastuzumab Clinical Experience in Adjuvant Breast Cancer 
 
Four large, randomized, phase III trials showed significant reduction in risk of disease 
recurrence with the addition of 1 year of trastuzumab to adjuvant therapy in patients with 
HER2-positive, early breast cancer. The 3-year planned joint interim analysis of the 
National Surgical Adjuvant Breast and Bowel Project (NSABP B-31) and the North 
Central Cancer Treatment Group (NCCTG N-9831) trials demonstrated significant 
improvements in disease-free survival (DFS) (hazard ratio [HR] 0.48, p<0.0001) and 

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overall survival (OS) (HR 0.67, p=0.015) when 1-year of trastuzumab is added to 
adjuvant chemotherapy in patients with HER2-positive breast cancer.32  At the 4-year 
follow-up, DFS and OS results were consistent.33  In HERA (trastuzumab adjuvant), 
single agent trastuzumab after adjuvant chemotherapy demonstrated significant 
improvements in DFS (HR 0.64, p<0.0001) and OS (HR 0.66, p=0.0115) compared with 
observation alone at a median follow-up of 23.5 months.34  At a median follow-up of 48.4 
months, a DFS benefit was observed (HR 0.66, p=0.0115) with 1 year of trastuzumab, 
however, the OS benefit was not statistically significant at 4 years (HR 0.85, p=0.11). At 
the time of analysis, over 50% of patients in the observation arm had crossed-over to 
receive trastuzumab.35 The third protocol-specified analysis of the Breast Cancer 
International Research Group (BCIRG) 006 study continued to show that the addition of 
52 weeks of trastuzumab to docetaxel-based adjuvant regimens significantly improved 
DFS. At a median follow-up of 65 months, 5-year DFS rates were 84% (HR 0.64, 
p<0.001) and 81% (HR 0.75, p=0.04) in the doxorubicin-containing trastuzumab and 
non-anthracycline-containing trastuzumab arms, respectively.36 
 
2.3 
Pertuzumab Clinical Experience 
 
Pertuzumab, a humanized monoclonal antibody to the HER2 receptor, represents a promising 
new anti-HER2 agent with a novel mechanism of action targeting inhibition of HER2 
dimerization. Nonclinical and clinical data to date indicate that pertuzumab provides a broader 
HER2 blockade through inhibition of HER2 heterodimerization. Pertuzumab has been shown in 
preclinical experiments to have superior anti-tumor effects when combined with other anti-HER2 
treatments such as trastuzumab than when used as monotherapy. 
 
Trastuzumab and pertuzumab monoclonal antibodies bind to distinct epitopes on the HER2 
receptor without competing with each other, resulting in distinctive mechanisms for disrupting 
HER2 signaling. These mechanisms are complementary and result in augmented therapeutic 
efficacy when pertuzumab and trastuzumab are given in combination. 
 
Preclinical data indicate at least additive efficacy when the two agents are administered together, 
resulting in significantly reduced tumor volume compared with either agent alone. Clinically, 
pertuzumab may have optimal therapeutic effects when given in combination with trastuzumab 
to patients with HER2-positive cancers, evidenced by data generated in a Phase II study of 
patients with previously treated HER2-positive MBC.37 A recently published meta-analysis of 
pertuzumab phase II trials concluded that pertuzumab has a low cardiac risk and there is no 
notable increase in cardiac events when pertuzumab is used in combination with other anticancer 
agents.38  
 
2.4 
Trastuzumab and Pertuzumab Combination Therapy in Patients with HER2-
positive Metastatic Breast Cancer 
 
In the Phase III, pivotal study WO20698/TOC4129g (CLEOPATRA; N=808) in patients with 
previously-untreated HER2-positive MBC, a statistically significant and clinically meaningful 
improvement in progression-free survival (PFS) was observed in patients treated with 

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pertuzumab, trastuzumab and docetaxel (N=406) compared to those receiving placebo, 
trastuzumab and docetaxel (N=402). PFS was prolonged at the median by 6.1 months and the 
risk of disease progression or death was reduced by 38% (Hazard ratio [HR] = 0.62; 95% CI = 
0.51, 0.75; p < 0.0001) with an improvement in median PFS from 12.4 months to 18.5 months.39  
In a Phase II, single-arm study (BO17929; N= 66) in patients with previously-treated HER2-
positive MBC, four complete responses and 12 partial responses (24% objective response rate) 
were observed following combined treatment with pertuzumab and trastuzumab.37 
 
2.5 
Trastuzumab and Pertuzumab Safety 
 
2.5.1 Trastuzumab Safety 
 
Experience with trastuzumab administration has shown that the drug is relatively safe. 
The most significant safety signal observed during clinical trials was cardiac dysfunction 
(principally clinically significant heart failure (CHF), particularly when trastuzumab was 
given in combination with an anthracycline-containing regimen. Much of the cardiac 
dysfunction was reversible on discontinuation of trastuzumab.  
 
In addition, during the first infusion with trastuzumab, a symptom complex most 
commonly consisting of fever and/or chills was observed in approximately 40% of 
patients. The symptoms were usually mild to moderate in severity and controlled with 
acetaminophen, diphenhydramine, or meperidine. These symptoms were uncommon with 
subsequent infusions. However, in the postapproval setting, more severe adverse 
reactions to trastuzumab have been reported. These have been categorized as 
hypersensitivity reactions (including anaphylaxis), infusion reactions, and pulmonary 
events. Rarely, these severe reactions culminated in a fatal outcome. 
 
Trastuzumab appears to be relatively nonimmunogenic. Only 1 of 903 patients evaluated 
developed neutralizing antibodies to trastuzumab. The development of anti-trastuzumab 
antibodies in this patient was not associated with clinical signs or symptoms.  
 
2.5.2 Pertuzumab Safety 
 
As of 7 November 2011, 1757 patients with cancer have been treated with pertuzumab in 
all company-sponsored pertuzumab trials, and an additional 114 patients have received 
pertuzumab in combination studies with trastuzumab emtansine. Overall, data indicate 
that pertuzumab is well-tolerated as monotherapy and that it can be given in combination 
with trastuzumab and a range of other therapeutic agents with manageable additional 
toxicity. No new or unexpected toxicities were encountered other than those that are 
known for agents that target the HER family of receptors. Serious or severe infusion-
associated symptoms have been rarely observed in patients receiving pertuzumab. A low 
level of cardiac toxicities, predominantly asymptomatic declines in left ventricular 
ejection fraction (LVEF), has been reported. In the pivotal Phase III trial 
WO20698/TOC4129g the rates of symptomatic and asymptomatic left ventricular 
systolic dysfunction (LVSD) were not higher in patients receiving pertuzumab, 
trastuzumab and docetaxel than in those receiving placebo, trastuzumab and docetaxel. 

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No fetal studies in humans have been performed but pertuzumab caused 
oligohydramnios, delayed renal development and embryo-fetal deaths in pregnant 
cynomolgus monkeys. Moreover, in the post-marketing setting, cases of 
oligohydramnios, some associated with fatal pulmonary hypoplasia of the fetus, have 
been reported in pregnant women receiving trastuzumab (for further details, see 
trastuzumab prescribing information). Therefore, pertuzumab should not be used in 
pregnant women. Protocols for ongoing pertuzumab studies indicate that highly effective 
contraceptive measures must be used; continuous pregnancy monitoring must be 
performed during the trials and for seven months after the last dose of study drug is 
administered. Because of the long half-life of pertuzumab women should be warned not 
to become pregnant for at least seven months after completion of treatment. 
 
2.6 
Rationale for the Use of Pertuzumab and Trastuzumab in IBC 
 
The goal of neoadjuvant or preoperative systemic therapy for breast cancer is to render 
inoperable disease operable without compromising overall survival. In addition, the pathologic 
response, i.e. residual carcinoma in the breast and/or lymph nodes, often correlates with the 
disease prognosis. 40 Patients with IBC treated with neoadjuvant therapy also have a more 
favorable outcome when a complete pathologic response (pCR) is achieved. 41 Therefore, pCR is 
often used as a primary outcome in clinical trials investigating novel neoadjuvant therapy, 
because it is an acceptable surrogate marker for disease-free survival (DFS) and overall survival 
(OS).  
 
The majority of studies evaluating the efficacy of trastuzumab added to neoadjuvant 
chemotherapy include other subtypes of breast cancer in addition to, or excluding IBC. The 
NOAH (NeOAdjuvant Herceptin) study included 63 patients with HER2 positive IBC and found 
that the addition of trastuzumab to neoadjuvant chemotherapy resulted in a54.8% pathologic 
complete response (pCR) rate compared with chemotherapy alone (pCR = 19.3%), which 
translated into a HR = 0.27 for event-free survival. 42, 43 
 
Combination pertuzumab, trastuzumab and chemotherapy were investigated neoadjuvantly in the 
NeoSphere trial. 44 This study also included patients with IBC, though only 29 among 417 
patients carried this diagnosis. The NeoSphere trial compared the pCR rate among four groups of 
patients receiving neoadjuvant treatment:  trastuzumab and docetaxel vs. pertuzumab, 
trastuzumab and docetaxel vs. pertuzumab and trastuzumab vs. pertuzumab and docetaxel. The 
combination arm including pertuzumab, trastuzumab and docetaxel achieved the highest pCR 
rate of 39.9%. This favorable response suggests that combination HER2 targeting therapy using 
pertuzumab and trastuzumab with chemotherapy should be investigated as neoadjuvant treatment 
for with IBC.  
 
2.7 
Correlative Studies Background 
 
2.7.1 Gene Expression Microarrays 
 
The efficacy of trastuzumab and pertuzumab is dependent upon HER2 over-expression, 

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which clinically can be detected by immunohistochemistry (IHC) or fluorescence in situ 
hybridization (FISH) on breast cancer tissue. However, documentation of HER2 positive 
disease is not always associated with a clinical response to HER2-targeted therapy, either 
due to the development of resistance pathways or because of imprecision in the 
determination of true HER2-driven disease. More specific techniques of molecular 
profiling have been able to determine subtle changes in gene expression which may 
impact the selection of appropriate patients to receive specific targeted therapy, such as 
trastuzumab and pertuzumab. 
 
DNA microarray analysis using a 50-gene assay (Prediction Analysis of Microarray or 
PAM-50) found that IHC or FISH assessment of HER2 status does not provide as 
complete a classification of the HER2 enriched intrinsic subtype. 45In fact, a significant 
proportion of HER2-positive breast cancers determined by clinical methods are not 
classified within the HER2-enriched intrinsic subtype, and this may have implications 
overall tumor response to neoadjuvant therapy and on choosing the most efficacious 
chemotherapy regimen to combine with trastuzumab. 46, 47 To build on these principles, 
next-generation sequencing technology will be able to explore a larger array of gene 
expression which may offer more insight into disease response of HER2 positive IBC.  
 
Both de novo and acquired mechanisms of resistance to HER2-directed therapies result in 
disease recurrence or progression. There are many mechanisms of resistance postulated to 
exist including the presence of truncated p95HER2 fragments, changes in downstream 
signaling pathways including loss of PTEN function and mutations in PI3KCA, and the 
activation of other signaling pathways including IGR1R and HER3 signaling pathways. 
48,49, 50, 51 Investigating the development of these compensatory mechanisms of resistance 
will allow further exploration into optimizing therapeutic interventions and provide a 
greater understanding of the utilizing multiple agents simultaneously to target HER2.  
 
The setting of pre-operative therapy provides an optimal opportunity to use expression 
profiling and examine mechanisms of drug resistance.  Initially, tumors have not been 
exposed to extensive therapies, thus avoiding resultant additional genetic changes.  The 
endpoints are readily measurable, are reached in a short time frame, and are clinically 
relevant (complete and partial response, measured clinically, radiographically, or 
pathologically). 52 Sequential analysis of tumor tissue allow for comparison of signal 
pathway activation and induction of resistance mechanisms. The application of this 
translational research to IBC is much needed and the information gained will extend to 
non-inflammatory breast cancer.  
 
2.7.2 Circulating Biomarkers 
 
In order to develop and test novel therapeutic agents for inflammatory breast cancer, 
better model systems that faithfully recapitulate the human disease at the molecular and 
cellular level are needed. In the past we have developed new breast cancer cell lines from 
biopsy specimens, and these cells lines are being used all over the world to study breast 
cancer biology. To develop even better models of breast cancer that are free from cell 
culture artifacts, we would now like to develop patient-derived xenograft (PDX) models 

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by transplanting small pieces of breast cancer tissue orthotopically into the gonadal fat 
pads of immunodeficient, hormone supplemented mice (e.g., NOD scid gamma (NSG) 
mice).55-60 This methodology permits development of a renewable resource which retains 
the morphology and molecular profile of each original patient tumor. These models will 
therefore be useful tools for studies of breast cancer genetics, cell biology, and 
experimental therapeutics. Importantly, once tumors develop in the primary hosts, these 
tumors can be serially transplanted over many generations.  
 
In addition to developing new techniques to analyze tumor tissues, it has become 
increasingly recognized that mutations that are present in the tumor can be detected in 
circulating cell-free tumor DNA (ctDNA).61-63 More than 90% of patients with metastatic 
breast cancer have detectable ctDNA. Serial assessment of ctDNA via detection of these 
mutations may be useful for monitoring of patients for disease recurrence or 
progression.61-63  The majority of studies published thus far are from the metastatic 
setting. Few studies have been reported examining the use of ctDNA in patients with 
early stage breast cancer, and most of those have been conducted in patients with intact 
disease who are receiving primary systemic therapy. In one study, 29 patients had ctDNA 
isolated from before and after surgery.64 Fifteen had PIK3CA mutations identified in pre-
surgery ctDNA, and 14 of the 15 had the corresponding mutation in the surgical sample. 
Ten of the 15 had post-surgical blood samples collected, of which 5 (50%) still had 
detectable PIK3CA mutations. 
 
3. PARTICIPANT SELECTION 
 
3.1 
Inclusion Criteria 
 
Participants must meet the following criteria on screening examination to be eligible to 
participate in the study. 
 
3.1.1 Participants must have histologically confirmed invasive breast cancer. All 
histologic subtypes are eligible.  
 
3.1.2 HER2-positive breast cancer, defined by ASCO CAP 2013 guidelines 
• IHC 3+ based on circumferential membrane staining that is complete, intense  
 
-AND/OR-  
 
• FISH positive based on one of the following three criteria:  
o Single-probe average HER2 copy number ≥ 6.0 signals/cell OR 
o Dual-probe HER2/CEP17 ratio < 2.0 with an average HER2 copy number ≥ 
6.0signals/cell; OR  
o Dual-probe HER2/CEP17 ratio ≥ 2.0  
 

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3.1.3 Patients must have the clinical diagnosis of inflammatory breast cancer as evidenced 
by the onset of all signs and symptoms noted below within a 6 month time-period: 
 
• Erythema of the breast  
• Edema of the skin of the breast 
• Enlargement of the breast 
 
3.1.4 Patients must be without visceral or bone involvement with metastatic breast cancer 
on physical exam or any diagnostic study. Patients with extensive nodal involvement 
classified as Stage IV disease, are eligible.  
 
3.1.5 Age ≥ 18 years. Because no dosing or adverse event data are currently available on 
the use of trastuzumab and pertuzumab in participants <18 years of age. 
 
3.1.6 ECOG performance status 0 or 1. 
 
3.1.7 The effects of pertuzumab on the developing human fetus are unknown. For this 
reason and because these agents are known to be teratogenic, women of child-
bearing potential and men must agree to use adequate contraception (hormonal or 
barrier method of birth control; abstinence) prior to study entry and for the duration 
of study participation and for at least 7 months after the last dose of study treatment. 
Should a woman become pregnant or suspect she is pregnant while participating in 
this study, she should inform her treating physician immediately. 
 
3.1.8 Willingness to undergo a research biopsy of the effected breast.  
 
• Biopsies may be done with local anesthesia or intravenous conscious sedation, 
according to standard institutional guidelines.   
• If a biopsy requires general anesthesia, then it is not allowed on this protocol. 
• Patients who undergo a research biopsy procedure for the purpose of this protocol, 
and in whom inadequate tissue is obtained, are still eligible and are not required to 
undergo a repeat biopsy in order to enter the study. 
• Some patients may have had a clinically indicated biopsy upon recent disease 
progression and agreed to submit tissue to their institution’s frozen tumor bank.  If the 
tissue was processed as specified in this protocol, no additional pre-treatment biopsy 
is required as that specimen can be used for the purposes of participation in this 
clinical trial. 
 
3.1.9 Prior Therapy for the treatment of breast cancer is not allowed. 
 
3.1.10 Participants must have normal organ and marrow function as defined below: 
 
• Leukocytes > 3,000/mcL 
• Absolute neutrophil count > 1,500/mcL 

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• Platelets > 100,000/mcL 
• total bilirubin within normal institutional limits 
• AST (SGOT)/ALT (SGPT) < 2.5 X institutional upper limit of normal 
• Adequate renal function, as indicated by creatinine ≤1.5× upper limit of normal 
(institutional ULN). 
 
3.1.11 Cardiac ejection fraction, as assessed by either MUGA scan or echocardiogram, 
greater than or equal to 50%, within 28 days prior to registration. 
 
3.1.12 Ability to understand and the willingness to sign a written informed consent 
document. 
 
3.2 
Exclusion Criteria 
 
Participants who exhibit any of the following conditions at screening will not be eligible for 
admission into the study. 
 
3.2.1 Participants may not be receiving any other investigational or commercial agents or 
therapies other than those described in this protocol to treat their malignancy. 
 
3.2.2 Participants with known brain metastases should be excluded from this clinical trial 
because of their poor prognosis and because they often develop progressive 
neurologic dysfunction that would confound the evaluation of neurologic and other 
adverse events. 
 
3.2.3 Symptomatic intrinsic lung disease or extensive tumor involvement of the lungs, 
resulting in dyspnea at rest.  
 
3.2.4 History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to paclitaxel, trastuzumab, pertuzumab. Patients with minor (grade 1 or 
2) allergic reactions to these agents, controlled with standard supportive measures, 
are eligible. 
 
3.2.5  Uncontrolled intercurrent illness including, but not limited to ongoing or active 
infection, symptomatic congestive heart failure, unstable angina pectoris, 
cardiac arrhythmia, or psychiatric illness/social situations that would limit 
compliance with study requirements. 
 
3.2.6 Pregnant women are excluded from this study because paclitaxel, trastuzumab, and 
pertuzumab have the potential for teratogenic or abortifacient effects. Because there 
is an unknown but potential risk of adverse events in nursing infants secondary to 
treatment of the mother with these agents, breastfeeding should be discontinued if 
the mother is treated on study. These potential risks may also apply to other agents 
used in this study. 
 

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3.2.7 Individuals with a history of a different malignancy are ineligible except for the 
following circumstances. Individuals with a history of other malignancies are 
eligible if they have been disease-free for at least 5 years and are deemed by the 
investigator to be at low risk for recurrence of that malignancy. Individuals with the 
following cancers are eligible if diagnosed and treated within the past 5 years: 
cervical cancer in situ, and basal cell or squamous cell carcinoma of the skin. 
 
3.2.8 HIV-positive individuals on combination antiretroviral therapy are eligible so 
long as they meet all other criteria. HIV-positive individuals who are not on 
combination antiretroviral therapy are not eligible because these individuals are at 
increased risk of lethal infections when treated with marrow-suppressive therapy. 
Appropriate studies will be undertaken in participants receiving combination 
antiretroviral therapy when indicated. 
 
3.2.9 Patients with metastatic disease involving viscera or bones are ineligible. Patients 
with extensive nodal involvement alone classified as Stage IV disease, are eligible.  
 
3.3 
Inclusion of Women and Minorities 
 
Both men and women of all races and ethnic groups are eligible for this trial. 
 
4. REGISTRATION PROCEDURES 
 
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions 
 
Institutions will register eligible participants in the Clinical Trials Management System (CTMS) 
OnCore. Registrations must occur prior to the initiation of protocol therapy. Any participant not 
registered to the protocol before protocol therapy begins will be considered ineligible and 
registration will be denied. 
 
An investigator will confirm eligibility criteria and a member of the study team will complete the 
protocol-specific eligibility checklist. 
 
Following registration, participants may begin protocol therapy. Issues that would cause 
treatment delays should be discussed with the Overall Principal Investigator (PI). If a participant 
does not receive protocol therapy following registration, the participant’s registration on the 
study must be canceled. Registration cancellations must be made in OnCore as soon as possible. 
 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions 
 
DF/HCC Standard Operating Procedure for Human Subject Research Titled Subject Protocol 
Registration (SOP #: REGIST-101) must be followed.   
 
4.3 
General Guidelines for Other Investigative Sites 
 
Eligible participants will be entered on study centrally at the DFCI Coordinating Center by the 

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21 
Project Managers.  Following registration, participants should begin protocol therapy within 5 
business days. Issues that would cause treatment delays should be discussed with the Overall PI.  
If a participant does not receive protocol therapy following registration, the participant’s 
registration on the study must be canceled.  The Project Managers should be notified of 
cancellations as soon as possible. 
 
4.4 
Registration Process for Other Investigative Sites 
 
To register a participant, the following documents should be completed by the research nurse or 
data manager and faxed (617-632-5152) or e-mailed (ctopm@dfci.harvard.edu) to the Project 
Manager: 
• Signed participant consent form 
• HIPAA Authorization form (if separate from the informed consent document) 
• Eligibility Checklist 
• Clinic visit note documenting consent process, history, and physical exam documenting 
criteria for diagnosis of inflammatory breast cancer 
• Copy of required laboratory test including: Hematology (CBC with differential), Serum 
Chemistries (Sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose, total 
protein, albumin, total bilirubin, SGOT (AST), SGPT (ALT), and Alkaline Phosphatase, 
pregnancy test (for women of child-bearing potential only), PR/INR/PTT. 
• Breast MRI and Mammogram or Breast Ultrasound 
• PET/CT, CT of Chest/Abdomen/Pelvis 
• MUGA or Echocardiogram 
• EKG 
• Pathology report and documentation of HER2+ status 
 
To complete the registration process, the Project Manager will follow DF/HCC Standard 
Operating Procedure for Human Subject Research Titled Subject Protocol Registration (SOP #: 
REGIST-101) and register the participant on the protocol.  The project manager will fax or e-
mail the participant study number, and if applicable the dose treatment level, to the participating 
site.   
 
NOTE: Registration and randomization can only be conducted during the business hours 
of 8:00 AM and 5:00 PM Eastern Standard Time Monday through Friday. Same day 
treatment registrations will only be accepted with prior notice and discussion with the DF/HCC 
Lead Institution.  
 
5. TREATMENT PLAN 
 
5.1 
Treatment Regimen 
 
During the pre-operative treatment phase, trastuzumab will be administered weekly, pertuzumab 
will be administered every 3 weeks, and paclitaxel will be administered weekly.  Every 3 weeks 
with 21 consecutive days will defined as the pre-operative treatment cycle. Pertuzumab and 
trastuzumab will begin on Cycle 1 Day 1 (also known as Week 1). Beginning on Cycle 1 Day 8 

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(Week 2), paclitaxel will be given weekly for a total of 16 weekly doses.  Pre-operative treatment 
will conclude with the initiation of surgery..  Treatment will be administered on an outpatient 
basis.   
 
Following the pre-operative treatment phase, patients will move on to surgery.  After surgery, 
there are two options for further treatment.  In option 1, doxorubicin and cyclophosphamide will 
be given every two or three weeks with every two weeks (14 consecutive days) or three weeks 
(21 consecutive days) defined as this part of the post-operative treatment cycle.  Doxorubicin and 
cyclophosphamide will conclude after 4 cycles, at which time trastuzumab and pertuzumab will 
be administered every three weeks (21 consecutive days) to complete 12 months of treatment 
with trastuzumab and pertuzumab (12 months = total of 18 doses of pertuzumab).  Treatment 
will be administered on an outpatient basis.   
 
In option 2 of post-operative treatment, trastuzumab and pertuzumab will be administered every 
three weeks (21 consecutive days) to complete 12 months of treatment (12 months = total of 18 
doses of pertuzumab).  Treatment will be administered on an outpatient basis.   
 
Minor schedule changes due to observed holidays, inclement weather, etc. are permitted. Patients 
may interrupt therapy for protocol-directed reasons (i.e. toxicity) or for personal preferences 
(holidays, vacations, etc).  Treatment should resume according to protocol guidelines and the 
Study Flowchart found in Section 10.   
 
Refer to Section 5.3 for detailed administration instructions.  Reported adverse events and 
potential risks are described in Section 7.  Appropriate dose modifications are described in 
Section 6.  No investigational or commercial agents or therapies other than those described 
below may be administered with the intent to treat the participant's malignancy.  
 
Pre-Operative Treatment Phase 
Agent 
Premedications; 
Precautions 
Dose 
Route 
Schedule 
Cycle 
Length 
Trastuzumab 
No premedication is 
necessary.  
2 mg/kg 
 
(4 mg/kg loading 
dose) 
IV 
Weekly 
21 days 
(3 weeks) 
Pertuzumab 
No premedication is 
necessary. 
420 mg 
 
(840 mg loading 
dose) 
IV 
Every 3 
weeks 
Paclitaxel 
Dexamethasone 10 
mg po or IV; 
diphenhydramine 
12.5-50 mg po or IV; 
famotidine 20 mg 
IV; all agents 
administered per 
institutional 
guidelines 
80  mg/m2  
IV 
Begin on 
week 2, 
Weekly x 16 
 

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Post-Operative Treatment Phase (Option 1) 
Agent 
Premedications; 
Precautions 
Dose 
Route 
Schedule 
Cycle 
Length 
Doxorubicin 
No premedication is 
necessary. 
60 mg/m2 
 
IV push 
Every 2-3 
weeks x 4 
14-21 
days 
(2-3 
weeks) 
Cyclophospha
mide 
No premedication is 
necessary. 
600  mg/m2 
 
IV 
Every 2-3 
weeks x 4 
Trastuzumab 
No premedication is 
necessary.  
6 mg/kg 
 
(8 mg/kg loading 
dose) 
IV 
Every 3 
weeks to 
complete 12 
months total  
21 days  
(3 weeks) 
Pertuzumab 
No premedication is 
necessary. 
420 mg 
 
(840 mg loading 
dose) 
IV 
Every 3 
weeks to 
complete 12 
months total 
 
Post-Operative Treatment Phase (Option 2) 
Agent 
Premedications; 
Precautions 
Dose 
Route 
Schedule 
Cycle 
Length 
Trastuzumab 
No premedication is 
necessary.  
6 mg/kg 
 
(no loading dose 
required; 8mg/kg 
dose if reloading) 
IV 
Every 3 
weeks to 
complete 12 
months total  
21 days  
(3 weeks) 
Pertuzumab 
No premedication is 
necessary. 
420 mg 
 
(no loading dose 
required; 840mg 
dose if re-loading) 
IV 
Every 3 
weeks to 
complete 12 
months total 
 
5.2 
Pre-Treatment Criteria 
 
5.2.1 Run-In Phase, Cycle 1 Day 1 (Week 1) 
 
During the run-in phase, prior to administration with pertuzumab and trastuzumab on 
Cycle 1 Day 1 (Week 1), the following parameters must be met:  
 
• ANC ≥1,000/μl 
• Platelet count ≥100,000/μl 
• Bilirubin ≤ 1.5 x institutional ULN 
• ALT and AST < 2.5 X institutional ULN 
• Serum β-HCG Negative (in female patients unless S/P hysterectomy or menopausal 
or no menses for 24 consecutive months). 
• LVEF > 50%. 
 

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5.2.2 Preoperative Treatment Phase, Week 2, Day 8 and then weekly x 16 doses 
 
During the pre-operative treatment phase starting on Cycle 1 Day 8 (Week 2), and then 
weekly for a total of 16 additional weeks, the following parameters must be met prior to 
administration with paclitaxel: 
  
• ANC ≥1,000/μl 
• Platelet count ≥100,000/μl 
• Bilirubin ≤ 1.5 x institutional ULN 
• ALT and AST < 2.5 X institutional ULN 
 
NOTE: pertuzumab and trastuzumab do not require specific laboratory criteria for 
administration. 
 
5.2.3 Post-operative, Day 1 of Every Doxorubicin/Cyclophosphamide Cycle 
 
During the post-operative treatment phase with doxorubicin and cyclophosphamide, the 
following parameters must be met on day 1 of every cycle:  
 
• ANC ≥1,000/μl 
• Platelet count ≥100,000/μl 
• Bilirubin ≤ 1.5 x institutional ULN 
• ALT and AST < 2.5 X institutional ULN 
• LVEF > 50% - only assessed prior to cycle 1.  
 
5.2.4 Subsequent Cycles of Post-operative Trastuzumab/Pertuzumab 
 
The following parameters apply to both option 1 and option 2 post-operative treatments.  
• No laboratory criteria apply. 
• See Appendix A for LVEF criteria 
 
5.3 
Treatment Administration 
 
5.3.1 Trastuzumab During Pre-Operative Phase 
Trastuzumab is administered on Cycle 1 Day 1 (Week 1) at a loading dose of 4 mg/kg IV 
per institutional guidelines.  Following the initial infusion, subsequent trastuzumab 
infusions will be administered at 2 mg/kg IV per institutional guidelines weekly (+/- 2 
days) during the 16 doses of paclitaxel until the patient’s surgery. Post-infusion 
observation times will be per institutional guidelines.  On days when pertuzumab or 
paclitaxel are also administered, trastuzumab will be administered first or per institutional 
guidelines.   
Following the completion of trastuzumab and paclitaxel 16 concurrent doses, additional 
trastuzumab may be administered at a dose of 6 mg/kg IV every 3 weeks (+/- 1 week) 

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along with pertuzumab until surgery based upon physician discretion. Three weekly 
doses of trastuzumab must be completed prior to starting the every 3 week dose of 
trastuzumab and pertuzumab. 
Dosing should be made based on institutional guidelines. Trastuzumab reactions will be 
managed per institutional guidelines.  Additional management guidelines can be found in 
Section 6.1.  
 
5.3.2 Pertuzumab During Pre-Operative Phase 
 
Pertuzumab is administered on Cycle 1 Day 1 (Week 1) at a loading dose of 840 mg IV 
Infusion time and post-infusion observation period are per institutional guidelines. 
Subsequent doses will be administered at 420 mg IV every 3 weeks (+/- 2 days) with an 
observation period per institutional guidelines until surgery. If the first dose of 
pertuzumab was well tolerated, post-infusion observation times may be discontinued as 
per institutional guidelines.  On days when trastuzumab or paclitaxel are also 
administered, pertuzumab will be administered following the completion of trastuzumab 
through a separate administration set.  Pertuzumab will be administered prior to 
paclitaxel administration or per institutional guidelines.   
 
Dosing should be made based on institutional guidelines. Pertuzumab reactions will be 
managed per institutional guidelines. Additional management guidelines can be found in 
Section 6.1. 
 
5.3.3 Paclitaxel During the Pre-Operative Phase  
 
Beginning on Cycle 1 Day 8 (Week 2), paclitaxel is administered at a dose of 80 mg/m2 
IV weekly (+/- 2 days) per institutional guidelines for a total of 16 doses.  Missed doses 
should be made up to equal 16 doses.  Paclitaxel is administered following the 
completion of trastuzumab and pertuzumab administrations or per institutional 
guidelines. Premedications should be administered per institutional guidelines prior to 
paclitaxel and may include:  
• dexamethasone 10 mg po or IV 
- 
If treatment is tolerated through completion of the first 2 cycles, Dexamethasone 
may be decreased or discontinued. 
• diphenhydramine 12.5-50 mg PO or IV 
• famotidine 20 mg IV 
 
If the patient does not experience an allergic reaction, the premedication regimen may be 
altered at the discretion of the treating physician.  Anaphylaxis precautions should be 
observed during paclitaxel infusion.  Paclitaxel reactions will be managed per 
institutional guidelines. Additional management guidelines can be found in Sections 6.2 
and 6.3. 
 

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Dosing should be made based on institutional guidelines. 
 
If discontinuation of paclitaxel is required or requested, patients should be assessed for 
eligibility for mastectomy.  If they are deemed surgical candidates, then they should 
proceed to mastectomy and continue on treatment as per protocol. 
 
5.3.4 Surgery 
 
Prior to surgery, patients should be assessed for clinical response to preoperative 
treatment by physical examination and imaging of the breasts (MRI, mammogram, and 
ultrasound if indicated).  Primary breast surgery should be performed within 4 - 5 weeks 
after the last dose of paclitaxel combined with trastuzumab.  Surgery must be performed 
at one of the participating institutions.  Patients should undergo surgery with a total 
mastectomy; removal of the breast and level 1 and 2 axillary lymph node dissection.  
Pathological specimens will be analyzed for tumor extent and grade, ER and PR status, 
HER2 expression, and other markers of tumor biology.  Given the high risk of local 
regional disease recurrence with IBC, reconstruction surgery is to be delayed for at least 
6 months following the completion of radiation therapy.  
 
5.3.5 Post-operative Option #1: Doxorubicin and Cyclophosphamide followed by 
Trastuzumab and Pertuzumab 
 
Starting within 4-5 weeks following surgery, doxorubicin and cyclophosphamide is 
administered every two or three weeks for a total of 4 doses.  Doxorubicin is 
administered at a dose of 60 mg/m2 IV over approximately 3-5 minutes (or per 
institutional guidelines) every 14-21 days (+/- 2 days) for 4 cycles. Doxorubicin is 
administered prior to cyclophosphamide. Cyclophosphamide is administered at a dose of 
600 mg/m2 IV infusion over approximately 30 minutes (or per institutional guidelines) 
every 14-21 days (+/- 2 days) x 4 cycles. Cyclophosphamide is administered after 
doxorubicin.  
 
Dosing for doxorubicin and cyclophosphamide should be per institutional guidelines. 
Patients should not receive doxorubicin/cyclophosphamide treatment any sooner than 14 
days from administration of Neulasta (if applicable). Patients who need to discontinue 
doxorubicin or cyclophosphamide because of toxicity, can start radiation with 
trastuzumab and pertuzumab as outlined in the protocol. Reactions should be managed 
per institutional guidelines. Additional management guidelines can be found in Section 
6.3. 
 
Beginning 3-4 weeks following the completion of doxorubicin and cyclophosphamide 
administration (post-operative Option #1), trastuzumab and pertuzumab maintenance 
therapy will be administered every 3 weeks to complete 12 months of HER2-directed 
therapy (i.e., patients will typically complete around 8 months of HER2-directed therapy 
during the post-operative phase since they will have completed around 4 months in the 

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27 
pre-operative phase; 12 months = 18 doses of pertuzumab). Trastuzumab will be 
administered prior to pertuzumab or as per institutional guidelines.   
 
Trastuzumab is administered at a loading dose of 8 mg/kg IV per institutional guidelines 
for the first infusion.  Subsequent trastuzumab infusions are given at a dose of 6 mg/kg 
IV every 3 weeks (+/- 1 week) per institutional guidelines. Post-infusion observation 
times for trastuzumab will be per institutional guidelines.  Pertuzumab is administered at 
a loading dose of 840 mg IV with infusion timing and  post-infusion observation period 
per institutional guidelines.  Subsequent pertuzumab infusions may be given at 420 mg 
IV per institutional guidelines every 3 weeks (+/- 1 week). If the first dose of pertuzumab 
was well tolerated, post-infusion observation times may be discontinued as per 
institutional guidelines.   
 
Reactions to maintenance therapy will be managed per institutional guidelines.  
Additional management guidelines can be found in Section 6.1. 
 
Cardiac evaluation by MUGA or echocardiogram is to be completed within 1 week prior 
to initiating trastuzumab and pertuzumab maintenance therapy and again every 12 weeks 
(+/- 1 week) until maintenance therapy is completed.  
 
5.3.6 Post-operative Option #2: Trastuzumab and Pertuzumab 
 
Starting within 4-5 weeks following surgery, trastuzumab and pertuzumab maintenance 
therapy will be administered every 3 weeks (+/- 1 week) to complete 12 months of 
HER2-directed therapy (i.e., patients will typically complete around 8 months of HER2-
directed therapy during the post-operative phase since they will have completed around 4 
months in the pre-operative phase; 12 months = 18 doses of pertuzumab).   
 
There are no loading doses required for trastuzumab or pertuzumab when begun as the 
first treatment after surgery, however, patients can be re-loaded with pertuzumab and 
trastuzumab at physician discretion or per institutional guidelines. Trastuzumab is 
administered at a dose of 6 mg/kg IV every 3 weeks (+/- 1 week) with observation 
periods per institutional guidelines.  Pertuzumab is administered at a dose of 420 mg IV 
every 3 weeks (+/- 1 week) with an observation period per institutional guidelines. If the 
first dose of pertuzumab was well tolerated, post-infusion observation times may be 
discontinued as per institutional guidelines.   
 
If re-loading, trastuzumab is administered at a loading dose of 8 mg/kg IV per 
institutional guidelines for the first infusion. Subsequent trastuzumab infusions are given 
at a dose of 6 mg/kg IV every 3 weeks (+/- 1 week) per institutional guidelines. Post-
infusion observation times for trastuzumab will be per institutional guidelines.  
Pertuzumab is administered at a loading dose of 840 mg IV with infusion timing and  
post-infusion observation period per institutional guidelines.  Subsequent pertuzumab 
infusions may be given at 420 mg IV per institutional guidelines every 3 weeks (+/- 1 
week). 
 

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Reactions to maintenance therapy will be managed per institutional guidelines.  
Additional management guidelines can be found in Section 6.1. 
 
Cardiac evaluation by MUGA or echocardiogram is to be completed prior to initiating 
trastuzumab and pertuzumab maintenance therapy; to avoid repeating, pre-surgical 
cardiac evaluation may fulfill this requirement. Cardiac evaluation will continue to be 
completed every 12 weeks (+/- 1 week) from the start of maintenance therapy until 
maintenance therapy is completed.  
 
5.3.7 Radiation Therapy 
 
Radiation therapy should be initiated within 3-6 weeks following the last dose of 
doxorubicin and cyclophosphamide (Post-operative Option #1) or within 3-6 weeks 
following surgery (Post-Operative Option #2). Radiation therapy may start and continue 
during maintenance therapy with trastuzumab and pertuzumab. 
 
Radiation should be delivered to the chest wall and regional lymph nodes. Treatment will 
be administered per institutional guidelines for the treatment of inflammatory breast 
cancer. Radiation can be administered at a local facility.  
 
5.3.8 Endocrine Therapy 
 
Appropriate postoperative adjuvant endocrine therapy should be administered in patients 
with ER and/or PR positive disease. Either tamoxifen or an aromatase inhibitor should be 
administered per institutional standards as determined by the patient’s treating physician. 
Endocrine therapy should be initiated 3-4 weeks following the completion of doxorubicin 
and cyclophosphamide (Post-operative Option #1), or concurrent with maintenance 
therapy of trastuzumab and pertuzumab.  Endocrine therapy may begin concurrent with 
or after completion of radiation therapy per physician preference. 
 
5.3.9 Additional Therapy for Stage IV Disease 
 
Patients with Stage IV disease by virtue of nodal involvement alone will continue 
trastuzumab with pertuzumab every 3 weeks (+/- 1 week) until disease progression 
(beginning maintenance therapy per post-operative options noted in Sections 5.3.5 and 
5.3.6).  
 
5.4 
General Concomitant Medication and Supportive Care Guidelines 
 
Filgrastim or Peg- filgrastim: 
• May be administered during the treatment with doxorubicin / cyclophosphamide per 
institutional guidelines and at the treating physician’s discretion.  
• Not to be administered with paclitaxel.  
 
Anti-emetics: 

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• May be administered per physician discretion.  
 
5.5 
Criteria for Taking a Participant Off Protocol Therapy 
 
Duration of therapy will depend on individual response, evidence of disease progression and 
tolerance. In the absence of treatment delays due to adverse event(s), treatment may continue 
until the conclusion or post-operative therapy or until one of the following criteria applies: 
 
• Disease progression as evidenced by clinical examination and confirmed with imaging 
with MRI of the breast. 
 
• Intercurrent illness that prevents further administration of treatment 
 
• Unacceptable adverse event(s), including grade 4 congestive heart failure (CHF).  
 
• Participant demonstrates an inability or unwillingness to comply with the medication 
regimen and/or documentation requirements. 
 
• Participant decides to withdraw from the protocol. 
 
• General or specific changes in the participant's condition render the participant 
unacceptable for further treatment in the judgment of the treating investigator 
 
Participants will be removed from the protocol therapy when any of these criteria apply.  The 
reason for removal from protocol therapy, and the date the participant was removed, must be 
documented in the case report form (CRF). Alternative care options will be discussed with the 
participant. 
 
A ODQ Treatment Ended/Off Study Form will be filled out when a participant is removed from 
protocol therapy. This form can be found on the ODQ website or obtained from the DFCI 
Coordinator Center Project Managers. 
 
In the event of unusual or life-threatening complications, treating investigators must immediately 
notify the Overall PI, Filipa Lynce, MD at 617-632-3800, or filipa_lynce@dfci.harvard.edu.  
 
5.6 
Duration of Follow Up 
 
Following the completion of the study treatment or other items noted above in Section 5.5., 
participants will be followed every 3 months (+/- 1 month) for 1 year, then every 6 months (+/- 1 
month) for 4 years, and then annually (+/- 1 month) after removal from protocol therapy or until 
death, whichever occurs first.  Participants removed from protocol therapy for unacceptable 
adverse event(s) will be followed until resolution or stabilization of the adverse event. 

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Patients who are no longer being followed at the treating institution will be contacted either 
directly or their current treating physician will be contacted every 6 months for 4 years, and then 
annually to determine disease status until death.  
 
5.7 
Criteria for Taking a Participant Off Study 
 
Participants will be removed from study when any of the following criteria apply: 
 
• Lost to follow-up 
• Withdrawal of consent for data submission 
• Death 
 
The reason for taking a participant off study, and the date the participant was removed, must be 
documented in the case report form (CRF). 
 
A ODQ Treatment Ended/Off Study Form will be filled out when a participant comes off study. 
This form can be found on the ODQ website or obtained from the DFCI Coordinator Center 
Project Managers. 
 
5.8 
Study Discontinuation 
 
The Overall Principal Investigator has the right to terminate this study at any time.  Reasons for 
terminating the study may include the following: 
 
• The incidence or severity of adverse events in this or other studies indicates a potential 
health hazard to subjects. 
• Subject enrollment is unsatisfactory 
• Data recording are inaccurate or incomplete 
• Study protocol not followed 
 
6. DOSING DELAYS/DOSE MODIFICATIONS 
 
Dose delays and modifications will be made as indicated in the following table(s) and 
paragraphs. The descriptions and grading scales found in the revised NCI Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for dose delays and dose 
modifications. A copy of the CTCAE version 4.0 can be downloaded from the CTEP website 
 http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
If possible, symptoms should be managed symptomatically. In the case of toxicity, appropriate 
medical treatment should be used (including anti-emetics, anti-diarrheals, etc.). 
It is optimal to administer all study drugs as outlined, however each drug may be held 
individually as per outlined in the protocol. For example, pertuzumab and trastuzumab may 
continue as scheduled if paclitaxel is held for toxicity. Patients who discontinue chemotherapy 
due to toxicity should not systematically be withdrawn from all study treatments.  

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6.1 
Trastuzumab and Pertuzumab Dosage Modification 
 
Pertuzumab or trastuzumab dose modifications are not permitted.  Pertuzumab and trastuzumab 
doses may be delayed due to toxicities. If pertuzumab or trastuzumab are held for more than two 
cycles or need to be permanently discontinued, the patient will be withdrawn from all study 
treatment and treated at the discretion of the investigator as clinically indicated. The patient will 
continue to be followed post-treatment as described in Section 5.6. 
 
6.1.1 Criteria for Continuation and Discontinuation of HER2 Targeted Study Medication 
based on LVEF Assessments 
 
If the criteria to hold pertuzumab treatment are met (based on Appendix A) repeat LVEF 
assessment within approximately 3 weeks. If after a repeat assessment, the LVEF has not 
improved, or has declined further, discontinuation of pertuzumab and trastuzumab should 
be strongly considered, unless the benefits for the individual patient are deemed to 
outweigh the risks. For delayed or missed doses, if the time between 2 sequential 
infusions is less than 6 weeks, the 420 mg IV dose of pertuzumab should be 
administered. Do not wait until the next planned dose. If the time between 2 sequential 
infusions is 6 weeks or more, the initial dose of 840 mg pertuzumab should be re-
administered as a ~60 minute IV infusion followed every 3 weeks thereafter by a dose of 
420 mg IV administered over ~30-60 minutes. Pertuzumab should be withheld or 
discontinued if trastuzumab treatment is withheld or discontinued due to cardiac toxicity. 
Most patients who developed heart failure in the adjuvant trastuzumab breast cancer trials 
improved with standard medical treatment. This included ACE-inhibitors or angiotensin 
receptor blockers, beta-blockers and diuretics when needed.  
 
6.2 
Dose Modifications and Delays for Paclitaxel: 
The principle is to attempt to administer full doses of paclitaxel therapy on schedule. Paclitaxel 
may be modified or held as indicated below. Missed paclitaxel doses should be made up at the 
end of scheduled pre-operative therapy, prior to surgery to achieve 16 total doses.  In the case of 
discontinuation of paclitaxel, patients should be assessed for eligibility for mastectomy, and if 
they are deemed surgical candidates, then they should proceed to mastectomy and continue on 
treatment as per protocol. 
 
All dose modifications for paclitaxel are based on the dose level changes outlined below in Table 
1.  No more than 1 dose-reduction of paclitaxel chemotherapy should be made for toxicity.  If 
more than 1 dose-reduction is required, paclitaxel should be discontinued. If Paclitaxel is held for 
> 3 weeks for toxicity, paclitaxel should be discontinued.   
 
TABLE 1:  Dose Levels for Paclitaxel 
 
Dose level 0 
Dose Level -1  
Dose Level -2 

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Starting dose 
Paclitaxel 
(mg/m2) 
80 
64 
Discontinue 
 
The sections below outline modifications for paclitaxel-related hypersensitivity reactions, 
neurosensory toxicity, and musculoskeletal pain.  Instructions for management of all other 
toxicities related to paclitaxel are listed in Section 6.3, Table 5.  If a Grade 3 or 4 non-
hematologic toxicity not otherwise listed below is experienced, paclitaxel may be reduced from 
80 mg/m2 to 64mg/m2. If further dose reduction is needed, the paclitaxel should be discontinued 
as indicated above in Table 1.  
 
6.2.1 Hypersensitivity Reactions 
 
If paclitaxel-related hypersensitivity reaction occurs despite pre-medication, treatment as 
medically indicated will be instituted. For hypersensitivity reaction less than Grade 3, 
continuation of paclitaxel is at the Investigator’s discretion.  If Grade 4 hypersensitivity is 
experienced, paclitaxel must be permanently discontinued. 
 
6.2.2 Neurosensory Toxicity 
TABLE 2:  Dose Modifications for Paclitaxel-Related Neurosensory Toxicity 
Paresthesias/Dysesthesias 
1 – 7 Days Duration 
Persistent for > 
7 Days or 
Caused the 
Next Cycle to 
be  delayed 
Grade 1 
Paresthesias/dysesthesias that do 
not interfere with function 
Maintain paclitaxel dose 
Maintain 
paclitaxel dose 
 
Grade 2 
Paresthesias/dysesthesias 
interfering with function, but not 
activities of daily living 
Maintain paclitaxel dose a 
 
Decrease 
paclitaxel one 
dose level b 
 
Grade 3 
Paresthesias/dysesthesias with 
pain or with function impairment 
interfering with activities of daily 
living C 
First episode: 
Decrease paclitaxel one 
dose levela 
Second episode: 
Discontinue paclitaxel 
 
Discontinue 
paclitaxel 
 
a Must be resolved to ≤ Grade 1 on Day 1 of the next cycle. 
b Hold paclitaxel for persistent Grade 2 neurotoxicity. When ≤ grade 1, resume treatment with dose 
modification for paclitaxel. If grade 2 toxicity persists after 3 weeks of delay, discontinue paclitaxel. 
c For persistent paresthesias/ dysesthesias that are disabling or life-threatening, paclitaxel should be 
discontinued. 
 

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6.2.3 Musculoskeletal Pain 
 
TABLE 3:  Dose Modifications for Paclitaxel Musculoskeletal Pain Not Controlled by 
Analgesicsa 
Musculoskeletal Pain 
1 – 7 Days Duration 
Persistent for > 7 Days or 
Caused the Next Cycle to be 
Delayed 
Grade 1  
 
Maintain  paclitaxel dose 
Maintain paclitaxel dose 
Grade 2  
 
Maintain  paclitaxel dose 
 
Decrease paclitaxel one dose  
levelb 
 
Grade 3 
First episode: 
Decrease paclitaxel one 
dose level 
Second episode: 
Discontinue paclitaxel 
First episode: 
Decrease paclitaxel one dose 
levelb 
OR 
Discontinue paclitaxel 
Second episode: 
Discontinue paclitaxel 
a Use of narcotics and NSAIDs is encouraged to maintain dose of paclitaxel if possible. 
b Hold paclitaxel for persistent Grade 2 or 3 musculoskeletal pain (trastuzumab and pertuzumab 
should be continued while paclitaxel is held.) When ≤ grade 1, resume treatment with dose 
modification for paclitaxel. If Grade 2 or Grade 3 toxicity persists after 3 weeks of delay, 
discontinue paclitaxel. 
 
6.3 
Dose Modifications and Delays for Paclitaxel and doxorubicin/cyclophosphamide 
(AC) 
 
No more than 1 dose-reduction of doxorubicin/cyclophosphamide chemotherapy (AC) should be 
made for toxicity.  If more than 1 dose-reduction would be required, AC should be discontinued, 
and the patient may proceed with trastuzumab and pertuzumab and radiation. If AC is held for > 
3 weeks for toxicity, stop AC and proceed to trastuzumab and pertuzumab and radiation.  
Patients who need to discontinue AC because of toxicity, can proceed to trastuzumab and 
pertuzumab and radiation.  
TABLE 4:  Dose Levels for doxorubicin/cyclophosphamide (AC) 
 
Dose level 0 
Starting dose 
Dose Level -1  Dose Level -2 
doxorubicin 
(mg/m2) 
60 
45 
discontinue 
Cyclophosphamide 
(mg/m2) 
600 
450 
discontinue 
 
Table 5 below outlines modifications for various AC-related toxicities.  If a Grade 3 or 4 non-
hematologic toxicity not otherwise listed below is experienced, doxorubicin may be reduced 

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from 60 mg/m2 to 45 mg/m2, and cyclophosphamide may be reduced from 600 mg/m2 to 450 
mg/m2.  If further dose reduction is needed, the paclitaxel should be discontinued as indicated 
above in Table 4.  
TABLE 5:  Dose Modifications and Delays for Paclitaxel and 
doxorubicin/cyclophosphamide (AC) 
NCI CTCAE v 4.0 
[Category] 
Grade 
 
Modifications for AEs that 
occur during a cycle but 
resolve prior to the next 
treatment cyclea 
Modifications for AEs that 
require a delay in 
administration of the 
treatment cycle (i.e., they 
occur on Day 1)b 
HEMATOLOGICAL: 
Neutrophils count decreased 
Grades 2, 3, 4  
Maintain dose 
Hold until ≥ 1000/mm3 for 
paclitaxel and for AC. 
If recovery takes: 
• 1 wk: maintain dose 
• 2-3 wks: ↓ one dose 
level 
Platelet count decreased 
Grades 2, 3 
 
 
 
 
 
Grade 4 
Maintain dose 
 
 
 
 
 
↓ one dose level 
Hold until ≥ 100,000/mm3. 
If recovery takes: 
• 1 wk: maintain dose 
• 2-3 wks: ↓ one dose 
level 
 
↓ one dose level 
BLOOD AND LYMPHATIC SYSTEM DISORDERS: 
Febrile neutropenia 
Grade 3, 4  
 
↓ one dose level or 
discontinue. 
 
GASTROINTESTINAL DISORDERS (if related to chemotherapy): 
Diarrhea 
Grade 2 
Grade 3 
Grade 4 
 
Maintain dose 
↓ one dose level   
discontinue 
↓ one dose level 
↓ one dose level   
discontinue 
Mucositis oral (stomatitis) 
Grade 2 
Grade 3 
Grade 4 
 
Maintain dose 
↓ one dose level   
discontinue 
↓ one dose level 
↓ one dose level   
discontinue 
Vomiting (despite antiemetics) 
Grade 2 
Grades 3, 4 
↓ one dose level (optional) 
↓ one dose level or 
↓ one dose level   
discontinue 

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discontinue 
HEPATIC FUNCTION: 
Bilirubin or AST or ALP increased 
Grade 2 
 
 
 
 
 
Grade 3 
Grade 4 
↓ one dose level 
 
 
 
 
 
↓ one dose level 
Discontinue 
Hold until bilirubin returns 
to the baseline grade, and 
AST and alkaline 
phosphatase have returned to 
≤ grade 1. 
Then ↓ one dose level 
 
↓ one dose level 
Discontinue 
Grade 3 
Grade 4 
 
↓ one dose level 
↓ one dose level or 
discontinue 
↓ one dose level 
Discontinue 
 
• 
Dose modifications must be based on AEs that occur during the cycle (column 2) and AEs 
present on the scheduled cycle Day 1 (column 3). 
• 
Dose modifications must be based on the AE requiring the greatest modification.  
a Resolved means that all requiring dose modification are ≤ grade 1 (except ANC/AGC [which 
must be ≥ 1000/mm3 and bilirubin which must be ≤ the baseline grade]) on each week of 
paclitaxel or  (except ANC/AGC [which must be ≥ 1000/mm3] and bilirubin [which must be ≤ 
the baseline grade]) on Day 1 of the next scheduled cycle of AC (ie, treatment can be given 
without delay). 
b Hold and check weekly. With exception of ANC/AGC and bilirubin, resume treatment when 
toxicity is ≤ grade 1. If toxicity has not resolved after 3 weeks of delay, discontinue paclitaxel or 
doxorubicin/cyclophosphamide.  
c Determination of "clinically significant" AEs is at the discretion of the investigator. 
 
 
7. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS  
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  All adverse 
events experienced by participants will be collected from the time of the first dose of study 
treatment, through the study and until the final study visit. Participants continuing to experience 
toxicity at the off study visit may be contacted for additional assessments until the toxicity has 
resolved or is deemed irreversible. The following list of reported and/or potential AEs (Section 
7.1) and the characteristics of an observed AE (Section 7.2) will determine whether the event 
requires expedited reporting in addition to routine reporting. 
 
7.1 
Expected Toxicities 
 
7.1.1 Adverse Events List(s) for Trastuzumab and Pertuzumab 
a. Infusion-Associated Symptoms  

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Like other monoclonal antibodies, pertuzumab has been associated with infusion 
associated reaction (such as chills, diarrhea, fatigue, headache, nausea, and pyrexia), and 
with hypersensitivity reactions. Close observation of the patient during and for ~60 
minutes after the first infusion of pertuzumab or trastuzumab, and during and for ~30 
minutes following the first 30 minute infusion of pertuzumab or trastuzumab. If these 
infusions are tolerated well, post-infusion observation may be avoided following 
subsequent infusions as per institutional guidelines. If a significant IAR occurs, the 
infusion should be slowed down or interrupted and appropriate medical therapies should 
be administered. Patients should be evaluated and carefully monitored until complete 
resolution of signs and symptoms. Permanent discontinuation should be considered in 
patients with severe infusion reactions. This clinical assessment should be based on the 
severity of the preceding reaction and response to administered treatment for the adverse 
reaction. 
 
b. Serious Infusion-Associated Events  
 
Serious adverse reactions to trastuzumab infusion including dyspnea, hypotension, 
wheezing, bronchospasm, tachycardia, reduced oxygen saturation and respiratory distress 
have been reported infrequently.   In rare cases (4 per 10,000), these events were 
associated with a clinical course culminating in a fatal outcome. Serious reactions have 
been treated with supportive therapy such as oxygen, beta-agonists, corticosteroids and 
withdrawal of trastuzumab as indicated. 
 
c. Hematologic Toxicity and Neutropenic Infections 
 
In the clinical trials, an increased incidence of anemia was observed in patients receiving 
trastuzumab plus chemotherapy compared with patients receiving chemotherapy alone.  
The majority of these anemia events were mild or moderate in intensity and reversible; 
none resulted in discontinuation of trastuzumab therapy.   
 
In the clinical trials, the per-patient incidences of moderate to severe neutropenia and of 
febrile neutropenia were higher in patients receiving trastuzumab in combination with 
myelosuppressive chemotherapy as compared to those who received chemotherapy alone.  
In the post marketing setting, deaths due to sepsis in patients with severe neutropenia 
have been reported in patients receiving trastuzumab and myelosuppressive 
chemotherapy, although in controlled clinical trials (pre- and post-marketing), the 
incidence of septic deaths was not significantly increased.  The pathophysiologic basis 
for exacerbation of of neutropenia has not been determined; the effect of trastuzumab on 
the pharmacokinetics of chemotherapeutic agents has not been fully evaluated.  
 
Secondary acute leukemia or myelodysplastic syndrome has been reported in 4 of 
approximately 1200 patients who participated in trastuzumab clinical trials.  Patients 
treated with chemotherapeutic agents are known to be at increased risk for secondary 
leukemia.  The observed incidence of leukemia among trastuzumab-treated patients 
appears to be consistent with the expected incidence of leukemia among patients treated 

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with chemotherapy for metastatic breast cancer (7).  Therefore, the contribution of 
trastuzumab to the etiology of acute leukemia or myelodysplastic syndrome in these cases 
is unclear. 
 
d. Management of Hematologic Toxicities 
 
Care should be taken to carefully monitor the patient’s hematologic status throughout the 
course of the trial.  Use of hematopoietic growth factors to ameliorate hematologic 
toxicity is at the discretion of the physician investigator and should be in accordance with 
the American Society of Clinical Oncologists (ASCO) guidelines.  
 
Please refer to the trastuzumab and pertuzumab Investigator Brochure for a detailed 
description of the safety profile of trastuzumab. 
 
e. Risk of Respiratory Events 
 
A low rate of respiratory events that are compatible with an IAR or hypersensitivity 
reaction/anaphylaxis has been reported. Although pertuzumab targets the HER2 receptor 
it inhibits heterodimerization with other members of the HER family (eg, EGFR 
[HER1]). Accordingly, it may cause toxicities associated with the use of EGFR 
inhibitors,such as ILD. The few reports of ILD occurring in pertuzumab-treated patients 
received so far also had evidence of alternative causes, eg, concomitant medication, 
preceding/concurrent neutropenia with potential infection or relevant medical history. 
 
f. Risk of EGFR-Related Toxicities 
 
Although pertuzumab targets the HER2 receptor, it inhibits heterodimerization with other 
members of the HER family (eg, EGFR [HER1]). Accordingly, it may cause toxicities 
associated with the use of EGFR inhibitors such as diarrhea, rash and other dermatologic 
toxicities (eg, dry skin, pruritus, nail disorders, mucositis). 
 
g. Diarrhea 
 
In the 7-week IV and 26-week toxicity studies in cynomolgus monkeys, there was a 
treatment-related increase in the incidence of diarrhea. Diarrhea has been observed in 
approximately 60% of patients (treatment-related diarrhea in 50% of patients) being 
treated with pertuzumab in phase II single-agent studies, and up to approximately 70% of 
patients in combination therapy studies. Diarrhea was CTC Grade 1 or 2 in the majority 
of cases. To prevent dehydration, early treatment of diarrhea with anti-diarrheal 
medication should be considered and patients treated with fluids and electrolyte 
replacement, as clinically indicated. 
 
h. Rash 
 
Rash has also been observed with EGFR inhibitors, mostly of mild to moderate intensity. 
Rash has been observed in approximately 17% of patients receiving pertuzumab in Phase 

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II single-agent studies and up to 73% of patients in combination studies. The rash was 
generally of CTC Grade 1 or 2 in severity. Treatment recommendations for EGFR 
associated rash include topical or oral antibiotics, topical pimecrolimus, topical or (for 
severe reactions) systemic steroids. These agents may be used in patients experiencing 
pertuzumab-related rash, as clinically indicated, although they have not been studied in 
this context. 
 
i. Risk of Neutropenia 
 
Neutropenic events are virtually absent with chemotherapy-free Pertuzumab regimens 
and with single-agent pertuzumab. In the pivotal study WO20698/TOC4129g incidence 
of neutropenic events was increased in patients receiving pertuzumab, trastuzumab and 
docetaxel, compared to patients in the placebo-controlled arm. This was largely driven by 
an increase in Grades 3 and 4 febrile neutropenia. No febrile neutropenia events occurred 
after docetaxel discontinuation.  Pertuzumab, at a dose of 420 mg, was well tolerated in 
combination with docetaxel up to 75 mg/m2 in the Phase Ib study, BO17021. However, 
pertuzumab in combination with 100 mg/m2 docetaxel was not well tolerated. Dose-
limiting toxicity was observed, including febrile neutropenia. However, the registered 
dose of docetaxel in combination with trastuzumab ranges from 65 to 100 mg/m2, and 
there is evidence that outcomes might be improved when higher doses of docetaxel are 
given. Given that the DLTs in Study BO17021 were not life threatening and that 
exposure to docetaxel shows interpatient variability, patients receiving pertuzumab in 
combination with docetaxel in ongoing studies are treated initially with 75 mg/m2 
docetaxel, and then dose escalation of docetaxel to 100 mg/m2 is recommended (as 
described in the protocol dose escalation rules), provided that the patient does not 
experience significant toxicities at the starting dose. This strategy is intended to ensure 
optimum individual exposure for patients receiving docetaxel in combination with 
pertuzumab. The tolerability of the combination therapy at the higher (100 mg/m2) dose 
of docetaxel is encouraging in those patients who tolerate the 75 mg/m2 starting dose 
well. Patients receiving pertuzumab in combination with docetaxel or other cytotoxic 
agents should undergo careful hematological monitoring for neutropenia during 
treatment, and should be treated promptly with antibiotics and other supportive measures 
as clinically indicated. 
 
j. Risk of Left Ventricular Dysfunction  
 
Decreases in LVEF have been reported with drugs that block HER2 activity.  
Trastuzumab and pertuzumab both target HER2, thus there is a risk of cardiac 
dysfunction with these agents. In the CLEOPATRA pivotal trial WO20698/TOC4129g, 
pertuzumab in combination with trastuzumab and docetaxel was not associated with 
increases in the incidence of symptomatic LVSD or decreases in LVEF compared with 
placebo in combination with trastuzumab and docetaxel.  Pertuzumab combined with 
trastuzumab and chemotherapy also did not result in any significantly greater incidence 
of symptomatic LVSD or decreases in LVEF than trastuzumab and chemotherapy in 
patients with EBC (Study WO20697). However, in the pivotal MBC trial (Study 
WO20698/TOC4129g) a greater proportion of patients who developed symptomatic 

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LVSD had received prior anthracyclines and/or radiotherapy compared to the proportion 
of patients receiving prior anthracyclines and/or radiotherapy in the overall pertuzumab-
treated population. Therefore patients who have received prior anthracyclines or prior 
radiotherapy to the chest area may be at higher risk of decreased LVEF.   
 
Pertuzumab has not been studied in patients with: a pretreatment LVEF value of ≤ 50%; a 
prior history of CHF; decreases in LVEF to <50% during prior trastuzumab adjuvant 
therapy; conditions that could impair left ventricular function such as uncontrolled 
hypertension, recent myocardial infarction, serious cardiac arrhythmia requiring 
treatment or a cumulative prior anthracycline exposure to > 360mg/m2 of doxorubicin or 
its equivalent.  
 
Cardiac exclusion criteria are specified in this protocol and should be closely followed.  
 
k. Management of Cardiac Safety   
 
All patients must have a baseline evaluation of cardiac function including a measurement 
of LVEF by either MUGA or ECHO prior to entry into the study.  Only patients with an 
LVEF ≥ 50% should be entered into this study.   
 
All patients should have cardiac monitoring at regular intervals (e.g., every three months) 
during treatment with pertuzumab and trastuzumab. ECHO or MUGA scans should be 
scheduled at the same radiology facility where the patient’s baseline ECHO or MUGA 
was conducted. LVEF measurements should be required at protocol-specified time-points 
and after a patient has any of the following: discontinuation of protocol therapy, 
congestive heart failure (CHF), breast cancer recurrence, or a second primary cancer. 
When a cardiac event occurs, the Cardiac Report Form must be submitted within 14 days 
of learning of the event.   
 
During the course of trastuzumab and pertuzumab therapy, patients should be monitored 
for signs and symptoms of CHF (i.e., dyspnea, tachycardia, new unexplained cough, neck 
vein distention, cardiomegaly, hepatomegaly, paroxysmal nocturnal dyspnea, orthopnea, 
peripheral edema, and rapid unexplained weight gain). The confirmation of the CHF 
diagnosis should include the same method used to measure LVEF at baseline (either 
ECHO or MUGA).     
 
Pertuzumab and trastuzumab should be discontinued in any patient who develops clinical 
signs and symptoms suggesting CHF. CHF should be treated and monitored according to 
standard medical practice. 
 
At present, there are inadequate data available to assess the prognostic significance of 
asymptomatic drops in LVEF.  
 
7.1.2 Adverse Events List(s) for Paclitaxel 
 
Myelosuppression, abnormalities on liver function tests (elevated SGOT, SGPT, 

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bilirubin, alkaline phosphatase), nausea, vomiting, diarrhea, mucositis, peripheral 
neuropathy, transient asymptomatic bradycardia, and much less frequently, arrhythmias, 
hypotension, hypersensitivity/anaphylactic reactions (dyspnea, tachycardia, rash, 
urticaria, hypotension, or hypertension), myalgias, arthralgias, and alopecia. 
 
7.1.3 Adverse Events List(s) for Doxorubicin 
 
a. Hematologic:  
 
Leukopenia (dose-limiting), also thrombocytopenia, and anemia.  Nadir at 10-14 days, 
recovery in 21 days. 
 
b. Dermatologic: 
 
Reversible, usually complete alopecia; increased sensitivity to sunlight; 
hyperpigmentation of skin and nail beds. 
 
c. Gastrointestinal: 
 
Nausea and vomiting, sometimes severe; anorexia; diarrhea; mucositis (stomatitis and 
esophagitis) 
 
d. Cardiovascular:  
 
Arrhythmias, EKG changes, rarely sudden death. Cardiomyopathy may occur and is 
related to the total cumulative lifetime dose.  The risk of cardiomyopathy increases with 
total doses >450 mg/m2. 
 
7.1.4 Adverse Events List(s) for Cyclophosphamide 
 
a. Hematologic:  
 
Leukopenia, with nadirs about 8-14 days after administration and recovery in 18-25 days, 
and thrombocytopenia 
 
b. Dermatologic:  
 
Temporary alopecia 
 
c. Gastrointestinal:  
 
Nausea and vomiting 
 
d. Genitourinary:  
 
Hemorrhagic cystitis (onset of cystitis may be delayed for a period ranging from 24 hours 

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41 
to several weeks).  Subject should be well hydrated before, during, and after treatment. 
 
e. Other:  
 
Amenorrhea, which may be long-term; possible irreversible sterility in both sexes; 
teratogenic effects; in rare cases, anaphylaxis; may cause secondary neoplasms. 
 
7.2 
Adverse Event Characteristics 
 
• CTCAE term (AE description) and grade:  The descriptions and grading scales found 
in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
4.0 will be utilized for AE reporting.  All appropriate treatment areas should have access 
to a copy of the CTCAE version 4.0.  A copy of the CTCAE version 4.0 can be 
downloaded from the CTEP web site 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
 
• For expedited reporting purposes only:   
- 
AEs for the agent(s) that are listed above should be reported only if the adverse event 
varies in nature, intensity or frequency from the expected toxicity information which 
is provided. 
 
• Attribution of the AE: 
- 
Definite – The AE is clearly related to the study treatment. 
- 
Probable – The AE is likely related to the study treatment. 
- 
Possible – The AE may be related to the study treatment. 
- 
Unlikely – The AE is doubtfully related to the study treatment. 
- 
Unrelated – The AE is clearly NOT related to the study treatment. 
 
• Expectedness of the AE: 
- 
Expected adverse events are those that have been previously identified as resulting 
from administration of the agent. For the purposes of this study, an adverse event is 
considered expected when it appears in the current adverse event list, the 
Investigator’s Brochure, the package insert or is included in the informed consent 
document as a potential risk.   
- 
For the purpose of this study, an adverse event is considered unexpected when it 
varies in nature, intensity or frequency from information provided in the current 
adverse event list, the Investigator’s Brochure, the package insert or when it is not 
included in the informed consent document as a potential risk.   
 
• Serious Adverse Events: A serious adverse event (SAE) is any adverse event, occurring 
at any dose and regardless of causality that:  
- 
Results in death 
- 
Is life-threatening. Life-threatening means that the person was at immediate risk of 
death from the reaction as it occurred, i.e., it does not include a reaction which 
hypothetically might have caused death had it occurred in a more severe form. 

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- 
Requires or prolongs inpatient hospitalization (i.e., the event required at least a 24-
hour hospitalization or prolonged a hospitalization beyond the expected length of 
stay). Hospitalization admissions and/or surgical operations scheduled to occur during 
the study period, but planned prior to study entry are not considered SAEs if the 
illness or disease existed before the person was enrolled in the trial, provided that it 
did not deteriorate in an unexpected manner during the trial (e.g., surgery performed 
earlier than planned). 
- 
Results in persistent or significant disability/incapacity. Disability is defined as a 
substantial disruption of a person’s ability to conduct normal life functions. 
- 
Is a congenital anomaly or birth defect; or 
- 
Is an important medical event when, based upon appropriate medical judgment, it 
may jeopardize the participant and require medical or surgical intervention to prevent 
one of the outcomes listed above. Examples of such medical events include allergic 
bronchospasm requiring intensive treatment in an emergency room or at home; blood 
dyscrasias or convulsions that do not result in inpatient hospitalization, or the 
development of drug dependency or drug abuse. 
- 
Meets the reporting criteria defined in Section 7.3.1, Table 6.  
 
- 
Events not considered to be serious adverse events are hospitalizations for: 
• routine treatment or monitoring of the studied indication, not associated with 
any deterioration in condition, or for elective procedures 
• elective or pre-planned treatment for a pre-existing condition that did not 
worsen 
• emergency outpatient treatment for an event not fulfilling the serious criteria 
outlined above and not resulting in inpatient admission 
• respite care 
 
7.3 
Expedited Adverse Event Reporting  
 
Investigators must report to the Overall PI any serious adverse event (SAE) that occurs after the 
initial dose of study treatment, during treatment, or within 30 days of the last dose of treatment 
on the local institutional SAE form.  
 
For multi-institution studies where a DF/HCC investigator is serving as the Overall Principal 
Investigator, each participating institution must abide by the reporting requirements set by the 
DF/HCC. This applies to any medical event equivalent to an unexpected grade 2 or 3 with a 
possible, probable or definite attribution, unexpected grade 4 toxicities, and grade 5 (death) 
regardless of study phase or attribution. 
 
7.3.1 DF/HCC Expedited Reporting Guidelines 
 
Investigative sites within DF/HCC and DF/PCC will report SAEs directly to the DFCI 
Office for Human Research Studies (OHRS) per the DFCI IRB reporting policy.  
 
Other investigative sites will report SAEs to their respective IRB according to the local 

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43 
IRB’s policies and procedures in reporting adverse events. A copy of the submitted 
institutional SAE form should be forwarded to the Overall PI and Project Managers 
within the timeframes detailed in the table below.   
Filipa Lynce, MD 
Phone:  617-632-3800 
Fax:  617-632-1930 
Email: filipa_lynce@dfci.harvard.edu and ctopm@dfci.harvard.edu  
 
TABLE 6: DF/HCC Reportable AEs 
 
 
 
Attribution 
DF/HCC Reportable AEs 
Gr. 2 & 3 AE 
Expected 
Gr. 2 & 3 AE 
Unexpected 
Gr. 4 AE Expected 
Gr. 4 AE 
Unexpected 
Gr. 5 AE 
Expected or 
Unexpected 
Unrelated 
Unlikely 
Not required 
Not required 
5 calendar days# 
5 calendar days 
24 hours* 
Possible 
Probable 
Definite 
 
Not required 
 
5 calendar days 
 
5 calendar days# 
 
5 calendar days 
 
24 hours* 
# If listed in protocol as expected and not requiring expedited reporting, event does not need to be reported. 
 
* For participants enrolled and actively participating in the study or for AEs occurring within 30 days of the last 
intervention, the AE should be reported within 1 business day of learning of the event. 
 
 
The Overall PI will submit SAE reports from outside institutions to the DFCI OHRS 
according to DFCI IRB policies and procedures in reporting adverse events.  
 
7.4 
Expedited Reporting to the Food and Drug Administration (FDA) 
 
The Overall PI, as study sponsor, will be responsible for all communications with the FDA. The 
Overall PI will report to the FDA, regardless of the site of occurrence, any serious adverse event 
that meets the FDA’s criteria for expedited reporting following the reporting requirements and 
timelines set by the FDA. 
 
7.5 
Reporting to Genentech Drug Safety 
 
7.5.1 AEs of Special Interest (AESIs) 
 
The Trastuzumab and Pertuzumab Events of Special Interest are: 
 
• Left Ventricular Ejection fraction decrease (<50%)  
• LV dysfunction 
• Heart Failure 
• Embryo-fetal Toxicity or Birth Defects 
 

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7.5.2 AESI and SAE Reporting to Genentech 
Investigators must report all SAEs and AESIs to Genentech Drug Safety within the 
timelines described below. A completed Medwatch 3500A form should be faxed 
immediately upon completion with the cover sheet in Appendix B to Genentech Drug 
Safety at: 
(650) 225-4682 
OR 
(650) 225-5288 
 
Relevant follow-up information should be submitted to Genentech Drug Safety as soon as 
it becomes available. SAE reports that are related to trastuzumab and pertuzumab and 
AEs of Special Interest (regardless of causality) will be transmitted to Genentech within 
fifteen (15) calendar days of the Awareness Date.  Serious AE reports that are unrelated 
to the trastuzumab and pertuzumab will be transmitted to Genentech within thirty (30) 
calendar days of the Awareness Date.  
Additional Reporting Requirements to Genentech include the following: 
Any reports of pregnancy following the start of administration with the trastuzumab and 
pertuzumab will be transmitted to Genentech within thirty (30) calendar days of the 
Awareness Date.  
 
For questions related to safety reporting, please contact Genentech Drug Safety: 
 
Tel: (888) 835-2555 
Fax: (650) 225-4682    OR    (650) 225-5288 
 
7.5.3 Non-serious AE Reporting to Genentech 
 
Listings of non-serious AEs from the study will be forwarded to Genentech on a quarterly 
basis by the DFCI Coordinating Center. 
 
7.6 
Expedited Reporting to Hospital Risk Management 
 
Participating investigators will report to their local Risk Management office any participant 
safety reports or sentinel events that require reporting according to institutional policy.  
 
7.7 
Monitoring of Adverse Events and Period of Observation 
 
All adverse events, both serious and non-serious, and deaths that are encountered from initiation 
of study intervention, throughout the study, and within 30 days of the last study intervention 
should be followed to their resolution, or until the participating investigator assesses them as 
stable, or the participating investigator determines the event to be irreversible, or the participant 

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45 
is lost to follow-up. The presence and resolution of AEs and SAEs (with dates) should be 
documented on the appropriate case report form and recorded in the participant’s medical record 
to facilitate source data verification.  
 
For some SAEs, the study sponsor or designee may follow-up by telephone, fax, and/or 
monitoring visit to obtain additional case details deemed necessary to appropriately evaluate the 
SAE report (e.g., hospital discharge summary, consultant report, or autopsy report).  
 
Participants should be instructed to report any serious post-study event(s) that might reasonably 
be related to participation in this study. Participating investigators should notify the DF/HCC 
Overall Principal Investigator and their respective IRB of any unanticipated death or adverse 
event occurring after a participant has discontinued or terminated study participation that may 
reasonably be related to the study.   
 
7.8 
Routine Adverse Event Reporting 
 
All Adverse Events must be reported in routine study data submissions to the Overall PI on the 
toxicity case report forms.  AEs reported through expedited processes (e.g., reported to the 
IRB, FDA, etc.) must also be reported in routine study data submissions. 
 
8. PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the investigational or other agents 
administered in this study can be found in Section 7.1. 
 
8.1 
Pertuzumab 
 
8.1.1 Description, Form, and Preparation 
Pertuzumab drug product is provided as a single use formulation containing 30 mg/mL 
pertuzumab in 20 mM L-histidine acetate (pH 6.0), 120 mM sucrose and 0.02% 
polysorbate 20. Each 20 mL vial contains 420 mg of Pertuzumab (14.0 mL/vial).  
Prepare the solution for infusion, using aseptic technique, as follows: 
• Parenteral drug products should be inspected visually for particulates and 
discoloration prior to administration. 
• Withdraw the appropriate volume of pertuzumab liquid concentrate from the vial(s). 
• Dilute into the 250 mL 0.9% sodium chloride PVC or non-PVC polyolefin infusion 
bags. Do not withdraw saline out of the infusion bag. 
• Mix diluted solution by gentle inversion.  Do not shake. 
• Administer immediately once prepared. 
• Dextrose (5%) solution should not be used to dilute pertuzumab. 
 
Refer to the Investigator’s Brochure for detailed pertuzumab information and FDA 
approved package for more information. 

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8.1.2 Storage and Stability 
Upon receipt, pertuzumab vials are to be refrigerated at 2°C–8°C (36°F–46°F) until use.  
Pertuzumab vials should not be used beyond the expiration date provided by the 
manufacturer. Because the formulation does not contain a preservative, the vial seal may 
only be punctured once. Any remaining solution should be discarded. Vial contents 
should be protected from light, and should not be frozen or shaken. The solution of 
pertuzumab for infusion, diluted in PVC or non-PVC polyolefin bags containing 0.9% 
Sodium Chloride Injection, USP, may be stored at 2°C–8°C for up to 24 hours prior to 
use. Diluted pertuzumab has been shown to be stable for up to 24 hours (up to 30°C). 
However, since diluted pertuzumab contains no preservative, the diluted solution should 
be stored refrigerated (2°C–8°C). 
 
8.1.3 Compatibility 
 
No incompatibilities between pertuzumab and polyvinylchloride, polyethylene or non- 
PVC polyolefin bags have been observed. Dextrose (5%) in water (D5W) solution should 
not be used to dilute pertuzumab since it was chemically and physically unstable in such 
solutions (dilute formulations of pertuzumab liquid formulations in D5W IV bags did not 
maintain stable pH after storage at room temperature (27-33°C) for 24 hours followed by 
24 hours at refrigerator temperature [2°C -8°C]). Pertuzumab should not be mixed or 
diluted with other drugs. 
 
8.1.4 Handling 
 
Qualified personnel, familiar with procedures that minimize undue exposure to 
themselves and the environment, should undertake the preparation, handling, and safe 
disposal of the chemotherapeutic agent in a self-contained and protective environment.  
 
8.1.5 Availability 
 
Pertuzumab is an investigational agent and will be supplied free-of-charge from 
Genentech. 
 
8.1.6 Administration 
 
Pertuzumab will be administered in an outpatient setting.  The initial dose of pertuzumab 
is 840 mg administered with infusion timing and  post-infusion observation period per 
institutional guidelines.  Subsequent infusions will be given every 3 weeks thereafter by a 
dose of 420 mg administered with infusion timing and post-infusion observation period 
per institutional guidelines.  If the previous loading dose or previous doses were well 
tolerated, the post-infusion observation time may be discontinued as per institutional 
guidelines. DO NOT ADMINISTER AS AN IV PUSH OR BOLUS.   
 
If pertuzumab is being administered concomitantly with chemotherapy, monoclonal 

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antibody administration should precede chemotherapy administration.  Patients should be 
observed for fever and chills or other infusion-associated symptoms.  Refer to Sections 
5.3.2, 5.3.5, and 5.3.6 for more details. 
 
8.1.7 Ordering 
 
The investigator or those named as sub-investigators agree to supply study drug only to 
those subjects who are enrolled in the study. The investigator or designee will keep a 
current and accurate inventory of all clinical drug supplies provided by Genentech. The 
study site will maintain a dispensing log and compliance with the treatment regimen will 
be calculated at the site from this information at each visit. Each participating center will 
order its own inventory of drug. Drug will be shipped directly to that participating site by 
Genentech. 
 
8.1.8 Drug Supplies and Accountability 
 
The investigator, or a responsible party designated by the investigator, should maintain a 
careful record of the inventory and disposition of the agent using the NCI Drug 
Accountability Record Form (DARF) or another comparable drug accountability form.   
 
8.1.9 Destruction and Return 
 
At the end of the study, unused supplies of pertuzumab should be destroyed according to 
institutional policies. Destruction will be documented in the Drug Accountability Record 
Form. 
 
8.2 
Trastuzumab 
 
8.2.1 Description, Form, and Preparation 
 
Trastuzumab is a sterile, white to pale yellow, preservative-free lyophilized powder for 
intravenous (IV) administration.  Each vial of trastuzumab contains either 440 mg  or 
150mg of trastuzumab (may vary based upon availability).  
Use appropriate aseptic technique.  Each 440 mg vial of trastuzumab should be 
reconstituted with 20 mL of BWFI, USP, 1.1% benzyl alcohol preserved, as supplied, to 
yield a multidose solution containing 21 mg/mL trastuzumab.  Immediately upon 
reconstitution with BWFI, the vial of trastuzumab must be labeled in the area marked “Do 
not use after” with the future date that is 28 days from the date of reconstitution. 
If the patient has known hypersensitivity to benzyl alcohol, trastuzumab must be 
reconstituted with sterile water for injection.  Trastuzumab that has been reconstituted 
with SWFI must be used immediately and any unused portion discarded.  Use of other 
reconstitution diluents should be avoided. 

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48 
Each 150 mg vial is reconstituted with 7.4 ml of Sterile Water for Injection (SWFI). The 
reconstituted vial yields a solution containing 21mg/ml trastuzumab.  
Determine the dose of trastuzumab needed, based on a loading dose of 8 mg 
trastuzumab/kg body weight for q3wk dosing schedules or 4 mg trastuzumab/kg body 
weight for weekly dosing schedules; or a maintenance dose of 6 mg/kg trastuzumab/kg 
body weight for q3w dosing schedules or 2 mg trastuzumab/kg body weight for weekly 
dosing schedules.  Calculate the correct dose using  21 mg/mL trastuzumab solution.  
Withdraw this amount from the vial and add it to an infusion bag containing 250 mL of 
0.9% sodium chloride, USP.  DEXTROSE (5%) SOLUTION SHOULD NOT BE 
USED.  Gently invert the bag to mix the solution.  The reconstituted preparation results 
in a colorless to pale yellow transparent solution.  Parenteral drug products should be 
inspected visually for particulates and discoloration prior to administration. 
 
No incompatibilities between trastuzumab and polyvinylchloride or polyethylene bags 
have been observed. 
Trastuzumab should not be mixed or diluted with other drugs.  Trastuzumab 
infusions should not be administered or mixed with Dextrose solutions. 
 
8.2.2 Storage and Stability 
 
Vials of trastuzumab are stable at 2°C–8°C (36°F–46°F) prior to reconstitution.  Do not 
use beyond the expiration date stamped on the vial.  A vial of 440 mg trastuzumab 
reconstituted with BWFI, as supplied, is stable for 28 days after reconstitution when 
stored refrigerated at 2°C–8°C (36°F–46°F), and the solution is preserved for multiple 
use.  Discard any remaining multi-dose reconstituted solution after 28 days.  If 
unpreserved SWFI (not supplied) is used, the reconstituted trastuzumab solution should 
be used immediately and any unused portion must be discarded. A vial of 150 mg 
trastuzumab once reconstituted with SWFI should be used immediately, as it contains no 
preservative and is intended for single-dose only.  If not used immediately, store the 
reconstituted Herceptin solution for up to 24 hours at 2°C–8°C; discard any unused 
Herceptin after 24 hours. 
 
 DO NOT FREEZE TRASTUZUMAB THAT HAS BEEN RECONSTITUTED. 
 
The solution of trastuzumab for infusion diluted in polyvinylchloride or polyethylene 
bags containing 0.9% sodium chloride for injection, USP, may be stored at 2°C–8°C 
(36°F–46°F) for up to 24 hours prior to use.  Diluted trastuzumab has been shown to be 
stable for up to 24 hours at room temperature 15°C–25°C; however, since diluted 
trastuzumab contains no effective preservative the reconstituted and diluted solution 
should be stored refrigerated (2°C–8°C). 
 
8.2.3 Compatibility 
 

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49 
No incompatibilities between trastuzumab and polyvinylchloride, polyolefin or 
polypropylene bags have been observed. Dextrose 5% solution should not be used since it 
causes aggregation of the protein. Trastuzumab should not be mixed or diluted with other 
drugs. 
 
8.2.4 Handling 
 
Qualified personnel, familiar with procedures that minimize undue exposure to 
themselves and the environment, should undertake the preparation, handling, and safe 
disposal of the chemotherapeutic agent in a self-contained and protective environment.  
 
8.2.5 Availability 
 
Trastuzumab is an investigational agent and will be supplied free-of-charge from 
Genentech. 
 
8.2.6 Administration 
Trastuzumab will be administered in an outpatient setting.  The recommended initial 
loading dose for weekly administration is 4 mg/kg trastuzumab administered per 
institutional guidelines.  The recommended maintenance weekly trastuzumab dose is 2 
mg/kg and should be administered per institutional guidelines.  DO NOT ADMINISTER 
AS AN IV PUSH OR BOLUS (see ADMINISTRATION).   
The recommended initial loading dose for every 3 week administration is 8 mg/kg 
trastuzumab administered per institutional guidelines.  The recommended every 3 week 
maintenance trastuzumab dose is 6 mg/kg q3wk and should be administered per 
institutional guidelines.  Trastuzumab may be administered in an outpatient setting.  DO 
NOT ADMINISTER AS AN IV PUSH OR BOLUS (see ADMINISTRATION).   
 
Post-infusion observation periods may be done as per institutional guidelines.  If the 
previous loading dose or previous doses were well tolerated, the post-infusion 
observation time may be discontinued as per institutional guidelines. 
 
If trastuzumab is being administered concomitantly with chemotherapy, monoclonal 
antibody administration should precede chemotherapy administration.  Patients should be 
observed for fever and chills or other infusion-associated symptoms.  Refer to Sections 
5.3.1, 5.3.5, and 5.3.6 for more details. 
 
8.2.7 Ordering 
 
The investigator or those named as sub-investigators agree to supply study drug only to 
those subjects who are enrolled in the study. The investigator or designee will keep a 
current and accurate inventory of all clinical drug supplies provided by Genentech. The 
study site will maintain a dispensing log and compliance with the treatment regimen will 
be calculated at the site from this information at each visit. Each participating center will 

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order its own inventory of drug. Drug will be shipped directly to that participating site by 
Genentech. 
 
8.2.8 Drug Supplies and Accountability 
 
The investigator, or a responsible party designated by the investigator, should maintain a 
careful record of the inventory and disposition of the agent using the NCI Drug 
Accountability Record Form (DARF) or another comparable drug accountability form.   
 
8.2.9 Destruction and Return 
 
At the end of the study, unused supplies of pertuzumab should be destroyed according to 
institutional policies. Destruction will be documented in the Drug Accountability Record 
Form. 
 
8.3 
Paclitaxel 
 
8.3.1 Description, Form, and Preparation 
Paclitaxel is commercially available in 30 mg/5ml, 100 mg/16.7 ml, and 300 mg/50 ml 
multidose vials containing a clear colorless to slightly yellow viscous solution.  Each ml 
of sterile nonpyrogenic solution contains 6 mg of paclitaxel, 527 mg of purified 
Cremophor EL (polyoxyethylated castor oil), and 49.7% (v/v) dehydrated alcohol, USP.  
Please refer to the FDA-approved package insert for complete product information. 
Paclitaxel must be diluted before administration with 0.9% sodium chloride for injection, 
USP; 5% dextrose for injection, USP for a final concentration of 0.3 to 1.2 mg/ml.   
 
Paclitaxel should be prepared and stored in glass, polypropylene, or polyolefin containers 
because of the leaching of DEHP [di(2ethylhexyl)phthalate] plasticizer from polyvinyl 
chloride (PVC) containers.  Non-PVC-containing tubing and connectors should be used, 
such as the IV administration sets (polyethylene or polyolefin) used to infuse parenteral 
nitroglycerin.  In-line filtration should be accomplished by incorporating a hydrophilic, 
microporous filter of pore size not greater than 0.22 micron (e.g. IVEX-2) into the IV 
fluid pathway distal to the infusion pump.  The Chemo Dispensing Pin device and similar 
devices with spikes should not be used with vials of paclitaxel since they can cause the 
stopper to collapse, resulting in loss of sterile integrity of the paclitaxel solution. 
 
8.3.2 Storage and Stability 
 
Intact vials should be stored between 20°- 25°C (68°-77°F) in the original package to 
protect from light, and remain stable until the expiration date on the label. Neither 
freezing nor refrigeration adversely affects stability. Upon refrigeration components in 
the paclitaxel vial may precipitate, but will redissolve upon reaching room temperature 
with little or no agitation. There is no impact on product quality under these 
circumstances. If the solution remains cloudy or if an insoluble precipitate is noted, the 
vial should be discarded. Solutions for infusion prepared as recommended are stable at 

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ambient temperature (approximately 25°C) and lighting conditions for up to 27 hours. 
 
8.3.3 Compatibility 
 
Avoid the use of PVC bags and infusion sets due to leaching of DEHP (plasticizer). 
Ketoconazole may inhibit paclitaxel metabolism, based on in vitro data. Prescription of 
concomitant drugs should address the Launch Lexi-Interact™ Drug Interactions Program. 
 
8.3.4 Handling 
 
Qualified personnel, familiar with procedures that minimize undue exposure to 
themselves and the environment, should undertake the preparation, handling, and safe 
disposal of the chemotherapeutic agent in a self-contained and protective environment.  
 
8.3.5 Availability 
 
Paclitaxel is commercially available agent. Each institutional pharmacy should assure 
availability for the study. 
 
8.3.6 Administration 
 
Paclitaxel will be administered as an IV infusion with the use of an in-line 0.22-micron 
filter.  Refer to Section 5.3.3 for more details including the premedication regimen.  
 
8.3.7 Ordering 
 
Paclitaxel is a commercially available agent and therefore ordering should be performed 
as standard policy in the investigational site. 
 
8.3.8 Accountability 
Paclitaxel is a commercially available agent and therefore accountability should be 
performed as standard policy in the investigational site. 
 
8.3.9 Destruction and Return 
 
Discard unused portions of injectable chemotherapeutic agents that do not contain a 
bacteriostatic agent or that are prepared with unpreserved diluents (i.e., sterile water for 
injection, USP, or 0.9% sodium chloride for injection, USP) within 8 hours of vial entry 
to minimize the risk of bacterial contamination. 
 
8.4 
Doxorubicin 
 
8.4.1 Description, Form, and Preparation 
 
Commercially available as lyophilized powder for reconstitution in 10-, 20-, 50-, 100-and 
150-mg vials.  Also available as solution (2 mg/ml) in 10-, 20-, 50- and 200-mg vials for 

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injection.  Please refer to FDA-approved package insert for complete product 
information. 
 
Reconstitute the vials with 5, 10, 25, 50, or 75 ml, respectively, of sodium chloride for 
injection, USP. 
 
8.4.2 Storage and Stability 
 
Intact vials of doxorubicin should be stored in the refrigerator.  Intact vials of powder for 
reconstitution should be stored at room temperature.  Reconstituted solutions are stable 
for 7 days at room temperature and 15 days under refrigeration when protected from 
light.  Commercially available solutions labeled as such are intended to be multi-dose 
vials. 
 
8.4.3 Handling 
 
Qualified personnel, familiar with procedures that minimize undue exposure to 
themselves and the environment, should undertake the preparation, handling, and safe 
disposal of the chemotherapeutic agent in a self-contained and protective environment.  
 
8.4.4 Availability 
 
Doxorubicin is commercially available agent. Each institutional pharmacy should assure 
availability for the study. 
 
8.4.5 Administration 
 
Administer doxorubicin intravenously, either peripherally as a bolus injection or through 
a central venous line.  Avoid extravasation, since severe local tissue necrosis may result. 
Refer to Section 5.3.5 for more details.  
 
8.4.6 Ordering 
 
Doxorubicin is a commercially available agent and therefore ordering should be 
performed as standard policy in the investigational site. 
 
8.4.7 Accountability 
 
Doxorubicin is a commercially available agent and therefore accountability should be 
performed as standard policy in the investigational site. 
 
8.4.8 Destruction and Return 
 
Doxorubicin is a commercially available agent and therefore drug destruction should be 
performed as standard policy in the investigational site. 
 

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8.5 
Cyclophosphamide 
 
8.5.1 Description, Form, and Preparation 
 
Commercially available as powder for injection in 100-mg, 200-mg, 500-mg, 1-g, and 2-
g vials.  Please refer to the FDA-approved package insert for complete product 
information. 
 
Reconstitute 100-mg, 200-mg, 500-mg, 1-g, and 2-g vials with 5,10, 25, 50, or 100 ml of 
sterile water for injection respectively, for a final concentration of 20 mg/ml.  Vigorous 
shaking an/or gentle warming may be necessary.  Bacteriostatic water (paraben-preserved 
only) may also be used for reconstitution. 0.9% sodium chloride or 5% dextrose may also 
be used for reconstitution.   
 
8.5.2 Storage and Stability 
 
Store intact vials of powder at room temperature (15° to 30°C). Reconstitute lyophilized 
cyclophosphamide is chemically and physically stable for 24 hours at room temperature 
or for 6 days in the refrigerator (2° to 8°C).  It does not contain any antimicrobial 
preservative, and care must therefore be taken to ensure the sterility of prepared solution. 
 
8.5.3 Handling 
 
Qualified personnel, familiar with procedures that minimize undue exposure to 
themselves and the environment, should undertake the preparation, handling, and safe 
disposal of the chemotherapeutic agent in a self-contained and protective environment.  
 
8.5.4 Availability 
 
Cyclophosphamide is commercially available agent. Each institutional pharmacy should 
assure availability for the study. 
 
8.5.5 Administration 
 
Cyclophosphamide is administered via intravenous injection per institutional guidelines. 
Refer to Section 5.3.5 for more details.  
 
8.5.6 Ordering 
 
Cyclophosphamide is a commercially available agent and therefore ordering should be 
performed as standard policy in the investigational site. 
 
8.5.7 Accountability 
 
Cyclophosphamide is a commercially available agent and therefore accountability should 
be performed as standard policy in the investigational site. 

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54 
 
8.5.8 Destruction and Return 
 
Cyclophosphamide is a commercially available agent and therefore drug destruction 
should be performed as standard policy in the investigational site. 
 
9. BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 
 
9.1 
Biospecimen Collection 
 
Biopsies will be performed prior to treatment and after 1 week on treatment. If there is residual 
disease on gross exam, an additional sample of tissue will be obtained at the time of breast 
surgery. Collection guidelines are described in Section 9.4.  
Blood collection will also be done to look for potential interference with drug metabolites.  
Blood and biopsy sample acquisition, processing, and shipping details are outlined in section 9.3.  
 
Samples will be stored at the DF/HCC Core Blood and Tissue Bank until requested for further 
processing. RNA and DNA will be made from the core biopsy samples. Other genomic analysis 
may also be performed as part of a hypothesis generating practice. 
Tumor tissue may be stored at -80°C until exhaustion.  There are multiple checks on 
specimen/data quality at various steps in the procedure.  
 
9.2 
Tissue Studies 
 
9.2.1 Gene Expression Microarrays 
 
Frozen invasive breast adenocarcinoma is evaluated by frozen section to determine tumor 
percentage and stroma/fat and necrosis percentages.  An adjacent section of the tumor is 
homogenized and RNA is purified.  Tumor RNA and universal reference RNA are separately 
converted to cDNA and then to cRNA in which the tumor and reference are labeled with two 
different fluorescent dyes.  These two RNA populations are incubated together and compete for 
binding to an array surface covered by single stranded DNA 60-mers which represent multiple 
copies of nearly every human gene.  Analysis by the Agilent scanner produces data which 
indicates relative expression levels for all of the genes compared to the universal reference in 
known locations on the array.  A Single Sample Predictor (SSP) algorithm is applied to classify 
the tumor into one of the 5 major intrinsic subtypes of breast cancer. 54 
 
This analysis will take place in collaboration with Nanostring Technologies, whereby de-
identified tissue samples will be shared and analyzed.  
 
9.2.2 Cyclic Immunofluorescence (cyCIF) 
 
FFPE tissue samples collected from participants will be sectioned and assessed by IHC and/or IF 
assays for various markers, as deemed appropriate and informative.  

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This analysis will take place in collaboration with Dr. Peter Sorger at Harvard Medical School, 
whereby de-identified tissue samples will be shared and analyzed. 
 
9.2.3 Whole Exome, Whole Genome Sequencing, DNA Methylation 
 
All DNA sequencing will be performed at the Broad Institute; this may include SNP-arrays for 
germline genomic analyses, as well as exome and/or whole genome sequencing. Specimens may 
be assessed using the most current and informative methodologies at the time that correlative 
science is performed. Potential assays that may be performed on frozen or FFPE samples 
include: 
• Whole Genome sequencing depth of ≥ 40X coverage, or Whole Exome sequencing depth 
of ≥ 500X coverage.  
• AFFY SNP 6.0, or Illumina SNP arrays for genotypes and DNA copy number changes may 
be performed. 
• DNA methylation: Illumina Infinium 450K methylation arrays. 
 
 
9.3 
Circulating Biomarkers 
 
We plan to collect samples for analysis of circulating biomarkers, including ctDNA, on this 
clinical protocol and indicated in Section 2.7.2. Blood and biopsy sample acquisition, processing, 
and shipping details are outlined in Section 9.3. We will evaluate associations between change in 
ctDNA during therapy and residual disease at the time of definitive surgery. In addition we will 
be able to explore genotypic and phenotypic changes that occur during therapy, which may yield 
insights into mechanisms underlying resistance to therapy. 
 
Samples will be stored at the DF/HCC Core Blood and Tissue Bank until requested for 
processing, at DF/HCC or the Broad Institute. Samples transferred to the Broad will be de-
identified specimens. 
 
 
 
9.4 
Sample Acquisition 
 
TABLE 7. Specimen Collection 
 
 
Baseline 
(at screening or on 
Week 1 (Day 1) 
prior to tx start) 
Pre-Operative 
Therapy  Week 2 
(Day 8 prior to tx) 
After 
paclitaxel Pre-
operatively 
Surgery 
Post 
mastectomy 
Ship to 
Lavender Top 
Blood Sample 
x 
 
 
 
 
DFCI 
Lab 
Streck Tubes 
x 
 
x 
 
x 
 
x 
DFCI Lab 

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Breast Tissue 
x 
x 
 
Xa 
 
 
DFCI 
Lab and 
Michigan 
Lab  
a If adequate residual disease present; per pathology discretion  
 
 
9.4.1 Blood Samples 
 
a. Lavender Top Blood Sample  
 
One 10mL lavender top (EDTA Fisher #366643) tube of whole blood will be collected at 
baseline or on Week 1, Day 1 prior to treatment start.  This specimen will become the 
property of the DF/HCC.  Participants will be informed that their specimens may be used 
for future research by DF/HCC investigators. Specimens will be identified with a linked 
sample ID number; all participant identification will be removed. 
 
Following blood collection, label the specimens with the assigned DFCI participant study 
ID, date of collection, time point of collection, and protocol number. Include a copy of 
the 12-497 DFCI Specimen Requisition Form (Appendix D) with your shipment.  
 
All blood samples should be shipped ambient overnight Monday through Thursday at 
ambient temperature by either FedEx or UPS to: 
 
DF/HCC Core Blood and Tissue Bank 
Dana-Farber Cancer Institute 
Rm: SM 956 
450 Brookline Ave 
Boston, MA 02215 
 
If blood specimens must be collected on Friday, the specimens should be stored over the 
weekend and shipped on Monday.  When storing tubes over a weekend, lavender top 
tubes should be frozen at -80oC until shipment. 
 
Email the DFCI study coordinator, Grace Winship, and Project Managers with the sample 
information and tracking information the day before shipping specimens: 
gwinship@partners.org and ctopm@dfci.harvard.edu.  
 
b. Streck Tubes 
 
Circulating biomarkers will be collected via two 10 mL Streck tubes each at the 
following time points: 
 
• Week 1 (Day 1): Before the start of trastuzumab and pertuzumab 
• Week 2  (Day 8): Before the start of paclitaxel, trastuzumab and pertuzumab 
• After completing  paclitaxel preoperatively  
• At the first visit post-mastectomy 

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Streck tubes are to be kept at room temperature, and centrifuged within 2 hours of 
collection if possible.  
 
• Place Streck Cell-Free Blood Collection Tubes in centrifuge with swinging-out rotor 
and appropriate buckets.  
• Centrifuge blood samples for 10 min at 1900 x g [3000 rpm] at room temperature.  
• Carefully collect plasma supernatant without disturbing the buffy coat layer. About 
4–5ml of plasma can be obtained from one 10 ml primary blood tube. 
• Aspirated plasma is transferred into multiple labeled 1.5 or 2mL RNase/DNase free 
tubes for use with the Beckman Coulter Microfuge 22R, or transfer aspirated plasma 
into fresh 15 ml centrifuge tubes with conical bottom for use with the Sorvall RC5C 
plus (*Check RCF factor of 15mL tubes).  
• Centrifuge plasma samples for 10 min at 16,000 x g [in fixed-angle rotor] at room 
temperature setting. This will remove additional cellular nucleic acids attached to cell 
debris. Carefully remove plasma supernatant without disturbing any possible debris at 
the bottom of each tube. There will end up being residual volume of plasma that is 
not used.   
• Store plasma and buffy coat at -80°C freezer in RNase/DNase free tubes in 1-5mL 
aliquots until shipment.  
• Label the specimens with the assigned DFCI participant study ID, date of collection, 
time point of collection, and protocol number.  
 
Samples will be stored in the Core Blood and Tissue bank until requested for processing. 
 
9.4.2 Biopsy Collection 
Core needle tumor biopsies (14-gauge) will be acquired with 5-8 cores each at the 
following timepoints: 
 
• Week 1 (Day 1): Before the start of trastuzumab and pertuzumab 
• Week 2 (Day 8): Before the start of paclitaxel, trastuzumab and pertuzumab 
• If adequate residual tumor is present (per pathology discretion) in the mastectomy 
specimen, samples of it will also be obtained.  
 
a. Processing biopsy samples for DFCI: 
Following biopsy collection, use at minimum 4 core samples for research at DFCI (one 
core will be used for research at Michigan). The tissue will be immediately snap-frozen 
in dry ice and stored at -80°C with the suggested supplies and procedure listed below.  
The tumor section size should be about 20 mg. Only residual tumor measuring > 1 cm 
found within the mastectomy specimen will be snap frozen in dry ice and stored at -80°C. 
• Supplies: 
o Tissue-Tek Cryomold,  

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 Standard size 25x20x5mm (#4557), Fisher Scientific Cat# NC9511236 
-OR- 
 Intermediate size 15x15x5mm (#4566), Fisher Scientific Cat# 
NC9542860 
o Tissue-Tek O.C.T. Compound, 4oz (#4583): Fisher Scientific Cat# 
NC9638938 
o Small specimen bag: Fisher Cat# 01-002-37 (or equivalent) 
o Forceps: Fisher Cat# NC9832137 (or equivalent) 
o Dry Ice and Cooler 
o Cryoware Pen: Fisher Cat# 13-382-88 
 
• Procedure: 
o Prepare cryomolds ahead of time: Squeeze small amount of OCT into 
cyromolds* – enough for there to be a thin layer covering the bottom let settle 
on a flat surface for a minute or two. It is crucial for future sectioning that 
these core biopsies are placed on a very flat OCT surface, so the best way to 
make sure these mold are flat is the freeze the bottom layer on a -80 freezer 
shelf.  
 *If time permits, the cryomolds can be placed onto the dry-ice once a 
thin layer of OCT has been put it but before the tissue is put in. Once 
this is frozen or begins to freeze, the tissue can be placed on top of the 
now frozen OCT and then covered with more liquid OCT and then 
placed back onto the dry ice to freeze completely.  
o Bring all supplies needed to the biopsy as the tissue needs to be frozen 
immediately.  
o As soon as the specimen is ready, use disposable forceps to gently place only 
1 core into each cryomold. Gently pick up the tissue with the forceps from one 
end of the core biopsy, being careful not to crush the tissue and immediately 
lay out the fresh biopsy tissue onto the center of the mold. Be sure to lay the 
tissue as flat to the mold, and as straight as possible. Keep molds on dry ice at 
all times. 
o You should ideally collect between 3 and 5 separate cores. 
o Once the specimen is in the cryomold, cover with more OCT making sure the 
tissue is entirely submerged.  
o Immediately place cryomold with OCT and tissue onto dry-ice making sure 
the cryomold is level and will not tip over.  
o The OCT will freeze into a solid white block within 5-10 minutes 
o Once the blocks have completely frozen they can be put into a specimen bag 
and sealed. More than one block can be put into a bag. 
o The bag should be labeled with: 
 Patient name 
 DFCI Study #: 12-497 
 DFCI MRN # 
 Date of biopsy 
 Time Point (Biopsy #1, Biopsy #2, or Surgery) 

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 Number of blocks in the bag 
o Samples should be kept on dry ice at all times until they can be placed in a -
80oC freezer. Samples should remain frozen at -80oC until shipment. 
 
All biopsy samples should be shipped frozen overnight Monday through Thursday at 
frozen temperature by either FedEx or UPS to: 
 
DF/HCC Core Blood and Tissue Bank 
Dana-Farber Cancer Institute 
Rm: SM 956 
450 Brookline Ave 
Boston, MA 02215 
 
If biopsy specimens must be collected on Friday, the specimens should be stored over the 
weekend and shipped on Monday.  When storing tubes over a weekend, biopsy tubes 
should be frozen at -80oC until shipment. 
 
Email the DFCI study coordinator, Grace Winship, and Project Managers with the sample 
information and tracking information the day before shipping specimens: 
gwinship@partners.org and ctopm@dfci.harvard.edu.  
 
b. Processing biopsy samples for Michigan: 
 
From the biopsy samples obtained above, at most one core from each time point will be 
used for Michigan samples (i.e., Week 1 (Day 1), Week 2 (Day 8), and residual tumor). 
Place the pieces separately into 2 ml cryogenic vials, then add 90% FBS and 10% DMSO 
to the vials so the will be slowly frozen. Place the vials on dry ice. 
 
Following processing, label the specimens with the assigned DFCI participant study ID, 
date of collection, time point of collection, and protocol number.  
 
Samples will be shipped frozen to Dr. Merajver’s laboratory overnight as soon as 
possible post-biopsy.  Include a copy of the 12-497 Michigan Specimen Requisition 
Form (Appendix E) with your shipment.  
Dr ZhiFen Wu 
c/o Merajver Lab 
7121 CC 
1500 East Medical Center Drive 
Ann Arbor, MI 48109 
 
9.5 
Future Use of Biospecimens and Data  
 
All biospecimens and data will be banked for future research and may be made available to other 
researchers for proposed research projects. These projects will be approved by the PI, Breast 
Users Committee, and/or the IRB, as appropriate.   

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9.6 
Consent to Sharing and Future Use 
 
In November 2019, the protocol and consent form were updated with language about correlative 
plans due to new regulations pertaining to the use of biospecimens and data in collaboration with 
external entities. At the time of this amendment, all samples have been collected and no 
participants remain on active treatment. In total, 23 participants took part on this study; currently 
2 participants have passed away and 1 participant is lost to follow-up. Therefore, notification of 
deceased subjects is not feasible and locating the lost participant likely puts them at a larger risk 
than in sharing their de-identified samples for analysis. As such, the study team would like to 
move forward with utilizing these participant’s samples as described in Section 9.0 given the 
lack of feasibility in notification of this new information.  
 
The study team will practice due diligence in locating and notifying the remaining 20 subjects by 
letter. Should the patient actively decline this information, samples and data will not be shared. If 
due diligence is exercised and the patient cannot be reached, the study team would like 
permission to share these de-identified samples and data, given that it puts the patient at no more 
than minimal additional risk.  
 
 

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10. STUDY CALENDAR 
 
Baseline evaluations are to be conducted within 28 days prior to registration except pregnancy 
test (within 14 days prior to registration).  Baseline scans must be done <4 weeks (28 days) prior 
to registration.  In the event that the participant’s condition is deteriorating, laboratory 
evaluations should be repeated within 48 hours prior to initiation of the next cycle of therapy. 
 
During pre-operative therapy, patients will be seen by exam at Week 1, Week 2, and each time 
point they receive Pertuzumab (i.e., week 4, week 7, week 10, week 13, week 16, and then every 
three weeks during pertuzumab/trastuzumab therapy prior to surgery). The pre-surgical 
evaluation is to be done at week 18. or at the conclusion of pertuzumab/trastuzumab, as this 
therapy may be given after week 16 per investigator discretion.  
 
Assessments must be performed prior to administration of any study agent. Study assessments 
and agents should be administered according to the schedule below, unless otherwise noted.

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TABLE 8: Study Calendar 
 
Screening 
Preoperative Therapy 
Pre-Surgical 
Evaluation 
Post-Operative 
Therapy Option 1 
(AC) 
Maintenance Therapy  
Options 1 and 2  
(H/P) 
Follow-up g 
(+/- 1 month) 
Tests and Procedures 
≤28 Days 
Prior to 
Registration 
Wk 1  
(Day 1) 
Wk 2 to  
Wk 16 
Wk 18 
(+/- 1 wk) 
Complete medical history 
x 
 
 
 
 
 
 
Complete physical exam, 
including tumor 
assessment 
x 
x 
Wk 2, Wk 4, then 
Every 3 wks 
(+/- 2 days) 
x 
Every 2 to 3 wks 
(+/- 2 days) 
Every 9 wks 
(+/- 1 wk) and at last 
treatment 
 
Weight, vital signs, height, 
and ECOG PS 
x 
x 
x 
 
Toxicity evaluation 
x 
x 
x 
 
EKG (12 lead) 
x 
 
 
x 
 
 
 
Clinical breast imaging a 
x 
 
 
x 
 
 
xh 
PET/CT, CT of 
Chest/Abdomen/Pelvis 
x 
 
 
xi 
 
 
 
MUGA or  
Echocardiogram b 
x 
 
 
x 
 
Before H/P start,  
Every 12 wks  
(+/- 1 wk)f 
 
Serum pregnancy testc 
x e 
 
 
 
 
 
 
Hematology (CBC with 
differential) 
x 
 
Weekly 
(+/- 2 days) 
x 
Every 2 to 3 wks 
(+/- 2 days) 
Every 9 wks 
(+/- 1 wk) 
 
Serum chemistry d 
x 
 
x 
 
PT/INR/PTT 
x 
 
 
 
 
 
 
Survival status 
 
 
 
 
 
 
x 
Research Specimens 
(Blood, Biopsy, or Tissue  
(See Section 9.3) 
x 
x 
x 
x 
x 
x 
 
AC= doxorubicin/cyclophosphamide 
 
H/P= Trastuzumab and Pertuzumab 
a Breast imaging includes a bilateral MRI, Mammogram, and ultrasound if indicated. 
b Cardiac evaluations should consistently use one modality across all study evaluations.  
c Women of childbearing potential. 
 d Sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose, total protein, albumin, total bilirubin, SGOT(AST), 
SGPT(ALT), alkaline phosphatase. 

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e Serum pregnancy testing at screening is required within 14 days prior to registration.  
f If Option 2, pre-surgical MUGA/ECHO can be used; does not require repeating prior to H/P start. Further MUGA/ECHOs every 12 
weeks from Day 1 of H/P maintenance therapy (Section 5.3.6).  
gSee section 5.6. 
hBreast imaging per standard practice recommendations.  
i PET/CT and/or CT required for Stage 4 disease; otherwise optional  
 

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11. MEASUREMENT OF EFFECT 
 
Inflammatory breast disease is considered non-measurable.  The major effect to be measured in 
this study is the tumor/pathological response and response on exam to study drugs. 
 
11.1 
Antitumor Effect 
 
A baseline and presurgical imaging study of the breast is required; mammogram, ultrasound (if 
indicated), and bilateral MRI.  The baseline imaging must be obtained within 28 days prior to 
registration.  The pre-surgical imaging should occur at week 18 +/- 1 week during pre-operative 
treatment.  Patients will also be examined at baseline within 28 days prior to registration, every 3 
weeks during pre-operative treatment with Trastuzumab, Pertuzumab, and Paclitaxel, and again 
at week 18 (+/- 1 week).  Photographs of the affected breast may be obtained.    
 
If the patient demonstrates clinical progression at any time, repeat imaging may be necessary.  If 
there is discordance (clinical progression, but radiographic stable disease or response), the study 
PI should be contacted to solve the discordance. 
 
Tumor response will be evaluated based upon resolution of edema, erythema and any density 
palpable within the effected breast.   
 
11.1.1 Evaluable for objective response definition.  
 
All participants who initiate the preoperative treatment phase will be considered as 
evaluable for the two preoperative treatment endpoints.  
 
11.1.2 Disease Parameters 
 
Non-measurable disease.  Inflammatory breast disease is considered non-measurable. 
 
Non-target lesions.  All other lesions, including small lesions < 10 mm or pathological 
lymph nodes measuring > 10 mm to < 15 mm in short axis, as well as truly non-
measurable lesions, which include inflammatory breast disease. 
 
11.1.3 Response Criteria 
 
Pathologic Complete Response pCR  
 
Complete pathologic disease response (pCR) is defined as absence of invasive carcinoma 
within the breast and axillary lymph nodes following preoperative THP therapy. 
Participants whose disease is not surgically resectable following preoperative treatment 
are considered as not having pCR. 
 
Residual cancer burden (RCB)  
 
RCB after preoperative therapy will be determined, as defined by Symmans et al.36  

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Clinical Progressive Disease 
 
Subjects, who in the opinion of the treating physician investigator have had a substantial 
decline in their performance status and have clinical evidence of progressive disease may 
be classified as having progressive disease. 
 
 
11.1.4 Evaluable for Toxicity 
 
All participants who receive at least one dose of study treatment will be evaluable for 
toxicity from the time of their first treatment. 
 
11.1.5 Disease-Free Survival(DFS), Time to Treatment Failure (TTF), and Overall Survival 
(OS)  
 
• Disease-free survival (DFS) will be defined among participants who undergo surgery, 
as the duration of time from surgery until ipsilateral local-regional, contralateral or 
distant invasive recurrence or death from any cause; in the absence of an event, DFS 
will be censored at the date last know alive and free from recurrence. 
• Time to treatment failure (TTF) will be defined among all participants, as the duration 
of time from treatment initiation to a DFS event or progressive disease during 
preoperative therapy or treatment disease that is not surgically resectable; in the 
absence of an event, TTF will be censored at the date last know alive and free from 
recurrence or progression. 
• Overall survival (OS) will be defined among all participants, as the duration of time 
from treatment initiation to death from any cause, or is censored at date last known 
alive. Post-surgery OS will be defined among the participants who undergo surgery, 
as the duration of time from treatment initiation to death from any cause, or is 
censored at date last known alive. 
 
12. DATA REPORTING / REGULATORY REQUIREMENTS 
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.0 
(Adverse Events: List and Reporting Requirements). 
 
12.1 
Data Reporting 
 
12.1.1 Method 
 
The ODQ will collect, manage, and perform quality checks on the data for this study. 
 
12.1.2 Responsibility for Data Submission 
 
Investigative sites within DF/HCC or DF/PCC are responsible for submitting data and/or 
data forms to the ODQ according to the schedule set by the ODQ. 

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12.2 
Data Safety Monitoring 
 
The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor toxicity 
and accrual data from this study. The committee is composed of clinical specialists with 
experience in oncology and who have no direct relationship with the study. Information that 
raises any questions about participant safety will be addressed with the Overall PI and study 
team. 
 
The DSMC will review each protocol up to four times a year or more often if required to review 
toxicity and accrual data. Information to be provided to the committee may include: up-to-date 
participant accrual; current dose level information; DLT information; all grade 2 or higher 
unexpected adverse events that have been reported; summary of all deaths occurring with 30 
days of intervention for Phase I or II protocols; for gene therapy protocols, summary of all deaths 
while being treated and during active follow-up; any response information; audit results, and a 
summary provided by the study team. Other information (e.g. scans, laboratory values) will be 
provided upon request.  
 
12.3 
Multicenter Guidelines 
 
This protocol will adhere to the policies and requirements of the DF/HCC Multi-Center Data and 
Safety Monitoring Plan.  The specific responsibilities of the Overall PI, Coordinating Center, and 
Participating Institutions and the procedures for auditing are presented in Appendix C. 
 
• The Overall PI/Coordinating Center is responsible for distributing all IND Safety Reports 
to all participating institutions for submission to their individual IRBs for action as 
required. 
 
• Mechanisms will be in place to ensure quality assurance, protocol compliance, and 
adverse event reporting at each site. 
 
• Except in very unusual circumstances, each participating institution will order the study 
agent(s) directly from supplier.  A participating site may order the agent(s) only after the 
initial IRB approval for the site has been forwarded to the Coordinating Center. 
 
12.4 
Collaborative Research and Future Use of Data and Samples 
 
Tissue, blood, and other materials derived from these will be collected in this study to analyze 
genes, DNA, RNA, proteins and cells for the study’s correlative endpoints and potential future 
research, utilizing new types of biomarker testing as it becomes available.  
 
These samples and any data generated as a part of these clinical trials may be used for future 
research studies and may be provided to collaborating investigators both within and outside of the 
DF/HCC for either correlative endpoints or secondary use. Samples and data may be shared with 
outside non-profit academic investigators, as well as with for-profit pharmaceutical investigators 
or commercial entitites, with whom we collaborate. When samples or data are sent to collaborators 

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67 
and when any research is performed on them, all information will be identified with a code, and 
will not contain any PHI, such as name, birthday, or MRNs.  
 
In order to allow the greatest amount of research to be performed on the specimens and information 
generated as a part of this trial, researchers in this study may share results of genetic sequencing 
with other scientists. De-identified specimen or genetic data may be placed into one of more 
publicly-accessible scientific databases, such as the National Institutes of Health’s Database for 
Genotypes and Phenotypes (dbGaP). The results from the correlative research on this study will 
be shared with these public databases. Through such databases, researchers from around the world 
will have access to de-identified samples or data for future research. More detailed information, 
beyond the public database, may only be accessed by scientists at other research centers who have 
received special permission to review de-identified data. 
 
13. STATISTICAL CONSIDERATIONS 
 
13.1 
Study Design/Endpoints 
 
The primary objective of this phase II trial is to determine pathologic complete response (pCR) 
rate after preoperative therapy with combination paclitaxel (T), trastuzumab (H) and pertuzumab 
(P) in HER2+ inflammatory breast cancer, as well as to assess the residual cancer burden (RCB) 
after preoperative therapy. Participants are enrolled using a single-arm, two-stage Simon 
minimax design. 
 
Following surgery, participants will be treated with 4 cycles of adjuvant AC chemotherapy, as 
per physician preference, and HP for 12 a total of 12 months; radiation therapy and endocrine 
therapy are given according to standard of care. Participants will be followed post-therapy for 
recurrence and survival (see Section 10). Efficacy of protocol therapy, defined as disease-free 
survival (DFS), time to treatment failure (TTF), and overall survival (OS), will be assessed. 
 
For correlative studies, research biopsies and whole blood will be obtained prior to start of 
preoperative therapy, and prior to day 8 of preoperative therapy. A sample of residual disease 
within the breast at time of surgery will be obtained. 
 
13.2 
Design and Sample Size 
 

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The study was planned using Simon minimax two-stage design. Pathologic complete response 
(pCR) is the primary endpoint. We propose that if the proportion of participants experiencing 
pCR is ≤ 0.15 then the preoperative THP regimen is considered minimally effective, versus an 
alternative hypothesis that the TPH regimen is worthy of further study if proportion pCR ≥ 0.40. 
After testing the regimen on 16 participants in the first stage, the study will be terminated if ≤ 2 
have pCR, and will proceed if ≥ 3 of 16 have pCR. If the study goes on to the second stage, the 
regimen is rejected as not if ≤7 of 27 participants in total have pCR. If the preoperative THP 
regimen is actually not effective, there is an α=0.039 probability of concluding that it is (target 
α=0.05); if the THP regimen is actually effective, there is an 0.099 probability of concluding that 
it is not (target β=0.10). Up to 30 participants will be enrolled, allowing up to 3 participants not 
evaluable for the pCR endpoint (see below). 
 
13.3 
Analysis of Primary Endpoints 
 
Primary endpoint definitions  
• Pathologic complete response (pCR) is defined as absence of invasive carcinoma within 
the breast and axillary lymph nodes following preoperative THP treatment.  Participants 
whose disease is not surgically resectable following preoperative THP treatment are 
considered as not having pCR. 
• Residual Cancer Burden following preoperative treatment is defined according to 
Symmans et al53.  
• All participants who initiate the preoperative treatment phase will be considered as 
evaluable for the two preoperative treatment endpoints.  
Statistical analysis  
• The number and proportion of participants achieving pCR following preoperative THP 
treatment will be summarized with 90% confidence interval (CI) that accounts for the 
two-stage design.   
• The number and proportion of participants achieving RCB-0, I, II, III will be summarized 
with 90% exact binomial CI. 
 
13.4 
Analysis of Secondary Endpoints, Reporting and Exclusions 
 
13.4.1 Evaluation of Toxicity 
 
The frequencies of adverse events (AE) while on study treatment will be summarized and 
tabulated according to treatment phase (preoperative vs. post-surgical), and at any time. 
Enrolled patients who received at least one dose of study treatment will be included in the 
analyses. 
 
13.4.2 Efficacy of Protocol Therapy 
 
• Disease-free survival (DFS) will be defined among participants who undergo surgery, 
as the duration of time from surgery until ipsilateral local-regional, contralateral or 

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69 
distant invasive recurrence or death from any cause; in the absence of an event, DFS 
will be censored at the date last know alive and free from recurrence. 
• Time to treatment failure (TTF) will be defined among all participants, as the duration 
of time from treatment initiation to a DFS event or progressive disease during 
preoperative therapy or treatment disease that is not surgically resectable; in the 
absence of an event, TTF will be censored at the date last know alive and free from 
recurrence or progression. 
• Overall survival (OS) will be defined among all participants, as the duration of time 
from treatment initiation to death from any cause, or is censored at date last known 
alive. Post-surgery OS will be defined among the participants who undergo surgery, 
as the duration of time from treatment initiation to death from any cause, or is 
censored at date last known alive. 
Time-to-event distributions will be summarized using the method of Kaplan-Meier and 
two-sided 90% CI for the medians will be summarized. Exploratory analyses will 
summarize DFS and post-surgery OS distributions according to pCR and of RCB, and 
estimates hazards ratios with 90% CI using Cox proportional hazards models.  
 
13.4.3 Correlative Studies 
 
• PAM50 analysis will be performed on the pre-treatment biopsy specimen. 
Participants’ pCR will be tabulated according to the intrinsic subtype with 90% CI, 
and the association of intrinsic subtype (HER2-enriched vs. other) with pCR will be 
assessed using Fisher’s exact test.  
• Gene expression profiling will be assessed on pre-treatment and day-8 biopsies to 
identify early adaptive responses that are associated with resistance to HER2 directed 
therapies. Differential expression analysis, using standard procedures in 
R/Bioconductor package limma, will seek expression at either time point, or changes 
in expression between time points, consistently associated with pCR.   
• Residual disease within the breast at time of mastectomy will be assessed by PAM50 
and microarray analysis. Changes in gene expression, including those genes used for 
definition of intrinsic subtype, will be analyzed to investigate the intrinsic subtype of 
the resistance clone with residual disease.    
• Samples will be collected for analysis of circulating biomarkers, including ctDNA. 
Associations between change in ctDNA during therapy and residual disease at the 
time of definitive surgery will be evaluated.  
 
14. PUBLICATION PLAN 
 
The results should be made public within 24 months of reaching the end of the study. The end of 
the study is the time point at which the last data items are to be reported, or after the outcome 
data are sufficiently mature for analysis, as defined in the section on Sample Size, Accrual Rate 
and Study Duration. If a report is planned to be published in a peer-reviewed journal, then that 
initial release may be an abstract that meets the requirements of the International Committee of 
Medical Journal Editors. A full report of the outcomes should be made public no later than three 

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(3) years after the end of the study.  
 
 

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APPENDIX A.  LVEF ASSESSMENTS ALGORITHM 
Algorithm for Continuation and Discontinuation of Pertuzumab and Trastuzumab Based on LVEF Assessments. 

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APPENDIX B.  GENENTECH SAFETY REPORTING FAX COVER SHEET 
 
 
 
 
SAFETY REPORTING FAX COVER SHEET 
 
Genentech Supported Research 
 
AE / SAE FAX No: (650) 225-4682 
 
Alternate Fax No: (650) 225-5288 
 
Genentech Study Number 
 
 
Principal Investigator 
 
 
Site Name 
 
 
Reporter name 
 
 
Reporter Telephone # 
 
 
Reporter Fax # 
 
 
 
Initial Report Date 
[DD] / [MON] / [YY] 
 
Follow-up Report Date 
[DD] / [MON] / [YY] 
 
 
Subject Initials 
(Enter a dash if patient has no 
middle name) 
[ ] - [ ] - [ ] 
 
 
SAE or Safety Reporting questions, contact Genentech Safety: (888) 835-2555 
 
PLEASE PLACE MEDWATCH REPORT or SAFETY REPORT BEHIND THIS COVER 
SHEET 
 
 

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APPENDIX C. DF/HCC MULTI-CENTER DATA AND SAFETY MONITORING PLAN 
 
 
 
 
 
 
DFCI IRB Protocol #: 12-497 
 
 
 
 
 
APPENDIX C 
 
Dana-Farber/Harvard Cancer Center 
Multi-Center Data and Safety Monitoring Plan 
 
 

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TABLE OF CONTENTS 
 
1. INTRODUCTION 
 
1.1 Purpose 
 
1.2 Multi-Center Data and Safety Monitoring Plan Definitions 
 
1. GENERAL ROLES AND RESPONSIBILITIES 
 
2.1 DF/HCC Sponsor 
 
2.2 Coordinating Center  
 
2.3 Participating Institution 
 
2. DF/HCC REQUIREMENTS FOR MULTI-CENTER PROTOCOLS 
 
3.1 Protocol Distribution 
 
3.2 Protocol Revisions and Closures 
 
3.3 Informed Consent Requirements 
 
3.4 IRB Documentation 
 
3.5 IRB Re-Approval 
 
3.6 Participant Confidentiality and Authorization Statement 
 
3.7 DF/HCC Multi-Center Protocol Registration Policy 
 
3.8 DF/HCC Protocol Case Number 
 
3.9 Safety Assessments and Toxicity Monitoring 
 
3.10 Data Management 
 
3.11 Data Forms Review 
 
3. REQUISITIONING INVESTIGATIONAL DRUG 
 
4. MONITORING: QUALITY CONTROL 
 
5.1 Ongoing Monitoring of Protocol Compliance 
 

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5.2 Monitoring Reports 
 
5.3 Accrual Monitoring 
 
5. AUDITING: QUALITY ASSURANCE 
 
6.1 Audit Plan: DF/HCC Sponsored Trials 
 
6.2 Audit Notification 
 
6.3 Audit Reports  
 
6.4 Participating Institution Performance 
 
 

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1.  INTRODUCTION 
 
The Dana-Farber/Harvard Cancer Center Multi-Center Data and Safety Monitoring Plan (DF/HCC 
DSMP) outlines the procedures for conducting a DF/HCC Multi-Center research protocol. The 
DF/HCC DSMP should serve as a reference for any sites external to DF/HCC that will be 
participating in the research protocol. 
 
1.1  
Purpose 
 
To establish standards that will ensure that a Dana-Farber/Harvard Cancer Center Multi-Center 
protocol will comply with Federal Regulations, Health Insurance Portability and Accountability 
Act (HIPAA) requirements and applicable DF/HCC Standard Operating Procedures. 
 
1.2  
Multi-Center Data and Safety Monitoring Plan Definitions 
 
DF/HCC Multi-Center Protocol:  A research protocol in which one  or more outside institutions 
are collaborating with Dana-Farber/Harvard Cancer Center where  a DF/HCC investigator is the 
sponsor. DF/HCC includes Dana-Farber/Partners Cancer Care (DF/PCC) Network Clinical Trial 
Affiliates.  
 
Lead Institution:  One of the Dana-Farber/Harvard Cancer Center consortium members (Dana-
Farber Cancer Institute (DFCI), Massachusetts General Hospital (MGH), Beth Israel Deaconess 
Medical Center (BIDMC), Boston Children’s Hospital (BCH), Brigham and Women’s Hospital 
(BWH)) responsible for the coordination, development, submission, and approval of a protocol as 
well as its subsequent amendments per the DFCI IRB and applicable regulatory guidelines (CTEP, 
Food and Drug Administration (FDA), Office of Biotechnology Activities (OBA) etc.).  The Lead 
Institution is typically the home of the DF/HCC Sponsor. The Lead Institution also typically serves 
as the Coordinating Center for the DF/HCC Multi-Center Protocol.   
 
DF/HCC Sponsor:  The person sponsoring the submitted Multi-Center protocol.  Within 
DF/HCC, this person is the Overall Principal Investigator who takes responsibility for initiation, 
management and conduct of the protocol at all research locations. In applicable protocols, the 
DF/HCC Sponsor will serve as the single liaison with any regulatory agencies (i.e. FDA)The 
DF/HCC Sponsor has ultimate authority over the protocol and is responsible for the conduct of the 
study at DF/HCC and all Participating Institutions. In most cases the DF/HCC Sponsor is the same 
person as the DF/HCC Overall Principal Investigator; however, both roles can be filled by two 
different people.  
 
Participating Institution:  An institution that is outside the DF/HCC and DF/PCC consortium 
that is collaborating with DF/HCC on a protocol where the sponsor is a DF/HCC Investigator.  The 
Participating Institution acknowledges the DF/HCC Sponsor as having the ultimate authority and 
responsibility for the overall conduct of the study.    
 
Coordinating Center: The entity (i.e. Lead Institution, Medical Monitor, Contract Research 
Organization (CRO), etc) that provides administrative support to the DF/HCC Sponsor in order 
that he/she may fulfill the responsibilities outlined in the protocol document and DSMP, and as 

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specified in applicable regulatory guidelines (i.e. CTEP Multi-Center Guidelines). In general, the 
Lead Institution is the Coordinating Center for the DF/HCC Multi-Center Protocol. Should the 
DF/HCC Sponsor decide to use a CRO, the CRO will be deemed the Coordinating Center.   
 
DF/HCC Quality Assurance Office for Clinical Trials: A group within DF/HCC responsible 
for registering human subjects for trials, ensuring high-quality standards are used for data 
collection and the ongoing management of clinical trials, auditing, and data and safety monitoring. 
ODQ also coordinates quality assurance efforts related to multi-center clinical research. 
 
2. GENERAL ROLES AND RESPONSIBILITIES 
 
For DF/HCC Multi-Center Protocols, the DF/HCC Sponsor, the Coordinating Center, and the 
Participating Institutions are expected to adhere to the following general responsibilities:  
 
2.1  
DF/HCC Sponsor 
 
The DF/HCC Sponsor, Filipa Lynce, MD will accept responsibility for all aspects of conducting a 
DF/HCC Multi-Center protocol which includes but is not limited to:  
• Oversee the coordination, development, submission, and approval of the protocol as well 
as subsequent amendments.  
• Ensure that the investigators, study team members, and Participating Institutions are 
qualified and appropriately resourced to conduct the protocol.   
• Include the Multi-Center Data and Safety Monitoring Plan as an appendix to the protocol. 
• Ensure all Participating Institutions are using the correct version of the protocol. 
• Ensure that each participating investigator and study team member receives adequate 
protocol training and/or a Site Initiation Visit prior to enrolling participants and throughout 
trial’s conduct as needed. 
• Ensure the protocol will be provided to each participating site in a language understandable 
to all applicable site personnel when English is not the primary language.  
• Monitor progress and overall conduct of the study at all Participating Institutions.  
• Ensure all DFCI Institutional Review Board (IRB), DF/HCC and other applicable (i.e. 
FDA) reporting requirements are met.  
• Review data and maintain timely submission of data for study analysis.  
• Act as the single liaison with FDA (investigator-held IND trials), as applicable. 
• Ensure compliance with all requirements as set forth in the Code of Federal Regulations, 
applicable DF/HCC requirements, HIPAA requirements, and the approved protocol. 
• Commit to the provision that the protocol will not be rewritten or modified by anyone other 
than the DF/HCC Sponsor. 
• Identify and qualify Participating Institutions and obtain accrual commitments prior to 
extending the protocol to that site. 
• Monitor accrual and address Participating Institutions that are not meeting their accrual 
requirements.  
 
2.2  
Coordinating Center  
 

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The general responsibilities of the Coordinating Center may include but are not limited to: 
• Assist in protocol development.  
• Maintain FDA correspondence, as applicable. 
• Review registration materials for eligibility and register participants from Participating 
Institutions with DF/HCC ODQ. 
• Distribute protocol and informed consent document updates to Participating Institutions as 
needed. 
• Oversee the data collection process from Participating Institutions. 
• Maintain documentation of Serious Adverse Event (SAE) reports and 
deviations/violation submitted by Participating Institutions and provide to the DF/HCC 
Sponsor for timely review.   
• Distribute serious adverse events reported to the DF/HCC Sponsor that fall under the DFCI 
IRB Adverse Event Reporting Policy to all Participating Institutions. 
• Provide Participating Institutions with information regarding DF/HCC requirements that 
they will be expected to comply with. 
 
• Carry out plan to monitor Participating Institutions either by on-site or remote monitoring.  
• Maintain Regulatory documents of all Participating Institutions which includes but is not 
limited to the following: local IRB approvals/notifications from all Participating 
Institutions, confirmation of Federalwide Assurances (FWAs) for all sites,  all SAE 
submissions, Screening Logs for all sites, IRB approved consents for all sites 
• Conduct regular communications with all Participating Institutions (conference calls, 
emails, etc) and maintain documentation all relevant communications. 
 
2.3  
Participating Institution 
 
Each Participating Institution is expected to comply with all applicable federal regulations and 
DF/HCC requirements, the protocol and HIPAA requirements.  
 
The general responsibilities for each Participating Institution may include but are not limited to: 
• Document the delegation of research specific activities to study personnel. 
• Commit to the accrual of participants to the protocol. 
• Submit protocol and/or amendments to their local IRB. 
• Maintain regulatory files as per sponsor requirements. 
• Provide the Coordinating Center with regulatory documents or source documents as 
requested. 
• Participate in protocol training prior to enrolling participants and throughout the trial as 
required (i.e. teleconferences). 
• Update Coordinating Center with research staff changes on a timely basis. 
• Register participants through the Coordinating Center prior to beginning research related 
activities.  
• Submit Serious Adverse Event (SAE) reports to local IRB per local requirements and to 
the Coordinating Center, in accordance with DF/HCC requirements.  
• Submit protocol deviations and violations to local IRB per local requirements and to the 
DF/HCC Sponsor in accordance with DF/HCC requirements. 

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• Order, store and dispense investigational agents and/or other protocol mandated drugs per 
federal guidelines and protocol requirements. 
• Have office space, office equipment, and internet access that meet HIPAA standards. 
• Participate in any quality assurance activities and meet with monitors or auditors at the 
conclusion of a visit to review findings. 
• Promptly provide follow-up and/or corrective action plans for any monitoring queries or 
audit findings. 
 
3. DF/HCC REQUIREMENTS FOR MULTI-CENTER PROTOCOLS 
  
The following section will clarify DF/HCC Requirements and further detail the expectations for 
participating in a DF/HCC Multi-Center protocol.  
 
3.1  
Protocol Distribution 
 
The Coordinating Center will distribute the final DFCI IRB approved protocol and any subsequent 
amended protocols to all Participating Institutions.    
 
3.2  
Protocol Revisions and Closures 
 
The Participating Institutions will receive notification of protocol revisions and closures from the 
Coordinating Center.  It is the individual Participating Institution’s responsibility to notify its IRB 
of these revisions. 
 
• Non life-threatening revisions: Participating Institutions will receive written notification 
of protocol revisions regarding non life-threatening events from the Coordinating Center. 
Non-life-threatening protocol revisions must be IRB approved and implemented within 90 
days from receipt of the notification. 
 
• Revisions for life-threatening causes: Participating Institutions will receive immediate 
notification from the Coordinating Center concerning protocol revisions required to protect 
lives with follow-up by fax, mail, e-mail, etc.  Life-threatening protocol revisions will be 
implemented immediately followed by IRB request for approval. 
 
• Protocol closures and temporary holds: Participating Institutions will receive 
notification of protocol closures and temporary holds from the Coordinating Center. 
Closures and holds will be effective immediately.  In addition, the Coordinating Center, 
will update the Participating Institutions on an ongoing basis about protocol accrual data 
so that they will be aware of imminent protocol closures. 
 
3.3  
Informed Consent Requirements 
 
The DF/HCC approved informed consent document will serve as a template for the informed 
consent for Participating Institutions. The Participating Institution consent form must follow the 
consent template as closely as possible and should adhere to specifications outlined in the DF/HCC 

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Guidance Document on Model Consent Language for PI-Initiated Multi-Center Protocols.  This 
document will be provided separately to each Participating Institution. 
 
Participating Institutions are to send their version of the informed consent document and HIPAA 
authorization, if a separate document, to the Coordinating Center for review and approval prior to 
submission to their local IRB. The approved consent form must also be submitted to the 
Coordinating Center after approval by the local IRB for all consent versions. 
 
The Principal Investigator (PI) at each Participating Institution will identify the physician members 
of the study team who will be obtaining consent and signing the consent form for therapeutic 
protocols. Participating institutions must follow the DF/HCC requirement that only attending 
physicians obtain informed consent and re-consent to interventional trials (i.e. drug and/or device 
trials).   
 
3.4  
IRB Documentation 
 
The following must be on file with the Coordinating Center: 
• Initial approval letter of the Participating Institution's IRB.  
• Copy of the Informed Consent Form(s) approved by the Participating Institution’s IRB.  
• Participating Institution’s IRB approval for all amendments. 
• Annual approval letters by the Participating Institution's IRB. 
 
3.5  
IRB Re-Approval 
 
Verification of IRB re-approval from the Participating Institutions is required in order to continue 
research activities.  There is no grace period for continuing approvals. 
 
The Coordinating Center will not register participants if a re-approval letter is not received from 
the Participating Institution on or before the anniversary of the previous approval date.   
 
 
3.6  
Participant Confidentiality and Authorization Statement 
 
In 1996, congress passed the first federal law covering the privacy of health information known as 
the Health Insurance Portability and Accountability Act (HIPPA). Any information, related to the 
physical or mental health of an individual is called Protected Health Information (PHI). HIPAA 
outlines how and under what circumstances PHI can be used or disclosed.  
 
In order for covered entities to use or disclose protected health information during the course of a 
study, the study participant must sign an authorization statement.  This authorization statement 
may or may not be separate from the informed consent document.  The Coordinating Center, with 
the approval from the DFCI IRB, will provide a consent template, with information regarding 
authorization for the disclosure of protected health information.  
 
The DF/HCC Sponsor will use all efforts to limit its use of protected health information in its trials. 
However, because of the nature of these trials, certain protected health information must be 

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collected. DF/HCC has chosen to use authorizations, signed by the participant in the trial, rather 
than limited data sets with data use agreements. 
 
3.6.1  DF/HCC Multi-Center Protocol Confidentiality 
 
All documents, investigative reports, or information relating to the participant are strictly 
confidential. Whenever reasonably feasible, any participant specific reports (i.e. Pathology 
Reports, MRI Reports, Operative Reports, etc.) submitted to the Coordinating Center 
should be de-identified. It is recommended that the assigned DF/HCC ODQ case number 
(as described below) be used for all participant specific documents. Participant initials may 
be included or retained for cross verification of identification.  
 
3.7  
DF/HCC Multi-Center Protocol Registration Policy 
 
Please refer to Section 4.4 for participant registration information. 
 
3.7.1  Participant Registration and Randomization  
 
Please refer to Section 4.4 for participant registration information. Treatment may not 
begin without confirmation from the Coordinating Center that the participant has been 
registered.  
 
3.7.2  Initiation of Therapy 
 
Participants must be registered with the DF/HCC ODQ before receiving treatment.  
Treatment may not be initiated until the Participating Institution receives confirmation of 
the participant’s registration from the Coordinating Center. The DF/HCC Sponsor and 
DFCI IRB must be notified of any violations to this policy. 
 
3.7.3  Eligibility Exceptions 
 
The DF/HCC ODQ will make no exceptions to the eligibility requirements for a protocol 
without DFCI IRB approval. The DF/HCC ODQ requires each institution to fully comply 
with this requirement. 
 
3.8  
DF/HCC Protocol Case Number 
 
At the time of registration, ODQ requires the following identifiers for all subjects: initials, 
date of birth, gender, race and ethnicity. Once eligibility has been established and the 
participant successfully registered, the participant is assigned a unique protocol case 
number.  Participating Institutions should submit all de-identified subsequent 
communication and documents to the Coordinating Center, using this case number to 
identify the subject.   
 
3.8.1  Protocol Deviations, Exceptions and Violations 
 

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Federal Regulations require an IRB to review proposed changes in a research activity to 
ensure that researchers do not initiate changes in approved research without IRB review 
and approval, except when necessary to eliminate apparent immediate hazards to the 
participant. DF/HCC requires all departures from the defined procedures set forth in the 
IRB approved protocol to be reported to the DF/HCC Sponsor, who in turn is responsible 
for reporting to the DFCI IRB. 
 
 
For reporting purposes, DF/HCC uses the terms “violation”, “deviation” and “exception” 
to describe departures from a protocol. All Participating Institutions must adhere to these 
requirements for reporting to the DF/HCC Sponsor and will follow their institutional policy 
for reporting to their local IRB. 
 
3.8.2  Definitions 
 
Protocol Deviation: Any departure from the defined procedures set forth in the IRB-
approved protocol which is prospectively approved prior to its implementation. 
 
Protocol Exception:  Any protocol deviation that relates to the eligibility criteria, e.g. 
enrollment of a participant who does not meet all inclusion/exclusion criteria. 
 
 
 
Protocol Violation: Any protocol deviation that was not prospectively approved by the IRB 
prior to its initiation or implementation.  
 
 
 3.8.3  Reporting Procedures 
 
DF/HCC Sponsor: is responsible for ensuring that clear documentation is available in the 
medical record and/or regulatory documents to describe all protocol exceptions, deviations 
and violations. The DF/HCC Sponsor will also be responsible for ensuring that all protocol 
violations/deviations are promptly reported per DFCI IRB guidelines.  
 
Participating Institutions: Protocol deviations require prospective approval from the DFCI 
IRB. The Participating Institution must submit the deviation request to the Coordinating 
Center who will then submit the deviation request to the DFCI IRB. Upon DFCI IRB 
approval the deviation is submitted to the Participating Institution IRB, per institutional 
policy. A copy of the Participating Institution’s IRB report and determination will be 
forwarded to the Coordinating Center within 10 business days after the original submission.  
 
All protocol violations must be sent to the Coordinating Center in a timely manner.  
 
Coordinating Center:  Upon receipt of the violation/deviation report from the Participating 
Institution, the Coordinating Center will submit the report to the DF/HCC Sponsor for 
review. Subsequently, the Participating Institution’s IRB violation/deviation report will be 
submitted to the DFCI IRB for review per DFCI IRB reporting guidelines. DF/HCC will 
forward all violation reports to CTEP via an internal DF/HCC process, as applicable. 
 
3.9 Safety Assessments and Toxicity Monitoring 

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The study teams at all participating institutions are responsible for protecting the safety, rights and 
well-being of study participants. Recording and reporting of adverse events that occur during the 
course of a study help ensure the continuing safety of study participants.  
 
All participants receiving investigational agents and/or other protocol mandated treatment will be 
evaluated for safety. The safety parameters include all laboratory tests and hematological 
abnormalities, physical examination findings, and spontaneous reports of adverse events reported 
by participants.  All toxicities encountered during the study will be evaluated according to the 
NCI criteria specified in the protocol. Life-threatening toxicities must be reported immediately to 
the DF/HCC Sponsor via the Coordinating Center.  
 
Additional safety assessments and toxicity monitoring will be outlined in the protocol. 
 
3.9.1  Guidelines for Reporting Serious Adverse Events  
 
Guidelines for reporting Adverse Events (AEs) and Serious Adverse Events (SAEs) are 
detailed in protocol Section 7. 
 
 
 
 
 
Participating Institutions must report the SAEs to the DF/HCC Sponsor and the 
Coordinating Center following the DFCI IRB Adverse Event Reporting Policy.  
 
The Coordinating Center will maintain documentation of all Participating Institution 
Adverse Event reports and be responsible for communicating to all participating 
investigators, any observations reportable under the DFCI IRB Reporting Requirements.  
Participating Institutions will review and submit to their IRB according to their institutional 
policies and procedures 
 
3.9.2  Guidelines for Processing IND Safety Reports  
 
The DF/HCC Sponsor will review all IND Safety Reports and ensure that all IND Safety 
Reports are distributed to the Participating Institutions. Participating Institutions will 
review and submit to their IRB according to their institutional policies and procedures. 
 
 
3.10  Data Management 
 
The DF/HCC ODQ develops case report forms (CRF/eCRFs), for use with the protocol.  
These forms are designed to collect data for each study. The DF/HCC ODQ provides a web 
based training for eCRF users.  
   
3.11  Data Forms Review 
 
Data submissions are monitored for timeliness and completeness of submission. 
Participating Institutions are notified of their data submission delinquencies in accordance 
with the following: 
 

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Incomplete or Questionable Data 
If study forms are received with missing or questionable data, the submitting institution 
will receive a written or electronic query from the DF/HCC ODQ Data Analyst, 
Coordinating Center or designee.  Responses to all queries should be completed and 
submitted within 14 calendar days.  Responses may be returned on the written query or on 
an amended paper case report form, or in the case of electronic queries, within the 
electronic data capture (eDC) system. In the case of a written query for data submitted on 
a paper case report form, the query must be attached to the specific data being re-submitted 
in response.   
 
Missing Forms 
If study forms are not submitted on schedule, the Participating Institution will receive a 
Missing Form Report from the Coordinating Center noting the missing forms.  These 
reports are compiled by the DF/HCC ODQ and distributed on a monthly basis.  
 
4. REQUISITIONING INVESTIGATIONAL DRUG 
 
The ordering of investigational agent is specified in the protocol Section 8.  
 
5. MONITORING: QUALITY CONTROL 
 
The quality control process for a clinical trial requires verification of protocol compliance and data 
accuracy. The Coordinating Center, with the aid of the ODQ provides quality control oversight for 
the protocol. 
 
5.1  
Ongoing Monitoring of Protocol Compliance 
 
The Participating Institutions may be required to submit participant source documents to the 
Coordinating Center for monitoring. Participating Institution may also be subject to on-site 
monitoring conducted by the Coordinating Center.  
 
The Coordinating Center will implement ongoing monitoring activities to ensure that Participating 
Institutions are complying with regulatory and protocol requirements, data quality, and participant 
safety. Monitoring will occur during protocol performance and through study completion. 
Additional monitoring practices may include but are not limited to; source verification, review and 
analysis of the following: eligibility requirements of all participants, informed consent procedures, 
adverse events and all associated documentation, study drug administration/treatment, regulatory 
files, protocol departures, pharmacy records, response assessments, and data management.  
 
Remote Monitoring: The Coordinating Center will request source documentation from 
Participating Institutions as needed to complete monitoring activities. Participating Institutions 
will be asked to forward de-identified copies of participants’ medical record and source 
documents to the Coordinating Center to aid in source documentation verification. 
 
On-Site Monitoring: On-site monitoring will occur on an as-needed basis.  Participating 
Institutions will be required to provide access to participants’ complete medical record and source 

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documents for source documentation verification during the on-site visit. In addition, upon request 
from a monitor or auditor, Participating Institutions should provide access to regulatory 
documents, pharmacy records, local policies related to the conduct of research, and any other trial-
related documentation maintained by the participating site. If there are concerns for protocol 
compliance, issues that impact subject safety or the integrity of the study are found, or trends 
identified based on areas of need, additional monitoring visits may be scheduled. On site 
monitoring visits can be supplemented with virtual monitoring assessments, provided that the 
minimum monitoring frequencies are adhered to. 
 
5.2  
Monitoring Reports 
 
The DF/HCC Sponsor will review all monitoring reports for on-site and remote monitoring of 
Participating Institutions to ensure protocol compliance. The DF/HCC Sponsor may increase the 
monitoring activities at Participating Institutions that are unable to comply with the protocol, 
DF/HCC Sponsor requirements or federal and local regulations. Participating Institutions may also 
be subject to an audit as determined by the DF/HCC Sponsor. 
 
5.3  
Accrual Monitoring 
 
Prior to extending a protocol to an external site, the DF/HCC Sponsor will establish accrual 
requirements for each participating institution. Accrual will be monitored for each participating 
institution by the DF/HCC Sponsor or designee. Sites that are not meeting their accrual 
expectations may be subject to termination. 
 
A minimum of 3 participants per site annually is typically recommended for Phase II protocols. 
However, given the rarity of inflammatory breast cancer, this protocol will have an accrual 
expectation of 0-1 accruals annually per site.  
 
6. AUDITING: QUALITY ASSURANCE 
 
Auditing is a method of Quality Assurance. Its main focus is to measure whether standards and 
procedures were followed. Auditing is the systematic and independent examination of all trial 
related activities and documents.  Audits determine if evaluated activities were appropriately 
conducted and whether data was generated, recorded and analyzed, and accurately reported per the 
protocol, Standard Operating Procedures (SOPs), and the Code of Federal Regulations (CFR). 
 
6.1  
Audit Plan: DF/HCC Sponsored Trials 
 
The DF/HCC Sponsor will trigger an audit if significant issues with non-compliance are noted at 
participating sites.  This study will be monitored as required by the federal regulations. If violations 
which impact participant safety or the integrity of the study are found, more participant records 
may be audited.  
 
6.2  
Audit Notification 
 

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It is the Participating Institution’s responsibility to notify the Coordinating Center of all scheduled 
audit dates (internal or NCI) and re-audit dates (if applicable), which involve this protocol. All 
institutions will forward a copy of final audit and/or re-audit reports and corrective action plans (if 
applicable) to the Coordinating Center, within 12 weeks after the audit date.  
 
6.3  
Audit Reports  
 
The DF/HCC Sponsor will review all final audit reports and corrective action plans if applicable. 
The Coordinating Center, must forward these reports to the DF/HCC ODQ per DF/HCC policy 
for review by the DF/HCC Audit Committee. Based upon the audit assessments the DF/HCC Audit 
Committee could accept or conditionally accept the audit rating and final report. Conditional 
approval could require the DF/HCC Sponsor to implement recommendations or require further 
follow-up.  For unacceptable audits, the DF/HCC Audit Committee would forward the final audit 
report and corrective action plan to the DFCI IRB as applicable. 
 
6.4  
Participating Institution Performance 
 
The DF/HCC Sponsor and DFCI IRB is charged with considering the totality of an institution’s 
performance in considering institutional participation in the protocol. 
 
6.4.1  Corrective Actions 
 
Participating Institutions that fail to meet the performance goals of accrual, submission of 
timely and accurate data, adherence to protocol requirements, and compliance with state 
and federal regulations, may be recommended for a six-month probation period. Such 
institutions must respond with a corrective action plan and must demonstrate during the 
probation period that deficiencies have been corrected, as evidenced by the improved 
performance measures. Participating Institutions that fail to demonstrate significant 
improvement will be considered by the DF/HCC Sponsor for revocation of participation. 
A DF/HCC Sponsor and/or the DFCI IRB may terminate a site’s participation if it is 
determined that a site is not fulfilling its responsibilities as described above.

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APPENDIX D 
12-497 DFCI SPECIMEN REQUISITION FORM 
Complete this form and include with the specimen shipment.  Label ALL materials with participant initials, DFCI participant study ID, and the 
date the specimen was obtained. Include a pathology report with any archival tissue specimens being submitted.  
 
Ship specimen(s) to: DF/HCC Core Blood and Tissue Bank, DFCI, Smith Bldg- SM 956, 450 Brookline Ave, Boston, MA 02215 
____________________________________________________________________________________________________________ 
Specimen Information 
Participant Initials (FML): ______________    DFCI Participant Study ID Number: ______________     DFCI Assigned MRN: _______________ 
Date specimen(s) shipped: _________________________              Time Point: 
 Pre-treatment (week 1)     
 Week 2     
 Surgery 
 Site of tumor: 
 Right breast     
 Left breast             
Specimen Type  
(indicate inclusion in shipment by checking box) 
Pathology Number(s) 
or Serial Coding 
Quantity 
submitted 
Date specimen 
obtained 
Time from resection 
to fixative immersion 
 One 10 ml Whole Blood Lavender (EDTA) Top 
Tube 
 
 
 
 
 Two 10 ml Streck Tubes 
 
 
 
 
 Core biopsies in OCT 
 
 
 
Minutes 
 Other, specify: 
 
 
 
 
  
 
 
Responsible contact: _______________________________ 
 
Email: ___________________________________________ 
 
Phone Number: ___________________________________      
 
 
 
 

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APPENDIX E 
12-497 MICHIGAN SPECIMEN REQUISITION FORM 
Complete this form and include with the specimen shipment.  Label ALL materials with participant initials, DFCI participant study ID, and the 
date the specimen was obtained. Include a pathology report with any archival tissue specimens being submitted.  
 
Ship specimen(s) to: Dr ZhiFen Wu, c/o Merajver Lab, 7121 CC, 1500 East Medical Center Drive, Ann Arbor, MI 48109 
____________________________________________________________________________________________________________ 
Specimen Information 
Participant Initials (FML): ______________    DFCI Participant Study ID Number: ______________     DFCI Assigned MRN: _______________ 
Date specimen(s) shipped: _____________________       Time Point: 
 Pre-treatment (week 1)     
 Week 2     
 Surgery 
 Post Mastectomy 
 Site of tumor: 
 Right breast     
 Left breast             
Specimen Type  
(indicate inclusion in shipment by checking box) 
Pathology Number(s) 
or Serial Coding 
Quantity 
submitted 
Date specimen 
obtained 
Time from resection 
to fixative immersion 
 Core biopsies in liquid nitrogen 
 
 
 
Minutes 
 Other, specify: 
 
 
 
 
  
 
Responsible contact: _______________________________ 
 
Email: ___________________________________________ 
 
Phone Number: ___________________________________