DIANA-5: Randomized Trial to Test the Efficacy of Dietary Change and Physical Activity to Prevent or Delay the Development of Recurrences in Breast Cancer Patients Estimated to be at High Risk of Recurrence Hormonal and Metabolic Reasons
Phase: NA
Conditions: Breast Cancer Invasive
Sponsor: Fondazione IRCCS Istituto Nazionale dei Tumori, Milano

Randomized trial of diet, physical activity and breast cancer 
recurrences: the DIANA-5 study.  
DIANA (DIet and ANdrogens)-5: randomized controlled trial to 
test the efficacy of dietary change and physical activity to prevent 
or delay the development of recurrences in breast cancer (BC) 
patients estimated to be at high risk based on their hormonal or 
metabolic milieu 
 
 
 
 
NCT  
 
 
 
 
 
 
Date of Document 21 febr 2007 
 
 
 

 
 
Background 
Prospective epidemiological studies consistently showed that high serum levels of testosterone 
predict the subsequent occurrence of BC, both before and after menopause. After menopause also 
high oestrogen and low sex hormone-binding globulin (SHBG) levels are associated with increased 
BC risk, but the association with testosterone persists upon adjustment for estrogens. Also high 
serum levels of insulin and insulin-like growth factor-I (IGF-I) are associated with increased BC risk. 
Insulin has gonadotropic properties and stimulates the synthesis of androgens in the ovary; 
moreover, it inhibits the liver synthesis of SHBG and of two IGF-binding proteins (IGFBP1 and 2), 
thus increasing the bio-availability of both sex hormones and IGF-I.  
In BC patients, overweight and high serum levels of insulin and testosterone are associated with a 
significantly increased risk of recurrences. We also showed an increased recurrence rate in patients 
with metabolic syndrome, defined as the presence of three or more of the following: abdominal 
obesity, hypertension, hyperglycemia, high triglycerides or low HDL cholesterol values.  
Our previous DIANA randomized trials showed that an insulin lowering diet, based on traditional 
Mediterranean ad macrobiotic recipes, significantly decreases body weight, serum testosterone, 
insulin, and the bioavailability of estrogens and IGF-I, in both healthy women and BC patients. A 
significant decrease in insulin resistance and serum testosterone also occurred in a randomized trial 
of moderate physical activity. Consistently, several observational studies suggested that physical 
activity and weight reduction help preventing both BC and BC recurrences. The WINS randomized 
trial of low versus high total fat consumption in BC patients showed a significant 24% reduction of 
recurrences over 5 years.  
We now propose a randomized dietary and physical activity intervention trial to reduce BC 
recurrences (local, distant, or second BC) in BC patients at high risk because of high serum 
testosterone (>0.4 ng/ml), or insulin (>50 pmol/L), or the presence of metabolic syndrome. In these 
patients the estimated 5-year cumulative recurrence rate is 30%. Participants will be recruited 
through hospitals, patients’ associations, and the media. We plan to recruit 1,200 patients and to 
randomize them in two groups: 600 shall receive standard recommendation for healthy lifestyle 
without, however, any active support; 600 shall receive a combination of individual and group 
contacts over the course of one year, including kitchen courses, gym and dance classes, common 
meals and reinforcing meetings, with emphasis on a comprehensive dietary change including low 
saturated fat and low refined carbohydrates, and high whole grain cereals and pulses consumption. 
Compliance will be monitored through weight change and plasma glucose, triglycerides, cholesterol 
and testosterone.  
The main analysis will be by intention to treat. Under the hypothesis of reducing recurrence rate by 
25% or 33% the statistical power of the study is 80% or, respectively, 90%, (P<0.05, 5-year follow-
up).  
 
Background  
There is increasing scientific evidence that endogenous hormones and metabolic factors effect 
breast cancer incidence and prognosis (Figure 1).  
Figure 1. Hormonal, metabolic and dietary correlates of breast cancer risk and recurrences  
 

 
Serum testosterone levels effect BC risk 
Prospective epidemiological studies consistently showed that high serum levels of testosterone 
predict the subsequent occurrence of BC, both before (1-3) and after menopause (4-6). The relative 
risk (RR) increases linearly with increasing testosterone levels, and the women in the top quartile or 
quintile of testosterone distribution are 2 to 4 times as likely to develop BC compared with women 
in the bottom quantile. After menopause also, high estrogen and low SHBG levels are associated 
with increased BC risk. When testosterone and estradiol are included in the same model, however, 
the effect of testosterone is greater than that of estradiol (4-6). Consistently with the elevation in 
risk with increasing endogenous testosterone level, menopausal women using estrogens and 
testosterone as hormonal replacement therapy (HRT) have a significantly increased BC risk 
compared with estrogen only therapy and greater risk also compared with estrogen and 
progestogens therapy (7). Moreover, HRT with synthetic testosterone-derived progestogens are 
associated with a significantly greater BC risk compared with those with natural (micronized) 
progesterone (8). The mechanism underlying the association between androgens and BC risk is not 
well understood. Androgens may act directly, stimulating the growth and division of BC cells via 
binding to the androgen receptor or the estrogen receptor (9), or indirectly, via conversion to 
estrogens in target tissues (10), or by increasing the bioavailability of estradiol because of the 
greater affinity of testosterone and dihydrotestosterone with SHBG.  
Insulin and related metabolic factors effect BC risk 
Overweight and sedentary lifestyle are associated with insulin resistance. Women who gain weight 
in adulthood and overweight postmenopausal women have a greater risk for BC than lean women 
(11, 12). Postmenopausal women who engage in regular exercise (> 3 hours per week) have a 
reduced risk for BC compared with inactive women (13, 14). Several epidemiological studies found 
that high serum insulin and IGF-I levels are associated with increase BC risk (15-20), with, however, 
some inconsistencies as for the effect modification of age and menopausal status.  
Insulin and testosterone effect prognosis in BC patients  

In BC patients, high serum levels of insulin (21) and testosterone (22 and Micheli et al, submitted) 
are significantly associated with increased risk of recurrences; after adjustment for traditional 
prognostic factors (cancer stage at diagnosis, ER and PR) the RRs for BMI and for insulin in the upper 
quartile were about 2, while the RRs for testosterone in the upper tercile ranged from 2 to 7. We 
also found a borderline significant association of ER+ cancer with serum levels of estradiol, which, 
however, disappeared upon adjustment for testosterone levels (22). Testosterone levels are higher 
than estradiol levels, are easier to measure reproducibly and have lower intra- individual variability 
(23-25). For this reason, and because it proved to be predictive at any age, we chose testosterone 
as the main hormonal indicator of BC risk.  
We also showed an high risk of recurrence in patients with metabolic syndrome, defined as the 
presence of three or more of the following factors: abdominal obesity (waist circumference >88 
cm), hypertension (SBP>130 and /or DBP >85), hyperglycemia (>110mg/100ml), high triglycerides 
(>150 mg/100ml) or low HDL cholesterol (<50 mg/100ml) (26) (Table 1). Consistently, several 
observational studies suggested that sedentary habits (28) and overweight (27) are associated with 
increased BC incidence and BC recurrences.  
Table 1. Hazard ratio of developing recurrences during 5.5-year follow-up of 110 BC patients 
according to the presence or absence of metabolic syndrome and serum testosterone levels above 
or under the median value (26).  
 
 
Healthy diet and physical activity decrease insulin and testosterone levels  
The DIANA (DIet and ANdrogens) randomized controlled trials showed that a highly satiating and 
insulin lowering diet, based on traditional Mediterranean ad macrobiotic recipes, significantly 
decreases body weight, serum testosterone and the bioavailability of both estrogens and IGF-I, in 
healthy postmenopausal women (29, 30) and in BC patients (22). In these trials’ testosterone 
decreased by 18% and, respectively, 10% (tables 2 and 3).  
A randomized trial of 12-month physical activity versus stretching in healthy postmenopausal 
women proved that moderate intensity sports/recreational activity can reduce serum insulin (31), 
testosterone (32), and, to a lesser extent, estrogen levels (33). Among exercisers who lost >2% body 
fat, testosterone declined by 10% and free testosterone by 12% (P < 0.01 compared with controls).  
In a randomized trial, Mediterranean-style diet with increased consumption of whole grains, 
vegetables, fruits, nuts, and olive oil, succeeded in significantly reducing the prevalence of metabolic 
syndrome and insulin resistance (34).  
Table 2. DIANA-1: Hormonal changes after 5 months of insulin lowering diet in healthy 
postmenopausal women: % change in the intervention group and P value with respect to the change 
in control group (52 women each) (29,30)  

 
Table. 3 - DIANA-2: Hormonal changes after 12 months of insulin lowering diet in breast cancer 
patients (N =110) (22 and unpublished)  
 
 
 
Mechanistic considerations  
Various mechanism by which diet and life-style may promote increased risk for and progression of 
breast cancer, summarized in figure 2, have been recently reviewed (16, 27, 35). 
In short, sedentary lifestyle, overweight, hyper-caloric diet, high saturated fat and high glycemic 
index food are major determinants of metabolic syndrome, which in turn is associated with insulin 
resistance and increased androgenic activity. Insulin stimulates the synthesis of androgens in the 
ovary and the expression of GH receptors, and inhibits the liver production of SHBG and IGFBP1 and 
2, thus increasing the bio-availability of both sex hormones and IGF-I. IGF-I is increased by a diet rich 
in protein, in particular milk protein (36). Alcohol intake increases the synthesis of androgens and 
estrogens (37). Postmenopausal overweight is associated with increased concentrations of total and 
free androgens, increased peripheral conversion of androgens into estrogens, decreased SHBG, and 
increased insulin levels. Sedentary lifestyle is associated with higher levels of estrogens, androgens 
(38) insulin (39) and C-peptide (40).  
Figure 2. Mechanistic relationship between diet, physical activity and hormones 

 
Previous randomized dietary intervention trials to decrease BC recurrences  
Two randomized trials carried out in the eighties on a small number of BC cases (about 100 each) 
suggested that calorie restriction may reduce BC recurrences (41) and total mortality (42). The 
Women’s Intervention Nutrition Study (WINS), a large randomized controlled trial investigating the 
role of dietary fat reduction on relapse-free survival in postmenopausal women with early-stage 
resect able BC (n = 2,700), found that patients on the reduced-fat diet had a lower risk of recurrence 
(hazard ratio = 0.76, 95% CI = 0.60-0.98) than women on the standard diet (39). A further large-scale 
trial aimed at reducing fat and increasing fruit and vegetable intake in women diagnosed with BC is 
currently ongoing (43).  
 
 
Study aims and design  
We propose a randomized intervention trial of diet and physical activity to reduce BC relapse (local, 
distant), and second ipsilateral or contralateral BC, in BC patients at high risk of recurrence because 
of biochemical markers of increased risk, namely high serum testosterone and/or high fasting insulin 
and/or metabolic syndrome. Several other markers of increased recurrence risk are available, such 
as cancer stage at diagnosis, histological grade, hormonal receptors and other gene expression 
profile. All these will be registered, but we are specifically interested in markers of the host that can 
be modified through life-style.  
 
Secondary aims include assessing: 
 
- the effect of the combined dietary and physical activity change on the prevalence of metabolic 
syndrome and on biomarkers that are hypothesized to be intermediate factors in the association of 
diet and physical activity with BC 
- the effect of the intervention on the development of other life-style related health conditions, such 
as other cancers, diabetes, hypertension and dyslipidemia, and on total mortality.  
 
Phases of the study and milestones: 
 
Identification of eligible patients, Recruitment, Randomization, Intervention, Baseline and yearly 
measurements, Compliance evaluation, Follow up, Statistical analysis  

Identification of eligible patients  
Inclusion criteria: 
 
1) Mastectomy or conservative surgery for invasive breast carcinoma, any type, in the last five years 
(we expect to recruit mostly patients at the time of diagnosis or at the end of the first follow-up 
year after surgery, i.e when chemotherapy has been concluded and hormonal therapy, if necessary, 
started) 
2) 
Absence 
of 
signs 
or 
symptoms 
suggestive 
of 
recurrences 
Presence of one or more of the following endocrine/metabolic indicators:  
• 
serum testosterone level ≥ 0.4 ng/ml (1 nmol/ml), corresponding to the median  
value in BC patients, or  
• 
serum insulin ≥ 7 uU/ml ( 50 pmol/L), corresponding to the upper quartile of  
insulin distribution in BC patients, or  
• 
metabolic syndrome, present in about 15% of BC patients  
 
Exclusion criteria: 
 
1) Metastatic disease, or previous relapse 
2) Age >70 
3) Physical or mental handicaps that would impede to engage in moderate physical activity or 
participate in kitchen classes  
Setting: The study will be carried out in collaboration by two institutes in Milan (the National Cancer 
Institute and the European Institute of Oncology), and one in Palermo (the Department of Oncology 
of the ARNAS-Civico Hospital).  
 
Recruitment  
Potential participants will be recruited at the time of diagnosis or through follow-up clinics, patients’ 
associations, or the media. Patients will be requested to sign an informed consent, including 
authorization for getting blood samples, for storing samples for future studies on the effect of diet 
on blood parameters, and on DNA polymorphisms that may modify the response to dietary changes, 
and for follow-up. We shall collect demographic information, measure body weight, height, waist 
circumference, and blood pressure, and take an early morning (0800-1000h) fasting blood sample 
to measure blood glucose, LDL and HDL cholesterol, triglycerides, testosterone and insulin. Eligible 
patients shall fill in a baseline questionnaire on medical history, medication use, reproductive and 
body weight history, usual physical activity (frequency, duration and intensity), and a validated 
semi-quantitative food frequency questionnaire.  
Biological bank: Every about 12 month we shall collect and store at -80°C one aliquot of whole blood 
and three 2-ml serum aliquot. In a sample of cases we shall also preserve blood with RNAlater 
solution to allow the expression assay of several relevant genes.  
Randomization  
We plan to recruit 1,200 high risk patients (400 per year) and to randomize them in two groups: 600 
(control group) shall receive general standard written recommendation for healthy lifestyle without, 
however, any active support; 600 (intervention group) shall receive a combination of individual and 
group contacts over the course of one year, including kitchen courses, gym and dance classes, 
common meals and reinforcing meetings, with emphasis on a comprehensive dietary and life-style 
change.  

Randomization will be carried out within strata of age, treatment group (no adjuvant therapy, 
chemotherapy only, hormonal therapy only, both hormonal and chemotherapy) and axillary nodal 
status at diagnosis. Allocation will be done centrally and blindly.  
Patients not fulfilling the high-risk criteria will be given the same general recommendations as the 
control group, and will be followed up as an external low risk group.  
Intervention  
The intervention shall aim at increasing physical activity, controlling weight, and promoting healthy, 
low calorie diet. 
 
a) 
Physical 
activity. 
The 
goals 
of 
the 
physical 
activity 
intervention 
are: 
- Achieve and maintain regular participation in a moderate intensity physical activity (approximately 
3 to 5 METs) program of 210 minutes/week (30 min on average per day) over at least 3 days /week  
-Decrease sedentary behaviors by 30 minutes/day on at least 5 days/week. During the first 12 
months one group physical activity session per month will be offered to enhance program adoption. 
Women who wish to take up vigorous sports will be encouraged to do so. For those who do not 
progress to more vigorous activity, the focus will be on maintaining moderate intensity activities, 
such as walking. For self-monitoring and compliance enhancement, study participants will use logs 
and fill-in questionnaires 
 
b) Weight control. Reducing energy intake relative to expenditure is the primary dietary focus for 
promoting weight loss in overweight or obese participants, and maintaining a healthy energy 
balance is the primary focus for normal weight participants. Energy density of the diet has emerged 
as a dietary characteristic that can be easily manipulated to maintain volume and satiation despite 
reduced energy intake. Participants will be encouraged to include whole grains and high-fiber 
vegetables, which add bulk and volume to the meal, as major components of their diet, to choose 
cooked cereals rather than bread or dry crackers, eat a vegetable salad, vegetables or soup before 
eating higher energy foods, choose fresh fruit rather than juice, and plan the meals in order to limit 
the opportunities to wrestle with food choices, and to reduce overeating prior to the eating 
situation itself. 
 
c) Healthy diet .In order to reduce glycemic and insulinemic response, recommendations will 
include: 
- reducing calorie intake, through the preferred consumptions of highly satiating foods, such as 
unrefined cereals, legumes and vegetables. 
- reducing high glycemic index food, such as refined flours, potatoes, white rice, corn flakes, and 
high insulinemic foods, such as sugar and milk, preferring instead whole grain rice, barley, millet, 
oat, spelt, quinoa and buckwheat, legumes (any type including traditional soy products), vegetables 
(any type, except potatoes) 
- reducing sources of saturated fat (red and processed meat, milk and dairy products) preferring 
instead unrefined vegetable fats, such as olive oil, nuts and oleaginous seeds. 
- reducing protein intake, mainly animal protein (except fish)  
To reach these goals a multiple intervention strategy will be developed, based on the following: a) 
actions for both the intervention and the control group  
1. invitation leaflet, explaining the rationale of the study and including basic life-style 
recommendations, based on the 1997 WCRF recommendations (to be updated in 2007) and 
the Italian National Institute of Nutrition food pyramid.  
2. dissemination of the information on the study by media  
3. yearly follow-up questionnaire on breast events and dietary and physical activity change  

b) actions for the intervention group  
4. Individual advice on diet  
5. Individual advice on physical activity  
6. Kitchen courses to teach basic Mediterranean and macrobiotic recipes (two 1-day course  
plus, ten 3-h courses associated with common dinner) (15-20 participants at a time)  
7. Fortnightly common lunch or dinner (50-60 participant at a time)  
8. Basic gymnastic course (twelve – monthly- 2-hour courses)  
9. Organization of “Solidal Buying Groups” in order to buy recommended food and other  
commonly used goods directly from the producers or from big retailers at a discounted  
rate.  
10. Agreement with healthy food shops and organic farmers to obtain special price  
11. Agreement with fitness centers, yoga or martial arts centers, and dance schools  
12. Study newsletter, with scientific information, kitchen recipes, study facilities  
13. DIANA-5 website and chat line to exchange recipes and experience  
14. Periodic conferences on diet and health  
15. Periodic reinforcement meetings with common meals, gymnastic sessions, and dancing,  
after the first year 
16. Periodic body weight assessment (weekly self measurement and monthly measurement  
at the study center)  
17. Discounted rate for advanced kitchen courses  
18. Psychological support groups  
19. Individual advise on the basis of the changes in body weight and blood parameters at  
follow-up examinations  
 
Baseline and yearly measurements  
Height and weight: electronic scale with women in light clothes and without shoes. In a sample of 
cases body fat and lean mass will be measured with bioelectric impedance.  
Blood pressure: electronic device.  
Serum glucose, triglycerides and cholesterol: standard quality controlled laboratory techniques  
Serum Testosterone and Insulin: Radioimmunoassay (RIA). For testosterone we shall use a direct 
RIA kit which has been validated by comparison with indirect assay after organic extraction of serum 
samples and celite purification (44). 
For a sample of patients, we plan to apply for further financial support to measure several other 
metabolic, endocrine and inflammation markers (estrogens, SHBG, IGF-I, IGFBP 1, 2 and 3, C- 
reactive protein, leptin and adiponectin) as well as the DNA polymorphism and RNA expression of 
several relevant gene, in collaboration with the Dept of Oncology of the Ospedale Civico ARNAS in 
Palermo and at the Institute of Endocrinology at the Milan University.  
 
Compliance  
Compliance will be monitored through lifestyle compliance questionnaires, dietary questionnaires, 
weight change and plasma glucose, triglycerides, cholesterol, insulin, testosterone changes after 
one year of intervention. As adjuvant treatment may alter these biomarkers’ level and confound the 
effect of the intervention, we shall compare blood samples collected in the same treatment phase: 
at least 3 months after the end of chemotherapy, if any, and 3 months after the start of hormonal 
therapy, if any, and one year later.  
Altering the proportion of energy from dietary carbohydrate and fat has been shown to affect 
plasma lipid concentrations in controlled feeding studies. As we recommend to obtain 
carbohydrates from low glycemic index food, however, we do not expect any increase in 

triglycerides. We expect a substantial reduction of total and LDL cholesterol and fasting glycaemia, 
minor changes in HDL cholesterol and triglycerides, and a substantial reduction of body weight and  
waist circumference in the intervention group compared with the control group. Total cholesterol 
change is an estimate of saturated fat intake change. Testosterone and insulin are also expected to 
decrease in subsequent samples, which will be assayed in the same batch. A compliance score will 
be computed, based on the direction of change in all these biomarkers. 
 
Follow-up and outcome events  
The main outcome will be new BC events including: - new primary breast cancer  
- local/regional recurrence 
- distant/metastatic recurrence 
The follow up will be based on the routine clinical follow-up at the collaborating hospitals, the 
periodic questionnaires to study participants, the regional cancer registry and hospital discharge 
diagnosis system, and death certificates  
 
Statistical power  
The survival of BC patients in Italy is dramatically increasing: 5-year relative survival increased from 
80.6% for patients diagnosed in the early 1990s (Berrino et al, EUROCARE-3) (45) to 85.6% for 
patients diagnosed in the early 2000s (EUROCARE-4, unpublished). For these patients the estimated 
relapse free survival is 81.9 (EUROCARE high resolution study, unpublished). Such a survival 
improvement is accompanied by a postponement of the incidence of relapse (table 4).  
Table 4. incidence rate of local + distant recurrences (EUROCARE, unpublished)  
 
 
Based on EUROCARE data we estimate that the 5-year distant recurrences plus second ipsilateral or 
contralateral BC for patients recruited in the first few years after diagnosis will be about 20%. In the 
subgroup of patients selected on the basis of high insulin and/or testosterone levels (50% of cases 
with RR of the order of 3), we estimate that about 30% of patients will develop a recurrence or a 
second primary BC within 5-year follow-up: 360 cases out of 1200. Considering that the WINS 
randomized study obtained a 24% reduction of recurrence rate changing a single dietary factor 
(total fat) (39), and that observational studies suggested that a moderate physical activity may 
reduce recurrence rate by over 40% (28), we hypothesize that a comprehensive dietary intervention 
plus physical activity will reduce BC recurrence rate by 33% or more, but we consider also a more 
prudent estimate of 25% reduction.  
The following table gives the number of patients (per arm) that we should recruit in order to have 
90% or 80% power to detect a significant difference with α < 0.05, two sided, or one sided (α <0.10).  
 

 
 
Our aim is to recruit 1,200 high risk patients in order to have 600 patients per arm, which shall 
guarantee 80% chance of getting a significant difference also with 25% reduction, and allowing for 
90% compliance in the intervention group and 10% contamination of the control group.  
 
Statistical analysis  
We shall first assess the baseline association between androgens, insulin, and several measures of 
adiposity including body mass index, waist circumference and (in a sample of cases) percentage 
body fat, with Spearman correlation coefficients. We shall then compare the change in food 
consumption, body weight, and geometric means of hormone end points from baseline to 12 
months in the intervention and control group.  
The main analysis of the intervention effect on the incidence of recurrences will be by intention to 
treat, i.e. based on assigned treatment at the time of randomization, regardless of adherence. As a 
secondary analysis we shall assess the effect by change in body weight and biomarkers. We shall 
compute total survival, disease free survival and relapse free survival. 
Hazard ratios and confidence intervals will be computed by the Cox proportional hazard model, with 
standard clinical-pathological prognostic covariates as potential confounders. Separate analyses will 
be carried out by ER, PR and erbB2 status. Interim analyses will be carried out as soon as the total 
follow-up person-years reach 2,500 (corresponding to α =0.10 and β= 0.20 for a 33% reduction of 
recurrence rate).  
 
Feasibility  
The principal investigator has long term experience in carrying on and coordinating epidemiological 
studies, including small-scale dietary intervention studies (22, 29, 30). The European Institute of 
Oncology has long term experience in chemoprevention studies. The Milan National Cancer Institute 
is fully equipped with facilities for kitchen courses, dedicated cafeteria, gym facilities. The Palermo 
oncology center has access to kitchen facilities in a nearby technical institute and has already carried 
out a dietary intervention study with very high compliance. The above institutions treat, 
respectively, about 3,000, 1,000 and 200 BC patients per year.  
 
Control of potential biases  
Selection bias: the randomization will be carried out blindly, without any possibility of changing the 
allocation, within strata of age, date of diagnosis, treatment allocation (depending on stage and 
hormone receptor status) and number of positive axillary nodes at diagnosis (none, 1-3, 3 or more). 
Performance bias: patients will be recruited after the main treatments have been planned or 
delivered. In no case the allocation to the intervention or control group or the compliance will affect 
treatment.  
Measurement bias: patients and researchers cannot be blinded, but the ascertainment of outcome 
will 
be 
carried 
out 
by 
clinicians 
that 
are 
not 
involved 
in 
the 
study. 
Attrition bias: Based on previous studies we expect a fairly high compliance in the intervention 

group (>90%) but also some modification in the control group. After the main analysis by intention 
to treat, therefore, secondary analyses will be carried out by compliance score.  
Milestones and timing:  
1st) 
3rd 
Month: 
2nd) 
12th 
Month: 
3rd) 
16th 
Month: 
testosterone by 10% or more and serum glucose and insulin by 5% or more in at least 50% of 
participants.  
Operative study protocol and information system 
Recruitment of at least 300 patients in the first year. 
Compliance evaluation. The aim is to decrease serum cholesterol and  
4th) 24th Month: Test of follow-up procedures and comparison of observed and expected number of 
recurrences 
5th) 35th Month: First outcome analysis  
 
 
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