A Randomized Double-blind Placebo-controlled Study With ASA Treatment in Colorectal Cancer Patients With Mutations in the PI3K Signaling Pathway
Phase: PHASE3
Conditions: Colorectal Cancer
Sponsor: Anna Martling

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A randomized double-blind placebo-controlled study with ASA treatment in 
colorectal cancer patients with mutations in the PI3K signaling pathway 
Coordinating Investigator 
Professor Anna Martling 
Department of Molecular medicine and Surgery 
Karolinska Institutet 
Department of Pelvic Cancer, Gastrointestinal oncology and 
colorectal surgery unit 
D2:05, Karolinska University Hospital  
SE-171 76 Stockholm, Sweden 
+46 8 517 728 02
+46 76 050 57 97
anna.martling@ki.se
anna.martling@sll.se
Sponsor´s representative 
Professor Anna Martling 
Department of Molecular medicine and Surgery 
Karolinska Institutet 
Department of Pelvic Cancer, Gastrointestinal oncology 
and colorectal surgery unit 
, D2:05, Karolinska University Hospital  
 SE-171 76 Stockholm, Sweden 
+46 8 517 728 02
+46 76 050 57 97
anna.martling@ki.se
anna.martling@sll.se
NCT02647099

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1 
PROTOCOL SYNOPSIS 
Trial Title 
A randomized double-blind placebo-controlled study with ASA treatment in colorectal cancer patients with 
mutations in the PI3K signaling pathway 
Trial code 
ALASCCA 
EudraCT No 
2015-004240-19 
Coordinating Investigator 
Professor Anna Martling, Department of Molecular medicine and Surgery 
Karolinska Institutet, Center of Digestive Diseases Gastrocentrum , Karolinska University Hospital 
Trial centre(s) 
Departments of Surgery in Sweden actively registering patients in the Swedish ColoRectal Cancer 
Registry (SCRCR)   
Trial period 
Estimated date of first patient randomized Q3-Q4 2016 
Estimated date of last patient completed Q3-Q4 2026  
Phase of development 
Phase III 
Objectives and endpoints 
Primary objective 
•
To determine whether adjuvant treatment with 160 mg Acetylsalicylic Acid (ASA)
once daily for 3 years can improve Time To Recurrence (TTR) in patients with
colorectal cancer with somatic alterations in the PIK3CA (exon 9 and 20), compared
with placebo.
Secondary objective 
•
To determine whether adjuvant treatment with 160 mg ASA once daily for 3 years
can improve Disease-Free Survival (DFS) in patients with colorectal cancer with
somatic alterations in the PIK3CA (exon 9 and 20) compared with placebo.
•
To determine whether adjuvant treatment with 160 mg ASA once daily for 3 years
can improve DFS in patients with colorectal cancer with somatic alterations in the
PIK3CA (other than exon 9 and 20), PIK3R1 or PTEN genes, compared with placebo.
•
To determine whether adjuvant treatment with 160 mg ASA once daily for 3 years
can improve TTR in patients with colorectal cancer with somatic alterations in the
PIK3CA (other than exon 9 and 20), PIK3R1 or PTEN genes compared with placebo.
•
To compare overall survival (OS) at 5 years from randomization in patients receiving
low-dose ASA compared with placebo.
•
To assess overall safety and tolerability.
Primary Endpoint 
•
TTR at 3 years, in patients with tumors harboring PIK3CA mutations in exon 9 and
20

 
 
 
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Secondary Endpoints  
• DFS at 3 years, in patients with tumors harboring PIK3CA mutations in exon 9 and 
20.  
• DFS at 3 years, in patients with tumors harboring PIK3CA mutations other than in 
exon 9 and 20 and in PIK3R1 and PTEN.  
• TTR at 3 years, in patients with tumors harboring PIK3CA mutations other than in 
exon 9 and 20 and in PIK3R1 and PTEN. 
• OS at 5 years, in patients with tumors harboring PIK3CA mutations in exon 9 and 20, 
other than in exon 9 and 20 and in PIK3R1 and PTEN.  
 
Safety Endpoints 
• Frequency and severity of adverse events (AE)   
• Cerebral and gastric haemorrhage (for interims analysis) 
 
Exploratory objectives  
• 
Description and presentation of data on patients already on administration with ASA 
• In a technical pilot study (50 patients), ensure the handling and shipping of the gene 
samples 
 
In addition, the study will add clinical value for the patient’s future treatment by genetically 
identifying the tumor’s potential mutation in the genes BRAF, KRAS, NRAS and Mismatch 
Repair (MMR) status (Microsatellite Instability, MSI, alt Immunohistochemistry, IHC, for 
MMR genes). This is already performed at the hospitals according to clinical praxis. 
 
 
Trial design 
 
ALASCCA (Adjuvant Low dose ASpirin in Colorectal CAncer) 
is a randomized, parallel group, double blind, multicenter, placebo-controlled, biomarker-
based study of adjuvant treatment with ASA in colorectal cancer. Patients (adult male and 
female) with colon cancer pathology stage II-III or rectal cancer pathology stage I-III and 
somatic alterations in PIK3CA, PIK3R1, or PTEN are considered for the study. The study 
will compare DFS, time to relapse and OS and will also assess safety and tolerability. 
 
Patients will be randomized to receive 160 mg ASA or placebo. Patients already treated with 
ASA at inclusion will be included in an observation group. The treatment can be 
administered alone or in combination with adjuvant chemotherapy. Last date for 
randomization and start of treatment is 12 weeks postoperatively. The treatment will be 
administered for 3 years. There will be a follow-up period for two years. Outside the trial, the 
patient will be treated according to standard care at the site. 
 
A phone contact will be made 3 months after the randomization visit and thereafter every 6th 
month. The patients will also visit the site 6 months after randomization and thereafter every 
6th month i.e. the patients will be in contact with the site every 3rd month. There will be a 
visit/phone contact at the end of the follow-up period. 
 

 
 
 
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An interim analysis will be made on safety, i.e. incidence and type of serious bleeding 
complication grade > 1 every 12 months. An independent safety data monitoring committee 
will be responsible for evaluating and follow-up of the safety annually. 
The primary statistical analysis will be done at 3 years of study treatment and an analysis of  
overall survival (OS) will be done at 5 years. 
 
Number of patients planned at study start 
If 12% of the patients screened have hotspot mutations (exon 9 and 20) in PI3KCA a total of 
3900 patients will needed to be screened. This also includes approximately 15 % of the 
patients that will be excluded due to tumor stage 1 (for patients with colon cancer).   
Number of patients revised per protocol v. 5.2 
If 15% of the patients screened have hotspot mutations (exon 9 and 20) in PI3KCA a total of 
3750 patients will needed to be screened. This also includes approximately 15 % of the 
patients that will be excluded due to tumor stage 1 (for patients with colon cancer).   
 
Diagnosis and main eligibility criteria 
 
Inclusion criteria 
- 
Tumor with somatic alterations in PIK3CA, PIK3R1 or PTEN 
- 
Colon cancer tumor stage II-III or rectal cancer tumor stage I-III  
- 
Patient between18-80 years (including) 
- 
Radical surgery according to surgeon and pathologist 
- 
Karnofsky performance status ≥60%  
- 
Platelets ≥ 100 x 109 / L  
- 
Clean Colonoscopy or Computed Tomography (CT) colon within 3 months 
preoperatively or postoperatively but before randomization 
- 
Patient able to swallow tablets 
- 
Patient able to understand and sign written informed consent 
Exclusion criteria 
- 
Hereditary colorectal cancer linked to familial colonic polyposis or Lynch syndrome  
- 
Inflammatory bowel disease (Crohn's disease or ulcerative colitis)  
- 
Distant metastases  
- 
Other cancers (excluding colorectal cancer or other skin cancer than melanoma) 
within 3 years from screening  
- 
Known bleeding diathesis (such as hemophilia) 
- 
Concomitant antiplatelet therapy (eg clopidrogrel or ticlopidine) or anticoagulant 
therapy (warfarin or low molecular weight heparin). Post-operative treatment with 
low molecular weight heparin must be withdrawn before administration of study 
treatment  
- 
Active gastritis or peptic ulcer, or significant surgical post-op bleeding, within the 
previous three months assessed at screening and randomization 
- 
Ongoing regular use of corticosteroids, Nonsteroidal Anti-Inflammatory Drug 
(NSAID)  
- 
Uncontrolled hypertension according to Investigator’s judgment 
- 
Clinically significant liver impairment according to Investigators judgment 
- 
Existing renal failure according to Investigator’s judgment. Renal failure with 
decreased creatinine clearance <60 should lead to consultation with a nephrologist. 

 
 
 
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- 
Significant medical illness that would interfere with study participation 
- 
Pregnancy or breastfeeding females 
- 
Known allergy to NSAIDs or ASA 
- 
Current participation in another clinical trial that will be in conflict with the present 
study 
- 
Patients who are unlikely to comply with the protocol (e.g. uncooperative attitude, 
inability to return for subsequent visits) and/or otherwise considered by the 
Investigator to be unlikely to complete the study 
 
 
Patients with regular administration of ASA, defined as >3 doses/week, will be included in 
the observation group. Other additional regular use of ASA must be withdrawn before 
randomization. 
 
Investigational Medical Product (IMP) 
 
Acetylsalicylic acid (ASA) 160 mg, orally once daily 
 
Placebo tablet orally once daily 
 
Duration of treatment 
The duration of treatment will be 3 years 
 
Duration of patients involvement in the trial 
The patients will participate in the study for a total of 5 years. The treatment period will last 
for 3 years and the follow-up period will be 2 years. 
 
Safety assessments  
Safety assessments will be AEs.  
An interim analysis will be made on safety i.e incidence and type of serious bleeding 
complication grade > 1 every 12 months. An independent safety data monitoring committee 
will be responsible for evaluating and follow-up of the safety annually. 
 
Statistical methods 
The statistical analyses will be described in detail in the Statistical Analysis Plan including a 
Data Display Plan, which will be in a final draft version prior to study start and finalized and 
approved before database lock.  
All data will be presented using descriptive statistics. Results will be presented in total and 
by treatment group. Continuous variables will be summarized using mean, standard 
deviation, median, minimum and maximum. Categorical variables will be summarized using 
the number and percentage of patients. 
The primary efficacy variable is TTR. Subjects who have not experienced loco-regional 
recurrence, distant metastases or death from colorectal cancer at time of statistical analysis 
will be censored at the time of the latest assessment. The log-rank test will be applied to test 
for difference in TTR between the treatment groups. 
Kaplan-Meier estimates will be used for the estimation of median times to an event and their 
confidence intervals. Secondary endpoints will be assessed using the log-rank test or a Cox 

 
 
 
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regression model, with time to event (relapse, secondary malignancy or death) as response 
variable and treatment group as factor. 
All secondary variables will be presented descriptively with point estimate and 95% 
confidence intervals. 
The data from the observation group will only be presented descriptively. 
Determination of sample size 
Primary endpoint: TTR. 
Power was set to 80%, , total follow-up to 36 months and significance level to 0.05 (two-
sided). The 36 months recurrence rate in the placebo arm was estimated to 18% based on the 
Stage/RF-specific estimates in Osterman and Glimelius (ref*). With the assumptions of 10% 
loss to follow-up and a sample size of 150 patients in each arm, a reduction of 62% 
(RR=0.38) in the 36 months recurrence rate can be detected. 
*Recurrence Risk After Up-to-Date Colon Cancer Staging, Surgery, and Pathology: Analysis of the Entire 
Swedish Population. Osterman E, Glimelius B.Dis Colon Rectum. 2018 Sep;61(9):1016-1025. 
 
 
Patient sample calculation at study start 
If 12% of the patients screened have hotspot mutations (exon 9 and 20) in PI3KCA a total of 
3900 patients will be needed to be screened. This also includes approximately 15 %  of the 
patients that will be excluded due to tumor stage 1. Number of patients revised per 
protocol v. 5.2 
If 15% of the patients screened have hotspot mutations (exon 9 and 20) in PI3KCA a total of 
3750 patients will needed to be screened. This also includes approximately 15 % of the 
patients that will be excluded due to tumor stage 1 (for patients with colon cancer).   
 
 
 
 
 
 

 
 
 
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2 
REVISION HISTORY 
 
Number 
Document date 
Revision (main changes from previous version) 
1.0 
24 March 2015 
 
2.0 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
4.0 
28 January 2016 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1 February 2016 
 
 
 
Synopsis: EudraCT No added. 
Synopsis clarification added: The primary statistical analysis will 
be done at 3 years of study treatment and an analysis of overall 
survival (OS) will be done at 5 years. 
Inclusion criteria: Karnofsky performance status changed from 
≥70% to ≥60%. This allows for participation of patients with 
lower Karnofsky score. 
Section 10.5 The patients will be carefully informed that they 
only can take the tablets included in the study and no additional 
ASA. Compliance will be checked every third months.   
Section 10.8.3: In addition, 2x4 ml (EDTA) plasma samples for 
biobank storage is added, to allow for future analyses.  
Clarification regarding statistical analysis section 10.13: The 
primary statistical analysis will be done at 3 years of study 
treatment and an analysis of overall survival (OS) will be done at 
5 years. 
Inclusion criteria: adding of birth control methods. 
Section 11.7.7 Emergency unblinding, is rephrased to clarify the 
unblinding process. 
 
Biobank, plasma: Additional blood samples will be taken (in 
total 15 ml) for genetic analysis and biobanking of plasma, that 
will make future analyses possible that can lead to new treatment 
and prognostic models. The patient information has been 
changed accordingly and reviewed by the ethics committee. 
 
Biobank, DNA and RNA: Additional DNA from tumour and 
normal tissue and RNS from tumour tissue will be kept in a 
biobank, that will make future analyses possible that can lead to 
new treatment and prognostic models.  
5.0 
09 Oct 2017 
Patients with rectal cancer tumor stage I-III will be included 
(change from stage II-III). 
5.1 
30 Nov 2017 
Page 22: 
Documentation of Carcinoembryonic antigen (CEA), if results 
are older than 30 days from visit 2, a sample will be taken. CEA 
measurement is optional. 
 
Page 24: 

 
 
 
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In addition to the items that will be performed during the 
treatments visits, the following will be performed at the time of 
visit 7 and 15 (after 1 and 3 years); 
• CT/MRI (Magnetic Resonance Imaging) thorax and 
abdomen  
• CEA (Optional) 
 
The following assessments will be performed during the follow-
up visit; 
• Documentation of CEA (Optional), if not available a 
sample will be taken 
• Review if there is any clinical suspicion of recurrence 
 
Page 26: 
CEA (Optional) 
5.2 
25 Jan 2021 
The total number of patients to be included is changed from 816 
to 600 (300 in group A and 300 in group B) and the study time 
table is changed. 
 
 
 

 
 
 
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3 
TABLE OF CONTENTS 
1 
PROTOCOL SYNOPSIS ................................................................................................ 2 
Inclusion criteria ................................................................................................................. 4 
Exclusion criteria ................................................................................................................ 4 
2 
REVISION HISTORY ..................................................................................................... 7 
3 
TABLE OF CONTENTS ................................................................................................. 9 
4 
PROTOCOL SIGNATURE PAGE .............................................................................. 12 
5 
INVESTIGATOR SIGNATURE PAGE ...................................................................... 13 
6 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ............................... 14 
7 
ETHICS ........................................................................................................................... 15 
7.1 
Ethical and Regulatory review .............................................................................. 15 
7.2 
Ethical conduct of the trial .................................................................................... 15 
7.3 
Patient information and consent ........................................................................... 15 
7.4 
Patient data protection ........................................................................................... 15 
8 
INVESTIGATOR(S) AND TRIAL ADMINISTRATIVE STRUCTURE ................ 16 
9 
INTRODUCTION .......................................................................................................... 17 
10 TRIAL OBJECTIVES AND ENDPOINTS ................................................................. 19 
10.1 
Primary objective ................................................................................................... 19 
10.2 
Primary endpoint ................................................................................................... 19 
10.3 
Secondary objective ................................................................................................ 19 
10.4 
Secondary endpoint ................................................................................................ 19 
10.5 
Exploratory objectives ........................................................................................... 20 
10.6 
Safety Endpoints ..................................................................................................... 20 
11 INVESTIGATIONAL PLAN ........................................................................................ 20 
11.1 
Overall trial design ................................................................................................. 20 
11.2 
Study procedures .................................................................................................... 22 
11.2.1 
Screening (Visit 1) ........................................................................................... 22 
11.2.2 
Randomization (Visit 3) ................................................................................... 23 
11.2.3 
Phone calls (Visit 4, 6, 8, 10, 12 and 14) ......................................................... 23 
11.2.4 
Treatment visits (Visit 5, 7, 9, 11, 13, 15) ........................................................ 23 
11.2.5 
Follow-up period (Final visit 16 ) .................................................................... 24 
11.3 
Observation group .................................................................................................. 24 
11.4 
Rationale for trial design, doses and control group ............................................ 27 

 
 
 
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11.5 
Risk/benefit assessment .......................................................................................... 27 
11.6 
Selection of trial population .................................................................................. 27 
11.6.1 
Inclusion criteria ............................................................................................... 28 
11.6.2 
Exclusion criteria .............................................................................................. 28 
11.6.3 
Patients treated with ASA before randomization ............................................. 29 
11.6.4 
Removal of trial patients from treatment or assessments ................................. 29 
11.7 
Treatments .............................................................................................................. 30 
11.7.1 
Identity of Investigational Medicinal Product (IMP) ....................................... 30 
11.7.2 
Packaging, labeling and storage of IMP ........................................................... 30 
11.7.3 
Doses and treatment regimens .......................................................................... 30 
11.7.4 
Investigational Medicinal Product accountability ............................................ 30 
11.7.5 
Method of assigning patients to treatment groups ........................................... 31 
11.7.6 
Blinding ............................................................................................................ 31 
11.7.7 
Emergency unblinding for safety reason .......................................................... 31 
11.7.8 
Prior and concomitant therapy ......................................................................... 32 
11.7.9 
Treatment compliance ...................................................................................... 32 
11.8 
Trial assessments .................................................................................................... 32 
11.8.1 
Demographic and baseline characteristics ....................................................... 32 
11.8.2 
Molecular profiling of the tumors .................................................................... 33 
11.8.3 
Laboratory measurements ................................................................................ 33 
11.8.4 
Efficacy assessments ........................................................................................ 34 
11.8.5 
Safety assessments ........................................................................................... 34 
11.8.6 
Safety Monitoring committee ........................................................................... 34 
11.8.7 
Adverse Events (AEs) ...................................................................................... 34 
11.8.7.1 Definitions .................................................................................................... 34 
11.8.7.2 Eliciting and recording of AEs ..................................................................... 35 
11.8.7.3 Pre-existing condition: ................................................................................. 36 
11.8.7.4 Reporting of SAEs ....................................................................................... 36 
11.8.7.5 Follow-up of unresolved AEs ...................................................................... 37 
11.8.7.6 Procedures in case of pregnancy .................................................................. 37 
11.8.7.7 Coding of AEs .............................................................................................. 37 
11.9 
Data Management .................................................................................................. 37 
11.10 Swedish Colorectal Cancer Registry (SCRCR) ................................................... 38 

 
 
 
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11.11 Quality Control ....................................................................................................... 38 
11.12 Data Quality Assurance ......................................................................................... 38 
11.12.1 Case Report Forms (eCRFs) ............................................................................ 38 
11.12.2 Monitoring ........................................................................................................ 38 
11.12.3 Training of staff ................................................................................................ 39 
11.12.4 Audit and inspections ....................................................................................... 39 
11.12.5 Changes in the approved Trial Protocol ........................................................... 39 
11.13 Statistical methods and determination of sample size ........................................ 39 
11.13.1 Demographics and baseline data ...................................................................... 40 
11.13.2 Endpoints .......................................................................................................... 40 
11.13.2.1 Primary Endpoint ......................................................................................... 40 
11.13.2.2 Secondary Endpoint ..................................................................................... 40 
11.13.2.3 Safety Endpoints .......................................................................................... 40 
11.13.3 Analysis of efficacy .......................................................................................... 40 
11.13.4 Analysis of safety ............................................................................................. 41 
11.13.5 Interim analyses and data monitoring .............................................................. 41 
11.13.6 Analysis data sets ............................................................................................. 41 
11.13.7 Determination of sample size ........................................................................... 41 
12 TRIAL MANAGEMENT .............................................................................................. 42 
12.1 
Trial time table ....................................................................................................... 42 
12.2 
Insurance/indemnity .............................................................................................. 42 
12.3 
Trial agreements ..................................................................................................... 42 
12.4 
Criteria for termination of the trial ...................................................................... 43 
12.5 
Reporting of results and publication policy ......................................................... 43 
12.6 
Record retention ..................................................................................................... 43 
12.7 
Disclosure and confidentiality ............................................................................... 43 
13 EMERGENCY PROCEDURES ................................................................................... 44 
13.1 
Emergency contacts ................................................................................................ 44 
13.2 
Procedures in case of medical emergency ............................................................ 44 
13.3 
Procedures in case of overdose .............................................................................. 44 
14 REFERENCES ............................................................................................................... 45 
 

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4 PROTOCOL SIGNATURE PAGE
Sponsor and Coordinating Investigator 
Trial title: 
A randomized double-blind placebo-controlled study with ASA treatment 
in colorectal cancer patients with mutations in the PI3K signaling pathway 
Sponsor 
Professor Anna Martling 
Signature 
Date 
Coordinating Investigator 
Professor Anna Martling 
Signature 
       Date 
Anna Martling
2021-02-01
Anna Martling
2021-02-01

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INVESTIGATOR SIGNATURE PAGE 
Investigator 
Trial title: 
A randomized double-blind placebo-controlled study with ASA treatment 
in colorectal cancer patients with mutations in the PI3K signaling pathway 
“I agree to the terms of this trial protocol. I will conduct the study in accordance with the 
procedures specified in the protocol, the ethical principles in the latest version of the 
Declaration of Helsinki, ICH Good Clinical Practice and applicable regulatory 
requirements”. 
Investigator Name 
Signature 
Date 

 
 
 
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5 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
 
Abbreviation or term                   Explanation 
 
  
AE 
ALASCCA 
ASA 
Adverse Event 
Adjuvant Low dose ASpirin in Colorectal Cancer 
Acetylsalicylic Acid 
CEA 
COX-2 
Carcinoembryonic Antigen 
Cyclooxygenase-2 
CT 
Computed Tomography 
DFS 
eCRF 
FAP 
Disease-Free Survival 
electronic Case Report Form 
Full Analysis Population 
 
GCP 
HR 
ICF 
Good Clinical Practice 
Hazard Ratio 
Informed Consent Form 
ICH 
IXRS 
International Conference on Harmonization 
Interactive Response System 
IEC 
Independent Ethics Committee 
IMP 
MedDRA 
MMR 
NSAID 
OS 
PP 
QC 
RA 
Investigational Medicinal Product 
Medical Dictionary for Regulatory Activities 
Mismatch Repair 
Nonsteroidal Anti-Inflammatory Drug 
Overall Survival 
Per Protocol 
Quality Control 
Regulatory Authorities 
SAE 
SCRCR 
Serious Adverse Event 
Swedish ColoRectal Cancer Registry 
SUSAR 
TTR 
Suspected Unexpected Serious Adverse Reaction 
Time To Recurrence 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
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6 
ETHICS 
6.1 
Ethical and Regulatory review 
Necessary approvals of the Trial Protocol, the Patient Information and Informed Consent Form 
(ICF) must be obtained before enrolment of any patient into the trial. Furthermore, it is the 
responsibility of the Sponsor to keep the applicable Independent Ethics Committee (IEC) informed 
of any Suspected Unexpected Serious Adverse Reactions (SUSARs) and any substantial 
amendments to the protocol during the trial period. The written approval from the IEC, including a 
trial identification and the date of approval, will be filed at the Sponsor representative and at the 
trial site(s) together with a list of the IEC members, their titles or occupation, and their institutional 
affiliations.  
6.2 
Ethical conduct of the trial 
The trial will be performed in accordance with the recommendations guiding physicians in 
biomedical research involving human patients that were adopted in 1964 by the 18th World 
Medical Assembly, in Helsinki, Finland, with later revisions. 
6.3 
Patient information and consent 
It is the responsibility of the Investigator to give each patient (or the patient’s legal representative), 
adequate verbal and written information regarding the objectives and the procedures of the trial as 
well as any risks or inconvenience involved before including the patient in the trial. The patient (or 
the patient’s legal representative) should be informed that by signing the ICF he/she authorizes 
monitor(s), auditor(s), the IEC and the Regulatory Authorities (RA) to have direct access to the 
patient’s medical records for verification of clinical trial procedures. The patient must be informed 
about the right to withdraw from the trial at any time. The patient should be allowed sufficient time 
for consideration of the proposal.  
It is the responsibility of the Investigator to obtain signed informed consent from all patients before 
including them in the trial. The ICF must be signed and dated before any trial-specific procedures 
are performed, including screening procedures. The signed ICFs must be filed by the Investigator 
for possible future audits and/or inspections.  
The final version of the Patient Information and ICF is submitted to the Ethics Committee(s) and 
concerned RA and must not be changed without permission from the Sponsor and the local IEC. 
6.4 
Patient data protection 
The Investigator must file a patient identification list which includes sufficient information to link 
records, i.e. the Case Report Form (CRF) and clinical records. This list should be preserved for 
possible future inspections/audits but should not be made available to the Sponsor except for 
monitoring or auditing purposes. 

 
 
 
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The patients will be informed that the data will be stored and analyzed by computer, that Swedish 
regulations for the handling of computerized data will be followed and that identification of 
individual patient data will only be possible for the Investigator.  
The patients will be informed about the possibility of inspections/audits of relevant parts of the 
clinical records by representatives of the Sponsor, and/or RA. Authorization to direct access to the 
patient’s clinical records, as described above, is given by signing the ICF. 
7 
INVESTIGATOR(S) AND TRIAL ADMINISTRATIVE STRUCTURE 
This is an Investigator initiated study where Professor Anna Martling will be the Sponsor 
representative and the coordinating Investigator. The Sponsor is ALASCCA Study group, that 
includes the members listed in the table below. Departments of surgery in Sweden with a defined 
high volume of colorectal resections and that are actively registering patients in the Swedish 
ColoRectal Cancer Registry (SCRCR) will be asked to participate in the study. 
 
Name 
Role 
Titel 
Adress 
Phone 
Email 
Mef Nilbert 
Sponsor 
Professor of 
Oncology, 
Institute of 
Clinical 
Sciences, 
Division of 
Oncology and 
Pathology, Lund 
University  
 
Medicon 
Village, 
building 404  
Scheelevägen 
2 
223 81 Lund 
 
+46 707 96 80 
69 
mef.nilbert@med.lu.se 
Henrik 
Grönberg 
Sponsor 
Professor of 
Cancer 
Epidemiology, 
Department of 
Medical 
Epidemiology 
and 
Biostatistics, 
Karolinska 
Institutet 
Department 
of Medical 
Epidemiology 
and 
Biostatistics, 
Karolinska 
Institutet, Box 
281, 17177 
Stockholm 
+46 8 52 48 23 
47 
Henrik.gronberg@ki.se 
Bengt 
Glimelius 
Sponsor 
Professor of 
Oncology, 
Department of 
Immunology, 
Genetics and 
Pathology, 
Uppsala 
University 
Department 
of Oncology, 
Akademiska 
Sjukhuset, 
85185 
Uppsala 
+46 18 611 55 
13 
Bengt.glimelius@igp.uu
.se 
Scandinvian 
CRO 
CRO 
 
Skolgatan 8  
Box 15027 
750 15 
Uppsala 
+46 18 100 
5500 
 

 
 
 
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8 
INTRODUCTION 
Colorectal cancer annually affects 6000 individuals in Sweden.1 Refined surgery, addition of 
radiotherapy (in rectal cancer) and novel medical treatments have improved survival. Despite a 
localized primary tumor, 20-40% of patients with colorectal cancer stage II-III develop metastatic 
disease with a high risk of death from the disease.2, 3 More efficient adjuvant therapies thus have a 
strong potential to improve survival in colorectal cancer.  
Colorectal cancer represents a model system for how mutations in cancer-associated genes 
accumulate during progression from adenoma to cancer. These mutations have been of great 
importance for the diagnosis of hereditary forms of colorectal cancer and to predict of treatment 
response. Inherited mutations in the APC gene cause familial colonic polyposis and mutations in 
mismatch repair genes MLH1, MSH2, MSH6 and PMS2 cause Lynch syndrome.4, 5 Individuals 
with hereditary predisposition are offered surveillance or preventive procedures to decrease 
morbidity and mortality from colorectal cancer. Acquired mutations in the genes KRAS, NRAS and 
BRAF are in metastatic colorectal cancer used to predict response to and benefit from targeted 
inhibitors of EGFR.6 Hence, there are currently diagnostic markers for hereditary colorectal cancer 
and treatment predictive markers for advanced disease, but a lack of markers to predict benefit 
from adjuvant therapy.  
Low-dose acetylsalicylic acid (ASA) therapy reduces the risk of colorectal cancer, reduces the 
incidence of adenomas in patients with previous adenomas or cancer and decreases the incidence 
of metastases after diagnosis of colorectal cancer. 7, 8, 9 These findings have been confirmed in both 
animal studies and in human studies. ASA works by inhibiting the enzyme Cyclooxygenase-2 
(COX-2) that is overexpressed in colorectal cancer.10 Several observational studies have also 
suggested that treatment with ASA after a colorectal cancer diagnosis improves disease-free and/or 
overall survival (OS). These observations have been made in unselected patient populations and 
have shown a benefit equivalent to a Hazard Ratio (HR) of about 0.55 for colorectal cancer-
specific survival.11  
The PI3K pathway is frequently altered in colorectal cancer e.g. through mutations/inactivation of 
genes including PIK3CA, PIK3R1 IGF2, IGR2 and PTEN. Recently, acquired mutations in the 
PIK3CA gene were shown to predict benefit from treatment with ASA.12, 13 While patients whose 
tumors did not carry PIK3CA a mutation had no benefit from aspirin therapy, patients whose 
tumors carry PIK3CA mutations had an HR of 0.11-0.18 for colorectal cancer-specific death. These 
data are based on retrospective analyzes and require confirmation in prospective randomized trials 
to establish treatment recommendations with ASA in patients with colorectal cancer. The 
connection between PIK3CA mutations and prediction of response to ASA fits well with the effect 
that PIK3CA mutation have in terms of increased AKT signaling, which in turn up-regulates COX-
2. Inhibition of COX-2 in tumor cells with mutant PIK3CA will inhibit tumor cell survival.  
Liao et al. (2012) 12 used a retrospective cohort (Nurses’ Health Study) to study 964 patients with 
colorectal cancer. PIK3CA mutations were detected in 17% of the tumors. Patients whose tumors 
lacked mutations showed no difference in prognosis in relation to ASA use, whereas patients 
whose tumors carried PIK3CA mutations showed longer cancer-specific survival (HR for cancer-
related death 0.18). Only 3/66 patients with PIK3CA mutated tumors died of the disease. Patients 
who took aspirin before the cancer diagnosis, as those who started after diagnosed had the benefit 
of treatment - if the tumor had a PIK3CA mutation.  
Domingo et al. (2013) 13 analyzed retrospectively the 896 patients enrolled in a study of COX-
inhibitor rofecoxib (Vioxx). PIK3CA mutations were identified in 12% of the tumors and did not 

 
 
 
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correlate with the Vioxx treatment. In the ASA-treated group, the risk of relapse correlated with 
PIK3CA mutations. Of the patients whose tumors did not have PIK3CA mutations, 23/90 (26%) 
relapsed, compared to 0/14 ASA-treated patients with PIK3CA mutant tumors. This finding 
corresponds to a HR for relapse at 0.11. 
 
From Liao et al. N Engl J Med 367;17, 2012 
Acquired changes in the PI3K signaling pathway are important for cell proliferation and cell survival 
and are estimated to be existing in one-third of colorectal cancers.14 In addition to activating 
mutations in PIK3CA, mutations and deletions of PIK3R1 or PTEN genes are present and it may be 
hypothesized that these changes may also have an effect related to benefit from ASA treatment 
though these genes were not investigated in the studies by Liao et al and Domingo et al. 12, 13 
The two retrospective studies point in the same direction and show a highly significant reduction in 
the risk of relapse in patients with PIK3CA-mutated colorectal cancer who for some reason were 
treated with ASA, whereas patients with wild-type tumors did not benefit from the treatment. 12, 13 
On the other hand, two recent publications with similar design and sample size did not show any 
effect of low dose ASA in patients with PIK3CA mutations.15, 16 
The role of mutations in the other PI3K genes, PIK3R1 or PTEN, in relation to effect form ASA is 
unknown. These genes can, because of their central location in the PI3K pathway, be hypothesized 
to have the same effect on ASA benefit, but this remain to be demonstrated. The ALASCCA study 
design is based on power calculations in relation to PIK3CA mutations in exon 9 and 20 (hotspots), 
but will include an additional 12% patients with mutations in PIK3CA (mutations outside exon 9 
and 20) PIK3R1 (mutations) or PTEN (mutations and homozygote deletions). 
Adjuvant chemotherapy is administrated to patients with high risk of relapse. The treatment has 
side effects and reduces the risk of relapse in stage II by about 20% and about 35-40% in stage III. 

 
 
 
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Since ASA has well-known and limited side effects it is not necessary with an extensive toxicity 
study. Adjuvant use of ASA can be used as monotherapy or in combination with adjuvant 
chemotherapy.  
The current study will focus at patients with stage I-III rectal cancer or II and III colon cancer, who 
are at >10% risk of recurrence and will evaluate clinical benefit from adjuvant treatment with ASA 
in patients with mutations in the PI3K signaling pathway. The study will also introduce multi-gene 
molecular diagnostics in colorectal cancer, which benefits patients irrespective of mutation in 
relation to treatment with targeted drugs in case of disease recurrence. 
9 
TRIAL OBJECTIVES AND ENDPOINTS 
9.1 
Primary objective 
• To determine whether adjuvant treatment with 160 mg ASA once daily for 3 years can 
improve Time To Recurrence (TTR) in patients with colorectal cancer with somatic 
alterations in the PIK3CA (exon 9 and 20) compared with placebo.   
9.2 
Primary endpoint 
• Time To Recurrence (TTR) at 3 years in patients with tumors harboring PIK3CA mutations 
in exon 9 and 20 
9.3 
Secondary objective 
• To determine whether adjuvant treatment with 160 mg ASA once daily for 3 years can 
improve Disease-Free Survival (DFS) in patients with colorectal cancer with somatic 
alterations in the PIK3CA (exon 9 and 20) compared with placebo. 
• To determine whether adjuvant treatment with 160 mg ASA once daily for 3 years can 
improve DFS in patients with colorectal cancer with somatic alterations in the PIK3CA 
(other than exon 9 and 20), PIK3R1 or PTEN genes compared with placebo.  
• To determine whether adjuvant treatment with 160 mg ASA once daily for 3 years can 
improve TTR in patients with colorectal cancer with somatic alterations in the PIK3CA 
(other than exon 9 and 20), PIK3R1 or PTEN genes compared with placebo 
• To compare overall survival (OS) at 5 years from randomization in patients receiving low-
dose ASA versus placebo. 
• To assess overall safety and tolerability. 
 
9.4 
Secondary endpoint 
• Disease-Free Survival (DFS) at 3 years, in patients with tumors harboring PIK3CA 
mutations in exon 9 and 20.  

 
 
 
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• Disease-Free Survival (DFS) at 3 years, in patients with tumors harboring PIK3CA 
mutations other than in exon 9 and 20 and in PIK3R1 and PTEN.  
• Time To Recurrence (TTR) at 3 years, in patients with tumors harboring PIK3CA mutations 
other than in exon 9 and 20 and in PIK3R1 and PTEN. 
• OS at 5 years in patients with tumors harboring PIK3CA mutations in exon 9 and 20, other 
than in exon 9 and 20, and in PIK3R1 and PTEN.  
9.5 
 Exploratory objectives  
• Description and presentation of data on patients already on administration with ASA 
• In a technical pilot study (50 patients), ensure the handling and  shipping of the gene 
samples 
 
In addition, the study will add clinical value for the patient’s future treatment by genetically 
identifying the tumor’s potential mutation in the genes BRAF, KRAS, NRAS and Mismatch Repair 
(MMR) status (Microsatellite Instability, MSI, alt Immunohistochemistry, IHC, for MMR genes). 
This is already performed at the hospitals according to clinical praxis. 
9.6 
Safety Endpoints 
• Frequency and severity of adverse events (AE)   
• Cerebral and gastric haemorrhage (for interims analysis) 
10 INVESTIGATIONAL PLAN 
10.1 Overall trial design  
ALASCCA is a randomized, parallel group, double blind, multicenter, placebo-controlled, 
biomarker-based study of adjuvant treatment with ASA in colorectal cancer. The study will 
compare DFS, time to relapse and OS and will assess safety and tolerability.  
Patients (adult male and female) with colorectal cancer clinical stage I-III with localized disease 
are considered for the study. Patients will be screened for inclusion at the time of surgery of the 
tumor (at time of routine patient visit before elective surgery or postoperatively within 12 weeks in 
case of emergency procedure or if screening was missed preoperatively). After inclusion and when 
surgery is performed, patients with PIK3 mutations and colon cancer stage II and III tumors or 
rectal cancer stage I-III, will be randomized to receive 160 mg ASA or placebo orally. Last date for 
randomization and start of treatment is 12 weeks postoperatively. The treatment can be 
administered alone or in combination with adjuvant chemotherapy. The choice of any adjuvant 
chemotherapy is made by the Investigator and should follow the guidelines in the National Care 
Program (www.cancercentrum.se).  The treatment will be administered for 3 years. There will be a 
follow-up period for two years. Outside the trial, the patient will be treated according to standard 
care at the site. 
A phone contact will be made 3 months after the randomization visit and thereafter every 6th 
month. The patients will also visit the site 6 months after randomization and thereafter every 6th 

 
 
 
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month i.e. the patients will be in contact with the site every 3rd month. There will also be a 
visit/phone contact at the end of the follow-up period.  
A total of 3750 patients will be screened in order to include 300 patients with PIK3CA (Exon 9 and 
20) mutated tumors in each treatment arm (Group A). With an estimated 10 % drop-out rate, 150 
patients will be randomized in each arm. This also includes approximately 15 % of the patients that 
will be excluded due to tumor stage 1.    
An additional 300 patients with mutations in other PI3K pathway genes PIK3CA (other than exon 
9 and 20), PIK3R1 or PTEN will also be randomized in each arm and will be treated as a separate 
group in the analyses (Group B). With an estimated 20 % drop-out rate, 150 patients will be 
randomized in each arm. 
The randomization process is expected to take 24 months. 
Patients already treated with ASA at inclusion will be included in an observation group. 
An interim analysis will be made on safety i.e incidence and type of serious bleeding complication 
grade > 1 every 12 months. An independent safety data monitoring committee will be responsible 
for evaluating and follow-up of the safety annually. 
For details see figure 1 and figure 2.  

 
 
 
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10.2 Study procedures  
Patients planned for surgery of a colon cancer (clinical stage II-III) or rectal cancer (clinical stage 
I-III) will be screened for this study. The investigations and assessments performed according to 
standard care of the surgery of the primary cancer in the colon or the rectum will not be part of the 
documentation of the study. 
10.2.1 Screening (Visit 1)  
Screening Part 1 
The purpose with screening visit part 1 is to be able to select patients with alterations in PIK3CA, 
PIK3R1 or PTEN and colon cancer tumor stage II-III or rectal cancer tumor stage I-III.   
Pre-operation;  
The screening visit will take place in connection of surgery of the primary tumor in the colon or 
rectum. The visit could preferably be at the same time as the pre-operative visit. Randomization will 
take place within 12 weeks after surgery. 
Post-operation; 
In case of emergency procedures or if screening was missed preoperatively, patients can be screened 
postoperatively. The screening visit can not be performed later than allowing randomization 12 
weeks after surgery.  
The Investigator will explain to the patient the nature and aim of the study, its procedures, possible 
side effects, requirements and restrictions. The patient will sign the written informed consent before 
any study related procedures are performed. 
 
The following assessments will be performed during the screening visit; 
• Obtain written informed consent  
Post-operative characterization of; 
• tumor tissue for mutations in the genes 
• 4 ml (EDTA) blood samples for extraction of germline DNA that will be used for the 
molecular profiling. In addition, 2 x 4 ml (EDTA) plasma sample for biobank storage for 
any future analysis. The sample will be taken in connection with screening part 1.  
• tumor stage  
Patients without somatic alterations in PIK3CA, PIK3R or PTEN or tumor stage I in the colon 
cancer group or IV will be withdrawn from the study. 
Screening Part 2 (Visit 2) 
Patients with somatic alterations in PIK3CA, PIK3R1 or PTEN and colon cancer tumor stage II-III 
or rectal cancer tumor stage I-III, are able for screening part 2. This visit will take place after 
screening visit part 1 when the result of the mutation analysis and tumor stage is available. The 
following assessments will be performed; 
 

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•
Karnofsky performance status
•
Documentation of platelets; if results are older than 60 days from visit 2, a sample will be
taken.
•
Documentation of Carcinoembryonic antigen (CEA), if results are older than 30 days from
visit 2, a sample will be taken. CEA measurement is optional.
•
Colonoscopy or Computed Tomography (CT) colon available within 3 months
preoperatively
•
Obtain medical and surgical history
•
Record demographic information
•
Record prior and concomitant medication
•
Distant recurrence investigation available within 3 months preoperatively or for emergency
cases immediately postoperatively
•
Pregnancy test (urine dipstick)
•
Assess of all inclusion and exclusion criteria
10.2.2 Randomization (Visit 3) 
Patients with somatic alterations in PIK3CA, PIK3R1 or PTEN and tumor pathological stage II-III 
for colon cancer patients or tumor pathological stage I-III for rectal cancer patients that fulfil the 
inclusion criteria and none of the exclusion criteria will be randomized to one of the treatment arms. 
If all data is available from screening visit part 2, the randomization visit can be performed at the 
same time. The treatment period begins at the Randomization visit and ends after 3 years. 
The following assessments will be performed during the randomization visit; 
•
Randomization of the patient
•
Provide the patient with IMP for 6 months + 1 week
10.2.3 Phone calls (Visit 4, 6, 8, 10, 12 and 14) 
The patient will be contacted every 3rd months by a study nurse. A visit window of ± 21 days is 
allowed. The following will be reviewed every 3rd months; 
•
Assess AEs
•
Compliance check
•
Record concomitant medication
10.2.4 Treatment visits (Visit 5, 7, 9, 11, 13, 15) 
The patient will visit the site every 6 months. A visit window of ± 21 days is allowed. Follow-up is 
otherwise according to standard national guidelines. 

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The following assessments will be performed during the treatment visits; 
•
Assess AEs
•
Record concomitant medication
•
Compliance and drug accountability check
•
Provide the patient with IMP for 6 months + 1 week (not applicable for visit 15)
In addition to the items that will be performed during the treatments visits, the following will be 
performed at the time of visit 7 and 15 (after 1 and 3 years); 
•
CT/MRI (Magnetic Resonance Imaging) thorax and abdomen
•
CEA (Optional)
In case of any recurrence the patient will be taken care of according to standard treatment at the 
site and will be withdrawn from further study treatment. 
10.2.5 Follow-up period (Final visit 16 ) 
The follow-up period will start after the final treatment visit and ends after 2 years. The patient will 
visit the site or be contacted by phone at the end of the follow-up period i.e. after 2 years. A visit 
window of ± 30 days is allowed. Any other assessment e.g. endoscopic investigation that will be 
performed according to standard care will not be documented in the study. 
The following assessments will be performed during the follow-up visit; 
•
Documentation of CEA (Optional), if not available a sample will be taken
•
Review if there is any clinical suspicion of recurrence
10.3 Observation group 
Patients already on ASA treatment, > 3 doses per week, at the screening visit will be included in 
the observation group. These patients will be handled according to standard care and will only be 
followed through the Swedish ColoRectal Cancer Registry.  

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Figure 1 Study design 
. 
Randomization 
Screening  
Part 1 
Treatment phase (double-blind) 
Maintenance  
(3 years) 
Follow-up phase 
ASA 160 mg 
Group A 150 patients 
Group B 150 patients 
Placebo 
Group A 150 patients 
Group B 150 patients 
Patients already on ASA 
No treatment 
Follow-up 
(2 years) 
ASA according to standard 
care 
Group A: 
• Patients with PIK3CA mutation 
(Exon 9 and 20) 
Group B 
• Patients with PIK3CA mutation
(Other than Exon 9 and 20) 
• PIK3RI, or PTEN mutation/ 
deletion
Screening  
Part 2 
Patients with tumor 
stage I-III will be 
screened. 
Patients with colon cancer 
stage 1 and  without 
mutation/deletion in 
PI3Ksignalling pathway. 

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Figure 2 Schedule of activities 
Activities 
Screening 
Randomiza- 
tion1 
Treatment Period 
F-U
period 
Visits 
V1 
V2 
V3 
V4 
V5 
V6 
V7 
V8 
V9 
V10 
V11 
V12 
V13 
V14 
V15 
V16 
Weeks 
≤-12 
X2 
0 
Months 
3 
6 
9 
12 
15 
18 
21 
24 
27 
30 
33 
36 
60 
Phone call 
X 
X 
X 
X 
X 
X 
X 
Visit window (days) 
±21 
±21 
±21 
±21 
±21 
±21 
±21 
±21 
±21 
±21 
±21 
±21 
±30 
Informed consent 
X 
Demographics 
X 
Medical and surgical  history 
X 
Prior. and concom. Medication 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Inclusion/Exclusion Criteria 
X 
Karnofsky status 
X 
Distant recurrence investigation 
X 
Colonoscopy or CT colon 
X 
CT thorax and abdomen 
X 
X 
Characterizing of tumor stage 
X 
Characterizing of tumor tissue for mutations  
X 
Blood sampling for germline DNA extraction 
X 
Randomization 
X3 
X 
Platelets 
X 
CEA (Optional) 
X 
X 
X 
X 
Pregnancy test urine dipstick  (female patients) 
X 
IMP administration 
X 
X 
X 
X 
X 
X 
Compliance and drug accountability check 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
AEs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X4 
1)
Randomization will take place within 12 weeks from surgery. 
2)
V2 will take place when the result of the mutation analysis and tumor stage is available. 
3)
If all results are available with regards to inclusion and exclusion criteria the randomization visit can take place at visit 2. 
4)
Review of clinical recurrence 

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10.4 Rationale for trial design, doses and control group 
In order to evaluate the ASA effect on AEs and efficacy, a placebo control group is added. To 
avoid bias the study is double-blinded to participants, Investigator and sponsor. 
Rationale for 3 years of treatment: Previous studies on ASA have described effect after 3 
years of treatment and this treatment time is relevant also in relation to the standardized 
follow-up for patients with colorectal cancer who in the standard program undergo medical 
and radiologic evaluations after 1 and 3 years following surgery.  
Rationale for the dose selected: Studies that have described an effect from ASA treatment in 
colorectal cancer have detected effect at doses of 0.5-5 tablets of 325 mg/week (HR 0.57) and 
a stronger effect (HR 0.47) at doses of >6 tablets. A dose of 650 mg ASA/week has been 
defined as the lower limit. 12 Studies of the primary preventive effect from ASA have 
demonstrated an effect from daily doses of 300 mg. 17, 9 There is thus evidence for an 
effective dose between 100-300 mg/day, which led us to choose the 160 mg daily regimen.   
10.5 Risk/benefit assessment 
Regular ASA is associated with an increased risk of gastrointestinal bleeding of around 0.1% 
per year and a risk of intracranial haemorrhage that is estimated to be around 0.01%. 18 The 
risk is estimated to be dose-dependent and the risk of intracranial haemorrhage is probably 
linked to platelet inhibition.19 The dose administrated in the study, 160 mg once daily, is 
considered so low that the risk of bleeding is small. 
ASA uses is not recommended in pregnancy and may in rare cases cause sensitivity reactions 
and exacerbate asthma. 
The side-effects of ASA are well documented and are estimated not to outnumber the 
potential benefit in relation to a reduced risk of death from cancer. Moreover, ASA use has 
preventive effects related to cardiovascular disease and thromboembolic disease.19 
Due to the risk of adverse reactions and a possible interference with the study drug, patients 
are advised not to use Nonsteroidal Anti-Inflammatory Drug (NSAID), but to choose 
paracetamol in case of pain or fever. The patients will be carefully informed that they only 
can take the tablets included in the study and no additional ASA. Compliance will be checked 
every third months.   
An independent Safety Monitoring Committee will be responsible for evaluating and follow-
up of the safety. 
10.6 Selection of trial population 
The target group is patients with localized colon cancer stages II-III or rectal cancer stages I-
III, with tumor mutations in PIK3CA or related genes, regardless of adjuvant chemotherapy. 

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The patients will be selected from the surgery clinic. Each clinic will keep a log of all patients 
screened and included. The reason for screen failure should be stated for all patients screened 
but not included. The reason for withdrawal should be stated for all patients included but not 
completed. 
10.6.1 Inclusion criteria 
-
Tumor with somatic alterations in PIK3CA, PIK3R1 or PTEN
-
Colon tumor stage II-III or rectal cancer tumor stage I-III
-
Patient between18-80 years (including)
-
Radical surgery according to surgeon and pathologist
-
Karnofsky performance status ≥60%
-
Platelets ≥ 100 x 109 / L
-
Clean Colonoscopy or CT colon within 3 months preoperatively or postoperatively but
before randomization
-
Patient able to swallow tablets
-
Patient able to understand and sign written informed consent
-
If a woman, before inclusion she must be:
-
Postmenopausal, defined as: >45 years of age with amenorrhea for at least 24 months
or
-
If menstrual, surgically sterile (have had a hysterectomy or bilateral oophorectomy,
tubal ligation, or otherwise be incapable of pregnancy), or
-
If heterosexually active, practicing a highly effective method of birth control,
including combined (estrogen and progestogen containing) hormonal prescription oral,
intravaginal, transdermal contraceptives, or progestogen containing hormonal
prescription oral, injectable, implantable contraceptives or intrauterine device (IUD),
or intrauterine hormone-releasing system (IUS), or male partner sterilization, or
-
If not heterosexually active (if refraining from heterosexual intercourse during the
entire period of risk associated with the study treatments. The reliability of sexual
abstinence needs to be evaluated in relation to the preferred and usual lifestyle of the
subject).
Women must agree to continue using these methods of contraception throughout the study 
and up to the last dose of study treatment. 
10.6.2 Exclusion criteria 
-
Hereditary colorectal cancer linked to familial colonic polyposis or Lynch syndrome
-
Inflammatory bowel disease (Crohn's disease or ulcerative colitis)
-
Distant metastases
-
Other cancers (excluding colorectal cancer or other skin cancer than melanoma) within
3 years from screening
-
Known bleeding diathesis (such as hemophilia)

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-
Concomitant antiplatelet therapy (eg clopidrogrel or ticlopidine) or anticoagulant
therapy (warfarin or low molecular weight heparin). Post-operative treatment with low
molecular weight heparin must be withdrawn before administration of study treatment
-
Active gastritis or peptic ulcer, or significant surgical post-op bleeding, within the
previous three months assessed at screening and randomization
-
Ongoing regular use of corticosteroids, NSAID
-
Uncontrolled hypertension according to Investigator’s judgment
-
Clinically significant liver impairment according to Investigators judgment
-
Existing renal failure according to Investigator’s judgment. Renal failure with
decreased creatinine clearance <60 should lead to consultation with a nephrologist.
-
Significant medical illness that would interfere with study participation
-
Pregnancy or breastfeeding females
-
Known allergy to NSAIDs or ASA
-
Current participation in another clinical trial that will be in conflict with the present
study
-
Patients who are unlikely to comply with the protocol (e.g. uncooperative attitude,
inability to return for subsequent visits) and/or otherwise considered by the
Investigator to be unlikely to complete the study
10.6.3 Patients treated with ASA before randomization 
Patients with regular administration of ASA defined as >3 doses /week will be included in 
observation group. Other additional regular use of ASA must be withdrawn before 
randomization. 
10.6.4 Removal of trial patients from treatment or assessments 
A patient should be withdrawn from the trial treatment if, in the opinion of the Investigator, it 
is medically necessary, or if it is the expressed wish of the patient. Patients are free to 
discontinue their participation in the trial at any time. Irrespective of the reason for 
withdrawal and when ever possible, data from the Swedish colorectal registry can be 
collected.  
The electronic case report form (eCRF) should be completed as far as possible and collected 
by the Monitor. 
A withdrawn patient is not allowed to re-enter into the trial. A withdrawn patient will not be 
replaced. The criteria for withdrawal are the following:  
-
Patient wishes to discontinue
-
Unacceptable AE, including laboratory values
-
In case the patient experience a relapse
-
Non-compliance with the study protocol
-
Patient refuses to cooperate
-
Other medical reasons
-
Pregnancy
-
Unblinding of treatment

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10.7 Treatments 
10.7.1 Identity of Investigational Medicinal Product (IMP) 
The Investigator must ensure that the IMP will only be used in accordance with the protocol. 
The IMPs for this study are; 
•
Acetylsalicylic acid 160 mg tablet
•
Placebo tablets matching Acetylsalicylic acid 160 mg
10.7.2 Packaging, labeling and storage of IMP 
The IMP will be manufactured and packed according to Good Manufacturing Procedure by 
Pfizer. The package will be labeled with the following information: 
•
Route of administration, quantity of dosage, pharmaceutical dosage form
•
Directions for use
•
Storage conditions
•
Batch number
•
Limited to investigational use
•
Name of Sponsor
•
Protocol Number
•
Patient Number
•
Name of Investigator
•
Expiration date
•
“Keep out of reach of children”
The IMP will be stored in room temperature (15-25̊C). 
10.7.3 Doses and treatment regimens 
The patient will receive IMP in a package covering a period of 6 months+1 week. The patient 
will receive one package at each treatment visit. One tablet will be administered once daily. 
The tablet will be swallowed with a glass of water. 
The randomized schedule will make sure that 300 patients (150 patients from Group A and 
Group B) will receive 160 mg ASA and 300 patients (150 patients from Group A and B) will 
receive a matching placebo tablet.  
10.7.4 Investigational Medicinal Product accountability 
The IMP will be released to the trial site(s) after approvals of the trial protocol have been 
received from the IEC and the RA and the trial agreement has been finalized and signed by 
the site.  

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The Investigator is responsible for keeping detailed records, which show the quantity of IMP 
that is received, stored, delivered to and taken out from the place of storage. Any 
discrepancies between dispensed and returned IMP must be explained and documented. 
Products deliberately and/or accidentally destroyed by the Investigator/ Hospital Pharmacy or 
the patient must also be accounted for. 
The Monitor will perform IMP accountability and make sure that all unused IMP is 
adequately destroyed/returned and documented.  
10.7.5 Method of assigning patients to treatment groups 
Randomization will be performed centrally using an Interactive Response System (IXRS). At 
time for randomization the Investigator or study personnel will contact or access the IXRS to 
register the patient. When the patient is confirmed as eligible, the Investigator will obtain the 
identification number of the IMP that should be dispensed to the patient.  
The randomization schedule will be generated by an independent statistician. 
10.7.6 Blinding 
This is a double-blind study i.e. nor the patient or the Investigator will know which treatment 
that will be administrated to the patient. Placebo tablets matching the ASA will make sure that 
the blinding is kept.   
10.7.7 Emergency unblinding for safety reason 
In case of a rare emergency where, in the opinion of the Investigator, discontinuation of the 
study treatment is not sufficient and the study treatment must be unblinded in order to 
evaluate further course of action, the Investigator will access the IXRS system to initiate 
patient unblinding.  
In the event the blind is broken, the sponsor should be informed as soon as possible. The date, 
time, and reason for unblinding must be documented by the IXRS, in the appropriate section 
of the eCRF, and in the source document. The documentation received from the IWRS 
indicating the code break must be retained with the subject's source documents in a secure 
manner. 
Information about the treatment assignment must be restricted to designated study site staff 
who are providing immediate care to the patient.  
As a backup system, the investigator or other treating physician can contact the sponsor staff 
according to instructions that will be provided to the investigators, to unblind the treatment for 
an individual patient in a manual way. The sponsor is not entitled to stall or reject unblinding. 
Once the study treatment has been unblinded, the patient will complete the final visit of the 
treatment period.  

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10.7.8 Prior and concomitant therapy 
Adjuvant chemotherapy or other therapy that are considered necessary for the patient’s 
welfare may be given at the discretion of the Investigator.  
Post operative treatment with low dose heparin must be withdrawn before administration of 
study treatment.  
Administration of IMP will be temporary discontinued during enterostomy closure or any 
other procedure requiring administration of low molecular weight heparin. The IMP will be 
stopped the day before administration of the low molecular weight heparin. The IMP will be 
administered again the day after the treatment with low molecular weight heparin has stopped. 
The temporary discontinuation of IMP cannot be longer than 30 days. 
In patients receiving adjuvant chemotherapy and that have a drop in their platelets count 
(<100 x 109/L) due to this, administration of IMP can be temporary discontinued until the 
chemotherapy treatment stops. The IMP will be administered again as soon as platelets are 
over ≥ 100 x 109/L.  
Patients with regular administration of ASA defined as >3 doses /week will be included in 
observation group. Other additional regular use of ASA must be withdrawn before 
randomization. 
All concomitant therapy used during the trial period must be recorded in the eCRF. Adjuvant 
chemotherapy administrated prior to the trial period will also be documented. 
No other drug under investigation may be used concomitantly with the trial medication. 
10.7.9 Treatment compliance 
Treatment compliance will be made by medication count by the study personnel at the site. 
10.8 Trial assessments  
The following will be assessed during the study. 
10.8.1 Demographic and baseline characteristics 
•
Demographics such as gender and age will be recorded.
•
Karnofsky status will be assessed by the Investigator according to the following;
o
100%, normal no complaints, no evidence of disease
o
90% able to carry on normal activity, minor signs or symptoms of disease
o
80% normal activity with effort, some signs or symptoms of disease
o
70% cares for self, unable to carry on normal activity or to do active work

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o
60% require occasional assistance, but is able to care for most of their personal
needs
•
All relevant medical and surgical history with in the last 3 years must be documented
in the eCRF.
•
A colonoscopy or CT colon performed within 3 months from surgery demonstrating a
clean colon i.e. no tumors available apart from the tumor that will be removed during
surgery.
•
A distant recurrence investigation according to local practice available within 3
months before surgery will be collected.
10.8.2 Molecular profiling of the tumors 
Patients with stage I-III will be included in the screening process preoperatively or short after 
surgery. The pathology result will classify the tumor and patients with tumor stage II-III and 
colon cancer or tumor stage I-III and rectal cancer will be randomized. Patients with clinical 
tumor stage IV will be excluded before screening Part 1. 
From all patients that are pre- or postoperatively eligible to be included in the ALASCCA 
study, a standardised piece (approximately 10x20x5 mm) is routinely cut from the primary 
tumor and fixated in formalin at the local pathology department. At the regional or local 
pathology department, this piece is sectioned, stained and the tumor content in the selected 
piece is estimated. This selected tumour piece is then sent to the selected laboratory of choice. 
The following somatic alterations in the tumours are defined as inclusion criteria in the 
ALASCCA study: 
•
Somatic mutations affecting the function of the PIK3CA, PIK3R1 or PTEN genes
•
Homozygous deletion of the PTEN gene
In addition, mutation analysis of the BRAF, KRAS and NRAS genes and Mismatch Repair 
(MMR) status (Microsatellite instability, MSI, alt Immunohistochemistry, IHC, for MMR 
genes) are also performed on the selected tumour piece/sections and forwarded back to both 
the treating doctor and to the local pathology lab. These genomic alterations are already used 
in clinical routine today and will add value to the clinic. 
The molecular analyses can either be performed at a regional pathology department or at the 
national reference laboratory at Science for Life Laboratory in Stockholm.  
10.8.3 Laboratory measurements 
If CEA and platelets are not available according to normal praxis, the samples will be taken. 
The handling of the samples will be made according to the routines at each site. Analysis will 
be made by the local lab at the sites.  
•
CEA- 3.5 ml (serum) will be taken for analysis of CEA.
•
Platelets- 4 ml (EDTA) ml blood sample will be taken for analysis of platelets.
•
A urine pregnancy test- will be taken on all female patients with child-bearing
potential unless they

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o
have undergone surgical sterilization
o
are post menopausal
The pregnancy test will be a commercially available urine test. 
•
A 4 ml (EDTA) blood sample is sent directly to Karolinska Institutet Biobank for
extraction of germline DNA to be used for the molecular profiling.
•
Plasma- 2 x 4 ml (EDTA) blood will be taken for biobank storage for any future
analysis.
10.8.4 Efficacy assessments 
Primary clinical efficacy assessments 
The primary clinical efficacy assessment will be CT thorax and abdomen. The CT will be 
performed, year 1 and 3 during the treatment phase.   
Secondary clinical efficacy assessments 
OS will be reviewed during the study. In case the patient dies during the study the cause of 
death will be recorded.  
Time until relapse will also be documented. 
10.8.5 Safety assessments  
The safety assessment will include AEs. Especially focus will be on bleeding complications. 
10.8.6 Safety Monitoring committee 
An independent Safety Monitoring Committee will be responsible for evaluation of safety. 
The committee will consist of independent physicians. A separate document will be written 
describing the process in details 
10.8.7 Adverse Events (AEs) 
10.8.7.1 Definitions 
Adverse Event 
Any untoward medical occurrence in a patient or clinical trial patient administered a 
medicinal product and which does not necessarily have to have a causal relationship with this 
treatment. An AE can therefore be any unfavourable and unintended sign (e.g. an abnormal 
laboratory finding), symptom, or disease temporally associated with the use of an IMP, 
whether or not considered related to the IMP. 
Serious Adverse Event (SAE) 

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An SAE is any untoward medical occurrence or event, at any dose, that: 
•
results in death
•
is life threatening
•
requires hospitalization or prolongation of existing hospitalization
•
results in persistent or significant disability/incapacity
•
is a congenital anomaly/birth defect.
or
•
other important medical event (example of such events are convulsions that do not
result in hospitalization)
Medical and scientific judgment should be exercised in deciding whether expedited reporting 
is appropriate in other situations, such as important medical events that may not be 
immediately life-threatening or result in death or hospitalization but may jeopardize the 
patient’s health or may require intervention to prevent one of the other outcomes listed in the 
definitions above. These AEs should also usually be considered as serious. 
Suspected Unexpected Serious Adverse Reaction (SUSAR) 
A SUSAR is a suspected unexpected serious adverse reaction, potentially causally related to 
the investigational medicinal product, and will be reported to the appropriate IEC and RA. 
10.8.7.2 Eliciting and recording of AEs 
The method for collecting and recording AEs will be spontaneous reporting and open question 
e.g. “How have you felt since previous visit” during the treatment and follow-up period.
All AEs, serious and non-serious, and pre-existing conditions, should be recorded in the
eCRFs. If no AE has occurred during the trial period, this should also be recorded.
Exception 
Events directly connected to expected chemotherapeutics side effects e.g. nausea, diarrhoea 
neutropenia and infections related to neutropenia will not be reported as AEs.  
Planned enterostomy closure performed after administration of IMP and complications after 
the closure will not be reported as AE/SAE. 
In case of any bleeding events related to the above, the event should be reported as an 
AE/SAE. 
The following evaluations are to be done by the Investigator in connection with the AE: 
•
description of the AE
-
If possible the Investigator uses the diagnosis for description of the event. If not the
diagnosis is decided, report the primary sign or symptom as the AE or SAE term
•
seriousness
-
Yes or No, see definition of a SAE for seriousness, as of above.
•
intensity
-
Mild - Symptoms which are easily tolerated (acceptable)

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-
Moderate - Symptoms which interfere with usual activity (disturbing)
-
Severe - Symptoms which give incapacity to do usual activity (unacceptable)
If the intensity changes during the period of the AE the maximum intensity should be 
recorded. 
•
duration of the AE (start - end)
•
action taken due to the AE
-
None
-
IMP stopped
•
causality rating with investigational medicinal product
-
Not related:  Indicates that the AE is definitely not related to the study drug.
-
Related: .
o
The AE could have been produced by the patient´s clinical status or the
medicinal product.
o
The AE follows a reasonable temporal sequence from the time of
administration of the medicinal product, and can not be reasonably explained
by the known characteristics of the patient´s clinical status.
•
outcome of the AE
-
Recovered/Resolved
-
Recovering/Resolving
-
Not recovered/Not resolved
-
Recovered/Resolved with sequelae
-
Fatal
-
Unknown
10.8.7.3 Pre-existing condition: 
Events available at the first administration of IMP are part of baseline information (pre-
existing conditions). These events will be considered as AE, only if they worsen after first 
administration of IMP.  
Elective procedures or surgery planned before first administration of IMP is not considered as 
an AE/SAE.  
10.8.7.4 Reporting of SAEs 
All SAEs must be reported by the Investigator using phone, mail or fax within 24 hours from 
the Investigator's knowledge of the event to the Monitor or other members of the staff at the 
Sponsor, regardless of the time that may have elapsed from the time the event occurred to 
when the Investigator first learns of it. The initial report should contain as a minimum the 
following information: 

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•
patient identification
•
treatment specification
•
diagnosis or symptoms
•
time specification for the SAE
•
name of the original reporter
A SAE report form must also be completed, signed by the Investigator and submitted to the 
monitor or the Sponsor no later than five working days after the initial information was 
received. Apart from the information above, this follow-up report should also contain the 
following information: 
•
assessment of intensity
•
assessment of causality
No distinction should be made between the tested investigational product and the 
reference/comparator product regarding reporting of SAEs as long as the code is not broken. 
Only SAEs that are both unexpected and assessed as related to IMP(s), i.e. SUSARs, are 
patient to expedited reporting to the appropriate IEC and RA, by the Sponsor. 
10.8.7.5 Follow-up of unresolved AEs 
If a patient is withdrawn due to an AE, or if an AE persists at the end of the trial treatment 
period, this should be followed up until the condition has ceased or until the patient is under 
professional medical care and a potential causality between IMP and the AE has been 
penetrated. An outcome assessment should be performed when an AE persists. 
10.8.7.6 Procedures in case of pregnancy 
In case of pregnancy or suspicion of possible pregnancy, the trial treatment must be stopped 
immediately, and the patient discontinued from participation in the trial. Pregnancy itself is 
not regarded as an AE unless there is a suspicion that the IMP may have interfered with the 
effectiveness of the contraceptive medication. However, the outcome of all pregnancies 
(spontaneous miscarriage, elective termination, normal birth or congenital abnormality) must 
be followed up and documented even after the patient was discontinued from the trial. 
All events of congenital abnormalities/birth defects are SAEs. Spontaneous miscarriages 
should also be reported and handled as SAEs. All outcomes of pregnancy must be reported to 
the Sponsor on the pregnancy report forms; Part I (at confirmed  pregnancy) and Part II 
(pregnancy outcome). 
10.8.7.7  Coding of AEs 
All AEs will be coded according to Medical Dictionary for Regulatory Activities (MedDRA). 
All SAEs are coded upon reporting to the Sponsor. The coding will be performed by the 
Sponsor.  
10.9 Data Management 

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Data from the study will be collected from the medical records and from the Swedish 
Colorectal Cancer Registry (SCRCR). Part of the information from the medical records will 
be entered into eCRF e.g. date of visits, study treatment, concomitant medication and AEs. 
Other parts will be imported to the study data base from the SCRCR e.g. tumor 
characteristics, surgical procedure, adjuvant treatment and long term follow-up. 
Other external data e.g. laboratory data will be entered or transferred into the study database. 
10.10   Swedish Colorectal Cancer Registry (SCRCR) 
Patients included in the study are also part of the SCRCR. The register was launched in 1995 
for rectal cancer and since 2007 it also includes patients with colon cancer. The database is 
continuously validated and updated and >98 % of the patients are included in the register. The 
SCRCR contains information such as patient demographics, (neo) adjuvant treatment, surgical 
procedure, tumor characteristics and short and long term follow-up.  
10.11   Quality Control 
A quality control (QC) of data will be performed to ensure that data entry and verification 
have been performed correctly in accordance to pre-defined instructions. The QC will be 
performed as described in the Data Management Plan. The QC will be performed before data 
is declared clean. 
10.12   Data Quality Assurance 
10.12.1  Case Report Forms (eCRFs) 
The Monitors will review and verify the data collected in the eCRFs and SCRCR against the 
source documents during monitoring visits. The Monitors will address the discrepancies 
found in the data and will ensure that corrections to the data are properly made and 
documented by the site personnel. All corrections will be documented in an audit trail.  
10.12.2  Monitoring 
The trial site will be visited by the Monitor and/or the Clinical Trial Manager (co-monitoring) 
periodically at times agreed with the Investigator. It is the function of the Monitor to ascertain 
that all aspects of the protocol are complied with and that the conduct of the trial conforms to 
applicable regulatory requirements and established rules for Good Clinical Practice (GCP).  
Preferably at the time of each monitoring visit, the Monitor will 
• review the completed eCRFs to ascertain that items have been completed and that the
data provided are accurate and obtained in the manner specified in the protocol.
• verify that the data in the eCRF and SCRCR register are consistent with the clinical
records or other relevant record (Source Data Verification) and that trial results are
recorded completely and correctly.

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• verify compliance with the procedures for reporting of SAEs, product accountability
and record keeping.
For this purpose the Monitor must be given direct access to clinical records, original 
laboratory data, etc., as far as these relate to the trial and without jeopardizing patient 
integrity. The Investigator and other relevant personnel should be available during the 
monitoring visit and should devote sufficient time. 
10.12.3  Training of staff 
All Investigators and staff carrying out observations of primary or other major efficacy 
variables involved in the trial should provide a curriculum vitae. The Investigator will keep a 
list of all personnel involved in the trial together with their function and trial related duties 
delegated. He/she will ensure that appropriate trial related training is given to all of these 
staff, and that any new information of relevance to the performance of this trial is forwarded 
to the staff involved. 
Before inclusion of patients the Monitor will perform a trial initiation visit to inform and train 
relevant trial staff. 
10.12.4  Audit and inspections 
The trial site may be patient to quality assurance audit by the Sponsor or someone appointed 
for this task by the Sponsor. A RA may request to make an inspection of the trial site. The 
procedures of such a visit would be similar to those of a monitoring visit, and data already 
checked by the Monitor may be checked again. The Investigator is required to inform the 
Sponsor immediately of an inspection requested by a RA. The Investigator and other relevant 
personnel must be available during the audit/inspection and must devote sufficient time. 
10.12.5  Changes in the approved Trial Protocol 
Trial procedures must not be changed without the mutual agreement of the Investigator and 
the Sponsor. 
Any substantial change to the approved Final Trial Protocol will be documented in a written 
and numbered Protocol Amendment. Any proposed substantial change to the Final Trial 
Protocol must be discussed with and approved by the Sponsor before submitted to IEC and 
Regulatory Authority for approval, according to applicable national regulations.  
10.13   Statistical methods and determination of sample size 
The statistical analysis will be described in detail in the Statistical Analysis Plan including a 
Data Display Plan, which will be in a final draft version prior to study start and finalized and 
approved before database lock.  
The primary statistical analysis will be done at 3 years of study treatment and an analysis of 
overall survival (OS) will be done at 5 years. 

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10.13.1  Demographics and baseline data 
All data will be presented using descriptive statistics. Results will be presented in total and by 
treatment group. Continuous variables will be summarized using mean, standard deviation, 
median, minimum and maximum. Categorical variables will be summarized using the number 
and percentage of patients. 
10.13.2  Endpoints 
10.13.2.1 
Primary Endpoint 
Primary endpoint TTR at 3 years will be analyzed in patients with tumors harboring PIK3CA 
mutations in exon 9 and 20. 
TTR is defined as time from randomization to occurrence of any of the following; loco-
regional recurrence, distant metastases or death from colorectal cancer. 
10.13.2.2 
Secondary Endpoint 
Secondary endpoint DFS at 3 years will be analyzed in patients with tumors harboring 
PIK3CA mutations in exon 9 and 20. 
DFS and TTR at 3 years will be analyzed in patients with tumors harboring PIK3CA 
mutations other than in exon 9 and 20 and in PIK3R1 and PTEN. 
DFS is defined as time from randomization to occurrence of any of the following events; 
loco-regional recurrence, distant metastases, second primary colorectal cancer, second 
primary other cancer, death from colorectal cancer, death from other cancer, non-cancer 
related death and treatment-related death whichever comes first. 
OS at 5 years will be analyzed in patients receiving low-dose ASA versus placebo. 
10.13.2.3 
Safety Endpoints 
Safety endpoints will be frequency and severity of AEs. 
The safety endpoints for the interim analysis will be the bleeding complications cerebral and 
gastric haemorrhage will. 
10.13.3  Analysis of efficacy 
The primary efficacy variable is TTR. Subjects who have not experienced loco-regional 
recurrence, distant metastases or death from colorectal cancer at time of 3- and 5- years will 
be censored at the time of the latest assessment. The log-rank test will be applied to test for 
difference in TTR between the treatment groups. 
Kaplan-Meier estimates will be used for the estimation of median times to treatment failure 
and their confidence intervals. Secondary endpoints will be assessed using the log-rank test or 

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a Cox regression model, with time to treatment failure (relapse or death) as response variable 
and treatment group as factor. 
All secondary variables will be presented descriptively with point estimate and 95% 
confidence intervals. 
The data from the observation group will only be presented descriptively. 
10.13.4  Analysis of safety 
AEs will be classified into standardized medical terminology from the verbatim description 
(Investigator term) using MedDRA. AEs will be presented by preferred term nested within 
System Organ Class. Verbatim description and all MedDRA level terms, including the lower 
level terms, for all AEs will be contained in the data listings of the clinical study report for 
this protocol. 
AEs will be summarized by presenting, for treatment group the incidence of AEs. The 
incidence of AEs will be based on the numbers and percentages of patients with AEs. 
Although a MedDRA term may be reported more than once for a subject, that subject will be 
counted only one time in the incidence count for that MedDRA term. 
10.13.5  Interim analyses and data monitoring 
Interim analyses on the safety endpoints, will be performed when data are available for all 
patients still included in the study after one years of treatment. The objective of the interim 
analyses is to follow up safety.  
No adjustment of the significance level will be made due to the interim analyses. 
10.13.6  Analysis data sets 
The Full Analysis Population (FAP) consists of all patients who were randomized and had 
eligible measure at baseline and at least one eligible measure post baseline. Patients 
withdrawn after randomization and with follow-up data will also be included. 
The Per Protocol Population at 3 year (PP3) consists of all patients in the FAP who had 
complete at least 3 years in the study, 80 % compliance and no significant protocol violations. 
The Per Protocol Population 5 year (PP5) consists of all patients in the FAP who had 
completed at least 5 years in the study, 80 % compliance and no significant protocol 
violations. 
The analyses will be performed on both FAP and PP. 
The Safety Population which consists of all patients who were included into the study and met 
all inclusion criteria and met no exclusion criteria and had at least one exposure to the study 
interventions. 
10.13.7   Determination of sample size 
Power was set to 80%, total follow-up to 36 months and significance level to 0.05 (two-
sided). The 36 months recurrence rate in the placebo arm was estimated to 18% based on the 
Stage/RF-specific estimates in Osterman and Glimelius (ref*). With the assumptions of 10% 

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loss to follow-up and a sample size of 150 patients in each arm, a reduction of 62% 
(RR=0.38) in the 36 months recurrence rate can be detected. 
*Recurrence Risk After Up-to-Date Colon Cancer Staging, Surgery, and Pathology: Analysis of the Entire
Swedish Population. Osterman E, Glimelius B.Dis Colon Rectum. 2018 Sep;61(9):1016-1025.
If 15% of the patients screened have hotspot mutations (exon 9 and 20) in PI3KCA a total of 
3750 patients will needed to be screened. This also includes approximately 15% of the 
patients that will be excluded due to tumor stage 1. In protocol version 5.2, the number of 
patients is changed after pilots and first 1000 patients have been included when better 
estimation on drop-out and mutation rate in PIK3CA was available. 
11 TRIAL MANAGEMENT 
11.1 Trial time table 
The study will start during Q2 2015 with a technical pilot. The process for handling of the 
gene sampling will be investigated. No IMP will be administrated. The estimated time for 
randomization of the first patient taking IMP will be Q1 2016. The recruitment period is 
estimated to5 years and will continue until June 2021. Included the treatment period of 3 
years and follow-up period of 2 years, the study will end approximately by end of year 2026. 
11.2 Insurance/indemnity 
The trial patients are covered by the Swedish Patient Insurance and the Swedish Drug 
Insurance. 
The Sponsor agrees to indemnify (legal and financial coverage) and hold the Investigator free 
of harm from any claim, whether based on legal principles or on generally accepted liability 
standards within the pharmaceutical industry, made against him by reason of personal injury, 
including death, to any person arising out of or connected with the performance of the trial to 
the extent that the injury is not caused by: 
1. failure by the Investigator to adhere to the terms of the Protocol;
2. failure by the Investigator to comply with any applicable governmental regulations;
3. malpractice, negligence or willful malfeasance by the Investigator.
The Investigator agrees to notify the Sponsor whenever he/she becomes aware of a claim or 
action, and to co-operate with and to authorize the Sponsor to carry out sole management of 
such claim or action. 
The Sponsor’s responsibility is covered by LFF Läkemedelsförsäkring via an association 
agreement with Judicial Board (Kammarkollegiet). The insurance covers ALASCCA study 
group’s liability under law and generally accepted liability standards within the pharmaceutical 
industry towards any third parties, including participating women, as Sponsor of the study. 
11.3 Trial agreements 

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The Principal Investigator at the investigational site must comply with all the terms, 
conditions, and obligations of the Clinical Trial Agreement (CTA) for this trial.  
11.4 Criteria for termination of the trial 
The Sponsor reserves the right to discontinue the trial at any time, but intends only to exercise 
this right for valid scientific or administrative reasons. 
After such a decision, the Investigator must call in all participating and inform the patients as 
well as perform relevant assessments, preferably according to the scheme for the final 
assessments. All delivered and unused trial products and other trial materials must be returned 
and all CRFs completed as far as possible. 
Investigator(s) will be reimbursed for reasonable expenses incurred, in the event this becomes 
necessary. 
11.5 Reporting of results and publication policy 
A clinical trial report, in compliance with ICH E3; Guideline for Industry, will be prepared by 
the Sponsor describing the conduct of the trial, the statistical analysis performed and the 
obtained results. 
The data generated by this trial are considered confidential information and the property of 
the Sponsor. Said confidential information may be published only in collaboration with 
participating personnel from the Sponsor. The Sponsor reserves the right to review and 
comment on the proposed publication prior to being submitted and/or published.” 
11.6 Record retention 
The Investigator must arrange for retention at the investigational site of a list of the patients 
and their identifying code, patient files and other trial documents. The archiving period must 
be adapted to regulations in force but should not be shorter than ten years after the termination 
of the trial and the presentation of the final report.   
It is the responsibility of the Sponsor to inform the Investigator/institution as to when these 
documents no longer need to be retained. 
11.7 Disclosure and confidentiality 
All unpublished information concerning the IMP and research carried out by ALASCCA 
study group, including patent applications, manufacturing processes, basic scientific data, etc., 
is considered confidential and the sole property of ALASCCA study group. Disclosure to 
third parties must be limited to those undertaking legitimate peer review of the scientific and 
ethical aspects of the trial and to those participating, including the recipients of drugs, so that 
customary medical care and informed consent can be achieved. 

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12 EMERGENCY PROCEDURES 
12.1 Emergency contacts 
In case of a medical emergency, contact Sponsor representative; 
Professor Anna Martling 
+46 8 517 728 02
+46 76 050 57 97
12.2 Procedures in case of medical emergency 
The Investigator is responsible for ensuring that there are procedures and expertise available 
to cope with medical emergencies during the trial. 
12.3 Procedures in case of overdose 
Very high doses of ASA can cause severe acidosis with fatal multiorgan failure. In these cases 
the patients will be taken care of according to standard treatment.   

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rapporter/rekti2013_140613.pdf
4. Jaspersson KW et al, Hereditary and familial colon cancer. Gastroenterology 2010 Jun;138(6):
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10. Fink SP et al, Aspirin and the risk of colorectal cancer in relaton to the expression of 15-
hydroxyprostaglandin dehydrogenase (HPGD). Sci Transl Med. 2014 Apr 23;6(233):233re2. doi: 10.
1126/scitranslmed.3008481.
11. Chan et al, Aspirin use and survival after diagnosis of colorectal cancer. JAMA. 2009 Aug
12;302(6):649-58. doi: 10. 1001/jama.2009.1112.
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