Pilot Study of Denosumab in BRCA1/2 Mutation Carriers Scheduled for Risk-Reducing Salpingo-Oophorectomy
Phase: EARLY_PHASE1
Conditions: Ovarian Carcinoma
Sponsor: National Cancer Institute (NCI)

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COVER PAGE 
 
 
 
 
 
DCP Protocol #: 
MDA2017-09-03  
 
Local Protocol #: Cornell: 19-04020123; CUMC: AAAR6281; DFCI: 18-727; Sheba: 5166-18- SMC; 
TASMC: 0229-18-TLV 
 
Pilot study of denosumab in BRCA1/2 mutation carriers scheduling risk-reducing salpingo-
oophorectomy 
 
 
Consortium Name: 
 
 
University of Texas MD Anderson Early Phase Clinical Research 
 
 
 
 
 
Consortium 
Name of Consortium Principal  
Powel H. Brown, MD, PhD 
Investigator:  
 
 
Professor and Chair, Department of Clinical Cancer Prevention 
 
 
 
 
 
University of Texas MD Anderson Cancer Center 
1515 Holcombe Boulevard, Unit 1360 
Houston, TX 77030-4009 
Telephone: (713) 792-4509 
Fax: (713) 794-4679 
E-mail address: phbrown@mdanderson.org 
 
MD Anderson Consortium 
 
Lana A. Vornik, MHA, MS 
Administrative Director: 
 
Associate Director, Research Planning and Development 
 
 
Department of Clinical Cancer Prevention 
 
 
University of Texas MD Anderson Cancer Center 
 
 
1515 Holcombe Boulevard, Unit 1360 
Houston, TX 77030-4009 
Telephone: (713) 792-9594 
Fax: (713) 745-4230 
 
 
E-mail address: lavornik@mdanderson.org 
 
MD Anderson Consortium 
 
Saba Abutaseh, BS 
Lead Org Coordinator: 
 
CLO Coordinator 
 
 
Department of Clinical Cancer Prevention 
 
 
University of Texas MD Anderson Cancer Center 
 
 
1515 Holcombe Boulevard, Unit 1360 
Houston, TX 77030-4009 
Telephone: 713-745-8181 
Fax: (713) 745-4230 
E-mail address: sgabutas@mdanderson.org  
 
 
Organization Name: 
 
 
Columbia University Irving Medical Center 
Protocol Principal Investigator: 
Meghna S. Trivedi, MD, MS 
 
 
 
 
 
Medical Oncology 
 
 
 
 
 
161 Fort Washington Ave, HIP 10 
 
 
 
 
 
New York, NY 10032 
 
 
 
 
 
Telephone: 646-317-2280 
 
 
 
 
 
Fax: 212-305-0178 
 
 
 
 
 
E-mail address: mst2134@cumc.columbia.edu  

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Organization:  
 
 
Columbia University Irving Medical Center  
Co-Principal Investigator: 
 
Katherine D. Crew, MD, MS 
 
 
 
 
 
Medical Oncology 
 
 
 
 
 
161 Fort Washington Ave, 10-1072 
 
 
 
 
 
New York, NY 10032 
 
 
 
 
 
Telephone: 212-305-1732 
 
 
 
 
 
Fax: 212-305-0178 
 
 
 
 
 
E-mail address: kd59@cumc.columbia.edu  
 
Organization:   
 
 
Columbia University Irving Medical Center  
Investigator:  
 
 
Jason D. Wright 
 
 
 
 
 
Gynecologic Oncology 
 
 
 
 
 
161 Fort Washington Avenue, 4th floor 
 
 
 
 
 
New York, NY 10032 
 
 
 
 
 
Telephone: 212-305-3410 
 
 
 
 
 
Fax: 212-305-3412 
 
 
 
 
 
E-mail address: jw2459@cumc.columbia.edu  
 
Organization:   
 
 
Weill Cornell Medical Center  
Site Principal Investigator:   
Kevin Holcomb, MD 
 
 
 
 
 
Gynecologic Oncology 
 
 
 
 
 
525 E. 68th Street, Suite J-130 
 
 
 
 
 
New York, NY 10065 
 
 
 
 
 
Telephone: 212-746-7553 
 
 
 
 
 
Fax: 212-746-8402 
 
 
 
 
 
E-mail address: keh2004@med.cornell.edu  
 
Organization:   
 
 
Dana-Farber Cancer Institute  
Site Principal Investigator: 
 
Judy E. Garber, MD, MPH 
 
 
 
 
 
Medical Oncology 
 
 
 
 
 
450 Brookline Avenue 
 
 
 
 
 
Boston, MA 02215 
 
 
 
 
 
Telephone: 617-632-2282 
 
 
 
 
 
Fax: 617-632-2649 
 
 
 
 
 
E-mail address: judy garber@dfci.harvard.edu  
 
Organization:   
 
 
Dana-Farber Cancer Institute 
Investigator:  
 
 
Neil S. Horowitz, MD 
 
 
 
 
 
Gynecologic Oncology 
 
 
 
 
 
75 Francis Street 
 
 
 
 
 
Boston, MA 02115 
 
 
 
 
 
Telephone: 617-732-8843 
 
 
 
 
 
Fax: 617-738-5124 
 
 
 
 
 
E-mail address: nhorowitz@partners.org  
 
 
 
 
 

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Organization:   
 
 
Tel Aviv Sourasky Medical Center  
Site Principal Investigator: 
 
Nadir Arber, MD, MSc, MHA 
 
 
 
 
 
Medical Oncology 
 
 
 
 
 
6 Weizman St 
 
 
 
 
 
Tel Aviv, Israel 64239 
 
 
 
 
 
Telephone: 972-3-697-3561/4968 
 
 
 
 
 
Fax: 972-3-697-4867 
 
 
 
 
 
E-mail address: nadira@tlvmc.gov.il  
 
Organization:   
 
 
Chaim Sheba Medical Center 
Site Investigator: 
 
       Eitan Friedman MD, PhD 
 
 
 
 
 
Medical Oncology 
 
 
 
 
 
Tel-Hashomer 52621, Israel 
 
 
 
 
 
Telephone: 972-3-530-3173 
 
 
 
 
 
Fax: 972-3-535-7308 
 
 
 
 
 
E-mail address: eitan.friedman@sheba.health.gov.il 
 
 
Organization:  
 
 
University of Texas MD Anderson Cancer Center 
Statistician: 
 
 
 
J. Jack Lee, PhD 
 
 
 
 
 
151 Holcombe Boulevard, Unit 447 
 
Houston, TX 77230 
 
Telephone: 713-794-4158 
 
Fax: 713-563-4242 
 
E-mail address: jjlee@mdanderson.org  
 
IND Sponsor:  
 
NCI/Division of Cancer Prevention  
 
 
 
 
IND#  
 
 
 
 
Agent(s)/Supplier: 
Denosumab  /  NCI DCP 
 
NCI Contract # 
HHSN261201200034I 
 
Protocol Version Date: 
7/24/20 
 
Protocol Revision or   
Amendment #  
Version 13 
 
 

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cleaved caspase-3 (IHC), RANK/RANKL (IHC), estrogen receptor (ER)/progesterone receptor (PR) (IHC), 
CD44 (IHC), p53 (IHC), STAT3 (IHC), and pSTAT3 (IHC) 
c) Gene expression profiling of the fimbrial end of the fallopian tube and ovarian surface epithelium after denosumab 
treatment compared to no treatment 
d) Change in serum biomarkers from baseline (pre-treatment) to time of surgery (post-treatment) with denosumab 
treatment compared to no treatment, including: progesterone, estradiol, and denosumab drug levels 
e) Change in serial serum C-terminal telopeptide (CTX) from baseline (pre-treatment) to time of surgery to 6 months 
and 12 months after start of intervention with denosumab treatment compared to no treatment  
f) 
Toxicity profile and frequency of adverse effects of denosumab treatment compared to no treatment 

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TABLE OF CONTENTS 
 
COVER PAGE.............................................................................................................................................. 1 
SCHEMA ...................................................................................................................................................... 4 
1. 
OBJECTIVES ..................................................................................................................................... 8 
1.1 
Primary Objectives ...................................................................................................................................... 8 
1.2 
Secondary Objectives .................................................................................................................................. 8 
2. 
BACKGROUND................................................................................................................................. 8 
2.1 
BRCA1/2 mutation carriers ......................................................................................................................... 8 
2.2 
Rationale for Denosumab .......................................................................................................................... 10 
2.3 
Rationale for Biomarkers ........................................................................................................................... 12 
3. 
SUMMARY OF STUDY PLAN ...................................................................................................... 14 
4. 
PARTICIPANT SELECTION .......................................................................................................... 15 
4.1 
Inclusion Criteria ....................................................................................................................................... 15 
4.2 
Exclusion Criteria ...................................................................................................................................... 16 
4.3 
Inclusion of Women and Minorities .......................................................................................................... 17 
4.4 
Recruitment and Retention Plan ................................................................................................................ 17 
5. 
AGENT ADMINISTRATION .......................................................................................................... 18 
5.1 
Dose Regimen and Dose Groups ............................................................................................................... 18 
5.2 
Denosumab Administration ....................................................................................................................... 19 
5.3 
Run-in Procedures ..................................................................................................................................... 19 
5.4 
Contraindications ....................................................................................................................................... 19 
5.5 
Concomitant Medications .......................................................................................................................... 19 
5.6 
Dose Modification ..................................................................................................................................... 20 
5.7 
Adherence/Compliance .............................................................................................................................. 20 
6. 
PHARMACEUTICAL INFORMATION ......................................................................................... 20 
6.1 
Denosumab (IND #, IND Sponsor) ............................................................................................................ 20 
6.2 
Reported Adverse Events and Potential Risks ........................................................................................... 20 
6.3  
Availability ................................................................................................................................................ 22 
6.4 
Agent Distribution ..................................................................................................................................... 23 
6.5  
Agent Accountability ................................................................................................................................. 23 
6.6 
Packaging and Labeling ............................................................................................................................. 23 
6.7 
Storage ....................................................................................................................................................... 23 
6.8 
Registration/Randomization ...................................................................................................................... 23 
6.9 
Blinding and Unblinding Methods ............................................................................................................. 24 
6.10 Agent Destruction/Disposal ....................................................................................................................... 24 
7. 
CLINICAL EVALUATIONS AND PROCEDURES ...................................................................... 25 
7.1 
Schedule of Events .................................................................................................................................... 25 
7.2 
Baseline Testing/Prestudy Evaluation ....................................................................................................... 30 
7.3 
Evaluation During Study Intervention ....................................................................................................... 30 
7.4 
Evaluation at Completion of Study Intervention ....................................................................................... 32 
7.5 
Post-intervention Follow-up Period ........................................................................................................... 33 
7.6 
Methods for Clinical Procedures ............................................................................................................... 33 
8.  
CRITERIA FOR EVALUATION AND ENDPOINT DEFINITION............................................... 34 
8.1 
Primary Endpoint ....................................................................................................................................... 34 
8.2 
Secondary Endpoints ................................................................................................................................. 34 
8.3 
Off-Agent Criteria ..................................................................................................................................... 35 
8.4 
Off-Study Criteria ...................................................................................................................................... 35 
8.5 
Study Termination ..................................................................................................................................... 35 
9. 
CORRELATIVE/SPECIAL STUDIES ............................................................................................ 35 
9.1 
Rationale for Methodology Selection ........................................................................................................ 35 
9.2 
Comparable Methods ................................................................................................................................. 36 
10. 
SPECIMEN MANAGEMENT ......................................................................................................... 36 
10.1 Laboratories ............................................................................................................................................... 36 

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10.2 Collection and Handling Procedures ......................................................................................................... 37 
10.3 Shipping Instructions ................................................................................................................................. 38 
10.4 Tissue Banking .......................................................................................................................................... 38 
11. 
REPORTING ADVERSE EVENTS ................................................................................................. 39 
11.1 Adverse Events .......................................................................................................................................... 39 
11.2 Serious Adverse Events ............................................................................................................................. 41 
12. 
STUDY MONITORING ................................................................................................................... 42 
12.1 Data Management ...................................................................................................................................... 42 
12.2 Case Report Forms .................................................................................................................................... 42 
12.3 Source Documents ..................................................................................................................................... 42 
12.4 Data and Safety Monitoring Plan ............................................................................................................... 42 
12.5 Sponsor or FDA Monitoring ...................................................................................................................... 43 
12.6 Record Retention ....................................................................................................................................... 43 
12.7 Cooperative Research and Development Agreement (CRADA)/Clinical Trials Agreement (CTA) ......... 43 
13. 
STATISTICAL CONSIDERATIONS .............................................................................................. 44 
13.1 Study Design/Description .......................................................................................................................... 44 
13.2 Randomization/Stratification ..................................................................................................................... 45 
13.3 Accrual and Feasibility .............................................................................................................................. 45 
13.4 Primary Objective, Endpoint(s), Analysis Plan ......................................................................................... 45 
13.5 Secondary Objectives, Endpoints, Analysis Plans ..................................................................................... 46 
13.6 Reporting and Exclusions .......................................................................................................................... 47 
13.7 Evaluation of Toxicity ............................................................................................................................... 48 
13.8 Evaluation of Response ............................................................................................................................. 48 
13.9 Interim Analysis......................................................................................................................................... 48 
13.10 Ancillary Studies ....................................................................................................................................... 48 
14. 
ETHICAL AND REGULATORY CONSIDERATIONS ................................................................ 48 
14.1 Form FDA 1572 ......................................................................................................................................... 48 
14.2 Other Required Documents ....................................................................................................................... 48 
14.3 Institutional Review Board Approval ........................................................................................................ 49 
14.4 Informed Consent ...................................................................................................................................... 49 
14.5 Submission of Regulatory Documents ....................................................................................................... 49 
14.6 Other .......................................................................................................................................................... 50 
15. 
FINANCING, EXPENSES, AND/OR INSURANCE ...................................................................... 50 
REFERENCES ........................................................................................................................................... 51 
APPENDIX A ............................................................................................................................................. 54 
APPENDIX B ............................................................................................................................................. 54 
APPENDIX C ............................................................................................................................................. 60 
APPENDIX D ............................................................................................................................................. 65 
APPENDIX E ............................................................................................................................................. 68 
APPENDIX F.............................................................................................................................................. 70 

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1. 
OBJECTIVES 
 
1.1 
Primary Objectives  
The primary objective of this study is to compare the effect of denosumab 120 mg subcutaneously every 4 
weeks for 1-2 doses to no treatment in the pre-surgical setting on Ki67 proliferation index by 
immunohistochemistry (IHC) in the fimbrial end of the fallopian tube of premenopausal BRCA1/2 mutation 
carriers undergoing risk-reducing salpingo-oophorectomy, with or without hysterectomy.   
 
1.2 
Secondary Objectives  
The secondary objectives are: 
• 
To assess Ki67 proliferation index by IHC in ovarian surface epithelium and endometrium (if 
also undergoing a hysterectomy, ~20% of participants) after exposure to denosumab compared 
to no treatment  
• 
To investigate other tissue-based biomarkers in the fimbrial end of the fallopian tube, ovarian 
surface epithelium, and endometrium (if also undergoing hysterectomy) after exposure to 
denosumab compared to no treatment, including:  
o Apoptosis with cleaved caspase-3 by IHC 
o Receptor activator of NF-KB (RANK) and RANK ligand (RANKL) expression by IHC 
o Estrogen receptor (ER) and progesterone receptor (PR) expression by IHC 
o CD44 and p53 expression by IHC 
o Signal transducer and activator of transcription 3 (STAT3) and phosphorylated-STAT3 
(pSTAT3) expression by IHC 
• 
To analyze gene expression profiling in the fimbrial end of the fallopian tube and ovarian 
surface epithelium after exposure to denosumab compared to no treatment 
• 
To investigate serum biomarkers at baseline (pre-treatment) and time of surgery (post-
treatment) with denosumab compared to no treatment, including:  
o Progesterone 
o Estradiol 
o Denosumab drug levels  
• 
To investigate serial serum C-terminal telopeptide (CTX) levels from baseline (pre-treatment) 
to time of surgery to 6 months and 12 months after start of intervention with denosumab 
compared to no treatment 
• 
To monitor safety and adverse effects of denosumab compared to no treatment 
 
2. 
BACKGROUND 
 
2.1 
BRCA1/2 mutation carriers 
 
Cancer risk and prevention in BRCA1/2 mutation carriers 
BRCA1/2 genes play a role in DNA repair. The prevalence of BRCA mutations is 1 in 400 in the general 
population, whereas the prevalence of a founder mutation in the BRCA1 (5382insC or 185delAG) or BRCA2 
(6174delT) genes is up to 2.5% (1 in 40) among individuals of Ashkenazi (central and eastern European) 
Jewish descent.1,2 Female carriers of BRCA1/2 mutations have an elevated lifetime risk of developing breast 
cancer and ovarian cancer of 40-60% and 20-40%, respectively.1,3-5 High-grade serous carcinoma (HGSC) 
is the most common and fatal ovarian cancer histologic subtype and BRCA1/2 mutations are found in 17% 
of HGSC cases.6 Risk management options for mutation carriers include intensive breast cancer screening 
with clinical breast exam, mammography, and breast MRI, risk-reducing surgeries such as prophylactic 
mastectomy and bilateral salpingo-oophorectomy (BSO), and chemoprevention.7-11 Unfortunately, there is 
no effective method of screening for ovarian cancer.12,13   
 

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With regards to risk-reducing surgery for ovarian cancer, the National Comprehensive Cancer Network 
(NCCN) recommends risk-reducing bilateral salpingo-oophorectomy (RR-BSO) between the ages of 35-
40 or upon completion of childbearing.12 RR-BSO was associated with a 72-86% relative risk reduction of 
ovarian cancer, 37% reduction in risk of breast cancer in BRCA1 carriers, and a 64% reduction in risk of 
breast cancer in BRCA2 carriers.9 Mutation carriers who underwent RR-BSO compared to those who did 
not had a 79% reduction in ovarian cancer-specific mortality, 56% reduction in breast cancer-specific 
mortality9, and a 60-77% reduction in all-cause mortality.9,10 The prevalence of occult ovarian and fallopian 
tube cancers detected on RR-BSO in BRCA mutation carriers (excluding serous tubal intraepithelial 
carcinoma) has been reported between 1.8-17%.14-20 While RR-BSO is effective in reducing risk of breast 
and ovarian cancer, it is also associated with adverse effects related to premature menopause, including 
osteoporosis, cardiovascular disease, cognitive impairment, and increased anxiety.21 There is also data to 
suggest that BRCA1 mutation carriers may have an increased risk for serous/serous-like endometrial 
carcinoma and thus the risks and benefits of undergoing hysterectomy at the time of RR-BSO should be 
discussed with the patient.22 
 
Role of sex hormones in breast and ovarian cancer in BRCA1/2 carriers 
While BRCA1/2 mutations are believed to cause cancer via 
defects in DNA damage repair pathways, this does not 
explain the breast and ovary-specific cancer penetrance. 
Widschwendter et al. reported that BRCA1/2 carriers have 
higher titers of serum estrogen and progesterone during the 
luteal phase of the menstrual cycle (Figure 1) and 
hypothesized that this sex hormone dysregulation and 
altered end-organ hormone sensitivity might explain the 
organ-specific penetrance.23 While estrogen exposure is 
thought to be a risk factor for ovarian cancer, progesterone 
exposure has long been hypothesized to play a protective 
role in ovarian cancer.24 This hypothesis is supported by 
numerous epidemiologic studies that have demonstrated a 
protective effect of pregnancy and oral contraceptive use on 
ovarian cancer risk, both of which increase levels of circulating progesterone. Premenopausal women with 
>10 years of oral contraceptive use had a significant decreased risk (odds ratio [OR]=0.3, 95% confidence 
interval [CI]=0.2-0.6), with reductions of 20-30% for each 5 years of use.25 This protection is present with 
as little as 1-5 years of use (OR=0.62, 95% CI=0.56-0.69).26 With regards to pregnancy, parous women 
were found to be at reduced risk of ovarian cancer compared with non-parous women (OR=0.5, 95% 
CI=0.3-0.7)25, with protection increasing as number of pregnancies increases.26 Studies in premenopausal 
BRCA1/2 mutation carriers by the Hereditary Breast Cancer Clinical Study Group demonstrated a similar 
protective effect of oral contraceptive use and pregnancy on ovarian cancer risk.27 While the protective role 
of progesterone has been well established, the mechanism by which it renders protection is still unclear. 
Experimental studies in cell lines and animals have demonstrated that progesterone exposure induces 
apoptosis through increased expression of p53 in ovarian epithelium28-30; however, additional studies are 
necessary to elucidate the mechanism by which progesterone influences proliferation and apoptosis in the 
ovaries of premenopausal women. Tubal ligation has also been associated with a reduction in the risk of 
ovarian cancer, with a meta-analysis of 13 studies showing a reduction in risk of epithelial ovarian cancer 
of 34% (risk ratio [RR] = 0.66, 95% CI=-.60-0.73).31-33 
 
In contrast to its protective role in ovarian cancer, progesterone levels have been demonstrated to be 
associated with an increased risk of breast cancer. Epidemiologic studies have shown that postmenopausal 
estrogen and progesterone combined therapy increases proliferation in breast tissue, mammographic 
density, and breast cancer risk over estrogen alone.34,35 In premenopausal women, oral contraceptive use as 
Figure 1. Serum estradiol and progesterone levels 
in BRCA1/2 mutation carriers and non-carriers23 

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well as high progesterone levels during pregnancy are associated with an increased risk of breast cancer.36 
In some animal models, tumor formation has been shown to be progesterone-dependent, with progesterone 
thought to play a role in the expansion of mammary stem cells.37 This stem cell effect of progesterone is 
protected in part by the BRCA1 protein; thus, progesterone inhibitors or antagonists are being tested in 
mouse models of BRCA1/2 mutations and among female carriers that are at high risk of developing breast 
cancer. 
 
2.2 
Rationale for Denosumab 
 
Role of Receptor activator of NF-KB ligand (RANKL) signaling in BRCA1 tumorigenesis 
RANKL is an osteoclast differentiation factor that is 
essential for the development and activation of 
osteoclasts. RANKL is secreted by progesterone 
receptor (PR)-positive epithelial cells in response to 
progesterone, and acts as a paracrine factor on the 
estrogen receptor (ER)/PR-negative progenitor cells 
through its receptor RANK (Figure 2). RANK is 
expressed in the luminal progenitor subset of cells and 
there is significantly increased RANK expression in 
progenitors from BRCA1 mutation carriers when 
compared to BRCA1 WT controls.38 RANK and 
RANKL are expressed in breast tumors. In mouse 
models, RANK signaling have been shown to 
promote 
mammary 
tumor 
formation 
and 
progression,39,40 while inhibition of RANKL signaling reduces mammary tumorigenesis.41 RANK+ luminal 
progenitors are the probable ‘cell-of-origin’ for basal-like breast cancers.38  
 
Denosumab 
Denosumab is a monoclonal antibody that inhibits RANKL. It is approved for prevention of fractures in 
patients with osteoporosis (60 mg subcutaneously every 6 months) and in patients with bone metastases 
from solid tumor malignancies (120 mg subcutaneously every 4 weeks).42-44 Denosumab has a good safety 
profile and the adverse effects include hypocalcemia, osteonecrosis of the jaw, atypical femoral fracture, 
and skin problems. The rate of serious adverse events in three randomized controlled trials over 4 years was 
11% with placebo versus 18% with denosumab. There is limited data on adverse events in the setting of 
denosumab treatment discontinuation. One study investigated the adverse event rates over 24 months after 
discontinuation of denosumab 60 mg every 6 months for 24 months or placebo injections for 24 months in 
postmenopausal women with osteoporosis and found no difference in adverse event rates during the off-
treatment phase between the 2 groups.45 However, there have been case reports of rebound-associated 
vertebral fractures after discontinuation of denosumab in postmenopausal women with osteoporosis.46 
 
Denosumab for Breast Cancer Prevention 
Due to the link between progesterone signaling in breast cancer and RANKL contribution to mammary 
tumorigenesis, denosumab is being pursued as a potential preventive agent for breast cancer in BRCA1/2 
mutation carriers. Sigl et al. published a study of RANK signaling inhibition in two different mouse models 
of breast cancer.47 In a BRCA1mut p53mut model, inactivation of RANK in the mammary epithelium resulted 
in delayed onset and reduced incidence and progression of mammary tumors. In addition, pharmacologic 
inhibition of RANKL eliminated the development of pre-neoplastic lesions. A study by Nolan et al. 
identified RANK+ luminal progenitor cells as putative cells of origin in BRCA1 mutation carriers. Further, 
in an ongoing pre-surgical window of opportunity study in BRCA1/2 mutation carriers, the investigators 
demonstrated that treatment with 120 mg denosumab monthly for 3 months resulted in decreased 
Figure 2. Role of RANKL in BRCA1 mammary tumorigenesis38 

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proliferation in breast tissue as measured by Ki-67 staining.38 
 
While these studies show promise for RANKL inhibition as a breast cancer prevention strategy in BRCA1/2 
mutation carriers, it is unclear whether the protective role of progesterone in ovarian cancer may be usurped 
by RANKL inhibition in this high-risk population. There is currently no published data on the effect of 
RANKL inhibition on gynecologic tissues, including fimbrial tissue, ovarian surface epithelium, and 
endometrial tissue. The mechanism of the protective effect of progesterone in ovarian cancer is not known 
and it is unclear if the RANK/RANKL signaling pathway plays a role in this effect. There are ongoing trials 
investigating the use of denosumab as chemoprevention for breast cancer in BRCA1/2 mutation carriers. 
Additionally, the ABCSG-18 trial studied the use of adjuvant denosumab in the treatment of 
postmenopausal women with early stage hormone receptor-positive breast cancer receiving aromatase 
inhibitors. In this phase III trial, an interim analysis reported at the San Antonio Breast Cancer Symposium 
in 2015 showed that adjuvant denosumab had a trend towards improved disease free survival (hazard ratio 
[HR]=0.816, p=0.051).48 This suggests that effects of denosumab in breast cancer may be applied outside 
of BRCA1/2 mutation carriers.  
 
Rationale for dosing of denosumab 
In this study, we will be administering denosumab 120 mg every 4 weeks for a total of 1-2 doses. This is 
the dose used in patients with bone metastases from solid tumor malignancies and has a good safety 
profile.42,43 Additionally, this is the dose being investigated in an ongoing pre-surgical window of 
opportunity study in normal breast tissue of BRCA1/2 mutation carriers. In this window of opportunity 
study, patients are given 120 mg denosumab monthly for 3 months and the primary endpoint is change in 
proliferation in breast tumor tissue as measured by Ki-67 staining.38 Based on this dosing regimen, we have 
decided to investigate the effect of denosumab 120 mg every 4 weeks for a total of 1-2 doses on the 
proliferation rate of the fimbrial end of the fallopian tube. While the optimal number of doses to reach 
steady state levels is not certain, we believe that one dose should allow for sufficient circulating levels of 
the drug. A second dose of denosumab will be allowed in order to ensure a dose is delivered within 4 weeks 
of scheduled surgery. Since participants in the study will be undergoing risk-reducing salpingo-
oophorectomy during the luteal phase of the menstrual cycle, in order to ensure consistent exposure to 
denosumab across all participants in the treatment arm, the first dose of denosumab will be administered 
within the first 3 days of the menstrual cycle.  
 
This proposed study will address whether denosumab alters proliferation in the fimbrial end of the fallopian 
tube, the presumed site of origin of HGSC in BRCA1/2 mutation carriers. Given the high risk for ovarian 
cancer in this population, high mortality associated with the diagnosis, and limited options for ovarian 
cancer prevention and screening, there is a large unmet need for an ovarian cancer chemopreventive agent. 
The purpose of this pilot study is to assess the biomarker effects of denosumab in premenopausal women 
scheduled for risk-reducing salpingo-oophorectomy with or without hysterectomy. Our primary objective 
is to determine whether there is a difference (either an increase or decrease) in Ki67 proliferation index in 
the fimbrial end of the fallopian tube among premenopausal BRCA1/2 mutation carriers after denosumab 
treatment compared to no treatment. Even if there is no difference in Ki67 expression, demonstrating no 
detrimental effect of denosumab on proliferation in the ovaries and fallopian tubes would be of interest, as 
this agent is actively being investigated for breast cancer prevention among female mutation carriers.  
 
Rationale for including Alcohol and Tobacco Assessment Questionnaires 
Increasing evidence suggests that tobacco and alcohol use are risk factors in the development of 
intraepithelial neoplasia and cancer. In addition, tobacco and alcohol use may adversely affect agent 
intervention, for example by altering the safety profile or metabolism of a drug. Standardized assessments 
of tobacco and alcohol use during clinical trials will aid in understanding the potential relationship between 
the use of these products and clinical endpoints or cancer prevention biomarkers. Therefore, NCI, DCP is 

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including assessment of tobacco and alcohol use at baseline and (include follow-up timepoint), to determine 
the potential impact of tobacco and alcohol use on 1) treatment toxicity and symptom burden, and 2) the 
efficacy of treatment intervention. 
 
 
2.3 
Rationale for Biomarkers 
 
Tissue proliferation rate (Ki67) and apoptosis (cleaved caspase-3) 
Ki67 expression as a marker of proliferation has been associated with progression to malignancy and thus 
may be used as a measure of a tissue’s risk for becoming dysplastic.49 Nolan et al. demonstrated that the 
mitogenic response of BRCA1mut/+ breast tissue to exogenous progesterone, as measured by Ki67, was more 
pronounced than in wild-type breast tissue. Additionally, when the BRCA1mut/+ breast tissue was 
concomitantly exposed to denosumab and progesterone, the progesterone-induced increase in Ki67+ cells 
was blocked.38   
 
In the fallopian tube epithelium (FTE), Ki67 expression has been shown to be increased globally in women 
with BRCA1 mutations (when compared to average-risk women)50,51; however, another study suggested 
that Ki67 is increased in the follicular phase when compared to the luteal phase and is not dependent on 
BRCA mutation status.52 Norquist et al. hypothesized that the haploinsufficiency of BRCA1 leads to 
increased tubal epithelial proliferation and this proliferation does not decrease appropriately with advancing 
age, as it does in average-risk women. This increased proliferation allows for the clonal expansion of tubal 
cells with random TP53 mutations and subsequently neoplastic potential.50 George et al. demonstrated that 
there is an increase in Ki67 expression in FTE cells starting from benign cells to disease development.52 
Kuhn et al. also demonstrated that serous tubal intraepithelial carcinoma (STIC) and HGSC have higher 
Ki67 expression than normal FTE.53 In our proposal, our aim is to assess the impact of RANKL inhibition 
with denosumab on the proliferation rate of the fimbrial tissue (primary endpoint) and ovarian and 
endometrial epithelium [if also undergoing hysterectomy] (secondary endpoints). Ki67 expression is readily 
determined by immunohistochemistry (IHC) of formalin-fixed paraffin-embedded (FFPE) tissue. Since 
there is variation in Ki67 expression in the FTE depending on phase of menstrual cycle (luteal versus 
follicular), all participants in the study will undergo risk-reducing salpingo-oophorectomy during the luteal 
phase of the menstrual cycle for consistency. We will assess whether denosumab exposure affects cell death 
in the fimbrial tissue, ovarian epithelium, and endometrium (if also undergoing hysterectomy). Cleaved 
caspase-3 is a marker of apoptosis and can be readily determined with IHC of stained tissue sections.  
 
RANK/RANKL tissue expression 
As described above, RANK/RANKL signaling has been shown to play a role in mammary tumorigenesis 
and RANK/RANKL expression has been demonstrated in breast cancer tumors. There are no published 
reports of the role of RANK/RANKL signaling in ovarian cancer. This study will assess for the presence 
of RANK and RANKL protein expression (IHC) in fimbrial tissue, ovarian epithelium, and endometrium 
(if also undergoing hysterectomy).  
 
ER/PR tissue expression 
In normal fimbrial tissue, there is strong ER expression in the early/mid-follicular phase, gradually 
declining to faint expression at around the time of ovulation. During the luteal phase, there is moderate ER 
expression.54 In normal fimbrial tissue, PR staining showed greater variability in the follicular phase and 
decreased expression in the late luteal phase.54 In breast tissue, exposure to denosumab significantly reduced 
colony formation in the ER-/PR- luminal progenitor subset which express RANK.38 We will assess if 
ER/PR expression in fimbrial tissue, ovarian epithelium, and endometrium (if also undergoing 
hysterectomy) differs after denosumab treatment versus no treatment and whether ER/PR expression is 
associated with Ki67 proliferation index. 

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CD44 and p53 tissue expression 
CD44 is a hyaluronate receptor and a putative marker of epithelial progenitor cells in the fallopian tube and 
has been shown to be concentrated in the distal fimbria.55,56 Tiourin et al. showed that there is a significant 
reduction in CD44+ progenitors as well as a reduction in proliferation (Ki67) of progenitors in the distal 
fallopian tube epithelium with tubal ligation.49 We will assess if there is a reduction in CD44+ progenitors 
in the fimbrial tissue, ovarian epithelium, and endometrium (if also undergoing hysterectomy) after 
denosumab treatment versus no treatment. 
 
Mutation in TP53 is seen in the vast majority of high grade serous carcinomas and is thought to be an early 
event in carcinogenesis.57-59 The p53 signature is the staining of p53 of a consecutive number of nuclei in 
the fallopian tube epithelium by IHC and is thought to be a precursor of serous tubal intraepithelial 
carcinoma (STIC).60 We will assess if denosumab versus no treatment affects p53 expression in fallopian 
tube epithelium, ovarian epithelium, and endometrium (if also undergoing hysterectomy).     
 
STAT3 and pSTAT3 tissue expression 
STAT3 plays a key role in cell growth, apoptosis, transformation, differentiation, migration, and cell 
survival.61 It becomes phosphorylated in response to cytokines and growth factors. George et al. have 
demonstrated that STAT3 expression is higher in BRCA1 mutated fallopian tube epithelium as compared 
to non-BRCA1 mutated fallopian tube epithelium.62 We will assess if there is a reduction in STAT3 and 
pSTAT3 in the fimbrial tissue, ovarian epithelium, and endometrium (if also undergoing hysterectomy) 
after denosumab treatment versus no treatment. 
 
Tissue gene expression profiling 
In RANK+ luminal progenitor (LP) cells of breast tissue, there is upregulation of genes implicated in 
proliferation, including TOP2A, MKI67, PBK, and CDK1. Expression of these genes is markedly increased 
in RANK+ LP cells from BRCA1mut breast tissue when compared to wild-type breast tissue.38 Additionally, 
gene expression analyses have revealed that there is a significant elevation of inflammation or immune 
related mRNA in the normal fallopian tube of BRCA1 mutation carriers.52 We will look for enrichment of 
genes involved in the RANKL, cell proliferation, cell cycle progression, and inflammation pathways in 
fimbrial tissue and ovarian epithelium.  
 
Gene expression profiling will be performed with the nCounter™ PanCancer Pathways Panel by nanoString 
Technologies on fimbrial and ovarian tissue of participants from both the treatment and control arms. The 
system can directly assay tissue to analyze 770 essential genes representing 13 canonical pathways, 
including cell cycle, apoptosis, and DNA damage control pathways. This assay can use FFPE-derived and 
purified total RNA and does not require reverse transcriptase reactions. Results of this assay using FFPE-
derived tissue were highly correlated with purified total RNA from fresh tissue (R2>0.97). The assay 
demonstrates a high level of sensitivity and precision even at very low levels of expression.  
 
Serum progesterone and estradiol levels 
BRCA1/2 carriers have higher titers of serum estrogen and progesterone during the luteal phase as compared 
to non-mutation carriers.23 In breast tissue, progesterone stimulates the secretion of RANKL, which binds 
to RANK in luminal progenitor cells and stimulates mammary epithelial cells to proliferate.40,41 We will 
explore if there is variation in progesterone and estradiol levels based on exposure to denosumab and if 
Ki67 expression in fimbrial tissue is associated with serum progesterone and estradiol levels.  

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phase will be estimated as the second half of the menstrual cycle. For women who take hormonal 
contraceptive with continuous progesterone (i.e. progestin IUD), first dose of denosumab and surgery do 
not need to be timed with menses as these patients will be in the luteal phase at all times. On the day of 
surgery for risk-reducing salpingo-oophorectomy with or without hysterectomy, physical exam/vitals 
(within 5 days prior to surgery), concomitant medications, toxicity assessment, calcium/vitamin D 
supplement pill compliance, blood collection for clinical labs (within 3 days prior to surgery) and research 
circulating biomarkers, and tissue collection will be performed.  
 
Additional assessments will occur at months 1-5 (+/- 1 week) for calcium/vitamin D supplement pill 
compliance, 7-14 days post-surgery for calcium/vitamin D supplement pill compliance by telephone 
contact, month 6 (+/- 1 week) for toxicity assessment and calcium/vitamin D supplement pill compliance 
by telephone contact, and clinic visits at months 6 and 12 (+/- 90 days) for toxicity assessment and research 
blood draw for serum CTX level.  Collection of calcium/vitamin D pill bottles will occur at month 6 visit. 
 
4. 
PARTICIPANT SELECTION 
 
4.1 
Inclusion Criteria 
 
4.1.1 
Participants must be female, ≥18 years of age, and premenopausal (defined as < 3 months since last 
menstrual period OR serum follicle-stimulating hormone (FSH) < 20 mIU/mL). 
 
4.1.2 
Documented germline pathogenic or likely pathogenic variant in the BRCA1 or BRCA2 genes.  
 
4.1.3 
Participants must be scheduled for or in the process of scheduling a risk-reducing salpingo-
oophorectomy with or without hysterectomy – either bilateral or unilateral (if prior unilateral 
oophorectomy or salpingectomy for benign condition).  
 
4.1.4 
ECOG performance status ≤1 (Karnofsky ≥70%; see Appendix A). 
 
4.1.5 
Participants must have normal organ and marrow function as defined below: 
Leukocytes 
 
≥ 3,000/microliter 
Absolute neutrophil count 
≥ 1,500/microliter 
Platelets 
 
≥ 100,000/microliter 
Total bilirubin  
≤ 2 x institutional upper limit of normal (ULN) 
AST (SGOT)/ALT (SGPT) 
≤ 1.5 x institutional ULN 
Creatinine clearance 
> 30 mL/min 
Serum calcium or albumin adjusted 
≥ 8.0 mg/dL and ≤ 11.5 mg/dL 
 
4.1.6 
Participant must have a negative urine or serum pregnancy test 14 days prior to randomization or 
drug administration. The effects of denosumab on the developing human fetus at the recommended 
therapeutic dose may cause fetal harm when administered to pregnant women. Women of child-
bearing potential must agree to use adequate contraception from time of drug administration to time 
of surgery. Should a woman become pregnant or suspect she is pregnant while participating in this 
study, she should inform her study physician immediately. 
 
4.1.7 
Women currently on hormonal contraception (i.e., oral contraceptives, Mirena® intrauterine device 
[IUD]) are eligible to participate if they have been on a stable dose for at least 3 months. Women 
who have undergone bilateral tubal ligation are also eligible to participate in this study. There will 
be stratification for hormonal contraceptive use within 3 months prior to registration. 
 

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4.1.8 
Participants must be willing to take supplemental oral calcium 1000 mg (two 500 mg tablets) and 
vitamin D3 1000 IU daily for six months (which will be supplied by the research study) after 
receiving denosumab treatment or no treatment. 
 
4.1.9  Ability to understand and the willingness to sign a written informed consent document in English 
or Spanish or Hebrew. 
 
4.1.10 Participants must have a dental examination < 6 months of study registration. 
 
4.1.11 Willing to not undergo any other elective surgery procedure with general anesthesia or conscious 
sedation during the treatment period. The treatment period is completed after the last injection of 
denosumab is administered.  
 
4.2 
Exclusion Criteria 
 
4.2.1 
History of ovarian cancer. History of breast cancer or any other malignancy is permitted if last 
chemotherapy treatment was greater than 6 months prior to registration and participant is not using 
endocrine therapy (as per 4.2.7). 
 
4.2.2 
Previous treatment with denosumab (including Prolia for osteoporosis or Xgeva for bone 
metastases) or use of bisphosphonate within 3 months of registration to the study. 
 
4.2.3 
Participants receiving any other investigational agents. 
 
 
4.2.4 
History of allergic reactions or hypersensitivity attributed to denosumab or any components of 
denosumab or compounds of similar chemical or biologic composition to denosumab, such as other 
RANKL inhibitors. 
 
4.2.5 
Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, 
symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric 
illness/social situations that would limit compliance with study requirements. 
 
4.2.6 
Pregnant and breastfeeding women are excluded from this study because denosumab is an agent 
with the potential for teratogenic or abortifacient effects. Because there is an unknown but potential 
risk for adverse events (AEs) in nursing infants secondary to treatment of the mother with 
denosumab, breastfeeding should be discontinued if the mother is treated with denosumab. There 
is no minimum amount of time since pregnancy/breastfeeding required before enrolling into the 
study. However, the date of delivery, pregnancy termination, or weaning from breast-feeding will 
be documented on case report forms. Female subjects of child bearing potential and not willing to 
use, in combination with her partner, highly effective contraception during treatment will be 
excluded.  
 
4.2.7 
Use of endocrine therapy (selective estrogen receptor modulator, aromatase inhibitor, GnRH 
agonist) within 6 months of registration to the study. 
 
4.2.8 
Prior history or current evidence of osteonecrosis or osteomyelitis of the jaw, evidence of untreated 
local gum or oral infection, or non-healed dental or oral surgery. 
 

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4.2.9 
Active dental or jaw conditions which require oral surgery/dental procedures, including tooth 
extraction within 6 months of the registration to the study. Dental fillings are permitted within 6 
months of study registration. 
 
4.2.10 Other risk factors for the development of osteonecrosis of the jaw (ONJ) including poor oral 
hygiene, use of a dental appliance, immunosuppressive therapy, treatment with angiogenesis 
inhibitors, systemic corticosteroids, diabetes, or gingival infections. 
 
4.2.11 Known sensitivity to any of the products to be administered during the study (e.g., calcium or 
vitamin D). 
 
4.2.12 Known serious infections, including a history of active hepatitis B, hepatitis C, or HIV. Screening 
for these infections is not required for study enrollment. 
 
4.2.13 Hypocalcemia (serum calcium or albumin adjusted calcium < 8.0 mg/dL) or renal dysfunction 
(creatinine clearance < 30 mL/min).  
 
4.2.14 Women with known osteoporosis or history of osteoporotic (fragility) fracture of the spine. 
 
4.3 
Inclusion of Women and Minorities 
 
Participants will be adult women of all races and ethnic groups who are at least 18 years old. Male 
participants will not be recruited as the primary objective is to determine the effect of denosumab on 
fallopian tube fimbrial cells. Children will not be recruited into the trial because risk-reducing surgery is 
not applicable in the pediatric population.  
 
Our goal is to ensure that the study is available to women of all races and ethnic groups. At US sites, efforts 
will be made to enroll women from diverse racial, ethnic and socio-economic backgrounds. Of note, 
BRCA1/2 mutations have a prevalence of 1:400 among most racial/ethnic groups and a prevalence of 1:40 
among those of Ashkenazi Jewish descent.1,2 
 
4.4 
Recruitment and Retention Plan 
 
This multicenter protocol will be conducted at the following five sites: Columbia University Irving Medical 
Center (CUIMC), New York, NY; Weill-Cornell Medical Center, New York, NY; the Dana Farber Cancer 
Institute (DFCI), Boston, MA; and Tel Aviv Sourasky Medical Center and Chaim Sheba Medical Center, 
Tel Aviv, Israel. CUIMC will be the Lead Site. The rates of risk-reducing salpingo-oophorectomies at these 
sites will allow the recruitment of the required sample size. Efforts will be made to enroll women from 
diverse ethnic and socio-economic backgrounds. Prior to enrollment on the study, the physician will discuss 
the study protocol in detail with the participant, including possible toxicities. The informed consent 
document will be reviewed by study personnel with the participant. All participants will be offered 
compensation for parking, time and travel for each of the following study-related visits ($30 or the amount 
needed to cover parking expenses at the time of each study-related visit, depending on the site): baseline 
visit, Dose #1 denosumab (treatment group) or dispensing of vitamin D/calcium supplement (no treatment 
group), and Dose #2 denosumab (treatment group, if administrered). To facilitate accrual, information about 
the trial will be advertised, for example, on the websites of participating institutions. Recruitment and 
retention efforts will be evaluated routinely by the site coordinator and the study staff. The study recruitment 
and retention plan will be modified as necessary to promote rapid accrual. Please refer to the study-specific 
recruitment and retention plan for more details. The domestic and international planned enrollment tables 
are shown below. 

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hour window, it will be considered a missed dose and should be resumed the next day. There is no minimum 
amount of time required between doses. If a dose is vomited, it does not need to be repeated. Tablets may 
be crushed, chewed, or dissolved in water. Tablets may be taken with or without food. There are no foods 
that need to be avoided while taking the calcium and vitamin D3 supplements. These instructions will be 
given in writing to the participant (“Calcium and Vitamin D3 Tablet Information” sheet found in Appendix 
E). 
 
 
5.2 
Denosumab Administration 
 
According to the package insert for denosumab, it should be visually inspected for particulate matter and 
discoloration prior to administration. Denosumab is a clear, colorless to pale yellow solution that may 
contain trace amounts of translucent to white proteinaceous particles. Denosumab should not be used if the 
solution is discolored or cloudy or if the solution contains many particles or foreign particulate matter. Prior 
to administration, denosumab may be removed from the refrigerator and brought to room temperature (up 
to 25°C/77°F) by standing in the original container. This generally takes 15 to 30 minutes. Denosumab 
should not be warmed in any other way. A 27-gauge needle may be used to withdraw and inject the entire 
contents of the vial and the vial should be discarded after single-dose or entry. A healthcare provider 
approved at each institution to deliver the injection will administer the injection in a sterile fashion in the 
clinical facility at each study site. The 1.7 mL by volume (120 mg) injection of denosumab will be 
administered subcutaneously in the upper arm, upper thigh, or abdomen. The healthcare provider will 
determine the best site for drug administration and will rotate the injection site on subsequent visits. Each 
site will be responsible for furnishing the 25-to-27-gauge ½-inch to 5/8-inch in length needle to administer 
the drug injections. The injection will be administered within the first 3 days of the participant’s menstrual 
cycle (Dose #1) with a possible dose (Dose #2) 4 weeks after that for a total of 1-2 doses. Dose #2 will be 
administered if the surgery cannot be performed within 4 weeks of Dose #1 of denosumab. For women who 
take hormonal contraceptive with continuous progesterone (i.e. progestin IUD), first dose of denosumab 
does not need to be timed with menses. The participant will be monitored by clinical observation for 30 
minutes after each injection to assess for any acute or anaphylactic reactions, such as rash, low blood 
pressure, wheezing, shortness of breath, swelling of the face or throat. 
 
5.3 
Run-in Procedures  
 
This trial will not include a run-in period. 
 
 
5.4 
Contraindications 
 
Eligible participants should not have specific contraindication to denosumab. Any pre-existing dental 
condition should be carefully evaluated before enrolling the participants. Evidence of hypocalcemia or renal 
dysfunction on baseline laboratory evaluation will exclude participation in the study. 
 
5.5 
Concomitant Medications 
 
All medications (prescription and over-the-counter), vitamin and mineral supplements, and/or herbs taken 
by the participant will be documented on the concomitant medication CRF and will include: 1) start and 
stop date, dose and route of administration, and indication. Medications taken for a procedure (e.g., biopsy) 
should also be included. Women already taking calcium or vitamin D supplementation will be asked to stop 
taking these supplements during the 6-month study period, because these supplements will be provided for 
all study participants. 

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dyspnea. The most common adverse reactions resulting in discontinuation of Xgeva® were osteonecrosis 
and hypocalcemia. Warnings and Precautions in the package insert include severe symptomatic hypocalcemia 
(fatal cases have been reported), osteonecrosis of the jaw (ONJ), hypersensitivity, atypical subtrochanteric 
and diaphyseal femoral fracture, and clinically significant hypercalcemia following treatment discontinuation 
in patients with growing skeletons. The risk of atypical femoral fracture continues after stopping therapy and 
increases with longer duration of treatment with denosumab. Some patients had fractures up to 9 months after 
treatment when denosumab was discontinued. 
 
Based on data from nonclinical studies and the mechanism of action, Xgeva® can cause fetal harm when 
administered to a pregnant women. In animal reproduction studies, administration of denosumab to 
cynomolgus monkeys throughout pregnancy at a dose 25-fold higher than the recommended human dose of 
Xgeva® based on body weight resulted in increased fetal loss, stillbirths, and postnatal mortality, along with 
evidence of absent peripheral lymph nodes, abnormal bone growth, and decreased neonatal growth. Exposure 
to Xgeva® during pregnancy or within five mots prior to conception can result in fetal harm. 
 
Summarized below are safety data from clinical trials of Xgeva® in approved indications and settings. 
 
Bone Metastasis from Solid Tumors: The safety of Xgeva® for the prevention of skeletal-related events 
in patients with bone metastasis from solid tumors or lytic bony lesions from multiple myeloma was 
evaluated in three international randomized, double-blind, active-controlled, noninferiority trials 
recruiting over 5000 patients. In all three trials, patients were randomized to receive 120 mg 
Xgeva® subcutaneously every 4 weeks or 4 mg zoledronic acid intravenously (iv) every 4 weeks. The 
most common adverse reactions (per-patient incidence ≥25%) in patients who received Xgeva® were 
fatigue/asthenia, hypophosphatemia, and nausea. Severe hypocalcemia (corrected serum calcium 
<7 mg/dL or <1.75 mmol/L) were also noted at an increased incidence in the denosumab group 
(3.1%) compared with the zoledronic group (1.3%). Severe hypophosphatemia also occurred in 
15.4% of patients treated with Xgeva® compared with 7.4% of patients treated with zoledronic acid. 
ONJ occurred in 1.8% of patients in the Xgeva® group compared with 1.3% of patients in the zoledronic 
acid group. Atypical femoral fracture has been reported with Xgeva®.  
 
Giant Cell Tumor of Bone: Single- arm trials evaluated the safety of Xgeva® in about 300 adults or 
skeletally mature adolescent patients with giant cell tumor of bone who received at least one dose 
of Xgeva®. The most common adverse reactions in patients (per-patient incidence ≥10%) were 
arthralgia, headache, nausea, back pain, fatigue, and pain in extremity. The most common serious 
adverse reactions were osteonecrosis of the jaw (ONJ) and osteomyelitis (per-patient incidence of 
0.7%). The most common adverse reactions resulting in discontinuation of Xgeva® were ONJ 
(per-patient incidence of 0.7%), and tooth abscess or tooth infection (per-patient incidence of 0.7%). 
Moderate hypocalcemia and severe hypophosphatemia occurred in 2.6% and 9.5% of patients, 
respectively. The adverse reaction profile appeared similar in skeletally mature adolescents (13–17 
years of age). 
 
Hypercalcemia of Malignancy: The adverse reaction profile of Xgeva® was also evaluated in an open-
label, single-arm trial in which 33 patients with hypercalcemia of malignancy (with or without bone 
metastases) refractory to treatment with iv bisphosphonate therapy were enrolled. Adverse reactions 
occurring in >20% of patients were nausea (30%), dyspnea (27%), decreased appetite (24%), 

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headache (24%), peripheral edema (24%), vomiting (24%), anemia (21%), constipation (21%), and 
diarrhea (21%). The following adverse reactions of grade 3 or greater severity considered related to 
therapy were reported on study: fatigue (3%) and infection (6%). Grade 3 laboratory abnormalities 
included hypomagnesemia (3%), hypokalemia (3%), and hypophosphatemia (76%). No deaths on 
study were related to Xgeva® therapy. 
 
In addition to the previously described approved indications, Xgeva® is also being investigated in other 
settings, as detailed in the Investigator’s Brochure [Investigator’s Brochure Denosumab (AMG 162) 
Cancer-related Bone Disease] and discussed briefly below: 
 
Prevention of Bone Metastasis in Subjects with Cancer: The clinical program evaluating Xgeva® in the 
prevention of bone metastasis in subjects with advanced malignancies includes two studies. The first 
study (20050147) was a phase 3, randomized, double-blind, placebo-controlled study in men with 
hormone refractory castration-resistant prostate cancer (CRPC). Adverse drug reactions such as 
hypocalcemia and ONJ (4.6%) were consistent with the drug’s mechanism of action, as reported in the 
package insert, and no new risks were identified. Incidences of adverse events, serious adverse events, 
fatal adverse events, and grade 3 to 5 adverse events were similar between the Xgeva® and placebo 
groups and reflective of underlying disease. Fatal adverse events were generally associated with disease 
progression or age-related comorbidities. The second study (20060359) is a phase 3, randomized, 
double-blind, placebo-controlled study in women with early stage breast cancer evaluating Xgeva® as a 
potential treatment for the prevention of bone metastasis and extraosseous disease recurrence. Results 
are currently unavailable as the study is ongoing.  
 
Non-Small Cell Lung Cancer (NSCLC): Study 20120249 was a randomized phase 2, double blind, 
placebo-controlled study of Xgeva® in subjects with untreated Stage IV NSCLC with or without bone 
metastasis (n=226). Safety results were comparable to those seen in other Xgeva® studies. There were 
four events of ONJ and one of hypocalcemia in the Xgeva® group. 
 
Multiple Myeloma: Clinical studies have been conducted to evaluate Xgeva® prevention of skeletal-
related events (SREs) in multiple myeloma. Study 20090482 comparing Xgeva® to zolendronic acid was 
designed to be an adequately powered phase 3 study with appropriate stratification of key multiple 
baseline prognostic factors for survival as well as SREs and anti-myeloma treatments together with 
myeloma disease monitoring. Overall, adverse event incidences were similar between the two treatment 
groups. Safety results from this study were generally comparable to those seen in previous SRE studies. 
Subject incidence of adverse events of hypocalcemia was 16.9% in the Xgeva® group and 12.4% in the 
zoledronic acid group. There were 35 (4.1%) and 24 (2.8%) positively adjudicated events of ONJ in the 
Xgeva® and zoledronic acid groups, respectively. 
 
Post-marketing Experience: Adverse reactions identified from post-marketing experience include severe 
hypocalcemia, musculoskeletal pain, and hypersensitivity. Please refer to the Investigator’s Brochure for 
details. 
 
 
6.3  
Availability 
 
Denosumab is an investigational agent supplied to investigators by NCI, DCP. The calcium 1000 mg (two 
500 mg tablets) and vitamin D 1000 IU supplements will also be supplied by NCI, DCP. 
 
 
 

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6.4 
Agent Distribution 
 
Agents will only be released by NCI, DCP after documentation of Institutional Review Board approval of 
the DCP-approved protocol and consent is provided to DCP, and the collection of all essential documents 
is complete (see DCP website for description of essential documents).  
 
NCI, DCP-supplied agents may be requested by the investigator (or their authorized designees) at each 
organization. DCP guidelines require that the agent be shipped directly to the institution or site where it 
will be prepared and administered. DCP does not permit the transfer of agents between institutions (unless 
prior approval from DCP is obtained). DCP does not automatically ship agents; the site must make a request. 
Agents are requested by completing the DCP Clinical Drug Request form (NIH-986) (including complete 
shipping contact information) and faxing or mailing the form to the DCP agent repository contractor: 
 
John Cookinham 
MRIGlobal 
DCP Repository 
1222 Ozark Street 
North Kansas City, MO 64116 
Phone:  (816) 360-3805 
FAX:  (816) 753-5359 
Emergency Telephone: (816) 360-3800 
 
6.5  
Agent Accountability 
 
The investigator, or a responsible party designated by the investigator, must maintain a careful record of 
the inventory and disposition of all agents received from DCP using the NCI Drug Accountability Record 
Form (DARF). The investigator is required to maintain adequate records of receipt, dispensing, and final 
disposition of the study agent. This responsibility has been delegated to the site pharmacists. Include on 
receipt record: from whom the agent was received, to whom study agent was shipped, date, quantity, and 
batch or lot number. On the dispensing record, note the quantities and the dates the study agent was 
administered to each participant.  
 
6.6 
Packaging and Labeling 
 
Denosumab and the oral calcium/vitamin D supplements will be packaged and labeled by NCI, DCP. 
 
6.7 
Storage 
 
Denosumab is supplied in single-dose vials and a 6-month supply of oral calcium/vitamin D supplements 
will be dispensed, and should be stored in a secure location at temperatures between 2°C to 8°C (36°F to 
46°F).  
 
6.8 
Registration/Randomization 
 
Screening and Registration into the DMI Database:  
Once informed consent has been signed, participants will be registered into the DMI database.  The DMI 
database will assign a participant’s ID (PID) upon completion of the registration process. 
 
 

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Randomization:  
Participants will be assigned a randomization number once the following has been accomplished: eligibility 
has been verified at the site level, eligibility has been confirmed by the site PI, and eligibility CRF has been 
entered into the DMI web application.  The randomization number will be generated by the database and 
assigned to the participant.  Refer to Section 13.2 for details of randomization.  
 
Screening/Registration/Randomization into site-specific databases: 
The DMI is the database of record for the study. Registration and randomization should occur per the 
procedures outlined above. If the site staff needs to enter study data into site-specific electronic databases 
per their institutional requirements, they should do so in accordance with their institutional policies and 
procedures. 
 
Appropriate CRFs must be completed for any participant who signs an informed consent. If a consented 
participant is a screen failure and deemed ineligible, the following CRFs must be completed: 1) the 
Registration CRF; 2) the Randomization CRF with the eligibility box checked “no”, 3) the Inclusion and 
Exclusion CRFs showing why the participant is ineligible, 4) the Off-Study CRF, 5) the Adverse Event 
CRF, 6) the Concomitant Medication CRF and 7) the Verification CRF. If no Adverse Event and/or 
Concomitant Medications were assessed by the time the participant is deemed ineligible, the “NONE” box 
will be checked to complete both CRFs.  All participants who sign an informed consent must formally go 
off study. All participant registration information will be entered into DMI. If a participant experiences a 
serious Adverse Event during the screening process, a Serious Adverse Event (SAE) form must be 
completed. 
 
6.9 
Blinding and Unblinding Methods 
 
Not applicable 
 
6.10 
Agent Destruction/Disposal 
 
DCP-supplied agents: at the completion of investigation, all unused study agent will be returned to NCI, 
DCP Repository according to the DCP “Guidelines for AGENT RETURNS” and using the DCP form 
“Return Drug List”.  

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7. 
CLINICAL EVALUATIONS AND PROCEDURES 
 
7.1.1 
Schedule of Events: Denosumab Arm 
 
Baseline/ 
Registration 
(within 30 days 
prior to 
randomization) 
Randomi
zation 
Dose #1 of 
denosumab 
given on 
Day 1-3 of 
menstrual 
cyclen  
 Day 8-10 of 
menstrual 
cycle  
Doses #2 of 
denosumab 
(possible)  
Surgerya,n 
7-14 days 
post-
surgery 
Month 1-5  
from Dose 
#1 calls 
6 months 
from Dose 
#1 visit 
12 months 
from Dose 
#1 visit 
Window (days) 
 
 
 
 
+/- 3 days 
 
 
+/- 7 days 
+/- 90 days 
+/- 90 days 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
Physical exam 
Xb 
 
 
 
 
Xc 
 
 
 
 
Oral examinationd 
X 
 
X 
 
X 
Xm 
 
 
 
 
Dental examinationd 
X 
 
 
 
 
 
 
 
 
 
All concurrent medications 
X 
 
 
 
 
Xq 
 
 
 
 
Confirm eligibility 
X 
 
 
 
 
 
 
 
 
 
Randomization 
 
Xe 
 
 
 
 
 
 
 
 
Toxicity assessment 
 
 
 
Xf 
X 
Xq 
 
 
X 
X 
Clinical  blood drawg 
X 
 
Xh 
 
Xh 
Xr 
 
 
 
 
Urine or serum pregnancy 
test  
Xp 
 
Xp 
 
Xp 
 
 
 
 
 
Serum FSH 
X 
 
 
 
 
 
 
 
 
 
Denosumab administrationi 
 
 
X 
 
X 
 
 
 
 
 
Dispensing of 
calcium/vitamin D 
 
 
X 
 
 
 
 
 
 
 
Collect unused study agent 
 
 
 
 
 
 
 
 
X 
 
Calcium/vitamin D pill 
compliance assessment 
 
 
 
Xf 
Xo 
Xo,q 
Xf 
Xf,l 
Xo 
 
Research blood collection 
X 
 
 
 
 
X 
 
 
X 
X 
   Serum progesterone 
X 
 
 
 
 
X 
 
 
 
 
Serum estradiol 
X 
 
 
 
 
X 
 
 
 
 
   Serum denosumab 
X 
 
 
 
 
X 
 
 
 
 
Serum CTX 
X 
 
 
 
 
X 
 
 
X 
X 
Research tissue collection 
(fimbria, ovarian 
epithelium, endometrium 
[if undergoing 
hysterectomy]) 
 
 
 
 
 
X 
 
 
 
 
   Ki67 (IHC) 
 
 
 
 
 
X 
 
 
 
 
   RANK/RANKL 
 
 
 
 
 
X 
 
 
 
 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–26– 
08/31/2016 
   (IHC) 
   Cleaved caspase-3 
   (IHC) 
 
 
 
 
 
X 
 
 
 
 
   ER/PR (IHC) 
 
 
 
 
 
X 
 
 
 
 
CD44/p53 (IHC) 
 
 
 
 
 
X 
 
 
 
 
STAT3/pSTAT3 
(IHC) 
 
 
 
 
 
X 
 
 
 
 
Gene expression profiling 
(only on fimbrial and 
ovarian tissue) 
 
 
 
 
 
X 
 
 
 
 
Tobacco and Alcohol Use 
Assessment 
Xj 
 
 
 
 
 
 
 
 
Xk 
Abbreviations: CBC=complete blood count; ER=estrogen receptor; IHC=immunohistochemistry; LFTs=liver function tests; PR=progesterone receptor; 
RANK=receptor activator of NF-KB; RANKL=receptor activator of NF-KB ligand 
a. 
Risk-reducing salpingo-oophorectomy (bilateral or unilateral) will be scheduled during the luteal phase (day 14-28) of the same menstrual cycle after 
administration of the last dose of denosumab (Dose #1 or 2). For women with irregular periods or menstrual cycles of >28 days, then the luteal phase will be 
estimated as the second half of the menstrual cycle. For women who do not cycle, please see Sections 7.3 and 7.4. 
b. Full physical examination including vital signs, height, and weight 
c. 
Focused physical examination based on symptomatology and including vital signs and weight. Physical exam may be performed up to 5 days prior to surgery 
(-5 days). 
d. A visual examination of the oral cavity, including teeth, mucosa, and jaws, will be conducted by the investigator, or designated licensed healthcare professional, 
at screening, to establish baseline oral health conditions, and at follow-up, to identify and document any new abnormalities or changes in pre-existing 
conditions. If any new abnormalities or changes in pre-existing conditions are identified, the investigator may refer the participant to follow up with a dentist 
or other oral health specialist. A dental exam is required < 6 months of study registration. 
e. 
Randomization can be completed on the same day/visit as baseline evaluation 
f. 
Assessed via telephone contact. Contact may occur over email if patient prefers.  
g. HEMATOLOGY: 
CBC (hemoglobin, hematocrit, RBC, WBC, platelet count) with differential (neutrophils, bands [may be included within neutrophil 
count or reported separately], lymphocytes, monocytes, eosinophils, basophils) 
CHEMISTRY: 
Na+, K+, Cl-, CO2, BUN, creatinine, glucose, Ca+2, PO4, Mg, total protein, albumin, total bilirubin, alkaline phosphatase, AST (SGOT), 
ALT (SGPT); FSH (only at baseline to assess menopausal status) 
h. Only Na+, K+, Cl-, CO2, BUN, creatinine, glucose, Ca+2, PO4, Mg, total protein, albumin, total bilirubin, alkaline phosphatase, AST (SGOT), and ALT (SGPT) 
are required with each denosumab injection. Labs prior to first injection only need to be repeated if the first dose of denosumab falls outside of 30-day window 
from registration.  
i.     Denosumab is administered every 4 weeks. Dose #2 is given if the surgery cannot be performed within the specified time frame of Dose #1 of denosumab 
j. 
See Appendix B “Alcohol and Tobacco Use Assessment Questionnaires – Baseline” 
k. See Appendix C “Alcohol and Tobacco Use Assessment Questionnaires – Month 12”. Assessed in person or on the phone.  
l. 
At Month 5 remind the participant to bring pill bottles and remaining pills to Month 6 visit.  
m.   The oral examination planned at the time of surgery can be performed up to 4 weeks after the surgery. 
n.    For women who take hormonal contraceptive with continuous progesterone (i.e. progestin IUD), the first dose of denosumab and surgery do not need to be 
timed with menses. 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–27– 
08/31/2016 
o.  In-person contact for calcium/Vitamin D compliance assessment. Compliance assessments for treatment arm participants at Dose 2 of denosumab will replace 
the telephone compliance assessments at Month 2. 
p. Urine or serum pregnancy test must be within 14 days prior to randomization and 14 days prior to each denosumab injection. 
q. Telephone contact the day before surgery may be used instead of in person assessment of concurrent medications, toxicity assessment, and calcium/Vitamin D 
compliance assessment. 
r. Only calcium and phosphate levels should be drawn within 3 days of the day of surgery (-3 days).  These may also be drawn at the same time as day of surgery 
research blood draw. 
 
7.1.2 
Schedule of Events: Control Arm 
 
Baseline/ 
Registration 
(within 30 days 
prior to 
randomization) 
Randomi
zation 
Day 1-3 of 
menstrual 
cyclea  
 Day 8-10 of 
menstrual 
cycle  
Surgery a,b 
7-14 days 
post-
surgery 
Months 1-5 
from start 
of Calcium/ 
Vitamin D 
calls 
6 months 
from start 
of Calcium/ 
Vitamin D 
visit 
12 months 
from start 
of Calcium/ 
Vitamin D 
visit 
Window (days) 
 
 
 
 
 
 
+/- 7 days 
+/- 90 days 
+/- 90 days 
Informed consent 
X 
 
 
 
 
 
 
 
 
Physical exam 
Xc 
 
 
 
Xd 
 
 
 
 
Oral examinatione 
X 
 
 
 
Xf 
 
 
 
 
Dental examinatione 
X 
 
 
 
 
 
 
 
 
All concurrent medications 
X 
 
 
 
Xo 
 
 
 
 
Confirm eligibility 
X 
 
 
 
 
 
 
 
 
Randomization 
 
Xg 
 
 
 
 
 
 
 
Toxicity assessment 
 
 
 
Xh 
Xo 
 
 
X 
X 
Clinical  blood drawi 
X 
 
 
 
Xp 
 
 
 
 
Urine or serum pregnancy 
test  
Xj 
 
 
 
 
 
 
 
 
Serum FSH 
X 
 
 
 
 
 
 
 
 
Dispensing of 
calcium/vitamin D 
 
 
X 
 
 
 
 
 
 
Collect unused study agent 
 
 
 
 
 
 
 
X 
 
Calcium/vitamin D pill 
compliance assessment 
 
 
 
Xh 
Xk,o 
Xh 
Xh,l 
Xk 
 
Research blood collection 
X 
 
 
 
X 
 
 
X 
X 
   Serum progesterone 
X 
 
 
 
X 
 
 
 
 
Serum estradiol 
X 
 
 
 
X 
 
 
 
 
   Serum denosumab 
X 
 
 
 
X 
 
 
 
 
Serum CTX 
X 
 
 
 
X 
 
 
X 
X 
Research tissue collection 
(fimbria, ovarian 
epithelium, endometrium 
 
 
 
 
X 
 
 
 
 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–28– 
08/31/2016 
[if undergoing 
hysterectomy]) 
   Ki67 (IHC) 
 
 
 
 
X 
 
 
 
 
   RANK/RANKL 
   (IHC) 
 
 
 
 
X 
 
 
 
 
   Cleaved caspase-3 
   (IHC) 
 
 
 
 
X 
 
 
 
 
   ER/PR (IHC) 
 
 
 
 
X 
 
 
 
 
CD44/p53 (IHC) 
 
 
 
 
X 
 
 
 
 
STAT3/pSTAT3 
(IHC) 
 
 
 
 
X 
 
 
 
 
Gene expression profiling 
(only on fimbrial and 
ovarian tissue) 
 
 
 
 
X 
 
 
 
 
Tobacco and Alcohol Use 
Assessment 
Xm 
 
 
 
 
 
 
 
Xn 
 
Abbreviations: CBC=complete blood count; ER=estrogen receptor; IHC=immunohistochemistry; LFTs=liver function tests; PR=progesterone receptor; 
RANK=receptor activator of NF-KB; RANKL=receptor activator of NF-KB ligand 
a.    For women who take hormonal contraceptive with continuous progesterone (i.e. progestin IUD), the first dose of calcium/vitamin D and surgery do not need 
to be timed with menses. 
b. Risk-reducing salpingo-oophorectomy (bilateral or unilateral) will be scheduled during the luteal phase (day 14-28) of the menstrual cycle 2-8 weeks after 
initiation of calcium and vitamin D supplement. For women with irregular periods or menstrual cycles of >28 days, then the luteal phase will be estimated as 
the second half of the menstrual cycle. For women who do not cycle, please see Sections 7.3 and 7.4. 
c. 
Full physical examination including vital signs, height, and weight 
d. Focused physical examination based on symptomatology and including vital signs and weight. Physical exam may be performed up to 5 days prior to surgery 
(-5 days). 
e. 
A visual examination of the oral cavity, including teeth, mucosa, and jaws, will be conducted by the investigator, or designated licensed healthcare professional, 
at screening, to establish baseline oral health conditions, and at follow-up, to identify and document any new abnormalities or changes in pre-existing 
conditions. If any new abnormalities or changes in pre-existing conditions are identified, the investigator may refer the participant to follow up with a dentist 
or other oral health specialist. A dental exam is required < 6 months of study registration. 
f. 
The oral examination planned at the time of surgery can be performed up to 4 weeks after the surgery. 
g. Randomization can be completed on the same day/visit as baseline evaluation 
h. Assessed via telephone contact. Contact may occur over email if patient prefers.  
i. 
HEMATOLOGY: 
CBC (hemoglobin, hematocrit, RBC, WBC, platelet count) with differential (neutrophils, bands [may be included within neutrophil 
count or reported separately], lymphocytes, monocytes, eosinophils, basophils) 
CHEMISTRY: 
Na+, K+, Cl-, CO2, BUN, creatinine, glucose, Ca+2, PO4, Mg, total protein, albumin, total bilirubin, alkaline phosphatase, AST (SGOT), 
ALT (SGPT); FSH (only at baseline to assess menopausal status) 
j.     Urine or serum pregnancy test must be within 14 days prior to randomization 
k.    In-person contact for calcium/Vitamin D compliance assessment.  

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–29– 
08/31/2016 
l. 
At Month 5 remind the participant to bring pill bottles and remaining pills to Month 6 visit.  
m. See Appendix B “Alcohol and Tobacco Use Assessment Questionnaires – Baseline” 
n.    See Appendix C “Alcohol and Tobacco Use Assessment Questionnaires – Month 12”. Assessed in person or on the phone. 
o. Telephone contact the day before surgery may be used instead of in person assessment of concurrent medications, toxicity assessment, and calcium/Vitamin D 
compliance assessment. 
p. Only calcium and phosphate levels should be drawn within 3 days of the day of surgery (-3 days).  These may also be drawn at the same time as day of surgery 
research blood draw. 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–30– 
08/31/2016 
7.2 
Baseline Testing/Prestudy Evaluation 
 
Baseline testing/prestudy evaluation will be conducted within 30 days of randomization, may require multiple visits and 
will consist of the following procedures: 
 
• 
Informed consent must be obtained prior to starting any further study procedures. 
• 
Registration: Once informed consent has been signed, participants will be registered into the DMI database. The 
DMI database will assign a participant’s ID upon completion of the registration process. Participants will also be 
registered into site-specific registry databases as applicable. 
• 
Baseline medical history, to include a review of previous medical and surgical history, reproductive history, family 
history, demographic information, including age and race. 
• 
Pathogenic germline mutation or likely pathogenic variant in the BRCA1 or BRCA2 genes must be confirmed by 
review of genetic test report.  
• 
Use of concomitant medications will be reviewed. 
• 
A physical examination will be done that will include vital signs (temperature, blood pressure, heart rate, respiratory 
rate). 
• 
An oral examination will be done that will include a visual examination of the oral cavity, including teeth, mucosa, 
and jaws. 
• 
A dental examination is required < 6 months of study registration. 
• 
Height, weight. 
• 
Pre-study blood draw will include the following: 
o Clinical laboratory tests: CBC (hemoglobin, hematocrit, RBC, WBC, platelet count) with differential 
(neutrophils, bands [may be included within neutrophil count or reported separately], lymphocytes, 
monocytes, eosinophils, basophils); Chemistry (Na+, K+, Cl-, CO2, BUN, creatinine, glucose, Ca+2, PO4, 
Mg, total protein, albumin, total bilirubin, alkaline phosphatase, AST [SGOT], ALT [SGPT]; FSH [to 
assess menopausal status]) 
o Research blood collection 
▪ 
Serum progesterone  
▪ 
Serum estradiol 
▪ 
Serum denosumab level 
▪ 
Serum CTX level 
• 
A urine or serum pregnancy test must be done within 14 days prior to randomization. Results must be known prior 
to randomization and drug dispensing. 
o If the pregnancy test result is positive at Baseline (any time before randomization), the participant is a 
Screen Failure. 
• 
Tobacco and Alcohol Use Assessment, using the Baseline questionnaires. See Appendix B “Alcohol and Tobacco 
Use Assessment Questionnaires – Baseline”. Refer to Appendix D for resources for alcohol and tobacco quitting. 
These resources can be given to individuals if there is concern about alcohol or tobacco dependence. It is not 
expected that investigators will refer individuals for assistance or that they will undertake the care of individuals 
for alcohol or tobacco dependence.  
• 
Confirm eligibility: At the completion of the screening period, eligibility must be confirmed. Only after eligibility 
is confirmed, can eligible participants be randomized.  
 
7.3 
Evaluation During Study Intervention 
 
The first denosumab injection (Dose #1) will be administered within the first 3 days of the first or second menstrual cycle 
after baseline evaluation (treatment arm only). For women who take hormonal contraceptive with continuous progesterone 
(i.e. progestin IUD), the first dose of denosumab does not need to be timed with menses. In those patients receiving 
denosumab (treatment arm only), an oral examination will be done prior to Dose #1 that will include a visual examination 
of the oral cavity, including teeth, mucosa, and jaws. Participant must have a negative urine or serum pregnancy test 
within 14 days prior to or on the day of Dose #1. 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–31– 
08/31/2016 
 
In addition, all participants (control and treatment groups) will be given a 6-month supply of oral calcium and vitamin D 
supplements.  If randomized to treatment group, the first dose of denosumab and calcium and vitamin D supplements will 
be administered within the first 3 days of the menstrual cycle. If randomized to no treatment group, the calcium and 
vitamin D supplements will be administered within the estimated first 3 days of the menstrual cycle.  For women who take 
hormonal contraceptive with continuous progesterone (i.e. progestin IUD), the first dose of oral calcium and vitamin D 
supplements and first dose of denosumab (if applicable) do not need to be timed with menses.  
 
If a participant does not cycle and has FSH < 20 mIU/mL, the date of last menstrual period (LMP) will be documented and 
the follicular and luteal phases of the participant’s menstrual cycle will be estimated based on a 28-day cycle (follicular 
phase as Days 1-13 and luteal phase as Days 14-28).  
 
One week later (Days 8-10 of menstrual cycle), study personnel will make telephone contact with all participants (control 
and treatment groups) for toxicity assessment and calcium and vitamin D pill compliance. They will be specifically asked 
about denosumab-related toxicities, including skin rashes, infections, perioral numbness, tingling in fingers, or groin or 
thigh pain indicative of atypical fracture.  Calcium and vitamin D pill compliance will be assessed every month (+/- 1 
week) from start of supplements. 
 
In the treatment arm only, participants may receive a second dose of denosumab (Dose #2) after four weeks (+/- 3 days) 
from Dose #1 if the surgery cannot be performed within 4 weeks of Dose #1 of denosumab. At each visit for denosumab 
administration, the following assessments will be performed: 
o 
Study personnel will perform toxicity assessment and assess calcium and vitamin D compliance. 
Participants will be specifically asked about denosumab-related toxicities, including skin rashes, infections, 
perioral numbness, tingling in fingers, or groin or thigh pain indicative of atypical fracture.  
o 
An oral examination will be done at each dose administration that will include a visual examination of the 
oral cavity, including teeth, mucosa, and jaws.  
o 
Participant must have a negative urine or serum pregnancy test within 14 days prior to or on the day of each 
denosumab dose.  
o 
Prior to each dose of denosumab, there will be a blood draw including the following laboratory tests: 
▪ 
Chemistry (Na+, K+, Cl-, CO2, BUN, creatinine, glucose, Ca+2, PO4, Mg, total protein, albumin, 
total bilirubin, alkaline phosphatase, AST [SGOT], ALT [SGPT] 
 
Results of clinical blood draw and urine or serum pregnancy test will be reviewed prior to denosumab dosing. Denosumab 
dose will be held in the case of any of the following results: 
o 
Positive urine or serum pregnancy test 
o Total bilirubin > 2 x institutional upper limit of normal (ULN) 
o AST (SGOT)/ALT (SGPT) > 1.5 x institutional ULN 
o Creatinine clearance < 30 mL/min 
o Serum calcium or albumin adjusted < 8.0 mg/dL  
o 
Serum magnesium < 1.7 mg/dL 
o 
Serum phosphate < 2 mg/dL 
 
If denosumab is not given due to an abnormal blood lab result or other grade 2 or higher toxicity which is possibly, probably, 
or definitely related to denosumab, the participant can receive a dose of denosumab the following month if the lab values 
are corrected or the grade 2 toxicity improves to grade 0 or 1.  If abnormal blood lab results or other grade 2 or higher 
toxicities are present in the following month, then no further denosumab will be administered. If the denosumab is not given 
due to a positive urine or serum pregnancy test, the participant will be taken off study. 
 
After each denosumab dose administration, the participant will be monitored by clinical observation for 30 minutes after 
each injection to assess for any acute or anaphylactic reactions, such as rash, low blood pressure, wheezing, shortness of 
breath, swelling of the face or throat. 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–32– 
08/31/2016 
 
 
7.4 
Evaluation at Time of Surgery 
 
The participant must undergo risk-reducing surgery during the luteal phase (Days 14-28) of the menstrual cycle after the 
last dose of denosumab (either Dose #1 or #2, which must be administered within 4 weeks of surgery) or 2-8 weeks after 
starting calcium/vitamin D supplement (in the no treatment control arm). This will allow for some flexibility in the surgical 
scheduling.  
 
For women with irregular periods or menstrual cycles of >28 days, then the luteal phase will be estimated as the second half 
of the menstrual cycle.  
 
For women who do not cycle, the date of last menstrual period (LMP) will be documented and the follicular and luteal 
phases of the participant’s menstrual cycle will be estimated based on a 28-day cycle (follicular phase as Days 1-13 and 
luteal phase as Days 14-28). If randomized to the treatment group, surgery will be scheduled 2-4 weeks after dose 1 or 2 of 
denosumab as this would be the estimated time frame for the luteal phase. If randomized to the no treatment group, surgery 
will be scheduled during the estimated luteal phase 2-8 weeks after initiation of calcium and vitamin D supplements. If the 
participant resumes menstruating during the course of the intervention, the timing of surgery can be rescheduled based on 
the participant’s new LMP.  
 
For women who take hormonal contraceptive with continuous progesterone (i.e. progestin IUD), the surgery does not need 
to be timed with menses. 
 
Given the prolonged absorption of denosumab with drug tissue levels lasting for 3-6 months, a delay in surgery should not 
affect our biomarker endpoints, however, we will adjust for time (in days) from denosumab treatment (or no treatment) to 
surgery in our data analysis. The average wait time for risk-reducing surgery at all the participating sites is 2-6 weeks, which 
is within the timeframe between drug administration and surgery for this trial. If the surgery cannot be performed within the 
specified time frame of Dose #1 of denosumab, the participant may receive an additional dose of denosumab.  
 
On the day of surgery and prior to the operation, the following procedures must be completed: 
o Research blood collection 
▪ 
Serum progesterone 
▪ 
Serum estradiol 
▪ 
Serum denosumab level 
▪ 
Serum CTX level 
o 
Clinical blood collection, which should be drawn within 3 days of the day of surgery (-3 days).  These may 
also be drawn at the same time as the research blood collection. 
▪ 
Serum calcium level 
▪ 
Serum phosphate level   
o 
A focused physical examination based on symptomatology and including vital signs and weight will be 
obtained. The physical exam may be performed up to 5 days prior to the day of surgery (-5 days). 
o 
An oral examination will be done that will include a visual examination of the oral cavity, including teeth, 
mucosa, and jaws. If the oral examination is not performed on the day of surgery, it must be performed 
within 4 weeks of the surgery.  
o 
Concomitant medications will also be obtained. This may also be done via telephone contact the day before 
the scheduled surgery. 
o 
Toxicity assessment will be performed during a clinical encounter by study personnel. For toxicity 
assessment, the participant will be specifically asked about denosumab-related toxicities, including skin 
rashes, infections, perioral numbness, tingling in fingers, or groin or thigh pain indicative of atypical 
fracture. This may also be done via telephone contact the day before the scheduled surgery. 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–33– 
08/31/2016 
o 
Compliance with calcium and vitamin D supplements will be assessed. This may also be done via telephone 
contact the day before the scheduled surgery. 
 
At the time of surgery, research tissue (fimbrial end of the fallopian tube, ovarian surface epithelium, and endometrium [if 
also undergoing hysterectomy, ~20% or N=12]) will be collected. Immediate fixation in formalin, embedding, processing, 
and sectioning will follow. Official local pathology review will rule out malignancy. Formalin-fixed paraffin-embedded 
(FFPE) tissue slides will be sent to Columbia University Irving Medical Center (CUIMC) to evaluate for the following 
tissue biomarkers: 
• 
Ki67 (IHC) - fimbrial end of the fallopian tube, ovarian surface epithelium, endometrium (if also undergoing 
hysterectomy) 
• 
Apoptosis with cleaved caspase-3 (IHC) - fimbrial end of the fallopian tube, ovarian surface epithelium, 
endometrium (if also undergoing hysterectomy) 
• 
RANK/RANKL expression (IHC) - fimbrial end of the fallopian tube, ovarian surface epithelium, endometrium (if 
also undergoing hysterectomy) 
• 
ER/PR expression (IHC) - fimbrial end of the fallopian tube, ovarian surface epithelium, endometrium (if also 
undergoing hysterectomy) 
• 
CD44 and p53 expression (IHC) - fimbrial end of the fallopian tube, ovarian surface epithelium, endometrium (if 
also undergoing hysterectomy) 
• 
STAT3/pSTAT3 expression (IHC) - fimbrial end of the fallopian tube, ovarian surface epithelium, endometrium (if 
also undergoing hysterectomy) 
• 
Gene expression profiling - fimbrial end of the fallopian tube, ovarian surface epithelium 
 
7.5 
Evaluations During Follow-up Period 
 
Compliance to calcium/vitamin D pill supplements will be conducted at 1, 2, 3, 4, and 5 months (+/- 7 days) after start of 
treatment (by telephone contact or in person). The participants will be reminded at Month 5 to bring in the pill bottles and 
remaining pills to their next visit at Month 6. 
  
Seven to 14 days after surgery, calcium and vitamin D supplement compliance will be assessed by telephone contact. 
 
At 6 months (+/- 90 days) after the start of treatment, participant will present for clinic visit for toxicity assessment, calcium 
and vitamin D pill compliance, and research blood draw for serum CTX level. Toxicity assessment will be performed by 
research personnel. The pill bottles and remaining pills will be collected at Month 6. 
 
At 12 months (+/- 90 days) after the start of treatment, participant will present for clinic visits for toxicity assessment and 
research blood draw for serum CTX level. Toxicity assessment will be performed by research personnel.  
 
For toxicity assessment, the participant will be specifically asked about denosumab-related toxicities, including skin rashes, 
infections, perioral numbness, tingling in fingers, or groin or thigh pain indicative of atypical fracture. The participant will 
also be assessed for symptoms of hypercalcemia, including stomach upset, nausea, vomiting, headache and decreased 
alertness.  
 
Tobacco and Alcohol use assessment will be performed at Month 12, using the Month 12 questionnaires (see Appendix C 
“Alcohol and Tobacco Use Assessment Questionnaires – Month 12”).   
 
7.6 
Methods for Clinical Procedures 
 
Oral Examination: A visual examination of the oral cavity, including teeth, mucosa, and jaws, will be conducted by the 
investigator, or designated licensed healthcare professional, at screening, to establish baseline oral health conditions, and at 
follow-up, to identify and document any new abnormalities or changes in pre-existing conditions. If any new abnormalities 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–34– 
08/31/2016 
or changes in pre-existing conditions are identified, the investigator may refer the participant to follow up with a dentist or 
other oral health specialist. 
 
All tissue specimens obtained at the time of surgery will be submitted to the Pathology Department at each site. After 
standard of care local pathology review to rule out malignancy, residual tissue from the fimbrial end of the fallopian tube, 
ovarian surface epithelium, and endometrium from hysterectomy will be submitted for research purposes. FFPE tissue from 
15 immunoblanks (for IHC) and 10 regular blanks (for gene expression profiling) from each research tissue (fimbrial end 
of the fallopian tube, ovarian surface epithelium) and 15 immunoblanks (for IHC) from the endometrium (if also undergoing 
hysterectomy) will be shipped to Columbia University Irving Medical Center [CUIMC] as a one-time shipment at the end 
of the trial (please refer to the Manual of Operations and Procedures for complete instructions). Immunoblanks are coated 
with a special adhesive for immunohistochemistry analysis, whereas regular blanks are uncoated and will be used for RNA 
extraction for the gene expression profiling. All tissue slides from the same site will be cut as a single batch to minimize 
variability in tissue biomarker analyses. For the purposes of the interim biomarker analysis, 2 immunoblanks from the 
fimbrial end of the fallopian tube will be submitted for the first 10 patients enrolled on the study (for Ki67 IHC evaluation).  
 
 
8.  
CRITERIA FOR EVALUATION AND ENDPOINT DEFINITION 
 
8.1 
Primary Endpoint 
 
The primary endpoint of the trial is to evaluate the Ki67 proliferation index in fallopian tube fimbrial epithelial cells after 
denosumab treatment compared to no treatment. The primary biomarker therefore is Ki67, which will be assessed using 
immunohistochemistry (IHC). Quantitative measures of the expression of Ki67 based upon percentage of positive cells will 
be scored by a pathologist blinded to treatment assignment. 
 
8.2 
Secondary Endpoints 
 
Secondary endpoints include: 
 
8.2.1 
Evaluation of proliferation index in ovarian surface epithelium and endometrium (if also undergoing hysterectomy) 
after exposure to denosumab compared to no treatment using Ki67 as assessed by IHC.  
 
8.2.2  Investigation of other tissue-based biomarkers in the fimbrial end of the fallopian tube, ovarian surface epithelium, 
and endometrium (if also undergoing hysterectomy) after exposure to denosumab compared to no treatment, 
including:  
 
• 
Apoptosis with cleaved caspase-3 (IHC) 
• 
RANK/RANKL (IHC) 
• 
ER/PR (IHC) 
• 
CD44 and p53 (IHC) 
• 
STAT3 and pSTAT3 (IHC) 
 
8.2.3  Analysis of gene expression profiling of RANK, cell proliferation, cell cycle progression, and inflammation 
pathways in the fimbrial end of the fallopian tube and ovarian surface epithelium after exposure to denosumab 
compared to no treatment 
 
8.2.4 
Investigation of serum biomarkers at baseline (pre-treatment) and time of surgery (post-treatment) after exposure 
to denosumab compared to no treatment, including:  
 
• 
Progesterone 
• 
Estradiol 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–35– 
08/31/2016 
• 
Denosumab drug levels 
 
8.2.5  Investigation of serial serum C-terminal telopeptide (CTX) levels at the following time points after exposure to 
denosumab compared to no treatment: 
• 
Baseline (pre-treatment) 
• 
Time of surgery 
• 
6 months after start of intervention 
• 
12 months after start of intervention  
 
8.2.6 
Toxicity profile and frequency of adverse effects in premenopausal BRCA1/2 mutation carriers undergoing risk-
reducing surgery receiving denosumab compared to women receiving no treatment 
 
8.3 
Off-Agent Criteria  
 
Participants may stop taking study agent for the following reasons: completed the protocol-prescribed intervention, AE or 
serious adverse event (SAE), inadequate agent supply, noncompliance, concomitant medications or medical 
contraindication. Participants will continue to be followed, if possible, for safety reasons and in order to collect endpoint 
data according to the schedule of events. 
 
 
8.4 
Off-Study Criteria 
 
Participants may go ‘off-study’ for the following reasons: the protocol intervention and any protocol-required follow-up 
period is completed, AE/SAE (serious adverse event), lost to follow-up, non-compliance, medical contraindication, 
withdraw consent, did not undergo surgery within specified time period, or death. Participants found to be ineligible during 
the screening phase and after signing the Informed Consent document and assigning the PID number, will be considered 
“screen failures”.  Such participants will be taken off study and the appropriate end of study CRFs will be completed for 
these participants. For those participants who need to go off-study due to inability to go to surgery, additional participants 
will be enrolled to replace these women.  
 
8.5 
Study Termination 
 
NCI, DCP as the study sponsor has the right to discontinue the study at any time.  
 
9. 
CORRELATIVE/SPECIAL STUDIES 
 
We will collect and process paraffin-embedded tissue and serum for evaluation of biomarkers. 
 
9.1 
Rationale for Methodology Selection 
 
Tissue biomarkers of proliferation and apoptosis (Ki67and cleaved caspase-3), RANK/RANKL, ER/PR, CD44, p53, 
STAT3, and pSTAT3 
Immunohistochemical analysis of the following proteins will be performed on paraffin-embedded sections of fimbrial, 
ovarian, and endometrial (if also undergoing hysterectomy) tissue by Dr. H. Hibshoosh at the Herbert Irving Comprehensive 
Cancer Center (HICCC) Molecular Pathology Shared Resource (MSPR) at Columbia University Medical Center (CUIMC), 
as described in previous reports: Ki67, cleaved caspase-3, RANK/RANKL, ER, PR, CD44, p53, STAT3, and pSTAT3. 
Qualitative changes and quantitative analysis of the expression of markers will be assessed in a blinded fashion. For each 
protein, both percentage of positive cells and intensity of staining will be scored by a designated gynecologic pathologist at 
CUIMC, Dr. X. Chen. 
 
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tissue have used IHC-based procedures. Previous studies investigating the expression of CD44, p53, STAT3, and pSTAT3 
in the fimbrial and ovarian epithelium tissue have used IHC-based procedures. IHC allows a more precise analysis of protein 
expression in specific cell types, while avoiding contamination of surrounding connective tissue elements. In addition, if 
these proteins are to be developed as potential biomarkers, IHC-based procedures, as compared with western blot analysis, 
provide more feasible methods for analyzing these proteins in clinical specimens. 
 
Gene expression profiling of cell proliferation, cell cycle progression, and inflammation pathways  
Gene expression profiling will be performed with the nCounter™ PanCancer Pathways Panel by nanoString Technologies 
on fimbrial and ovarian tissue of participants from both the treatment and control arms. The system can directly assay tissue 
to analyze 770 essential genes representing 13 canonical pathways, including cell cycle, apoptosis, and DNA damage control 
pathways.  
 
This assay can use FFPE-derived and purified total RNA and does not require reverse transcriptase reactions. Results of 
this assay using FFPE-derived tissue were highly correlated with purified total RNA from fresh tissue (R2>0.97). The assay 
demonstrates a high level of sensitivity and precision even at very low levels of expression.  
 
Serum progesterone and estradiol level 
Serum progesterone level will be measured at the CUIMC Irving Institute for Clinical and Translational Research 
Biomarkers Core Laboratory using a LCMS assay on Xevo TQ instrument (Waters; Milford, MA), with an inter-assay and 
intra-assay precision of <10% and <5%, respectively. Serum estradiol level will be measured using a LCMS/MS method 
on Xevo TQS instrument (Waters; Mildford, MA), with an inter-assay and intra-assay precision of <10%. 
 
Serum denosumab level 
The assay for denosumab drug levels will be performed by the PPD testing facility using the assay developed by Amgen. 
 
Serum C-telopeptide (CTX) level 
Serum CTX level will be measured at the CUIMC Irving Institute Biomarkers Core Laboratory. Serum CTX will be 
measured by ELISA (Immunodiagnostic Systems; Scottsdale, AZ), with an inter-assay and intra-assay precision of 10.9% 
and 3.0%, respectively. Serum calcium and free calcium will be measured using colorimetric assay with Cobas Integra 400 
Plus (Roche Diagnostics; Indianapolis, IN), with an inter-assay and intra-assay precision of 3.5% and 0.99%, respectively.  
 
Please refer to the Pharmacokinetic and Biomarker Methods Development Report for methodology. 
 
9.2 
Comparable Methods 
 
We will use established and validated assays for determination of changes in biomarkers expression in this study. We plan 
to evaluate biomarkers in serum and gynecologic tissue for secondary endpoints evaluation. As to the primary endpoint, the 
method has been validated and already described in peer-reviewed publications.49,50 
 
For secondary serum biomarkers we will utilize standardized protocols of commercially available kits already described in 
peer-reviewed publications. Standard control samples as well as an in-house pooled serum sample will be analyzed in each 
run to monitor for inter- and intra-assay coefficient of variation. We will pair samples obtained from the same participant 
(pre and post-treatment) and run samples in batches to reduce analytical variability.  
 
 
10. 
SPECIMEN MANAGEMENT  
 
10.1 
Laboratories 
 

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A pathologist from each site will perform local review of tissue specimens obtained at the time of surgery. These pathologists 
are: Dr. Xiaowei Chen (CUIMC), Dr. Lora Ellenson (Cornell), Dr. Chris Crum (DFCI), and Dr. Iris Barshack and Dr. Dov 
Hershkowitz (Tel Aviv Sourasky).  
 
The tissue-based biomarker analyses of the research tissue will be conducted by the Molecular Pathology Shared Resource 
(MSPR) for the Herbert Irving Comprehensive Cancer Center (HICCC) directed by Dr. H. Hibshoosh (CUIMC). 
 
The serum biomarkers will be assayed at the Irving Institute for Clinical and Translational Research Biomarkers Core 
Laboratory directed by Dr. R. Nandakumar (CUIMC). 
 
10.2 
Collection and Handling Procedures 
 
For each participant, research tissue (fimbrial epithelium, ovarian surface epithelium, and endometrium [if also undergoing 
hysterectomy]) will be obtained at the time of surgery. Official local pathology review will rule out malignancy. The 
protocol for Sectioning and Extensively Examining the FIMbriated End (SEE-FIM) of the fallopian tube will be followed, 
which includes amputation of each fimbria at the infundibulum, longitudinal sectioning of the fimbria, and cross-sectioning 
of the remaining fallopian tube at 2-mm intervals.66 If malignancy, including serous tubal intraepithelial carcinoma (STIC), 
is detected in the pathology review, this will be reported to the study team. The paraffin section from each tissue type 
(fimbrial epithelium, ovarian surface epithelium, and endometrium [if also undergoing hysterectomy]) will yield fifteen 4 
μm immunoblanks for immunohistochemical analyses. In addition, ten regular 10 μm blanks for gene expression profiling 
of fimbrial and ovarian surface tissue will be obtained. Blood collected for biomarker analysis at baseline and at time of 
surgery will be collected in three 4 mL SST tubes. Blood collected for serum CTX level at 6 and 12 months will be collected 
in one 4 mL SST tube. Detailed instructions on collection and processing for circulating biomarkers are in the lab manual 
for the study. 
 
For the purposes of the interim biomarker analysis, 2 immunoblanks from the fimbrial end of the fallopian tube will be 
submitted for the first 10 patients enrolled on the study (for Ki67 IHC evaluation). 
 
10.2.1 Paraffin Sections 
• 
Amount to be collected at the end of the study: 25 unstained slides (15 immunoblanks and 10 regular blanks) 
of each (fimbrial epithelium, ovarian surface epithelium) and 15 immunoblanks from endometrium (if also 
undergoing hysterectomy) 
• 
When specimen should be obtained – at time of risk reducing surgery 
• 
Processing of specimen – immediate fixation in formalin, embedding, processing and sectioning to follow 
• 
Labeling of specimen – protocol number (MDA2017-09-03), participant identifier, date of collection 
• 
Tracking of specimens – logs or tracking sheets for participants 
• 
Temperature shipping requirements – room temperature 
• 
Temperature storage requirements – -80C 
• 
Storage duration – several years 
 
 
10.2.2 Blood Samples 
• 
Amount to be collected – 10 ml/sample for research blood draw at baseline and time of surgery; 4 ml/sample 
for research blood draw at 6 and 12 months; 5-20 ml for clinical blood draws at baseline, denosumab injections, 
and at the time of surgery 
• 
When specimen should be obtained – baseline (progesterone, estradiol, denosumab level, and CTX level), time 
of surgery (progesterone, estradiol, denosumab level, and CTX level), 6 months (CTX level), 12 months (CTX 
level) 
• 
Processing of specimen – spun, aliquotted into Cryovials (1 mL each), and promptly snap frozen; any extra 
serum should be aliquotted in a separate Cryovial; detailed instructions are in the lab manual for the study 
• 
Labeling of specimen – detailed instructions are in the lab manual for the study  
• 
Tracking of specimens – logs or tracking sheets for participants 

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• 
Temperature shipping requirements – dry ice 
• 
Temperature storage requirements – -80C freezer (stored locally and then shipped quarterly to CUIMC) 
• 
Storage duration – several years 
 
 
10.3 
Shipping Instructions 
 
FFPE tissue slides from the surgical specimens from all study sites will be sent to Kristina Hosi at Columbia University, 
161 Ft. Washington Ave, Mezzanine level, New York, NY  10032; telephone (212) 304-5580; email: 
kkh2130@cumc.columbia.edu. Specimens should be sent as a single batch shipment at the end of the study. For the interim 
analysis, specimens from the first 10 patients enrolled on the study will be sent to the same address when requested by the 
study team. 
 
Serum specimens (for progesterone, estradiol, denosumab level, and CTX level) will be shipped quarterly on dry ice to Dr. 
Regina Santella at Columbia University Biomarkers Core Facility, 650 West 168th Street, Room 1608, New York, NY 
10032; telephone (212) 305-8158 where further sample processing will take place. The Columbia University Biomarkers 
Core Facility will serve as a central repository for blood storage.   
 
All samples will be shipped in compliance with the International Air Transport Association (IATA) Dangerous Goods 
Regulations. 
 
10.4 
Tissue Banking 
 
The Tumor Bank Service is responsible for procurement, storage, retrieval, and distribution of human tumor and normal 
tissue samples to all investigators at CUIMC. This service protects against the loss of valuable tissue specimens by 
monitoring of surgical schedules and provides maximum protection to the rights of participants through the acquisition of 
only those tissues which remain after the appropriate diagnostic and prognostic studies have been carried out in the 
pathology departments. The tumor bank operates within the scope of a specific protocol that has been approved by the IRB 
of CUIMC. Tissue collection is done in a manner that ensures optimum quality of tissue without compromising the quality 
of care and the privacy of the participant's medical information. Participant identifiers are removed from the specimens prior 
to release to investigators unless they have specific authorization from the IRB to obtain participant identifiers. 
 
Storage: Long term storage is in one of two −80C freezers that are dedicated to the tumor bank. These freezers are housed 
in approximately 200 square feet of an equipment room on the 14th floor of the Physicians and Surgeons building in the 
Pathology Department. These freezers plug into outlets that are connected to the emergency back up generators of the 
medical center. In case of freezer breakdown, a back up system consisting of liquid carbon dioxide tanks and an automatic 
dial-out alarm system is activated for protection of samples. Currently, the two freezers are filled at approximately 80% 
capacity. Additional −80C freezer space is available nearby on a limited basis only. 
 
Data storage and retrieval: Information on each specimen is organized in spreadsheet form in the Tumor Bank Information 
System (TBIS). Every case is given a unique tumor bank accession number that is separate from the participant's clinical 
identifiers. The TBIS also contains important clinical information including tissue type, pathologic diagnosis including 
tumor subtype, and occasionally, additional clinical information relevant to the case. The exact location of each specimen 
i.e., freezer shelf, rack, and box number, and number of pieces per case are also recorded. 
 
Quality assurance: Internal quality control experiments are performed in an ongoing fashion to verify the integrity of the 
specimens in the bank. This includes microscopic examination (by the tumor bank director) of frozen sections to verify the 
tissue diagnosis, and total RNA extraction and gel electrophoresis (by the research assistant) of selected samples to 
determine the integrity of the ribosomal RNA bands. These experiments show that approximately 65% of the samples in 
the bank yield high quality total RNA with either no degradation or minimal degradation visible as a faint smear below well 
defined bands on an agarose gel. The remainder of specimens yield partially degraded RNA that nevertheless retains utility 

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for numerous applications. A recently conducted survey of the tumor bank users indicates that tissue has been successfully 
used in a variety of molecular biological experiments that include RNA, DNA and protein extraction, RT-PCR, Northern 
blots, gene expression profiling on microarrays, tissue in situ hybridization, immunostains, western blots, and genomic 
sequencing. The vast majority of these users indicate that 75-100% of samples obtained from the tumor bank yielded 
acceptable results in their particular application. 
 
Biologic specimens collected during the conduct of each clinical trial that are not used during the course of the study will 
be considered deliverables under the contract and thus the property of the NCI. At study completion, NCI reserves the option 
to either retain or relinquish ownership of the unused biologic specimens. If NCI retains ownership of specimens, the 
Contractor shall collect, verify and transfer the requested biologic specimens from the site to a NCI-specified repository or 
laboratory at NCI’s expense.  
 
 
11. 
REPORTING ADVERSE EVENTS  
 
DEFINITION: AE means any untoward medical occurrence associated with the use of a drug in humans, whether or not 
considered drug related. An AE can therefore be any unfavorable and unintended sign), symptom, or disease temporally 
associated with participation in a study, whether or not related to that participation. This includes all deaths that occur while 
a participant is on a study. 
 
Please note that all abnormal clinical laboratory values that are determined to be of clinical significance based on a 
physician’s assessment are to be reported as AEs. Those labs determined to be of no clinical significance or of unknown 
clinical significance (per the physician’s assessment) should not be reported as AEs. Any lab value of unknown clinical 
significance should continue to be investigated/followed-up further for a final determination, if possible. 
 
A list of AEs that have occurred or might occur  can be found in §6.2 Reported Adverse Events and Potential Risks, as well 
as the Investigator Brochure or package insert.  
 
11.1 
Adverse Events 
 
11.1.1 Reportable AEs 
 
All AEs that occur after the informed consent is signed and baseline assessments are completed through the toxicity 
assessment on the day of surgery must be recorded on the AE CRF (paper and/or electronic) whether or not related to study 
agent. 
 
11.1.1.2 All AEs related to surgery that occur during surgery or prior to discharge will not be recorded on the AE CRF 
(paper and/or electronic).  All other AEs, whether or not related to study agent, will be recorded as outlined in the study 
schedule of events.  
  
11.1.1.3 All SAEs, including all hospitalizations, during the study period will be reported as per DCP SAE reporting 
procedures, with the following exception:  
 
Hospitalization for planned surgery will not be reported. However, if this hospitalization event lasts longer than the usual 
period at the institution (as determined by the Site Principal Investigator), it will be reportable as an SAE. Adverse events 
(AEs) relevant to the prolongation of this hospitalization will be collected and reported on AE CRFs. 
 
Pregnancy/Lactation Notifications will be sent to Amgen (Fax 888-814-8653) within 10 calendar days. The Pregnancy 
Notification Worksheet and Lactation Notification Worksheet are included in the Appendix F. 
 
11.1.2 AE Data Elements: 
 

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The following data elements are required for AE reporting. 
• 
AE verbatim term 
• 
NCI Common Terminology Criteria for Adverse Events version 4.0 (CTCAE v4.0) AE term (MedDRA lowest level 
term) 
• 
CTCAE (MedDRA) System Organ Class (SOC) 
• 
Event onset date and event ended date 
• 
Treatment assignment code (TAC) at time of AE onset 
• 
Severity grade 
• 
Attribution to study agent (relatedness) 
• 
Whether or not the event was reported as a SAE 
• 
Whether or not the subject dropped due to the event 
• 
Outcome of the event 
 
11.1.3  Severity of AEs 
 
 
 
11.1.3.1 
Identify the AE using the CTCAE version 4.0. The CTCAE provides descriptive terminology (MedDRA 
lowest level term) and a grading scale for each AE listed. A copy of the CTCAE can be found at 
http://ctep.cancer.gov/protocolDevelopment/electronic applications/ctc.htm 
 
AEs will be assessed according to the grade associated with the CTCAE term. AEs that do not have a corresponding CTCAE 
term will be assessed according to the general guidelines for grading used in the CTCAE v4.0. as stated below.  
 
CTCAE v4.0 general severity guidelines:  
 
Grade 
Severity 
Description  
1 
Mild 
Mild; asymptomatic or mild symptoms; clinical or diagnostic 
observations only; intervention not indicated. 
2 
Moderate 
Moderate; minimal, local or noninvasive intervention indicated; 
limiting age-appropriate instrumental activities of daily living 
(ADL)*. 
3 
Severe 
Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; 
disabling; limiting self-care ADL**. 
4 
Life-threatening 
Life-threatening consequences; urgent intervention indicated. 
5 
Fatal 
Death related to AE. 
   
ADL 
 
*Instrumental ADL refers to preparing meals, shopping for groceries or clothes, using the telephone, managing money, etc. 
 
**Self-care ADL refers to bathing, dressing and undressing, feeding self, using the toilet, taking medications, and not 
bedridden. 
 
11.1.4 Assessment of relationship of AE to treatment 
 
 
The possibility that the AE is related to study agent will be classified as one of the following: not related, unlikely, possible, 
probable, definite. 
  
11.1.5 Follow-up of AEs 
 

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All AEs, including lab abnormalities that in the opinion of the investigator are clinically significant, will be followed 
according to good medical practices and documented as such.  
 
 
11.2 
Serious Adverse Events  
 
11.2.1 DEFINITION: Regulations at 21 CFR §312.32 (revised April 1, 2014) defines an SAE as any untoward medical 
occurrence that at any dose has one or more of the following outcomes: 
 
• 
Death 
• 
A life-threatening AE 
• 
Inpatient hospitalization or prolongation of existing hospitalization 
• 
A persistent or significant incapacity or substantial disruption of the ability to perform normal life functions 
• 
A congenital anomaly or birth defect 
• 
Important medical events that may not be immediately life-threatening or result in death or hospitalization 
should also be considered serious when, based upon appropriate medical judgment, they may jeopardize 
the patient and may require intervention to prevent one of the other outcomes. 
 
11.2.2 Reporting SAEs  
The organization that experiences the serious adverse event (SAE) should report the SAE to the following three (3) entities: 
1) NCI DCP; 2) DCP’s regulatory contractor CCSA; and 3) MDACC, the CLO.  Detailed reporting instructions are provided 
below.  In addition, all participating organizations will follow Central IRB (CIRB) and their local IRB requirements for 
SAE reporting.   
 
11.2.2.1 
The Lead Organization and all Participating Organizations will report SAEs on the DCP SAE Report Form. 
 
11.2.2.2 
Contact the DCP Medical Monitor by phone within 24 hours of knowledge of the event.  
 
Edward Sauter, MD, PhD 
Breast and Gynecologic Cancer Research Group 
Division of Cancer Prevention 
9609 Medical Center Dr., Rm 5E326 
Bethesda, MD 20892-9783 
Office: (240)276-7657 
Cell: (240)944-3279 
Email: edward.sauter@nih.gov 
 
Include the following information when calling the Medical Monitor: 
• 
Date and time of the SAE 
• 
Date and time of the SAE report 
• 
Name of reporter 
• 
Call back phone number 
• 
Affiliation/Institution conducting the study 
• 
DCP protocol number 
• 
Title of protocol 
• 
Description of the SAE, including attribution to drug 
 
11.2.2.3 
Contact the Consortium Lead Organization (CLO) PI, Dr. Powel Brown, or designee by phone or email 
listed on the protocol face page within 24 hours of knowledge of the event.  The same information reported to the DCP 
Medical Monitor should be provided to the CLO PI or designee via email, phone or fax within 24 hours of knowledge of 
the event. 

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11.2.2.4 
The Lead Organization and all Participating Organizations will email written SAE reports to DCP’s 
Regulatory Contractor CCS Associates, Inc. (CCSA; phone: 650-691-4400) at safety@ccsainc.com within 48 hours of 
learning of the event using the fillable PDF SAE Report Form.    
 
11.2.2.5 
The CLO PI, Dr. Brown, or designee must be copied on the email sent to DCP’s Regulatory Contractor 
CCS Associates, Inc. 
 
11.2.2.6 
The DCP Medical Monitor and CCSA regulatory and safety staff will determine which SAEs require FDA 
submission as IND safety reports. SAEs will be sent to Amgen (Fax 888-814-8653 or secure email svc-ags-in-
us@amgen.com) at time of regulatory submission to the FDA. 
 
11.2.2.7 
The Site will comply with applicable regulatory requirements related to reporting SAEs to the IRB/IEC.  
 
11.2.3 Follow-up of SAE 
Site staff should send follow-up reports as requested when additional information is available. Additional information 
should be entered on the DCP SAE Report Form in the appropriate format. Follow-up information should be sent to DCP 
as soon as available. SAEs related to the study agent will be followed until resolved.  
 
 
12. 
STUDY MONITORING 
 
12.1 
Data Management 
 
This study will report clinical data using the Data Management Initiative (DMI) web-based application managed by the 
Consortium Biostatistics and Data Management Core.  Data Management Initiative (DMI) infrastructure has been developed 
in the Division of Quantitative Sciences (DQS), MD Anderson Cancer Center.  This infrastructure supplies integrated 
database and software services for web-based data collection, randomized treatment assignment, reporting, query, data 
download, and data quality management.  The DMI will be the database of record for the protocol and subject to NCI and 
FDA audit.  All DMI users will be trained to use the DMI system and will comply with the instructions in the protocol-
specific “DMI User Manual” as well as applicable regulatory requirements such as 21 CFR; Part 11.  Data management 
procedures for this protocol will adhere to the Data Management Plan (DMP) on file at the DCP for contract 
HHSN261201200034I.  
 
12.2 
Case Report Forms 
 
Participant data will be collected using protocol-specific CRF developed from the standard set of DCP Chemoprevention 
CRF Templates and utilizing NCI-approved Common Data Elements (CDEs). The approved CRFs will be used to create 
the electronic CRF (e-CRF) screens in the DMI application. Site staff will enter data into the e-CRFs in DMI. CRF 
amendments, if needed, will be submitted to the DCP Protocol Information Office for review and approval prior to 
deployment in DMI.  Approved changes will be programmed into the DMI database by the Consortium Biostatistics and 
Data Management Core. 
 
12.3 
Source Documents 
 
Source documentation will include only those documents containing original forms of data, including clinic charts, shadow 
files, hospital charts, and physician notes.  Data recorded directly on the CRFs designated as source documents (i.e., no 
prior written or electronic record of data) will be considered source data.  All other data recorded on the CRFs will not be 
considered source documentation. 
 
12.4 
Data and Safety Monitoring Plan 

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This study will be monitored on an annual basis by the MD Anderson Cancer Center (MDACC) Data and Safety Monitoring 
Board, the data and safety monitoring board of record for this study. The Data Safety and Monitoring Board (DSMB) reports 
to the President, or his designee, as the on-campus representative of MDACC. It oversees the data and patient safety issues 
for randomized clinical trials that originate at MDACC; that are coordinated or analyzed by MDACC and are not being 
monitored by any other DSMB; or have been designated as requiring DSMB monitoring at the request of the IRB, the CRC, 
or institution. The primary objectives of the DSMB are to ensure that patients' rights pertaining to participation in a research 
study are protected, and that patients' interests are prioritized over the interests of the scientific investigation. 
Responsibilities include: 
(a) Review interim analyses of outcome data (prepared by the study statistician or other responsible person at the time points 
defined in the study) approved by the IRB and additional time points as determined by the DSMB, and to recommend, if 
necessary, whether the study needs to be changed or terminated based on these analyses;  
(b) Determine whether, and to whom, outcome results should be released prior to the reporting of study results;  
(c) Review interim toxicity data and efficacy of treatment;  
(d) Review major research modifications proposed by the investigator or appropriate study committee prior to 
implementation (e.g., termination, dropping an arm based on toxicity results from the study or results of other studies, 
increasing target sample size). 
 
12.5 
Sponsor or FDA Monitoring 
 
The NCI, DCP (or their designee), pharmaceutical collaborator (or their designee), or FDA may monitor/audit various 
aspects of the study. These monitors will be given access to facilities, databases, supplies and records to review and verify 
data pertinent to the study.  
 
12.6 
Record Retention 
 
Clinical records for all participants, including CRFs, all source documentation (containing evidence to study eligibility, 
history and physical findings, laboratory data, results of consultations, etc.), as well as IRB records and other regulatory 
documentation will be retained by the Investigator in a secure storage facility in compliance with Health Insurance 
Portability and Accountability Act (HIPAA), Office of Human Research Protections (OHRP), Food and Drug 
Administration (FDA) regulations and guidances, and NCI/DCP requirements, unless the standard at the site is more 
stringent. The records for all studies performed under an IND will be maintained, at a minimum, for two years after the 
approval of a New Drug Application (NDA). For NCI/DCP, records will be retained for at least three years after the 
completion of the research. NCI will be notified prior to the planned destruction of any materials. The records should be 
accessible for inspection and copying by authorized persons of the Food and Drug Administration. If the study is done 
outside of the United States, applicable regulatory requirements for the specific country participating in the study also apply. 
 
12.7 
Cooperative Research and Development Agreement (CRADA)/Clinical Trials Agreement (CTA) 
 
The agent(s) supplied by DCP, NCI, used in this protocol, is/are provided to the NCI under a Collaborative Agreement 
(CRADA, CTA) between the Pharmaceutical Company(ies) (hereinafter referred to as Collaborator(s)) and the NCI 
Division of Cancer Prevention. Therefore, the following obligations/guidelines, in addition to the provisions in the 
“Intellectual Property Option to Collaborator@ contained within the terms of award, apply to the use of Agent(s) in this 
study: 
 
12.7.1 Agent(s) may not be used for any purpose outside the scope of this protocol, nor can Agent(s) be transferred or 
licensed to any party not participating in the clinical study. Collaborator(s) data for Agent(s) are confidential and proprietary 
to Collaborator(s) and shall be maintained as such by the investigators. The protocol documents for studies utilizing 
investigational agents contain confidential information and should not be shared or distributed without the permission of 

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the NCI. If a patient participating on the study or participant’s family member requests a copy of this protocol, the individual 
should sign a confidentiality agreement. A suitable model agreement can be downloaded from the DCP website. 
 
12.7.2 For a clinical protocol where there is an Investigational Agent used in combination with (an) other investigational 
Agent(s), each the subject of different collaborative agreements, the access to and use of data by each Collaborator shall be 
as follows (data pertaining to such combination use shall hereinafter be referred to as "Multi-party Data”). 
 
12.7.3 NCI must provide all Collaborators with prior written notice regarding the existence and nature of any agreements 
governing their collaboration with NIH, the design of the proposed combination protocol, and the existence of any 
obligations that would tend to restrict NCI's participation in the proposed combination protocol. 
 
12.7.4 Each Collaborator shall agree to permit use of the Multi-Party Data from the clinical trial by any other Collaborator 
solely to the extent necessary to allow said other Collaborator to develop, obtain regulatory approval, or commercialize its 
own investigational agent. 
 
12.7.5 Any Collaborator having the right to use the Multi-Party Data from these trials must agree in writing prior to the 
commencement of the trials that it will use the Multi-Party Data solely for development, regulatory approval, and 
commercialization of its own investigational agent. 
 
12.7.6 Clinical Trial Data and Results and Raw Data developed under a collaborative agreement will be made available 
exclusively to Collaborator(s), the NCI, and the FDA, as appropriate. All data made available will comply with HIPAA 
regulations. 
 
12.7.7 When a Collaborator wishes to initiate a data request, the request should first be sent to the NCI, who will then 
notify the appropriate investigators of Collaborator's wish to contact them. 
 
12.7.8 Any manuscripts reporting the results of this clinical trial must be provided to DCP for immediate delivery to 
Collaborator(s) for advisory review and comment prior to submission for publication. Collaborator(s) will have 30 days (or 
as specified in the CTA) from the date of receipt for review. Collaborator shall have the right to request that publication be 
delayed for up to an additional 30 days in order to ensure that Collaborator’s confidential and proprietary data, in addition 
to Collaborator(s)’s intellectual property rights, are protected. Copies of abstracts must be provided to DCP for forwarding 
to Collaborator(s) for courtesy review as soon as possible and preferably at least three days prior to submission, but in any 
case, prior to presentation at the meeting or publication in the proceedings. Press releases and other media presentations 
must also be forwarded to DCP prior to release. Copies of any manuscript, abstract, and/or press release/ media presentation 
should be sent to the Protocol Information Office at NCI DCP PIO@mail.nih.gov.  
 
 
 
 
The Protocol Information Office will forward manuscripts to the DCP Project Officer for distribution to the Collaborator(s). 
No publication, manuscript or other form of public disclosure shall contain any of Collaborator’s confidential/proprietary 
information. 
 
 
13. 
STATISTICAL CONSIDERATIONS 
 
13.1 
Study Design/Description 
 
This is a randomized pilot study. A total of 60 participants will be randomized 1:1 to one of the two arms, 1) 1-2 doses of 
120 mg denosumab subcutaneously, with Dose #1 given within first 3 days of the menstrual cycle and a subsequent possible 
dose given in 4 weeks or 2) no treatment. Participants will return for risk-reducing salpingo-oophorectomy with or without 
hysterectomy during the luteal phase of the menstrual cycle (Days 14-28). In the treatment arm, it will be during the luteal 
phase of the menstrual cycle after the last dose of denosumab. In the no treatment arm, it will be during the luteal phase of 
the menstrual cycle within 2-8 weeks of starting calcium and vitamin D supplements. For women who take hormonal 

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contraceptive with continuous progesterone (i.e. progestin IUD), the surgery does not need to be timed with menses. At the 
time of surgery, research blood draw and tissue collection will be performed. Assuming a 10% drop-out or unevaluable rate, 
we expect to have 54 evaluable women (27 per arm). With a total number of 54 subjects and assuming a conservative 
estimation of the standard deviation (SD) of 5.0% in Ki67 expression in fallopian tube epithelium (FTE), we will have 82% 
power to detect a 4.0% difference (or effect size of 0.8) in Ki67 proliferation index between the denosumab and no treatment 
groups by applying a two-sided 2-sample t-test at a 0.05 significance level. The sample size calculation is performed using 
nQuery + nTerim 4.0. 
 
13.2 
Randomization/Stratification  
 
In order to keep at minimum the imbalance in treatments, a stratified randomization technique will be applied considering 
the most relevant prognostic factors, BRCA1/BRCA2 mutation status and use of hormonal contraceptives within 3 months 
of registration. We will stratify the randomization by BRCA mutation status (BRCA1 vs. BRCA2) and use of hormonal 
contraceptives within the past 3 months (Yes/No) using the random permutated block design with the block sizes of 2-4. 
On the designated case report forms, we will also document prior hormonal contraceptive use, duration of use, date of last 
use, and prior bilateral tubal ligation. If the participant had a recent pregnancy within the past 6 months, we will also 
document date of pregnancy termination, date of delivery, and date of weaning from breast-feeding (if applicable). 
 
13.3 
Accrual and Feasibility 
 
We plan to randomize 60 eligible women (30 per arm) over 16 months at an accrual rate of 3-4 participants per month across 
all five sites. Assuming a 10% drop-out or unevaluable rate, we expect to have 54 evaluable participants (27 per arm). 
 
13.4 
Primary Objective, Endpoint(s), Analysis Plan 
 
Primary endpoint 
The primary objective of this study is to evaluate Ki67 proliferation index (IHC) in the fimbrial epithelial cells in the 
denosumab arm compared to no treatment arm based on the intent-to-treat principle. The primary endpoint is Ki67 
expression (IHC) in the fimbrial specimen obtained at the time of risk-reducing surgery. The intent-to-treat population is 
defined as all participants who are randomized and have Ki67 expression (IHC) measured in the fimbrial specimen after 
treatment. The primary analysis will be performed per randomization, regardless of the compliance of each participant. 
 
Analysis plan  
We will present mean, standard deviation, median and range of Ki67 expression at the time of surgery, by arms, regardless 
of compliance. In order to evaluate the difference of Ki67 expression between the two arms, 2-sample t-test will be 
considered. The data will be tested for all underlying assumptions (e.g., normality, homoscedasticity) of the model to ensure 
that they are all met. In case there is a violation of any of these assumptions, data transformation (log, square-root, etc.) or 
non-parametric tests such as Wilcoxon rank sum test may be considered. A linear regression may be considered to evaluate 
the difference of Ki-67 between the two groups, adjusting for other important covariates such as participant age, race, BRCA 
mutation status, etc. The compliance will be included as one of the covariates in the linear regression. A sensitivity analysis 
will be conducted excluding participants whose surgery did not occur during the luteal phase.  
 
Power analysis 
A total of 60 eligible women (30 per arm) will be enrolled and randomized 1:1 to the denosumab or no treatment arms. 
Assuming a 10% drop-out or unevaluable rate, we expect to have 54 evaluable women (27 per arm). With a total number 
of 54 subjects and assuming a conservative estimation of the standard deviation (SD) of 5.0% in Ki67 expression in FTE, 
we will have 82% power to detect a 4.0% difference (or effect size of 0.8) in Ki67 proliferation index between the 
denosumab and no treatment groups by applying a two-sided 2-sample t-test at a 0.05 significance level. The baseline Ki67 
in the fallopian tube epithelium in premenopausal non-BRCA1/2 mutation carriers is 1.92% with a standard deviation of 
2.4%.53 George et al. report that proliferation rate in fallopian tube epithelium does not vary with BRCA mutation status52, 
while others have reported that BRCA mutation carriers have increased proliferation rate in fallopian tube epithelium.48,49 

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We assumed a conservative standard deviation of 5.0% because a standard deviation of 2.4% in Ki67 proliferation index is 
estimated from normal fallopian tube epithelium.53 
 
13.4.1 Supplementary Bayesian Analysis and Interim Futility Monitoring 
 
Based on the same assumptions described above, under the Bayesian framework, we will claim denosumab promising if at 
the end of the study, there is a posterior probability of more than 97% that the average Ki67 in fallopian tube epithelium 
(FTE) in subjects treated with denosumab is lower than that in subjects with no treatment, i.e., Prob(µdenosumab<µcontrol| 
data)>97%, where µdenosumab denotes the average Ki67 in subjects treated with denosumab and µcontrol for subjects with no 
treatment.   Per our preliminary data, we make a conservative estimation that the standard deviation (SD) of Ki67 is 5.0%.  
Under the alternative hypothesis that the mean Ki67 in the denosumab arm is 4.0% lower compared to the mean Ki67 in 
the no treatment arm, we will have an 82% chance to claim Prob(µdenosumab<µcontrol| data)>97% with 27 subjects per arm.  For 
example, the mean KI67 of 10.0% in the no treatment arm vs 6.0% in the denosumab arm corresponds to a 4.0% lower 
mean Ki67 in the denosumab arm.  On the other hand, under the null hypothesis, we will have only 2.8% chance to claim 
that the denosumab is promising when there is no difference between the two arms.  The calculation was performed by 
simulating 1,000 trials assuming a non-informative Jeffreys prior for Ki67.   
 
Interim futility analysis: 
We will implement an interim futility analysis after 10 subjects, 5 in each arm, have been treated and Ki67 been evaluated. 
We will apply a Bayesian predictive probability method to evaluate whether or not the interim result is promising enough 
to move forward.  We will suspend accrual if the predictive probability of claiming a promising trial is less than 25%, i.e., 
Prob (Prob(µdenosumab<µcontrol| interim data)>97% | future data )<25%.  With this rule, we will have more than 70% chance to 
suspend the trial early if there is actually no difference between the two arms under the null hypothesis.  Under the alternative 
hypothesis, we will have <5% chance to suspend the trial early if the mean Ki67 is 4.0% lower in denosumab arm compared 
to the mean Ki67 in the no treatment arm. The calculation was done by simulating 100 trials assuming a non-informative 
Jeffreys prior for Ki67.  Upon the suspension of accrual, the interim results and all the study outcomes will be reviewed by 
the Data Safety and Monitoring Board and experts from the National Cancer Institute to determine whether the study should 
be stopped early or not.   If the interim futility analysis does not trigger the suspension of accrual, the study enrollment will 
continue.     
 
Bayesian Analysis plan  
We will present mean, standard deviation, median and range of Ki67 expression at the time of surgery, by arms, regardless 
of compliance. In order to evaluate the difference of Ki67 expression between the two arms, Bayesian posterior probability 
of Prob(µdenosumab<µcontrol| data) will be estimated. The data will be tested for normality. In case there is a violation of 
normality assumptions, data transformation (log, square-root, etc.) will be used before the Bayesian posterior probability is 
estimated. A Bayesian linear regression may be considered to evaluate the difference of Ki-67 between the two arms, 
adjusting for other important covariates such as participant age, race, BRCA mutation status, etc. The compliance will be 
included as one of the covariates in the linear regression. A sensitivity analysis will be conducted excluding participants 
whose surgery did not occur during the luteal phase.  
 
13.5 
Secondary Objectives, Endpoints, Analysis Plans 
 
We will attempt to understand the mechanism of action of denosumab on the primary endpoint of the study. More 
specifically, we will assess the effects of denosumab compared to no treatment on the secondary endpoint biomarkers.  
 
The secondary objectives are:  
• 
Evaluating Ki67 proliferation index (IHC) in ovarian surface epithelium and endometrium (if also undergoing 
hysterectomy, N=~12) in the denosumab arm compared to no treatment arm 
• 
Evaluating other tissue-based biomarkers in the fimbrial end of the fallopian tube, ovarian surface epithelium, and 
endometrium (if also undergoing hysterectomy) in both arms. 
o Apoptosis with cleaved caspase-3 (IHC) 

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o RANK/RANKL expression (IHC) 
o ER/PR expression (IHC) 
o CD44 and p53 expression (IHC) 
o STAT3 and pSTAT3 expression (IHC) 
• 
Analyzing gene expression profiling in the fimbrial end of the fallopian tube and ovarian surface epithelium in the 
denosumab arm compared to the no treatment arm 
• 
Evaluating changes in serum biomarkers at baseline (pre-treatment) and time of surgery (post-treatment): 
• 
Progesterone 
• 
Estradiol 
• 
Denosumab drug levels  
• 
Evaluating serial serum C-terminal telopeptide (CTX) levels at the following time points in both arms: 
• 
Baseline (pre-treatment) 
• 
Time of surgery 
• 
6 months after start of intervention 
• 
12 months after start of intervention  
• 
Monitor safety and adverse effects of denosumab 
 
Analysis plan 
All available data will be summarized and analyzed for the secondary analysis. Participant demographic characteristics will 
be summarized using descriptive statistics. Values of tissue-based and serum biomarkers measurements such as tissue Ki67 
proliferation index, serum progesterone, etc., which are continuous variables, will be summarized by descriptive statistics 
including mean, standard deviation, median and range. Categorical variables, such as adverse events, will be summarized 
by frequency and proportion. In order to evaluate any change in serum biomarkers from baseline to after intervention 
between denosumab and no treatment arm, 2-sample t-test may be applied after testing the data for all the underlying 
assumptions of the model (i.e., normality, homoscedasticity, etc.); in case there is any violation, proper transformation (log, 
square root, etc.) will be applied to the data. Non-parametric tests such as Wilcoxon rank sum test may be used instead. 
Furthermore, to investigate the overall changes in serum biomarkers, a linear mixed model that accommodates intra-
participant correlation due to repeated measurements will be utilized adjusting for any potential covariates. 
 
For tissue biomarkers, linear regression models will be employed to investigate the association of treatment while adjusting 
for possible confounders (i.e., age, race, etc.). Normality, homoscedasticity, independence of errors, and lack of 
multicollinearity in the covariates will be evaluated; if needed, proper transformation will be considered.   
 
For gene expression profiling analysis, nSolver Analysis Software™ (nanoString Technologies, WA) will be used. nSolver 
performs data normalization using a positive control series comprised of External RNA Control Consortium sequences as 
well as content normalization probes chosen based on abundance of expression and coefficient of variation to ensure 
housekeeping genes that display robust expression and minimal inter-sample variability. Geometric mean is used for 
calculation of normalization factors.  Student’s t test is used to calculate differential expression. 
 
Other statistical methods may be used when appropriate. 
 
13.6 
Reporting and Exclusions 
 
The primary analysis will include all women who undergo surgery and have available Ki67 expression in fimbria specimen. 
Participants who do not have Ki67 expression in fimbria specimen due to technical failure (i.e., inadequate tissue sample) 
will be considered unevaluable. All participants will be evaluable for adverse events as long as they receive at least 1 dose 
of denosumab treatment (active arm only). Participants who do not undergo surgery will be replaced with additional 
participants enrolled. Every effort will be made to minimize missing data. When it happens, we will build regression models 
to predict the missing data and apply multiple imputations to fill in the missing data for analysis. Sensitivity analysis will 
be performed with and without multiple imputations. Statistical inference will be drawn with the caveat of the imputed data. 
 

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13.7 
Evaluation of Toxicity 
 
All participants who receive study agent will be included in the toxicity evaluation.  
 
The grade, attribution, onset and resolve date of all toxicities will be recorded and summarized for each arm and reported 
to the DCP monthly and to the MDACC DSMB annually as well as at the end of the study.  
 
13.8 
Evaluation of Response 
 
All participants included in the study must be assessed for response to intervention, even if there are major protocol 
deviations or if they are ineligible.  
 
All of the participants who met the eligibility criteria will be included in the main analysis. All conclusions regarding 
efficacy will be based on all eligible participants. 
 
13.9 
Interim Analysis 
 
An interim analysis will be planned after the first 10 participants are enrolled on the trial, as described above in Section 
13.4.1.  
 
13.10 Ancillary Studies 
 
No ancillary studies are planned. 
 
 
14. 
ETHICAL AND REGULATORY CONSIDERATIONS 
 
14.1 
Form FDA 1572 
 
Prior to initiating this study, the Protocol Lead Investigator at the Lead or Participating Organization(s) will provide a signed 
Form FDA 1572 stating that the study will be conducted in compliance with regulations for clinical investigations and 
listing the investigators, at each site that will participate in the protocol. All personnel directly involved in the performance 
of procedures required by the protocol and the collection of data should be listed on Form FDA 1572. 
 
 
 
 
14.2 
Other Required Documents 
 
14.2.1 Current (within two years) CV or biosketch for all study personnel listed on the Form FDA 1572 and Delegation of 
Tasks form for the Lead Organization and all Participating Organizations.  
 
14.2.2 Current medical licenses (where applicable) for all study personnel listed on Form FDA 1572 and Delegation of 
Tasks form for the Lead Organization and all Participating Organizations. 
 
▪ 
Lab certification (e.g., CLIA, CAP) and lab normal ranges for all labs listed on Form FDA 1572 for the Lead 
Organization and all Participating Organizations. 
 
▪ 
Documentation of training in “Protection of Human Research Subjects” for all study personnel listed on the 
FDA Form 1572 and Delegation of Tasks form for the Lead Organization and all Participating Organizations. 
 

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▪ 
Documentation of Federalwide Assurance (FWA) number for the Lead Organization and all Participating 
Organizations. 
 
▪ 
Signed Investigator’s Brochure/Package Insert acknowledgement form 
 
▪ 
Delegation of Tasks form for the Lead Organization and all Participating Organizations signed by the Principal 
Investigator for each site and initialed by all study personnel listed on the form 
 
▪ 
Signed and dated NCI, DCP Financial Disclosure Form for all study personnel listed on Form FDA 1572 for 
the Lead Organization and all Participating Organizations 
 
14.3 
Institutional Review Board Approval 
 
Prior to initiating the study and receiving agent, the Investigators at the Lead Organization and the Participating 
Organization(s) must obtain written approval to conduct the study from the appropriate IRB. Should changes to the study 
become necessary, protocol amendments will be submitted to the DCP PIO according to DCP Amendment Guidelines. The 
DCP-approved amended protocol must be approved by the IRB prior to implementation 
 
14.4 
Informed Consent 
 
All potential study participants will be given a copy of the IRB-approved Informed Consent to review. The investigator will 
explain all aspects of the study in lay language and answer all questions regarding the study. If the participant decides to 
participate in the study, he/she will be asked to sign and date the Informed Consent document. The study agent(s) will not 
be released to a participant who has not signed the Informed Consent document. Subjects who refuse to participate or who 
withdraw from the study will be treated without prejudice. 
 
Participants must be provided the option to allow the use of blood samples, other body fluids, and tissues obtained during 
testing, operative procedures, or other standard medical practices for further research purposes. If applicable, statement of 
this option may be included within the informed consent document or may be provided as an addendum to the consent. A 
Model Consent Form for Use of Tissue for Research is available through a link in the DCP website. 
 
Prior to study initiation, the informed consent document must be reviewed and approved by NCI, DCP, the Consortium 
Lead Organization, and the IRB at each Organization at which the protocol will be implemented. Any subsequent changes 
to the informed consent must be approved by NCI, DCP, the Consortium Lead Organization’s IRB, and then submitted to 
each organization’s IRB for approval prior to initiation. 
 
14.5 
Submission of Regulatory Documents 
 
All regulatory documents are collected by the Consortia Lead Organization and reviewed for completeness and accuracy. 
Once the Consortia Lead Organization has received complete and accurate documents from a participating organization, the 
Consortium Lead Organization will forward the regulatory documents to DCP’s Regulatory Contractor: 
 
 
Paper Document/CD-ROM Submissions: 
 
Regulatory Affairs Department 
 
CCS Associates, Inc. 
 
2001 Gateway Place, Suite 350 West 
 
San Jose, CA 95110 
 
Phone: 650-691-4400 
 
Fax: 650-691-4410 
 
 
E-mail Submissions: 

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regulatory@ccsainc.com 
 
Regulatory documents that do not require an original signature may be sent electronically to the Consortium Lead 
Organization for review, which will then be electronically forwarded to DCP’s Regulatory Contractor. 
 
14.6 
Other 
 
This trial will be conducted in compliance with the protocol, Good Clinical Practice (GCP), and the applicable regulatory 
requirements. 
 
 
15. 
FINANCING, EXPENSES, AND/OR INSURANCE 
 
Participants will not be responsible for non-standard of care costs of this study. Study agent will be provided at no cost to 
the participant. If, as a result of participation in this study, an individual experiences injury from known or unknown risks 
of the research procedures as described in the informed consent, immediate medical care and treatment, including 
hospitalization, if necessary, will be available.  No monetary compensation is available for the costs of medical treatment 
for an injury, thus, the participant will be responsible for the costs of such medical treatment, either directly or through their 
medical insurance and/or other forms of medical coverage. Participants will be compensated $30 for time and travel or the 
amount needed to cover parking expenses at the time of the first visit during which eligibility will be determined. In the 
Denosumab group, participants will also be reimbursed $30 for their time and travel or the amount needed to cover parking 
expenses at the time of each visit with a denosumab injection. In the control group participants will be compensated $30 for 
time and travel or the amount needed to cover parking expenses at the time of their clinic visit during which vitamin D and 
calcium will be dispensed. 
 
 
 
 

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proliferation and carcinogenesis. Nature. 2010;468(7320):103-107. 
42. 
Stopeck AT, Lipton A, Body JJ, et al. Denosumab compared with zoledronic acid for the treatment of bone 
metastases in patients with advanced breast cancer: a randomized, double-blind study. J Clin Oncol. 
2010;28(35):5132-5139. 
43. 
Fizazi K, Carducci M, Smith M, et al. Denosumab versus zoledronic acid for treatment of bone metastases in men 
with castration-resistant prostate cancer: a randomised, double-blind study. Lancet. 2011;377(9768):813-822. 
44. 
Cummings SR, San Martin J, McClung MR, et al. Denosumab for prevention of fractures in postmenopausal 
women with osteoporosis. The New England journal of medicine. 2009;361(8):756-765. 
45. 
Bone HG, Bolognese MA, Yuen CK, et al. Effects of denosumab treatment and discontinuation on bone mineral 
density and bone turnover markers in postmenopausal women with low bone mass. The Journal of clinical 
endocrinology and metabolism. 2011;96(4):972-980. 
46. 
Anastasilakis AD, Polyzos SA, Makras P, Aubry-Rozier B, Kaouri S, Lamy O. Clinical Features of 24 Patients 
With Rebound-Associated Vertebral Fractures After Denosumab Discontinuation: Systematic Review and 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–53– 
08/31/2016 
Additional Cases. J Bone Miner Res. 2017;32(6):1291-1296. 
47. 
Sigl V, Owusu-Boaitey K, Joshi PA, et al. RANKL/RANK control Brca1 mutation-driven mammary tumors. Cell 
Res. 2016;26(7):761-774. 
48. 
Gnant M, Pfeiler G, Dubsky PC, et al. The impact of adjuvant denosumab on disease-free survival: results from 
3425 postmenopausal patients of the ABCSG-18 trial. Presented at: 2015 San Antonio Breast Cancer Symposium; 
San Antonio, TX; December 8-12, 2015. Abstract S2-02.. 
49. 
Tiourin E, Velasco VS, Rosales MA, Sullivan PS, Janzen DM, Memarzadeh S. Tubal Ligation Induces 
Quiescence in the Epithelia of the Fallopian Tube Fimbria. Reprod Sci. 2015;22(10):1262-1271. 
50. 
Norquist BM, Garcia RL, Allison KH, et al. The molecular pathogenesis of hereditary ovarian carcinoma: 
alterations in the tubal epithelium of women with BRCA1 and BRCA2 mutations. Cancer. 2010;116(22):5261-
5271. 
51. 
Piek JM, van Diest PJ, Zweemer RP, et al. Dysplastic changes in prophylactically removed Fallopian tubes of 
women predisposed to developing ovarian cancer. J Pathol. 2001;195(4):451-456. 
52. 
George SH, Milea A, Shaw PA. Proliferation in the normal FTE is a hallmark of the follicular phase, not BRCA 
mutation status. Clinical cancer research : an official journal of the American Association for Cancer Research. 
2012;18(22):6199-6207. 
53. 
Kuhn E, Kurman RJ, Sehdev AS, Shih Ie M. Ki-67 labeling index as an adjunct in the diagnosis of serous tubal 
intraepithelial carcinoma. Int J Gynecol Pathol. 2012;31(5):416-422. 
54. 
Amso NN, Crow J, Shaw RW. Comparative immunohistochemical study of oestrogen and progesterone receptors 
in the fallopian tube and uterus at different stages of the menstrual cycle and the menopause. Hum Reprod. 
1994;9(6):1027-1037. 
55. 
Garson K, Vanderhyden BC. Epithelial ovarian cancer stem cells: underlying complexity of a simple paradigm. 
Reproduction. 2015;149(2):R59-70. 
56. 
Paik DY, Janzen DM, Schafenacker AM, et al. Stem-like epithelial cells are concentrated in the distal end of the 
fallopian tube: a site for injury and serous cancer initiation. Stem Cells. 2012;30(11):2487-2497. 
57. 
Cancer Genome Atlas Research N. Integrated genomic analyses of ovarian carcinoma. Nature. 
2011;474(7353):609-615. 
58. 
George SH, Shaw P. BRCA and Early Events in the Development of Serous Ovarian Cancer. Front Oncol. 
2014;4:5. 
59. 
Ahmed AA, Etemadmoghadam D, Temple J, et al. Driver mutations in TP53 are ubiquitous in high grade serous 
carcinoma of the ovary. J Pathol. 2010;221(1):49-56. 
60. 
Cass I, Walts AE, Barbuto D, Lester J, Karlan B. A cautious view of putative precursors of serous carcinomas in 
the fallopian tubes of BRCA mutation carriers. Gynecol Oncol. 2014;134(3):492-497. 
61. 
Snyder M, Huang XY, Zhang JJ. Identification of novel direct Stat3 target genes for control of growth and 
differentiation. The Journal of biological chemistry. 2008;283(7):3791-3798. 
62. 
George SH, Greenaway J, Milea A, et al. Identification of abrogated pathways in fallopian tube epithelium from 
BRCA1 mutation carriers. J Pathol. 2011;225(1):106-117. 
63. 
Body JJ, Lipton A, Gralow J, et al. Effects of denosumab in patients with bone metastases with and without 
previous bisphosphonate exposure. J Bone Miner Res. 2010;25(3):440-446. 
64. 
Peris P, Alvarez L, Monegal A, et al. Biochemical markers of bone turnover after surgical menopause and 
hormone replacement therapy. Bone. 1999;25(3):349-353. 
65. 
Inc. A. Xgeva (denosumab) injection, for subcutaneous use. Full prescribing information. Revised 03/2016 
http://pi.amgen.com/~/media/amgen/repositorysites/pi-amgen-com/xgeva/xgeva pi.ashx. 2016. 
66. 
Medeiros F, Muto MG, Lee Y, et al. The tubal fimbria is a preferred site for early adenocarcinoma in women with 
familial ovarian cancer syndrome. Am J Surg Pathol. 2006;30(2):230-236. 
67. 
Cutter GR, Burke GL, Dyer AR, et al. Cardiovascular risk factors in young adults. The CARDIA baseline 
monograph. Control Clin Trials. 1991;12(1 Suppl):1S-77S. 
68. 
Gehi A, Haas D, Pipkin S, Whooley MA. Depression and medication adherence in outpatients with coronary heart 
disease: findings from the Heart and Soul Study. Arch Intern Med. 2005;165(21):2508-2513. 
 
 
 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
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APPENDIX A 
 
Performance Status Criteria 
 
ECOG Performance Status Scale 
Grade 
Descriptions 
0 
Normal activity. Fully active, able to carry on all pre-
disease performance without restriction. 
1 
Symptoms, but ambulatory. Restricted in physically 
strenuous activity, but ambulatory and able to carry out 
work of a light or sedentary nature (e.g., light 
housework, office work). 
2 
In bed <50% of the time. Ambulatory and capable of 
all self-care, but unable to carry out any work activities. 
Up and about more than 50% of waking hours. 
3 
In bed >50% of the time. Capable of only limited self-
care, confined to bed or chair more than 50% of waking 
hours. 
4 
100% bedridden. Completely disabled. Cannot carry 
on any self-care. Totally confined to bed or chair. 
5 
Dead. 
 
 
 
Karnofsky Performance Scale 
Percent 
Description 
100 
Normal, no complaints, no evidence of disease. 
90 
Able to carry on normal activity; minor signs or 
symptoms of disease. 
80 
Normal activity with effort; some signs or symptoms 
of disease. 
70 
Cares for self, unable to carry on normal activity or to 
do active work. 
60 
Requires occasional assistance, but is able to care for 
most of his/her needs. 
50 
Requires considerable assistance and frequent medical 
care. 
40 
Disabled, requires special care and assistance. 
30 
Severely disabled, hospitalization indicated. Death not 
imminent. 
20 
Very sick, hospitalization indicated. Death not 
imminent. 
10 
Moribund, fatal processes progressing rapidly. 
0 
Dead. 
 
 
 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
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08/31/2016 
APPENDIX B 
 
Alcohol and Tobacco Use Assessment Questionnaires – Baseline 
 
 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–56– 
08/31/2016 
ALCOHOL ASSESSMENT – BASELINE 
 
 
 
 
 
Instructions: 
For the following questions about drinking alcoholic beverages, a drink means a 12 oz. beer, a 5 oz. glass of wine, or 
one and a half ounces of liquor. 
 
1. In your entire life, have you had at least 12 drinks of any kind of alcoholic beverage?  
 
 Yes 
 No (End) 
 Refused (End) 
 Don’t know/Not sure 
 
2. In the past 12 months, on average, how often did you drink any type of alcoholic beverage?  
 
________ (Enter the number of days you drank based on the timeframe checked below.  Enter 0 if you never drank and 
skip to Question 6.)  
 Week  
 Month 
 Year 
 Refused 
 Don’t know/Not sure 
 
3. In the past 12 months, on those days that you drank alcoholic beverages, on average, how many drinks   
did you have per day?  
 
________ (Enter the average number of drinks per day) 
 
 Refused 
 Don’t know/Not sure 
 
4. In the past 12 months, on how many days did you have 5 or more drinks of any alcoholic beverage?  
 
_________ (Enter the number of days you had 5 or more drinks, or enter 0 if none.) 
 
 Refused 
 Don’t know/Not sure 
 
5. Was there ever a time or times in your life when you drank 5 or more drinks of any kind of alcoholic beverage almost 
every day?  
 
 Yes 
 No  
 Refused 
 Don’t know/Not sure 
INSTITUTION CODE 
 
________________ 
PARTICIPANT ID 
 
______________ 
VISIT TYPE 
 
________________ 
VISIT DATE 
(MM/DD/YYYY)  
___ ___ / ___ ___ / ___ ___ ___ ___ 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–57– 
08/31/2016 
 
6. If you do not currently drink alcoholic beverages, but did in the past, how long has it been since 
you last drank regularly?  
 
 Within the past month (0 to 1 month ago) 
 Between 1 and 3 months (1 to 3 months ago) 
 Between 3 and 6 months (3 to 6 months ago) 
 Between 6 and 12 months (6 to 12 months ago) 
 Between 1 and 5 years (1 to 5 years ago) 
 Between 5 and 15 years (5 to 15 years ago) 
 More than 15 years ago  
 Don’t know/Not sure 
 Never drank regularly 
 
7. At the heaviest point, either now or in the past, on the days when you drank, about how many drinks did you drink a 
day on the average?  
 
__________ (Enter the number of drinks a day) 
 Refused 
 Don’t know/Not sure 
 
8. How many years have you been drinking (or did drink) regularly?  
 
______ years 
 Refused 
 Don’t know/Not sure  
 
9. At what age did you begin drinking regularly?  
 
______ years of age 
 Refused 
 Don’t know/Not sure  
 
10. What type(s) of alcohol do you drink? (Mark ALL that apply) 
 
 Wine 
 Liquor 
 Beer 
 Wine cooler 
 
 
Signature of Individual Completing This Form___________________   Date  __ __ / __ __ / __ __ __ __ 
(MM/DD/YYYY) 
Name of Individual Completing This Form (please print) ______________________________________ 
 
 
 
 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–58– 
08/31/2016 
TOBACCO ASSESSMENT – BASELINE 
 
 
Section A. Basic Cigarette Use Information 
 
1. Have you smoked at least 100 cigarettes (5 packs = 100 cigarettes) in your entire life? 
 
Yes  
 
 No → Skip to Section B 
 Don’t know/Not sure → Skip to Section B 
 
2. How old were you when you first smoked a cigarette (even one or two puffs)? 
 
_______ Years old  
 
3. How old were you when you first began smoking cigarettes regularly?   
 
_______ Years old  
  Check here if you have never smoked cigarettes regularly. 
 
4. How many total years have you smoked (or did you smoke) cigarettes? Do not count any time you may have stayed off 
cigarettes. 
 
______ Years (If you smoked less than one year, write “1.”)  
 
5. On average when you have smoked, about how many cigarettes do you (or did you) smoke a day? (A pack usually has 
20 cigarettes in it).  
 
_____ Number of cigarettes per day 
 
6. Do you NOW smoke cigarettes?  
 
 Everyday 
 Some days 
 Not at all → Skip to question 8 
 
7.  How soon after you wake up do you smoke your first cigarette?  
 
  Within 30 minutes 
  After 30 minutes 
 
 
INSTITUTION CODE 
 
________________ 
PARTICIPANT ID 
 
______________ 
VISIT TYPE 
 
________________ 
VISIT DATE 
(MM/DD/YYYY)  
___ ___ / ___ ___ / ___ ___ ___ ___ 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–59– 
08/31/2016 
 
8. How long has it been since you last smoked a cigarette (even one or two puffs)? 
 
First check which one of the following choices applies to you. Then, if applicable, write a number on the line 
for how many days, weeks, months, or years it has been since your last cigarette. 
 
 I smoked a cigarette today (at least one puff) 
 1-7 days → Number of days since last cigarette  ________ 
 Less than 1 month → Number of weeks since last cigarette  _________ 
 Less than 1 year → Number of months since last cigarette  __________ 
 More than 1 year → Number of years since last cigarette  ___________ 
 Don’t know/Don’t remember 
 
Section B. Use of Other Forms of Tobacco 
 
9.  Have you ever used other forms of tobacco, not including cigarettes? 
  
 Yes  
 No → Skip to Section C 
 
10. How often do you/did you use other forms of tobacco?  
 
 Every day → Number of times per day  ________ 
 Some days → Number of days _______ per 
 Week 
 Month 
Year 
 
11. Which of the following products have you ever used regularly? 
 Check all that apply  
 
 Cigarettes 
 E-cigarettes or other electronic nicotine delivery system 
 Traditional cigars, cigarillos or filtered cigars 
 Pipes 
 Hookah 
 Clove cigarettes or kreteks 
 Bidis  
 Smokeless tobacco, like dip, chew, or snuff 
 Snus 
 Paan with tobacco, gutka, zarda, khaini 
 Other, Please specify:___________________________ 
 
 

DCP Protocol Number: MDA2017-09-03 
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DCP Protocol Template Version 8.5 
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12. If you do not currently use other forms of tobacco, but did in the past, how long has it been since you last used other 
forms of tobacco regularly?  
 
 Within the past month (0 to 1 month ago) 
 Between 1 and 3 months (1 to 3 months ago) 
 Between 3 and 6 months (3 to 6 months ago) 
 Between 6 and 12 months (6 to 12 months ago) 
 Between 1 and 5 years (1 to 5 years ago) 
 Between 5 and 15 years (5 to 15 years ago) 
 More than 15 years ago 
 Don’t know/Not sure 
 Never used other forms of tobacco regularly 
 
Section C. Second-Hand Smoke Exposure 
 
13. Are you currently living with a smoker?   
 
Yes 
 
 No  
 
14. In the past 30 days, have you lived in a place where other people smoked cigarettes indoors?  
 
Yes 
 
 No  
 
15. In the past 30 days, have you worked in a place where other people smoked cigarettes indoors? 
 
Yes 
 
 No  
 
16. Thinking of all your childhood and adult years, have you ever lived in a place where other people smoked cigarettes 
indoors? 
 
 Yes 
In total, for about how many years?_______ If less than 1, write “1.”   
 No  
 
17. Thinking of all the years you have worked, have you ever worked in a place where other people smoked cigarettes 
indoors?    
 
Yes 
→ In total, for about how many years?_______ If less than 1, write “1.”    
 No 
 
 
Signature of Individual Completing This Form___________________   Date  __ __ / __ __ / __ __ __ __ 
(MM/DD/YYYY) 
Name of Individual Completing This Form (please print) ______________________________________ 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–61– 
08/31/2016 
APPENDIX C 
 
Alcohol and Tobacco Use Assessment Questionnaires – Month 12 
 
 
 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–62– 
08/31/2016 
ALCOHOL ASSESSMENT – MONTH 12 
 
Instructions: 
 
For the following questions about drinking alcoholic beverages, a drink means a 12 oz. beer, a 5 oz. glass of wine, 
or one and a half ounces of liquor. 
 
1. During the past 30 days, did you drink any alcoholic beverages?  
 
 Yes 
 No (End) 
 Refused (End) 
 Don’t know/Not sure 
 
2. During the past 30 days, how many days per week or per month did you drink any alcoholic beverages, on the average?  
 
________ (Enter number of days you drank based on the timeframe checked below.  Enter 0 if you did not drink.)  
 
 Week  
 Month 
 Refused 
 Don’t know/Not sure 
 
3. On the days when you drank, on average, about how many drinks did you have?  
 
________ (Enter the average number of drinks you had per day.) 
 
 Refused 
 Don’t know/Not sure 
 
4. In the past 30 days, on how many days did you have 5 or more drinks per day?  
 
_____________Number of times 
 
 None  
 Do not know/Not sure 
 
 
Signature of Individual Completing This Form___________________   Date  __ __ / __ __ / __ __ __ __ 
(MM/DD/YYYY) 
Name of Individual Completing This Form (please print) ______________________________________ 
 
 
 
INSTITUTION CODE 
 
________________ 
PARTICIPANT ID 
 
______________ 
VISIT TYPE 
 
________________ 
VISIT DATE 
(MM/DD/YYYY)  
___ ___ / ___ ___ / ___ ___ ___ ___ 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–63– 
08/31/2016 
TOBACCO ASSESSMENT – MONTH 12 
 
 
 
1. Do 
you 
NOW smoke cigarettes?  
 
 Everyday 
 Some days 
 Not at all → Skip to Question 3. 
 
2. On average, when you smoked, about how many cigarettes do you (or did you) smoke a day? (A pack usually has 20 
cigarettes in it).    
 
_____ Number of cigarettes per day 
 
3. How long has it been since you last smoked a cigarette (even one or two puffs)?    
 
First check which one of the following choices applies to you. Then, if applicable, write a number on the line  
for how many days, weeks, months, or years it has been since your last cigarette. 
 
 I smoked a cigarette today (at least one puff) 
 1-7 days → Number of days since last cigarette ________ 
 Less than 1 month → Number of weeks since last cigarette _________ 
 Less than 1 year → Number of months since last cigarette __________ 
 More than 1 year → Number of years since last cigarette ___________ 
 Don’t know/Don’t remember 
 
4. Since your last visit, have you used other forms of tobacco, not including cigarettes?  
 
 Yes 
  No (End) 
 
5. How often do you/did you use other forms of tobacco?  
 
 Every day → Number of times per day ________ 
 Some days → Number of days _______ per 
 Week 
 Month 
Year 
 
 
6. Since your last visit, which of the following products have you used?  Check all that apply 
 
 Cigarettes 
 E-cigarettes or other electronic nicotine delivery system 
 Traditional cigars, cigarillos or filtered cigars 
 Pipes 
 Waterpipe 
 Hookah 
INSTITUTION CODE 
 
________________ 
PARTICIPANT ID 
 
______________ 
VISIT TYPE 
 
________________ 
VISIT DATE 
(MM/DD/YYYY)  
___ ___ / ___ ___ / ___ ___ ___ ___ 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
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 Clove cigarettes or kreteks 
 Bidis  
 Smokeless tobacco, like dip, chew, or snuff 
 Snus 
 Paan with tobacco, gutka, zarda, khaini 
 Other, Specify____________________________________________________________________ 
 
7. If you do not currently use other forms of tobacco, but did in the past, how long has it been since you last used other 
forms of tobacco regularly?  
 
 Within the past month (0 to 1 month ago) 
 Between 1 and 3 months (1 to 3 months ago) 
 Between 3 and 6 months (3 to 6 months ago) 
 Between 6 and 12 months (6 to 12 months ago) 
 Between 1 and 5 years (1 to 5 years ago) 
 Between 5 and 15 years (5 to 15 years ago) 
 More than 15 years ago 
 Don’t know/Not sure 
 Never used other forms of tobacco regularly 
 
The following instructions pertain to questions 8 - 10.  During each of the following time frames, please indicate whether 
you smoked cigarettes every day, some days, or not at all. 
 
8.  During study treatment 
 
 Smoked every day 
 Smoked some days 
 Did not smoke at all 
 Don’t know/not sure 
 Not applicable  
 
9.  After the end of study treatment 
 
 
 Smoked every day 
 Smoked some days 
 Did not smoke at all 
 Don’t know/not sure 
 Not applicable (I have not completed the study treatment) 
 
 
 
 
10.  Since your last visit to this clinic 
 
 
 Smoked every day 
 Smoked some days 
 Did not smoke at all 
 Don’t know/not sure 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–65– 
08/31/2016 
 Not applicable (This is my first visit to this clinic) 
 
 
Signature of Individual Completing This Form___________________   Date  __ __ / __ __ / __ __ __ __ 
(MM/DD/YYYY) 
Name of Individual Completing This Form (please print) ______________________________________ 
 
 
 
 
 
 
 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–66– 
08/31/2016 
APPENDIX D 
 
Resources for tobacco and alcohol quitting 
 
 
 
 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–67– 
08/31/2016 
National and local resources to help with alcohol abuse and 
alcoholism 
NIAAA’s online guide Treatment for Alcohol Problems: Finding and Getting Help is written for individuals, 
and their family and friends, who are looking for options to address alcohol problems. It is intended as a 
resource to understand what treatment choices are available and what to consider when selecting among them. 
https://pubs.niaaa.nih.gov/publications/treatment/treatment.htm 
Other resources: 
National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov  
301–443–3860  
National Institute on Drug Abuse www.nida.nih.gov  
301–443–1124  
National Clearinghouse for Alcohol and Drug Information www.samhsa.gov  
1–800–729–6686  
Substance Abuse Treatment Facility Locator www.findtreatment.samhsa.gov  
1–800–662–HELP  
Alcoholics Anonymous (AA) www.aa.org  
212–870–3400 or check your local phone directory under “Alcoholism”  
Moderation Management www.moderation.org 
212–871–0974  
Secular Organizations for Sobriety www.sossobriety.org  
323–666–4295  
SMART Recovery www.smartrecovery.org  
440–951–5357  
Women for Sobriety www.womenforsobriety.org  
215–536–8026  
Al-Anon Family Groups www.al-anon.alateen.org  
1–888–425–2666 for meetings  
Adult Children of Alcoholics  www.adultchildren.org 
310–534–1815  
 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–68– 
08/31/2016 
National and local resources to help with quitting smoking 
NCI’s Smokefree.gov offers science-driven tools, information, and support that has helped smokers quit. You 
will find state and national resources, free materials, and quitting advice from NCI. 
Smokefree.gov was established by the Tobacco Control Research Branch of NCI, a component of the National 
Institutes of Health, in collaboration with the Centers for Disease Control and Prevention and other 
organizations. 
Publications available from the Smokefree.gov Web site include the following: 
• 
Clearing the Air: Quit Smoking Today for smokers interested in quitting. 
• 
Clear Horizons for smokers over age 50. 
• 
Forever Free™  for smokers who have recently quit. 
• 
Forever Free for Baby and Me™, in English and Spanish, for pregnant smokers who have recently quit. 
• 
Pathways to Freedom: Winning the Fight Against Tobacco for African American smokers. 
NCI’s Smoking Quitline at 1–877–44U–QUIT (1–877–448–7848) offers a wide range of services, including 
individualized counseling, printed information, referrals to other resources, and recorded messages. Smoking 
cessation counselors are available to answer smoking-related questions in English or Spanish, Monday through 
Friday, 8:00 a.m. to 8:00 p.m., Eastern time. Smoking cessation counselors are also available through LiveHelp, 
an online instant messaging service. LiveHelp is available Monday through Friday, 8:00 a.m. to 11:00 p.m., 
Eastern time. 
Your state has a toll-free telephone quitline. Call 1–800–QUIT–NOW (1–800–784–8669) to get one-on-one 
help with quitting, support and coping strategies, and referrals to resources and local cessation programs. The 
toll-free number routes callers to state-run quitlines, which provide free cessation assistance and resource 
information to all tobacco users in the United States. This initiative was created by the Department of Health 
and Human Services. For more information about quitlines, speak to an expert on the Smokefree.gov Web site. 
 
 
 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–69– 
08/31/2016 
 
APPENDIX E 
 
 
Calcium and Vitamin D3 Tablet Information 
 
 
 
INSTRUCTIONS: 
 
1. Please take two 500 mg calcium tablets by mouth daily and one 1000 IU vitamin D3 
tablet by mouth daily. 
2. Tablets should be taken within the same 12-hour window each day. Tablets not taken 
within this window are considered missed doses. 
3. Please do not take an extra tablet to make up for missed or vomited doses. Take your 
next tablet as scheduled. 
4. Tablets may be taken with or without food or water and may be crushed, chewed, or 
dissolved in water. Fasting is not required. 
5. Please take your tablets at home as scheduled on days where you have a clinic visit for 
the study. 
6. Store the calcium and vitamin D3 tablets at home at room temperature and avoid 
extreme heat or cold during transportation from the clinic to home. 
7. You have been provided with 180 days of calcium and vitamin D3 tablets. Do not 
discard any tablets or bottles. 
8. Bring all bottles and unused tablets to your 6-month study appointment. 
 
 
 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 13, Dated 7/24/2020 
 
DCP Protocol Template Version 8.5 
–70– 
08/31/2016 
Assessment of calcium and vitamin D compliance 67,68 
 
The following questions should be asked of the participant and the responses documented in the form below. 
 
Date of compliance check (MM-DD-YYYY): ___________________________ 
 
Study ID: ______________________________________________ 
 
Circle the compliance timepoint:  1 week    1 month   2 month   3 month   4 month   5 month   6 month 
 
 
 
 
 
 
 
At surgery          1 week post-surgery 
 
 
 
 
1) “In the past week [for 1 week assessment] / month [for all other assessments], how often did you take your 
calcium and vitamin D supplements as instructed?”  
o 
All of the time (100%) 
o 
Nearly all of the time (90%) 
o 
Most of the time (75%) 
o 
About half the time (50%) 
o 
Less than half the time (<50%) 
 
Questions 2 and 3 are only asked at 1, 2, 3, 4, 5, and 6 month and 1 week post-surgery calls and at time of surgery 
visit. 
 
2) “In the past month, how often did you forget to take the calcium and vitamin D supplements?”  
o 
Never 
o 
Once in the past month 
o 
2 to 3 times in the past month 
o 
Once per week 
o 
Several times per week 
o 
Nearly every day 
 
3) “In the past month, how often did you decide to skip the calcium and vitamin D supplements?”  
o Never 
o Once in the past month 
o 2 to 3 times in the past month 
o Once per week 
o Several times per week 
o Nearly every day 
 
Staff Signature  _______________________________   Date  __ __ / __ __ / __ __ __ __ 
 
(MM/DD/YYYY) 
Staff Name (please print)  ___________________________________________________ 

DCP Protocol Number: MDA2017-09-03 
Protocol Version 11, Dated 2/14/2020 
 
DCP Protocol Template Version 8.5 
–70– 
08/31/2016 
APPENDIX F 
 
AMGEN Pregnancy Notification Worksheet 
 
AMGEN Lactation Notification Worksheet