Metabolic Parameters and Quality of Life in Women on Neo-/Adjuvant Therapy for Breast Cancer: a Randomized Controlled Trial on the Effectiveness of an Intensive Dietary Intervention
Phase: NA
Conditions: Breast Cancer, Breast Cancer Invasive
Sponsor: Federico II University

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Clinical Study Protocol    
Metabolic Parameters and Quality of Life in Women on Neo-/Adjuvant Therapy 
for Breast Cancer: a Randomized Controlled Trial on the Effectiveness of an 
Intensive Dietary Intervention  
 
Promoter 
Grazia Arpino 
Università degli Studi di Napoli Federico II 
Dipartimento di Medicina Clinica e Chirurgia  
Via Pansini, 5   
80131 Napoli 
 
 
 
Scientific Board 
Sabino De Placido, Federico II University, Naples 
Franco Contaldo, Federico II University, Naples 
Grazia Arpino, Federico II University, Naples 
Mario Giuliano, Federico II University, Naples 
Fabrizio Pasanisi,Federico II University, Naples 
Lidia Santarpia, Federico II University, Naples 
Dario Bruzzese, Federico II University, Naples 
Giuseppe Buono, Federico II University, Naples 
Iolanda Cioffi, Federico II University, Naples 
Marianna Naccarato, Federico II University, Naples 
Maurizio Marra, Federico II University, Naples 
 
 
 
 
 

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1. STUDY BACKGROUND AND RATIONALE  
 
The correlation between breast cancer (BC) and obesity is an intriguing research topic since 1980s. 
As widely described in the literature, (3-10, 12, 13, 15, 17, 18) women on adjuvant therapy for BC, 
are prone to weight gain. On the other hand, weight gain and obesity seem to negatively influence 
BC outcome (1, 2, 9, 11, 12, 14, 16); increased body weight during/after chemo-therapyfor BC 
seems to be related to a higher risk of disease relapse and a lower disease free survival (DFS) and 
overall survival (OS). 
BC adjuvant therapy is also associated with modifications of the patient’s metabolic profile, and in 
particular with dyslipidaemia (reduction in the HDL cholesterol serum concentration and increase in 
total/LDL cholesterol, and triglycerides) (21). High plasma cholesterol levels have been suggested 
to enhance the risk of BC because of its role as a precursor of steroid hormones.  Moreover, in post-
menopause, the oestrogens produced from androgens through the activity of aromatase in the fat 
tissue, are a potent stimulus for mammary carcinogenesis. 
 
2. OBJECTIVES AND ENDPOINTS 
The present trial aims to compare the effectiveness of an “intensive” vs a “standard” nutritional 
intervention on body weight regulation and some metabolic parameters in women on adjuvant 
therapy for BC. 
 
2.1 PRIMARY ENDPOINT 
• To investigate the effects of an intensive nutritional intervention on body weight control 
(defined as weight changes ≤+5% of the initial body weight) at 12 months after the 
beginning of systemic treatment 
 
2.2 SECONDARY ENDPOINTS 
• To evaluate the effects of an intensive nutritional intervention at 6, 12 and 24 months after 
the beginning of systemic treatment on: 
 
- 
Body weight and Body Mass Index (BMI)  
- 
Body composition and Resting Energy Expenditure (REE) 

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- 
Serum metabolic variables 
- 
Quality of life (QoL) 
 
• To evaluate the effects of an intensive nutritional intervention on patient outcome and 
tolerance of systemic treatment: 
 
- 
Chemo-therapy side effects 
- 
Disease free survival (DFS) 
- 
Event free survival (EFS) 
- 
Overall survival (OS) 
 
 
 
3. STUDY DESIGN 
 
The effectiveness of an “intensive” versus “non-intensive” dietary intervention will be assessed in 
120 patients on adjuvant therapy for BC in a prospective, randomized controlled study for a total of 
3 years. The eligibility of participants will be verified according to the inclusion/exclusion criteria 
at the screening visit; therefore, after a detailed explanation of the study protocol, Informed Consent 
will be signed. After the recruitment, subjects will be randomized into an “intensive” (ARM A) and 
“non-intensive” (ARM B) dietary intervention group. After the 6 month treatment period, patients 
will be followed up for the following 18 months.  
 
ARM A: Visits will be set up monthly in order to assess body weight, waist circumference, diet 
compliance (etc...) for all period of the BC adjuvant treatment (6 months). 
 
 
ARM B: Visits will be set up only at the baseline, after 6 months namely at the end .  
 
 
 
 
 
 

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Figure 1. Study Design 
 
This study will be carried out at the Department of Clinical Medicine and Surgery of Federico II 
University in Naples 
On the day first, patients in a fasting condition will reach the Department at 8.30 a.m. by calm mode 
of transportation. On the day before, they will be asked to follow a standardized fasting procedure, 
i.e. abstention from alcohol and hard physical activity. After their arrival, blood samples will be 
taken and then anthropometrics variables, REE, body composition, handgrip and breast size will be 
measured. At the end of all measurements, they will receive a dietary prescription and a specific 
visit schedule, according to their randomization.  
 
5. SELECTION OF PATIENTS 
This study will be carried out in pre- and post-menopausal women with operable stage I-III breast 
cancer, candidate to receive adjuvant/neoadjuvant therapy for BC at the Department of Clinical 
Medicine and Surgery of Federico II University in Naples. Patients will be randomized to the 
treatment with a ratio 1:1, according to an assignment list previously generated by a statistician.  
 
5.1 INCLUSION CRITERIA 
 
• Women ≥18 years old 
• BMI < 30 kg/m2 
• Caucasians 
Random. 
 Nutritional visit and counseling 
 
 Monthly dietary follow up during 
the BC adjuvant therapy (6 
months) and every 3 months  in the 
following 18 months 
 Nutritional visit and counseling 
 
 Dietary follow up  at the end of  the 
BC adjuvant therapy  (6 months) 
and at 12, 18 and 24 months 
Pre and post 
menopausal BC 
patients that are 
going to perform 
adjuvant therapy 
with a BMI < 29.9 

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• Histological diagnosis of invasive breast cancer 
• Starting an adjuvant systemic treatment for breast cancer  
• Available past medical history  
• Informed consent to participate to the study 
 
5.2 EXCLUSION CRITERIA 
 
• Metastatic disease  
• BMI >30 kg/m2 
• Presence of a serious medical condition that could alter food absorption or prognosis 
• Refusal to provide informed consent to participate in the study 
 
6. MEASUREMENT 
 
 
6.1 Tumor characteristics 
 
Histological type, tumour dimension (T), nodal status (N), grading (G), Ki67, estrogen receptor 
status (ER), progesterone receptor status (PgR), c-erbB2 (HER2) evaluation will be collected at 
study entry at basal visit. 
 
6.2 Clinical history  
Past history including weight history, co-morbidities and current medications. Information about breast size 
will be also collected. All these informations will be collected at basal visit. 
 
6.3 Blood sample 
Venous blood sampling for routine biochemistry (fasting glucose, serum insulin concentration, C-
peptide, glycosylated haemoglobin, total cholesterol, HDL cholesterol, LDL cholesterol, 
triglycerides, urea, creatinine, urate, AST, ALT, GGT, ALP, VES, PCR, TSH, FT3, FT4,  vitamin 
D) will be collected at patients enrolment and thereafter every 6 months. 
 

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6.4 Body weight, height and BMI 
Body weight will be measured at each visit. The participants will be weighed dressed in light 
clothing or underwear after emptying the bladder to the nearest 0.05 kg and height using a wall-
mounted stadiometer to the nearest 0.5 cm, then noted in the source data (Seca 709; Seca, Hamburg, 
Germany). The participants’ height should be measured without shoes and only at baseline. BMI 
was calculated as weight (kg) divided by squared of height (m). 
 
6.5  Waist and hip circumference, waist-to-hip ratio  
Waist and hip circumferences will be measured according to the established methods. Waist 
circumference will be taken at the midpoint between the lower margin of the last palpable rib and 
the top of the iliac crest; while hip measurement will be taken around the widest portion of the 
buttocks, using a plastic metric tape. 
The circumference will be measured on subjects without heavy outer garments with all tight 
clothing, including the belt, loosened and with pockets emptied. Subjects should stand with their 
feet close together (no more than 15 cm apart) with their weight equally distributed on each leg. 
Subjects should be asked to breathe normally and at the time of the reading of the measurements 
asked to breath out gently. This will prevent subjects from contracting their muscles or from 
holding their breath.  
 
6.6  Handgrip strength  
Functional assessment of muscle status will be performed by handgrip strength using a 
dynamometer. The participant will be in a standing position, arms at their side, not touching their 
body, keeping the elbow bent slightly. Then, it will be administer the test on the non-dominant hand 
and will be asked the participant to squeeze the dynamometer with as much strength as possible, 
being careful to squeeze only once for each measurement. Three measurements will be made with a 
pause of about 10-20 seconds between each repetition to avoid the effects of muscle fatigue. 
 
6.7 Body composition  
Body composition will be assessed with Bio-impedance analysis (BIA) at 50 kHz (Human Im Plus 
II, DS Medica) at room temperature of 22-25 °C. Measurements will be carried out on the non-

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dominant side of the body in the post-absorptive state, after being in the supine position for 20 
minutes, subjects will void prior to measurements. The measured BIA variables are resistance (R) 
and reactance (Xc); Fat Free Mass (FFM) and Fat Mass (FM) will be estimated using the prediction 
equations developed by Kushner and phase angle (PA). 
6.8 Resting Energy Expenditure  
Resting Energy Expenditure will be measured (MREE) by indirect calorimetry using a canopy 
system (V max29, Sensor Medics, Anaheim, U.S.A.) at an ambient temperature of 23-25 °C. The 
instrument is checked by burning ethanol while oxygen and carbon dioxide analyzers are calibrated 
using nitrogen and standardized gases (mixtures of nitrogen, carbon dioxide and oxygen). Subjects 
will be in the post-absorptive condition (12-14 h fasting), lying down on the bed, in a quiet 
environment. Females of child bearing age are evaluated within 5-10 days from the onset of 
menstrual cycle. After a 15 minutes adaptation period, oxygen consumption and carbon dioxide 
production will be determined for 45 minutes. The inter-day coefficient of variation (as determined 
in six individuals on subsequent days) was less than 3%. Energy expenditure is then calculated with 
the abbreviated Weir’s formula, neglecting protein oxidation. 
 
6.9 Food records  
At baseline, a Food Frequency Questionnaire (FFQ) will assess the habitual food intake of 
participants enrolled in the study; while, the compliance to the prescribed diet, according to the 
study design, will be assessed by 24h recall that will record all meals consumed during 24 h prior to 
the visit. 
In addition, a face-to-face interview with the participants will be performed at baseline and at the 
end of the study by dietitians to assess the adherence to the Mediterranean diet using the validated 
14-item Questionnaire of Mediterranean diet adherence, developed by Martínez-González MA et al. 
2002 (PREDIMED study) (File 1).  
 
6.10 
Physical activity 
Physical activity will be assessed using the self-administered short form of the International 
Physical Activity Questionnaires (IPAQ) that takes into account three specific types of activity such 
as walking, moderate-intensity activities and vigorous intensity activities through simple questions. 
IPAQ is self-administered (File 2). 

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7. TREATMENT 
 
7.1  
Investigational Treatment 
No drug treatment will be administered in this study 
 
7.2  
Dietary Treatment   
7.2.1   Nutritional counseling  
Dietary recommendations will be given by two registered dietitians and will be based on a 
Mediterranean diet, which includes whole cereals, legumes, seeds, blue fish, extra virgin olive oil, 
vegetables, and other Mediterranean seasonal food; taking into account all recommendations 
provided by the World Cancer Research Fund International as well (File 3).   
According to randomization, outpatient visits will be scheduled monthly or half-yearly. 
Dietitians will explain the main goal of the dietary advices in order to balance energy intake and 
promote healthy lifestyle. They will provide information about the dietary changes, the correct 
choice of food pairings, portion control and energy density of food as well as how to manage the 
feeling of hunger; they will illustrate how to understand nutritional labels, select seasonal and 
traditional foods, increase use and variety of typical Mediterranean foods. 
Dietitians will advise patients about the benefit of physical activity, the timing and type of physical 
exercise, the consequences of a sedentary lifestyle. 
 
7.3  
Concomitant Medications 
Patients’ current medications will be collected before study randomization at first visit. The patient 
will inform the investigational site about any new medications she takes after the start of the study 
treatment.  
 
 
 

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8. STUDY SCHEDULE  
X *: only body weight will be assessed monthly during neo-/adjuvant treatment 
 
 
Treatment Phase 
 
 
Visit name 
 
V1 
 
V2 
 
V3 
 
V4 
 
V5 
 
V6 
 
V7 
 
V8 
 
V9 
 
V10 
 
V11 
 
V12 
 
V14 
 
Month 
 
0 
 
1 
 
2 
 
3 
 
4 
 
5 
 
6 
 
9 
 
12 
 
15 
 
18 
 
21 
 
24 
 
Inclusion/Exclusion 
Criteria 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain Informed 
Consent 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient cancer history, 
co-morbidities 
and 
current medications 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tumor 
histology, 
disease staging 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Age, 
menopausal 
status 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weight, height, BMI, 
WC, 
HC, 
WHR, 
handgrip strength 
 
X 
 
X* 
 
X* 
 
X* 
 
X* 
 
X* 
 
X 
 
 
X 
 
 
 
 
 
X 
Laboratory 
assessment 
with 
venous 
blood 
collection 
 
X 
 
 
 
 
 
 
X 
 
 
X 
 
 
 
 
 
X 
 
BIA 
and 
Indirect 
calorimetry 
 
X 
 
 
 
 
 
X 
 
 
X 
 
 
 
 
X 
 
Dietary  questionnaire 
 
X 
 
 
 
X 
 
 
 
X 
 
 
X 
 
 
 
 
 
X 
 
Quality 
of 
life 
assessment 
 
X 
 
 
 
X 
 
 
 
X 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
Nutritional visit: 
 
 
Interventional group 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
Control group 
 
X 
 
 
 
 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X 

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8.1 Study Flow and Visit Schedule 
All of the assessments and indicates with an “X”, the visits when they are performed. All data 
obtained from these assessments must be supported in the patient’s source documentation. Tests, 
procedures and visits should occur on schedule whenever possible, the +/- 14 days window is 
allowed. 
 
 
 
9. DATA COLLECTION AND MANAGEMENT 
 
9.1 Data Confidentiality  
Information about study subjects will be kept confidential and managed under the applicable laws 
and regulations. The data collection system for this study uses built-in security features to encrypt 
all data for transmission in both directions, preventing unauthorized access to confidential 
participant information.  
 
 
10. STATISTICAL METHODS AND DATA ANALYSIS 
 
10.1 STUDY SIZE DEFINITION 
Assuming a percentage of women who experienced a weight changes >+5% of the initial body 
weight after twelve months of adjuvant therapy for BC, equal to 30% and considering as clinically 
relevant that such percentage become equal to 10% or less, a sample size of 60 women for each 
treatment arm will allow to detect such difference, if truly exists, with a power of 80% and a two 
sided significance level equal to 5%. 
 
10.2 STATISTICAL ANALYSIS 
 
In all analyses, a 2-sided significance level of 5% (p-value < 0.05) will be used to determine if the 
difference between the two treatment groups is statistically significant.  No formal test of normality 
will be carried on, but all the statistical assumption will be checked by visual inspection of the 
distribution of the outcome variables. All statistical analyses will be performed using the Statistical 
Platform R (vers. 3.2.3 or next). 

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Demographic and clinical data measured at baseline visit will be analysed using standard 
descriptive statistics and compared between group (without reporting statistical significance) in 
order to assess whether good balance of baseline characteristics was achieved by randomization. 
Frequencies and Percentages of missing data will be also reported. 
Treatment success, defined as weight changes ≤+5% of the initial body weight at 12 months after 
the beginning of systemic treatment, will be evaluated by computing the crude odds ratio, with the 
corresponding 95% Confidence Interval, with respect the treatment group. A logistic regression 
model will be also developed in order to adjust the odds ratio for the baseline weight of patients. 
Longitudinal trajectories of body weight will be analysed using a linear mixed model (LMM) 
approach with random term for both intercept and slope. The fixed effects of the model will include 
the group factor, the time coded continuously (defined as months from baseline) and the interaction 
term group x time. Time of the baseline observation of the outcome variable will be coded as 0. All 
the other comparisons will be based on standard statistical method for comparing numerical and 
categorical factors between two groups.  
 
 
10.3 RANDOMIZATION 
 
Allocation of women to the intervention or control arm will be based on a block randomization 
schema with constant block size of 6. Each block will thus be composed of three codes for the 
treatment arm and three codes for control arm. 
 
 
11.ADMINISTRATIVE FEATURES 
 
 
This is a randomized clinical trial promoted by the Dipartimento di Medicina Clinica, UOC di 
Oncologia Clinica, Università Federico II di Napoli, Italy, which is the not-profit Sponsor.  
This clinical study was designed, shall be implemented and reported in accordance with the ICH 
Harmonized Tripartite Guidelines for Good Clinical Practice, with applicable local regulations 
(including European Directive 2001/20/EC), and with the ethical principles laid down in the 
Declaration of Helsinki. 
Data deriving from this clinical trial are intended only for scientific and educational purposes, 
which include presentation and scientific meetings, congresses and symposia and/or publication in 
scientific journals. These data are the property of the Dipartimento di Medicina Clinica, UOC di 

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Oncologia Clinica, Università Federico II di Napoli, Italy, which share it with all participating 
researchers.  
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