A Randomized Pilot Study to Evaluate the Effects of a Short Course of Metformin Versus No Therapy in the Period Prior to Hysterectomy for Grade 1-2 Adenocarcinoma of the Endometrium in Obese Non-Diabetic Women
Phase: PHASE2
Conditions: Adenocarcinoma of the Endometrium
Sponsor: University of Arkansas

Official Title: A Randomized Pilot Study to Evaluate the Effects of a Short Course of Metformin versus No 
Therapy in the Period Prior to Hysterectomy for Grade 1‐2 Adenocarcinoma of the Endometrium in 
Obese Non‐Diabetic Women 
 
Protocol, v10 dated 5/24/2016 
 

 
 
 
A Randomized Pilot Study to Evaluate the Effects of a Short Course of 
Metformin versus No Therapy in the Period Prior to Hysterectomy for 
Grade 1-2 Adenocarcinoma of the Endometrium in Obese Non-
Diabetic Women 
 
 
 
 
 
 
 
 
 
 
 
 
Principal Investigator: Alexander Burnett, MD 
Sub-Investigators: Matthew Quick, MD, Kristen Zorn, MD, Rosalia C. M. Simmen, PhD, 
and Frank A. Simmen, PhD 
Statistician: Eric R. Siegel, MS 
Medical Monitor: Sanjay Maraboyina, MD 
 
 
 
 
 
 
Version 10 
5.24.2016 
IRB #138647 
 
 
 

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Table of Contents 
 
Table of Contents ..................................................................................................... 2 
Abbreviations ............................................................................................................ 3 
Study Schema  ......................................................................................................... 5 
Study Summary  ....................................................................................................... 5 
Protocol Summary  ................................................................................................... 6 
Background and Rationale ........................................................................................ 6 
Trial Objectives ......................................................................................................... 8 
Trial Design .............................................................................................................. 9 
Study Population .....................................................................................................13 
Feasibility of Study Population Recruitment .............................................................14 
Study Calendar ........................................................................................................15 
Risk and Benefits .....................................................................................................16 
Adverse Event Reporting .........................................................................................17 
Ethical and Regulatory Considerations ....................................................................17 
Outcome Measures .................................................................................................18 
Data Handling and Recordkeeping ..........................................................................19 
Monitoring ................................................................................................................19 
Statistical Considerations .........................................................................................19 
Dissemination of Data ..............................................................................................20 
References ..............................................................................................................21 
 
 
 

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Abbreviations 
AE 
Adverse event 
Akt 
serine/threonine protein kinase Akt 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase 
AMP 
Adenosine monophosphate 
AMPK 
AMP kinase 
AST 
Aspartate transaminase 
ATP 
Adenosine triphosphate 
BMI 
Body mass index 
Clin Lab 
UAMS Clinical Laboratory 
BSO 
Bilateral salpingo-oophorectomy 
BUN 
Blood urea nitrogen 
CCTO 
Cancer Clinical Trials Office 
CO2 
Carbon dioxide 
ECC-1 
Endometrial carcinoma cell-1 
ELISA 
Enzyme-linked immunosorbent assay 
ER 
Estrogen receptor 
Erk1/2 
Extracellular signal-regulated kinases 1 and 2 
FASN 
Fatty acid synthase 
HbA1c 
Hemoglobin A1c 
HDL-C 
High-density lipoprotein cholesterol 
HEC-1B 
Human endometrial carcinoma-1B 
hTERT 
Human telomerase 
IGF-I 
Insulin-like growth factor -1 
IGF-II 
Insulin-like growth factor -2 
IHC 
Immunohistochemistry 
IRB 
Institutional Review Board 
IUD 
Intrauterine device                                  
Ki67 
Antigen KI-67 
KRAS 
v-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog 
KLF9 
Kruppel-like factor 9 
LDL-C 
Low-density lipoprotein cholesterol 
mg 
Milligram 
miR 
Micro RNA 
mRNA 
Messenger RNA 
NIH/NCI 
National Institutes of Health/National Cancer Institute 
NTU 
Non-tumor uterine 
PCOS 
Polycystic Ovarian Syndrome 
PI 
Principal Investigator 
PR 
Progesterone receptor 
PTEN 
Phosphatase and tensin homolog 
RT-PCR 
Reverse transcriptase polymerase chain reaction 
SD 
Standard deviation 
 

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TUNEL 
Terminal deoxynucleotidyl transferase dUTP nick end labeling 
UTR 
Untranslated region 
UAMS 
University of Arkansas for Medical Sciences 
 
 
 
 

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Study Schema 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study Summary 
 
Title 
A Randomized Pilot Study to Evaluate the Effects of a Short 
Course of Metformin versus No Therapy in the Period Prior to 
Hysterectomy for Grade 1-2 Adenocarcinoma of the Endometrium 
in Obese Non-Diabetic Women 
Short Title 
Effect of Metformin on Proliferation Markers in Endometrial Cancer   
Protocol Number 
138647 
Phase 
Pilot study 
Methodology 
A randomized open-label study of metformin vs. no metformin 
Study Duration 
18 months 
Study Center(s) 
Single-center  
Objectives 
To determine metformin tolerability.  To determine metformin effect 
on tissue markers of proliferation, apoptosis, and insulin-mediated 
signaling.  To determine metformin effect on a number of different 
markers measured in blood and plasma.  To determine metformin 
effect on mRNA levels and miR profiles. 
Number of Subjects 
40 total: 20 metformin, 20 control 
Diagnosis and Main 
Inclusion Criteria 
Obese (BMI≥30) non-diabetic women with newly diagnosed Grade 
1-2 adenocarcinoma of the endometrium 
Study Product(s), Dose, 
Route, Regimen 
Metformin 500 mg po bid x 14 - 21 days  
Duration of 
administration 
14-21 days 
Reference therapy 
Non-treatment arm 
Statistical Methodology 
Wilcoxon rank-sum tests will be used to compare treatment arms 
for differences in each study endpoint. 
 
 
 
Metformin 500 mg bid x 14-21 days  
 
Consent  
Hysterectomy, BSO, possible 
staging for endometrial cancer 
Control Arm (No Metformin)  
 

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Protocol Summary 
 
This is a randomized, open-label clinical investigation of the effects of short-term oral 
metformin therapy on biomarkers for tumor growth in subjects with endometrial cancer. Metformin 
is a well-tolerated drug widely prescribed for treatment of Type 2 diabetes mellitus and for 
treatment of Polycystic Ovarian Syndrome (PCOS) in non-diabetic women (1, 2).  Clinical trials are 
ongoing to explore this possibility in breast cancer (NCT01101438). This investigation is the first 
study of metformin in endometrial cancer patients, and is designed to understand the mechanism 
of its anti-cancer actions, if any, and its interactions with biomarkers in endometrial cancer 
patients. 
 
Forty non-diabetic subjects will be randomized so that 20 will receive oral metformin for 
14-21 days and the remaining 20 will receive no metformin for 14-21 days. Subjects will be 
monitored for adverse events (AEs).  All subjects will have blood samples collected on Day 1 
(prior to start of metformin for subjects randomized to metformin) and prior to surgery.  These 
samples will undergo metabolic, lipid and tumor-specific biomarker analyses. Tumor and adjacent 
normal tissue taken from subjects from the diagnosis and at the time of surgery will be analyzed 
for 
cellular 
proliferation, 
apoptosis 
and 
biomarker 
levels. 
The Primary objectives of this study are as follows: 
1. To determine the effect of metformin on tissue markers of proliferation, apoptosis, and 
insulin-mediated signaling in endometrial cancer in non-diabetic obese women.   
2. To determine the tolerability of a short course of metformin in non-diabetic obese women 
with newly diagnosed endometrial cancer. 
The Secondary objectives of this study are as follows: 
1. To determine the effect of metformin on HbA1c and blood lipid profiles measured at baseline 
and just before surgery. 
2. To determine the effect of metformin on the following hormones measured in blood plasma 
at baseline and just before surgery:  Insulin, IGF-I, leptin, and adiponectin. 
3. To determine the effect of metformin on the expression levels of mRNAs and miRs 
measured in blood plasma at baseline and just before surgery. 
4. To determine the effect of metformin on the expression levels of mRNAs and miRs 
measured in tumor and adjacent non-tumoral uterine tissue. 
Background and Rationale 
 
Endometrial cancer is the most common gynecologic malignancy in the United States, 
with approximately 45,000 cases per year (3). The single biggest risk factor for development of 
this disease is obesity (4).  There is a direct correlation between the extent of obesity and the 
development of endometrial cancer.  Peripheral adipose tissue contains high amount of the 
enzyme aromatase, which converts androstenedione into estrone.  This source of estrogen then 
exerts a proliferative effect on the lining of the uterus, leading over time to endometrial hyperplasia 
and carcinoma.  This type of endometrial cancer is referred to as Type I and represents ~80% of 
all endometrial cancers in this country (5).  More recently it has been shown that obesity is a risk 
factor for insulin resistance leading to higher levels of circulating insulin. If the insulin resistance 
is great enough, obesity will lead to diabetes. 
Serum insulin levels have now been shown to have a direct correlation with the 
development of endometrial cancer (6).  Case-control studies have documented higher serum 
 

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insulin levels in women who develop endometrial cancer versus women who underwent 
gynecologic surgery for benign disease (7).  Both insulin and insulin-like growth factor 1 (IGF-1) 
are highly associated with endometrial cancer.  In one study, women with high circulating insulin 
levels had a hazard ratio of 2.33 for developing endometrial cancer versus women with low levels 
of insulin, after adjusting for age and estradiol(8).  
High insulin levels are associated with the metabolic syndrome, which includes insulin resistance, 
elevated circulating hormones, obesity, elevated lipids, and can clinically manifest as anovulation 
and infertility. The metabolic syndrome in women is often referred to as the polycystic ovarian 
syndrome (PCOS). In these women, medical reduction of circulating insulin leads to 
improvements in all factors associated with the metabolic syndrome, including an increase in 
ovulatory cycles and improved pregnancy rates (9).  Metformin, a biguanide compound, is a 
primary therapy used to treat insulin resistance associated with type II diabetes.  Among diabetics 
on metformin, there is a reduction in the development of cancer and the rate of cancer death (10).  
It is not precisely known how metformin reduces the development of cancer.  The reduction in 
cancer is not seen with other diabetic treatments such as sulfonylureas and insulin. 
Since the early 1990s, metformin has been used to treat PCOS.  A meta-analysis of the 
use of metformin and polycystic ovary syndrome in 2003 documented from controlled trials a 
significant improvement, compared with placebo, in ovulation rates, pregnancy rates, fasting 
insulin levels, blood pressure, and cholesterol(9).  It is important to note that these studies were 
performed in non-diabetic women.  Metformin is now used routinely as therapy for PCOS. 
Because high circulating levels of insulin have been associated with the development of 
endometrial cancer, reduction of insulin levels with metformin may have a direct effect on the 
development or maintenance of this cancer.  Anecdotal reports have occurred of women with 
early low-grade endometrial cancer being successfully treated with a regimen including metformin 
(11).  Also, women who had initially responded to progesterone therapy for endometrial cancer and 
then became resistant, showed a renewal of progesterone response when they were started on 
metformin (12).  Laboratory data has documented that metformin is a potent inhibitor of endometrial 
cancer-cell proliferation (13).  Metformin has also been shown to promote progesterone receptor 
expression in endometrial cancer cells and to reverse progesterone resistance in endometrial 
cancer cells by several different mechanisms (14, 15).  Progesterone receptor expression and 
sensitivity in endometrial cancer are associated with improved clinical outcomes. 
 
Arkansas is one of the top states for obesity in the United States.  More than 30% of the 
adult population is characterized as obese, with a Body Mass Index (BMI) of 30 or higher (16). At 
UAMS, we see approximately 160 new cases of endometrial cancer in obese women each year.  
Most of these women are not diabetic, but are at risk for developing diabetes. 
 
The present study proposes to treat obese endometrial-cancer patients with a four-week 
course of metformin prior to their definitive surgical therapy.  This information will be used to apply 
for further funding to determine the exact role metformin may have in treatment of endometrial 
cancer. This drug also has the potential to be a chemo-preventive agent in women at high risk for 
developing endometrial cancer.  There is currently no randomized trial to investigate the influence 
of metformin on endometrial cancer in obese non-diabetic women. 
 
 
 

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Proliferation Markers 
Human endometrial cancer cell lines ECC-1 and Ishikawa, when treated with metformin, 
showed decreased proliferation and decreased hTERT expression relative to non-treated cells 
(17). In women treated with metformin to manage PCOS, sera from PCOS women after 6 months 
of metformin significantly decreased the invasive properties of ECC-1, in part, by attenuating pro-
inflammatory NF-κB expression and activation of Akt and Erk1/2 pathways (18). Further, the 
increase in progesterone receptor expression in metformin-treated Ishikawa and HEC-1B cells 
was associated with pathways targeted by adipokines and insulin.    
In this pilot study, we will evaluate the effect of metformin on endometrial tumor-cell 
proliferation and apoptosis, obesogenic and pro-tumorigenic marker gene expression, and anti-
oncogenic micro-RNA (mIR) expression. mIRs are potentially important regulators of expression 
of tumor-enhancing and tumor-suppressing pathway components. Endometrial tumors and 
adjacent non-involved tissues will be obtained at surgery. Tissues will be processed for 
histopathology and immunohistochemistry, and frozen in liquid nitrogen for RNA and protein 
analyses. Fasting blood sera will be obtained prior to and after the 14-to-21-day treatment period 
for measurement of insulin, adiponectin, leptin, and IGF-1 levels. Fixed tumor and ‘normal’ tissues 
will be analyzed for markers of proliferation (Ki67; phospho-histone H3) and apoptosis (TUNEL), 
and for expression of estrogen receptor (ER)α, progesterone receptor (PR), and tumor suppressor 
PTEN by immunohistochemistry.  Isolated tissue RNAs will be assessed for PR, PTEN, ERα, 
KRAS, and hTERT transcripts by quantitative RT-PCR. Protein extracts will be evaluated by 
Western immunoblotting for PR, PTEN, total and activated Akt and Erk 1/2, and insulin receptor 
expression. Sera from both groups at both time points will also be subjected to analysis using 
miR-profiling arrays. Data obtained from analyses of all biological endpoints will be compared 
using standard statistical procedures.  
 The efficacy of metformin in potentially reversing the pro-tumorigenic parameters of 
endometrial cells (to be evaluated in adjacent non-involved endometrium) has not been previously 
explored. Our studies may provide information on a subset of patients who are more likely to 
respond to metformin based on their endocrine profiles and clinico-pathologic factors, and hence 
may lead to metformin as a standard chemopreventive strategy for women with high risk for EC. 
The analyses of metformin-responsive mIRs that are associated with EC may also offer non-
invasive biomarkers for predicting women diagnosed with lower stage of EC and who are likely to 
suffer from EC recurrence.       
Trial Objectives 
Primary Objectives  
1. To determine the effect of metformin on tissue markers of proliferation, apoptosis, 
and insulin-mediated signaling in endometrial cancer in non-diabetic obese 
women.  Specifically,  to determine the effect of metformin on the following tissue 
markers measured in tumor and adjacent non-tumor uterine (NTU) tissue: 
a. Proliferation: Ki67, phosphorylated histone H3, estrogen receptor (ER), 
progesterone receptor (PR), and telomerase (hTERT). 
 

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b. Anti-proliferation and apoptosis:  PTEN, KLF9, cleaved caspase-3, and 
TUNEL staining. 
c. Insulin-mediated signaling:  total and phosphorylated versions of Akt, 
Erk1/2, AMPK, and receptors for Insulin, IGF-I, and IGF-II.   
2. To determine the tolerability of a short course of metformin in non-diabetic obese 
women with newly diagnosed endometrial cancer. 
Secondary Objectives 
1. To determine the effect of metformin on HbA1c and blood lipid profiles measured 
at baseline and just before surgery. 
2. To determine the effect of metformin on the following hormones measured in blood 
plasma at baseline and just before surgery:  Insulin, IGF-I, IGF-II, leptin, and 
adiponectin. 
3. To determine the effect of metformin on the expression levels of mRNAs and miRs 
measured in blood plasma at baseline and just before surgery. 
4. To determine the effect of metformin on the expression levels of mRNAs and miRs 
measured in tumor and adjacent NTU tissue: 
Exploratory Objectives 
1. To examine how BMI influences tumor-cell responses to treatment with metformin.  
2. To explore the possible interactions of BMI, the plasma miR profiles and tumor and 
tumor mRNA profiles in final responses of endometrial tissue to metformin.  
Trial Design 
This is a single-center, two-arm, open-label, randomized proof-of-concept pilot study to ascertain 
the therapeutic potential of metformin in obese women with Type I endometrial cancer.  Forty 
non-diabetic obese subjects with confirmed stage I or II adenocarcinoma of the endometrium will 
be recruited from the University of Arkansas for Medical Sciences (UAMS).  
A. Method of assigning subjects to treatment groups. 
Subjects will be assigned randomly to one of two groups.  Group 1 will receive treatment 
with metformin, while Group 2 will receive no treatment.  Subjects assigned to Group 1 
will be administered oral metformin at 500 mg twice a day for 14-21 days followed by 
surgery.  These doses are therapeutic, and will permit patients to undergo their surgical 
therapy within an appropriate time frame.  
Subject eligibility will be established before treatment randomization.  Once a subject’s 
eligibility is determined, the Research Staff will be notified to implement the randomization 
process.  Randomization will be completed when the Research Staff receives a copy of 
the signed consent and the physician’s orders for study agent to be dispensed. 
 

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To minimize imbalance between treatment arms, the randomization procedure will employ 
a stratified block randomization with randomly chosen blocks of size 2, 4, and 6, and with 
BMI as the stratification factor.  Randomization will be conducted using sealed envelopes 
located at the Cancer Clinical Trials Office (CCTO).  There will be two sets of consecutively 
numbered envelopes, one set for subjects with BMI from 30 to 39.9 and one set for subject 
with BMI of 40 or higher.  At each randomization, the lowest numbered envelope will be 
chosen.  The Research Staff will open the envelope and assign the subject to the 
treatment arm based on the contents of the envelope.  The appropriate treatment will then 
be dispensed to the subject.   
Methods for ensuring blinding. 
Not applicable: this is an open-label study. 
Methods for unblinding the study. 
Not applicable: this is an open-label study. 
Procedure for unblinding in case of medical emergency. 
Not applicable: this is an open-label study. 
Metformin will be administered to patients (randomized to receive metformin) for a 
minimum of 14 days and a maximum of 21 days, representing the typical time interval 
between confirmation of tumor diagnosis and surgical resection.  Following surgical 
resection, any unused study drug will be returned to the physician at the time of the 
subject’s first post-operative visit. 
B. Blood Draws and Laboratory Tests 
Blood will be drawn from each subject, approximately 18 mL in purple top vacutainers, 
prior to treatment assignment (if not preformed previously as conventional care) and after 
completion of the therapy at the time of surgery.  The blood sample below will be subjected 
to the following tests at the UAMS Clinical Laboratory:   
a) A comprehensive metabolic panel (glucose, calcium, albumin, total protein, sodium, 
potassium, CO2, chloride, BUN, creatinine, ALP, ALT, AST and total bilirubin), to be 
performed prior to starting treatment only. 
b) A lipid panel (cholesterol, HDL-C, LDL-C, triglycerides), to be performed both prior 
to treatment assignment and at the time of surgery.  
c) Determination of HbA1c, to be performed both prior to treatment assignment and at 
the time of surgery. 
 
The blood samples listed below will be utilized for correlative laboratory studies in the 
research laboratory of Dr. Rosalia Simmen at the UAMS Biomed Bldg. Aliquots of each 
blood sample will be centrifuged to separate out the plasma portion. Plasma will be stored 
at -80°C in the Co-Investigator’s lab until analysis is performed.  
 
 

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The following biomarkers will be assayed in the plasma samples collected at baseline and 
at the time of surgery through enzyme-linked immunosorbent assays (ELISA) or multiplex 
assays. All of these tests will be performed by laboratory personal in Dr. Rosalia Simmen’s 
lab:  
a) Insulin 
b) Leptin 
c) Adiponectin 
d) IGF-I and IGF-II  
 
Remaining plasma samples will be subjected to global profiling of miRs and mRNAs to 
evaluate/validate the relative expression of specific candidate metformin-regulated miRs 
and mRNAs (Dr. Frank Simmen’s lab). miR and mRNA  levels will be determined using 
quantitative SYBR green-based real time reverse transcriptase polymerase chain reaction 
(RT-PCR) assays and a microarray platform. These tests will be performed in Dr. Frank 
Simmen’s laboratory by his personnel and/or by commercial providers of microarray 
profiling services. 
C. Tissue Specimens and Laboratory Tests 
A sample of tumor with adjacent normal mucosa will be obtained after surgery from the 
Pathology department from the tissue remaining after normal gross and histological 
assessments.   
Fresh tissue samples will be transported by designated research personnel to Dr. Rosalia 
Simmen’s laboratory at the UAMS Biomed Bldg .  Fixed tumor and ‘normal’ tissues will be 
subjected to IHC for markers of proliferation (Ki-67, phospho-histone H3), and apoptosis 
(TUNEL, cleaved caspase-3). Tumor (and ‘normal’) tissues will also be examined by 
Western blot and/or ELISA for expression levels of FASN, total and phosphorylated insulin 
receptors, and total and phosphorylated IGF-I receptors. Total and phosphorylated AMPK 
levels will be assessed by IHC or Western blot. Lastly, tissues will be used for miR and 
mRNA profiling.        
D. Subject Data 
Subject data to be obtained and recorded will consist of the following:  
a) Patient characteristics: gender; age; BMI; race and ethnicity; smoking status 
(including approximate packs per day for current and former smokers); alcohol 
intake. 
b) Tumor characteristics: tumor stage; tumor differentiation status (well, moderate, 
poor); lymph node involvement; depth of invasion; tumor margins.   
c) Comprehensive metabolic panel: glucose, calcium, albumin, total protein, sodium, 
potassium, CO2, chloride, BUN, creatinine, ALP, ALT, AST and bilirubin. 
d) Lipid panel: cholesterol, HDL-C, LDL-C, triglycerides. 
e) Plasma markers: plasma HbA1c; plasma insulin; plasma leptin; plasma adiponectin; 
plasma IGF-I; plasma IGF-II; plasma profiles of miR and mRNA. 
 

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f) Tissue markers: endometrial cancer and uterine apoptotic indices; endometrial 
cancer and uterine proliferative indices; endometrial tumor miR and mRNA profiles; 
endometrial (adjacent NTU) miR and mRNA profiles. 
E.  Subject Diary 
A subject who is randomized to metformin will receive a diary on Day 1.  The subject is to 
record the date and time of self-administration of the study drug.  The diary will be 
reviewed weekly by members of the study team via telephone for compliance.  The diary 
will be collected at the subject’s post-operative visit.   
F.  Treatment modifications 
Patients will be monitored for their ability to tolerate the study medication during weekly 
follow-up telephone calls.  If necessary, anti-diarrheal or anti-emetic therapy may be 
prescribed to ease any discomfort associated with the medicine.  If a patient cannot 
tolerate the study medication and misses two or more doses in a row, they will be 
withdrawn from the study.   
G. Subject removal 
Any patient who develops a grade 3 or higher gastrointestinal toxicity while on study will 
be discontinued.  Subjects that withdraw from the study or that are withdrawn from the 
study due to unacceptable toxicity will return all unused study drug at their next scheduled 
clinic appointment.  
H. Study Drug  
 
Metformin (Fortamet®; Glucophage®; Glucophage® XR; Glumetza®; Riomet®) 
 
 
Description: 
Meformin is an oral antihyperglycemic drug used in the 
management of type 2 diabetes. 
 
 
Molecular formula: C4H11N5 • HCl 
 
 
Molecular weight: 165.62 
Adverse Events: 
>10%: Gastrointestinal: Diarrhea. Neuromuscular & skeletal: Weakness.  
1% to 10%: Cardiovascular: Chest discomfort, flushing, palpitation. Central 
nervous 
system: 
Headache, 
chills, 
dizziness, 
lightheadedness. 
Dermatologic: 
Rash. 
Endocrine 
& 
metabolic: 
Hypoglycemia. 
Gastrointestinal: Indigestion, abdominal discomfort, abdominal distention, 
abnormal stools, constipation, dyspepsia/ heartburn, taste disorder. 
Neuromuscular & skeletal: Myalgia. Respiratory: Dyspnea, upper 
 

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respiratory tract infection. Miscellaneous: Diaphoresis increased, vitamin 
B12 levels decreased, flu-like syndrome, nail disorder  
<1%: Megaloblastic anemia  
Postmarketing and/or case reports: Lactic acidosis, leukocytoclastic 
vasculitis, pneumonitis. 
 
 
Pregnancy and Lactation: 
Metformin is classified as FDA pregnancy risk category B.  Adverse events 
have not been observed in animal studies; therefore, metformin is classified 
as pregnancy category B. Metformin has been found to cross the placenta 
in concentrations which may be comparable to those found in the maternal 
plasma. Females of childbearing potential should be instructed to avoid 
becoming pregnant during the study.  It is known that low amounts of 
metformin are excreted into breast milk. 
Administration (Dosing):  See Trial Design section above 
 
 
Storage and Stability: 
 
 
 
Tablets:  Store between 20 - 25°C; excursion permitted to 15 - 30°C. 
Study Population 
Subjects are eligible for the study if the following inclusion and exclusion criteria are met: 
A. Inclusion Criteria 
1. Histological confirmed diagnosis of grade I or II adenocarcinoma of the 
endometrium 
2. Must be obese as defined by a BMI greater than or equal to 30 kg/m2 
3. Candidate for surgical removal of their uterus as part of their endometrial cancer 
treatment 
4. Subjects must have signed informed consent 
5. Age 42 - 75 years of age 
6. ECOG Performance status of 0 – 2 
7. History of adequate renal, liver, and bone marrow function:  
a. Hb: (adequate for surgical intervention, with transfusion if necessary) 
b. WBC: (normal range) 
c. Platelets: (180K/cmm) 
d. LFTs: Normal bilirubin (<2.0mg/dL), AST/ALT (2xULN) 
e. Renal function: creatinine less than 1.4 
8. Female subjects must either not be of child-bearing potential or must have a 
negative urine pregnancy test within 7 days of randomization to metformin. 
Subjects are considered not of child-bearing potential if they are surgically sterile 
or they are postmenopausal for greater than 12 months.  
 
 
 

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             B. Exclusion Criteria  
1. Poorly differentiated cancer or any of the high-risk subtypes of endometrial cancer 
including serous, clear cell, or carcinosarcoma 
2. History of diabetes mellitus Type 1 or Type 2. 
3. Receiving metformin prior to enrollment 
4. Known hypersensitivity to metformin. 
5. Unable to swallow and retain oral medication. 
6. Pregnant or lactating. 
7. Previous or concurrent malignancies, except non-melanoma skin cancers, unless 
curatively treated and with no evidence of recurrence for > 5 years 
8. If the physician feels that the candidate is not suitable for the study, he/she will be 
excluded.  
9. Currently taking biguanides, sulfonylurea drugs, thiazolidenediones, insulin, or              
mTOR or DPP-4 inhibitors or having taken any of these medications during the 12 
weeks prior to study participation. 
 
10. Clinical symptoms of gastrointestinal obstruction or bleeding and consideration for 
immediate surgery or immediate neoadjuvant chemoradiation. 
11. History of lactic or other metabolic acidosis. 
12. Uncontrolled infectious disease. 
13. History of positivity for human immunodeficiency virus (HIV). 
14. History of congestive heart failure requiring pharmacologic treatment. 
15. History of excessive alcohol abuse, defined by a habitual intake of more than three 
drinks daily. 
16. Mal-absorption syndrome, disease affecting gastrointestinal function, or previous 
resection of the stomach or small bowel. 
17. Current use of medications for weight loss. 
 
Feasibility of Study Population Recruitment: 
At the UAMS Gynecologic Oncology clinic, approximately 160 new cases of endometrial 
cancer in obese women are seen each year (three new cases per week).  The majority of these 
women are not diabetic at the time of the diagnosis of endometrial cancer.  This represents the 
target population for this study.  All new patients are seen by Dr. Burnett or Dr. Zorn.  Except in 
rare circumstances, all these women will be scheduled for hysterectomy and bilateral salpingo-
oophorectomy to stage their cancer.  The typical time period between initially being seen by Dr. 
Burnett or Dr. Zorn and surgery is approximately 3weeks.  Thus, those women who agree to 
participate in this trial can begin the intervention with metformin and expect no delay to the time 
of their surgery. 
 
 
 

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Study Calendar 
Procedure 
Pre-
study 
 
Study Period 
Post-
Operative 
clinic visit / 
Early 
Termination 
f 
Day 1  
(Day of 
first 
dose) 
Day 
8 
 
 
 
 
Days 14 
-21 
(Surgery) 
Eligibility Assessments 
 
 
 
 
 
 
 
Informed Consent 
X 
 
 
 
 
 
 
Inclusion/Exclusion 
Criteria 
X 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
Study Assessments 
 
 
 
 
 
 
 
Physical Examination 
X 
X 
 
 
 
 
 
Physical Measurements e 
X 
X 
 
 
 
X 
 
Demographics h 
X 
 
 
 
 
 
 
Vital signs b 
 
X 
 
 
 
 
 
Body Mass Index (BMI) 
X 
 
 
 
 
X 
 
Smoking Status 
X 
 
 
 
 
 
 
Alcohol Status 
X 
 
 
 
 
 
 
Concomitant Medications j 
X 
X 
X k 
 
 
X 
 
Adverse Events (AEs) 
 
X 
X k 
 
 
X 
 
Telephone contact 
 
 
X k 
 
 
 
 
Laboratory Test 
 
  
 
 
 
 
 
CBC Panel c 
X 
 
 
 
 
X 
 
Comprehensive 
Metabolic Panel  
X 
 
 
 
 
X 
 
Lipid Panel (Cholesterol, 
HDL-C, LDL-C, 
Triglycerides) * 
X 
 
 
 
 
X 
 
Urine Pregnancy  Test d 
 
X 
 
 
 
 
 
HbA1c * 
X 
 
 
 
 
X 
 
Study labs (send to 
Simmen lab) g 
X 
 
 
 
 
X 
 
Clinical Drug Supplies 
 
 
 
 
 
 
 
Randomize 
 
X 
 
 
 
 
 
Dispense study drug 
 
X 
 
 
 
 
 
Dispense patient diary 
 
X 
 
 
 
 
 
Review of drug diary 
 
 
X k 
 
 
 
 
Collect unused study drug 
 
 
 
 
 
 
X 
Collect subject diary 
 
 
 
 
 
 
X 
Pathology 
 
 
 
 
 
 
 
Tumor Stage 
 
 
 
 
 
 
X 
Tumor Differentiation 
X 
 
 
 
 
 
X 
Lymph Node Involvement 
 
 
 
 
 
 
X 
Tissue Collection (send to 
Simmen lab) 
Xi 
 
 
 
 
X 
 
 

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*Above standard of care (investigational-to be paid for by grant). 
a A comprehensive panel will determine the following serum levels for the following:  glucose, 
calcium, albumin, total protein, sodium, potassium, CO2, chloride, BUN, creatinine, ALP, ALT, 
AST, and total bilirubin (standard of care). 
b Temperature, blood pressure, pulse, respiration rate. 
c  WBC, Platelets, Hb 
d Within 7 days of randomization 
e Physical measurements to include ECOG, performance status, weight and height (height only) 
f Unused drug and diary to be collected during standard of care visit, no other research activities 
will be performed. 
g Insulin, Leptin, Adiponectin, IGF-I and IGF-II 
h Age, sex, race, and ethnicity  
i If available  
j Record concomitant medications that are actively being taken at time of consent till completion 
of study. 
k Subjects receiving Metformin only  
Risks and Benefits 
A. Potential toxicities, risks and precautions  
Blood Samples: Pain and bruising at the injection site and rare infections can occur.  
Experienced personnel will perform the phlebotomies using approved techniques.  
Pressure and dressings will be used to minimize pain, bruising and infection. 
Metformin Treatment: Common (50% of the time): Diarrhea; Rare (10 – 25% of the 
time ): Nausea or vomiting, gas; Very rare (1 – 10% of the time): Weakness, 
indigestion, abdominal discomfort, headache, taste changes, abnormal stools, pain in 
the muscles, lightheadedness or dizziness, difficulty breathing, nail problems, 
increased sweating, flu-like symptoms, flushing, feeling of a fast beating heart. 
Very rare side effects include Hirsutism (rare), lactic acidosis (3 cases per 100,000 
patient years; 1) occurs most often in individuals with concomitant renal and liver 
disorders, 2) who are 80 years of age or older, 3) who have heart, liver or kidney 
failure, 4) who have a history of heavy alcohol intake. 
B. Potential Benefits 
 
It is unknown if 14-21 days of metformin treatment will provide any therapeutic benefit. 
For this reason, there is no guaranteed personal health benefit for subjects 
participating in this study.  However, information obtained from this study may improve 
prevention and treatment of endometrial cancer for individuals in the future. 
 
 
 

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Adverse Event Reporting  
All events listed below must be reported to the UAMS Institutional Review Board (IRB) 
within 10 days of the event or notification of event.  
 
1). Local AEs that the investigator determines are: 
 
 
a. Unexpected; and 
 
 
b. Related to the research; and 
 
 
c. Involve new or increased risks to subjects or others. 
 
2). Any accidental or unintentional change to the IRB-approved protocol that place one 
or more subjects at increased risk or affects the rights and welfare of subjects or 
others.  
 
3). Any new information that indicates an unexpected change to the risks or potential 
benefits of the research.  
 
4). A breach in confidentiality that may involve risk to subject or others.  
 
5). Any complaint of a participant that indicates an unanticipated risk or any complaint 
that cannot be resolved by the research team. 
 
6). Incarceration of a subject. 
 
7). Change in FDA labeling 
 
8). Restrictions, terminations, or suspension of the study. 
 
9). Premature completion. 
 
10). Notifications of pending audits, inquiries or investigations by federal agencies. 
 
11). Written reports from study monitor. 
Ethical and Regulatory Considerations 
A. Recruitment 
 
Subjects will be recruited during clinic visits at the UAMS Gynecologic Oncology clinic.  
B. Informed Consent 
Subjects will be consented for their participation in the study and the use of their data, 
tissues and blood samples for research purposes. The principal investigator (PI), a 
sub-investigator or a designated staff member will discuss the informed consent form 
with the potential subject. The consent process will take place in a quiet and private 
room.  Subjects may take as much time as needed to make a decision about their trial 
participation and may take the document home if desired. An interpreter will be utilized 
if native language is a barrier to understanding the consent form. The individual 
 

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obtaining consent will thoroughly explain each element of the document and outline 
the risks and benefits, alternate treatment(s), and follow-up requirements of the study. 
Participation privacy will be maintained and questions regarding participation will be 
answered. No coercion or undue influence will be used in the consent process. No 
research related procedures will be performed prior to obtaining informed consent. All 
signatures and dates will be obtained. A copy of the signed informed consent form will 
be given to the subject. The informed consent process will be documented in each 
subject’s research record. 
C. Protocol Management 
 
Study management will be handled by the Cancer Clinical Trials Office (CCTO)  
 
in the Winthrop P. Rockefeller Cancer Institute.   
D. Drug Accountability 
 
Drug supplies will be kept in a secure, limited access storage area under the 
recommended storage conditions in the research pharmacy in the Winthrop P. 
Rockefeller Cancer Institute under the direction of the research pharmacist.  
Outcome Measures 
 
A. The primary endpoints of this study consist of the following: 
a. IHC-based tissue markers of proliferation: Ki67, phosphorylated histone H3, 
estrogen receptor (ER), progesterone receptor (PR), and telomerase (hTERT).   
b. IHC-based tissue markers of anti-proliferation and apoptosis:  PTEN, KLF9, 
cleaved caspase-3, and TUNEL staining. 
c. IHC-based tissue markers of insulin-mediated signalling:  total and phosphorylated 
versions of Akt, Erk1/2, AMPK, and receptors for Insulin, IGF-I, and IGF-II. 
d. Meformin-related adverse events. 
B. The secondary endpoints of this study consist of the following: 
a. Blood levels of HbA1c and the lipid-panel analytes (cholesterol, HDL-C, LDL-C, 
triglycerides). 
b. Plasma hormone levels (Insulin, IGF-I, IGF-II, leptin, and adiponectin). 
c. Plasma-measured expression levels of mRNAs and miRs, measured using 
quantitative RT-PCR and miR-profiling microarrays, respectively. 
d. Tissue-measured expression levels of mRNAs and miRs, measured using 
quantitative RT-PCR and miR-profiling microarray, respectively. 
 
 

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Data Handling and Recordkeeping 
 
The PI will carefully monitor study procedures to protect the safety of research subjects, 
the quality of the data and the integrity of the study.  The data will be kept in an electronic 
database in the office of clinical trials at the Winthrop P. Rockefeller Cancer Institute. Only 
the PI and Co-I, CRAs, regulatory personnel, biostatistician and lab personnel performing 
the analyses will have access to the data.  In the event that a subject fails screening, only 
the eligibility criteria case report form will be completed. 
 
Monitoring 
Medical Monitor:  The Medical Monitor, Principal Investigator and study staff will meet 
quarterly, once the PI has monitored the data, to review safety data (adverse events, 
serious adverse events and other scientific observations). 
Study Monitor:  The study will be monitored to ensure that the rights and well-being of 
human subjects are protected, that the data are accurate, complete and verifiable from 
source documents and that the trial is conducted in compliance with currently approved 
protocol/amendments on a quarterly basis. 
Statistical Considerations 
 
General approach:  For each tissue endpoint, the tumor-NTU difference will be calculated 
in each patient as the paired difference in values between tumor and adjacent NTU tissue.  
For each blood endpoint, the endpoint response to treatment will be calculated in each 
patient as the paired difference between post-study and pre-study values.  All data will be 
summarized by treatment arm as the mean, standard deviation (SD), median, and range, 
and will be graphed as box plots.  Tumor-NTU differences and endpoint responses will be 
compared against zero via signed-rank test within each treatment arm.  Treatment arms 
will be compared to each other for differences via Wilcoxon rank-sum tests, with additional 
details provided below.  All statistical comparisons will be two-sided, and will employ a 
10% alpha to reduce Type II error in this pilot proof-of-concept study.   
 
Analysis plan for tolerability:  Meformin-related adverse events will be summarized by type 
and treatment arm, both as proportions at each grade and as average grades (i.e., mean 
scores).  For each type, the Wilcoxon rank-sum test will be used to compare treatment 
arms for differences in average grade.   
 
Analysis plan for the IHC-based primary endpoints:  The IHC-based primary endpoints will 
be measured in tissue, and will include markers of proliferation (Ki67, phospho-histone 
H3, ERα, PR, and hTERT), anti-proliferation and apoptosis (PTEN, KLF9, cleaved 
caspase-3 
and TUNEL 
staining), 
and 
insulin-mediated 
signalling 
(total 
and 
phosphorylated versions of Akt, Erk1/2, AMPK, and receptors for Insulin, IGF-I, and IGF-
 

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II).  Endpoints measured in tumor tissue, adjacent NTU tissue, and tumor-NTU differences 
will be summarized and graphed as described above.  Wilcoxon rank-sum tests will be 
used to compare endpoints measured in tumor, and likewise endpoints measured in 
adjacent NTU tissue, for differences between the metformin and no-metformin treatment 
arms.   
 
Analysis plan for secondary endpoints measured in blood or plasma:  The secondary 
endpoints measured in blood will be the levels of HbA1c, cholesterol, HDL-C, LDL-C, and 
triglycerides.  The secondary endpoints measured in plasma will be the plasma hormone 
levels (Insulin, IGF-I, IGF-II, leptin, and adiponectin) and the plasma-measured expression 
levels of mRNAs and miRs.  Endpoints measured at pre-study and post-study, and 
endpoint responses to treatment will be summarized and graphed as described above.  
Wilcoxon rank-sum tests will be used to compare endpoint responses to treatment for 
differences between the metformin and no-metformin treatment arms.   
 
Analysis plan for secondary endpoints measured in tissue:  The secondary endpoints 
measured in tissue will be the expression levels of mRNAs and miRs.  Endpoints 
measured in tumor tissue, adjacent NTU tissue, and tumor-NTU differences will be 
summarized and graphed as described above.  Wilcoxon rank-sum tests will be used to 
compare endpoints measured in tumor, and likewise endpoints measured in adjacent NTU 
tissue, for differences between the metformin and no-metformin treatment arms. 
 
Sample Size and Power: There will be 20 subjects on each treatment arm, yielding a total 
of 40 subjects.  The two-sided Wilcoxon rank-sum test will be used at 10% alpha to 
compare all endpoints and endpoint responses for differences between the metformin arm 
and the no-metformin arm.  This study will be considered sufficiently powered to meet 
research objectives if the Wilcoxon rank-sum test has >90% power at 10% alpha to detect 
a treatment-arm difference of 1.0 SDs or more.  Statistical power of the Wilcoxon rank-
sum test was calculated using the 2-sample t-test module of PASS 2011 by selecting 
options corresponding to the worst-case scenario of underlying normal distributions with 
unknown SDs.  Under this worst case scenario, 20 subjects per treatment arm (for a total 
of 40 subjects) give the two-sided Wilcoxon rank-sum test 91.6% power at 10% alpha to 
detect a difference of 1.0 SDs between the metformin and no-metformin arms, thereby 
establishing that this study is sufficiently powered to meet research objectives.   
Dissemination of Data 
 
 
The results will be analyzed after the analysis of all the blood and tissue samples. Then 
the two groups will be compared and the statistical analysis will be performed. The results 
will be submitted for presentation at national meetings, manuscripts will be written for 
publication and the data will be used to apply for additional funding from federal agencies 
including the National Institutes of Health/National Cancer Institute (NIH/NCI). 
 
 
 

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