Mechanism and Predictors of Cardiotoxicity After Prostate Cancer Treatment: A Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation Plus Leuprolide, and Radiation Plus Relugolix
Phase: PHASE2
Conditions: Biochemically Recurrent Prostate Carcinoma, Localized Prostate Carcinoma, Stage I Prostate Cancer AJCC v8, Stage II Prostate Cancer AJCC v8, Stage IIA Prostate Cancer AJCC v8, Stage IIB Prostate Cancer AJCC v8, Stage IIC Prostate Cancer AJCC v8, Stage III Prostate Cancer AJCC v8, Stage IIIA Prostate Cancer AJCC v8, Stage IIIB Prostate Cancer AJCC v8, Stage IIIC Prostate Cancer AJCC v8
Sponsor: Emory University

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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RAD5484-21: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix  
PRINCIPAL INVESTIGATOR: 
 
Sagar A. Patel, MD (Contact) 
Associate Professor 
Department of Radiation Oncology 
205-370-8119 
Sagar.patel@emory.edu 
 
Anant Mandawat, MD 
Associate Professor 
Department of Medicine, Division of Cardiology 
Department of Hematology and Medical Oncology 
Anant.mandawat@emory.edu 
 
CO-INVESTIGATORS: 
 
Ashesh Jani, MD FASTRO 
Professor, Department of Radiation Oncology 
Winship Cancer Institute 
Emory University School of Medicine 
 
Stephanie Cantu, MD 
Assistant Professor 
Department of Medicine, Division of Cardiology 
Emory University School of Medicine 
 
Arthur Stillman, MD PhD 
Professor 
Division of Cardiothoracic Imaging, Department of Radiology 
Emory University School of Medicine 
 
Pretesh Patel, MD  
Associate Professor, Department of Radiation Oncology 
Winship Cancer Institute 
Emory University School of Medicine 
 
Bruce Hershatter, MD 
Associate Professor; Department of Radiation Oncology 
Winship Cancer Institute 
Emory University School of Medicine 
 
Karen Godette, MD 
Associate Professor; Department of Radiation Oncology 
Winship Cancer Institute 
Emory University School of Medicine 
 
Nikhil Sebastian, MD 
Assistant Professor, Department of Radiation Oncology 
Winship Cancer Institute 
Emory University School of Medicine 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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Clinical Research Coordinators 
 
Bill Zheng, BS 
Bill.zheng@emory.edu 
 
Leslie Gantt, BS 
legantt@emory.edu 
 
Lead Study Statistician 
 
Yuan Liu, PhD 
Biostatistics Shared Resource 
Winship Cancer Institute 
Emory University School of Medicine 
Email: yliu31@emory.edu 
 
 
 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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IRB Form BIO 03152021 
 
Table of Contents 
 
1. 
Study Summary ..................................................................................................................................... 4 
2. 
Objectives .............................................................................................................................................. 4 
3. 
Background ............................................................................................................................................ 5 
4. 
Study Endpoints ..................................................................................................................................... 7 
5. 
Study Intervention/Investigational Agent ............................................................................................... 9 
6. 
Procedures Involved .............................................................................................................................. 9 
7. 
Data Specimen Banking ...................................................................................................................... 13 
8. 
Sharing of Results with Participants .................................................................................................... 13 
9. 
Study Timelines ................................................................................................................................... 14 
10. 
Inclusion and Exclusion Criteria ....................................................................................................... 14 
11. 
Vulnerable Populations .................................................................................................................... 15 
12. 
Local Number of Participants ........................................................................................................... 15 
13. 
Recruitment Methods ....................................................................................................................... 15 
14. 
Withdrawal of Participants ............................................................................................................... 15 
15. 
Risk to Participants .......................................................................................................................... 16 
16. 
Potential Benefits to Participants ..................................................................................................... 16 
17. 
Compensation to Participants .......................................................................................................... 16 
18. 
Data Management and Confidentiality............................................................................................. 17 
19. 
Provisions to Monitor the Data to Ensure the Safety of Participants ............................................... 17 
20. 
Provisions to Protect the Privacy Interest of Participants ................................................................ 19 
21. 
Economic Burden to Participants ..................................................................................................... 19 
22. 
Informed Consent ............................................................................................................................ 20 
23. 
Setting .............................................................................................................................................. 21 
24. 
Resources Available ........................................................................................................................ 21 
25. 
Multi-Site Research When Emory is the Lead Site.......................................................................... 29 
26. 
References ....................................................................................................................................... 23 
 
 
 
 
 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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1. Study Summary 
 
Project Title 
Biomarker-Based Approaches to Understand and 
Predict Cardiovascular Toxicity from Androgen 
Deprivation Therapy Targeting the Gonadotropin 
Releasing Hormone Pathway in Prostate Cancer Men 
Project Design 
Open-label randomized clinical trial with parallel prospective 
cohort study  
Primary Objective 
Elucidating the pathophysiologic link between gonadotropin 
releasing hormone agonist hormone therapy (e.g. Lupron) 
and cardiovascular (CV) toxicity, and the mechanism by 
which CV risk-reduction is achieved by the novel oral 
GNRH-antagonist, relugolix. This objective will be studied 
using imaging and blood biomarkers.  
Secondary Objective(s) 
Identify genomic alterations that predispose an individual to 
enhanced CV toxicity following hormone therapy with 
GNRHa or relugolix 
Research 
Intervention(s)/Interactions 
A) GNRHa versus relugolix [randomization] 
B) Parallel, non-interventional cohort of men receiving 
no hormone therapy 
Study Population 
Men >18 years  with localized intact or recurrence prostate 
cancer undergoing radiation therapy (with or without prior 
prostatectomy), with or without hormone therapy 
Sample Size 
90 men (30 men in GNRHa arm, 30 men in relugolix arm, 
30 men in non-hormone therapy cohort) 
Study Duration for individual 
participants 
12 months 
Study Specific Abbreviations/ 
Definitions  
Radiation therapy (RT)  
Androgen deprivation therapy (ADT)  
Gonadotropin-releasing hormone agonist (GNRHa)  
Gonadotropin-releasing hormone antagonist (GNRHaa) 
Nonsteroidal anti-androgen (AA)  
Combined androgen blockade (CAB) 
Major adverse cardiac events (MACE) 
Funding Source (if any) 
Prostate Cancer Foundation-Pfizer-Myovant Challenge 
Award, Prostate Cancer Foundation Young Investigator 
Award 
 
2. Objectives 
Androgen deprivation therapy (ADT) with a gonadotropin-releasing hormone agonist (GNRHa) is a highly 
effective and commonly used treatment for prostate cancer (PCa) with over 500,000 men with PCa 
receiving ADT annually in the United States3,4. However, large observational studies suggest GNRHa is 
associated with increased risk of myocardial infarction (MI) and sudden cardiac death, raising concerns that 
ADT causes cardiovascular (CV) harm4-6. In fact, as more men survive PCa due to increasing ADT use, CV 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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mortality, not cancer, is now the most common cause of death in PCa patients7,8. However, this 
increased CV damage has been greatly diminished with the approval of GNRH antagonists such as 
relugolix, which demonstrated a decreased incidence of CV adverse events compared with GNRHa2. Yet, 
despite this increased risk of CV damage, GNRHa remain the most widely utilized form of ADT due to high 
cytoreductive efficacy, lower cost, convenience in delivery, and minimal injection-associated adverse 
effects compared with available injectable GNRH antagonists. It is critically important to identify both 
the mechanism as well as predictive biomarkers that drive ADT-induced CV damage to triage patients 
towards the method of ADT that will be most effective for a patient’s overall health.  
The immune system can play a central role in the development of CV injury, including promoting 
accelerated atherosclerosis via cholesterol deposition and immune cell aggregation in the arterial wall. 
Peripheral innate and adaptive immune cells (both pro- and anti-inflammatory) regulate subsequent 
atherosclerosis progression9,10. Additionally, baseline genomic aberrations (including clonal hematopoiesis 
of indeterminate potential (CHIP)) are also associated with enhanced inflammatory immunity and CV 
injury11,12. While the link between immune-mediated inflammation and acute coronary syndrome remains 
complex, accumulating evidence has demonstrated that vascular inflammation plays pivotal roles in the 
pathogenesis of atherosclerosis and plaque rupture, and thus coronary artery disease (CAD) is considered 
an inflammation-related disease. 
To examine the role that the immune system plays in ADT-induced CV disease, we propose a mixed-
methods clinical study using patient-level data from our Cardio-Oncology PROstate Cancer (CO-PRO) 
institutional, open-label prospective clinical trial. In this study, patients with stage I-III PCa will receive 
leuprolide or relugolix with radiation therapy, or radiation alone. Using imaging and peripheral blood 
samples from this trial, the main goal of this proposal is elucidating the pathophysiologic link between 
GNRHa and CV toxicity and the mechanism by which CV risk-reduction is achieved by the novel 
oral GNRH-antagonist, relugolix. We hypothesize that early CV toxicity from GNRHa is mediated by 
a GNRHa-activated inflammatory cascade directly impacting vascular integrity and resulting in 
accelerated coronary atherosclerosis, and this effect will not be observed in men receiving 
relugolix. Aim 1 of this study will utilize non-invasive imaging to identify how leuprolide versus relugolix 
affect the development of coronary artery disease, and whether validated imaging biomarkers can predict 
these changes. As secondary laboratory-based correlative studies, Aim 2 will evaluate how pre-existing or 
augmented immune responses following ADT predict for development of CV toxicity. Finally, in Aim 3 we 
will examine how pre-existing genomic alterations that pre-dispose an individual to enhanced inflammatory 
immunity (and have been associated with accelerated atherosclerosis) correlate with the development of 
CV toxicity following ADT with leuprolide or relugolix. By identifying major contributors to CV risk from ADT, 
we will ultimately develop a precision medicine approach to optimize risk prediction and allow clinicians to 
appropriately counsel patients on risk-benefit ratio of ADT and utilize novel risk-reducing ADT agents such 
as relugolix.  
3. Background 
Association of ADT and Cardiovascular Morbidity 
The role of ADT in CV harm was ignited with the publication of large observational studies in the past 
decade, which suggested that ADT use in the form of a GNRHa for PCa men was associated with a 20% 
increased risk of CAD, 10-30% increased risk of MI, and a 15% increased risk of sudden cardiac death4-6. 
With increasing ADT use and improving radiation/surgical technique, CV mortality, not cancer, is now 
the most common cause of death in PCa patients7,8. Additionally, while the addition of ADT with radiation 
therapy has been shown to improve survival for men with unfavorable risk PCa, multiple post-hoc studies 
have suggested that the addition of ADT may result in a survival detriment in men with CV comorbidities13,14. 
 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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Traditionally, CV injury following ADT is thought to be driven by an indirect mechanism of prolonged 
hypogonadism precipitating metabolic syndrome, insulin resistance, and weight gain over several years7,15-
17. However, the effect of ADT, namely GNRHa, may be direct. There are several observations from 
recent studies that support this premise. First, studies have shown that ADT, after only 3-6 months of 
therapy, is associated with an increased risk of atherothrombotic events7,8. Second, data from the recent 
HERO trial2 evaluating GNRHa (leuprolide) versus GNRH-antagonist (relugolix) in PCa men showed an 
increased incidence of major adverse CV events with 
GNRHa compared with GNRH-antagonist as soon as 4 
weeks after initiation of treatment (Figure 1). Further, 
testosterone suppression was greater with GNRH-
antagonist than GNRHa, countering the testosterone-
mediated CV effect. Finally, the excess CV event risk with 
ADT in the large observational studies mentioned above4-
6 
was 
seen 
with 
GNRHa 
therapy, 
not 
orchiectomy/surgical castration. In fact, meta-analysis of 
several observational studies5 have shown a hazard ratio 
for risk of MI with GNRHa (compared with other forms of 
ADT) to be 1.57 (95% CI 1.26-1.94). Nonetheless, 
GNRHa remains the most widely utilized form of ADT in 
the United States due to lower cost, convenience in 
delivery, and minimal injection-associated adverse effects 
compared with injectable GNRH-antagonist. 
 
Association of Immune Response and Coronary Atherosclerosis 
Most acute CV events, including MI, are caused by rupture of an atherosclerotic plaque. The molecular 
mechanisms of atherosclerosis involve cholesterol deposition and immune cell aggregation in the arterial 
wall. Innate and adaptive immune cells with both proinflammatory and anti-inflammatory effects regulate 
subsequent atherosclerosis progression9,10. The link between inflammation and acute coronary syndrome 
is complex, but accumulating evidence has shown that vascular inflammation plays a central role in the 
pathogenesis of atherosclerosis and plaque rupture, making acute coronary syndrome an inflammation-
related disease. 
Plaques prone to rupture are characterized by a large core of lipids and necrotic debris covered by a thin 
cap of smooth muscle cells and connective tissue. The rupture is caused by a degradation of the cap 
connective tissue by infiltrating macrophages releasing matrix-degrading proteases18,19. Following systemic 
or local inflammatory activation, endothelial cells enhance the migration and attachment of T cells and 
macrophages to the arterial wall via upregulated adhesion molecules. During this process, both 
proatherogenic and antiatherogenic immune networks are activated, and if sustained, can lead to plaque 
disruption, rupture, and subsequent coronary arterial occlusion. These mechanisms are supported by the 
CANTOS trial20, which randomized >10,000 patients with prior myocardial infarction and hsCRP > 2.0 mg/L 
(i.e. marker of elevated baseline inflammation) to canakinumab, a monoclonal antibody targeting IL-1, 
versus placebo. Patients receiving canakinumab had significantly decreased rates of major adverse CV 
events and inflammatory biomarkers, independent of aggressive cholesterol control, demonstrating the role 
of inflammatory immunity in mediating CV toxicity.  
Figure 1. Incidence of major adverse cardiac events 
(MACE) in men with advanced PCa receiving leuprolide 
versus 
relugolix. 
Incidence 
curves 
separate 
immediately after onset of treatment, with GNRHa 
resulting in more MACE2. 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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Many other inflammatory cytokines/mediators have been implicated in the development of accelerated 
atherosclerosis and/or coronary plaque rupture9. For example, proinflammatory T-helper 1 (Th1) T cells are 
important macrophage activators and are the dominant T-cell type in atherosclerotic plaques21. T cells 
express 
GNRH 
receptors, 
and 
activation of these receptors via 
GNRHa has been shown to stimulate 
T-cell expansion and differentiation 
into Th1 phenotype, suggesting that 
GNRHa may promote destabilization 
of atherosclerotic plaques22 (Figure 
2). Additionally, follicle-stimulating 
hormone 
(FSH) 
is 
upregulated 
following GNRHa (e.g. leuprolide) but 
not 
GNRH-antagonists 
(e.g. 
relugolix), and has been implicated in 
excess 
adiposity, 
enhanced 
proinflammatory response secondary 
to adipocytes, and upregulation of RANK/osteoclast differentiation involved in calcium resorption (such as 
that found on stable coronary plaques)23-25. As such, the risk of atherosclerotic plaque destabilization and 
rupture may be mitigated with a GNRH-antagonist, such as relugolix.  
An underlying factor that can contribute to the development of this increased CV risk are somatic mutations 
that impact immune frequency and function. In particular, somatic alterations associated with clonal 
hematopoiesis of indeterminate potential (CHIP) have been shown to lead to dysregulated inflammatory 
immune responses and poor CV outcomes12. CHIP, present in 10-20% of the population over age 70, arises 
from somatic mutations in hematopoietic stem cells that produce abnormal circulating immune cells.  These 
CHIP mutations are associated with twice the risk of CAD and ischemic stroke, as well as increased CV 
events11,26,27. This is thought to occur via immune-mediated pathways, as CHIP-engineered mice have 
increased atherosclerosis mediated by inflammatory cytokines like IL-1β, TNFα, and IL-611,28,29. However, 
how CHIP mutations impact CV outcomes following ADT in PCa men remains to be explored. 
The role of inflammatory immune responses in potentiating CV disease ties directly in with the increased 
risk of CV disease following ADT in that ADT has long been shown to modulate systemic and prostate-
infiltrating inflammatory immune responses. These include the induction of thymic regrowth and release of 
naïve T cells into circulation, an increase in various inflammatory immune populations (both myeloid and 
lymphocytes, particularly CD4+ Th1 cells), and decreased numbers of regulatory T cells30-35. While these 
enhanced responses following GNRHa treatment has been well-established, the immunomodulatory effects 
of the GNRH-antagonist relugolix remain to be explored, as do the relationship between these enhanced 
inflammatory responses and increased CV disease. 
Understanding biological mechanisms of ADT-associated CV toxicity, especially the difference between 
that of GNRHa and GNRH-antagonists, will enhance our ability to decide on appropriate treatment 
strategies for PCa men receiving ADT, depending on an individual’s risk for CV injury. Additionally, we will 
explore novel associations between patient-level clinical and genomic features and baseline imaging 
biomarkers with ADT-associated CV toxicity. By identifying major contributors to CV risk from ADT, we 
ultimately plan to develop a precision medicine approach to optimize risk prediction and allow clinicians to 
appropriately counsel patients on risk-benefit ratio of ADT and utilize novel risk-reducing ADT agents such 
as relugolix 
4. Study Endpoints 
Aim 1: To identify and compare the association of GNRH-agonist leuprolide versus GNRH-
antagonist relugolix with accelerated coronary plaque development in men with prostate cancer 
Figure 2. Potential interaction between GNRH, immune effector response, and 
coronary atherosclerosis and plaque rupture resulting in major adverse 
cardiovascular events, such as myocardial infarction1 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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Rationale: Coronary atherosclerosis 
and plaque rupture is an immune-
mediated disease, and GNRH has been 
implicated 
in 
its 
pathogenesis. 
In 
addition to circulating T cells, GNRH 
receptors have been identified on 
cardiac endothelium38. We hypothesize 
that there is a direct GNRHa-mediated 
effect in susceptible vessels leading to 
plaque propagation and CV injury in PCa 
patients treated with ADT. This premise 
has been informed by preliminary data in 
a study that Dr. Sagar Patel led. This 
study 
was 
a 
multi-institutional 
retrospective analysis of coronary CT angiogram (CCTA) findings in PCa patients who did (n=60) and did 
not (n=42) receive ADT. CCTA is a non-invasive imaging tool with >95% sensitivity and >90 specificity for 
coronary atherosclerosis compared with the gold standard coronary catheterization, which is highly 
invasive39,40 (Figure 4).  
Value of CCTA as Primary Endpoint: Coronary computed tomographic angiography (CCTA) has 
emerged as an accurate non-invasive method for the detection of obstructive coronary artery disease 
(CAD). Further, CCTA permits evaluation of numerous other coronary artery plaque characteristics, 
including plaque compositions, which are generally graded as non-calcified, calcified, and mixed41. 
Classification of plaques by CCTA based upon composition has important clinical implications: calcified 
plaque is generally considered more stable, while non-calcified or mixed plaques possess a thin cap 
fibroatheroma that is more likely to rupture and result in acute cardiac events such as a MI. Using CCTA, 
the evolution of these plaques after starting ADT will be evaluated in this study, providing mechanistic 
insight into the pathophysiology underlying GNRHa-mediated CV toxicity (i.e. immune- and FSH-mediated 
responses involving cytokines and biomarkers that will be studied in Aims 2 and 3). For example, if we 
observe an increase in coronary occlusion involving non-calcified lesions with GNRHa (but not relugolix), 
this finding would provide insight that GNRHa leads to downstream pathways involving plaque instability 
and rupture. If we also observe an increase in coronary occlusion involving calcified lesions with GNRHa 
(but not relugolix), this finding would provide insight that GNRHa may lead to FSH upregulation leading to 
osteoclast-mediated breakdown of calcified caps and plaque disruption. Thus, this imaging technique will 
both characterize and validate a novel imaging biomarker to predict men are at high risk of CV events after 
initiating ADT, as well as provide further validation of hypothesized mechanisms of GNRHa-mediated CV 
disease. 
Aim 2: Determine the relationship between GNRH-agonist versus relugolix with downstream 
immune effector response that is implicated in atherosclerosis 
While the increased risk of CV disease and morbidity associated with ADT has been established by large 
observational studies, the mechanism behind this risk remains unclear. However, increasing evidence has 
demonstrated that inflammatory immunity can play a central role in mediating cardiac damage, especially 
at the coronary vessel endothelium. Aim 1 will provide insight into anatomic/pathophysiologic mechanism 
of ADT-associated CV toxicity, testing our hypothesis that CV damage following ADT is due to accelerated 
coronary artery atherosclerosis and/or plaque instability associated with inflammatory immune responses. 
In Aim 2, we will evaluate peripheral blood samples (drawn at 3-, 6-, and 12-months and stored) from 
patients enrolled on study to determine how pre-existing or augmented inflammatory immunity impacts the 
risk of CV injury following ADT, testing the underlying hypothesis that pre-existing inflammatory 
immunity increases the risk of CV injury following ADT due to an immune-mediated effect of GNRHa 
but not antagonists. These studies provide important mechanistic insight into how inflammatory immunity 
Figure 4. Coronary catheterization (left) compared to coronary CT 
angiogram (CCTA, right), in the same patient. This image demonstrates the 
high spatial resolution of coronary plaque/stenosis on CCTA. Early 
coronary changes can be detected with this non-invasive technique. 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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contributes to ADT-related CV toxicity, as well as identifying biomarkers that may predict individuals at 
heightened risk of adverse CV events from ADT, and thereby benefit from cardiac risk-reducing relugolix.  
Subaim 2.1: To determine how proteomic biomarkers associated with inflammatory immunity 
correspond with CV toxicity following ADT. 
We will conduct in-depth proteomic profiling, which has previously been utilized and validated to identify 
signatures associated with inflammatory immune responses and cardiovascular risk50,51. To evaluate 
whether these signatures are associated with CV toxicity following ADT using leuprolide but not relugolix, 
pre-treatment and 12-month post-ADT PBMC will be subjected to proteomic profiling in conjunction with 
the Emory Integrated Proteomic Core as published by our colleagues at the Winship Cancer Institute52. 
Aim 3: To determine how pre-existing genomic alterations promoting inflammatory immunity impact 
development of CV toxicity following GNRHa versus relugolix.  
Numerous genetic alterations have been shown to result in either enhanced or diminished ability to mount 
inflammatory immune responses, including genes associated with ‘clonal hematopoiesis of indeterminate 
potential’ (CHIP) such as DNMT3A, TET2, ASXL1, PPM1D, KDM6A, and BCOR53-55, as well as several 
others that alter inflammatory immune function56-62. The impact of these immune-related genomic 
alterations on the development of inflammatory immunity and CV toxicity following ADT will be examined 
in Aim 3, testing the underlying hypothesis that somatic mutations associated with enhanced effector 
responses lead to increased CV injury in men receiving GNRH agonists but not relugolix. 
 
5. Study Intervention/Investigational Agent  
Hormone Therapy Intervention 
For men who will be receiving ADT with radiation therapy, there will be a 1:1 randomization between 
GNRHa (i.e. leuprolide or triptorelin) versus oral relugolix. Dosing for these agents are per standard FDA-
approved guidelines, and the study has no impact on dose or duration of therapy. 
 
For men receiving GNRHa, standard FDA-approved intramuscular or subcutaneous injectable doses will 
apply (i.e. leuprolide 7.5 mg monthly, 22.5 mg q3month, 45 mg q6month; triptorelin 11.25 mg q3month, 
22.5 mg q6month). Each patient may receive 21-30 days of oral bicalutamide 50 mg daily beginning at 
the time of first injection (i.e. to hinder the initial testosterone flare associated with GNRHa) at the 
discretion of the treating provider. Duration of therapy will depend on the risk category of prostate cancer, 
as detailed in section 6. 
 
For men receiving oral relugolix, standard FDA-approved oral doses will apply (i.e. 360 mg on day 1, 
followed by 120 mg daily for the duration of therapy). The tablet is in doses of 120 mg, and it can be taken 
by mouth with or without food. If the subject misses > 7 days of medication, then a loading dose of 360 
mg will be initiated followed by re-initiation of 120 mg daily thereafter. Participants will be asked to 
complete a drug diary and bring the diary in addition to medication for reconciliation at each follow up 
visit. Duration of therapy will depend on the risk category of prostate cancer, as detailed in section 6. 
Relugolix will be provided at no cost by the study sponsor (i.e. Myovant Sciences). All medication supply 
will be stored and managed by Emory Investigational Drug Services Core. Medication delivery to enrolled 
subjects will be mediated by clinical research coordinators. Additionally, drug diaries will be reconciled by 
clinical research coordinators with oversite by the principal investigator Dr. Sagar Patel. 
Coronary Computed Tomography Angiogram (CCTA) Endpoint  
As discussed in Aim 1 above, this study will utilize a state-of-the-art, validated non-invasive cardiac 
imaging, coronary CT angiogram, as the primary endpoint in this study. This imaging technique offers 
remarkable spatial resolution of coronary vasculature to test the primary hypothesis that ADT-mediated 
CV risk, namely from GNRHa, is driven by accelerated atherosclerosis and coronary disease. With 
modern imaging techniques, such as prospective triggering, radiation exposure to the patient is 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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minimized, as imaging is gated to be performed in only one phase of the cardiac cycle (rather than 
continuous during the entire cardiac cycle). Additionally, other measures, including limited field of view, 
limited scan length, and minimal tube voltage, will ensure that the additional radiation exposure sustained 
by CCTA in this study will remain around 3.2 mSv per patient (which is comparable or lower than the 3-7 
mSv the average person receives annually from natural sources). Other cardiac imaging techniques, 
including catheter-based angiography or nuclear medicine studies, result in a substantially larger amount 
of radiation exposure to the patient (e.g. 21-41 mSv), and are therefore, less optimal to use as an 
endpoint in this study. Additionally, CCTA endpoints will allow to test both mechanism (e.g. involving 
accelerated coronary atherosclerosis and/or plaque instability), as well as help identify a novel imaging 
biomarker that may be used in clinical practice to identify those men at highest risk of an adverse CV 
outcome from ADT. 
6. Procedures Involved 
Men with localized intact PCa, or non-metastatic recurrence following prostatectomy, and prescribed 
radiation therapy (XRT) with or without concomitant ADT will be consented and enrolled on this prospective 
trial. Eligible subjects are men > 18 years old diagnosed with non-metastatic PCa planning to undergo 
curative-intent therapy. Men with prior cardiac stent or bypass surgery will be excluded. Men with prior 
exposure to ADT will be excluded.  
Each patient will undergo external beam XRT with or without concomitant ADT of 6-24 months duration. 
For those men with National Comprehensive Cancer Network (NCCN)-defined unfavorable 
intermediate- or high-risk disease, or with biochemically recurrent PCa requiring salvage XRT plus 
ADT, each will be randomized 1:1 between injectable intramuscular or subcutaneous GNRHa depot 
(leuprolide 22.5 mg every 3 months, leuprolide 45 mg every six months) versus GNRH-antagonist 
(oral relugolix 360 mg loading dose followed by 120 mg daily). Men with NCCN-defined low- or 
favorable intermediate-risk intact disease, or those with biochemically recurrent PCa requiring salvage XRT 
without ADT, will be treated with XRT alone. Each patient will provide consent for (1) pre-treatment and 12-
month post-ADT prospective ECG-gated, contrast-enhanced CCTA and (2) peripheral blood banking at 
baseline and at 3-, 6-, and 12-months post-treatment (Figure 5). 
 
ADT randomization will be created using preconstructed allocation sequences using maximal 
randomization (https://ctrandomization.cancer.gov/tool/). Patients will undergo a pre-randomization 
stratification based on Atherosclerotic Cardiovascular Disease (ASCVD) risk score (low/intermediate 
versus high). All principal investigators and co-investigators will be blinded to this randomization block. 
Lead statistician (Dr. Yuan Liu) and clinical research coordinators will have access to this allocation 
sequence.  
Methods: As seen in above study schema, each patient in each cohort will undergo pre-treatment and 12-
month post-ADT initiation coronary CT. Each patient will undergo a non-contrast CT scan using standard 
Figure 5. Study Schema 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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coronary artery calcium (CAC) imaging protocol for coronary calcium quantification prior to the acquisition 
of the CCTA. CAC images will be obtained using prospective ECG-triggering at 70% of the R-R interval, 
using tube voltage of 120 kV and an automated tube current modulation and minimum slice collimation (0.6 
mm). Images will be reconstructed in 3 mm slice thickness at 3 mm intervals. Following CAC scan, contrast-
enhanced CCTA will be performed using an ECG-gated, single-beat acquisition scan to include 30-80% of 
the R-R interval. Scanning will extend from the tracheal bifurcation to 2 cm below the left ventricular apex; 
0.5 mm detector collimation will be used.  
Additionally, peripheral blood will be drawn and stored in our established biorepository (under protocol 
WINSHIP5179-20) at the following intervals: pre-treatmnet, and 3-, 6-, and 12-months post-ADT initiation. 
Further details regarding analysis plan of peripheral blood below in Aims 2 and 3. 
Aim 1.1: To determine the relationship between ADT (i.e. GNRHa versus relugolix) and accelerated 
coronary plaque development and/or rupture in PCa men, all contrast enhanced CCTA images will be 
analyzed using a commercially-available, validated artificial intelligence-guided imaging analysis service 
(HeartFlow, Inc, Mountain View CA). Multiplanar reconstructed images will be assessed for the presence, 
volume, and qualitative composition (e.g. total, calcified, non-calcified, mixed) of atherosclerotic plaque for 
each coronary artery segmen. Luminal stenosis will be graded on an ordinal scale 0-100%. CCTA scans 
pre- and 12 months post-treatment will be compared. We hypothesize that men receiving GNRHa will be 
at increased risk of total plaque volume increase compared with men receiving relugolix or no ADT. 
Analysis Plan: We will measure coronary plaque volume using CCTA images at both baseline and 12-
months post-treatment initiation. The primary endpoint will be (1) total coronary plaque volume (continuous). 
Secondary endpoint will be non-calcified coronary plaque volume (continuous). Other outcome measures 
include (1) calcified plaque volume (continuous), (2) low-attenuation plaque volume (continuous), (3) 
coronary artery calcification score (continuous), and (4) coronary vessel stenosis (ordinal). The change in 
endpoint metrics between baseline and 12-month will be estimated for leuprolide versus relugolix versus 
no ADT. Data transformation to fit statistical assumptions will be done as needed. In addition, we will 
implement multivariable models that control for potential confounders (e.g. age, statin medication use) using 
general linear regression and/or logistic regression. 
Power: We hypothesized that there will be significantly greater total plaque burden (i.e. summation of total 
plaque volume of all major coronary territories) increase from baseline to month 12 following GNRHa versus 
no ADT or relugolix. Using a standard deviation of 30 mm3 for the change in total plaque volume from scans 
obtained at two time points approximately 12 months apart in the study, 60 participants (30 in each 
comparative treatment arm) with both baseline and month 12 CCTA would provide 80% power to detect a 
difference of ≥ 20 mm3  in the change in total plaque volume [P(X>Y) 0.72] from baseline to 12 months.  
Aim 2.1: To determine how pre-existing and ADT-augmented inflammatory immune responses 
impact CV toxicity, we will evaluate pre-treatment, 3-, 6-, and 12-month peripheral blood mononuclear 
cells (PBMC) samples from all patients enrolled on trial. We will first evaluate the frequency and function of 
inflammatory immune populations by flow cytometry. While we will include a comprehensive panel 
evaluating lymphocyte and myeloid populations, we will specifically conduct an in-depth analysis 
quantifying the frequency, phenotype, and activation of T cells and macrophages. In particular, we will 
evaluate the frequency of naïve (CD44-CD62L+), effector memory (CD62LloCCR7-CD27lo/int), central 
memory (CD62Lhi CCR7hi CD44hi), CD4 T-helper subsets (staining for the transcription factors Tbet, 
EOMES, RORγ, and GATA), and CD4+ Tregs cells (CD25+GITR+CD127-Foxp3+)47. Circulating 
macrophages will be evaluated for inflammatory M1 (CD80, CD86) and immunosuppressive M2 (CD163, 
CD206) sub-populations. Immune cells will also be evaluated for expression of GNRH receptors, as well 
as function by expression of intracellular cytokines associated with T cell activity (including IFNγ, TNFα, IL-
2, IL-4, IL-6, IL-10, and Granzyme B as we have published48,49) or macrophage activity (Arg1, TNFσ, IL-6, 
IL-12).  
 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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In addition to evaluating peripheral immune populations, plasma will be isolated at the same timepoints and 
evaluated for chemokine and cytokine production by multiplex assay (Human Cytokine/Chemokine/Growth 
Factor 71-Plex Clinical Assay, Eve Technologies). This assay measures both inflammatory and suppressive 
chemokines and cytokines, as well as growth factors involved in cardiac activity. Factors found to be altered 
via multiplex (either following ADT, between treatment groups, or between patients who develop CV toxicity) 
will be validated by ELISA. Finally, to evaluate the mechanistic significance of these alterations, human 
cardiac myocytes (the AC16 cell line and primary cardiomyocytes (Sigma Aldrich)) grown under wild-type 
or androgen-deprived conditions will be evaluated for altered expression of these factors by ELISA. 
Supernatants from these cells will be used in transwell migration assays to evaluate how androgen 
deprivation-induced alteration of these factors  impacts the migration of T cells, macrophage, or other 
relevant immune populations across a transwell. Follow-up experiments will be conducted in which altered 
factors are either blocked or restored (recombinant protein) to determine if these factors are sufficient to 
alter immune migration towards cardiac cells. 
 
Aim 2.2: To determine how proteomic biomarkers associated with inflammatory immunity 
correspond with CV toxicity following ADT, we will conduct in-depth proteomic profiling, which has 
previously been utilized and validated to identify signatures associated with inflammatory immune 
responses and cardiovascular risk50,51. To evaluate whether these signatures are associated with CV 
toxicity following ADT using leuprolide but not relugolix, pre-treatment and 12-month post-ADT PBMC will 
be subjected to proteomic profiling in conjunction with the Emory Integrated Proteomic Core as published 
by our colleagues at the Winship Cancer Institute52. Using nanocapillary liquid chromatography coupled 
with tandem mass spectrometry, this technology will be used to analyze patient PBMC samples for highly 
sensitive protein identification, posttranslational site mapping, and protein quantification. Briefly, PBMCs 
will be thawed under controlled conditions, sonicated in the presence of lysis buffer, protease inhibitors and 
phosphatase inhibitors. Protein samples will be sequentially digested, desalted, and dried under vacuum. 
Following reconstitution, samples will be loaded and eluted from a silica column driven by a UPLC system, 
monitoring elution spectra on a Fusion Mass Spectrometer. The mass spectrometry scans will be collected 
at a resolution of 120,000 at m/ 200 in profile mode while in a higher-energy collision dissociation 
fragmentation MS/MS spectra. Following sequencing, the combined Homo sapiens UniProt subsets will be 
used as references for proteomics searches. Data will be normalized to account for systematic differences 
in protein signal distributions, by aligning the medians of the log2 protein signal distributions. Pathway 
enrichment will be conducted using gene sets obtained from the KEGG Pathway and MSigDB databases. 
 
Analysis Plan: Immune responses (e.g., frequency or function of immune populations) and circulating 
proteomic biomarkers will first be summarized and plotted by the follow-up time points to illustrate the 
change pattern over time for all patients and then separated by treatment arms. We will first test whether 
these biomarker change pattern would be altered by treatment groups (e.g., GNRH-agonist versus GNRH-
antagonist) using Kruskal-Wallis test, and then we will link such pattern (e.g., percentage change from 
baseline for biomarkers) with related CV injury metrics as in Aim 1 using the similar statistical strategy as 
in Aim 1.2. P-value will be adjusted for multiple testing using Holm-Bonferroni method to control familywise 
error rate.  
 
Aim 3: To determine how pre-existing genomic alterations promoting inflammatory immunity impact 
development of CV toxicity following GNRHa versus relugolix, pre-treatment PBMC samples will be 
subjected to whole exome sequencing to determine alterations to the protein-coding regions of the genome. 
DNA will be extracted from PBMC and analyzed for quality. Following this analysis, DNA will be fragmented 
using restriction enzymes and undergo a second round of quality control. Fragmented DNA will be used to 
generate next-generation sequencing libraries and will undergo capture for exomic DNA sequences 
(Illumina Nextera Rapid Capture Expanded Exome), followed by amplification and repeated QA/QC. DNA 
sequencing will be conducted using the Illumina HiSeq platform. The FASTQ data files will be aligned using 
BWA-MEM, and variants from the human genome will be determined using VarScan and annotated using 
ANNOVAR. To be considered a valid mutation it will need to comprise at least 2% of the reads, as has 
been utilized to identify CHIP-related mutations27,55.  
 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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Analysis Plan: The correlation among baseline genomic biomarkers, inflammatory biomarkers, and 
proteomic biomarkers will be described using Spearman Correlation Coefficient for all patients and by 
treatment group separately. The association of genomic alterations with CV injury metrics (as defined in 
Aim 1) will be handled by similar statistical strategy as in Subaim 1.2. Additionally, the association of genetic 
aberrations with peripheral immune responses (as in Aim 2) will be carried out by similar statistical strategy 
as in Aim 2. 
Other statistical considerations:  
Safety Population: All patients receiving at least one dose of GNRHa or Relugolix (for parallel randomized 
arms) or radiation alone (for parallel single cohort arm) will be considered evaluable for safety analyses.  
Intent-to-Treat Population: Patients who are evaluable for safety and who are furthermore evaluable at 
12-month CCTA assessment will be considered evaluable for correlative biomarker analyses. 
Safety Analysis: All AEs experienced data will be described by summary statistics. Adverse events will be 
assessed according to CTCAE version 5.0 and will be evaluated by grade, attribution, and organ 
class.  Adverse event listings and tabulated summaries of categorized AEs will be generated for all 
patients collectively and will be summarized by arms. Vital signs and laboratory data will be summarized 
for changes over time on study.  
Stopping Rule: The two ADT test agents are FDA-approved drugs that are used in clinical practice, and 
hence no stopping rule for safety is in place officially. 
 
7. Data Specimen Banking 
To achieve Aims 2 and 3 discussed above, peripheral blood specimens will be collected longitudinally 
four times for each enrolled patient (i.e. pre-treatment, 3 months, 6 months, 12 months).  
Draw 1 (pre) 
Draw 2 (3mo) 
Draw 3 (6mo) 
Draw 4 (12mo) 
Pre-ADT 
2-4 months 
post-ADT 
initiation 
6-8 months 
post-ADT 
initiation  
12-15 months 
post-ADT 
initiation 
 
The blood is collected and processed according to the standard operating practices and regulatory 
parameters of the Winship biorepository and under the guidance of a board-certified pathologist. 
At each collection, approximately 20-30 cc of venous blood will be collected in three purple-top tubes with 
EDTA anticoagulant, and about 6-8 cc of venous blood will be collected in one PAXgene tube. The blood 
will be procured for mononuclear cells and plasma, and it will be snap-frozen or cryopreserved. Blood 
samples will be processed via ficoll-hypaque density gradient centrifugation to obtain cellular material.  
Winship tissue procurement staff and other authorized personnel will provide the blood samples upon 
request to investigators on this protocol or their designees. Blood will be distributed according to the 
prioritization decided by the PIs and study team and utilizing the standard operating procedures of the 
Winship research biorepository core.  
This protocol and a detailed biorepository request will be submitted to the Winship Discovery prostate 
working groups for review and approval. If approved, deidentified blood and coded, limited datasets will 
be obtained from the Winship biorepository with oversight from the Winship informatics team under the 
Emory Honest Broker protocol. Blood will be distributed to Dr. Brian Olson Lab according to the standard 
practices and regulatory parameters of the Winship biorepository, WRISR, and the Winship Cancer 
Tissue and Pathology Shared Resource (CTPSR). Data will be transmitted through password protected 
systems within the Emory University/Healthcare Firewall.  
8. Sharing of Results with Participants 
Each enrolled participant on trial will be eligible to received results of their coronary CT scans 
(pretreatment #1, and 12-month #2) after completion of the 12-month study period. All CT scans will be 
blinded until completion of the 12-month scan (i.e. scan #2). After that period, patients are eligible to 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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IRB Form BIO 03152021 
receive report of the image findings (i.e. scan #1 and #2). These scans are guideline-concordant cardiac 
screening tests, and findings may be used to appropriate manage patients with regards to his 
cardiovascular health. As all scans are blinded before completion of #2 scan (i.e. 12 months after 
enrollment), no scan #1 image findings will be disclosed to patients until after the 12 month study period. 
Of note, all CT images will be intereprted regarding coronary artery (e.g. stenosis, calcficiation) and 
epicardial adipose tissue findings only; any pulmonary, mediastinal, or osseous findings will not be 
interpreted by the cardiac radiologist.  
 
Blood bank analyses (for Aims 2 and 3) are for research purposes only and will not be disclosed to 
patients during or after completion of the study period. 
9. Study Timelines 
Each patient will be enrolled on study for a total of ~12 months, which includes time from pre-treatment 
coronary CT and blood draw, to 12-month coronary CT and final blood draw. Each patient will undergo 
XRT +/- ADT for management of localized prostate cancer in the interim.  
Based on current volume of newly diagnosed localized prostate cancer eligible for definitive XRT across 
all Winship Cancer Institute sites, we anticipate to complete accrual of the study (i.e. 3 treatment cohorts, 
n=30 in each arm; see Figure 5 Study Schema) within 12 months after study opening. Study endpoints for 
Aim 1-3 (i.e. imaging findings, blood analyses) will be completed on a rolling basis, and thus, we 
anticipate completion of data acquisition within 24 months after study opening.  
Completion of this mixed-methods research will involve a robust multidisciplinary team across Winship, 
including Radiation Oncology (Drs. Sagar Patel and Ashesh Jani; leading the accrual of patients to trial), 
Cardiology/Cardiac Imaging (Drs. Stephanie Cantu, Arthur Stillman, Anant Mandawat; leading the 
coronary CT interpretation on study for Aim 1), Hematology and Medical Oncology (Dr. Brian Olson; 
leading the laboratory analyses of peripheral blood for Aims 2-3), and Biostatistics (Dr. Yuan Liu; leading 
all statistical analyses for Aims 1-3).  
Projected funding start date: 12/1/2021  
Projected funding end date: 11/30/2023 
 
10. Inclusion and Exclusion Criteria 
Inclusion: 
- 
Men ≥18 years old 
- 
Non-metastatic prostate cancer  
- 
Non-metastatic, biochemically recurrent prostate cancer 
- 
Plan to undergo curative-intent pelvic radiation therapy (photons or protons) with or without 
brachytherapy 
Exclusion: 
- 
Metastatic prostate cancer requiring >24 months of ADT 
- 
Prior invasive cancer diagnosis 
- 
Prior exposure to androgen deprivation therapy 
- 
Prior exposure to chemotherapy, immunotherapy, or radiation therapy 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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- 
History of cardiac bypass surgery, percutaneous coronary intervention, or cardiac device 
implantation 
- 
Renal insufficiency, contrast allergy, or arrythmias that limits feasibility of CT acquisition  
 
11. Vulnerable Populations 
Not applicable. This study does not involve individuals who are vulnerable to coercion or undue influence, 
such as pregnant women, children/minors, cognitively-impaired, prisoners, etc.  
12. Local Number of Participants 
Our accrual goal for this protocol is 90 patients (n=30 in each arm).  
Based on current prostate cancer volume at Winship Cancer Institute, accrual is expected to be complete 
in 12 months. Specifically, approximately 40 new patients with localized intact or recurrent PCa eligible for 
XRT (with or without ADT) are seen at all Winship sites monthly. We predict an enrollment rate of 20% 
with a low dropout rate, given that the final blood draw and coronary CT will occur 12 months after 
treatment initiation, which corresponds to the time of first or second standard post-treatment follow up 
appointment after completion of therapy.  
Clinical research coordinators will screen all prostate cancer radiation oncology providers (directed by PI 
Dr. Sagar Patel) for all eligible patients to enroll. Co-investigators will be responsible for consenting 
patients in radiation oncology clinic.  
13. Recruitment Methods 
Patients will be recruited from those seen at the Department of Radiation Oncology at Winship Cancer 
Institute (EUH, EUHM, ESJH, EPTC). A brief description of the study will be given verbally to the patients, 
followed by written informed consent, and any relevant supplemental material as needed. The patients 
will be given ample time to review the consent and a time for questions and answer will be provided.  
Study Enrollment Procedures  
A copy of the institution’s IRB-approved informed consent document and written justification for any 
changes made to the informed consent for this protocol must be on file at the Online Collaborative Research 
Environment (OnCore, https://oncore.emory.edu) and available to the Emory University Office for Clinical 
Research) before any patients may enter. The Winship Cancer Center institution consent form must be 
reviewed and approved and all documents must be received (i.e., IRB approved documentation, IRB 
approved consent form, etc.). 
Patient Registration 
All patients entering this study will be registered with the Clinical Trials Office (CTO) at the Winship Cancer 
Institute, Atlanta, GA. The CTO is open Monday through Friday from 8am-5pm (EST). OnCore will be used 
to record information for all registered patients including their assigned patient ID.   
 
Study 
personnel 
will 
notify 
Winship 
Central 
Subject 
Registration 
(WCSR) 
by 
email 
at 
winshipcsr@emory.edu, once subject has been consented for a trial.  
Email notification must be done within 24 hours after consent has been obtained and it will include scanned 
copies of: 
• 
Signed patient consent form 
• 
HIPAA authorization form 
• 
Emory Research Management System (ERMS; https://erms.emory.edu) Enrollment Fax Cover  
 
The WCSR will enter the subject into the OnCore Research Management System, which is the system of 
record for Winship Cancer Institute Clinical Trials. 
 
Eligible patients will be enrolled on study centrally at Winship Cancer Institute by the Study Coordinator.  
When all required test results are available, complete the eligibility checklist and provide the checklist and 
the supporting documentation to the IRB approved investigator for review and sign-off. Once the 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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investigator (sub-investigator, Co-Investigator) has signed the eligibility checklist, enrollment may proceed. 
Oncore and ERMS must be updated to reflect eligibility and on treatment status. 
 
14. Withdrawal of Participants 
Participation in the study should continue until one of the following criteria applies: 
- 
Intercurrent illness that prevents delivery of planned radiation therapy or ADT 
- 
Unacceptable treatment-related adverse event(s), including patient death 
- 
Withdrawal of informed consent (subject’s decision to withdraw for any reason)  
- 
Noncompliance with treatment plan, including delays to treatment or acquisition of additional 
diagnostic imaging that significantly exceeds the proposed timeline of study events 
- 
General or specific changes in the patient's condition that render the patient  unacceptable to 
receive further treatment in the judgment of the investigator 
- 
Lost to follow up.  In the event of a patient’s withdrawal, the Investigator will make every effort to 
complete the End of Treatment/follow-up procedures specified in the Schedule of Events. 
 
15. Risk to Participants 
Radiation therapy +/- hormone therapy (either GNRHa or relugolix) are FDA-approved, guideline-
supported standard treatments for prostate cancer. There is no additional risk associated with treatment 
on study, including the randomized portion of treatment (i.e. GNRHa with Lupron/Trelstar and Relugolix 
are acceptable ADT options for men with prostate cancer undergoing radiation therapy). There is no 
additional risk associated with blood draws (which will correspond to blood draws taken at standard 
clinical intervals to minimize additional appointment or peripheral venous sticks).  
We have incorporated a state-of-the-art, validated non-invasive cardiac imaging, coronary CT angiogram, 
as the primary endpoint of Aim 1 in this study. This imaging technique offers remarkable spatial resolution 
of coronary vasculature to test the primary hypothesis that ADT-mediated CV risk, namely from GNRHa, is 
driven by accelerated atherosclerosis and coronary disease. With modern imaging techniques, such as 
prospective triggering, radiation exposure to the patient is minimized, as imaging is gated to be performed 
in only one phase of the cardiac cycle (rather than continuous during the entire cardiac cycle). Additionally, 
other measures, including limited field of view, limited scan length, and minimal tube voltage, will ensure 
that the additional radiation exposure sustained by coronary CT in this study will remain around 3.2 mSv 
per patient (which is comparable or lower than the 3-7 mSv the average person receives annually from 
natural sources). Other cardiac imaging techniques, including catheter-based angiography or nuclear 
medicine studies, result in a substantially larger amount of radiation exposure to the patient (e.g. 21-41 
mSv), and are therefore, less optimal to use as an endpoint in this study. Additionally, the coronary CT 
endpoints will allow us to both test mechanism (which we hypothesize to be GNRHa-mediated immune 
effector response resulting in accelerated coronary atherosclerosis and/or plaque instability), as well as 
help identify a novel imaging biomarker that may be used in clinical practice to identify those men at highest 
risk of an adverse CV outcome from ADT and therefore would be optimally treated with risk-reducing 
relugolix.  
 
16. Potential Benefits to Participants 
We plan to investigate early cardiac biomarkers and the comparative toxicity of ADT regimens delivered 
with radiation therapy for prostate cancer. The findings of our research could improve patient treatment 
and outcomes by improving our understanding of the pathophysiology behind CV toxicity from ADT. We 
also aim to identify men at especially high-risk of CV morbidity from ADT; these men may benefit from 
pre-treatment cardiac medical optimization or prostate cancer treatment modifications, such as truncation 
of concomitant ADT or utilization of alternative androgen signaling inhibitors, to minimize the risk of 
treatment-related morbidity and mortality. 
17. Compensation to Participants 
Financial incentive will be provided for each patient to account for additional travel time and transportation 
(e.g. vehicle gas) associated with non-standard coronary CT on study ($100 Visa gift card after 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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completion of each scan; total $200 eligible per patient). Gift cards will be distributed to patients by mail 
after completion of each coronary CT scan (i.e. pretreatment, 12-month). 
18. Data Management and Confidentiality 
All blood and data are deidentified or coded under the existing IRB-approved protocol described above 
before they are used in this study. Data cannot be linked to an individual other than by a biorepository or 
Honest Broker delegate. Investigators on this protocol will be responsible for the management of study 
data and specimens and disposal upon completion of this study. 
Clinical, imaging, blood analyses data will be stored in a password protected REDCap database. Access 
to stored data will be limited by personnel "roles" and comply with minimum necessary standards. Emory 
physicians on this study and their designees may access and use PHI to determine if patients are eligible 
to participate in this study and may also access PHI to assist with preparation of data for research. By 
limiting access to data through physical and cyber procedures, the risk of the improper release of PHI will 
be reduced. Appropriate administrative, technical, and physical safeguards to protect patient data will be 
implemented. Winship employees are trained in the protection of patient privacy; such training will be 
modified as needed to address privacy and security issues arising from new systems and processes 
created for this study. 
19. Provisions to Monitor the Data to Ensure the Safety of Participants 
Adverse Events (AEs) 
From the time of treatment allocation through 30 days following cessation of treatment, all adverse events, 
that begin or worsen after informed consent, must be recorded by the investigator or designee at each 
examination on the Adverse Event case report forms/worksheets.   
The investigator will make every attempt to follow all subjects with non-serious adverse events for outcome.  
Conditions that were already present at the time of informed consent should be recorded in the Medical 
History page of the patient’s CRF/worksheet. 
Adverse events will be assessed and graded according to the Common Terminology Criteria for Adverse 
Events (CTCAE) version 5.0  
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm). Grade 1 to 5 will be used to 
characterize the severity of the Adverse Event. If CTCAE grading does not exist for an adverse event, the 
severity of mild, moderate, severe, and life-threatening, death related to the AE corresponding 
respectively to Grades 1 - 5, will be used. The occurrence of adverse events should be sought by non-
directive questioning of the patient during the screening process after signing informed consent and at 
each visit during the study. Adverse events also may be detected when they are volunteered by the 
patient during the screening process or between visits, or through physical examination, laboratory test, 
or other assessments. As far as possible, each adverse event should be evaluated to determine:  
1. The severity grade (CTCAE Grade 1-5)  
2. Its duration (Start and end dates)   
3. Its relationship to the study treatment (Reasonable possibility that AE is related: No, Yes) or Its 
relationship to the study treatment (Reasonable possibility that AE is related: No, Yes, investigational 
treatment, Yes, the study treatment (non-investigational), Yes, both and/or indistinguishable)  
4. Action taken with respect to study or investigational treatment (none, dose adjusted, temporarily 
interrupted, permanently discontinued, unknown, not applicable)  
5. Whether therapy was given (no concomitant medication/non-drug therapy, concomitant 
medication/non-drug therapy)  
6. Whether it is serious,  
7.Outcome (not recovered/not resolved, recovered/resolved, recovering/resolving, recovered/resolved 
with sequelae, fatal, unknown). 
 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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If the event worsens the event should be reported a second time in the CRF noting the start date when the 
event worsens in toxicity. For grade 3 and 4 adverse events only, if improvement to a lower grade is 
determined a new entry for this event should be reported in the CRF noting the start date when the event 
improved from having been Grade 3 or Grade 4.  All adverse events should be treated appropriately. If a 
concomitant medication or non-drug therapy is given, this action should be recorded on the Adverse Event 
CRF. 
Once an adverse event is detected, it should be followed until its resolution or until it is judged to be 
permanent, and assessment should be made at each visit (or more frequently, if necessary) of any changes 
in severity, the suspected relationship to the study treatment, the interventions required to treat it, and the 
outcome. Progression of malignancy (including fatal outcomes), if documented by use of appropriate 
method (for example, as per RECIST criteria for solid tumors), should not be reported as a serious adverse 
event.  
Laboratory abnormalities that constitute an Adverse event in their own right (are considered clinically 
significant, induce clinical signs or symptoms, require concomitant therapy or require changes in study 
treatment), should be recorded on the Adverse Events CRF. 
Laboratory abnormalities, that do not meet the definition of an adverse event, should not be reported as 
adverse events. A Grade 3 or 4 event (severe) as per CTCAE does not automatically indicate a SAE unless 
it meets the definition of serious as defined below and/or as per investigator’s discretion. A dose hold or 
medication for the lab abnormality may be required by the protocol in which case the lab abnormality would 
still, by definition, be an adverse event and must be reported as such. 
Serious Adverse Events (SAEs) 
Any adverse event that results with any of the following outcomes:  
• 
Death 
• 
Life-threatening experience 
• 
Inpatient Hospitalization 
• 
Persistent or significant disability/incapacity 
• 
Congenital anomaly/birth defect 
• 
Other medically important events 
Important medical events that may not result in death, be life threatening, or require hospitalization may be 
considered an SAE, when, based upon medical judgment, they may jeopardize the patient and may require 
medical or surgical intervention to prevent one of the outcomes listed in the definition.  These events will 
also be recorded for each subject and is subject to review by the investigators and data safety monitoring 
committee (DSMC).  In addition, these events will be reported to the responsible Institutional Review Board 
(IRB) and the study PI.  All SAEs will be reported within 24 hours of discovery to Study Coordinator and the 
study PI, Dr. Sagar Patel (sagar.patel@emory.edu, 205-370-8119). SAEs will be reported using the SAE 
form in Appendix B. SAE should be emailed to both the study coordinator and Dr. Patel as well as inputted 
into OnCore. 
Data and Safety Monitoring 
The data safety monitoring plan will be implemented by Dr. Patel, the Principal Investigator (P.I.) of this 
study.  The plan is based on self-monitoring, internal CTO real time monitoring using the quality assurance 
committee, and monitoring via Winship Cancer Institute (“WCI”) Data Safety Monitoring Committee (DSMC) 
as per WCI CTO standard operating procedure. Dr. Patel and the investigators, the clinical research 
coordinator and the regulatory affairs coordinator will meet weekly to review and discuss study data to 
ensure subject safety. The research coordinators will maintain one spreadsheet that will summarize 1) all 
the patient data for patients actively being treated on the trial and 2) a roadmap detailing pending 
tests/treatments for each individual patient. The WCI DSMC is responsible for providing data safety-
monitoring oversight for this protocol. Any comments that are generated by the WCI DSMC are forwarded 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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IRB Form BIO 03152021 
to the IRB.  The P.I. and the study investigators will discuss any required modifications to this study at the 
weekly meetings. No modifications to this study are implemented until they are submitted for review and 
approved by the Emory University IRB. The comments from the WCI DSMC are forwarded to the IRB at 
the time of the annual renewal of this study or sooner if warranted and requested by the WCI DSMC.    
 
The Data and Safety Monitoring Committee (DSMC) of the Winship Cancer Institute will provide oversight 
for the conduct of this study. The DSMC functions independently within Winship Cancer Institute to conduct 
internal monitoring functions to ensure that research being conducted by Winship Cancer Institute 
Investigators produces high-quality scientific data in a manner consistent with good clinical practice (GCP) 
and appropriate regulations that govern clinical research. Depending on the risk level of the protocol, the 
DSMC review may occur every 6 months or annually. For studies deemed High Risk, initial study monitoring 
will occur within 6 months from the date of the first subject accrued, with 2 of the first 5 subjects being 
reviewed. For studies deemed Moderate Risk, initial study monitoring will occur within 1 year from the date 
of the first subject accrued, with 2 of the first 5 subjects being reviewed. Subsequent monitoring will occur 
in routine intervals per the Winship Data and Safety Monitoring Plan (DSMP).  
 
The DSMC will review pertinent aspects of the study to assess subject safety, compliance with the protocol, 
data collection, and risk-benefit ratio. Specifically, the Winship Cancer Institute Internal Monitors assigned 
to the DSMC may verify informed consent, eligibility, data entry, accuracy and availability of source 
documents, AEs/SAEs, and essential regulatory documents. Following the monitoring review, monitors will 
provide a preliminary report of monitoring findings to the PI and other pertinent individuals involved in the 
conduct of the study. The PI is required to address and respond to all the deficiencies noted in the 
preliminary report. Prior to the completion of the final summary report, monitors will discuss the preliminary 
report responses with the PI and other team members (when appropriate). A final monitoring summary 
report will then be prepared by the monitor. Final DSMC review will include the final monitoring summary 
report with corresponding PI response, submitted CAPA (when applicable), PI Summary statement, and 
available aggregate toxicity and safety data.  
The DSMC will render a recommendation and rating based on the overall trial conduct. The PI is responsible 
for ensuring that instances of egregious data insufficiencies are reported to the IRB. Continuing Review 
submissions will include the DSMC recommendation letter. Should any revisions be made to the protocol-
specific monitoring plan after initial DSMC approval, the PI will be responsible for notifying the DSMC of 
such changes. The Committee reserves the right to conduct additional audits if necessary. 
 
20. Provisions to Protect the Privacy Interest of Participants 
Participants will be assured of their voluntary participation in the study, their choice to answer or not any 
question, and the protocol for maintain confidentiality.  
Participant confidentiality is strictly held in trust by the participating investigators, their staff, and the 
sponsor(s) and their agents. This confidentiality is extended to cover testing of biological samples and 
genetic tests in addition to the clinical information relating to participants. Therefore, the study protocol, 
documentation, data, and all other information generated will be held in strict confidence. No information 
concerning the study or the data will be released to any unauthorized third party without prior written 
approval of the sponsor. 
 
The study monitor, other authorized representatives of the sponsor, representatives of the IRB or 
pharmaceutical company supplying study product may inspect all documents and records required to be 
maintained by the investigator, including but not limited to, medical records (office, clinic, or hospital) and 
pharmacy records for the participants in this study. The clinical study site will permit access to such records. 
The study participant’s contact information will be securely stored at each clinical site for internal use during 
the study. At the end of the study, all records will continue to be kept in a secure location for as long a 
period as dictated by local IRB and Institutional regulations. 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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Study participant research data, which is for purposes of statistical analysis and scientific reporting, will be 
transmitted to and stored. This will not include the participant’s contact or identifying information. Rather, 
individual participants and their research data will be identified by a unique study identification number. The 
study data entry and study management systems used by clinical sties and research staff will be secured 
and password-protected. At the end of the study, all study databases will be de-identified and archived.  
21. Economic Burden to Participants 
The costs of the patient’s primary treatment, including pre-treatment consultation and necessary 
evaluations, simulation, XRT treatment course, and follow-up surveillance laboratory studies are expected 
to be covered by the patient’s insurer/primary payor. For patients randomized to receive relugolix for ADT 
with XRT, drug will be provided by Myovant Sciences as part of the funding source (Pfizer-PCF-Myovant 
Challenge Award).  
 
All blood draw appointments for the biorepository correspond to intervals of standard blood draws for cancer 
surveillance. 
 
Patients will incur costs associated with travel and time (with non-routine coronary CT that will be taken 
pre-treatment and 12-months after initiating ADT (two imaging scans total per patient). Patients will be 
compensated $200 total (distributed at 2 intervals of $100 each, detailed above) to account for gas 
mileage usage for appointments/tests required on trial. 
 
22. Informed Consent  
This study will enroll patients with localized prostate cancer, or biochemically recurrent prostate cancer 
after prior prostatectomy, who are candidates for curative-intent radiation therapy (with or without ADT). 
Men who do not receive ADT will be enrolled on a prospective, single-arm cohort; men who are eligible 
for ADT will be randomized between two FDA-approved, guideline-supported ADT agents: (1) GNRHa 
(e.g. Lupron, Trelstar) or (2) Relugolix. 
  
Informed consent is to be obtained prior to commencing any research procedures. Patients will be 
recruited from those seen at the Department of Radiation Oncology at Winship Cancer Institute (EUH, 
EUHM, ESJH, EPTC), either at the time of initial consultation or pre-treatment follow up appointment. A 
brief description of the study will be given verbally to the patients by the treating physician (and co-
investigator of trial). This will be followed by written informed consent. The patients will be given ample 
time to review the consent and a time for questions and answer will be provided. The co-investigator may 
choose to consent the patient with or without presence of the clinical research coordinator. Once consent 
has been obtained, the treating physician will notify by email the contact principal investigator (Sagar 
Patel) and clinical research coordinators for final screening, enrollment, and (if needed) randomization. 
A study investigator shall seek such consent only under such circumstances that provide the prospective 
patient opportunity to consider whether or not to participate and that minimizes the possibility of coercion 
or undue influence. The information given to the patient, or the representative, shall be in a language 
understandable to the subject or representative. The informed consent document may not include any 
exculpatory language through which the subject or representative is made to waive any of the subject’s 
legal rights or releases, or appears to release the investigator, the sponsor or the institution from liability for 
negligence. 
Non-English-Speaking Participants   
A certified translator/interpreter will be present during the consenting process and all questions and 
concerns will be answered by the treating physician.  
 
A Short Form in that specific language will be used. A certified translator/interpreter will be present during 
the consenting process and this will be documented. We will use what's available on Emory IRB website. 
For the languages that are not available, we will have the short form translated to that language and 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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submit the IRB for review and approval prior to use. Process to Document Consent in Writing: Winship 
SOP 2.1:” Obtaining Informed consent for Interventional clinical trial” will be followed. 
 
Participants who are not yet adults (infants, children, teenagers): N/A 
Cognitively Impaired Adults: N/A 
Adults Unable to Consent: N/A 
Waiver or Alteration of Consent Process (consent will not be obtained, required information will 
not be disclosed, or the research involves deception): N/A 
 
23. Setting 
Winship Cancer Institute of Emory University School of Medicine (Atlanta, GA) is the only participating 
institution. Study/trial information will be made available to the Georgia Center for Oncology Research and 
Education (CORE) at https://www.georgiacancerinfo.org. Detailed trial information, including the protocol 
and all supplemental information will be submitted to, and made available to the Online Collaborative 
Research Environment (OnCore) at https://oncore.emory.edu in accordance with institutional regulations. 
 
24. Resources Available 
Emory University was founded in 1836 and is a national center for teaching, research, and service. Emory 
University has been named as one of the nation’s top 25 universities for more than a decade by the U.S. 
News and World Report. Emory University research partners include the Georgia Institute of Technology, 
the University of Georgia, Morehouse School of Medicine, the US Centers for Disease Control and 
Prevention, Children's Healthcare of Atlanta, and the Georgia Clinical and Translational Science Alliance 
(GACTSA). Emory University researchers received $734 million from external funding agencies in fiscal 
year 2018, including approximately $441 million in funding from federal agencies, $359 million of this from 
the National Institutes of Health (NIH). 
Facilities 
Olson Laboratory: Dr. Olson has designated laboratory and office space located on the 3rd floor of the 
Winship Cancer Institute of Emory University, which includes over 450 square feet of recently renovated 
laboratory space, as well as more than 200 sq. ft of adjacent hallway space. The lab space is fully equipped 
for immunology research, including multiple laminar air-flow biosafety cabinets, chemical fume hoods, 
refrigerators/freezers, liquid nitrogen tank, etc. The laboratory space is also equipped for biochemistry and 
molecular biology work with electrophoresis apparatus, DNA thermal cyclers, etc. Common areas adjacent 
to this lab space contain dark rooms equipped with X-ray film processors, ultracentrifuge, 
incubator/shakers, spectrophotometers, cold rooms, and an autoclave room for dishwashing/water 
purification.  
Clinical: The Winship Cancer Institute (a National Cancer Institute (NCI)-designed cancer center since 
2009), serves as the coordinating center for cancer research, education and care throughout Emory 
University Network, which includes Emory University Hospital (EUH), EUH-Midtown, Emory Saint Joseph’s 
Hospital, and Emory Johns Creek Hospital. Winship investigators conduct more than 250 therapeutic 
clinical trials onto which they enroll nearly 1000 patients annually and is the largest unit in Georgia for phase 
I clinical trials and a Lead Academic Participating Site for the NCI National Clinical Trials Network.  
Drs. Patel and Jani have clinical and office space in the Winship Cancer Institute, as well as at Emory 
Saint Joseph’s Hospital and Emory Proton Therapy Center. Dr. Mandawat has dedicated Cardio-Oncology 
clinic and office space in the Winship Cancer Institute and at the Winship Cancer Institute of Emory 
University Midtown location. Dr. Cantu will oversee cardiac CT imaging completed on trial, which will be 
conducted using a Canon Aquillon One 320/640 multidetector CT scanner (Toshiba Medical Systems, 
Japan) at Emory University Hospital, located immediately adjacent to the Winship Cancer Institute where 
Dr. Olson’s laboratory and the clinic and offices of Drs. Olson/Mandawat/Patel/Jani’s are located. This 
physical proximity will be advantageous to ensure timely completion of imaging endpoints and frequent ad 
hoc meetings.  

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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Shared Facilities: Emory University and Winship Cancer Institute provide independent investigators with 
a 
wide 
array 
of 
state 
of 
the 
art 
core 
facilities 
and 
resources 
(listed 
at 
https://winshipcancer.emory.edu/research/shared-resources and www.cores.emory.edu) that are all 
located in close proximity to Dr. Olson’s laboratory space and which he has access to at a subsidized rate. 
In particular, shared facilities relevant to the proposal include: 
Cancer Tissue and Pathology Shared Resource (CTP): The CTP shared resource is involved in the 
procurement and distribution of high-quality human cancer specimens. Within this core is also the Human 
Tissue Procurement Service, which is involved with collecting and preserving the peripheral blood 
collections on the CO-PRO study.  
Pediatrics/Winship Flow Cytometry Shared Resource: The Pediatric/Winship Flow Cytometry Core 
(located in Winship) provides cytometry services for the analysis and sorting of cells as well as expert 
consultation for experimental design and planning. The Flow Cytometry Core offers access to several 
analytical flow cytometers (including four 28-45 color flow cytometers, and two 6-13 color flow cytometers), 
high-speed cell sorters (two 18-color BD AriaII sorters), and an Amins Imagestream X Mark II imaging 
cytometer.  
Emory Integrated Genomics Core (EIGC): The EIGC uses state-of-the-art genomics platforms to help 
Emory investigators effectively pursue their research goals. Located at the Woodruff Memorial Research 
Building adjacent to Dr. Olson’s laboratory, their services include whole genome single nucleotide 
polymorphism (SNP) genotyping, whole genome and exome sequencing, and structural variation detection. 
The EIGC also maintains CLIA certification, offering assay validation and nucleic acid extraction services 
from a wide variety of biological sources, including blood, serum, plasma, solid tissues, cell extracts, etc., 
to support both basic research and clinical efforts on campus. They also provide bioinformatic services in 
analyzing and preparing the results for subsequent publication. 
Emory Integrated Proteomics Core (EIPC): The EPIC provides protein analytical services by cutting-
edge mass spectrometry (MS). Located in the Whitehead Biomedical Research Building (less than 0.4 
miles from Dr. Olson’s laboratory), the EIPC houses several mass spectrometers—hybrid 
quadrupoleorbitrap including a Q-Exactive, and a Q-Exactive HF-X; tribrid mass spectrometers including 
two Orbitrap Fusion, and an Orbitrap Fusion Lumos; and a TSQ Altis triple-stage quadrupole. Each 
instrument is coupled with an autosampler and HPLC system. The system allows automated capillary LC-
MS/MS runs for top-down, middle-down and bottom-up analyses with high resolution. These mass 
spectrometers are capable of detecting peptides at subfemtomolar level, identifying hundreds to thousands 
of proteins in complex mixtures, mapping posttranslational modification sites, and quantifying proteins. 
They also provide bioinformatic services in analyzing and preparing the results for subsequent publication. 
The Olson Laboratory has full access on a subsidized fee for services and will utilize this core for the 
proteomic studies in Aim 2. 
 

Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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25. Multi-Site Research when Emory is the Lead Site 
N/A. 
 
26. References 
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Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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Protocol Title: Mechanism and Predictors of Cardiotoxicity after Prostate Cancer Treatment: A 
Parallel Cohort and Randomized Trial Comparing Radiation Alone, Radiation plus Leuprolide, and 
Radiation plus Relugolix 
 
 
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