A Multi-Histology Phase II Study of 5-Fluoro-2'-Deoxycytidine With Tetrahydrouridine (FdCyd + THU)
Phase: PHASE2
Conditions: Head and Neck Neoplasms, Lung Neoplasms, Urinary Bladder Neoplasms, Breast Neoplasms
Sponsor: National Cancer Institute (NCI)

Clinical Center #09-C-0214
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Multi-Histology Phase II Study of 5-Fluoro-2’-Deoxycytidine with Tetrahydrouridine 
(FdCyd + THU)
Abbreviated Title:
Ph II FdCyd+THU
Coordinating 
Center:
Developmental Therapeutics Clinic, NCI 
10 Center Drive, 12N226
Bethesda, MD 20892
Participating 
Centers:
City of Hope National Medical Center (COH)
City of Hope Medical Group (COHMG), Pasadena
University of Southern California (USC)/Norris Comprehensive 
Cancer Center
University of California, Davis Cancer Center
Penn State Cancer Institute
University of Pittsburgh Cancer Institute (PK sample analysis only)
Principal 
Investigator:
James H. DoroshowA-E, MD, DCTD/NCI
31 Center Drive, Bldg 31/3A44
Bethesda, MD 20892
Phone: (240) 781-3320; Fax: (240) 541-4515
doroshoj@mail.nih.gov
Lead Associate 
Investigator:
A. P. ChenA-E, MD, DTC/NCI
31 Center Drive Bldg 31 Room 3A44
Bethesda, MD 20892
Phone: (240) 781-3320; Fax: (240) 541-4515
chenali@mail.nih.gov
NCI Associate 
Investigators:
Non-NCI Associate 
Investigators:
Jerry Collins, PhD E
Lyndsay HarrisA-E
Geraldine O’Sullivan Coyne MD, PhDA-E
Naoko Takebe, MD, PhDA-E
Sheila Prindiville, MD, MPHA-E
Jiuping Ji, PhDE
Lamin Juwara, CRNPA,B,E
Robert Kinders, PhDE
Ralph Parchment, PhDE
DTP/DCTD/NCI
CDP/DCTD/NCI
DCTD/NCI
DCTD/NCI
CCCT
Leidos Biomed/FNLCR
Leidos Biomed/FNLCR
Leidos Biomed/FNLCR
Leidos Biomed/FNLCR

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Responsible 
Research Nurse:
Statisticians:
CTEP Monitor:
Jennifer Zlott, RNA,B,E
Bldg 10/RM13N214
National Cancer Institute
Phone: (301) 594-5664
Fax: (301) 480-7281
zlottjh@mail.nih.gov
Seth M. Steinberg, PhDE
9609 Medical Center Drive, Room 
2W334, MSC 9716 
Phone: (240) 276-5563
steinbes@mail.nih.gov
Larry Rubinstein, PhDE
9609 Medical Center Drive, Room 
5W106, 
MSC 9735
Phone: (240) 276-6026
rubinsteinl@mail.nih.gov
Richard Piekarz, MD, PhD
DCTD/NCI
BDMS/CCR/NCI
BRB/DCTD/NCI
California Cancer Consortium (CCC) Participating Sites:
City of Hope (CoH)
Protocol Chairperson: Mihaela Cristea, MD
Co-investigator: Edward Newman, PhD
City of Hope National Medical Center
1500 E. Duarte Road, Duarte, California 91010
Phone: (626) 256-4673
mccristea@coh.org
MPA # M-1043
FWA# 00000692
Pharmacy: Sharon Denison PharmD/Oscar Martin, 
PharmD
Investigational Drug Service
City of Hope
1500 E. Duarte Rd.
Duarte, CA 91010
Phone (626) 256-4673 x62398; Fax: (626) 930-5378
sdenison@coh.org or omartin@coh.org
Site Coordinator: Mario Dimacali, BS, CCRP
Clinical Trials Office
City of Hope
1500 E Duarte Rd
Duarte, CA 91010
Phone: (626) 256-4673 ext. 63019; Fax: (626) 256-8655
mdimacali@coh.org
IRB: Amanda Hammond
IRB of Record Name: City of Hope Natl Med Ctr & the 
Beckman Rsch Inst IRB#1
IRB IORG#: IORG0000042
1500 E. Duarte Rd., Duarte, CA 91010
Phone: (626) 256-4673 X 89084; Fax: (626) 245-8695
ahammond@coh.org

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City of Hope Medical Group (COHMG), Pasadena
Principal Investigator: Stephen Koehler, MD
City of Hope Medical Group
209 Fair Oaks Avenue
South Pasadena, CA 91030
Phone: (626) 396-2900; Fax: (626) 799-2770
Skoehler@cohmg.com
MPA # M-1043
FWA# 00000692
Pharmacy: Sharon Denison PharmD/Oscar Martin, 
PharmD
Investigational Drug Service, City of Hope
1500 E. Duarte Rd,. Duarte, CA 91010
Phone (626) 256-4673 x62398
Fax: (626) 930-5378
sdenison@coh.org or omartin@coh.org
Site Coordinator: Doni Woo
209 Fair Oaks Avenue
South Pasadena, CA  91030
Tel: 626-396-2900; Fax: 626-396-2911
dwoo@coh.org
IRB: as for CoH
University of Southern California (USC)
Co-Principal Investigators: 
Jorge Nieva, MD 
USC/Norris Comprehensive Cancer Center 
NOR 1441 Eastlake Avenue
Los Angeles, CA 90033-0804
Phone: (323) 865-0421
jorge.nieva@med.usc.edu
Agustin A. Garcia, MD
USC/Norris Comprehensive Cancer Center
1441 Eastlake Ave. Rm 3449
Los Angeles, CA 90033
Phone: (323) 865-3900; Fax: (323) 865-0061
garcia_a@ccnt.usc.edu
FWA #00005906
IRB Director: Sandy Jean
USC Health Sciences Institutional Review Board 
IRB IORG#: IRB00000484
LAC+USC Medical Center
General Hospital Suite 4700 
1200 North State St., Los Angeles, CA 90033
Phone: (323) 276-2231
sjean@usc.edu 
Site Coordinator: Maria Brown
USC/Norris Comprehensive Cancer Center
1441 East Lake Ave., Room 7329
Los Angeles, CA 90033
maria.brown@med.usc.edu
Norris Hospital Pharmacy Contact: Alfred Chin, 
PharmD
USC/Norris Comprehensive Cancer Center
1441 Eastlake Avenue, Room 2409 B
Los Angeles, CA. 90033
Phone: (323) 865-3612; Fax: (323) 865-0051
achin@usc.edu
LAC/USC Pharmacy Contact: Vivian Ludan, PharmD
LAC/USC Medical Center Investigational Drug Service
1200 N. State Street, Trailer 25-A
Los Angeles, CA. 90033
Phone: (323) 222-8933; Fax: (323) 222-9925
vludan@health-research.org

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University of California Davis (UCD)
Principal Investigator: David Gandara, MD
University of California, Davis Cancer Center 
4501 X Street, Sacramento, CA 95817
Phone: (916) 734-3700
david.gandara@ucdmc.ucdavis.edu
MPA# M-1325
FWA00004557
Pharmacy: Andrea Iannucci, PharmD 
Investigational Drug Service, 
Pharmacy Dept. DT Room 0762 UCD Medical 
Center
2315 Stockton Blvd 
Sacramento, CA 95817 
(916) 703-4093
Site Coordinator: Frances Lara
UC Davis Comprehensive Cancer Center 
Clinical Trials Support Unit 
4501 X Street, Trailer #31, Sacramento, CA 95817 
Phone: (916) 734-8134; Fax: (916) 734-4177
frances.lara@ucdmc.ucdavis.edu
IRB: Donald Orescanin 
Assistant to the Director of IRB Administration 
IRB of Record Name: Davis Office of Research, IRB
Administration 
IRB IORG #: 0000251
2921 Stockton Blvd. Suite 1400, Room 1429 
Sacramento, CA 95817 
(916) 703-9152
donald.orescannin@ucdmc.ucdavis.edu
Penn State Cancer Institute Participating Site:
Principle Investigator: Chandra P. Belani, MD
Penn State Milton S. Hershey Medical Center
500 University Drive, H072
Hershey, PA 17033
Phone: (717) 531-1078; Fax (717) 531-0002
cbelani@psu.edu
FWA # 00004251
Pharmacy: Heather Heisey, R.Ph.
Penn State Milton S. Hershey Medical Center
Investigational Drug Service Pharmacy
Room HG313, MC H079
500 University Drive
Hershey, PA  17033
Site Coordinator: Michele St. Pierre
Penn State Hershey Cancer Institute
500 University Drive MC CI56
Cancer Institute Room T2200
Hershey, PA 17033
Phone: 717-531-0003 x287412; Fax: 717-531-1649
astpierre@hmc.psu.edu
IRB: Maria Hughes, BS, CCRP
Penn State Milton S. Hershey Medical Center
Penn State Cancer Center Clinical Trials Office
IRB of Record Name: Penn State College of Medicine
IRB IORG #: 0000031
Room C2705, MC H056
500 University Drive
Hershey, PA  17033
Phone: 717-531-6564
mhughes@hmc.psu.edu
University of Pittsburgh Cancer Institute Participating Site (PK sample analysis only):
Principle Investigator: Timothy Burns, MD, PhD
Hillman Cancer Center Research Pavilion,
5117 Centre Avenue, Office: Suite 2.18e Lab: 2.7
Pittsburgh, PA 15213
Phone: (412) 623-7770; Fax: (412) 623-7798
burnstf@upmc.edu
FWA # 00003338
IRB Director: Jean Barone, CIP 
IRB of Record: University of Pittsburgh
IRB IORG #: 0000196
3500 Fifth Avenue
Hieber Building
Main Office, Suite 106
Pittsburgh, PA 15213
Phone: (412) 383-1480; Fax: (412) 383-1508
E-mail: baronej2@pitt.edu
Research contact: Jan H. Beumer, PharmD, PhD
University of Pittsburgh Cancer Institute
Room G27E Hillman Research Laboratories
5117 Centre Avenue
Pittsburgh, PA 15213
Phone: (412) 623-3216; Fax: (412) 623-1212
E-mail: jhb11@pitt.edu
Site coordinator: Carrie Muniz, RN, BSN
University of Pittsburgh Cancer Institute
Hillman Cancer Center
Pittsburgh, PA 15213
Phone: (412) 623-6121
E-mail: munizca@upmc.edu

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NCI Supplied Agents:
5-Fluoro-2’-Deoxycytidine (FdCyd; NSC 48006)
Tetrahydrouridine (THU; NSC 112907)
IND number:
105843
Version date:
May 8, 2018
NCT Number:
NCT00978250

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Précis
Background:
x 5-Fluoro-2’-deoxycytidine (FdCyd), a fluoropyrimidine nucleoside analog, has a short 
(10-minute) half-life and is rapidly degraded in vivo by cytidine deaminase. However, co-
administration with tetrahydrouridine (THU), an inhibitor of cytidine/deoxycytidine 
deaminase, has been shown to increase the AUC of the parent compound more than 
4-fold.  Increased FdCyd exposure allows it to be taken up intracellularly and converted to 
its triphosphate, which is incorporated into DNA and inhibits the action of the enzyme 
DNA methyltransferase (DNMT). Inhibition of DNMT, and in turn DNA methylation,
can result in the re-expression of tumor suppressor genes.
Primary objective:
x Determine progression-free survival (PFS) and/or the response rate (CR + PR) of FdCyd 
administered 5 days per week for 2 weeks, in 28-day cycles, by intravenous infusion over 
3 hours along with THU in patients with breast cancer, head and neck cancer, non-small 
cell lung cancer, and urothelial transitional cell carcinoma.
Exploratory objectives:
x Evaluate whether treatment with FdCyd and THU alters DNA methylation patterns in 
tumor biopsy samples before and during treatment by LINE-1 analysis. 
x Evaluate the safety and tolerability of FdCyd (100 mg/m2) + THU (350 mg/m2)
administered 5 days per week for 2 weeks, in 28-day cycles, by intravenous infusion over 
3 hours.
x Measure changes in the number of CTCs following treatment with FdCyd plus THU. 
Eligibility:
x Patients with histologically documented non-small cell lung cancer, head and neck cancer,
urothelial transitional cell carcinoma, and breast carcinoma.
Design: 
x This is a multicenter trial with NCI as the coordinating center and the California Cancer 
Consortium and UPMC as participating sites.
x FdCyd will be administered as an IV infusion over 3 hours with 20% of the daily dose of 
THU administered as an IV push and the remaining 80% co-administered with FdCyd by 
3-hour infusion daily for 5 consecutive days of treatment per week for 2 consecutive 
weeks, followed by 2 weeks of no treatment, in a 28-day cycle.
x Blood and optional tumor biopsies for pharmacodynamic and pharmacokinetic studies will 
be obtained.
x The study will accrue a maximum of 165 patients including all centers.  

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Schema
a. FdCyd: 3-hour infusion in 5% dextrose injection, USP.
b. THU: 20% of the daily dose will be given by IV push, then 80% of the daily dose by 3-hour infusion in 
5% dextrose injection, USP at the same time as FdCyd.
c. Optional tumor biopsies will be collected prior to treatment in Cycle 1 and after completion of Cycle 2 
(i.e., following the restaging imaging scans).
d. Blood samples for PD analysis will be collected prior to drug administration on Day 1 in Cycles 1, 2,
and 4, and after the completion of treatment on Cycles 1, 2 and 4 (Day 12 +/- 1 day).
e. Blood samples for circulating tumor cells will be collected prior to drug administration on Day 1, on 
Cycle 1 Day 2 following treatment (up to 24 hours after end of infusion), on Cycle 1 Day 12 
(+/- 1 day), on Day 1 (+/- 1 day) of Cycle 2 and all subsequent cycles, on Day 12 (+/- 1 day) of Cycles 
2, 4, and 6, and at time of disease progression.
f. Blood and urine samples for PK analysis will be collected from 3 patients in each cohort (6 of the first 
12 patients with urothelial transitional cell carcinoma) during Cycle 1 only.  Blood will be collected 
pre-drug infusion and at 15 min, 30 min, 1 hr, 2 hr, and 2.5 hr during the infusion and then 15 min, 
30 min, 1 hr, 2 hr, 4 hr, and 6 hr post completion of infusion on Cycle 1 Day 1, and pre-drug infusion 
on Days 2, 3, 4, and 5.  Urine will be collected prior to treatment and at every void from 0 to 24 hours 
post drug infusion on Cycle 1 Day 1.

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Table of Contents
PRÉCIS ............................................................................................................................................6 
SCHEMA..........................................................................................................................................7 
1 
STUDY OBJECTIVES ...........................................................................................................10 
1.1 PRIMARY OBJECTIVE...............................................................................................................10 
1.2 EXPLORATORY OBJECTIVES.....................................................................................................10 
2 
BACKGROUND AND RATIONALE.....................................................................................10 
2.1 
BACKGROUND..................................................................................................................10 
2.2 
FDCYD.............................................................................................................................15 
2.3 
THU................................................................................................................................16 
2.4 
PRECLINICAL STUDIES......................................................................................................17 
2.5 
CLINICAL STUDIES............................................................................................................19 
2.6 
RATIONALE......................................................................................................................22 
2.7 
CORRELATIVE STUDIES.....................................................................................................23 
3 
PATIENT SELECTION .........................................................................................................27 
3.1 
ELIGIBILITY CRITERIA.......................................................................................................27 
3.2 
EXCLUSION CRITERIA .......................................................................................................29 
3.3 
RESEARCH ELIGIBILITY EVALUATION................................................................................29 
3.4 
PATIENT REGISTRATION....................................................................................................29 
3.5 
OFF PROTOCOL THERAPY AND OFF-STUDY PROCEDURE.....................................................30 
4 
TREATMENT PLAN .............................................................................................................30 
4.1 
FDCYD AND THU ADMINISTRATION..................................................................................31 
5 
DOSING DELAYS/MODIFICATIONS..................................................................................32 
5.1 
DOSE MODIFICATIONS ......................................................................................................32 
5.2 
DOSE REDUCTION.............................................................................................................33 
5.3 
GENERAL CONCOMITANT MEDICATION AND SUPPORTIVE CARE GUIDELINES.......................33 
5.4 
DURATION OF THERAPY....................................................................................................34 
5.5 
DURATION OF FOLLOW-UP................................................................................................34 
5.6 
CRITERIA FOR REMOVAL FROM STUDY..............................................................................34 
6 
HUMAN SUBJECTS PROTECTION ....................................................................................35 
6.1 
RATIONALE FOR SUBJECT SELECTION ................................................................................35 
6.2 
JUSTIFICATION FOR EXCLUSIONS .......................................................................................35 
6.3 
PARTICIPATION OF CHILDREN............................................................................................35 
6.4 
EVALUATION OF BENEFITS AND RISKS/DISCOMFORTS ........................................................35 
6.5 
CONSENT AND ASSENT PROCESS AND DOCUMENTATION.....................................................36 
6.6 
PROCEDURE FOR PROTECTING AGAINST OR MINIMIZING ANY POTENTIAL RISKS..................36 
7 
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS ....................................37 
7.1 
COMPREHENSIVE ADVERSE EVENTS AND POTENTIAL RISKS LISTS (CAEPRS) FOR 5-FLUORO-
2'-DEOXYCYTIDINE (FDCYD, NSC 48006) WITH TETRAHYDROURIDINE (THU, NSC 112907).............37 
7.2 
ADVERSE EVENT CHARACTERISTICS..................................................................................40 

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7.3 
EXPEDITED ADVERSE EVENT REPORTING...........................................................................41 
7.4 
MULTICENTER GUIDELINES FOR EXPEDITED ADVERSE EVENT REPORTING...........................46 
7.5 
ROUTINE ADVERSE EVENT REPORTING..............................................................................47 
8 
PHARMACEUTICAL INFORMATION................................................................................47 
8.1 
COMPOUND NAME: 5-FLUORO-2'-DEOXYCYTIDINE (NSC 48006) .........................................47 
8.2 
COMPOUND NAME: TETRAHYDROURIDINE (NSC 112907) ...................................................49 
9 
CORRELATIVE STUDIES....................................................................................................50 
9.1 
TISSUE SAMPLE ACQUISITION AND PROCESSING.................................................................50 
9.2 
PHARMACODYNAMIC STUDIES ..........................................................................................51 
9.3 
PHARMACOKINETICS STUDIES (CYCLE 1 ONLY)..................................................................53 
9.4 
SAMPLE COLLECTION AND PROCESSING AT THE NIH CLINICAL CENTER ..............................54 
10 
STUDY CALENDAR .............................................................................................................55 
11 
MEASUREMENT OF EFFECT.............................................................................................57 
11.1 
ANTITUMOR EFFECT – SOLID TUMORS...............................................................................57 
12 
DATA REPORTING / REGULATORY REQUIREMENTS ..................................................61 
12.1 
DATA REPORTING.............................................................................................................61 
12.2 
DATA SAFETY AND MONITORING PLAN .............................................................................61 
12.3 
MULTICENTER GUIDELINES...............................................................................................62 
12.4 
COOPERATIVE RESEARCH AND DEVELOPMENT AGREEMENT (CRADA) / CLINICAL TRIALS 
AGREEMENT (CTA) ......................................................................................................................63 
13 
STATISTICAL CONSIDERATIONS.....................................................................................63 
14 
REFERENCES .......................................................................................................................67 
APPENDIX A: PERFORMANCE STATUS...................................................................................71 
APPENDIX B: STUDY DIARY......................................................................................................72 
APPENDIX C: CTEP MULTICENTER GUIDELINES.................................................................73 
APPENDIX D: PREPARATION OF PK BLOOD DRAW TUBES AND URINE STORAGE 
CRYOGENIC VIALS WITH ZEBULARINE (ZEB)......................................................................75 
APPENDIX E: PROCEDURE FOR BLOOD AND URINE SAMPLES FOR 
PHARMACOKINETICS................................................................................................................76 
APPENDIX F: PROCEDURE FOR TUMOR BIOPSY AND BLOOD SAMPLES FOR
PHARMACODYNAMIC STUDIES...............................................................................................78 
APPENDIX G: CHEMOTHERAPY ADMINISTRATION LOG FOR PHARMACOKINETIC 
STUDIES ........................................................................................................................................82 
APPENDIX H: ELIGIBILITY/PRE-REGISTRATION WORKSHEET ........................................89 
APPENDIX I: INFORMED CONSENT FORM TEMPLATE FOR CANCER TREATMENT 
TRIALS ..........................................................................................................................................94 

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1 Study Objectives 
1.1 Primary Objective
x Determine progression-free survival (PFS) and/or the response rate (CR + PR) of FdCyd 
administered 5 days per week for 2 weeks, in 28-day cycles, by intravenous infusion over 3 
hours along with THU in patients with breast cancer, head and neck cancer, non-small cell 
lung cancer, and urothelial transitional cell carcinoma.
1.2 Exploratory Objectives
x Evaluate whether treatment with FdCyd and THU alters DNA methylation patterns in 
tumor biopsy samples before and during treatment by LINE-1 analysis. 
x Evaluate the safety and tolerability of FdCyd (100 mg/m2) + THU (350 mg/m2)
administered 5 days per week for 2 weeks, in 28-day cycles, by intravenous infusion over 3 
hours.
x Measure changes in the number of CTCs following treatment with FdCyd plus THU. 
2 Background and Rationale
2.1 Background
2.1.1
Methylation in Cancer
The observation that changes in DNA methylation potentially play a role in neoplastic 
transformation has existed for nearly 30 years [1].  Over the past decade, the importance of 
DNA methylation in the development of cancer has become more evident.  
DNA methylation involves the addition of a methyl group to any of the four bases which 
make up the coding sequence of DNA.  In humans, methylation typically occurs after DNA 
synthesis and is catalyzed by one of the DNA methyltransferases (DNMT).  DNA 
methylation that occurs in regulatory (i.e., promoter) sequences can promote or suppress 
the expression of particular genes.  In mammals, DNA methylation occurs almost 
exclusively in the 5’ position of cytosine residues within the dinucleotide CpG.  CpG-rich 
regions, also termed CpG islands, span the promoters of many genes.  In many normal 
cells, these CpG islands are not methylated and the nearby gene is active.  Methyl-binding 
proteins recognize methylated CpG islands and are thought to be responsible for the 
initiation of the events resulting in chromatin condensation and gene silencing.  The 
derangement of methylation patterns in human tumors results in a global hypomethylation 
of genes with hypermethylation of certain promoters of key genes such as retinoblastoma 1 
(RB1), p16, von Hippel-Lindau (VHL) and MutL protein homologue 1 (MLH1), among 
others [2]. A more detailed description of the methylation changes thought to play integral 
roles in the cancers to be studied in trial is included below.
2.1.2
Breast Cancer
In the United States, over 180,000 women are diagnosed with breast cancer annually, 
making it the most common cancer amongst females and the second most common cause 
of cancer death among women [3].  While great strides have been made over the past 

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30 years in the treatment of patients with localized breast cancer, up to 5% of patients 
present with metastatic disease at diagnosis and long-term survival for these patients with 
therapy is less than 5% [4]. The median PFS for patients who have failed multiple lines of 
therapy is measured in months. A recent review of published clinical trials in patients with 
metastatic breast cancer concluded that “There is little evidence from trials reported from 
2000 to 2007 that major survival differences exist between many commonly employed 
chemotherapy regimens” [5]. Taxane-containing regimens offer a slight survival advantage, 
but for patients with taxane-resistant or refractory cancers, no new agents substantially 
improve outcome.  Median PFS rates of 3.8 months and 4.2 months were obtained in a 
Phase II study of heavily and minimally pretreated patients with metastatic breast cancer,
respectively, on a Phase II study of gemcitabine and cisplatin [6]. Addition of the 
epothilone B analog ixabepilone to capecitabine in a Phase III trial in patients with locally 
advanced or metastatic cancer prolonged progression-free survival in the combination 
group from 4.2 to 5.8 months over capecitabine alone; pretreatment or resistance to 
anthracyclines and resistance to taxanes were eligibility criteria [7]. Response rates and 
PFS after failure of 2 lines of therapy are disappointing.  A retrospective review of 578 
patients with metastatic breast cancer, analyzing for overall survival related to each line of 
chemotherapy, reported PFS of 2-3 months and overall survival of 8 months after failing 2 
lines of therapy [8].
Number of lines of chemotherapy
No. of
patients
Median OS 
(months)
Median TTF (months)
1 line and more 
487
22.5
3.97
2 lines and more
331
17
3.45
3 lines and more 
225
12.3
2.79
4 lines and more 
141
9.3
2.93
5 lines and more 
77
8.7
2.99
6 lines and more 
40
8.2
2.07
7 lines and more 
25
7.5
3.68
8 lines and more 
11
Not evaluable
Not applicable
Table 1: Overall survival (OS) related to lines of chemotherapy in patients with 
metastatic breast cancer. OS was evaluated between Day 1 of the first chemotherapy 
line and the date of last report.  Time to treatment failure (TTF) was evaluated between 
Day 1 of the chemotherapy line and the day of progression of disease. From Tacca et al. 
2009 [8]
The integral roles of the estrogen and progesterone receptors as well as Her2neu in the 
pathogenesis of some breast cancer have led to the development of multiple therapies.  
However, with the knowledge that silencing of key tumor suppressor genes may play a part 
in breast carcinogenesis comes the opportunity to improve on current treatment approaches.  
Decreased expression of the tumor suppressor gene WWOX has been detected in over 60% 
of breast cancer tumor samples in one series [9]. When the demethylating agent decitabine 
was used in a breast xenograft model, tumor growth regressed and WWOX expression was 

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restored [10]. Other genes found to be methylated in breast tumor samples include BRCA1,
ER, PR, RASSF1A, and E-cadherin[11-14].
2.1.3
Head and Neck Cancer
Patients with locally recurrent or metastatic head and neck cancer have a poor prognosis.
Investigations into multiple cisplatin-based chemotherapy regimens and more recently, 
taxane-containing regimens have provided slight improvement in survival compared to 
supportive care alone, but the median survival for patients with recurrent and metastatic 
head and neck squamous cell carcinoma (HNSCC) is 4 to 6 months [15, 16]. New 
treatment modalities are needed.  A median PFS of 9.6 weeks was obtained in a Phase II 
study of erlotinib in heavily pretreated patients with locally recurrent or metastatic HNSCC 
[17]. A retrospective review of 151 patients with HNSCC refractory to platinum-based 
chemotherapy treated between 1990 and 2000 at seven different centers with second line 
therapies showed an overall survival of 103 days (95% confidence interval [CI]: 77-126
days) and an overall response rate of < 3% [18].
Administering cetuximab with platinum-based chemotherapy as first-line treatment in 
patients with recurrent or metastatic HNSCC increased median progression-free survival 
(PFD) from 3.3 to 5.6 months [15]. However, the difference in median PFS from an ECOG
Phase III study of patients with recurrent/metastatic HNSCC randomly assigned to receive 
cisplatinwith cetuximab or with placebo were statistically insignificant: 2.7 months for 
patients on placebo and 4.2 months for patients on cisplatin and cetuximab [19].
Analysis of tumor samples has revealed that several tumor suppressor genes thought to play 
a role in head and neck cancer development are methylated. Using Restriction Landmark 
Genomic Scanning (RLGS), 5 candidate genes were identified. These included septin 9 
(SEPT9), sodium-coupled monocarboxylate transporter (SLC5A8), functional smad-
suppressing element on chromosome 18 (FUSSEL18), early B-cell factor 3 (EBF3), and 
iroquois homeobox 1 (IRX1) [20]. In the 42 tumors studied, 27% to 67% demonstrated 
methylation of at least one of the 5 genes listed. Over 50% demonstrated methylation of 2 
or more genes. Treatment of head and neck cell lines with decitabine restored mRNA 
expression of these genes. The role of these genes in tumor suppression was corroborated 
by colony forming assays demonstrating growth restriction associated with gene expression
[21]. Additional genes thought to be methylated in squamous cell carcinoma of the head 
and neck that may contribute to tumor growth include MGMT, p16, and DAPK [20].
2.1.4
Non-small Cell Lung Cancer
Lung cancer remains the most common cause of cancer mortality in the United States with 
over 160,000 deaths attributed to the disease in 2007. Non-small cell lung cancer (NSCLC) 
comprises approximately 85% of all primary lung malignancies and includes 
predominantly adenocarcinoma, squamous cell, and large cell carcinomas, in decreasing 
order of incidence. For patients with unresectable disease, cure rates remain dismal and 
combination chemotherapy provides palliative benefit as well as modest prolongation of 
survival. Median survival for treated patients with a poor performance status has been 
reported as 2.9 to 5.8 months [22, 23]. Treatment options for patients who have progressed 
after a one prior regimen include docetaxel, pemetrexed, and erlotinib [24]. In the recent 
Phase II study comparing chemotherapy (docetaxel or pemetrexed) alone, bevacizumab 

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plus chemotherapy, and bevacizumab plus erlotinib, median PFS times were 3.0, 4.8, and 
4.4 months, respectively [25].
Response rates and improvement in PFS are modest in metastatic NSCLC after failure of 
first-line therapy.  In the initial Phase II study with gefitinib, patients were randomized to 
receive 250 mg or 500 mg daily of gefitinib (IDEAL trial).  The objective tumor response 
rates were 18.4% and 19.0% among evaluable patients, symptom improvement rates were 
40.3% and 37.0%, median progression free survival times were 2.7 and 2.8 months, and 
median overall survival times were 7.6 and 8.0 months, for 250 mg and 500 mg of gefitinib 
respectively [26]. The BR.21 placebo controlled, double-blinded study randomized 
patients who had progressed on chemotherapy in a 2:1 manner to receive erlotinib or 
placebo. The response rate was 8.9% in the erlotinib group and <1% in the placebo group 
(p<0.001).  Time to tumor progression was 2.2 months and 1.8 months, respectively 
(p<0.001) with an overall survival of 6.7 months and 4.7 months, (p<0.001) in favor of 
erlotinib [27].
Given the low response rates and poor PFS from agents that are currently FDA approved 
for the treatment of patients with relapsed NSCLC, we feel that in this initial trial of FdCyd 
+THU in NSCLC targeting a RR of 20% and a PFS of 4 months is appropriate in this 
disease setting. 
A number of genes are hypermethylated in non-small cell lung cancers, and 
hypermethylation of certain genes has been associated with a decrease in overall survival
[28]. In the largest series to date, tumor samples from 150 patients with various stages of 
NSCLC of either squamous or adenocarcinoma histology were analyzed [29]. Those with 
methylated p16 had a statistically significant decrease in median survival compared to 
those in whom the p16 promoter was not hypermethylated (21.7 months vs. 62.5 months, p 
= 0.0001).  Methylation of the p16 promoter is thought to be induced by tobacco smoke 
exposure; a direct correlation between p16 promoter methylation and number of pack-years 
smoked, duration of smoking history, and indirect correlation with time elapsed since 
smoking cessation has been demonstrated in a large series of patients with NSCLC [30].
When studied in combination with other genes in a series of tumor samples from patients 
with NSCLC, healthy volunteers and smokers without evidence of lung cancer, the 
hypermethylation of p16 appeared to be a late event during lung cancer progression [31].
In a NSCLC xenograft study, the use of decitabine resulted in tumor growth suppression 
and was associated with restoration of FHIT and WWOX gene expression [32].
2.1.5
Urothelial Transitional Cell Carcinoma
Urothelial transitional cell carcinoma (TCC) originates in the urothelium and accounts for 
about 90% of bladder cancers [33]. It is estimated that in 2008 there will be 69,000 new 
diagnoses of urinary bladder cancer in the United States with approximately 14,000 deaths 
[3].  Epidemiological studies have identified several chemical exposures associated with 
urinary bladder cancer, including cigarette smoking [34, 35]. Relative survival decreases 
as the carcinoma spreads to more distant sites.  For patients whose disease is not beyond 
the muscle wall, 75% 5-year progression-free survival can be achieved.  However, this 
survival rate diminishes markedly with more invasive disease such that almost no patients 

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with lymph node involvement survive 5 years [36, 37]. The need for improved therapies
especially in heavily pretreated patients is great (Table 2). Median progression-free 
survival in a Phase II trial of ixabepilone in patients with advanced transitional cell 
carcinoma was 2.7 months [38]. A median PFS of 3.0 months (95% CI: 2.4–3.8) was 
achieved in a Phase II study of the microtubule inhibitor vinflunine in patients with 
advanced TCC progressing after first-line platinum therapy [39]; the subsequent Phase III 
study also conferred a 2-month overall survival advantage (6.9 vs. 4.6 months) [40].
Drug
No. of 
pts
Evaluable 
pts
CR
PR
%
Duration 
(months)
TTP 
(months)
OS 
(months)
Paclitaxel
31
31
—
3
10
2.2
7.2
14
14
1
7
7.4
45
37
—
2
5
3.0
Docetaxel
30
30
—
4
13
4.0
9.0
Oxaliplatin
20
18
—
1
6
Lapatinib
59
59
—
2
3
Bortezomib
18
11
—
—
0
Pemetrexed
47
47
3
10
28
3.0
9.8
Table 2: Results from recently published Phase II trials in previously treated patients with 
advanced TCC.  TTP: time to progression; OS: overall survival. From Culine et al. 2006
[39].
As summarized in Table 3, salvage chemotherapy in patients with urothelial malignancies 
has low response rates and low PFS and overall survival [41].
Drug
n
Eligibility
RR (%)
Median PFS 
(months)
Median OS 
(months)
Ifosfamide
56
1 prior regimen
20
2.4
5.5
Ifosfamide– docetaxel
22
1 prior platinum-based regimen
25
Ifosfamide– paclitaxel
13
1 prior regimen
15
Paclitaxel (24 h)
9
1 prior regimen
56
Paclitaxel (weekly)
31
1 prior regimen for advanced disease, 
prior adjuvant chemotherapy and 
taxanes allowed
10
2.2
7.2
Docetaxel (every 3 
weeks)
30
1 prior cisplatin regimen, prior taxanes 
not allowed
13
9.0
Carboplatin–paclitaxel
44
1 prior platinum regimen within 1 
year, prior taxanes not allowed
16
4
6
Gemcitabine
35
1 prior platinum regimen
22.5
5.0
Gemcitabine
30
1 prior cisplatin regimen
11
4.9
8.7
Gemcitabine–paclitaxel
41
1 prior cisplatin regimen including 
perioperative therapy
60
14.4
Pemetrexed
47
1 prior regimen including perioperative 
therapy within 12 months
27.7
2.9
9.6
Pemetrexed
12
1 prior regimen
8
Vinflunine
51
1 prior platinum regimen
18
3.0
6.6
Ixabepilone
42
1 prior platinum regimen, prior taxane 
allowed
11.9
2.7
8.0

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Drug
n
Eligibility
RR (%)
Median PFS 
(months)
Median OS 
(months)
Oxaliplatin
18
1 prior regimen for advanced disease, 
prior adjuvant chemotherapy >6 
months earlier not counted
6
Table 3: Reported Phase II trials of salvage chemotherapy for patients with advanced 
urothelial cancer. OS: Overall survival; PFS: Progression-free survival; RR: Response rate.
From Sonpavde et al. 2008 [41]
In a series of over 340 bladder cancer samples, investigation of 16 tumor suppressor genes 
determined a nonrandom methylation pattern (p < 0.0001) and the suggestion of a CpG 
island methylator phenotype [42].  Methylation of death-associated protein (DAP) kinase in 
patients with superficial bladder cancer is associated with an increased risk of recurrence (p 
< 0.001) [43]. Methylation of RASSF1A in a series of 55 bladder tumors was detected in 
over 60% of the samples.  In bladder cancer cell lines that do not express RASSF1A,
treatment with decitabine resulted in gene re-expression [44]. However, a Phase II study of 
the histone deacetylase inhibitor SAHA in 14 patients with advanced TCC had limited 
efficacy with median disease-free survival and overall survival times of 1.1 and 4.3 
months, respectively [45].
2.2 FdCyd
FdCyd is a fluoropyrimidine analogue which has been shown to inhibit the enzyme DNMT, 
thus inhibiting DNA methylation. FdCyd administered by itself to mice or humans suffers 
much the same fate as other fluoropyrimidines including 5-fluoro-2’-deoxyuridine (FdUrd),  in 
vivo, such that the ubiquitous presence of thymidine and uridine phosphorylases causes rapid 
cleavage of FdUrd to FUra in most animals and in humans (Figure 1) [46].
However, a critical difference in the degradation of FdCyd, a cytosine nucleoside, is that it is
not subject to cleavage of the glycosidic bond in mammals [47, 48].  An obligatory first step in 
its degradation is deamination by cytidine/deoxycytidine (Cyd/dCyd) deaminase. Although it 
was originally proposed that deamination of FdCyd to FdUrd was responsible for its activity 
(5), later work has clearly demonstrated that FdCyd can be phosphorylated to 5-fluoro-2'-
deoxycytidylate (FdCMP) by deoxycytidine kinase and the nucleotide deaminated to 5-fluoro-
2'-deoxyuridine 5'-monophosphate (FdUMP) by deoxycytidylate (dCMP) deaminase [49, 50].
The activity of dCMP deaminase is reported to be higher in common human malignancies than 
in most normal tissues, which suggests the possibility of selective cytotoxicity toward 
neoplastic cells [49].

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FdCyd
FdCMP
FdCTP
dCMP
deaminase
FdUrd
cytidine
deaminase
thymidylate
synthase
inhibition
DNA-incorporation
FU
FUH2
FUrd
deoxycytidine
kinase
FdUMP
uridine/thymidine
phosphorylase
dihydropyrimidine
dehydrogenase
kinases
uridine
kinase
RNA
incorporation
FUTP
kinases
FC
cytidine
phosphorylase
(bacteria and
yeasts)
THU
inhibition
of RNA
maturation
DNA
methyltransferase
inhibition
glycosylase-excision
re-insertion cycling
single strand breaks
FdUTP/dUTP
accumulation
cytosine deaminase (bacteria and yeasts)
uridine/thymidine
phosphorylase
Figure 1: The metabolic pathway of FdCyd [51] (Courtesy: Drs. J. Beumer and M. Egorin;
used with permission)
In addition to inhibition of thymidylate synthase, the incorporation of FdCyd into DNA may
contribute to its antineoplastic activity. Incorporation correlated with cytotoxicity in the 
human breast carcinoma line MCF-7.  It was suggested that inhibition of DNA methylation 
distinguishes the effects of FdCyd from the effects of FdUrd and fluorouracil [52]. The 
expression of genes for metabolic enzymes silenced by DNA methylation, including 
deoxycytidine kinase, may also be reactivated by inhibitors of DNA (cytosine-5)-
methyltransferase [53]. It has been shown that oligonucleotides containing FdCyd form tight-
binding ternary complexes with the methyl group from S-adenosylmethionine and purified 
DNA (cytosine-5)-methyltransferase in vitro, adding support to the hypothesis that this enzyme 
is an additional site of action for FdCyd [54].
2.3 THU
Because FdCyd is phosphorylated by deoxycytidine kinase, the deamination of the nucleoside 
FdCyd may be inhibited without limiting its metabolism to FdUMP or its incorporation into 
DNA. THU is an effective non-toxic inhibitor of Cyd/dCyd deaminase, both in vitro and in 
vivo [55]. THU has been shown to decrease deamination of the deoxycytidine analog 1-ß-D-
arabinofuranosylcytosine (araC) in humans [56] and thereby to increase the potency of araC 
[57]. Either with or without THU, araC is only activated by deoxycytidine kinase. 1-ß-D-
Arabinofuranosyluridine (araU), the deamination product of araC, may have some modulatory 
activity but is relatively non-toxic. Decreasing the concentration of araU, per se, is of little 
benefit to the patient. Consequently, the combination of araC and THU was qualitatively the 

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same as araC alone. A lower dose of araC was required for activity when combined with THU, 
but the spectrum of activity and toxicity was the same as for araC alone [57]. In contrast to 
araU, FUra is not an innocuous compound and reducing patient exposure to FUra may well 
reduce undesired side effects of treatment with FdCyd. Improvement in therapeutic indices 
have been shown during in vivo treatment of two murine neoplasms, Lewis lung carcinoma and 
adenocarcinoma-755 (both the solid and ascites forms); FdCyd with THU was more effective
than equitoxic doses of FUra, FdUrd, or FdCyd alone [49]. The toxicities of FdCyd have been 
compared with those of FUra, FdUrd, 5-fluoroorotic acid, and 5-fluorouridine in mice, rats, 
cats, dogs, and Rhesus monkeys.
Co-administration of FdCyd with THU increases the AUC of FdCyd. Using a liquid 
chromatography/tandem mass spectrometry (LC-MS/MS) assay developed for the quantitation 
of THU in plasma, co-administration of THU (100 mg/kg) with FdCyd (25 mg/kg) decreased 
FdCyd clearance in mice by a factor of five relative to administration of FdCyd alone (from 2.1 
to 0.4 mL/min); co-administration increased the percentage of parent FdCyd recovered in 16-
hour (1.61% increasing to 35.6%) and 24-hour (1.94% increasing to 21.96%) urine collections
[58, 59]. FdCyd in combination with THU has demonstrated in vitroand in vivo efficacy in 
breast, lung, and lymphoma models [49, 54].
2.4 Preclinical Studies
2.4.1
Animal Toxicology Studies
From the results of the animal studies, FdCyd is expected to produce in patients the same 
kinds of toxic effects caused by FdUrd and FUra. However, the LD50 of FdCyd relative to 
that of FdUrd differed depending on animal species. In mice, cats, and Rhesus monkeys, 
the two deoxynucleosides were approximately equitoxic.  In dogs, FdCyd was 5 times more 
toxic than FdUrd; in rats, 14-times. The level of Cyd/dCyd deaminase activity is reported 
to be low in dogs and undetectable in rats [60].
We determined the toxicity and activity of 5 days of intravenous FdCyd, administered as a 
daily bolus with 100 mg/kg/day of THU, in CDF1 mice. The LD50 was estimated to be 31 
mg/kg/day with a 95% confidence interval of 27 to 38 mg/kg/day. The highest non-lethal 
dose (25 mg/kg/day x 5) produced reversible toxicity, an 18% weight loss during treatment,
and depletion of myeloid bone marrow elements.  In a pilot toxicology study, animals were 
treated with 35 mg/kg/day for 5 days and necropsied 3 days after the last dose. Bone 
marrow hyperplasia was present, consistent with a compensatory response secondary to 
prior marrow destruction. Small and large intestinal epithelial atrophy with concomitant 
crypt epithelial regeneration was also consistent with compensatory response to prior 
intestinal epithelial destruction. Gastric glandular atrophy and lymphoid depletion of 
spleen and thymus glands was clearly evident. FdCyd was highly effective in the 
L5178Y/TK- tumor model often used to assess the activity of thymidylate synthase 
inhibitors in mice. Doses between 10 and 25 mg/kg/day resulted in 100% long-term
survivors (LTS). Three of 4 mice treated with 5 mg/kg/day were LTS. Three of 12 mice 
treated with 2.5 mg/kg/day were LTS, and the dying animals had an increase in life span of 
74%, compared with saline-treated, tumor-bearing controls (p=0.0001 by log rank test).

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2.4.2
Human cell lines
In vitro time-dependence of the effect of FdCyd: In vitro experiments exposing
human tumor cell lines to various concentrations of FdCyd for various periods of time
indicated that exposure to FdCyd for periods of <1 week resulted in no discernable effect 
on DNA methylation by methylation-specific PCR, even at concentrations above 1 ȝ0
However, changes in DNA methylation occurred with exposure WLPHV weeks at 
FRQFHQWUDWLRQV RIȝ0DQGDERYH (Table 4). In the human breast cancer cell line MCF-7,
the 5'-promotor region of the glutathione S-transferase P1 gene (GSTP1) was heavily 
methylated and the mRNA for this gene was not detected by RT-PCR prior to treatment 
with FdCyd. There was a time-dependent decrease in DNA methylation and increase in 
mRNA expression of this gene during treatment of the MCF-7 cells with 1 ȝ0)G&\G
(E.M. Newman, unpublished observations; Figure 2).
Table 4: Hypermethylated-silenced genes become re-expressed following treatment with 
FdCyd.  RT-PCR analysis (+, expressed; -, not expressed) of the human breast cancer cell line 
MDA-MB 231 following treatment with 1 μM FdCyd x 4 weeks [61].
Figure 2: DNA methyltransferase inhibition by FdCyd. Exposure-dependent activation of the 
methylcytosine-silenced gene, GSTP1, at 1 μM FdCyd in MCF-7 cells; enhanced gene 
expression requires 7-10 days. The constitutively active HPRT gene was used as a control
(Newman and Sowers; personal communication).

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These in vitro findings are consistent with the ability of decitabine (DAC), another DNA 
(cytosine-5)-methyltransferase inhibitor, to induce fetal hemoglobin (HbF) in patients with 
sickle cell anemia in whom treatment with hydroxyurea did not increase HbF (28). In that
clinical trial, patients were treated with DAC 5 days a week for 2 weeks, followed by 2
weeks off therapy and a second 2 weeks on DAC treatment. The percentage of HbF
increased during the 2 weeks of treatment, remained stable during the 2 weeks off
treatment, and rose again during the second 2 weeks of treatment, reaching a peak of 13% 
that persisted for 2 weeks before falling below 90% of the peak percentage. In the ongoing
Phase I trial of FdCyd, preliminary pharmacokinetic (PK) analysis performed on plasma 
samples obtained near the end of the infusion from patients treated with 20, 40, and 
80 mg/m2/day indicated that all patients treated with 40 mg/m2/day and above obtained 
SODVPDFRQFHQWUDWLRQVRI)G&\Gȝ0 Increases in the percentage of HbF expression 
have been measured in patient samples from the ongoing Phase I trial (see Figure 5 below; 
Section 2.7.3).
2.5 Clinical studies 
The NCI is a participating site on the current Phase I study of FdCyd and THU (06-C-0221; A 
Phase I Trial of 5-Fluoro-2’-Deoxycytidine with Tetrahydrouridine in Advanced Malignancies, 
PI Dr. James Doroshow). The trial was initiated in 1999, and the first 20 patients were treated 
with FdCyd + THU administered as an IV infusion over 3 hours along with the infusion of 
THU daily for 5 consecutive days of treatment in 21-day cycles.  The daily dose of FdCyd was 
escalated geometrically in cohorts of 3 patients from 2.5 to 80 mg/m2/day. The dose of THU 
was fixed at 350 mg/m2/day.  Eighteen patients completed at least one cycle and were 
HYDOXDEOHIRUWR[LFLW\7KHUHZHUHQRWR[LFLWLHVGrade 3 attributable to the treatment other 
than anemia and lymphopenia. Seven patients had stable disease after 2 cycles of treatment; 3 
received additional cycles of FdCyd/THU (2 CRC; 1 NSCLC) [62].
Review of the PK data (see Section 2.5.1) and the available experimental data supported longer 
exposure times; thus, the schedule was changed from 1 week (daily x5) to 2 consecutive weeks 
(5 days per week for two weeks) of dosing, which is the regimen that will be explored in the 
current trial.  The dose of 80 mg/m2/day for 5 days q 21days was well tolerated.  Therefore, to 
ensure patient safety, the dose was modified to 40 mg/m2/day for 5 consecutive days of 
treatment per week for 2 consecutive weeks, q28 day cycles.  Through the NCI RAID program, 
additional drug was made available, and patients enrolled on the revised schedule.  Six patients 
were treated at this dose level followed by 3-6 patients at each subsequent dose level.  To date, 
29 patients have been treated on this regimen as part of the ongoing Phase I trial.  Six patients 
have completed at least one cycle of therapy at the 134 mg/m2/day dose level. Patients are 
currently being accrued to the 180 mg/m2/day dose level.  Toxicities have been generally mild, 
and have included Grade 1/2 nausea, vomiting, diarrhea, headache, fatigue; and grade 1 
leucopenia and thrombocytopenia (see Section 7.1). There has been one DLT, a case of Grade 
3 colitis at the 134 mg/m2/day dose level that responded to conservative management. 
The proposed starting dose for this trial, 100 mg/m2/day, has been safely administered to 
6 patients to date (ALT elevation observed in one patient was reversible and considered 
unlikely related to the study agents, see Section 2.5.3).

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2.5.1
Pharmacokinetics
A hydrophilic-interaction liquid chromatographic-MS/MS method developed by
Dr. Beumer and colleagues to simultaneously quantify FdCyd and downstream metabolites 
(FdUrd, 5-FU, FUrd, 5-FC) in mouse and human plasma [30] was employed to evaluate the 
PK of FdCyd in the first 20 patients on the Phase I study of FdCyd and THU.  The end-of-
infusion FU and FdUrd concentrations in plasma are <10% of those observed after 
therapeutic continuous infusions of FU or FdUrd. No FdCyd or metabolite was detected in 
day 5 pretreatment plasma.  FdCyd concentrations increased with the dose of FdCyd 
(Figure 3). Peak plasma concentrations of FdCyd (mean ± SD) increased from 110 ± 
50 nM in patients receiving 5 mg/m2/day (n = 3) to 1.54 ± 0.17 μM in patients receiving 
40 mg/m2/day to 5.5 ± 0.9 μM in patients receiving 80 mg/m2/day (n = 3) [63].
These results demonstrate that, at doses as low as 20 mg/m2, the observed FdCyd 
concentrations exceeded that which has been shown to inhibit in vitroDNA methylation in 
MCF-7 cells (24-hour incubation) [52].  This suggests that the intended biological effect 
may occur at an FdCyd dose level that is below the MTD, which was not reached in this 
cohort. A more complete evaluation of the clinical pharmacokinetics of FdCyd + THU will 
be performed once accrual to this trial is completed and all data are available.
Figure 3: End-of-infusion plasma concentrations of FdCyd achieved after i.v. 
administration of various doses of FdCyd co-administered with 350 mg/m2 THU on day 1 
(open square) or day 5 (open circle) in patients participating in the ongoing Phase I trial of 
FdCyd and THU.
2.5.2
Clinical Efficacy
One heavily pretreated patient with metastatic breast cancer had a confirmed partial 
response (PR) documented by CT scan (> 90 % reduction in the sum of the target lesions) 
while receiving treatment on the Phase I protocol at the FdCyd dose level of 67 mg/m2/day
(Figure 4). Although significant clinical improvement was noted after 2 cycles of 

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treatment, the PR was obtained after 4 cycles, and continued shrinkage of the tumor was 
noted after 6 cycles. The patient maintained a PR for 16 months before progression.  
Figure 4 shows the pre- and post-treatment CT scans demonstrating the 90% reduction in 
tumor size as well as the observed improvement in skin involvement.
Figure 4: Pre- and post-treatment CT scans of a 61-year-old female with metastatic breast 
cancer who had received multiple chemotherapy and hormonal regimens including high-
dose chemotherapy and autotransplant prior to enrolling on the Phase I trial of FdCyd 
+THU.
Data are available on 82 patients accrued to date (February 2016). The NSCLC cohort 
closed after 25 patients were accrued as the criteria for continuation after the first 20
patients (at least 7 instances of 4-month PFS) were not met.  The head and neck cohort is 
also closed after enrolling 21 patients; clinical benefit was observed in six patients
including one who achieved a partial response before coming off study after the 4th cycle 
for disease progression.  Five other patients had stable disease, four for at least 4 cycles and 
one for 2 cycles.
To date, 22 evaluable patients have been accrued to the breast cancer cohort.  Clinical 
benefit has been observed in 9 patients, including one with stage IV breast cancer who had 
stable disease for 5 cycles with progression after 7 cycles.  Six other patients had stable 
disease for at least 2 cycles, and two have had confirmed partial responses, one of whom
remained on study for 8 cycles before disease progression.  
Of the 14 evaluable patients accrued to the urothelial transitional cell carcinoma cohort, 
two have had partial responses and two met the criteria for continuation (4-month PFS). 

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2.5.3
Toxicity Observed on Protocol 06-C-0221
Notable toxicities observed on the ongoing Phase I protocol, including the current dose 
level of 180 mg/m2/day of FdCyd, include Grade 3 colitis at the 134 mg/m2 dose level 
(DLT), which resolved with conservative management. 
One patient developed an electrolyte imbalance that did not resolve immediately upon 
supplementation, but did resolve within 96 hours, at the FdCyd dose level of 40 mg/m2/day.
Another patient developed an elevation of ALT to >5 times the upper limit of normal on
the second cycle of treatment at the FdCyd dose level of 100 mg/m2/day. The elevation in 
ALT was more likely due to concurrent medication with ondansetron, and it resolved 
without sequelae when both the ondansetron and the FdCyd/THU were stopped, but a 
contribution to the toxicity by FdCyd/THU cannot be ruled out entirely.  Of note, this 
patient did not develop significantly elevated transaminases during a subsequent course of 
FdCyd/THU without ondansetron and did develop elevation of transaminases again when 
he received ondansetron as part of another chemotherapy regimen. 
2.6 Rationale 
The proposed trial is a Phase II study of FdCyd plus THU in patients with advanced non-small 
cell lung cancer, head and neck cancer, urothelial transitional cell carcinoma, or breast cancer. 
FdCyd is being evaluated as an antitumor agent due to its ability to inhibit DNA methylation,
resulting in epigenetic remodeling. Results of the PK studies from the ongoing Phase I clinical 
trial of FdCyd and 7+8LQGLFDWHWKDWDOOSDWLHQWVWUHDWHGZLWK mg/m2/day achieved a 
plasma concentration of at least 1 ȝ0)G&\G,QLWLDOFOLQLFDOUHVXOWVIURPWKH3KDVH,WULDO
include a partial response (>90% reduction in target lesions) that lasted 16 months in one 
patient with extensively pre-treated breast cancer enrolled at the NIH.  This patient was treated 
at the 67 mg/m2/day dose level.  The response seen in a patient with breast cancer as well as 
the activity of demethylating agents in a breast cancer xenograft model provide a rationale for 
testing the agent in this disease.  Most of the patients expected to be accrued to this protocol will 
have failed multiple lines of treatment; their median PFS without therapy is not expected to be 
more than 2 months (3 months for patients with breast cancer).  The study design will 
simultaneously discriminate, for patients with advanced non-small cell lung cancer, head and 
neck cancer, urothelial transitional cell carcinoma, or breast cancer, between tumor response 
rates of 20% vs. 5% or 4-month (6-month for the breast cancer stratum) PFS rates of 50% vs. 
25% (corresponding to median PFS of 4 vs. 2 months; 6 vs. 3 months for the breast cancer 
stratum).  
The growing evidence for the role of methylated genes in the pathogenesis of bladder, head 
and neck, and non-small cell lung cancer provide the basis for a trial of FdCyd/THU in patients 
with these diseases.  Along with clinical response, effects of study treatment on methylation of 
CpG islands and gene re-expression will be evaluated. 

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2.7 Correlative Studies 
2.7.1
LINE1 CpG Island Methylation by Pyrosequencing
Hypermethylation of CpG islands as a method of gene silencing is well-established, and it 
is clear that genes throughout the cancer genome can be hypermethylated. Dr. Allen 
Yang’s laboratory at the University of Southern California (USC)/Norris Comprehensive 
Cancer Center has demonstrated that measurement of hypermethylation of CpG islands in 
Long Interspersed Nuclear Elements (LINE1 Sequences) is a reasonable method of 
determining overall levels of genome methylation [64]. The method employs primer sets 
capable of hybridizing to 12,000 + copies of LINE1 sequences in the human genome. 
These sequences harbor significant numbers of CpG islands. The state of methylation of 
these CpG islands is established by PCR of the genomic DNA with and without bisulfite 
pretreatment of the DNA, which allows discrimination of methylated from non-methylated 
sequences [65]. Information is obtained from the DNA by sequencing the PCR product on 
a pyrosequencing instrument, the Pyromark MD (Biotage AB, Uppsala, Sweden). The 
information consists of a short run of average sequence of the LINE1 CpG islands of 
12,000 + genes, and not the sequence of individual genes; information collected actually 
reflects the inhibition of DNA methyltransferase activity on the bulk DNA in the presence 
or absence (pre-treatment measurements) of the drug.
The DCTD Pharmacodynamic Assay Development and Implementation Section (PADIS) 
has tested and confirmed the effect of the demethylating agent decitabine in altering DNA
methylation on three CpG islands found in the LINE1 sequence in several nude mouse 
xenograft models (Table 5).  Xenografts were implanted and staged to 150-200 mg before 
treatment. Decitabine or vehicle was administered IV for 10 consecutive days, with 
sampling of the subcutaneous tumors by 18-gauge needle biopsy under anesthesia on days 
1 or 3, 5 or 7, and 9 or 10.  Currently, the PADIS laboratory is setting up the 
pyrosequencing method at NCI-Frederick, and assay validation will be accomplished by 
transferring the assay into NCI from Dr. Yang’s laboratory using a common set of 
specimens.

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Xenograft Sensitivity to Decitabine: Percent Methylation Inhibition 
of 3 CpG Line1 Islands
Days Post-Dose
Day 5
Day 7
Day 9
Day 10
Xenografts
Decitabine 
HL60
2 mg/kg
18.5*
32.4*
1 mg/kg
18.9*
19*
0.5 mg/kg
6.9
12.8*
IGROV-1
2 mg/kg
12.8*
18.2*
1 mg/kg
14.2*
17*
0.5 mg/kg
4.8
10.8*
HCT-116
2 mg/kg
15.8*
6.66
1 mg/kg
13.4*
17.8*
0.5 mg/kg
6.3
14.3*
MDA-MB231
2 mg/kg
9.1*
0
1 mg/kg
8.4*
4.9
0.5 mg/kg
0
6.2
Table 5: Effect of the demethylating agent decitabine on LINE1 CpG Island methylation in 
4 xenograft models.  Xenografts are stack-ranked by demethylation response, but this 
ranking was concordant with decitabine effect on xenograft growth inhibition in all four 
models, which was dose-dependent. Asterisks (*) indicate statistically significant 
inhibition.  Percent CV of the LINE1 pyrosequencing assay results was 5% or less in the 
vehicle control groups used to set the baseline for establishing statistical significance.  No 
drug effect on methylation was observed at any dose level on day 1 or day 3 of decitabine 
treatment, consistent with the proposed mechanism of action of DNA methyltransferase 
inhibitors.
2.7.2
Measurement of Methylation-Silenced Gene Products by mRNA Transcript Assays
In addition to documented genome-wide alterations in CpG island methylation caused by 
inhibition of DNA methyltransferase activity, a number of specific genes have been 
reported to be silenced in cancer and re-expressed after treatment with DNMT1 inhibitors.  
One of these is E-cadherin; other targets of interest include alpha- and beta-catenin. 
We have examined alterations in E-cadherin and catenin expression levels in the same HL-
60 xenograft model (treated with decitabine) described above.  Expression of E-cadherin 
was analyzed by RT-qPCR employing an assay validated for performance on the Taqman 
platform.  Controls included actin and alpha- and beta-catenin, neither of which is silenced 
by CpG island methylation.  Results are shown in Table 6, and indicate statistically 
significant upregulation of E-cadherin mRNA levels at Day 5, consistent with literature 
reports [66, 67].

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Group
Day
Catenin A1
Catenin B1
E-cadherin-10
E-cadherin-15
huACTB
Vehicle
1
33.33
27.04
38.90
38.89
23.86
5
33.83
26.97
38.34
38.18
23.64
10
34.72
26.91
37.68
38.02
23.78
Decitabine:
2 mg/kg
1
33.41
27.21
38.53
38.65
23.83
5
34.03
28.39
36.55#
37.13
25.04*
10
32.97
28.48
37.45
38.26
26.35*
1 mg/kg
1
32.98
26.81
38.20
38.56
23.33
5
33.17
26.90
36.64#
36.92#
23.79
10
33.09
28.07
37.87
38.63
25.29*
0.5 mg/kg
1
33.89
27.66
38.45
38.85
24.23
5
34.57
28.60
37.39
37.58
25.01*
10
33.55
27.76
38.38
38.73
24.99*
Table 6: Analysis of mRNA expression levels for specific genes in response to decitabine 
treatment.  Results are the means for 4 mouse xenografts per treatment group at each time point 
in the HL60 model.  Control vehicle (human actin; huACTB) Ct values by RT-qPCR were 
23.76 +/- 0.436; control vehicle E-cadherin values were 38.35 +/- 0.685. Asterisks (*) indicate 
decreases in mRNA expression levels >2 SD from the mean vehicle. These decreases were 
observed in biopsy sections with evidence of substantial cell killing by immunohistochemistry,
and further correlated with inhibition of tumor growth.  Hash marks (#) indicate an increase in 
mRNA expression >2 SD from the mean vehicle.
Other mRNA assays for measuring re-expression of specific genes silenced by methylation 
are being explored in PADIS, and may be employed to analyze patient specimens if they 
have been analytically validated and demonstrated to correlate appropriately with LINE1 
and xenograft growth curves in the preclinical modeling experiments described above. As
of Amendment V (9/18/17), such additional mRNA assays validated include those for 
DAPK1, p16, MGMT, RASSF1a, and TIMP3. Furthermore, if sufficient tumor tissue is 
available, p16, DNMT1, and other relevant proteins may be assessed using validated 
immunofluorescence microscopy assays.
In addition, the Illumina RNA expression system has been optimized to search for 
alterations in expression profile of over 25,000 genes. These hybridization array chips 
typically require 100 ng RNA per chip, quantities which can be readily extracted from 
needle biopsies. As this technology measures RNA expression with pre-designed 
hybridization probes, sequence analysis is not performed. Instead, differences in the 
quantity of an mRNA are detected. The benefit of this approach is that it could enable 
investigators to sort out the difference between clinical responders and non-responders, 
which will help understand the pathways responsible for effective mechanism of action of 
FdCyd, and may also shed some light on pathways involved in toxicity of the compound.
Expression analysis by this method will be performed in Dr. Paul Meltzer’s laboratory 
(NCI/CCR).

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2.7.3
Measurement of Fetal Hemoglobin Gene Re-expression in Blood
Fetal hemoglobin gene expression is silenced perinatally by CpG island methylation, and 
has been reported to be re-expressed in response to decitabine treatment [68]. A 
quantitative real-time RT-PCR method of analysis of J- and E-globin mRNAs in primary 
human erythroid cells has been developed [69], and we have preliminary data indicating 
that this quantitative method can be applied to RNA extracted from peripheral RBC.  We 
obtained RBC samples diluted in RNAzol for RNA isolation and analysis. Preliminary 
results from the ongoing Phase I study of FdCyd plus THU are presented in Figure 5.
Figure 5: RT-3&5GDWDVKRZLQJFKDQJHVLQIHWDOȖ) hemoglobin expression in 4 patients 
on the ongoing Phase I trial of FdCyd +THU.  Results are presented relative to 
pretreatment (baseline) values and confirm that the silenced fetal hemoglobin gene is 
reactivated following FdCyd treatment. Note: isolation of RBCs as an exploratory analysis 
of fetal hemoglobin expression levels was suspended with Amendment E (3/16/11).
2.7.4
Measurement of Circulating Tumor Cells (CTC) in Peripheral Blood
CTCs may provide information on disease progression and response to therapy in patients 
with advanced cancer [70, 71].  In Figure 6, the number of CTCs in blood from 2 patients 
treated with topotecan is superimposed on the percentage of CTCs expressing J-H2AX—
one of the earliest markers of DNA double-strand breaks. Levels of J-H2AX can be used 
as a dosimeter and biomarker for drug-induced DNA damage.

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We propose to use the Veridex CellSearch instrument system, which can detect a single 
CTC in 7.5 mL of patient blood, to measure changes in the number of CTCs in patients on 
this study.  This device has been approved by the FDA for monitoring response to therapy 
in patients with breast, prostate, and colon cancer; other cancer indications are being 
evaluated.  The instrument is already supporting prostate vaccine trials in the CCR’s 
Laboratory of Tumor Immunology and Biology with the goal of developing a large enough 
patient database within NCI to understand the best use of the device in monitoring patient 
response during clinical trials.  CTCs are being collected from patients in the 
Developmental Therapeutics Section Clinic to obtain data on CTC count variability. 
Figure 6: The number of CTCs in blood from a patient treated with topotecan (bars) is 
superimposed with the percentage of CTCs expressing J-H2AX (diamond symbols).
A further important application of collecting CTCs in trials is their potential as tumor 
biopsy surrogates to measure drug effects on molecular targets. The number of CTCs at 
the various timepoints, if measurable, will be correlated in a pilot fashion with clinical 
information on patient response to drug therapy (Section 9.0).
Preliminary PD data from this trial indicated that 17 (33%) of 52 patients had more than 
one CTC at baseline, 15 (29%) patients had detectable CTCs after treatment (but not 
baseline), and 20 (39%) had no measurable CTCs at any time point.
3
Patient Selection
3.1 Eligibility Criteria
x
Patients must have histologically documented metastatic or unresectable non-small cell 
lung cancer, head and neck cancer, urothelial transitional cell carcinoma, or breast cancer
whose disease has progressed after at least one line of standard therapy. 

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x
Patients with solid tumors (non-small cell lung cancer, head and neck cancer, urothelial 
transitional cell carcinoma, and breast cancer) must have measurable disease, defined as at 
least one lesion that can be accurately measured in at least one dimension (longest 
diameter to be rHFRUGHGDV 20 PPZLWKFRQYHQWLRQDOWHFKQLTXHVRUDV 10 mm with 
spiral CT scan. Patients with the above tumor types whose disease is limited to the skin 
are eligible at the discretion of the PI and must have a physical exam with documentation 
of skin lesion(s) by color photography, including a ruler to estimate the size of the 
lesion(s).
x
Diagnosis of malignancy must be confirmed by the department of pathology at the
institution where the patient is enrolled prior to patient enrollment.
x
Any prior therap\PXVWKDYHEHHQFRPSOHWHG 4 weeks prior to enrollment on protocol 
and the participant must have recovered to eligibility levels from prior toxicity. Patients 
should be at least six weeks out from nitrosoureas and mitomycin C. Prior radiation 
should have been completed t 4 weeks prior to study enrollment and all associated 
toxicities resolved to eligibility levels. 3DWLHQWVPXVW EH 2 weeks since any 
investigational agent administered as part of a Phase 0 study (also referred to as an “early 
Phase I study” or “pre-Phase I study” where a sub-therapeutic dose of drug is 
administered) at the PI’s discretion, and should have recovered to eligibility levels from 
any toxicities.
x
$JH 18 years.  Because no dosing or adverse event data are currently available on the use 
of FdCyd and THU in patients < 18 years of age, children are excluded from this study, but 
may be eligible for future pediatric Phase I combination trials.
x
Karnofsky performance status  60%, see Appendix A.
x
Life expectancy of greater than 3 months.
x
Patients must have normal organ and marrow function as defined below:

absolute neutrophil count
PF/3.4.1

platelets
PF/

total bilirubin
<1.5 X institutional upper limit of normal

AST(SGOT)/ALT(SGPT)
 3 X institutional upper limit of normal;
;8/1IRUSDWLHQWVZLWKOLYHUPHWDVWDVHV

creatinine
<1.5 X institutional upper limit of normal
OR

creatinine clearance
P/PLQ IRUSDWLHQWVZLWKcreatinine levels
above 1.5 X institutional upper limit of normal.
x
Because FdCyd has been shown to be teratogenic in animals, pregnant women will be 
excluded from this trial. Nursing women are also excluded, as there is an unknown but 
potential risk for adverse events in nursing infants secondary to treatment of the mother 
with FdCyd. Women of child-bearing potential and men must agree to use adequate 
contraception (hormonal or barrier method of birth control; abstinence) for the duration of 
study participation, and for 3 months after completion of study.  Should a woman become 
pregnant or suspect she is pregnant while she or her partner is participating in this study, 
she or her partner should inform the treating physician immediately.

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x
Ability to understand and the willingness to sign a written informed consent document.
x
Patients should not be receiving any other investigational agents.
3.2 Exclusion Criteria
x
Patients with clinically significant illnesses which would compromise participation in the 
study, including, but not limited to: active or uncontrolled infection, immune deficiencies 
or confirmed diagnosis of HIV infection, active infection with Hepatitis B or Hepatitis C,  
uncontrolled diabetes, uncontrolled hypertension, symptomatic congestive heart failure, 
unstable angina pectoris, myocardial infarction within the past 6 months, uncontrolled 
cardiac arrhythmia; or psychiatric illness/social situations that would limit compliance with 
study requirements.
x
History of allergic reactions attributed to fluoropyrimidines (e.g., capecitabine, 
fluorouracil, fluorodeoxyuridine) or tetrahydrouridine.
3.3 Research Eligibility Evaluation
3.3.1
Clinical Evaluations
x
A complete history and physical examination will be completed within 8 days prior to 
subject enrollment.  This will include evaluation of measurable disease and 
determination of performance status. 
x
Diagnostic imaging studies must be performed within 28 days prior to enrollment.
3.3.2
Laboratory Evaluations
Eligibility evaluation laboratory tests should be performed within 8 days prior to subject 
enrollment unless stated otherwise.
x
Hematological profile: CBC with differential and platelet count
x
Biochemical profile: electrolytes, BUN, creatinine, glucose, AST, ALT, bilirubin, 
calcium, phosphorous, albumin, magnesium, alkaline phosphatase, LDH
x
Urine pregnancy test in women of childbearing potential
3.3.3
Pathology Review
A block or stained slides of primary tissue from the time of diagnosis will be required from 
each study subject to confirm diagnosis. Tissue blocks from a known recurrence will be 
accepted if the original tumor samples are unavailable. Diagnosis of malignancy must be 
confirmed by the department of pathology at the site where the patient is enrolled.
3.4 Patient Registration 
Eligible participants will be entered on study by a member of the Coordinating Center study 
team.  
3.4.1
Coordinating Site Registration Process
On Study: Authorized staff must register an eligible candidate with NCI Central 
Registration Office (CRO) within 24 hours of signing consent. A registration Eligibility 

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Checklist from the Web site (http:// home.ccr.cancer.gov/intra/eligibility/welcome.htm)
must be completed and sent via encrypted email to: NCI Central Registration Office 
(HOIS) <ncicentralregistration-l@mail.nih.gov>. After confirmation of eligibility at the 
Central Registration Office, CRO staff will call pharmacy to advise them of the acceptance 
of the patient on the protocol prior to the release of any investigational agents. Verification 
of Registration will be forwarded electronically via e-mail. Please note: it is very important 
for all registrars to acquire encrypted e-mail from NIH Help Desk, since the verification of 
registration includes patient’s information. A recorder is available during non-working 
hours.
3.4.2
Participating Site Registration
All patients must be registered through the NCI Central Registration Office (CRO) via the 
Coordinating Center.  A protocol registration form will be completed by the Coordinating 
Center, NCI CCR.  To register a subject after the participant has signed consent, complete 
Appendix H (Eligibility/Pre-Registration Worksheet) and fax or email the completed
Appendix H along with all supporting records to the Coordinating Center’s Research Nurse:
Jennifer Zlott, Fax: (301) 480-7281, zlottjh@mail.nih.gov. The Coordinating Center will 
notify you either by e-mail or fax that the protocol registration form has been received.  The 
Coordinating Center will register the patient and provide the participating site with the 
patient’s unique patient/subject ID number.  This unique ID number is to be used on all 
research samples and data entry for this subject.  Questions about eligibility should be 
directed to the Coordinating Center’s Research Nurse.
3.5 Off Protocol Therapy and Off-Study Procedure
NCI Clinical Center: Authorized staff must notify the Central Registration Office when a 
patient is taken off protocol therapy and when a patient is taken off-study.  A Participant Status 
Updates Form from http://home.ccr.cancer.gov/intra/eligibility/welcome.htm must be 
completed and sent via encrypted email to: NCI Central Registration Office (HOIS) 
ncicentralregistration-l@mail.nih.gov.
Participating sites: Authorized staff must notify the Coordinating Center Central Registration 
Office (CRO) when a patient is taken off protocol therapy and when a patient is taken off-
study.  The Participant Status Updates Form included in Appendix H must be completed and 
sent via encrypted email to: NCI Central Registration Office (HOIS) (ncicentralregistration-
l@mail.nih.gov) and faxed or emailed to the Coordinating Center’s Research Nurse, Jennifer 
Zlott, Fax: (301) 480-7281, zlottjh@mail.nih.gov.
4
Treatment Plan
This is a multicenter Phase II trial of FdCyd and THU in patients with breast cancer, head and 
neck cancer, non-small cell lung cancer, and urothelial transitional cell carcinoma who have 
failed at least one prior line of therapy (Section 3.1).

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Patient evaluations will be performed throughout the study as described below. Baseline 
history, physical examination, and laboratory evaluations must be conducted within 8 days 
prior to start of protocol therapy. If protocol therapy is started within 8 days of the eligibility 
screening evaluations (see Section 3.3.1 and Section 3.3.2), the results from these screening 
evaluations may be used as baseline measurements. If >8 days have passed since the screening 
evaluations, the medical history, physical examination, and laboratory evaluations must be 
repeated prior to starting protocol therapy. Baseline tumor imaging must be performed within 
28 days prior to start of protocol therapy. If protocol therapy is started within 28 days of the 
eligibility screening tumor imaging, the screening evaluation imaging results may be used as 
baseline measurements; if >28 days have passed since the screening evaluation tumor imaging, 
the imaging must be repeated prior to starting protocol therapy.
History and physical exam will be performed at baseline (within 8 days prior to the start of 
protocol therapy), and physical exams will be performed again during weeks 1 and 2 of cycle 
1, and at the start of every cycle thereafter (within 3 days prior to treatment).  The patient will 
be contacted by phone during weeks 3 and 4 of cycle 1.  Labs (CBC with differential; serum 
chemistries, including glucose) will be performed at baseline (within 8 days prior to the start of 
protocol therapy), weekly during cycle 1, and at the start (within 3 days prior to treatment) and 
during weeks 1 and 2 of every cycle thereafter. Samples for correlative studies will be 
collected as described in Section 9. Appropriate imaging studies will be performed at baseline
(within 28 days prior to the start of protocol therapy), and repeat imaging scans will be 
performed every 2 cycles for disease restaging (every 3 cycles for patients on study for more
than one year, every 4 cycles for patients on study more than 3 years).
4.1 FdCyd and THU Administration 
FdCyd will be administered as an IV infusion over 3 hours with 20% of the daily dose of THU 
administered as an IV push and the remaining 80% of the daily dose co-administered with 
FdCyd over a 3-hour infusion, daily for 5 consecutive days of treatment per week, for 
2 consecutive weeks, followed by 2 weeks of no treatment.  This means treatment will be 
administered on days 1-5 and 8-12 of each cycle, +/- 1 day for scheduling reasons (e.g., 
weekends, holidays, or patient convenience).  Additionally, 1 or 2 doses may be missed if they 
fall on a holiday, and treatment may be delayed up to 2 weeks for holidays or patient 
convenience after discussion with the coordinating center.  The dose of THU is fixed at 
350 mg/m2/day. The dose of FdCyd is 100 mg/m2/day and will not be escalated. The cycle 
length will be 28 days. Dose modifications are outlined in Section 5.
Patients will be treated at 100 mg/m2 FdCyd, a dose shown to be well tolerated at the same 
schedule in 6 patients in the ongoing Phase I study. 
Blood and urine samples for PK analysis will be obtained from a total of 15 patients accrued 
during Cycle 1 only.  Samples will be collected from 3 patients with each of the indications 
listed below except urothelial transitional cell carcinoma; samples will be collected from 6 of 
the first 12 patients with urothelial transitional cell carcinoma as the presence of ileal loops or 
neobladders in this population may have an impact on drug pharmacokinetics (Section 9.0).  

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Blood and optional tumor biopsies will be obtained from all patients to evaluate drug effect 
(Section 9.0).
Patients with the indications listed below whose disease has progressed after at least one line of 
therapy are eligible to participate per Section 3.1 (Eligibility Criteria).
A Non-Small Cell Lung Cancer
B
Urothelial Transitional Cell Carcinoma
C
Head and Neck Cancer
D Breast Cancer 
Patients will also be required to keep a study diary (Appendix B) to record any side effects, and 
any concurrent medications taken. 
5
Dosing Delays/Modifications
5.1 Dose Modifications 
Toxicities should have reVROYHGWRGrade 2 (except lymphopenia) prior to starting the next 
cycle. Treatment may be delayed for a maximum of 2 weeks beyond the actual cycle length of 
28 days; in case toxicities do not resolve to Grade 2 or less, the patient will not receive further 
therapy on this protocol and will be followed for resolution of toxicities.
Treatment will be held for all Grade 3 toxicities (hematological and non-hematologic, with the 
exception of electrolyte abnormalities and lymphopenia) until resolved to Grade 2 (except 
lymphopenia), regardless of when the toxicity occurs during the cycle.  
5.1.1
Grade 2 drug-related toxicity: No changes will be made to the doses of FdCyd and THU.
5.1.2
Grade 3-4 drug-related non-hematologic toxicities: Doses of both FdCyd and THU will be
KHOGXQWLOWR[LFLWLHVUHFRYHUWR*UDGHZLWKWKHH[FHSWLRQRIHOHFWURO\WHDEQRUPDOLWLHV
For the first occurrence of Grade 3 drug-related toxicity, study drugs can be re-initiated at 
the same dose level.  For second occurrence, the dose of FdCyd will be reduced by one 
dose level while THU will remain at 350 mg/m2/day.  For Grade 4 drug-related toxicities, 
FdCyd will be re-initiated at the next lower dose level while THU will remain at 350 
mg/m2/day.  Electrolyte abnormalities will not require dose reduction if resolution to Grade 
2 or less is documented within 24 hours.  A maximum of 2 dose reductions of FdCyd will 
be allowed before a patient is taken off study.  Dose modifications for nausea, vomiting and 
diarrhea will be made only if it is refractory to treatment (refer to Section 5.3). 
5.1.3
Grade 3 and 4 drug-related hematologic toxicities: FdCyd will be re-initiated at the next 
lower dose level while THU will remain at 350 mg/m2/day (except leucopenia with 
neutropenia <4 days or any degree of anemia or lymphopenia).  In case of leucopenia with 
neutropenia <4 days or any degree of anemia or lymphopenia, study drugs will be re-
initiated at the same dose level. 

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5.2 Dose Reduction
For the purposes of dose modification, the dose will be reduced to the next lower dose level as 
indicated in the table below. Patients who have had their dose de-escalated should have 
correlative studies performed at the new dose, if feasible.  No more than 2 dose reductions will 
be allowed.
Dose Modification Table
Dose Level
FdCyd Dose
THU dose
-2
67 mg/m2/day
350 mg/m2/day
-1
1
80 mg/m2/day
100 mg/m2/day
350 mg/m2/day
350 mg/m2/day
5.3 General Concomitant Medication and Supportive Care Guidelines 
All patients will be provided with the best available supportive care.
5.3.1
Vomiting
Nausea and vomiting will be considered refractory if it does not resolve to  Grade 1 with 
treatment with a combination of at least 2 antiemetics.
5.3.2
Diarrhea 
If diarrhea develops and does not have an identifiable cause other than study drug 
administration, anti-diarrheals such as Lomotil (diphenoxylate HCl 2.5 mg + atropine 
sulfate 0.025 mg/tablet) dosed according to package insert or loperamide 4 mg po after the 
first unformed stool with 2 mg po every 2 hours as long as unformed stools continue (4 mg 
every 4 hours while asleep). No more than 16 mg of loperamide should be taken in during 
a 24-hour period. This regimen can be repeated for each diarrheal episode. Diarrhea will 
be considered refractory if it does noWUHVROYHZLWKLQKRXUVWR*UDGHZLWKWKHDERYH
regimen (16 mg, or less if there is resolution of the symptoms, of loperamide in a 24-hour 
period).
5.3.3
Electrolyte Abnormalities
If hypokalemia, hypophosphatemia, or hypomagnesemia occur, the patient may receive 
oral or IV supplementation to correct the abnormality. If hyponatremia occurs, the patient 
may receive 0.9% Sodium Chloride intravenously to correct the abnormality. 
5.3.4
Neutropenia 
Febrile neutropenia is a life-threatening complication requiring hospitalization and urgent 
broad-spectrum antibiotics, as well as an aggressive search for the source and microbial 
cause of the episode. If clinically indicated, filgastrim will be administered per accepted 
guidelines (ASCO or Clinical Center). Study medications will not be reinitiated until at 
least 24 hours after filgastrim administration.

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5.3.5
Anemia 
Symptomatic anemia should be treated with red blood cell infusion and is recommended if 
the hemoglobin falls below 8 mg/dL. Use of erythropoeitin is allowed per accepted 
guidelines. 
5.3.6
Thrombocytopenia 
Thrombocytopenia will be treated conservatively. In the absence of bleeding, fever, or a 
necessary invasive procedure, platelet transfusions should be given for a platelet count 
10,000/mm3. In case the patient is febrile or has other evidence of infection, platelet 
transfusions should EHJLYHQIRUDSODWHOHWFRXQW20,000/mm3. If invasive procedure(s) are 
planned or the subject develops bleeding, platelet transfusions should be administered in 
accordance with standard of practice, usually maintaining a platelet count above 
50,000/mm3.
5.4 Duration of Therapy
In the absence of treatment delays due to adverse event(s), subjects may continue on the study
as long as they are tolerating the drugs and responding to the treatment, or until one of the 
following criteria are met:  
x
Disease progression,
x
Intercurrent illness that prevents further administration,
x
More than 2 dose reductions required for toxicity (as described in Section 5.1)
x
Patient decides to withdraw from the study, or
x
General or specific changes in the patient’s condition render the patient unacceptable 
for further treatment in the opinion of the principal investigator.
5.5 Duration of Follow-up
Patients will be followed for 30 days after the last dose is administered or until one of the 
following occurs: patient enrolls on another protocol, patient receives standard of care, or 
death, whichever comes first. The follow-up will consist of a phone call between Days 27-30
after the last dose to evaluate adverse events that were ongoing and any new events that might 
be deemed related to the therapy.  Unacceptable toxicities (i.e., AEs related to the intervention) 
that have not resolved by Day 30 post-treatment will be followed via biweekly phone calls 
until stabilization or resolution.
5.6 Criteria for Removal From Study
Patients will be removed from study for one of the following reasons: completed 30-day 
follow-up period, toxicities are unresolved but stabilized, patient enrolls on another protocol, or 
patient receives standard of care. The reason for study removal and the date the patient was 
removed must be documented in the medical record.

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6
Human Subjects Protection
6.1 Rationale for Subject Selection
This study will be open to all individuals regardless of gender, ethnicity, or race provided that 
the aforementioned inclusion and exclusion criteria are met.  For safety reasons, pregnant 
women and children are excluded from this study. The NCI is the coordinating center for this 
multi-institutional study.  This study will be recruited through internal referral, our physician 
referral base, and through various cancer information hotlines (i.e., Clinical Studies Support 
Center, 1-800-4Cancer.) Participants should realize that there is no guarantee of benefit to 
them from participation in this trial. The results of this trial may benefit future cancer patients.  
To date, there is no information that suggests that differences in drug metabolism or effect on 
tumor would be expected in one ethnic group compared to another.  Efforts will be made to 
extend accrual to each representative population, but a balance must be struck between 
participant safety considerations and limitations on the number of individuals exposed to 
potentially ineffective treatments on the one hand and the need to explore racial/ethnic aspects 
of clinical research on the other hand.  If differences in outcome that correlate to ethnic identity 
are noted, a follow-up study may be written to investigate those differences more fully.
Inclusion of Women and Minorities: 
This study will be open to all individuals regardless of gender, ethnicity, or race provided that 
the aforementioned inclusion and exclusion criteria are met.
6.2 Justification for Exclusions
Because FdCyd has been shown to be teratogenic in animals, pregnant women will be excluded 
from this trial. Nursing women are also excluded, as there is an unknown but potential risk for 
adverse events in nursing infants secondary to treatment of the mother with FdCyd. 
Participants with unstable or serious medical conditions (active or uncontrolled infection, 
immune deficiencies or confirmed diagnosis of HIV infection, Hepatitis B, Hepatitis C, or 
uncontrolled diabetes, uncontrolled hypertension, symptomatic congestive heart failure, 
unstable angina pectoris, myocardial infarction within the past 6 months, uncontrolled cardiac 
arrhythmia; or psychiatric illness/social situations that would limit compliance with study 
requirements) are excluded due to the possibility that the underlying condition may obscure the 
attribution of effect and adverse events with respect to the combination of FdCyd with THU 
and may limit study compliance. 
6.3 Participation of Children  
Participants under the age of 18 will be excluded from study because no dosing or adverse 
event data are currently available for the use of FdCyd and THU in participants <18 years of 
age. 
6.4 Evaluation of Benefits and Risks/Discomforts
There may or may not be any clinical benefit to a patient from participation in this trial. Their 
participation will benefit future cancer patients. Potential risks include the possible occurrence 
of any of a range of side effects that are listed in the consent document.  The procedure for 

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protecting against or minimizing risks will be to medically evaluate patients as described in 
protocol Section 6.6. Although no compensation is available, any injury will be fully evaluated 
and treated in keeping with the benefits or care to which participants are entitled under 
applicable regulations.
6.5 Consent and Assent Process and Documentation
An associate or principal investigator on the trial will inform patients of the purpose, 
alternatives, drug administration plan, research objectives and follow-up of this trial.  The 
patient will be provided an IRB-approved consent for review and signature and his/her 
questions will be answered.  After a decision is made to enroll into the study, a signature will 
be obtained from the patient.  The original signed consent goes to Medical Records; a copy will 
be placed in the research record.
All patients must have a signed informed consent form and an on-study (confirmation of 
eligibility) form filled out and signed by a participating investigator before entering on study.
For NCI only: adults unable to give consent are excluded from enrolling in the protocol.  
However, re-consent may be necessary and there is a possibility, though unlikely, that subjects 
could become decisionally impaired. For this reason and because there is a prospect of direct 
EHQHILWIURPUHVHDUFKSDUWLFLSDWLRQDOOVXEMHFWVDJHZLOOEHRIIHUHGWKHRSSRUWXQLW\WRILOO
in their wishes for research and care, and assign a substitute decision maker on the “NIH 
Advance Directive for Health Care and Medical Research Participation” form so that another 
person can make decisions about their medical care in the event that they become incapacitated 
or cognitively impaired during the course of the study. Note: The PI or AI will contact the 
NIH Ability to Consent Assessment Team for evaluation.  For those subjects that become 
incapacitated and do not have pre-determined substitute decision maker, the procedures 
described in MEC Policy 87-4 for appointing a surrogate decision maker for adult subjects who 
are (a) decisionally impaired, and (b) who do not have a legal guardian or durable power of 
attorney, will be followed.
6.6 Procedure for Protecting Against or Minimizing Any Potential Risks
All care will be taken to minimize side effects, but they can be unpredictable in nature and 
severity.  This study may involve risks to patients, which are currently unforeseeable.  All 
patients will be monitored for side effects from taking study medication and from 
undergoing blood sampling procedures.  The research component of this study required to 
obtain 2 CT tumor biopsies confers radiation exposure at an effective dose of 1.6 rem. This 
dose is below NIH RSC guidelines for adults of 5.0 rem per year and represents a slightly 
greater than minimal risk to patients.
6.6.1
Patient Advocate
The patients’ rights representative is available to patients receiving treatment on this 
protocol at the NIH Clinical Center at (301) 496-2626 in Building 10 of the Clinical 
Research Center, Room 1-3521, on the Bethesda NIH campus. Patients enrolled at other 
sites will be given information regarding their local patient advocate. Patients will be 
informed that they can contact the study PI or RN at any time with questions about their 

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medical care, and that the patients’ rights representative is also available to answer non-
medical questions about the study. 
7
Adverse Events:  List And Reporting Requirements 
7.1 Comprehensive Adverse Events and Potential Risks Lists (CAEPRs) for 5-Fluoro-2'-
deoxycytidine (FdCyd, NSC 48006) with Tetrahydrouridine (THU, NSC 112907)
7.1.1
CAEPRs for CTEP-Supplied Investigational Agent(s)
The Comprehensive Adverse Event and Potential Risks list (CAEPR) provides a single list of 
reported and/or potential adverse events (AE) associated with an agent using a uniform 
presentation of events by body system. In addition to the comprehensive list, a subset, the Specific 
Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column and is 
identified with bold and italicized text. This subset of AEs (SPEER) is a list of events that are 
protocol specific exceptions to expedited reporting to NCI (except as noted below).  Refer to the 
'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf for 
further clarification. Frequency is provided based on 166 patients. Below is the CAEPR for 5-
Fluoro-2'-deoxycytidine with tetrahydrouridine (FdCyd/THU).
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses 
next to the AE in the SPEER.  If this CAEPR is part of a combination protocol using 
multiple investigational agents and has an AE listed on different SPEERs, use the lower of 
the grades to determine if expedited reporting is required.
Version 2.2, January 17, 20141
Adverse Events with Possible 
Relationship to 5-Fluoro-2'-deoxycytidine with tetrahydrouridine 
(FdCyd/THU)
(CTCAE 4.0 Term)
[n= 166]
Specific Protocol Exceptions to Expedited 
Reporting (SPEER) 
Likely (>20%)
Less Likely (<=20%)
Rare but Serious (<3%)
BLOOD AND LYMPHATIC SYSTEM DISORDERS
Anemia
Anemia (Gr 2)
Febrile neutropenia
CARDIAC DISORDERS
Sinus tachycardia
Sinus tachycardia (Gr 2)
GASTROINTESTINAL DISORDERS
Abdominal distension
Abdominal pain
Abdominal pain (Gr 2)
Constipation
Constipation (Gr 2)
Diarrhea
Diarrhea (Gr 2)
Dry mouth
Dyspepsia
Flatulence
Ileus
Mucositis oral
Mucositis oral (Gr 2)
Nausea
Nausea (Gr 2)
Vomiting
Vomiting (Gr 2)
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS
Chills
Chills (Gr 2)

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Edema limbs
Fatigue
Fatigue (Gr 2)
Fever
Fever (Gr 2)
Non-cardiac chest pain
Pain
INVESTIGATIONS
Activated partial 
thromboplastin time 
prolonged
Activated partial thromboplastin time 
prolonged 
(Gr 2)
Alanine aminotransferase 
increased
Alanine aminotransferase increased (Gr 2)
Alkaline phosphatase 
increased
Alkaline phosphatase increased (Gr 2)
Aspartate aminotransferase 
increased
Aspartate aminotransferase increased (Gr 2)
Blood bilirubin 
increased
Blood bilirubin increased (Gr 2)
Cholesterol high
Creatinine increased
Creatinine increased (Gr 2)
Lymphocyte count 
decreased
Lymphocyte count decreased (Gr 2)
Neutrophil count decreased
Neutrophil count decreased (Gr 2)
Platelet count decreased
Platelet count decreased (Gr 2)
Weight loss
Weight loss (Gr 2)
White blood cell decreased
White blood cell decreased (Gr 2)
METABOLISM AND NUTRITION DISORDERS
Anorexia
Anorexia (Gr 2)
Dehydration
Dehydration (Gr 2)
Hypercalcemia
Hyperglycemia
Hyperglycemia (Gr 2)
Hyperkalemia
Hypermagnesemia
Hypoalbuminemia
Hypoalbuminemia (Gr 2)
Hypocalcemia
Hypocalcemia (Gr 2)
Hypokalemia
Hypokalemia (Gr 2)
Hypomagnesemia
Hypomagnesemia (Gr 2)
Hyponatremia
Hyponatremia (Gr 2)
Hypophosphatemia
Hypophosphatemia (Gr 2)
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS
Arthralgia
Generalized muscle 
weakness
Myalgia
NERVOUS SYSTEM DISORDERS
Dizziness
Dizziness (Gr 2)
Dysgeusia
Headache
Headache (Gr 2)
Peripheral motor 
neuropathy
Peripheral motor neuropathy (Gr 2)
Peripheral sensory 

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neuropathy
RENAL AND URINARY DISORDERS
Proteinuria
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS
Cough
Dyspnea
Dyspnea (Gr 2)
Epistaxis
SKIN AND SUBCUTANEOUS TISSUE DISORDERS
Alopecia
Dry skin
Hyperhidrosis
Palmar-plantar 
erythrodysesthesia 
syndrome
Pruritus
Rash maculo-papular
VASCULAR DISORDERS
Hypotension
Hypotension (Gr 2)
1This table will be updated as the toxicity profile of the agent is revised.  Updates will be 
distributed to all Principal Investigators at the time of revision.  The current version can be 
obtained by contacting PIO@CTEP.NCI.NIH.GOV. Your name, the name of the investigator, the 
protocol and the agent should be included in the e-mail.
Also reported on FdCyd/THU trials but with the relationship to FdCyd/THU still 
undetermined:
CARDIAC DISORDERS - Aortic valve disease; Atrial fibrillation; Cardiac arrest; Mitral valve 
disease; Myocardial infarction; Palpitations; Pericardial effusion; Pericarditis; Tricuspid valve 
disease; Ventricular tachycardia
EAR AND LABYRINTH DISORDERS - Ear pain; Middle ear inflammation; Tinnitus
EYE DISORDERS - Blurred vision; Conjunctivitis; Dry eye; Eye disorders - Other (right eye 
blindness [90-95% visual acuity loss]); Eye disorders - Other (subconjuctival hemorrhage); Eye 
disorders - Other (visual changes); Eye pain; Floaters; Photophobia; Watering eyes
GASTROINTESTINAL DISORDERS - Bloating; Colitis; Colonic obstruction; Duodenal ulcer; 
Dysphagia; Esophagitis; Gastrointestinal disorders - Other (pyloric ulcer); Gastrointestinal pain; 
Hemorrhoids; Lip pain; Oral pain; Rectal hemorrhage; Typhlitis; Upper gastrointestinal 
hemorrhage
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Edema face; Flu 
like symptoms; Infusion site extravasation; Injection site reaction; Localized edema; Malaise
INFECTIONS AND INFESTATIONS - Enterocolitis infectious; Eye infection; Lung infection; 
Mucosal infection; Sepsis; Skin infection; Upper respiratory infection
INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Bruising; Vascular 
access complication
INVESTIGATIONS - CPK increased; Hemoglobin increased; INR increased; Investigations -
Other (bicarbonate)
METABOLISM AND NUTRITION DISORDERS - Alkalosis; Hypernatremia; 
Hypertriglyceridemia; Hyperuricemia; Hypoglycemia

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MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Arthritis; Back pain; 
Bone pain; Chest wall pain; Joint range of motion decreased; Neck pain; Pain in extremity
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND 
POLYPS) - Tumor pain
NERVOUS SYSTEM DISORDERS - Cognitive disturbance; Nervous system disorders - Other 
(neuropathy - cranial); Neuralgia; Syncope; Tremor
PSYCHIATRIC DISORDERS - Agitation; Anxiety; Confusion; Depression; Insomnia
RENAL AND URINARY DISORDERS - Cystitis noninfective; Hematuria; Hemoglobinuria; 
Renal and urinary disorders - Other (bladder pain); Renal and urinary disorders - Other (urethra 
pain); Urinary frequency; Urinary incontinence; Urinary tract pain
REPRODUCTIVE SYSTEM AND BREAST DISORDERS - Breast pain; Gynecomastia; 
Pelvic pain
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Allergic rhinitis; 
Bronchopulmonary hemorrhage; Hiccups; Hypoxia; Pleural effusion; Sore throat
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Bullous dermatitis; Nail discoloration; 
Periorbital edema; Purpura; Rash acneiform; Skin and subcutaneous tissue disorders - Other 
(folliculitis); Skin hyperpigmentation; Skin hypopigmentation; Skin ulceration
VASCULAR DISORDERS - Flushing; Hot flashes; Hypertension
Note: FdCyd/THU in combination with other agents could cause an exacerbation of any adverse 
event currently known to be caused by the other agent, or the combination may result in events 
never previously associated with either agent.
7.2 Adverse Event Characteristics
CTCAE term (AE description) and grade:  The descriptions and grading scales found in the 
revised NCI Common Terminology Criteria for AE (CTCAE) version 3.0 will be utilized until 
December 31, 2010 for AE reporting.  CTCAE version 4.0 will be utilized beginning January 
1, 2011 and until March 31, 2018. CTCAE version 5.0 will be utilized for AE reporting 
beginning April 1, 2018.  All appropriate treatment areas should have access to a copy of the 
CTCAE version 5.0. A copy of the CTCAE version 5.0 can be downloaded from the CTEP 
web site (http://ctep.cancer.gov).
‘Expectedness’: AEs can be ‘Unexpected’ or ‘Expected’ (see Section 7.1 above) for expedited 
reporting purposes only.  ‘Expected’ AEs (the ASAEL) are bold and italicizedin the CAEPR 
(Section 7.1.1).
x
Attribution of the AE:

Definite – The AE is clearly related to the study treatment.

Probable – The AE is likely related to the study treatment.

Possible – The AE may be relatedto the study treatment.

Unlikely – The AE is doubtfully related to the study treatment.

Unrelated – The AE is clearly NOT related to the study treatment.

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7.3 Expedited Adverse Event Reporting
7.3.1
Expedited AE reporting for this study must use CTEP-AERS (CTEP Adverse Event 
Expedited Reporting System), accessed via the CTEP home page (HUhttp://ctep.cancer.govUH).  
The reporting procedures to be followed are presented in the “CTEP, NCI Guidelines: Adverse 
Event Reporting Requirements” which can be downloaded from the CTEP home page 
(HUhttp://ctep.cancer.govUH).  These requirements are briefly outlined in the table below (Section 
7.3.2).
A 24-hour notification is to be made to CTEP by telephone at 301-897-7497 only 
when internet connectivity is disrupted.  Once internet connectivity is restored, an 
AE report submitted by phone must be entered electronically into CTEP-AERS by 
the original submitter at the site.
CTEP-AERS is programmed for automatic electronic distribution of reports to the 
following individuals: Study Coordinator of the Lead Organization, Principal 
Investigator, and the local treating physician.  CTEP-AERS provides a copy feature 
for other e-mail recipients. 
7.3.2
Expedited Reporting Guidelines
Phase 1 and Early Phase 2 Studies:  Expedited Reporting Requirements for Adverse Events that 
Occur on Studies under an IND/IDE within 30 Days of the Last Administration of the Investigational 
Agent/Intervention 1, 2
FDA REPORTING REQUIREMENTS FOR SERIOUS ADVERSE EVENTS (21 CFR Part 312)
NOTE: Investigators MUST immediately report to the sponsor (NCI) ANY Serious Adverse Events, whether or not 
they are considered related to the investigational agent(s)/intervention (21 CFR 312.64)
An adverse event is considered serious if it results in ANY of the following outcomes:  
1)
Death
2)
A life-threatening adverse event 
3)
An adverse event that results in inpatient hospitalization or prolongation of H[LVWLQJKRVSLWDOL]DWLRQ IRU
hours 
4)
A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions 
5)
A congenital anomaly/birth defect. 
6)
Important Medical Events (IME) that may not result in death, be life threatening, or require hospitalization 
may be considered serious when, based upon medical judgment, they may jeopardize the patient or subject 
and may require medical or surgical intervention to prevent one of the outcomes listed in this definition. (FDA, 
21 CFR 312.32; ICH E2A and ICH E6).
ALL SERIOUS adverse events that meet the above criteria MUST be immediately reported to the NCI via CTEP-
AERS within the timeframes detailed in the table below.
Hospitalization
Grade 1 and Grade 2 Timeframes
Grade 3-5
Timeframes
Resulting in 
Hospitalization       
KUV
10 Calendar Days
24-Hour 5 Calendar 
Days
Not resulting in 
Hospitalization       
KUV
Not required

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NOTE: Protocol specific exceptions to expedited reporting of serious adverse events are found in the Specific 
Protocol Exceptions to Expedited Reporting (SPEER) portion of the CAEPR.
Expedited AE reporting timelines are defined as:
o “24-Hour; 5 Calendar Days” - The AE must initially be reported via CTEP-AERS within 24 hours of 
learning of the AE, followed by a complete expedited report within 5 calendar days of the initial 24-
hour report.
o
“10 Calendar Days” - A complete expedited report on the AE must be submitted within 10 calendar 
days of learning of the AE.
1Serious adverse events that occur more than 30 days after the last administration of investigational 
agent/intervention and have an attribution of possible, probable, or definite require reporting as follows: 
Expedited 24-hour notification followed by complete report within 5 calendar days for:
x
All Grade 3, 4, and Grade 5 AEs
Expedited 10 calendar day reports for:
x
Grade 2 AEs resulting in hospitalization or prolongation of hospitalization
2 For studies using PET or SPECT IND agents, the AE reporting period is limited to 10 radioactive half-lives, 
rounded UP to the nearest whole day, after the agent/intervention was last administered.  Footnote “1” above 
applies after this reporting period.
Effective Date:  May 5, 2011
Note:  A death on study requires both routine and expedited reporting regardless 
of causality, unless as noted below.  Attribution to treatment or other cause must 
be provided.
IMPORTANT: Deaths clearly due to progressive disease should be reported as 
Grade 5 “Disease Progression” in the system organ class (SOC) “General 
disorders and administration site conditions.”  Evidence that the death was a 
manifestation of underlying disease (e.g., radiological changes suggesting tumor 
growth or progression: clinical deterioration associated with a disease process) 
should be submitted. Deaths clearly due to progressive disease should NOT be 
reported via CTEP-AERS but rather should be reported via routine reporting 
methods (e.g., CDUS and/or CTMS).
Use the NCI protocol number and the protocol-specific patient ID assigned during trial 
registration on all reports.
7.3.3
Protocol-Specific Expedited Adverse Event Reporting Exclusions
Lymphopenia (any grade), alopecia (any grade), anemia (grade 2), electrolyes 
(grade 2; sodium, potassium, phosphorous, and magnesium), albumin (grade 2), 
hyperuricemia (grade 3), INR (grade 2), and PTT (grade 2) will not be reported via 
CTEP-AERS but will be included in the routine data submissions.
7.3.4
Pregnancy, Fetal Death, and Death Neonatal
NOTE: When submitting CTEP-AERS reports for “Pregnancy”, “Pregnancy loss”, 
or “Neonatal loss”, the Pregnancy Information Form should be completed for 
patients who became pregnant on study, and faxed along with any additional 

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medical information to 301-230-0159. The potential risk of exposure of the fetus to 
the investigational agent(s) or chemotherapy agent(s) should be documented in the 
“Description of Event” section of the CTEP-AERS report.
7.3.4.1 Pregnancy
x
Because patients who become pregnant on study risk intrauterine exposure 
of the fetus to agents which may be teratogenic, DCTD/DCP is requesting 
that pregnancy should be reported in an expedited manner via CTEP-AERS
as Grade 3 “Pregnancy, puerperium and perinatal conditions - Other 
(pregnancy)” under the Pregnancy, puerperium and perinatal conditions 
SOC.
x
The pregnancy outcome for patients on study should be reported via CTEP-
AERS at the time the outcome becomes known, accompanied by the same 
Pregnancy Report Form used for the initial report.
7.3.4.2 Pregnancy loss
x
Pregnancy loss is defined in CTCAE as “Death in utero.”
x
Any pregnancy loss should be reported expeditiously, as Grade 4 
“Pregnancy loss” under the Pregnancy, puerperium and perinatal conditions 
SOC.
x
A pregnancy loss should NOT be reported as a Grade 5 event under the 
Pregnancy, puerperium and perinatal conditions SOC, as currently CTEP-
AERS recognizes this event as a patient death.
7.3.4.3 Death Neonatal
x
Neonatal death, defined in CTCAE as “A disorder characterized by 
cessation of life occurring during the first 28 days of life” that is felt by the 
investigator to be at least possibly due to the investigational 
agent/intervention, should be reported expeditiously.
x
A neonatal death should be reported expeditiously as Grade 4 “Death 
neonatal” under the General disorders and administration SOC.
x
Neonatal death should NOT be reported as Grade 5 “Death neonatal” under 
the General disorders and administration SOC.  If reported as such, the 
CTEP-AERS interprets this as a death of the patient being treated.
7.3.5
NCI-IRB Expedited Reporting of Adverse Events, Unanticipated Problems, and 
Deaths
7.3.5.1 Definitions
Adverse event
An adverse event is defined as any reaction, side effect, or untoward event that occurs 
during the course of the clinical trial associated with the use of a drug in humans, 

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whether or not the event is considered related to the treatment or clinically significant.  
For this study, AEs will include events reported by the patient, as well as clinically 
significant abnormal findings on physical examination or laboratory evaluation.  A new 
illness, symptom, sign or clinically significant laboratory abnormality or worsening of a 
pre-existing condition or abnormality is considered an AE.  All AEs must be recorded 
on the AE case report form unless otherwise noted in Section 7.3.3.
All AEs, including clinically significant abnormal findings on laboratory evaluations, 
regardless of severity, will be followed until satisfactory resolution.  AEs should be 
reported up to 30 days following the last dose of study drug. 
An abnormal laboratory value will be considered an AE if the laboratory abnormality is 
characterized by any of the following:
x
Results in discontinuation from the study
x
Is associated with clinical signs or symptoms
x
Requires treatment or any other therapeutic intervention
x
Is associated with death or another serious adverse event, including 
hospitalization
x
Is judged by the Investigator to be of significant clinical impact
x
If any abnormal laboratory result is considered clinically significant, the 
investigator will provide details about the action taken with respect to the 
test drug and about the patient’s outcome.
Suspected adverse reaction
Suspected adverse reaction means any adverse event for which there is a reasonable 
possibility that the drug caused the adverse event.  For the purposes of IND safety 
reporting, ‘reasonable possibility’ means there is evidence to suggest a causal 
relationship between the drug and the adverse event.  A suspected adverse reaction 
implies a lesser degree of certainty about causality than adverse reaction, which means 
any adverse event caused by a drug.
Unexpected adverse reaction
An adverse event or suspected adverse reaction is considered “unexpected” if it is not 
listed in the investigator brochure or is not listed at the specificity or severity that has 
been observed; or, if an investigator brochure is not required or available, is not 
consistent with the risk information described in the general investigational plan or 
elsewhere in the current application. “Unexpected”, also refers to adverse events or 
suspected adverse reactions that are mentioned in the investigator brochure as occurring 
with a class of drugs or as anticipated from the pharmacological properties of the drug, 
but are not specifically mentioned as occurring with the particular drug under 
investigation.
Serious 

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An Unanticipated Problem or Protocol Deviation is serious if it meets the definition of 
a Serious Adverse Event or if it compromises the safety, welfare, or rights of subjects 
or others.
Serious Adverse Event
An adverse event or suspected adverse reaction is considered serious if in the view of 
the investigator or the sponsor, it results in any of the following:
x
Death,
x
A life-threatening adverse drug experience
x
Inpatient hospitalization or prolongation of existing hospitalization
x
A persistent or significant disability/incapacity
x
A congenital anomaly/birth defect.
x
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered a serious adverse drug experience when, based 
upon appropriate medical judgment, they may jeopardize the patient or subject and 
may require medical or surgical intervention to prevent one of the outcomes listed 
in this definition.
Disability
A substantial disruption of a person’s ability to conduct normal life functions.
Life-threatening adverse drug experience
Any adverse event or suspected adverse reaction that places the patient or subject, in 
the view of the investigator or sponsor, at immediate risk of death from the reaction as 
it occurred, i.e., it does not include a reaction that had it occurred in a more severe 
form, might have caused death.
Protocol Deviation (NIH Definitions)
Any change, divergence, or departure from the IRB approved research protocol.
Non-compliance (NIH Definition)
The failure to comply with applicable NIH Human Research Protections Program 
(HRPP) policies, IRB requirements, or regulatory requirements for the protection of 
human research subjects.
Unanticipated Problem
Any incident, experience, or outcome that:
x
Is unexpected in terms of nature, severity, or frequency in relation to 
(a) the research risks that are described in the IRB-approved research protocol and 
informed consent document; Investigator’s Brochure or other study documents, and
(b) the characteristics of the subject population being studied; AND
x
Is related or possibly related to participation in the research; AND

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x
Suggests that the research places subjects or others at a greater risk of harm
(including physical, psychological, economic, or social harm) than was previously 
known or recognized.
7.3.5.2
NCI IRB and Clinical Center Director Reporting Requirements 
The Coordinating Center PI will report in the NIH Problem Form to the NCI-IRB and 
NCI Clinical Director:
x
All deaths, except deaths due to progressive disease 
x
All Protocol Deviations
x
All Unanticipated Problems
x
All serious non-compliance
Reports must be received within 7 days of Coordinating Center PI awareness via iRIS.
7.3.5.3
NCI-IRB Reporting of IND Safety Reports
Only IND Safety Reports that meet the definition of an unanticipated problem will need 
to be reported to the NCI IRB.
7.4 Multicenter Guidelines for Expedited Adverse Event Reporting
7.4.1
Expedited Adverse Event Reporting for Participating Sites
7.4.1.1 Adverse Event Reporting via CTEP-AERS:
Follow sponsor expedited AE reporting requirements in Section 7.3.2. Copy 
Jennifer Zlott (zlottjh@mail.nih.gov) and Alice Chen, MD 
(chenali@@mail.nih.gov) on all CTEP-AERS reports.
7.4.1.2 Adverse Event Reporting to NCI IRB:
The site PI must immediately report to the Coordinating Center PI any serious 
adverse event, whether or not considered drug related, including those listed in 
the protocol or investigator brochure and must include an assessment of 
whether there is a reasonable possibility that the drug caused the event within 
24 hours of PI awareness of the event.  The site PI must also report any 
protocol deviations or violations to the Coordinating Center PI within 7 days of 
PI awareness.  Participating centers must also submit the report to their IRB in 
accordance with their institutional policies.
Follow NCI IRB expedited AE reporting requirements in Section 7.3.4.
Complete the NCI IRB Expedited AE form supplied by the Coordinating 
Center.  Send the completed form to Jennifer Zlott, RN either by e-mail to 
(zlottjh@mail.nih.gov) or by fax to (301) 480-4612.

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7.5 Routine Adverse Event Reporting
All Adverse Events must be reported in routine study data submissions.  AEs reported through 
CTEP-AERS must also be reported in routine study data submissions.
AML/MDS events will be reported via CTEP-AERS (in addition to routine AE reporting 
mechanisms). In CTCAE v5, the event(s) may be reported as either: 1) Leukemia secondary to 
oncology chemotherapy, 2) Myelodysplastic syndrome, or, 3) Treatment related secondary 
malignancy.
7.5.1
NCI IRB Requirements for Coordinating Site PI Reporting at Continuing Review 
System
Organ Class
CTCAE 
Term
Grade
# of Events 
since last CR
Total # of 
Events
Attribution to 
Research
Serious?
Unexpected?
The protocol PI will report to the NCI-IRB: 
1.
A summary of all protocol deviations in a tabular format to include the date the 
deviation occurred, a brief description of the deviation and any corrective action.
2.
A summary of any instances of non-compliance
3.
A tabular summary of the following adverse events:
x
All Grade 2 unexpected events that are possibly, probably or definitely 
related to the research; 
x
All Grade 3 and 4 events that are possibly, probably or definitely related to 
the research; 
x
All Grade 5 events regardless of attribution; 
x
All Serious Events regardless of attribution. 
NOTE: Grade 1 events are not required to be reported. 
8 Pharmaceutical Information  
8.1 Compound Name: 5-Fluoro-2'-deoxycytidine (NSC 48006)
Formula: C9H12FN3O4
Molecular Weight: 245.21
Other Names: FdCyd
Description: Fluoropyrimidine antimetabolite.
Dosage and Formulation: 5-Fluoro-2'-deoxycytidine (FdCyd) is supplied by the DCTD and 
distributed by the PMB/NCI as a sterile, single use vial. Each vial contains 100 mg 
(20 mg/mL; 5 mL) of a clear, colorless solution.

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Preparation: The prescribed daily dose should be further diluted in 5% dextrose injection, 
USP prior to administration.
Storage: Intact vials should be stored at controlled room temperature.
Stability: Shelf life stability testing of the intact vials is on-going.  CAUTION: The single-use 
dosage form contains no antibacterial preservatives.  Therefore, it is advised that the product be 
discarded 8 hours after initial entry.
Method of Administration: FdCyd may be mixed with tetrahydrouridine (THU, NSC 
112907) in 5% dextrose injection, USP and is stable for at least 24 hours at room temperature.
Toxicities: A list of the adverse events and potential risks associated with FdCyd can be found 
in Section 7.1.
Availability: This is an investigational agent supplied to investigators by the Division of 
Cancer Treatment and Diagnosis (DCTD), NCI.
Agent Ordering and Agent Accountability: NCI-supplied agents may be requested by the 
Principal Investigator (or their authorized designee) at each participating institution.  
Pharmaceutical Management Branch (PMB) policy requires that agent be shipped directly to 
the institution where the patient is to be treated.  PMB does not permit the transfer of agents 
between institutions (unless prior approval from PMB is obtained).  The CTEP-assigned 
protocol number must be used for ordering all CTEP-supplied investigational agents.  The
responsible investigator at each participating institution must be registered with CTEP, DCTD 
through an annual submission of FDA Form 1572 (Statement of Investigator), Curriculum 
Vitae, Supplemental Investigator Data Form (IDF), and Financial Disclosure Form (FDF).  If 
there are several participating investigators at one institution, CTEP-supplied investigational 
agents for the study should be ordered under the name of one lead investigator at that 
institution.
Active CTEP-registered investigators and investigator-designated shipping designees and 
ordering designees can submit agent requests through the PMB Online Agent Order Processing 
(OAOP) application (https://eapps-ctep.nci.nih.gov/OAOP/pages/login.jspx).  Access to OAOP 
requires the establishment of a CTEP Identity and Access Management (IAM) account 
(https://ctepcore.nci.nih.gov/iam/index.jsp) and the maintenance of an “active” account status 
and a “current” password. For questions about drug orders, transfers, returns, or 
accountability, call (240) 276-6575 Monday through Friday between 8:30 am and 4:30 pm 
(ET) or email PMBAfterHours@mail.nih.gov anytime.
Agent Inventory Records – The investigator, or a responsible party designated by the 
investigator, must maintain a careful record of the inventory and disposition of all agents 
received from DCTD using the NCI Drug Accountability Record Form (DARF).  (See the NCI 
Investigator’s Handbook for Procedures for Drug Accountability and Storage.)

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8.2 Compound Name: Tetrahydrouridine (NSC 112907)
Formula: C9H16N2O6
Molecular Weight: 248.2
Other Names: THU
Description: Cytidine deaminase inhibitor.
Dosage and Formulation: Tetrahydrouridine Injection is supplied by the DCTD and distributed 
by the PMB/NCI as a 500 mg vial (10 mg/mL; 50 mL).  The clear, colorless solution contains 10 
mg tetrahydrouridine per mL with dibasic phosphate, USP, monobasic phosphate, USP used as 
buffer to maintain pH at 7.4.
The total daily dose of THU will be 350 mg/m2. Each day, 20% of the dose of THU will be 
injected as an IV push; 80% of the dose of THU diluted in 5% dextrose injection, USP will be 
infused over 3 hours. 
Using retention of 90% of the initial potency as the criterion for stability, FdCyd and THU 
were stable when mixed together in 5% dextrose injection, USP for at least 24 hours, both at 
controlled room temperature and at 40°C (IND #54,223).
Preparation:  Tetrahydrouridine may be administered without further dilution or may be 
further diluted in 0.9% Sodium Chloride Injection, USP or 5% dextrose injection, USP to a 
concentration as low as 2.5 mg/mL.
Storage: Intact vials should be stored in the refrigerator (2o – 8oC).
Stability: Shelf life stability testing of the intact vials is ongoing.  THU as diluted above is 
stable for at least 24 hours at room temperature.  CAUTION: The single-use dosage form 
contains no antibacterial preservatives.  Therefore, it is advised that the product be discarded 8
hours after initial entry.
Toxicities: A list of the adverse events and potential risks associated with THU can be found 
in Section 7.1.
Availability: This is an investigational agent supplied to investigators by the DCTD, NCI.
Agent Ordering and Agent Accountability:  NCI-supplied agents may be requested by the 
Principal Investigator (or their authorized designee) at each participating institution.  
Pharmaceutical Management Branch (PMB) policy requires that agent be shipped directly to 
the institution where the patient is to be treated.  PMB does not permit the transfer of agents 
between institutions (unless prior approval from PMB is obtained).  The CTEP-assigned 
protocol number must be used for ordering all CTEP-supplied investigational agents.  The 
responsible investigator at each participating institution must be registered with CTEP, DCTD 
through an annual submission of FDA Form 1572 (Statement of Investigator), Curriculum 
Vitae, Supplemental Investigator Data Form (IDF), and Financial Disclosure Form (FDF).  If 
there are several participating investigators at one institution, CTEP-supplied investigational 

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agents for the study should be ordered under the name of one lead investigator at that 
institution.
Active CTEP-registered investigators and investigator-designated shipping designees and 
ordering designees can submit agent requests through the PMB Online Agent Order Processing 
(OAOP) application (https://eapps-ctep.nci.nih.gov/OAOP/pages/login.jspx).  Access to OAOP 
requires the establishment of a CTEP Identity and Access Management (IAM) account 
(https://ctepcore.nci.nih.gov/iam/index.jsp) and the maintenance of an “active” account status 
and a “current” password.  For questions about drug orders, transfers, returns, or 
accountability, call (240) 276-6575 Monday through Friday between 8:30 am and 4:30 pm 
(ET) or email PMBAfterHours@mail.nih.gov anytime.
Agent Inventory Records – The investigator, or a responsible party designated by the 
investigator, must maintain a careful record of the inventory and disposition of all agents 
received from DCTD using the NCI Drug Accountability Record Form (DARF). (See the NCI 
Investigator’s Handbook for Procedures for Drug Accountability and Storage.)
9 Correlative Studies
Tumor biopsies and blood samples will be obtained to characterize the effects of FdCyd and THU 
on the biology of tumor cells and to determine the pharmacokinetics of both the FdCyd and THU.  
Blood samples will be collected to measure DNA methylation and DNA methyltransferase 
activity.  Blood will also be collected to measure changes in the number of CTCs before and 
during treatment.
9.1 Tissue Sample Acquisition and Processing
9.1.1
Timing of Biopsies
Tumor biopsies are optional in this trial. 
Biopsies will be performed at the following times: 
x After consent, prior to treatment
x After the completion of Cycle 2 (i.e., following the restaging imaging scans)
9.1.2
Biopsy Procedure 
Serial tumor biopsies will be obtained through Interventional Radiology by a 
percutaneous approach. A maximum of 2 core biopsies 18-gauge in diameter will be 
obtained at each time point.  Only percutaneous biopsies will be performed on patients 
with solid tumors.  It is estimated that there will be between 2 to 5 million cells from 
each biopsy.  If a site is deemed appropriate for biopsy with minimal risk to the 
participant by agreement between the investigators and Interventional Radiology, an 
attempt at biopsy will be made. The use of imaging to facilitate biopsies will be 
decided by members of the Interventional Radiology team and may include ultrasound, 
CT scan, or MRI.  Should CT scan be needed for biopsy, the number of scans for each 
procedure will be limited to the minimum number needed to safely obtain a biopsy.  

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Tumor biopsies and local anesthesia will be administered only if they are considered to 
be of low risk to the participant as determined by the investigators and Interventional 
Radiology.
All cases will be carefully reviewed with the interventional radiologists who have 
extensive experience in performing such procedures.  Only if the procedure is 
considered to be low risk then we will proceed with tumor biopsy in a given participant.  
If the participant refuses a tumor biopsy, he/she will still remain on study and receive 
study medication and all other correlative studies will be performed.
If an initial attempt at percutaneous biopsy is unsuccessful, the patient will be given an 
option to proceed with a repeated attempt at percutaneous biopsy.  In case biopsy 
samples are unable to be obtained for a given patient, the patient will still remain on 
study, receive study medication, and all other correlative studies will be performed.
9.1.3
Laboratory Contact, NIH Clinical Center
For patients enrolled at the NCI, at least 24 hours prior to taking the biopsy, the 
research nurse will contact the NCI Phase I/II PK/PD Support Group in NIH Building 
10: E-mail: NCIPK-PDsupportgroup@mail.nih.gov; Pager: 102-12798; 
Phone: (301) 451-1169; Fax: (301) 480-5871.  Tubes pre-labeled with the participant 
ID, biopsy date, protocol #, and site of tissue biopsy will be provided.
Refer to Appendix F for biopsy processing and shipping information.
9.1.4
Measurement of Methylation-Silenced Gene Products by mRNA 
Transcript Assays in Tumor Biopsies
Biopsies will be utilized to measure methylation-silenced gene products by mRNA 
transcript assays prior and post treatment. Expression of E-Cadherin, DAPK1, p16, 
MGMT, RASSF1a, and TIMP3 will be analyzed by RT-qPCR employing an assay 
validated for performance on the Taqman platform.  The kit is purchased from ABI.  
Tumor specimens will be extracted with RNA-Easy, and the RNA purified, DNAse-
treated, and quantified by absorbance.  cDNA generated will be measured on a 
Nanodrop spectrophotometer; 20 ng of cDNA will be loaded into each of triplicate 
wells in 96-well plates for PCR amplification. Controls include actin and beta-catenin, 
neither of which is silenced by CpG island methylation. All samples will be initially 
stored and processed in Dr. Kinders’ laboratory (PADIS/LHTP/NCI-Frederick). If
VXIILFLHQWWXPRU WLVVXHLVDYDLODEOHLPPXQRIOXRUHVFHQFH PLFURVFRS\íEDVHG
assessments of p16, DNMT1, and other relevant proteins may also be performed.
9.2 Pharmacodynamic Studies
9.2.1
Blood Collection for PD Studies
PD samples will be collected for the following: plasma for DNA methylation status and
mononuclear cells for assessing DNA methyltransferase activity.  Two 4-mL EDTA 
(lavender-top) tubes of blood will be collected from the patient at each time point.  See 
Appendix F for reagents, shipping instructions, and procedures for PD studies. Current 

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SOPs can be found on the DCTD Web site: 
http://dctd.cancer.gov/ResearchResources/ResearchResources-biomarkers.htm
Blood will be collected at the following times for PD analysis:
x Prior to drug administration on Day 1 for Cycles 1, 2, and 4
x At the completion of treatment on Cycles 1, 2, and 4 (Day 12 +/- 1 day)
9.2.2
Blood Collection for CTC Studies
Blood for CTCs will be collected to determine the dose response to FdCyd/THU 
treatment in terms of the fraction of CTCs expressing p16.
Prior to CTC collection, each participating site should e-mail a request for specimen 
collection and shipping materials from NCI_PD_Support_CellSearch@mail.nih.gov.
Approximately 8 mL of blood will be collected from the patient into a 10-mL CellSave 
preservative tube at each time point.
Blood will be collected at the following times: 
x
Prior to treatment on Cycle 1, Day 1
x
Cycle 1, Day 2 following treatment (up to 24 hours after end of infusion)
x
Cycle 1, Day 12 (+/- 1 day)
x
Day 1 (+/- 1 day) of Cycle 2 and all subsequent cycles
x
Day 12 (+/- 1 day) of Cycles 2, 4, and 6
x
At time of disease progression
9.2.3
CTC collection
The blood will be collected (~8 mL) at the time points mentioned above.  Whole blood 
will be collected aseptically by venipuncture or from a venous port into a CellSave 
preservative tube. Invert tube 8 times following collection to distribute anticoagulant 
and preservative through blood.  The collected blood samples are stable for up to 96
hours at room temperature (15Û&WRÛ&SULRUWRSURFHVVLQJ.
9.2.4
Laboratory Contact, NIH Clinical Center
For patients enrolled at the NCI, at least 24 hours prior to taking the blood samples, the 
research nurse will contact the NCI Phase I/II PK/PD Support Group in NIH Building 
10: E-mail: NCIPK-PDsupportgroup@mail.nih.gov; Pager: 102-12798; Phone: (301)
451-1169; Fax: (301) 480-5871.
Testing and data analysis will be performed by Dr. Kinders (PADIS/LHTP/Frederick
National Laboratory for Cancer Research).  Refer to Appendix F for Participating Site 
sample shipping material request procedures and shipping information.

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9.3 Pharmacokinetics Studies (Cycle 1 Only)
FdCyd will be assayed in plasma and urine from 15 patients. Blood will be drawn from a 
site other than the one used to administer chemotherapy (from a contralateral limb or a 
central venous line of patients receiving FdCyd and THU by peripheral vein, or from a 
peripheral vein of patients receiving FdCyd and THU by central venous line). Urine will 
be collected to determine renal excretion of the drug.
9.3.1
PK Urine and Blood Samples
Blood samples for PK analysis will be obtained from a total of 15 patients during Cycle 
1 only. Samples will be collected from 3 patients from each cohort except urothelial 
transitional cell carcinoma; samples will be collected from 6 of the first 12 patients with 
urothelial transitional cell carcinoma as any ileal loops or neobladders in this patient 
population may have an impact on drug pharmacokinetics. One 3-mL heparinized 
(green-top) WXEHSUHORDGHGZLWKȝ/RIPJP/ RIZEB (see Appendix D for 
preparation of tubes) will be obtained for each of the time points.  The actual time of 
collection will be noted for each sample, and the sample will be placed immediately on 
ice.  See Appendix E for reagents and the procedure for PK studies.
Blood will be collected at the following times:
x
Cycle 1, Day 1 prior to treatment
x
Cycle 1 Day 1 at 15 min, 30 min, 1 hr, 2 hr, and 2.5 hr during the infusion
x
Cycle 1 Day 1 at 15 min, 30 min, 1 hr, 2 hr, 4 hr, and 6 hr post completion of 
infusion
x
Cycle 1 Days 2, 3, 4, and 5 prior to treatment
Based upon the results of the initial measurements, sampling times may be adjusted but 
neither the total number of samples nor the total amount of blood will be increased. All 
samples will be immediately placed on ice. Samples should be processed within 
10 minutes after collection.
A baseline urine collection of 10 mL will be collected just before drug administration. 
Urine will then be collected at every void from 0 to 24-hr post drug infusion on Cycle 1 
Day 1 for PK analysis. Samples should be placed on wet ice immediately after 
collection.  The total volume of urine collected for the 24-hour time period will be 
mixed, measured, and noted. A minimum sample of 10 mL will be saved by nursing in 
a specimen cup. The remainder of the unused sample can be discarded. Samples will 
be processed according to the procedures in Appendix E.
Record the date, planned time and actual time of collection for each specimen on the 
pharmacokinetic form; the study number and the patient’s unique patient identifier 
should be included on this form. In addition, the date and exact time when the FdCyd 
and THU doses were administered should be recorded on the appropriate 
pharmacokinetic form (Appendix G).

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9.4 Sample Collection and Processing at the NIH Clinical Center
Biospecimens will be collected and processed using validated SOPs that will ensure both 
specimen quality and patient confidentiality pursuant to informed consent provisions.
Using a computerized inventory system and a backup hardcopy process, all specimen 
collection and processing steps will be documented and the specific location of each specimen 
will be tracked. Each new specimen collected will be assigned a unique barcode identifier 
that can be linked to the original specimen collected and other relevant information within the 
inventory system. To ensure patient confidentiality, only containers used for the initial 
specimen collections will be labeled with patient identifiers. Only the barcode identifier will 
be applied to all subsequent specimen containers. When specimens are processed and 
aliquoted, no patient information will be included on the new containers. Original specimen 
containers will be discarded.  Only barcode-labeled specimens without patient identifiers will 
be shipped for analysis and/or storage. Specimen labels will indicate: protocol number, order 
in which the patient enrolled on the trial, type of sample, collection time, and total volume 
collected, as appropriate. Samples from sets of at least three patients will be grouped for 
scientific analysis.
The inventory process contains other security provisions sufficient to safeguard patient 
privacy and confidentiality. Access to the inventory system and associated documents will be 
restricted to appropriate individuals. Requests to use specimens stored in the repository must 
be approved. The only patient information available in the inventory system will be the 
patient sex, diagnosis, and level of informed consent given. SOPs ensure that any changes in 
informed consent made by a patient and relayed to the PI will be reflected in the inventory 
system to ensure that specimens are destroyed as appropriate. All laboratory personnel will be 
trained to adhere to SOPs and will be monitored for high-quality performance.
Following completion of this study, samples will remain in storage as detailed above. Access 
to these samples will only be granted following IRB approval of an additional protocol, 
granting the rights to use the material.
If, at any time, a patient withdraws from the study and does not wish for their existing samples 
to be utilized, the individual must provide a written request. Following receipt of this request, 
the samples will be destroyed (or returned to the patient, if so requested), and reported as such 
to the IRB. Any samples lost (in transit or by a researcher) or destroyed due to unknown 
sample integrity (i.e., broken freezer allows for extensive sample thawing, etc.) will be 
reported as such to the IRB.
Any new use of these samples will require prospective IRB review and approval; any loss or 
destruction of samples and the planned disposition of samples after the protocol is terminated 
will be reported to the IRB.

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10
Study Calendar
Eligibility screening evaluations are to be conducted within 8 days prior to enrollment, with the 
exception of diagnostic imaging, which must be done within 28 days prior to enrollment.  Baseline 
history, physical examination, and laboratory evaluations are to be conducted within 8 days prior 
to the start of protocol therapy.  If protocol therapy is started within 8 days of the eligibility 
screening evaluations, values from the screening evaluations may be used as baseline 
measurements; if > 8 days have passed since the screening evaluations, the medical history, 
physical examination, and laboratory evaluations must be repeated prior to starting protocol 
therapy.  Baseline imaging scans must be done within 28 days prior to the start of protocol therapy.  
If protocol therapy is started within 28 days of the eligibility screening tumor imaging, the 
screening evaluation imaging results may be used as baseline measurements; if >28 days have 
passed since the screening evaluation tumor imaging, the imaging must be repeated prior to 
starting protocol therapy. The research team may perform additional safety/monitoring tests as 
clinically indicated.

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Pre-Study
Eligibility 
Screening
Baseline
Clinical
Evaluation
Cycle 1
Cycle 2 
Cycle 3 onwards
Wk
1
Wk
2
Wk
3
Wk
4
Wk
1
Wk
2
Wk
3
Wk
4
FdCyda
X
X
X
X
X
THUa
X
X
X
X
X
Informed consent
X
Demographics
X
Med.History
X
Xi
X
X
(prior to treatment)
Physical examb
X
Xi
X
X
X
X
(prior to treatment)
Height and 
Weight
X
Xi
X
X
Performance 
Status
X
Xi
X
X
X
X
X
X
CBC w/diff, pltsc
X
Xi
X
X
X
X
X
X
X
Serum chemistryc
X
Xi
X
X
X
X
X
X
X
PD blood
samplesd
X
X
X
X
X (days 1, 12)
Blood samples 
for CTCf
X
post-treatment CTC blood sample collection
described in Section 9.2.2
Optional Tumor 
Biopsiesj
X
X
(at first restaging)
Tumor
Measuremente
X
Xi
X
Radiologic 
Evaluatione
X
Xi
X
B-HCGg
X
PK blood and 
urine samplesh
X
Adverse event 
evaluation
   X………………………………………………………………X
a.
FdCyd and THU will be administered IV on Days 1-5 and 8-12 of each cycle +/- 1 day for 
scheduling reasons (e.g., weekends, holidays, or patient convenience).
b.
A physical examination including vital signs will be conducted pre-study and during weeks 1 and 2
of Cycle 1, and then within 3 days prior to treatment every cycle thereafter.  The patient will be 
contacted by phone during weeks 3 and 4 of Cycle 1.
c.    Serum chemistries (sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose, AST, ALT, 
bilirubin, calcium, phosphorous, albumin, magnesium, alkaline phosphatase, LDH) and CBC with
differential and platelets will be performed at baseline, weekly during cycle 1, then within 3 days 
prior to the start of every cycle and during weeks 1 and 2 of every cycle.
d.
PD samples will be collected at multiple time points as specified in Section 9.
e.
Radiologic examination will be performed at baseline and then every two cycles (every three cycles 
for patients on study more than one year and every 4 cycles for patients on study more than 3 years).
f.
Blood samples for CTCs will be collected prior to study and as specified in Section 9.2.2.
g.
Urine pregnancy test (women of childbearing potential).

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h
Blood and urine for PK analysis will be obtained during Cycle 1 only as specified in Section 9.
i
Values from eligibility screening tests may be used as baseline evaluation values if the test was 
performed within 8 days of start of protocol therapy (or, for radiologic evaluation and tumor 
measurement, within 28 days of start of protocol therapy).  See Section 3.3 and Section 4.
j
Optional tumor biopsies will be performed as described in Section 9.1.1.
11 Measurement of Effect
Radiologic evaluation for tumor measurements will be performed at baseline within 28 days prior 
to the start of protocol therapy and then every 2 cycles.
11.1
Antitumor Effect – Solid Tumors
Response and progression will be evaluated in this study using the new international criteria 
proposed by the Response Evaluation Criteria in Solid Tumors (RECIST) Committee [JNCI
92(3):205-216, 2000]. Changes in only the largest diameter (unidimensional measurement) of 
the tumor lesions are used in the RECIST criteria.
11.1.1 Definitions
Evaluable for toxicity. All patients will be evaluable for toxicity from the time of their 
first treatment with FdCyd.
Evaluable for objective response. Only those patients who have measurable disease 
present at baseline, have received at least one cycle of therapy, and have had their 
disease re-evaluated will be considered evaluable for response. These patients will have 
their response classified according to the definitions stated below. (Note: Patients who 
exhibit objective disease progression prior to the end of Cycle 1 will also be considered 
evaluable.)
11.1.2 Disease Parameters
Measurable disease. Measurable lesions are defined as those that can be accurately 
measured in at least one dimension (longest diameter to be recRUGHGDVPPZLWK
conventional techniques (CT, MRI, ultrasound) or as 10 mm with spiral CT scan. All 
tumor measurements must be recorded in millimeters (or decimal fractions of 
centimeters)
Non-measurable disease. All other lesions (or sites of disease), including small lesions 
(longest diameter <20 mm with conventional techniques or <10 mm using spiral CT 
scan), are considered non-measurable disease. Bone lesions, leptomeningeal disease, 
ascites, pleural/pericardial effusions, lymphangitis cutis/pulmonis, inflammatory breast 
disease, abdominal masses (not followed by CT or MRI), and cystic lesions are all non-
measurable.
Target lesions. All measurable lesions up to a maximum of 5 lesions per organ and 
10 lesions in total, representative of all involved organs, should be identified as target 

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lesions and recorded and measured at baseline. Target lesions should be selected on the 
basis of their size (lesions with the longest diameter) and their suitability for accurate 
repeated measurements (either by imaging techniques or clinically). A sum of the 
longest diameter (LD) for all target lesions will be calculated and reported as the 
baseline sum LD. The baseline sum LD will be used as reference by which to 
characterize the objective tumor response.
Non-target lesions. All other lesions (or sites of disease) including any measurable 
lesions over and above the 10 target lesions should be identified as non-target lesions 
and should also be recorded at baseline. Measurements of these lesions are not required, 
but the presence or absence of each should be noted throughout follow-up.
11.1.3 Methods for Evaluation of Measurable Disease 
All measurements should be taken and recorded in metric notation using a ruler or 
calipers. All baseline evaluations should be performed as closely as possible to the 
beginning of treatment and never more than 4 weeks before the beginning of the 
treatment.
The same method of assessment and the same technique should be used to characterize 
each identified and reported lesion at baseline and during follow-up. Imaging-based 
evaluation is preferred to evaluation by clinical examination when both methods have 
been used to assess the antitumor effect of a treatment.
Clinical lesions: Clinical lesions will only be considered measurable when they are 
superficial (e.g., skin nodules and palpable lymph nodes). In the case of skin lesions, 
documentation by color photography, including a ruler to estimate the size of the lesion, 
is recommended.
Conventional CT and MRI: These techniques should be performed with cuts of 10 mm 
or less in slice thickness contiguously. Spiral CT should be performed using a 5 mm 
contiguous reconstruction algorithm. This applies to tumors of the chest, abdomen, and 
pelvis. Head and neck tumors and those of extremities usually require specific 
protocols.
Ultrasound (US): When the primary endpoint of the study is objective response 
evaluation, US should not be used to measure tumor lesions. It is, however, a possible 
alternative to clinical measurements of superficial palpable lymph nodes, subcutaneous 
lesions, and thyroid nodules. US might also be useful to confirm the complete 
disappearance of superficial lesions usually assessed by clinical examination.
Endoscopy, Laparoscopy: The utilization of these techniques for objective tumor 
evaluation has not yet been fully and widely validated. Their uses in this specific 
context require sophisticated equipment and a high level of expertise that may only be 
available in some centers. Therefore, the utilization of such techniques for objective 
tumor response should be restricted to validation purposes in reference centers. 

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However, such techniques may be useful to confirm complete pathological response 
when biopsies are obtained.
Tumor markers: Tumor markers alone cannot be used to assess response. If markers 
are initially above the upper normal limit, they must normalize for a patient to be 
considered in complete clinical response. Progression of disease will be determined per 
RECIST criteria as outlined below.
Cytology, Histology: These techniques can be used to differentiate between partial 
responses (PR) and complete responses (CR) in rare cases (e.g., residual lesions in 
tumor types, such as germ cell tumors, where known residual benign tumors can 
remain).
The cytological confirmation of the neoplastic origin of any effusion that appears or 
worsens during treatment when the measurable tumor has met criteria for response or 
stable disease is mandatory to differentiate between response or stable disease (an 
effusion may be a side effect of the treatment) and progressive disease.
11.1.4 Response Criteria 
11.1.4.1
Evaluation of Target Lesions 
Complete Response (CR): Disappearance of all target lesions
Partial Response (PR): At least a 30% decrease in the sum of the longest diameter 
(LD) of target lesions, taking as reference the baseline sum of the LD.
Progressive Disease (PD): At least a 20% increase in the sum of the LD of target 
lesions, taking as reference the smallest sum of the LD recorded since the treatment 
started or the appearance of one or more new lesions.
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum of the LD since the 
treatment started. 
11.1.4.2
Evaluation of Non-Target Lesions 
Complete Response (CR): Disappearance of all non-target lesions and normalization 
of tumor marker level Note: If tumor markers are initially above the upper normal 
limit, they must normalize for a patient to be considered in complete clinical 
response.
Incomplete Response/ Stable Disease (SD): Persistence of one or more non-target 
lesion(s) and/or maintenance of tumor marker level above the normal limits.
Progressive Disease (PD): Appearance of one or more new lesions and/or 
unequivocal progression of existing non-target lesions Although a clear progression 
of “non-target” lesions only is exceptional, the opinion of the treating physician 

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should prevail in such circumstances, and the progression status should be confirmed 
at a later time by the review panel (or Principal Investigator).
Target 
Lesions 
Non-Target 
Lesions 
New 
Lesions 
Overall 
Response 
Best Response for This
Category Also Requires: 
CR
CR
No
CR
>4 weeks confirmation 
CR
Non-
CR/Non-PD 
No
PR 
>4 weeks confirmation 
PR 
Non-PD 
No
PR 
SD 
Non-PD 
No
SD 
documented at least once 
>4 weeks from baseline 
PD 
Any 
Yes or 
No
PD 
no prior SD, PR or CR
Any 
PD* 
Yes or 
No
PD 
Any 
Any 
Yes
PD 
In exceptional circumstances, unequivocal progression in non-target lesions may be 
accepted as disease progression. Note: Patients with a global deterioration of health status 
requiring discontinuation of treatment without objective evidence of disease progression at 
that time should be reported as “symptomatic deterioration.” Every effort should be made 
to document the objective progression even after discontinuation of treatment.
11.1.4.3
Evaluation of Best Overall Response 
The best overall response is the best response recorded from the start of the treatment 
until disease progression/recurrence (taking as reference for progressive disease the 
smallest measurements recorded since the treatment started). The patient's best 
response assignment will depend on the achievement of both measurement and 
confirmation criteria.
11.1.4.4
Duration of Response 
Duration of overall response: The duration of overall response is measured from the 
time measurement criteria are met for CR or PR (whichever is first recorded) until the 
first date that recurrent or progressive disease is objectively documented (taking as 
reference for progressive disease the smallest measurements recorded since the 
treatment started). The duration of overall CR is measured from the time measurement 
criteria are first met for CR until the first date that recurrent disease is objectively 
documented.
Duration of stable disease: Stable disease is measured from the start of the treatment 
until the criteria for progression are met, taking as reference the smallest measurements 
recorded since the treatment started.

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12 Data Reporting / Regulatory Requirements
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.
12.1
Data Reporting
12.1.1 Method
This study will be monitored by the Clinical Data Update System (CDUS) version 3.0.
Cumulative CDUS data will be submitted quarterly to CTEP by electronic means.
Reports are due January 31, April 30, July 31, and October 31. Instructions for 
submitting data using the CDUS can be found on the CTEP Web site 
(http://ctep.cancer.gov).
Note:  All adverse events that have occurred on the study, including those reported 
through CTEP-AERS, must be reported via the monitoring method identified above.
12.1.2 Responsibility for Submission 
Study participants are responsible for submitting CDUS data and/or data forms to the 
Coordinating Center quarterly to allow time for Coordinating Center compilation, 
Principal Investigator review, and timely submission to CTEP (see Section 12.1.1.). The 
Coordinating Center is responsible for compiling and submitting CDUS data to CTEP 
for all participants and for providing the data to the Principal Investigator for review.
12.2
Data Safety and Monitoring Plan
The investigators at each participating center will be responsible for the collection, 
maintenance, and quality control of the study data. Adverse events observed in patients 
enrolled on the trial will be monitored in real time by the Principal and Associate 
Investigators, and attribution of these events to the research will be determined at the end of 
each treatment cycle in each subject. The clinical research team (PI, adjunct PI, research 
nurses, data managers) will meet weekly when patients are being actively treated on the trial 
to discuss each patient in detail and ensure that all events are graded appropriately, and that 
the attribution to study drug is correct.  The Coordinating Center is responsible for 
establishing conference calls between participating sites at least on a monthly basis to discuss 
the observed toxicities and protocol issues.
All SAEs will be reported through CTEP-AERS to CTEP, to the Coordinating Center PI at 
NCI, and forwarded to the IRB per Section 7. In all cases where the dose of the study 
treatment has been reduced/modified or the patient withdrawn due to unusual or unusually 
severe toxicity considered related to the study treatment, the investigator must contact and 
inform the Coordinating Center PI.  All sites will be monitored by the CTEP drug monitor 
who will receive data from all participating sites.

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Data will be monitored regularly by the principal investigator in order to identify significant 
toxicity trends. Any new significant finding that may affect the patient’s willingness to 
continue in the study will be shared with patients.
Confidentiality will be maintained as much as possible, consistent with applicable regulations.
Names of participants or identifying material will not be released without patient permission, 
except when such release is required by law. No patient’s name or identifying information will 
be released in any publication or presentation. Records are maintained according to current 
legal requirements, and are made available for review according to the requirements of the 
FDA or other authorized user, only under guidelines established by the Federal Privacy Act.
Safety Monitoring Committee:
Because this is a multi-institutional Phase II protocol for which the Developmental 
Therapeutics Clinic (DTC), NCI is the Coordinating Center, it will be monitored by the DTC 
Safety Monitoring Committee, NCI. Reviews will occur annually concurrent with NCI IRB 
continuing reviews.
12.3
Multicenter Guidelines 
This protocol will open initially at the NCI.  The NCI IRB will be notified once the 
participating centers’ IRBs have approved the studies to open. This protocol will follow the 
CCR’s Clinical Research Operations’ SOPs for multicenter trials.
12.3.1 IRB Approvals 
As the Coordinating Center for a trial, it is the PI’s responsibility to ascertain that no 
patients are entered on the trial at a participating institution without full IRB approval.
Thus, the NCI IRB must approve the addition of each participating institution to the 
protocol and will require a copy of the local IRB approval from each participating 
institution before NCI IRB approval will be granted.
The PI will provide the NCI IRB with a copy of the participating institution’s approved 
yearly continuing review. Registration will be halted at any participating institution in 
which a current continuing approval is not on file at the NCI IRB.
12.3.2 Amendments and Consents 
The NCI PI will provide the NCI IRB with copies of all amendments, consents and 
approvals from each participating institution.
12.3.3 Data Collection
The investigators will be responsible for the collection, maintenance, and quality control 
of the study data. All data collected for each study subject will be entered into the 
Cancer Central Clinical Database (C3D), an NCI electronic case report form/database, 
every 2 weeks. The participating sites will be able to enter the data remotely into the 
web-based C3D system. Each site investigator is also responsible for maintaining all 
source documentation related to the study, including any films, tracings, computer discs 
or tapes. NCI will be responsible for data management, data analysis, and reporting. 
Data collection forms will be provided to the participating institutions. Required data 

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include, not exclusively: prior disease-related therapies with dates, disease type, stage, 
disease sites, with measurements, and concurrent medications.
12.3.4 Data and Center Audits
Audits will be conducted yearly to ensure data integrity and provide quality control.
These audits will be conducted by the NCI research team. Selected patient charts should 
be audited as well as the participating institution’s Standard Operating Procedures (SOP) 
at the time of the visit. Data from participating institutions should be available when the 
protocol is audited at the NCI.
12.3.5 CTEP Multicenter Guidelines 
This protocol will adhere to the policies and requirements of the CTEP Multicenter 
Guidelines.  The specific responsibilities of the Principal Investigator and the 
Coordinating Center (Study Coordinator) and the procedures for auditing are presented 
in Appendix C.
x The Principal Investigator/Coordinating Center is responsible for distributing all IND 
Action Letters or Safety Reports received from CTEP to all participating institutions 
for submission to their individual IRBs for action as required.
x Except in very unusual circumstances, each participating institution will order 
DCTD-supplied agents directly from CTEP.  Agents may be ordered by a 
participating site only after the initial IRB approval for the site has been forwarded by 
the Coordinating Center to the CTEP PIO (PIO@ctep.nci.nih.gov) (except for Group 
studies).
12.4 Cooperative Research and Development Agreement (CRADA) / Clinical Trials 
Agreement (CTA)
N/A
13Statistical Considerations
The primary objective of this protocol is to determine if FdCyd/THU is associated with 
adequate response rates (RR) or progression-free survival (PFS) in patients with any of a 
variety of malignancies as defined below. PFS will be estimated using a Kaplan-Meier curve.  
The results obtained will be informally compared to those from other studies in similar 
patients to help determine the potential benefit of exploring use of these agents in a 
subsequent, more definitive study, if warranted.  These patients will have been previously 
treated with multiple prior chemotherapeutic regimens, so that any reasonable evidence of 
benefit will be interpreted as being a positive indicator. 
Exploratory study objectives relate to the safety of the agents in patients with various solid 
tumors, and an evaluation of the impact of FdCyd/THU on extent of LINE-1 methylation in 
tumor biopsies. Blood samples will also be collected to evaluate the number of circulating 
tumor cells before and during treatment. Changes from baseline will be determined in either 

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absolute or relative terms as appropriate, and evaluated for statistical significance, as well as 
to determine if the changes or the actual values at a time point are associated with clinical 
response. Paired comparisons with baseline will be done using a paired t-test or Wilcoxon 
signed rank test as appropriate, and the changes will be compared between responders and 
non-responders (PD) using a two-sample t-test (adequate numbers of subjects with normally 
distributed data in both groups) or a Wilcoxon rank sum test, if enough patients respond for 
this to be appropriate. In all such cases, these analyses will be considered exploratory and not 
formally adjusted for multiple comparisons. However, to ensure proper interpretation in the 
context of a potentially large number of explorations being performed, only p values <0.01 
will be interpretable as being associated with statistical significance.
Patients will be enrolled into one of 4 strata as follows:
A Non-Small Cell Lung Cancer
B Breast Cancer
C Urothelial Transitional Cell Carcinoma
D Head and Neck Cancer
In each stratum, the study will be conducted with a dual-endpoint design, based on RR and 4-
month (6-month for the breast cancer stratum) PFS as co-primary endpoints.  In strata A, C,
and D, evidence of positive results is sought in the first stage to determine if the particular 
stratum should be expanded into the second stage. In stratum B, a one-stage design is utilized.
Also, throughout the sections below, ‘response’ will refer to the appearance of a positive 
outcome as defined for each disease.
Stratum A: Non-Small Cell Lung Cancer
Stratum A will use a trial design for patients with NSCLC that judges the agents as promising 
if we achieve either tumor response rates of 20% vs. 5% or 4-month PFS rates of 50% vs. 
25% (corresponding to median PFS of 4 vs. 2 months).  The design requires a maximum of 45
evaluable patients. For each stratum, if at least 6 objective responses (at least 13%), or at least 
18 instances of 4-month PFS (at least 40%), are observed among the 45 evaluable patients, 
this regimen will be considered worthy of further testing in this disease.  If no more than one 
objective response (no more than 5%), and no more than 6 instances of 4-month PFS (no more 
than 30%), are observed among the initial 20 patients, the stratum will be terminated early and 
declared negative.
This design yields at least 87% power to detect a true objective response rate of at least 20%.  
It yields at least 90% power to detect a true 4-month PFS rate of at least 50% (median PFS of 
4 months).  It yields at least .96 probability of a negative result if the true objective response 
rate is no more than 5% and the true 4-month PFS rate is no more than 25% (median PFS of 2 
months), with approximately .58 probability, at least, of early negative stopping in this case.  
In addition, the over-all probability of negative results across all 4 strata, under the over-all 
null hypothesis, is .85. These last three probabilities are calculated assuming that tumor 
response rate and PFS rate are uncorrelated. If they are positively correlated, as is likely, the 
probabilities will be a bit higher.

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Stratum B: Breast Cancer
Stratum B will use a trial design for patients with breast cancer that judges the agents as 
promising if we achieve either tumor response rates of 20% vs. 5% or 6-month PFS rates of 
50% vs. 25% (corresponding to median PFS of 6 vs. 3 months).  The design requires a 
maximum of 35 evaluable patients.  If at least 5 objective responses (at least 14%), or at least 
15 instances of 6-month PFS (at least 43%), are observed among the 35 evaluable patients, 
this regimen will be considered worthy of further testing in this disease.  This design yields at 
least 85% power to detect a true objective response rate of at least 20%.  It yields at least 84%
power to detect a true 6-month PFS rate of at least 50% (median PFS of 6 months).  It yields 
at least .95 probability of a negative result if the true objective response rate is no more than 
5% and the true 6-month PFS rate is no more than 25% (median PFS of 3 months).  In 
addition, the over-all probability of negative results across all 4 strata, under the over-all null 
hypothesis, is .85.  These last three probabilities are calculated assuming that tumor response 
rate and PFS rate are uncorrelated. If they are positively correlated, as is likely, the 
probabilities will be a bit higher.
If accrual onto this stratum is slow, and the target to demonstrate promising response rate (5 
responders) or PFS rate (15 patients with 6-month PFS) has alreadybeen met among the
initial 30 patients, consideration will be given to stopping the trial and declaring the regimen
promising. The likelihood of demonstrating such promise under the alternative hypothesis is 
at least .57.
Stratum C: Urothelial Transitional Cell Carcinoma
Stratum C will use a trial design for patients with urothelial transitional cell carcinoma that 
judges the agents as promising if we achieve either tumor response rates of 20% vs. 5% or 4-
month PFS rates of 50% vs. 25% (corresponding to median PFS of 4 vs. 2 months).  The 
design requires a maximum of 45 evaluable patients.  If at least 6 objective responses (at least
13%), or at least 18 instances of 4-month PFS (at least 40%) are observed among the 45
evaluable patients, this regimen will be considered worthy of further testing in this disease.  If
no more than one objective response (no more than 5%), and no more than 6 instances of 4-
month PFS (no more than 30%), are observed among the initial 20 patients, the stratum will 
be terminated early and declared negative.
This design yields at least 87% power to detect a true objective response rate of at least 20%.  
It yields at least 90% power to detect a true 4-month PFS rate of at least 50% (median PFS of 
4 months).  It yields at least .96 probability of a negative result if the true objective response 
rate is no more than 5% and the true 4-month PFS rate is no more than 25% (median PFS of 2 
months), with approximately .58 probability, at least, of early negative stopping in this case. 
In addition, the over-all probability of negative results across all 4 strata, under the over-all 
null hypothesis, is .85. These last three probabilities are calculated assuming that tumor 
response rate and PFS rate are uncorrelated.  If they are positively correlated, as is likely, the 
probabilities will be a bit higher. 

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Stratum D: Head and Neck Cancer 
Stratum D will use a trial design for patients with head and neck cancer that judges the agents 
as promising if we achieve either tumor response rates of 20% vs. 5% or 4-month PFS rates of 
50% vs. 25% (corresponding to median PFS of 4 vs. 2 months).  The design requires a 
maximum of 45 evaluable patients.  If at least 6 objective responses (at least 13%), or at least 
18 instances of 4-month PFS (at least 40%), are observed among the 45 evaluable patients, 
this regimen will be considered worthy of further testing in this disease.  If no more than one 
objective response (no more than 5%), and no more than 6 instances of 4-month PFS (no more 
than 30%) are observed among the initial 20 patients, the stratum will be terminated early and 
declared negative.  
This design yields at least 87% power to detect a true objective response rate of at least 20%.
It yields at least 90% power to detect a true 4-month PFS rate of at least 50% (median PFS of 
4 months).  It yields at least .96 probability of a negative result if the true objective response 
rate is no more than 5% and the true 4-month PFS rate is no more than 25% (median PFS of 2 
months), with approximately .58 probability, at least, of early negative stopping in this case.  
In addition, the over-all probability of negative results across all 4 strata, under the over-all 
null hypothesis, is .85. These last three probabilities are calculated assuming that tumor 
response rate and PFS rate are uncorrelated.  If they are positively correlated, as is likely, the 
probabilities will be a bit higher.
For all strata, toxicity data will be obtained, and if there are 5 or more patients in a given 
stratum who experience Grade 3 or greater toxicity attributable to the agent, then comparisons 
between cohorts across grades of toxicity may be done using a Kruskal-Wallis test for ordered 
columns.  Otherwise, toxicities will be tabulated and described.
Comparisons between extent of LINE-PHWK\ODWLRQ DQGȖ- WRȕ-globin ratio will be made by 
subtracting pre-treatment from post-treatment levels and determining the statistical 
significance of the difference using a Wilcoxon signed rank test.  These measures will all be 
evaluated with exploratory intent, and findings will be reported without formal adjustment for 
multiple comparisons, but in the context of a study with multiple exploratory analyses 
performed.
A total of 160 evaluable patients may be required if the study enrolls patients onto the second 
stage of cohorts A and D. The diseases studied are quite different from one another; thus, 
imposing an overall rule about responses in the full spectrum of patients, prior to enrolling to 
the first stage is not practical.
To allow for inevaluable patients, a total of 165 patients will be set as the accrual ceiling. It is 
anticipated that approximately 8- 9 patients per month will be accrued such that 
approximately 21 months will be required to accrue up to 165 patients.

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14
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Smith, S.S., et al., Mechanism of human methyl-directed DNA methyltransferase and the 
fidelity of cytosine methylation.Proc Natl Acad Sci U S A, 1992. 89(10): p. 4744-8.

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55.
Camiener, G.W., Studies of the enzymatic deamination of ara-cytidine. V. inhibition in 
vitro and in vivo by tetrahydrouridine and other reduced pyrimidine nucleosides.Biochem 
Pharmacol, 1968. 17(9): p. 1981-91.
56.
Kreis, W., et al., Tetrahydrouridine: Physiologic disposition and effect upon deamination 
of cytosine arabinoside in man. Cancer Treat Rep, 1977. 61(7): p. 1347-53.
57.
Wong, P.P., et al., Phase I evaluation of tetrahydrouridine combined with cytosine 
arabinoside. Cancer Treat Rep, 1979. 63(8): p. 1245-9.
58.
Robert A. Parise, M.J.E., Julie L. Eiseman, Erin Joseph, Joseph M. Covey, Jan H. Beumer,, 
Quantitative determination of the cytidine deaminase inhibitor tetrahydrouridine (THU) in 
mouse plasma by liquid chromatography/electrospray ionization tandem mass 
spectrometry.Rapid Communications in Mass Spectrometry, 2007. 21(13): p. 1991-1997.
59.
Beumer, J., et al., Plasma pharmacokinetics and oral bioavailability of 3,4,5,6-
tetrahydrouridine, a cytidine deaminase inhibitor, in mice. Cancer Chemotherapy and 
Pharmacology, 2008. 62(3): p. 457-464.
60.
Camiener, G.W. and C.G. Smith, Studies of the enzymatic deamination of cytosine 
arabinoside. I. Enzyme distribution and species specificity.Biochem Pharmacol, 1965. 
14(10): p. 1405-16.
61.
Li, C., D. Villacorte, and E. Newman. 5-Fluoro-2’-deoxycytidine induces re-expression of 
hypermethylation-silenced genes in the human breast cancer cell line MDA-MB 231. in 
Cellular and Molecular Biology 23: DNA Methylation and Profiling. 2006: AACR 
Meeting Abstracts.
62.
Newman, E., et al. Phase I and clinical pharmacokinetic evaluation of the DNA 
methyltransferase inhibitor 5-Xuoro-2 -deoxycytidine: a California Cancer Consortium 
study. in Proc Am Soc Clin Oncol. 2002.
63.
Beumer, J., et al., Concentrations of the DNA methyltransferase inhibitor 5-fluoro-2͛-
deoxycytidine (FdCyd) and its cytotoxic metabolites in plasma of patients treated with 
FdCyd and tetrahydrouridine (THU). Cancer Chemotherapy and Pharmacology, 2008. 
62(2): p. 363-368.
64.
Yang, A.S., et al., DNA methylation changes after 5-aza-2'-deoxycytidine therapy in 
patients with leukemia. Cancer Res, 2006. 66(10): p. 5495-503.
65.
Colella, S., et al., Sensitive and quantitative universal Pyrosequencing methylation analysis 
of CpG sites. Biotechniques, 2003. 35(1): p. 146-50.
66.
Corn, P.G., et al., E-cadherin expression is silenced by 5' CpG island methylation in acute 
leukemia. Clin Cancer Res, 2000. 6(11): p. 4243-8.
67.
Reinhold, W.C., et al., Detailed DNA methylation profiles of the E-cadherin promoter in 
the NCI-60 cancer cells.Mol Cancer Ther, 2007. 6(2): p. 391-403.
68.
Ginder, G.D., et al., Silencing and activation of embryonic globin gene expression. Ann N 
Y Acad Sci, 1998. 850: p. 70-9.
69.
Smith, R.D., et al., Quantitative PCR analysis of HbF inducers in primary human adult 
erythroid cells. Blood, 2000. 95(3): p. 863-869.
70.
Allard, W.J., et al., Tumor cells circulate in the peripheral blood of all major carcinomas 
but not in healthy subjects or patients with nonmalignant diseases. Clin Cancer Res, 2004. 
10(20): p. 6897-904.
71.
Cristofanilli, M., et al., Circulating tumor cells, disease progression, and survival in 
metastatic breast cancer. N Engl J Med, 2004. 351(8): p. 781-91.

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Appendix A: Performance Status
Karnofsky Performance Scale
Percent 
Description 
100
Normal, no complaints, no evidence of disease.
90
Able to carry on normal activity; minor signs or 
symptoms of disease.
80
Normal activity with effort; some signs or symptoms 
of disease.
70
Cares for self, unable to carry on normal activity or 
to do active work.
60
Requires occasional assistance, but is able to care for 
most of his/her needs.
50
Requires considerable assistance and frequent 
medical care.
40
Disabled, requires special care and assistance.
30
Severely disabled, hospitalization indicated. Death 
not imminent.
20
Very sick, hospitalization indicated. Death not 
imminent.
10
Moribund, fatal processes progressing rapidly.
0
Dead.

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Appendix B: Study Diary
Patient Name: ____________________________________
Please note any side effects you experienced on this day
Do not list your daily medications, but note any other medication you took on 
this day (both prescription and non-prescription) and the reason why taken
Monday
Date:
Tuesday
Date:
Wednesday
Date:
Thursday
Date:
Friday
Date:
Saturday
Date:
Sunday
Date:
Signature of person completing form: ____________________________________
Date: ____________________

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Appendix C: CTEP Multicenter Guidelines
If an institution wishes to collaborate with other participating institutions in performing a CTEP 
sponsored research protocol, then the following guidelines must be followed.
Responsibility of the Protocol Chair 
x
The Protocol Chair will be the single liaison with the CTEP Protocol and Information Office 
(PIO).  The Protocol Chair is responsible for the coordination, development, submission, 
and approval of the protocol as well as its subsequent amendments.  The protocol must not 
be rewritten or modified by anyone other than the Protocol Chair.  There will be only one 
version of the protocol, and each participating institution will use that document.  The 
Protocol Chair is responsible for assuring that all participating institutions are using the 
correct version of the protocol.
x
The Protocol Chair is responsible for the overall conduct of the study at all participating 
institutions and for monitoring its progress.  All reporting requirements to CTEP are the 
responsibility of the Protocol Chair. 
x
The Protocol Chair is responsible for the timely review of Adverse Events (AE) to assure 
safety of the patients.
x
The Protocol Chair will be responsible for the review of and timely submission of data for 
study analysis.
Responsibilities of the Coordinating Center
x
Each participating institution will have an appropriate assurance on file with the Office for 
Human Research Protection (OHRP), NIH. The Coordinating Center is responsible for 
assuring that each participating institution has an OHRP assurance and must maintain copies 
of IRB approvals from each participating site. 
x
Prior to the activation of the protocol at each participating institution, an OHRP Form 310 
(documentation of IRB approval) must be submitted to the CTEP PIO.
x
The Coordinating Center is responsible for central patient registration.  The Coordinating 
Center is responsible for assuring that IRB approval has been obtained at each participating 
site prior to the first patient registration from that site.
x
The Coordinating Center is responsible for the preparation of all submitted data for review 
by the Protocol Chair.
x
The Coordinating Center will maintain documentation of AE reports.  There are two options 
for AE reporting: (1) participating institutions may report directly to CTEP with a copy to 
the Coordinating Center, or (2) participating institutions report to the Coordinating Center 
who in turn report to CTEP.  The Coordinating Center will submit AE reports to the 
Protocol Chair for timely review.
x
Audits may be accomplished in one of two ways:  (1) source documents and research 
records for selected patients are brought from participating sites to the Coordinating Center 
for audit, or (2) selected patient records may be audited on-site at participating sites.  If the 
NCI chooses to have an audit at the Coordinating Center, then the Coordinating Center is 
responsible for having all source documents, research records, all IRB approval documents, 
NCI Drug Accountability Record forms, patient registration lists, response assessments 

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scans, x-rays, etc. available for the audit.
Inclusion of Multicenter Guidelines in the Protocol
x
The protocol must include the following minimum information: 
x
The title page must include the name and address of each participating institution and the 
name, telephone number and e-mail address of the responsible investigator at each 
participating institution.
x
The Coordinating Center must be designated on the title page.
x
Central registration of patients is required.  The procedures for registration must be stated in 
the protocol.
x
Data collection forms should be of a common format.  Sample forms should be submitted 
with the protocol.  The frequency and timing of data submission forms to the Coordinating 
Center should be stated.
x
Describe how AEs will be reported from the participating institutions, either directly to 
CTEP or through the Coordinating Center.
x
Describe how Safety Reports and Action Letters from CTEP will be distributed to 
participating institutions.
Agent Ordering
Except in very unusual circumstances, each participating institution will order DCTD-supplied 
investigational agents directly from CTEP (See Section 8).  Investigational agents may be ordered 
by a participating site only after the initial IRB approval for the site has been forwarded by the 
Coordinating Center to the CTEP PIO. 

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Appendix D: Preparation of PK Blood Draw Tubes and Urine Storage Cryogenic Vials With 
Zebularine (ZEB)
Preparation of tubes:
Zebularine (ZEB) will be provided upon request as bulk powder.  Participating center pharmacies 
will make up a stock solution of ZEB at 100 mg/mL (wt of zebularine/volume of water added) and 
will prepare 1-mL frozen aliquots.
Requests for Zebularine powder can be sent to:
Rao Vishnuvajjala, PhD
Pharmaceutical Resources Branch, NCI, NIH 
9609 Medical Center Drive MSC 9734
Rockville, MD  20850-9734
Phone: (240) 276-5962
E-mail: raov@dtpepn.nci.nih.gov
*Please note: vacutainers and/or other supplies will not be provided by the NCI
Blood Draw Tubes:
Zebularine can be added to Vacutainer tubes up to one day in advance without causing significant 
loss of vacuum.  Using a 3/10 cc insulin syringe or other similar sized syringe with a fine needle, 
GUDZXSȝ/RIWKH=(%VROXWLRQDQGWUDQVIHULWWRD-mL heparinized Vacutainer tube (cat # 
366667) by piercing the stopper.  Do not draw up ZEB for more than one tube at a time.  You will 
not be able to control the amount of ZEB solution that leaves the needle, as it is sucked out by the 
vacuum.  Because of the fine needle, you will not lose the vacuum (apart from the volume added) in 
the collection tube.
Urine Storage Cryogenic Vials:
Five (5) μL of the 100 mg/mL ZEB solution should be added to each cryogenic vial to 
accommodate the 0.5 mL urine sample.  Because the cryogenic tubes are not under vacuum, you 
can use any appropriate device to measure the 5 μL, e.g., a micropipettor such as Pipetman.  This 
will yield the same final concentration of ZEB in the urine samples as in the blood samples (final 
concentration 1 mg/mL).

Clinical  Ce nter # 0 9- C- 0 2 1 4
C T E P # 8 3 5 1
7 6
A p pe n di x  E: Pr oce d ure   f or  Bl o o d  a n d  Uri ne   S a m ple s  f or P har mac o k i netics
Pl as ma:
S up pli es f or e ac h s a mpl e:
O ne ( 1) 3- m L he pari ni ze d ( gr ee n-t o p) t ube ( Vac utai ner ®
cat # 3 6 6 6 6 7 or e q ui val e nt) wit h 
z e b ul ari ne ( Z E B, s e e A p pe ndi x D .)
It is criti c al t hat t he vi als c o ntai ni ng  Z E B be use d t o mi ni mi ze  e x vi v o dea mi nati o n  of 
F d C yd d uri ng  pr ocessi ng a nd st or a ge.
T hr ee ( 3) 1- m L cr yo ge ni c vi als
Pr oce d ure : O btai n bl o o d i n a 3- m L he pari ni ze d ( gr ee n-t o p) t ube ( Vac utai ner cat # 3 6 6 6 6 7 or 
Z E B .  Ge ntl y  i nvert 3 ti mes t o mi x a nd pl ace
i m me di atel y  o n i ce.  F or eac h ti me p oi nt, l a bel 3 cr yo ge ni c vi als wit h t he  c o or di nati ng  ce nter 
pati e nt #, date, a nd ti me.  D o not i ncl ude pati e nt i de ntifi ers o n t he s a mpl e l a bels.  Ce ntrif uge  t he 
bl o o d at 6 0 0 x g f or 1 0 mi nutes  at 4
C.  Tr a nsfer 0. 5 m L  of t he pl as ma i nt o eac h of 2 cr yo ge ni c 
vi als a nd t he r e mai nder of t he pl as ma i nt o t he t hir d cr yo ge ni c vi al, if p ossi bl e wit ho ut dist ur bi ng t he 
cell pell et.  Kee p t he pl as ma o n i c e a nd fr eeze at or bel o w - 2 0
C wit hi n o ne ho ur.
Uri ne:
S up pli es f or e a c h s a mpl e:
O ne ( 1) s cr e w- ca p pe d ce ntrif uge  t ube ( 1 5 m L)
T hr ee ( 3) 1- m L cr yo ge ni c vi als wit h 5 μ L of 1 0 0 mg/ m L ze b ul ari ne  ( Z E B, A p pe ndi x D )
It is criti c al t hat t he vi als c o ntai ni ng  Z E B be use d t o mi ni mi ze  e x vi v o dea mi nati o n  of 
F d C yd d uri ng  st or a ge. 
Pr oce d ure : O btai n a p pr o xi matel y 1 0 m L  of uri ne fr o m t he pati e nt a nd pl ace i m me di atel y o n i ce.  
E xce pt f or t he pr etr eat me nt  s peci me n, o btai n t he 1 0 m L  ali q uot after t he t otal v ol u me of t he 2 4- hr 
c oll e cti o n has be e n me as ur e d.  Ma ke s ur e t he 2 4- hr uri ne is mi xe d  bef or e ta ki ng  t he ali q uot. If t he 
ali q uot is fr oze n, t ha w o n i ce or t ha w at r o o m te mper at ur e,  b ut  pl a c e o n i c e as s o o n as t ha w e d, mi x,
a nd pr ocess as s o o n as p ossi bl e.  P o ur t he uri ne s peci me n i nt o a scr e w- ca p pe d ce ntrif uge  t ube a nd 
ce ntrif uge  at 6 0 0 g f or 1 mi nute  at 4
C t o s e di me nt de bris.  Tr a nsfer 0. 5 m L  of t he uri ne i nt o eac h 
of 3 cr yo ge ni c vi als wit h  Z E B . La bel t he  vi als wit h t he  c o or di nati ng  ce nter pati e nt  # a nd date ( no 
pati e nt i de ntifi ers). Fr e e ze t he cr yo ge ni c vi als of uri ne at or bel o w - 2 0
C.
All P K s a m ples are t o be s hi p pe d  t o:
J a n H. Be u mer,  P har m D,  P h D
Uni versit y  of Pitts b ur gh  Ca ncer I nstit ute
R o o m G 2 7 E Hill ma n Res ear c h La b or at ori es
5 1 1 7 Ce ntr e A ve nue
Pitts b ur gh,  P A 1 5 2 1 3
Pl eas e notif y  eit her Mr. R o bert Paris e or Ms. S us a n C hrist ner ( 4 1 2- 6 2 3- 3 2 4 8) b y tel e p ho ne or fa x 
( 4 1 2- 6 2 3- 1 2 1 2) at l east 2 4 ho urs pri or t o s hi p me nt.   Sa mpl es s ho ul d be s hi p pe d t o arri ve T ues da y, 

Clinical Center #09-C-0214
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Wednesday, Thursday, or Friday.  A name, phone number, fax number, or e-mail address should be 
included with samples so that receipt can be acknowledged.
The shipment of human blood samples must comply with appropriate regulations as specified by 
the carrier.  At a minimum, all samples must be packaged within two containers with absorbent 
material between containers to control any spill or leakage.  The outer container must be puncture-
resistant (e.g., cardboard mailing tube, corrugated cardboard box).  A biohazard sticker must be 
affixed to both the inner and outer containers.
All samples should be shipped via overnight express courier in insulated containers with enough 
dry ice to maintain the samples in a frozen state.  A copy of each of the pharmacokinetic sample 
collection forms for the respective patients should be included with each shipment.

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Appendix F: Procedure for Tumor Biopsy and Blood Samples for Pharmacodynamic Studies
Tumor Biopsy Samples
Biopsies (once initial processing is complete in the procedure room; Section 9.1.2) will be flash-
frozen in a pre-chilled cryovial prelabeled with a Unique Identifier Code for the specimen per 
NCTVL HUSOP340507UH (Sample Handling Section 9.1), see the DCTD Web site for detailed 
instructions on biopsy collection and handling:
https://dctd.cancer.gov/ResearchResources/biomarkers/docs/par/SOP340507_Biopsy_Frozen.pdf.
At the NCI, frozen specimens will be transported on dry ice by Clinical Service Program courier to 
the PADIS lab at Frederick National Laboratory for Cancer Research, where they will be logged 
into the record keeping system and held in liquid nitrogen until processing.
Biopsy specimens from participating sites will be sent to:
Attention: Dan Danner
NCI-F/FNLCR
1073 Beasley Street, Building 1073
Fort Detrick
Frederick, MD 21701
Phone: 301-846-5748
NCI_PD_Support_CellSearch@mail.nih.gov
Please send an email to FNLCR PD Specimen Central Receiving (NCI_PD_Support@mail.nih.gov) 
to advise that biopsy samples are being prepared for shipment.  State “Protocol Name PD 
Specimens Ready for Shipment” in the subject line.  If needed, FNLCR PD Central Receiving can 
be contacted directly at 301-846-1951 (primary) or 240-344-5697 (mobile). All shipments should 
include a description of contents on the outside label/shipping slip and detailed packing slip 
included with the samples. 
If the biopsy specimen is large enough (i.e., 10 mm or longer), the specimen will be cut into two 
parts for subsequent DNA extraction (CpG island methylation analysis) and RNA extraction.  If the 
sample is not sufficient, it will be processed for DNA extraction only. 
Processing for CpG island methylation analysis will consist of DNA extraction (DNA-Easy kit, 
Ambion), purification and quantitation, and aliquoting in barcoded tubes.  LINE1 methylation
analysis will be performed on the Biotage Pyromark in the PADIS laboratory.  An additional 
analysis in Dr. Yang’s laboratory at USC will be performed with a blind aliquot of DNA isolated 
from the patient biopsy specimen should this prove necessary to confirm results.  
Isolation of CTCs 
Prior to CTC collection, each participating site should e-mail a request for specimen 
collection and shipping materials from NCI_PD_Support_CellSearch@mail.nih.gov.
Allow at least six business days for receipt of the blood shipment containers; a confirmation e-mail 
with the expected shipping date will be sent. 

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Blood (~8 mL) will be collected aseptically by venipuncture or from a venous port into a CellSave 
preservative tube pre-labeled with a unique identifier code for the specimen per PADIS SOP
LHTP003.8.1
http://dctd.cancer.gov/ResearchResources/biomarkers/docs/ctc/LHTP003.08.03_CellSave_Collecti
on_Subm.pdfU; the collected blood samples are stable for up to 96 KRXUVDWURRPWHPSHUDWXUHÛ&
WRÛ&SULRUWRSURFHVsing.
At the NCI, blood will be transported by Clinical Service Program courier to the PADIS lab at
Frederick National Lab. Do not ship on ice.  Once at PADIS, samples will be logged into a record 
keeping system and processed within the 96-hour window from sample collection.
Samples from participating sites will be sent to:
Attention: Dan Danner
NCI-F/FNLCR
1073 Beasley Street, Building 1073
Fort Detrick
Frederick, MD 21701
Phone: 301 846-5748
E-mail NCI_PD_Support_CellSearch@mail.nih.gov prior to shipping with expected arrival 
date/time and a description of contents.  All shipments should include a description of contents on 
the outside label/shipping slip and detailed packing slip included with the samples. Because of the
96-hour window of sample stability, CTC samples should be shipped to arrive within a 96-hour 
window as specified below:
Collection Day
Day/time samples must arrive at PADIS
Monday
Thursday (early morning)
Tuesday
Friday (early morning)
Wednesday
Friday (early morning)
Thursday
Friday (early morning)
Friday
Monday (early morning)
Saturday
Tuesday (early morning)
Sunday
Wednesday (early morning)
Testing and data analysis will be performed by Dr. Kinders (PADIS/LHTP/NCI-Frederick). Each
~8 mL of blood will be transferred from the CellSave preservative tube into a correspondingly 
labeled 15 mL AutoPrep conical tube.  The sample will be processed on the CellTracks AutoPrep 
system, using the CellSearch CTC kit, which contains a ferrofluid-based capture reagent 
(monoclonal antibody to EpCam) and immunofluorescent reagents.  After immunomagnetic capture 
and enrichment, fluorescently labeled monoclonal antibodies will be added for identification and 
enumeration of CTCs.  

Clinical  Ce nter # 0 9- C- 0 2 1 4
C T E P # 8 3 5 1
8 0
Is ol ati o n  of pl as ma  f or D N A met hyl ati o n  a nal ysis,  a n d  mo no n ucle ar  cells f or D N A 
met hylt r a nsf e r as e acti vit y
Re a ge nts:
T w el ve m L  of fi c oll- hypa q ue ( or e q ui val e nt l y mp hoc yte  s e par ati o n me di u m  wit h de nsit y  = 
1. 0 7 7), at r o o m te mper at ur e.
A p pr o xi matel y  5 0 m L  of steril e Ca + + a nd M g + + -fr ee  p hos p hate- b uffer e d  s ali ne ( P B S) or
ot her is ot o ni c dil ue nt at r o o m te mper at ur e.
A p pr o xi matel y  5 0 m L  of steril e 0. 1 5 M Na Cl (s ali ne).
Se ve n steril e 1 5 m L c o ni c al c e ntrif uge  t ubes.
Ei ght  2- m L  cr yo ge ni c  vi als.
Pr oce d ure : O btai n t w o 4- m L E D T A (l a ve nder-t o p) t ubes of bl o o d fr o m t he pati e nt. 
M o no n ucle ar  cells (t o ass ess D N A  met hylt r a nsf e r as es acti vit y) : Ce ntrif uge  o ne ( 1) 4- m L  E D T A
t ube of bl o o d at 1, 0 0 0 g f or 5 mi nutes.   Tr a nsfer as muc h  pl as ma fr o m eac h t ube as ca n be s afel y 
r e mo ve d wit ho ut dist ur bi ng t he b uff y  c oat t o a not her t ube.  Ge ntl y r es us pe nd t he c ell pell et ba c k t o 
t he ori gi nal bl o o d v ol u me i n r o o m-te mper at ur e  P B S b y i nverti ng s e ver al ti mes.  Di vi de t he p o ol e d, 
r es us pe nde d bl o o d i nt o t w o 1 5- m L  ce ntrif uge  t ubes.  Ta ki ng  car e t o mai ntai n sterilit y of t he st oc k 
b ottl e, dr a w 3 m L  of fi c oll- hypa q ue f or e ac h of t he f o ur t ubes i nt o a s yri nge.   ( T he fi c oll- hypa q ue 
c a n be dr a w n up i n a d va nc e s o t hat it w ar ms t o r o o m te mper at ur e   i n t he s yri nge i nstea d of w ar mi ng 
t he e ntir e b ottl e.)  Usi ng  a 2 0- ga s pi nal nee dl e (l o ng), car ef ull y l a yer 3 m L  of t he fi c oll- hypa q ue 
under t he dil ute d bl o o d cells i n eac h t ube.  Ce ntrif uge  at 4 0 0 g f or 3 0 mi nutes  at r o o m te mper at ur e.
Tr a nsfer t he o pa q ue i nterfa c e fr o m e a c h t ube wit h a Past ur e pi p ette i nt o a cl ea n c o ni cal ce ntrif uge 
t ube c o ntai ni ng  3  m L  of P B S a nd dil ute t he c o mbi ne d cell s us pe nsi o n t o a p pr o xi matel y 7  m L  wit h 
a d diti o nal P B S.  Ce ntrif uge  at 2 5 0 g f or 1 0 mi nutes.   As pir ate a nd dis car d t he s uper nata nt  P B S.  
Res us pe nd t he cell pell et i n 1 0 m L  of P B S.  Ce ntrif uge  at 2 5 0 g f or 1 0  mi nutes.   As pir ate t he 
s uper nata nt  P B S, l ea vi ng 0. 5 t o 1 m L  of P B S i n w hi c h t o r es us pe nd t he cell pell et.  Tr a nsfer t he cell 
s us pe nsi o n i nt o a cr yo ge ni c vi al a nd ce ntrif uge  at 6 0 0 g f or 1 0 mi nutes  or at a p pr o xi matel y  1 0, 0 0 0 
g i n a mi cr of uge  f or 1  mi nute.   As pir ate a nd dis car d t he s uper nata nt  P B S.  Ca p t he cr yo ge ni c vi al 
a nd v orte x it t o "s mear" t he pell et o n t he i nsi de of t he vi al, t he n fr eeze at - 8 0° C.  La bel t he vi al:
Pr ot oc ol # 
< dat e >
P B M C  
<c ycle # >
< Pt Acc # >  
< da y of c ycle >.
Pl as ma  (t o ass ess D N A  met hyl ati o n  st at us): Usi ng  t he r e mai ni ng  4- m L E D T A t ube, s pi n bl o o d 
f or pl as ma.  P o ol wit h t he pl as ma deri ve d fr o m t he  mo no nucl ear  cell bl o o d t ube a nd tr a nsfer 1. 5-
m L  ali q uots i nt o 2- m L  cr yo ge ni c vi als.  St or e at or bel o w - 2 0
C (- 7 0
C pr eferr e d).  La bel t he 
vi als:
Pr ot oc ol # 
< dat e >
Pl as ma 
<c ycle # >
< Pt Acc # >  
< da y of c ycle >.

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The isolated samples should be stored as directed above then shipped with the sample obtained with 
the first interim weekly labs.  At the NCI, specimens will be transported by Clinical Service 
Program courier to the PADIS lab at Frederick National Laboratory for Cancer Research. At 
participating sites, send the samples packed in dry ice to:
Attention: Dan Danner
NCI-F/FNLCR
1073 Beasley Street, Building 1073
Fort Detrick
Frederick, MD 21701
Phone: 301-846-5748
NCI_PD_Support_CellSearch@mail.nih.gov
Please send an email to FNLCR PD Specimen Central Receiving (NCI_PD_Support@mail.nih.gov) 
prior to shipping with expected arrival date/time and a description of contents.  State “Protocol 
Name PD Specimens Ready for Shipment” in the subject line.  If needed, FNLCR PD Central 
Receiving can be contacted directly at 301-846-1951 (primary) or 240-344-5697 (mobile). All 
shipments should include a description of contents on the outside label/shipping slip and detailed 
packing slip included with the samples.  
Note: With Amendment E (3/16/11 protocol version), isolation of RBCs from blood samples for
analysis of fetal hemoglobin expression levels was suspended.  RBCs collected prior to this will be 
stored frozen for future analysis.

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Appendix G: Chemotherapy Administration Log for Pharmacokinetic Studies
(First Cycle – First week)
Patient ID____________________
Institution: NCI / COH / USC / UCD / PENN
(circle one)
Height ________ cm
Weight:  ____ . __ kg
BSA __ . __ __ m2
Days 1-5:
THU ___________mg/day rapid IV infusion (push)
THU ___________mg/day continuous IV infusion over 3 hrs, with
FdCyd ___________mg/day continuous IV infusion over 3 hrs.
WEEK 1:
Day 1
Exact Day/Time of THU Push
___/___/___, ____:____am/pm 
(Hr 0)
Exact Day/Time of Start of THU/FdCyd Infusion
___/___/___, ____:____am/pm 
Exact Day/Time of End of THU/FdCyd Infusion
___/___/___, ____:____am/pm 
Day 2
Exact Day/Time of THU Push
___/___/___, ____:____am/pm 
(Hr 24)
Exact Day/Time of Start of THU/FdCyd Infusion
___/___/___, ____:____am/pm 
Exact Day/Time of End of THU/FdCyd Infusion
___/___/___, ____:____am/pm 
Day 3
Exact Day/Time of THU Push
___/___/___, ____:____am/pm 
(Hr 48)
Exact Day/Time of Start of THU/FdCyd Infusion
___/___/___, ____:____am/pm 
Exact Day/Time of End of THU/FdCyd Infusion
___/___/___, ____:____am/pm 
Day 4
Exact Day/Time of THU Push
___/___/___, ____:____am/pm 
(Hr 72)
Exact Day/Time of Start of THU/FdCyd Infusion
___/___/___, ____:____am/pm
Exact Day/Time of End of THU/FdCyd Infusion
___/___/___, ____:____am/pm
Day 5
Exact Day/Time of THU Push
___/___/___, ____:____am/pm 
(Hr 96)
Exact Day/Time of Start of THU/FdCyd Infusion
___/___/___, ____:____am/pm 
Exact Day/Time of End of THU/FdCyd Infusion
___/___/___, ____:____am/pm 

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(See separate PD flow sheet for Cycles 2 and beyond.)
Combined Specimen Collection Form (PK/PD Flow Sheet) for Pharmacokinetic and 
Pharmacodynamic Studies for Cycle 1 – Page 1 of 4
Patient ID ____________________
Cycle 1, Day 1:
Date
Hr:Min
Sample
Planned Time
Actual 
Time
RN
Init.
Comments
______
(Day 1)
:
#1
(P1)
Pretreatment -
3 mL of blood in a green-
topped tube with ZEB
:
______
:
#2
(B1)
Pretreatment -
2 lavender-topped tubes 
with 4 mL of blood each
:
______
:
#3
(B2)
Pretreatment -
7.5 mL of blood in a 
CellSave tube
:
______
:
#4
(U1)
Pretreatment -
10 mL of urine
:
______
Then ask patient to void completely prior to 24-hr urine collection.
Start 24-hr urine collection for FdCyd Analysis.
Send each sample when drawn to local lab for processing and interim storage according to Appendix E
for Pharmacokinetic (green-top) samples and Appendix F for Pharmacodynamic (lavender-top) and CTC 
(CellSave) samples.
Urine Collection Guidelines for the First 24 Hours Post-Drug Administration 
Collect and pool urine for the first 24 hours post drug (0-24 hours), and refrigerate.  Please note the total 
volume of urine collected. At end of 24 hours, mix the urine and take a 10 mL aliquot in a sterile urine cup, 
refrigerate, and discard the rest.  
Sample Collection for Day 1 continues on the next page.

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Combined Specimen Collection Form (PK/PD Flow Sheet) for Pharmacokinetic and Pharmacodynamic 
Studies for Cycle 1 – Page 2 of 4
Cycle 1, Day 1:                                                                                          Patient ID ________________
Date
Hr:Min
Sample
Planned Time
Actual 
Time
RN
Init.
Comments
______
(Day 1,
Cont.)
Important – Record time 
infusion started
:
______
:
#5
(P2)
15 Minutes -
3 mL of blood in a green-
topped tube with ZEB
:
______
:
#6
(P3)
30 Minutes -
3 mL of blood in a green-
topped tube with ZEB
:
______
:
#7
(P4)
1 Hour -
3 mL of blood in a green-
topped tube with ZEB
:
______
:
#8
(P5)
2 Hours -
3 mL of blood in a green-
topped tube with ZEB
:
______
:
#9
(P6)
2.5 Hours -
3 mL of blood in a green-
topped tube with ZEB
:
______
______
(Day 1,
Cont.)
Important – Record time 
infusion ended
:
______
:
#10
(P7)
15 Minutes -
3 mL of blood in a green-
topped tube with ZEB
:
______
:
#11
(P8)
30 Minutes -
3 mL of blood in a green-
topped tube with ZEB
:
______
:
#12
(P9)
1 Hour -
3 mL of blood in a green-
topped tube with ZEB
:
______
:
#13
(P10)
2 Hours -
3 mL of blood in a green-
topped tube with ZEB
:
______
:
#14
(P11)
4 Hours -
3 mL of blood in a green-
topped tube with ZEB
:
______
:
#15
(P12)
6 Hours -
3 mL of blood in a green-
topped tube with ZEB
:
______
Send each sample when drawn to local lab for processing and interim storage according to Appendix E.
Sample Collection for Days 2-5 begins on the next page.

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Combined Specimen Collection Form (PK/PD Flow Sheet) for Pharmacokinetic and Pharmacodynamic 
Studies for Cycle 1 – Page 3 of 4
Cycle 1, Days 2-5:                                                                                     Patient ID _______________
Date
Hr:Min
Sample
Planned Time
Actual
Time
RN
Init.
Comments
Ask patient to void just before ending urine collection.
______
(Day 2)
:
#16
(U2)
Before Day 2 Chemo -
End of 24-Hr urine
collection
:
_____
:
#17
(P13)
Before Day 2 Chemo -
3 mL of blood in a green-
topped tube with ZEB
:
_____
______
(Day 2,
Cont.)
Important – Record time 
infusion started
:
_____
______
(Day 2,
Cont.)
Important – Record time 
infusion ended
:
_____
:
#18
(B3)
After Day 2 Chemo (up
to 24 Hours) -
7.5 mL of blood in a 
CellSave tube
:
_____
______
(Day 3)
:
#19
(P14)
Before Day 3 Chemo -
3 mL of blood in a green-
topped tube with ZEB
:
_____
______
(Day 4)
:
#20
(P15)
Before Day 4 Chemo -
3 mL of blood in a green-
topped tube with ZEB
:
_____
______
(Day 5)
:
#21
(P16)
Before Day 5 Chemo -
3 mL of blood in a green-
topped tube with ZEB
:
_____
Send each sample when drawn to local lab for processing and interim storage according to Appendix E for
Pharmacokinetic (green-top) samples and Appendix F for Pharmacodynamic (lavender-top) and CTC 
(CellSave) samples.
Sample Collection for Day 12 begins on the next page.

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Combined Specimen Collection Form (PK/PD Flow Sheet) for Pharmacokinetic and Pharmacodynamic 
Studies for Cycle 1 – Page 4 of 4
Cycle 1, Continued:                                                                               Patient ID __________________
Date
Hr:Min
Sample
Planned Time
Actual 
Time
RN
Init.
Comments
Cycle 1, Day 12 +/- 1 day:
______
(Day 12 
+/- 1 day)
:
#22
(B4)
7.5 mL of blood in a 
CellSave tube
:
______
______
(Day 12 
+/- 1 day)
:
#23
(B5)
2 lavender-topped tubes 
with 4 mL of blood each
:
______
Send each sample when drawn to local lab for processing and interim storage according to Appendix E for
Pharmacokinetic (green-top) samples and Appendix F for Pharmacodynamic (lavender-top) and CTC 
(CellSave) samples.
The processed samples for Cycle 1 should be shipped according to Appendix E for Pharmacokinetic (green-
top) samples and Appendix F for Pharmacodynamic (lavender-top) and CTC (CellSave) samples.
Sample Collection for Cycle 2 and beyond begins on the next page.

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Flow Sheet for Cycle 2 and Beyond (See combined PK/PD flow sheet for cycle 1.)
Specimen Collection Form for Pharmacodynamic Studies
Patient ID____________________
Institution: NCI / COH / USC / UCD /PENN
(circle one)
Height ________ cm
Weight:  ____ . __ kg
BSA __ . __ __ m2
THU ___________mg/day rapid IV infusion (push)
THU ___________mg/day continuous IV infusion over 3 hrs, with
FdCyd ___________mg/day continuous IV infusion over 3 hrs.
Cycle # ________ 
Start of current treatment cycle (Day 1): Date ________ 
Sample
Date
Time
RN
Initials
Comment
#1 – Cycles 2 and 4 Pretreatment 
(Day 1)
2 lavender-topped tubes with 4 mL of 
blood each
#2 – Cycles 2, 4, 6 Day 1
7.5 mL of blood in CellSave tube
#3 – Cycles 2 and 4
Day 12 (+/- 1 day) 
2 lavender-topped tubes with 4 mL of 
blood each
#4 – Cycles 2, 4, 6
Day 12 (+/- 1 day) 
7.5 mL of blood in CellSave tube
Send each sample when drawn to local lab for processing and interim storage according to Appendix E for
Pharmacokinetic (green-top) samples and Appendix F for Pharmacodynamic (lavender-top) and CTC 
(CellSave) samples.
The processed samples should be shipped according to Appendix E for Pharmacokinetic (green-top)
samples and Appendix F for Pharmacodynamic (lavender-top) and CTC (CellSave) samples.

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Flow Sheet for Cycle 1 and Beyond (after patients in each cohort have completed PK requirements)
Specimen Collection Form for Pharmacodynamic Studies
Patient ID____________________
Institution: NCI / COH / USC / UCD / PENN
(circle one)
Height ________ cm
Weight:  ____ . __ kg
BSA __ . __ __ m2
THU ___________mg/day rapid IV infusion (bolus)
THU ___________mg/day continuous IV infusion over 3 hrs, with
FdCyd ___________mg/day continuous IV infusion over 3 hrs.
Cycle # ________ 
Start of current treatment cycle (Day 1): Date ________ 
Sample
Date
Time
RN Initials
Comment
#1 – Cycles 1, 2 & 4
Pretreatment Day 1
2 lavender-topped tubes with 4 mL 
of blood each
#2 – Cycles 1, 2, 4, & 6
Pretreatment Day 1
7.5 mL of blood in CellSave tube
#3 – Cycle 1, Day 2 after treatment 
(up to 24 hours after end of infusion)
7.5 mL of blood in CellSave tube
#4 – Cycles 1, 2 & 4
Day 12 (+/- 1 day) 
2 lavender-topped tubes with 4 mL 
of blood each
#5 – Cycles 1, 2, 4, & 6
Day 12 (+/- 1 day) 
7.5 mL of blood in CellSave tube
Send each sample when drawn to local lab for processing and interim storage according to Appendix F for
Pharmacodynamic (lavender-top) and CTC (CellSave) samples.  The processed samples should be shipped 
according to Appendix F for Pharmacodynamic (lavender-top) and CTC (CellSave) samples.

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Appendix H: Eligibility/Pre-Registration Worksheet
A Multi-Histology Phase II Study of 5-Fluoro-2-Deoxycytidine with Tetrahydrouridine 
(FdCyd + THU)
Coordinating Center: NCI
Protocol Chair: 
Bethesda, MD 20892
James H. Doroshow, MD
Contact: Jennifer Zlott
National Cancer Institute
Tel: 301-594-5664
Tel: 301-496-4291
Fax: 301-480-7281
doroshoj@mail.nih.gov
zlottjh@mail.nih.gov
Lead Associate Investigator:
A. P. Chen, MD
National Cancer Institute
Tel: 301-496 4291
chenali@mail.nih.gov
Patient’s Name: (FML)
Institution: 
Medical Record Number: 
Investigator: 
Patient’s Birth date: 
Signature of  Treating 
Physician
Sex: ______male ______female 
IRB approval valid until (date): 
Date Informed Consent was 
signed:
Race: 
Ethnicity: 
Projected start date of treatment: 
_____ Black 
___Hispanic 
_____ Caucasian 
___Non-Hispanic 
_____ Asian 
___Other:______ 
_____ American Indian 
_____ Native Hawaiian/Pacific
Islander
_____ Other _________________

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INCLUSION CRITERIA: All responses must be YES.  A NO response will make the subject 
ineligible.
Histologically documented (confirmed by the department of pathology at 
the institution where the patient is enrolled prior to patient enrollment) 
metastatic or unresectable non-small cell lung cancer, head and neck
cancer, urothelial transitional cell carcinoma, or breast cancer, whose 
disease has progressed after at least one line of standard therapy.  
Yes
No
N/A
Patients with solid tumors (non-small cell lung cancer, head and neck
cancer, urothelial transitional cell carcinoma, and breast cancer) must 
have measurable disease, defined as at least one lesion that can be 
accurately measured in at least one dimension (longest diameter to be 
UHFRUGHGDV PPZLWKFRQYHQWLRQDOWHFKQLTXHVRUDV 10 mm with 
spiral CT scan.  Patients with head and neck cancer whose disease is 
limited to the skin are eligible at the discretion of the PI and must have a 
physical exam with documentation of skin lesion(s) by color 
photography, including a ruler to estimate the size of the lesion(s).
$Q\SULRUWKHUDS\PXVW KDYHEHHQFRPSOHWHGZHHNVSULRUWR
enrollment on protocol, and the participant must have recovered to
eligibility levels from prior toxicity. Patients should be at least six weeks 
out from nitrosoureas and mitomycin C. Prior radiation should have 
EHHQFRPSOHWHGZHHNVSULRUWRVWXG\HQUROOPHQWDQGDOODVVRFLDWHG
toxicities should have resolved to eligibility levels. 3DWLHQWVPXVW EH
weeks since any investigational agent administered as part of a Phase 0 
study, and should have recovered to eligibility levels from any toxicities.
Age  18 years?
Karnofsky score______see Appendix A?
Life expectancy > 3 months?
Women of childbearing potential and men must agree to use adequate 
birth control
Has a signed informed consent/assent been obtained by the patient or 
parent/legal guardian?

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EXCLUSION CRITERIA: Responses should be NO
Uncontrolled intercurrent illness including, but not limited to: active or 
uncontrolled infection, immune deficiencies or confirmed diagnosis of HIV 
infection, active infection with Hepatitis B or Hepatitis C, uncontrolled 
diabetes, uncontrolled hypertension, symptomatic congestive heart failure, 
unstable angina pectoris, myocardial infarction within the past 6 months, 
uncontrolled cardiac arrhythmia; or psychiatric illness/social situations that 
would limit compliance with study requirements.
Yes
No
N/A
Pregnant?
Pregnancy Test Date:
Breastfeeding?
History of allergic reactions attributed to compounds of similar composition 
to the investigational agents?
Receiving any other investigational agents?
Pre Study Evaluations:
Date 
Done:
History and Physical Exam (within 8 days prior to enrollment)
Height, Weight, vital signs and performance status (within 8 days prior to 
enrollment)
CBC, Diff, Plts, Blood Chemistries* (within 1 week) * Na+, K+, Cl-, CO2,
Creatinine, BUN, calcium, glucose, albumin, SGPT (ALT), SGOT (AST), LDH, 
Alkaline Phos, Bilirubin Send actual lab results
CT scan chest/abd/pelvis (within 28 days prior to enrollment)
Pregnancy Test (if clinically indicated within 8 days prior to enrollment)
DESCRIPTIVE FACTORS:
Primary: ___________________________________               Histology: ____________________
Other Chronic Diseases: Y / N (If yes, please explain): 

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PRIOR THERAPY (Please specify date, procedure, agent, dose, response. Date of last 
treatment required.)
YES   NO
____    ____         1. Surgery/Biopsy:
____    ____         2. Chemotherapy:
____    ____         3. Radiotherapy:
____    ____         4. Hormonal Therapy: 
____    ____
5. Immunotherapy:
Physician’s Signature: _________________________ 
Date:______________
Printed Name of Physician: ________________________
To be completed by participating center when registering a patient:
Date Registered with NCI ______/_______/_______
Spoke With: ____________________________________
Study ID:_______________________________________
Eligibility Checklist Completed By: _________________
Assigned CRA / Data Manager: _____________________
A confirmation of registration will be sent to you by the NCI.

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Participant Status Updates Form
Complete form and send via encrypted email to:  
NCI Central Registration Office (HOIS) at ncicentralregistration-l@mail.nih.gov
Patient Information:
First name
Last name
Middle initial
ID number:________________________________________
Protocol Number (CC# preferred):______________________
Off Treatment Date (mm/dd/yy): _____________________
Off Treatment Reason: _____________________________
Off Study Date (mm/dd/yy): _________________________
Choose one of the following off-study reasons:
C: Completed Study
L: Lost to follow-up
R: Refused Further Treatment
T: Toxicity
D: Death
P: Progressive Disease 
O: Other
Death Date: (mm/dd/yy): ______________________________
Choose one or more of the following DOD Sources:
Social Security Death Index SS#:____________________
http://ssdi.rootsweb.com/
Obituaries Document:____________________  http://www.legacy.com/washingtonpost/DeathNotices
Cause of Death______________________________________________________________
Place of Death:______________________________________________________________
Family/staff member name notifying DOD:________________________________________
Registrar: 
Name:___________________________________________
Work Phone:_____________________
Today's Date: ________________________
Comments:

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Appendix I: Informed Consent Form Template for Cancer Treatment Trials
Study Title: A Multi-Histology Phase II Study of 5-Fluoro-2-Deoxycytidine with 
Tetrahydrouridine (FdCyd + THU)
Introduction
We invite you to take part in this research study.
First, we want you to know that:
Taking part in this research study is entirely voluntary.
You may choose not to take part, or you may withdraw from the study at any time.  In either 
case, you will not lose any benefits to which you are otherwise entitled.
You may receive no benefit from taking part.  The research may give us knowledge that may 
help people in the future.
Second, some people have personal, religious or ethical beliefs that may limit the kinds of medical 
or research treatments they would want to receive (such as blood transfusions).  If you have such 
beliefs, please discuss them with your doctors or research team before you agree to the study.
Now we will describe this research study.  Before you decide to take part, please take as much time 
as you need to ask any questions and discuss this study with family, friends or your personal 
physician or other health professional.
Why is this study being done?
This research study includes patients with advanced non-small cell lung cancer, breast cancer, 
urothelial transitional cell carcinoma, and head and neck cancer. You are being asked to volunteer 
to take part in this research study because you have advanced cancer that has progressed after 
receiving standard treatment or for which no effective therapy exists. We are doing this study to try 
to develop better treatments for cancer. On this study, two experimental drugs, FdCyd (also called 
5-fluoro-2’-deoxcytidine), and THU (also called tetrahydrouridine), will be given to you. The 
purpose of this study is to see if the drugs work together to control your tumor growth. FdCyd is 
thought to work by changing how genes work in cancer cells. THU does not have any anticancer 
effects on its own, but it helps keep the other drug, FdCyd, from being broken down by your body.
These drugs have been given to more than 170 patients as of February 2016. The two drugs have 
some side effects that will be reviewed with you by your medical team before you sign the consent 
form.
How many people will take part in this study?
Up to 165 patients will take part in this study across 6 centers in the United States.

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What will happen if I take part in this study?
If you are accepted and you choose to take part, you will begin receiving FdCyd and THU.  Please 
see the Study Chart below for more details.  You will also have tests and procedures done because 
you are in the study to see how FdCyd and THU are affecting your body.  This will include 
repeating some of the imaging studies (e.g., CT scans, a computerized x-ray examination) to find 
out if your cancer has responded.  Descriptions of the tests and procedures that will be performed 
during the study are listed below. For some study procedures we will need you to come to 
_______________________________ [name of center].
FdCyd and THU will be given in cycles.  Each cycle is 28 days long.  You will receive FdCyd and 
THU on days 1-5 and 8-12 of each cycle. You may continue to receive FdCyd and THU if your 
cancer does not grow, if you do not have too many side effects, and if you are willing to do so.
Clinic Visits: FdCyd and THU will be given through a vein each day on days 1-5 and 8-12 of each 
cycle.  We will ask that you come to ________________ [name of center] on these days during 
each cycle. While you are at ________________ [name of center] we will perform study tests and 
procedures to see how the study drugs are affecting your body.  So, for each cycle you will be 
coming to ________________ [name of center] for at least 12-14 days.  If you develop any side 
effects, you may be asked to visit more often.
Standard procedures being done because you are in this study; these may be done more often 
because you are in the study:
x
Clinic visit: to ask how you are feeling and to evaluate you with a physical examination 
every week during Cycle 1, and then at the beginning of each cycle.
x
Vital signs and physical examinations: will be performed during the clinic visits.
x
Blood tests: Measurement of your white blood cells, red blood cells, and platelets and 
measurements of your blood sugar and electrolytes and of how your liver, kidneys, and 
blood clotting work will be done every week during Cycle 1, and then before treatment on 
weeks 1 and 2 of all other cycles.  Approximately 1 tablespoon (15 mL) of blood will be 
drawn per visit.
x
Urine test: Depending on the results of blood tests, you may be asked to collect your urine 
for 24 hours for further testing.
x
CT scans or other imaging tests such as ultrasound (an examination using sound waves) or 
MRI (an examination using magnetic field and radio waves) that detect your tumor will be 
done before the study and every 8 weeks while you are receiving study drugs (less often if 
you have been on study for more than one year). This is done so that any benefit of the 
treatment can be determined, and if your cancer is not responding to the treatment, the study 
team can tell you and discuss other treatment options (discussed further below).  
Tests and procedures that are either being tested in this study or being done to see how the 
drug is affecting your body:
x
Measurement of FdCyd and THU in your blood: We will collect blood samples from 
some patients to measure the amount of study drugs in the blood and to help us find out how 
the body handles the drugs.  Blood will be collected during Cycle 1 only, on day 1 before 
the drugs are given, at multiple time points while the drugs are being given, at several  times 

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up to 6 hours after the drugs are given, and then once before treatment on days 2, 3, 4, and 
5.  The total blood for all these tests will be about 3 tablespoons (45 mL).
x
Other research blood samples: We will also be collecting blood samples to find out the 
effects of the drugs on cells in your blood.  Blood samples will be collected on days 1, 2, 
and 12 in Cycle 1, on day 1 of Cycle 2 and every subsequent cycle, on day 12 in Cycles 2, 4, 
and 6, and, if your disease comes back, at the time that your disease comes back. The total 
blood for all these tests will be about 1/2 a cup (about 115 mL).
x
Measurement of FdCyd and THU in your urine: We will collect urine samples from 
some patients to measure the amount of study drugs in the urine. Urine will be collected 
before the study drugs are given and for 24 hours after the drugs are given on Cycle 1, day 
1.
x
Tumor biopsies: After you are accepted to take part in the study, you will be asked to have 
a biopsy of your tumor (removal of a small bit of tissue for examination under a 
microscope) once before you receive study drugs and a second time on day 12 of Cycle 2.  
We are collecting biopsy samples to study how the drugs affect your tumor.  Biopsies are a 
very important part of this trial and are done for research purposes. Tumor biopsies are 
optional, and no more than two biopsy procedures will be performed during the study. You 
may choose not to have tumor biopsies, and this will not affect your taking part in this 
study.  If you decide not to have tumor biopsies, you will still receive study drugs and have 
other tests that are part of the study.
Tumor biopsies are only collected by trained personnel. Biopsies are collected using a small 
bore needle under imaging guidance (CT, MRI, or ultrasound as considered appropriate by 
the interventional radiologist performing the biopsy).  Imaging helps the specialized 
radiologist know that the needle has been placed into the tumor mass. 
Typical risks of biopsy collection include, but are not limited to, bleeding, infection, pain, 
and scarring.  If you experience any complications from the biopsy, medical care will be 
offered to you.  The amount of radiation you will receive in this study is ____ [insert center-
specific dosimetry value for 2 research biopsies] rem (a measurement of ionizing radiation 
such as emitted in x-rays), which is below the guideline of 5 rem per year allowed for 
research subjects by the NIH Radiation Safety Committee. You will be counseled in more 
detail about biopsies, and you will be asked to sign a separate consent form that will 
describe the procedures and risks at that time.  Your safety is the most important thing at all 
times. If upon attempting the first biopsy, no tissue can be obtained or it has caused you 
harm, the second biopsy procedure will not be done.  After you are enrolled in this study, if 
for any reason the biopsies cannot be done safely, you may still receive the study drugs but 
the biopsies will not be done.
I agree to allow biopsies for research purposes    Yes___
No____    Initials_________
x
Clinical evaluations, imaging studies, and biopsies will be done at ________________ 
[name of center].
Study Chart

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The drugs are given over 28-day periods of time called cycles.  FdCyd and THU are given through a 
vein for about 3 hours each day on days 1-5 and 8-12 of each cycle.  The days you receive study drugs 
may change by up to 1 day for scheduling reasons (for example, weekends, holidays, or for your 
convenience), but FdCyd and THU will only be given for 5 days in week 1 and 5 days in week 2.
The chart below shows what will happen to you during Cycle 1 and future cycles after you sign the 
consent and start the study.  Each cycle is numbered. The left-hand column shows the day in the 
cycle, and the right-hand column tells you what will happen on that day.
Day
What to do and what will happen to you
Before starting 
study drug
x
Have a history taken of how you feel and undergo a physical 
examination by a Health Care Provider (HCP)
x
Get routine blood tests
x
CT scan will be done
x
Tumor biopsy may be performed (optional, see above)
Cycle 1 onwards, 
Day 1
x
Have a history taken of how you feel and undergo a physical
examination by a HCP
x
Get routine blood tests
x
FdCyd and THU will be given through a vein for 3 hours
x
Blood draws for research will be obtained
x
Urine samples for research will be obtained over a 24-hour period 
(Cycle 1 only)
Cycle 1 onwards, 
Day 2, 3, 4, 5
x
FdCyd and THU will be given through a vein for 3 hours
x
Blood draws for research will be obtained (Cycle 1 only)
Cycle 1 onwards, 
Day 6, 7
x
No treatment
Cycle 1 onwards, 
Day 8
x
Have a history taken of how you feel and undergo a physical 
examination by a HCP (Cycles 1 and 2 only)
x
Get routine blood tests 
x
FdCyd and THU will be given through a vein for 3 hours
Cycle 1 onwards, 
Day 9, 10, 11
x
FdCyd and THU will be given through a vein for 3 hours
Cycle 1 onwards, 
Day 12
x
FdCyd and THU will be given through a vein for 3 hours
x
Blood draws for research will be obtained (Cycles 1, 2, 4, and 6)
Cycle 1 onwards, 
Day 13-28
x
No treatment
x
On approximately days 15 and 21, you will have a physical 
examination and blood draws for routine blood tests (Cycle 1 only)
Cycle 3 onwards
x
CT scans to determine how your tumor is responding to the treatment 
will be done every 2 cycles (every 3 cycles if you have been on the 
study for more than a year or every 4 cycles if for more than 3 years)
x
Tumor biopsy may be performed (at the end of Cycle 2/prior to start of 
Cycle 3 only; optional, see above)
x
Blood draw for research will be obtained if your disease comes back

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Are there reasons that my taking part in this study may end early?
Your study doctor will be watching you and your cancer while you are receiving FdCyd and THU.  
If your cancer is worsening, the study doctor will suggest that you stop taking the drugs and she or 
he will discuss other options with you.  Also, if you are having side effects from the drugs which 
are dangerous to your health or too difficult for you to tolerate, you and the study team may decide 
that you should stop taking the drugs.  The study doctor may stop you from taking part in this study 
at any time if he or she believes it is not in your best interest, if you do not follow the study rules, or 
if the study is stopped.
Stopping Therapy 
Your doctor may decide to stop your therapy for the following reasons:
x
if he/she believes that it is in your best interest
x
if your disease comes back during treatment
x
if you have side effects from the treatment that your doctor thinks are too severe
x
if new information shows that another treatment would be better for you
In this case, you will be informed of the reason therapy is being stopped.
You can stop taking part in the study at any time. However, if you decide to stop taking part in the 
study, we would like you to talk to the study doctor and your regular doctor first.
If you decide at any time to withdraw your consent to participate in the trial, we will not collect any
additional medical information about you. However, according to FDA guidelines, information 
collected on you up to that point may still be provided to the Cancer Therapy Evaluation Program 
(CTEP) at the National Cancer Institute (NCI) or designated representatives. If you withdraw your 
consent and leave the trial, any samples of yours that have been obtained for the study and stored at 
the NCI can be destroyed upon request. However, any samples and data generated from the 
samples that have already been distributed to other researchers or placed in the research databases 
cannot be recalled and destroyed.
What side effects or risks can I expect from being in the study?
If you choose to take part in this study, there is a risk that you may:
x
Lose time at work or home and spend more time in the hospital or doctor’s office than usual
x
Be asked sensitive or private questions which you normally do not discuss
The agents used in this study may affect how different parts of your body work such as your liver, 
kidneys, heart, and blood.  The study doctor will be testing your blood and will let you know if 
changes occur that may affect your health.  There is also a risk that you could have side effects from 
the study drug(s)/study approach.  Here are important points about side effects:
x
The study doctors do not know who will or will not have side effects.
x
Some side effects may go away soon, some may last a long time, or some may never go 
away.
x
Some side effects may interfere with your ability to have children.
x
Some side effects may be serious and may even result in death.
Here are important points about how you and the study doctor can make side effects less of a 
problem:

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x
Tell the study doctor if you notice or feel anything different so they can see if you are 
having a side effect.
x
The study doctor may be able to treat some side effects.
x
The study doctor may adjust the study drugs to try to reduce side effects.
The tables below show the most common and the most serious side effects that researchers know 
about. There might be other side effects that researchers do not yet know about. If important new 
side effects are found, the study doctor will discuss these with you.
Risks and side effects related to FdCyd and THU may include:
COMMON, SOME MAY BE SERIOUS  
In 100 people receiving FdCyd/THU, more than 20 and up to 100 may have:
x
Anemia which may require blood transfusion
x
Diarrhea, nausea, vomiting
x
Tiredness
x
Bruising, bleeding
x
Infection, especially when white blood cell count is low
x
Loss of appetite
OCCASIONAL, SOME MAY BE SERIOUS  
In 100 people receiving FdCyd/THU, from 4 to 20 may have:
x
Abnormal heartbeat
x
Bloating, constipation, heartburn, passing gas
x
Pain
x
Dry mouth, skin
x
Sores in mouth which may cause difficulty swallowing
x
Chills, fever
x
Swelling of arms, legs
x
Weight loss
x
Dehydration
x
Muscle weakness
x
Dizziness, headache
x
Changes in taste
x
Numbness, tingling or pain of the arms and legs
x
Cough, shortness of breath
x
Nose bleed
x
Hair loss, itching, rash
x
Increased sweating
x
Redness, pain or peeling of the palms and soles
x
Low blood pressure which may cause feeling faint

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THU has no expected side effects at the dose used in this study, but THU may make the side effects 
of FdCyd worse.  
Blood draws for routine laboratory tests may result in bruising, infection, and minor pain or 
discomfort comparable with a needle prick.  When the medication is put through a vein in your arm, 
you may experience a moment of pain.  In addition, there is the discomfort of having the catheter 
taped to your arm.  Other risks include bleeding, bruising, temporary clotting of the vein, and 
infection.  
The removal of tumor tissue for research biopsies can cause pain, bruising, and possibly infection at 
the site where the biopsy was taken.  The biopsy procedure will be discussed in detail with you,
including side effects, and we will ask you to sign a separate consent form before to the procedure.
Reproductive Risks: Because the drugs in this study can possibly affect unborn babies and 
infants, you should not become pregnant, father a baby, or breastfeed while you are on this study.  
Women of childbearing potential will be required to have a pregnancy test.  If you are a woman 
who can become pregnant, or are the partner of a woman who can become pregnant, you will need 
to practice an effective form of birth control before starting study treatment and for 3 months after 
you finish study treatment. If you think that you or your partner is pregnant, you should tell your 
study doctor or nurse at once. Avoiding sexual activity is the only certain method to prevent 
pregnancy.  But, if you choose to be sexually active, you should use an appropriate “double barrier” 
method of birth control (such as female use of a diaphragm, intrauterine device (IUD), or 
contraceptive sponge, in addition to male use of a condom) or the female should be using 
prescribed “birth control” pills, injections, or implants.  Male participants must also use adequate 
contraception. If you choose to be sexually active during this study, you understand that even with 
use of these birth control measures pregnancy could still result.  Some methods might not be 
approved for use in this study.  Ask about counseling and more information about preventing 
pregnancy.  For more information about risks and side effects, ask your study team.
Are there benefits to taking part in this study?
Taking part in this study may or may not make your health better.  While doctors hope the 
combination of FdCyd and THU will be useful against your cancer, there is no proof of this yet.  
You should discuss other treatment options with the study team and your home doctor before 
deciding to take part in this study.  We do know that information from this study will help doctors 
learn more about the combination of FdCyd and THU as a treatment for cancer.  This information 
will also help future cancer patients.
What other choices do I have if I do not take part in this study?
Talk to your doctor about your choices before you decide if you will take part in this study.  Your 
other choices may include:
x
Getting other therapies that, although might not improve survival, may have other benefits, 
such as delaying disease progression.
x
Taking part in another study.
x
Getting no treatment. 

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x
Getting comfort care, also called palliative care. This type of care helps reduce pain,
tiredness, appetite problems, and other problems caused by cancer. It does not treat the 
cancer directly, but instead tries to improve how you feel. Comfort care tries to keep you as 
active and comfortable as possible.
Will my medical information be kept private?
We will do our best to make sure that the personal information in your medical record will be kept 
private. However, we cannot guarantee total privacy. Your personal information may be given out 
if required by law. If information from this study is published or presented at scientific meetings, 
your name and other personal information will not be used.
Organizations that may look at and/or copy your medical records for research, quality assurance, 
and data analysis include:
x
The National Cancer Institute (NCI) and other government agencies, like the Food and Drug 
Administration (FDA), involved in keeping research safe for people.
x
Designated investigators from other cancer centers participating in this study, including the 
City of Hope National Medical Center; the City of Hope Medical Group, Pasadena; the 
University of Southern California/Norris Comprehensive Cancer Center; the University of 
California, Davis Cancer Center, and the Penn State Cancer Institute.
A description of this clinical trial will be available on http://www.ClinicalTrials.gov, as required by 
U.S. Law.  This Web site will not include information that can identify you.  At most, the Web site 
will include a summary of the results.  You can search this Web site at any time.
[Note to Informed Consent Authors: the above paragraph complies with the new FDA regulation 
found at 21 CFR 50.25(c) and must be included verbatim in all informed consent documents. The 
text in this paragraph cannot be revised.]
[Note to Local Investigators: The NCI has recommended that HIPAA regulations be addressed by 
the local institution.  The regulations may or may not be included in the informed consent form 
depending on local institutional policy.]
What are the costs of taking part in this study?
You and/or your health plan/ insurance company will need to pay for some or all of the costs of 
treating your cancer in this study. Some health plans will not pay these costs for people taking part 
in studies. Check with your health plan or insurance company to find out what they will pay 
for. Taking part in this study may or may not cost your insurance company more than the cost of 
getting regular cancer treatment. 
The study agents, FdCyd and THU, will be provided free of charge while you are participating in 
this study. Even though it is unlikely, there is a possibility that at some point the supply of study 
agent may run out necessitating taking you off-study.
[If applicable, inform the patient of any tests, procedures or agents for which there is no charge. 
The explanation, when applicable, should clearly state that there are charges resulting from 

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performance of the test or drug administration that will be billed to the patient and/or health plan. 
For example, “The NCI is supplying (drug) at no cost to you.  However, you or your health plan 
may need to pay for costs of the supplies and personnel who give you the (drug).”]
You will not be paid for taking part in this study.
For more information on clinical trials and insurance coverage, you can visit the National Cancer 
Institute’s Web site at http://cancer.gov/clinicaltrials/understanding/insurance-coverage. You can 
print a copy of the “Clinical Trials and Insurance Coverage” information from this Web site.
Another way to get the information is to call 1-800-4-CANCER (1-800-422-6237) and ask them to 
send you a free copy.
What happens if I am injured because I took part in this study?
It is important that you tell your study doctor, __________________ [investigator’s name(s)], if 
you feel that you have been injured because of taking part in this study. You can tell the doctor in 
person or call him/her at __________________ [telephone number].
You will get medical treatment if you are injured as a result of taking part in this study. You and/or 
your health plan will be charged for this treatment. The study will not pay for medical treatment.
What are my rights if I take part in this study?
Taking part in this study is your choice.  You may choose either to take part or not to take part in 
this study.  If you decide to participate, you may leave the study at any time.  No matter what 
decision you make, there will be no penalty to you, and you will not lose any of your regular 
benefits.  Leaving the study will not affect your medical care. You can still get your medical care 
from our center.  We will tell you about new information or changes in the study that may affect 
your health or your willingness to continue in the study.  In the case of injury resulting from this 
study, you do not lose any of your legal rights to seek payment by signing this form.
Who can answer my questions about the study?
You can talk to your study doctor about any questions or concerns you have about this 
study. Contact your study doctor __________________ [name(s)] at __________________ 
[telephone number].
For questions about your rights while taking part in this study, call the 
________________________ [name of center] Institutional Review Board (a group of people who 
review the research to protect your rights) at __________________ (telephone number). [Note to 
Local Investigator: Contact information for patient representatives or other individuals in a local 
institution who are not on the IRB or research team but take calls regarding clinical trial questions 
can be listed here.]

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Where can I get more information?
You may call the National Cancer Institute’s Cancer Information Service at: 1-800-4-CANCER (1-
800-422-6237).  You may also visit the NCI Web site at http://cancer.gov/.
x
For NCI’s clinical trials information, go to: http://cancer.gov/clinicaltrials/
x
For NCI’s general information about cancer, go to http://cancer.gov/cancerinfo/
You will get a copy of this form.  If you want more information about this study, ask your study 
doctor. 
Signature
I have been given a copy of all _____ [insert total of number of pages] pages of this form. I have 
read it or it has been read to me. I understand the information and have had my questions 
answered. I agree to take part in this study.
Participant ________________________________
Date _____________________________________