A Phase II Preoperative Single-Fraction Partial Breast Radiotherapy in Early Stage Breast Cancer: Analysis of Pathologic Response
Phase: PHASE2
Conditions: Breast Cancer
Sponsor: Duke University

 
 
A Radiation Therapy Study  
 
A PHASE II EVALUATION OF PREOPERATIVE SINGLE-FRACTION PARTIAL BREAST 
RADIOTHERAPY IN EARLY STAGE BREAST CANCER 
 
 
 
 
Sponsor: 
Duke Cancer Institute 
 
 
Funding Source: 
Gateway for Cancer Research  
 
 
Protocol Source: 
Duke Cancer Institute 
 
 
Duke IRB#: Pro00063848 
Pro00063848 
 
     Principal Investigator  
Rachel Blitzblau, M.D., Ph.D. 
Department of Radiation Oncology 
DUMC Box 3085 Durham, NC 27710 
  
     
Statisticians 
Donna Niedzwiecki, PhD 
Drew Neish 
 
 
Original version: 
10-02-2015 
 
Amended version1: 
1/29/2019 
 
Amended version 2:  
05/28/2021 
 
Amended version 3: 
10/1/2025 
 
 
 
 
 
 
 

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1 TABLE OF CONTENTS 
2 LIST OF ABBREVIATIONS .......................................................................................................................... 4 
3 PROTOCOL SYNOPSIS ............................................................................................................................... 6 
3.1 
Purpose ......................................................................................................................................... 6 
3.2 
Background and Significance ........................................................................................................ 6 
     3.3     Rationale…………………………………………………………………………………………………………………………………7 
3.4       Design and Procedure ................................................................................................................... 9 
3.5       Selection of Subjects and Sample Size .......................................................................................... 9 
3.6       Duration of Study .......................................................................................................................... 9 
4 SUBJECT ELIGIBILITY ............................................................................................................................... 10 
      4.1       Inclusion Criteria……………………………………………………………………………………………………………………..9 
      4.2       Exclusion Criteria…………………………………………………………………………………………………………….…….10 
      4.3       Inclusion of Women and Minorities ………………………………………………………………………………….….10 
5   TREATMENT PLAN…………………………………………………………………………………………………………………….………11 
5.1 Surgery ............................................................................................................................................. 11 
5.2 Radiation Therapy……………………………………………………………………………………………………………………….11 
      5.3 Supportive Care………………………………………………………………………………………………………………………….14 
6    PATIENT ASSESSMENTS……………………………………………………………………………………………………………………13 
6.1 Screening Examination ..................................................................................................................... 15 
6.2  Correlative Assessment ................................................................................................................... 15 
6.3  Treatment Period ............................................................................................................................ 16 
6.4 Follow-up Period .............................................................................................................................. 16 
6.5 Early Withdrawal of Subject(s) ......................................................................................................... 16 
6.5.1 Criteria for Early Withdrawal ........................................................................................................ 16 
6.5.2 Follow-up Requirements for Early Withdrawal ............................................................................ 16 
6.5.3 Replacement of Early Withdrawal(s) ............................................................................................ 17 
7 STATISTICAL METHODS AND DATA ANALYSIS ......................................................................................... 17 
8   SAFETY MONITORING AND REPORTING…………………………………………………………………………………………….16  
8.1 Adverse Events ................................................................................................................................. 18 

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8.1.1 AEs of Special Interest ................................................................................................................... 19 
8.1.2 Reporting of AEs ............................................................................................................................ 19 
8.2   Serious Adverse Events .................................................................................................................. 19 
8.3 Safety Oversight Committee (SOC) .................................................................................................. 19 
9.  QUALITY CONTROL AND QUALITY ASSURANCE ..................................................................................... 20 
9.1   Monitoring...................................................................................................................................... 20 
9.2   Audits ........................................................................................................................................... 209 
10.  ADMINISTRATIVE AND ETHICAL CONSIDERATIONS ............................................................................. 21 
10.1 Regulatory and Ethical Compliance ............................................................................................... 21 
10.2 DUHS Institutional Review Board and DCI Cancer Protocol Committee ....................................... 21 
10.3 Informed Consent .......................................................................................................................... 20 
10.4 Study Documentation .................................................................................................................... 22 
10.5 Privacy, Confidentiality, and Data Storage .................................................................................. 231 
10.6 Data and Safety Monitoring ........................................................................................................... 23 
10.7 Protocol Amendments ................................................................................................................... 23 
10.8 Records Retention .......................................................................................................................... 23 
11. REFERENCES .......................................................................................................................................... 24 
12. APPENDICES .......................................................................................................................................... 26 
APPENDIX I Tissue Studies .......................................................................................................................... 26 
APPENDIX II  RTOG Cosemesis Scale…………………………………………………………………………………………………..….25 
APPENDIX III Patient Self-Assessment ........................................................................................................ 28 
APPENDIX IV Quality of Life ........................................................................................................................ 29 
APPENDIX V Digital Photographs ................................................................................................................ 31 
APPENDIX VI Blood Processing……………………………………………………………………………………………………………… 32 
 

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2.  LIST OF ABBREVIATIONS 
 
 
3D                 3 Dimensional 
5-FU              5 fluoro-uracil 
AE                 Adverse events 
ANC              Absolute Neutrophil Count 
AP/PA           Anterior to Posterior, Posterior to Anterior 
APC               Argon Plasma Coagulation 
BED               Biologically Equivalent Dose 
BID                Twice Daily 
CBC               Complete Blood Count 
CBCT            Cone Beam Computed Tomography 
CDDP            Cisplatin 
Chemo          Chemotherapy 
CPC               Cancer Protocol Committee 
CRT              Chemoradiotherapy 
CT                Computed Tomography 
CTCAE        Common Terminology Criteria for Adverse Events 
CTEP           Cancer Therapy Evaluation Program 
CTV             Clinical Tumor Volume 
D10cc           Minimum dose to the 10 milliliters of any volume receiving the highest dose 
D2cc             Minimum dose to the 2 milliliters of any volume receiving the highest dose 
DCI              Duke Cancer Institute 
DCIS              Ductal carcinoma in situ 
DLT             Dose Limiting Toxicity 
Dmax            Maximum dose to any voxel within a volume 
DUHS           Duke University Health System 
ECOG           Eastern Cooperative Oncology Group 
EFRT            Extended Field Radiotherapy 
EQD2           Equivalent dose at 2 Gray per fraction 
FIGO            International Federation of Gynecology and Obstetrics 
G3 or G4      Grade 3 or Grade 4 toxicity 
GCP              Good Clinical Practice 
GOG             Gynecologic Oncology Group 
GTV             Gross Tumor Volume 
GU               Genitourinary 
GY               Gray 
HDR            High Dose Rate 
ICRU            International Commission on Radiation Units and Measurement 
ID                 Identification  
IMRT           Intensity Modulated Radiation Therapy (including Volumetric Modulated Arc Therapy) 
IRB              Institutional Review Board 
KPS             Karnofsky Performance Scale 
LDR             Low Dose Rate 

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LINAC         Linear Accelerator 
LRC             Loco-regional control 
MRI             Magnetic Resonance Imaging. 
MTD            Maximum Tolerated Dose 
MV              Megavoltage 
NCI             National Cancer Institute 
OS               Overall Survival 
PA               Para-aortic 
PBI                Partial Breast Irradiation 
PET             Positron Emission Tomography 
PI                Primary Investigator 
PTV            Planning Target Volume 
NRG             National Surgical Adjuvant Breast and Bowel Project (NSABP), the Radiation Therapy 
Oncology Group (RTOG), and the Gynecologic Oncology Group (GOG) 
SBRT             Stereotactic body radiation therapy 
SOC           Safety Oversight Committee 
TD5/5         Toxic dose of 5% at 5 years 
V18             Partial volume receiving greater than or equal to 18 Gray 
WAI            Whole abdominal irradiation 
WPRT         Whole Pelvic Radiotherapy 

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3.  PROTOCOL SYNOPSIS 
3.1 Purpose: 
This protocol seeks to build on the favorable results of our phase I trial (Pro00015617) by extending our 
findings to a larger cohort of subjects. 
 
Primary Objective 
1. Determine physician reported rates of good/excellent cosmesis at baseline and 6 months, 1, 2, 
and 3 years post-treatment as measured by the NRG cosmesis scale (Appendix II). 
 
Secondary Objectives 
1. Determine patient-reported rates of good/excellent cosmesis at baseline and 6 months, 1, 2, 
and 3 years post-treatment as measured by the NRG cosmesis scale.  
2. Assess patient-reported Quality of Life (FACT-B) and patient satisfaction at the same time points. 
3. Assess locoregional control in the treated breast relative to historical controls at 10 years.  
 
Exploratory Objectives 
1. Ki-67 will be assessed as a measure of tumor response. 
2. Assess the impact of radiation on gene expression  
3. Assess the impact of radiation on circulating cell-free DNA via serum markers and oxidative 
stress as measured by urinary biomarkers.  Please see Appendix VI for additional detail 
regarding serum and urine assessment. 
4. To review treatment plans, evaluate delivery techniques and assess positioning verification 
images 
 
 
      Hypotheses 
In this study, we hypothesize that 21Gy can be delivered preoperatively to a large group of subjects 
with high rates of good/excellent cosmetic outcomes 
 
3.2 Background and Significance: 
In 1990, the National Institutes of Health concluded that breast conservation, conservative surgery 
followed by radiotherapy, was the preferred treatment for women with early stage breast cancer as no 
survival advantage was seen in women receiving a more radical and disfiguring mastectomy.  As a result, 
breast conservation consisting of lumpectomy followed by 6 weeks of daily external beam radiotherapy 
became the standard of care in the United States (US).  Treatment typically consisted of 4.5-5 weeks of 
whole breast treatment followed by a 1-1.5 week boost to the surgical resection cavity.  Unfortunately, 
some women electing to receive breast conserving surgery struggled to complete the recommended 
radiotherapy.  Patterns of care studies demonstrated that older women, and those living in low-income 
regions or far from radiotherapy centers, often omitted radiotherapy altogether1-3.  Numerous studies 
have demonstrated that the local recurrence rates in these women receiving conservative surgery alone 
are unacceptably high4,5. 

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As a result, there has been much interest in development of a more convenient alternative to standard 
radiotherapy.  Recently, robust data has documented that a 3 week course of whole breast radiotherapy 
is an efficacious and safe alternative6,7 to standard therapy.  Much additional work has been done on 
partial breast irradiation (PBI), rapid treatment of the tumor bed plus a small margin of normal tissue, 
delivered in 1 to 5 days.  Several techniques have evolved to deliver PBI: low-dose rate (LDR) 
brachytherapy, high-dose rate (HDR) brachytherapy via intracavitary applicator, external beam 
radiotherapy and intra-operative radiation.  LDR brachytherapy has the most extensive follow-up but 
has not been widely adopted due to the significant technical expertise required for accurate and 
efficient delivery.  Intracavitary and external beam radiotherapy, the two most common forms of partial 
breast irradiation, are widely available and relatively easily applied.  However, treatment is still 
intensive, requiring 10 treatments delivered 6 hours apart over five days.  Furthermore, though most 
preliminary data suggest comparable rates of local control, increasing data are accumulating that soft 
tissue fibrosis and cosmetic outcomes may be suboptimal with the popular external beam technique8.  
Several investigators have suggested that this may be attributable to the large volume of tissue treated 
to high doses in the post-operative setting9,10.  
We proposed a phase I trial evaluating pre-operative radiation as a solution to this issue.  Delivery of 
radiation pre-operatively to the intact tumor allows more precise targeting of a much smaller volume 
than a large post-operative seroma.  Furthermore, the highly conformal nature of stereotactic 
radiosurgery is ideal to minimize the volume of uninvolved breast tissue and skin receiving high-dose 
radiation during PBI, two advantages of the intra-operative technique that likely contribute to the 
acceptable outcomes seen with this single dose therapy.  However, in contrast to intra-operative 
treatment which requires significant investment in costly intra-operative radiation equipment and a 
great deal of flexibility in operating room scheduling, most radiation facilities have the capability to treat 
with stereotactic radiosurgery.  This high precision, conformal, rapid, linear accelerator based external 
beam partial breast irradiation captures the appeal of single-dose intra-operative treatment but in a 
setting that is widely accessible. 
Therefore, we set out to determine the maximally tolerated dose of pre-operative radiation in our 
previous phase I trial11.  Our target dose was 21Gy, the dose established as effective in intraoperative 
partial breast trials12,13.   Our results have been positive thus far, with only one locoregional recurrence 
and no dose-limiting acute toxicities despite escalation to 21Gy.   Long-term toxicities at a median 
follow-up of 3 years are similar to expected toxicities with standard therapy.  As expected, the volume of 
breast receiving prescription dose was vastly decreased compared to post-operative treatment.  In this 
study, we hypothesize that 21Gy can be delivered preoperatively to a larger group of subjects with high 
rates of good/excellent cosmetic outcomes. 
3.3 Rationale: 
Rationale for single-fraction preoperative technique  
We propose in this trial to build on the favorable results of our phase I trial by extending our findings to 
a larger cohort of subjects.  The preoperative approach has several advantages:  

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1) a small intact breast tumor results in significantly less uninvolved breast tissue receiving high 
radiation doses which likely decreases toxicity;  
2) more accurate targeting of the high-risk areas of subclinical disease surrounding the tumor is possible,  
3) smaller treatment volumes are amenable to dose escalation which can further accelerate treatment 
and improve accessibility for subjects,  
4) this technical approach is widely utilized in other tumor sites and can be delivered at most radiation 
facilities   
5) the pre-operative approach provides a novel opportunity to study breast cancer radiation response.   
 
A. Rationale for magnetic resonance imaging (MRI) treatment planning 
Target delineation has always been highly subjective in the post-lumpectomy setting.  The tumor bed is 
currently defined as the area of architectural distortion plus surgical clips.  Defining this area is subject 
to inherent variability depending on the bias of the treating physician.  Pre-operative assessment of the 
tumor should certainly improve delineation of the target and the surrounding area at risk.  However, the 
typical tools used for defining breast tumors, mammography and ultrasound, cannot currently be used 
in conjunction with radiation planning software.  CT is commonly used for radiation treatment planning 
but, as we noted in our phase I trial, does not facilitate clear target delineation.  MRI, on the other hand, 
clearly identifies the tumor and can be used in conjunction with radiation treatment planning software.  
B. Rationale for patient selection 
Numerous trials have demonstrated that local recurrence rates are unacceptably high after lumpectomy 
alone in all but the elderly population with small, node negative, estrogen-receptor positive tumors14.    
Published data establishing partial breast techniques have demonstrated low local recurrence rates in 
conjunction with careful patient selection.  Those subjects felt to be suitable for partial breast treatment 
outside the setting of a clinical trial, as defined by the ASTRO consensus statement15,16 will be eligible for 
this study  
C. Rationale for endpoints 
Clinical data suggests that ER+ breast cancers have a larger proportional benefit from radiation than 
their ER- counterparts.  However, clinical assessment of radiation response (aside from long-term 
follow-up of local control) is rarely observed as radiation is typically delivered in the post-operative 
setting after resection of gross disease.  As a result, tumor and normal tissue radiation response remain 
relatively poorly understood.  Markers capable of predicting radiation response are rare indeed.  
Therefore, if biologic markers of radiation response could be identified in a subset of subjects, these 
clinical markers could be used in future clinical trials to explore the impact of alternative total doses, 
dose per fraction or concurrent therapy. 
In addition, two large randomized trials have documented less toxicity with intraoperative radiation at a 
single dose of 21Gy12,13 as compared to standard whole breast radiotherapy.   However, this technique 
does have the critical advantage of delivering radiation to the subcutaneous tissue and minimizing dose 
to the overlying skin.  Pre-operative treatment must necessarily be given with the skin intact.  Fibrosis 
and skin thickening in this area could contribute to suboptimal cosmesis.  In our phase I trial, there were 

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no dose-limiting acute toxicities.  In addition, all 29 subjects treated with only 21Gy of radiation (3 
subjects received post-operative radiation for high-risk features) had good or excellent outcomes.  
However, these promising early outcomes must be confirmed in a larger group of subjects with diverse 
tumor locations and radiation plans.   We would expect a rate of good/excellent cosmetic outcomes at 3 
years comparable to those seen in the clinical trials evaluating short-course whole breast radiation (75-
80% at 3 years)17.   Local control will also be carefully collected and gathered as a secondary endpoint. 
D. 10/01/2025 Amendment Summary and Rationale: 
The classification of several study endpoints is being revised. Due to the limited number of subjects 
enrolled, the small amount of tissue available for analysis, and the absence of prior data to inform 
statistical assumptions, current secondary endpoints 1 (Ki-67), 4 (gene expression), 5 (circulating DNA) 
and 6 (treatment planning) will now be considered exploratory in nature. 
The small sample size and restricted biospecimen availability preclude adequately powered, 
confirmatory analyses. Furthermore, without pre-existing data to guide selection of specific genes, 
biomarkers, or serum markers, it is not scientifically appropriate to designate these two endpoints as 
definitive or hypothesis-testing. Reframing these study endpoints as exploratory allows for hypothesis 
generation and identification of potential signals of interest, while ensuring that study results are 
interpreted within an appropriate methodological context. 
a. Amendment Impact on Risk/Benefit Profile: 
This amendment does not alter the study design, subject participation, or risk/benefit profile. 
No additional procedures will be performed. The change pertains only to the classification and 
interpretation of study endpoints 
3.4   Design and Procedure: 
Prospective, single arm study in subjects  with newly diagnosed ductal carcinoma in situ or invasive 
carcinoma of the breast 
3.5   Selection of Subjects and Sample Size: 
Women ages 60 or older with clinically node-negative, 2cm or less, biopsy proven ductal carcinoma in 
situ or invasive carcinoma will be considered for this trial. Women age 50-59 with a cT1N0 tumor and a 
low Oncotype score will also be eligible. 
The final sample size is 100 subjects.  Up to 150 subjects may be consented in order to enroll the target 
goal of 100. Given the rapid accrual of our previous trial with similar eligibility (approximately 30/32 
subjects over 2 years), we anticipate completion of this trial in 5 years.   
3.6   Duration of Study: 
Subjects will be on study for approximately 3 years. Thereafter subjects will continue to be followed by 
the treating medical oncologist and/or radiation oncologist/mid level provider as per standard of care 
for follow up care.  

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4.  SUBJECT ELIGIBILITY 
4.1 Inclusion Criteria:  
1. Women with a biopsy proven diagnosis of ductal carcinoma in situ or invasive carcinoma of the 
breast 
a. Biopsy tissue (either slides or block) from outside institutions will be reviewed to confirm 
diagnosis. 
2. Breast preservation candidates (no prior breast or nodal radiotherapy, no imaging evidence of 
multicentric or multifocal disease, no pregnant women, and no comorbid conditions precluding 
surgery)  
3. Clinical T1N0M0 invasive carcinoma or DCIS < or equal to 2cm 
4. 60 years of age or older or 50-59 with a low (0-17) Oncotype score .  Oncotype is not required 
for women diagnosed with DCIS. 
5. ER+, HER2- (HER2 status is not required for women diagnosed with DCIS) 
6. Women of child-bearing potential must consent to use adequate contraception during the 
course of the study. Female subjects must agree to use a medically acceptable contraceptives 
including: (1) surgical sterilization (such as a tubal ligation or hysterectomy), (2) approved 
hormonal contraceptives (such as birth control pills, patches, implants or injections), (3) barrier 
methods (such as a condom or diaphragm) used with a spermicide, or (4) an intrauterine device 
(IUD). Contraceptive measures such as Plan B (TM), sold for emergency use after unprotected 
sex, are not acceptable methods for routine use. 
7. WBC > 3000, Hgb > 9, platelets >100000 within 45 days of consent 
8. MRI is required for radiation treatment planning on this study.  A diagnostic MRI performed 
within  60 days of obtaining consent is acceptable and will not be repeated. Subjects who have 
not had a diagnostic MRI will be required to have a research treatment planning MRI with 
contrast ordered by a radiation oncologist; these subjects must have a GFR≥ 60 ml/min.   
9. Outside breast imaging will be reviewed at Duke to confirm findings are consistent with trial 
eligibility. 
 
4.2  Exclusion Criteria:  
1. Neoadjuvant chemotherapy 
2. Breast implant in the breast to be treated with SBRT 
3. Medical conditions that may increase risk for poor cosmetic outcome (i.e.  Lupus, rheumatoid 
arthritis, scleroderma) 
4. Subjects unable to receive study treatment planning secondary to body habitus or inability to lie 
flat on  the stomach at length 
5. HER-2+ ((HER2 status is not required for women diagnosed with DCIS) 
6. Positive serum pregnancy test 
7. Insufficient breast imaging to judge clinical stage 

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8. Subjects without placement of a biopsy clip at the diagnostic procedure who are unwilling to 
undergo clip placement. 
9. Subjects in whom treatment planning constraints cannot be met 
 
4.3  Inclusion of Women and Minorities 
Only women will be eligible for this study.  Minority groups will also be eligible and accrual is expected 
to reflect the population of subjects seen in the Duke Multi-disciplinary Breast Cancer Clinic.   
5.  TREATMENT PLAN 
5.1 Surgery:  
Surgical tumor resection will be completed within 10 days of RT delivery.  Subjects will undergo 
intraoperative lymphatic mapping and sentinel lymphadenectomy as is standard at our institution.  
Standard axillary nodal dissection is acceptable if there is a contraindication to the sentinel node 
procedure or if felt to be clinically indicated based on nodal involvement.  Omission of nodal assessment 
is also acceptable if clinically indicated and will not be performed in patient’s diagnosed with DCIS.  
Resection of the tumor will include a 2mm margin of normal tissue. In general, re-excision is required for 
histologic margins <2mm.  There may be exceptions, however, when a close margin occurs at an 
anatomic boundary (typically chest wall/skin) or is nearly 2mm or only focally close.  Those margins are 
generally felt to be less significant prognostically and the role for re-excision in these cases will be made 
by the treating surgeon and radiation oncologist. Typically, surgical clips marking the site of tumor 
excision will be placed to allow for localization of the tumor bed on follow-up imaging.  Standard 
pathologic assessment will follow.  
5.2 Radiation Therapy: 
Target Volume:  
Prior to treatment, a biopsy clip fiducial marker will be placed in the region of the tumor to provide 
localization for radiotherapy delivery. Kilovoltage on-board-imaging (OBI) and/or cone beam CT (CBCT) 
will be used for localization as described in the section on target localization.     
When required per protocol the patient will then undergo magnetic resonance (MR) imaging.  The 
patient will be placed on the MR table with the breast pendant in a dedicated breast surface coil with 
arms raised overhead.  Alternatively, the patient will be placed supine and specialized thoracic coils will 
be utilized in order to keep the breast in the same shape for the MR, CT, and radiation treatment to the 
extent possible.  MR/CT compatible surface markers will be used to assist in this effort.  T1-weighted 
imaging, T2-weighted imaging, inversion-recovery imaging, diffusion weighted imaging (DWI),  and 
Dynamic contrast enhanced (DCE) MRI of the breasts will be performed. More specifically, T1 weighted 
MRI will be acquired with a 3D gradient-echo with spoiler (SPGR) sequence to achieve spatial resolution 
of sub-millimeter; T2 weighted MRI will be acquired with a 2D fast spin-echo (FSE) sequence; inversion 
recovery MRI will be acquired by a 2D axial short-T1 inversion-recovery (STIR) sequence; DCE-MRI will be 

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acquired with a 3D SPGR sequence.  Before DCE-MRI acquisition, a MedRad Power Injector will be used 
to administer weight appropriate dose of gadolinium at 2cc/second after a 30 second inject delay.   
Axial T1, axial short-T1 inversion-recovery (STIR), and dynamic VIBRANT images will be required for the 
delineation of the enhancing tumor, the gross tumor volume (GTV).  A planning CT scan will also be 
acquired in order to generate dose calculations.   
Treatment Planning and Dose: 
The MR images will be used to define the GTV.  A 1.5 cm uniform expansion will be applied around the 
GTV to create the clinical target volume (CTV).  MRI images will be fused to the CT images for further 
identification of normal structures and target volumes.  The first 5mm of subcutaneous tissue and any 
chest wall (pectoralis muscle and deeper) if >1 cm from the GTV will be excluded from this volume.  The 
first 5mm of tissue is in the photon “build-up” region and to include this area would skew the dose 
calculations.  The chest wall is considered an anatomic boundary to tumor that is separate from the 
chest wall.  An additional 0.5 cm margin will be applied to the GTV and CTV to create two distinct PTV 
volumes (PTV-GTV and PTV-CTV).   PTV-GTVeval and PTV-CTVeval, which includes the same volumes 
minus the skin, will be utilized for analysis of dose coverage.. Subjects will receive a single fraction of 
21Gy to the PTV-GTV and 15Gy to the PTV-CTV.  This will allow for high dose to the area at greatest risk 
with a more moderate dose to the intermediate risk area and associated reduction in dose to the skin. 
The skin, ipsilateral and contralateral lung, ipsilateral and contralateral breast tissue, spinal cord and 
heart will be segmented as per institutional standard and analyzed for dose.  The skin will be defined as 
a 3 mm layer from the external body surface.  The ipsilateral and contralateral breast tissue will be 
segmented utilizing the guidelines from ongoing phase III NRG trials.  In short, the breast tissue typically 
included in standard breast tangents minus the lungs and chest wall will be designated the breast 
volume with hand modification as needed by the principal investigator/or designee. 
 
The skin, spinal cord, and lungs will be auto-contoured in standard fashion.   The heart should be 
contoured from the apex to the root of the great vessels.  The thyroid and brachial plexus will also be 
contoured as appropriate depending on tumor location.  The thyroid should be easily visible and 
contoured at the base of the neck.  The brachial plexus should be visible on MRI and will be contoured 
with the assistance of radiology as indicated.  Alternatively, the axillary vessels will be used as a 
surrogate for the brachial plexus18.   
 
A treatment plan utilizing arc therapy, or multiple conformal beams, or intensity-modulated therapy, or 
a combination of these techniques will then be designed.  The beam arrangement can be organized in 
any fashion provided that the dose constraints listed below are met.  The dose will be normalized to 
provide a desired coverage (95% to 98%) to the CTV.   
 
Dose constraints are based on our phase I experience, as well as that of our Dutch collegues19 (including 
a joint analysis of Duke/Utrecht data pending presentation/publication) and will be considered 
appropriate as follows:  
 
Target volumes: 

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(CTV):  prescribed dose (15Gy) covers >95% of the CTV without exceeding maximum dose of 
110% of prescribed dose 
PTV-GTVeval: ≥95% of the prescribed dose (21Gy) covers >95% volume without 
exceeding 110% 
PTV(CTV)eval: ≥95% prescribed dose (15Gy) covers >90% of the PTV-CTV eval without 
exceeding 110% of prescription dose 
Normal breast:  <30% of the whole breast reference volume should receive 50% or more of the 
prescribed dose and <15% of the whole breast reference volume should receive the prescribed 
dose  
• 
Optimal:  ipsilateral breast V100% <7%; V50<21% 
Contralateral breast:  the contralateral whole breast reference volume should receive <10% of 
the prescribed dose to any point 
• 
Optimal: Dmax ≤1.6Gy 
Lungs:  1) Mean lung dose <3.6Gy 2) <37% of lung volume should receive 8Gy, 2) <1500cc to        
7Gy, 3)   <1000cc 7.6Gy 
• 
Optimal: Mean ≤0.7Gy 
Heart:  1) Mean should not exceed 1.5Gy;  2) Point dose < 5Gy.  
• 
Optimal:  Mean ≤0.6Gy, Dmax ≤3.4Gy 
Chest wall:  D20cc <16.3Gy. 
• 
Optimal: D20cc ≤10.2Gy 
Thyroid:  maximum point dose < 10% of the prescribed dose 
Brachial plexus:  no point in the brachial plexus should receive more than 10% (2.1Gy 
maximum) of the prescribed dose.   
Skin dose:  1) Maximum dose will not exceed maximum prescription dose (21Gy).  2) Dose to 
1cc:  <14Gy 3) dose to 10cc <9Gy 
Cord: maximum dose to 1 cc should be 1 Gy. 
 
In addition, a low dose survey will be performed to ensure no unanticipated regions are receiving 
inappropriate dose. 
 
Target Localization and Treatment Delivery: 
Subjects will be taken to the treatment machine and positioned comfortably as they were at the time of 
CT simulation.  Image-guidance will be used to localize the treatment volume, including on-board 
radiographic imaging and cone-beam CT when possible. Positioning correction will be performed as 
necessary, verified and documented.  Implanted marker may be considered as surrogates for effective 
target localization.  The target localization procedure will be documented and adjustments will be made 
as appropriate.  Treatment will be delivered to the target volume in one fraction.  Each treatment plan 
will be checked for quality assurance in both calculation and dosimetry.  All treatment will be recorded 
and verified through ARIA information system. 
 
Post-operative Treatment:  
Within 10 days, subjects will proceed to surgical resection. Pathologic assessment will be completed and 
reviewed per standard of care.  Ki-67 will be assessed on core biopsy and definitive resection tumor (as 
per institutional standard) as a measure of tumor response. 
 
Systemic therapy will only be delivered if indicated. The role for adjuvant radiation will be discussed for 
any patient whose pathologic assessment reveals an unanticipated high risk feature.  Features judged by 
the multi-disciplinary treatment team to be of comparable clinical risk relative to the presenting 

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diagnosis (ex.  a 1.8cm tumor on imaging that is just over 2cm at resection) will not necessarily require 
post-operative radiation.  Additional radiation will be recommended to individual patients whose 
locoregional extent of disease is significantly greater than expected at the time of surgery (ex. nodal 
involvement). 
Treatment volumes and prescribed doses will follow institutional standards.  Hypofractionated breast 
treatment will be considered an acceptable alternative to standard therapy (46-50Gy) when clinically 
appropriate.   
 
Subjects requiring mastectomy will be included in the correlative portion of the trial.  However, their 
cosmesis, recurrence and late RT toxicities outcomes will be gathered and recorded separately.  It would 
not be accurate to compare the secondary endpoints of these subjects to those receiving breast 
conservation. 
 
5.3 Supportive Care: 
Standard supportive therapies at the discretion of the treating radiation oncologist. 
 
6.  PATIENT ASSESSMENTS 
 
Assessment 
Pre-Tx. 
Follow-up 
Consent 
X 
 
History/Physical 
X 
Xa 
Complete Blood Count (no differential)/CMP 
X 
 
Breast imaging (mammogram minimum)  
X 
Xa 
Core Biopsy/Fiducial Markers 
 Xb 
 
Planning MRI  
X 
 
Surgical Excision with Tissue Procurement 
 
Xc 
Acute Toxicity Evaluation 
 
Xd 
Cosmetic Evaluation Form/Digital Photographs/QOL 
Xe 
Xe 
Clinical Outcomes 
 
Xa 
Serum collection 
Xf 
Xf 
Urine collection 
Xg 
Xg 
BRPC Consent prior to surgery 
 
X h 
                                                          
 

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a.  Physical exam by member of oncology team recommended every 4-6 months for 2 years, every 6 
months through year 5 and annually years 5-10.  Bilateral mammogram recommended at least annually.   
b.  Verify placement of a biopsy clip at diagnostic procedure and availability of pre-treatment tissue for 
correlative science. 
c.  Within 10 days of radiation.   
d.  Appointment with the Radiation Oncologist/mid level provider  1-2 months after surgery. 
e.  At baseline (prior to treatment), six months and one year after treatment and then annually for 2 
additional years.  Cosmetic assessment to be filled out by both patient and physician/mid level provider.  
Digital photographs at the same time points and at investigator’s discretion.  
f. 2 lavender tubes drawn prior to radiation therapy and post radiation therapy (before surgery) 
g. Urine collected prior to radiation therapy and post radiation therapy (before surgery) 
h.  Subjects will be consented to the existing Biospecimen Repository and Processing Core (BRPC )tissue 
collection protocol which includes safeguards to ensure adequate tissue for diagnostic evaluation and 
biomarker assessment 
6.1 Screening Examination 
The screening examination can take place up to 45 days before study treatment.  An informed consent 
must be signed by the patient before any screening procedure takes place. If however, standard of care 
evaluation procedures have been obtained and are within the screening evaluation time points, the SOC 
procedures do not need to be repeated and may be included in the screening examination. Subject data 
to be collected includes a complete history and physical including signed informed consent, basic clinical 
laboratory studies, staging and a biopsy demonstrating ductal carcinoma in situ or invasive breast 
carcinoma.   
Assessment of the tumor by physical exam and mammogram (further imaging at radiologist/physician 
discretion) should include tumor measurements.  Each patient will complete a baseline cosmetic 
evaluation as will her physician/mid level provider.  QOL measures will also be assessed.  Prior to study 
treatment, placement of a biopsy clip at the time of diagnostic biopsy will be verified as this will serve as 
a fiducial marker (described in section 6.2) to assist in radiotherapy localization.  MRI and CT of the 
affected breast will then be completed for radiation treatment planning 
6.2 Correlative Assessment 
Blood and urine will be collected at two time points, once before radiation therapy is delivered and once 
after radiation therapy is delivered.  See Appendix VI for additional details regarding serum and urine  
processing and assessment.   Specimens will be stored in a -80° freezer in locked facilities in the 
Department of Radiation Oncology for future study and analysis. The specimens may be used specifically 

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for this study and potentially for unspecified research.  The reason, biomarkers and assays are changing 
rapidly. This study is expected to enroll over 5 years, during that time it is possible a new biomarker or 
assay could be developed that is relevant to the study of breast cancer. A study amendment would be 
submitted in the event of this occurring. 
 
6.3 Treatment Period: 
Lumpectomy will be completed within 10 days of RT delivery.  Tissue will be processed as described 
below in section 8.1.  A second biopsy will be collected for gene expression profiling as described in 
Appendix 1.  After preoperative treatment, the patient will be assessed  1-2 months after surgery by a 
Radiation Oncology faculty member/mid level provider to evaluate for acute toxicity.  Subjects will go on 
to systemic therapy or conventional radiation if a high risk feature not anticipated pre-operatively is 
noted at the time of surgery.   If indicated, subjects will be seen weekly during conventional treatment 
as is standard procedure in our department.  . 
6.4 Follow-up Period: 
Follow-up after completion of therapy will follow national guidelines and includes a history and physical 
every 4-6 months for the 1st 2 years, every 6 months to a year through year 5 and annually through year 
10.  Mammograms will be obtained at least annually.  Other laboratory or radiographic studies will be 
obtained as directed by patient symptoms or physical exam.  Quality of life and cosmetic assessments, 
physician/mid level provider and patient, will be performed at 6 month, 1 year, and then annually 
through 3 years of follow-up as will digital photographs.  Loco regional recurrence will be monitored on 
protocol at each follow-up visit.  
6.5 Early Withdrawal of Subject(s): 
Study treatment is a one-day event thus it is not foreseeable that subjects will withdraw from protocol 
therapy.  Extraordinary Medical Circumstances: If at any time the constraints of this protocol are 
detrimental to the patient’s health and/or the patient no longer wishes to continue on the study long-
term, the patient shall be removed from the protocol follow-up. In this event the reason(s) for 
discontinuation of study participation will be noted by the PI in the Radiation Oncology record. 
6.5.1 Criteria for Early Withdrawal 
Subjects may voluntarily withdraw from the study at any time.  The PI may also withdraw a subject from 
the study at any time based on his/her discretion.  Reasons for PI-initiated withdrawal may include, but 
is not limited to the following: 
- 
Adverse events 
- 
Abnormal laboratory values 
- 
Abnormal test procedure results 
- 
Protocol deviation 
- 
Administrative issues 
- 
Disease progression 
- 
Pregnancy 
6.5.2 Follow-up Requirements for Early Withdrawal 
Standard of care follow-up will be adhered to. 

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6.5.3 Replacement of Early Withdrawal(s) 
Subjects who prematurely withdraw will not be replaced unless radiation has not been initiated. 
7.   STATISTICAL METHODS AND DATA ANALYSIS 
7.1.  Amendment to the Statistical Section 
The original sample size of this trial was 40 patients, and the original primary objective was to estimate 
the pCR rate and test the null hypothesis that the true rate was less than or equal to 0.10. The trial has 
been amended so that the primary objective is now the estimation of the proportion of patients with 
good/excellent cosmesis. Pathologic response is no longer an endpoint in this trial. These changes were 
necessary for two reasons. First, it was determined during the course of the trial that long-term data on 
cosmesis with the partial breast approach are needed regardless of the pathologic response rate. 
Second, since an increase in post-operative toxicity (seroma/delayed wound healing) was seen when 
surgery was completed 6 weeks after radiation, the amendment includes a return to surgery within 10 
days of radiotherapy (as in our Phase I trial with minimal toxicity); this eliminates the opportunity to 
observe pathologic response. The sample size is now being increased to 100 in order to obtain a more 
precise estimate of the good/excellent cosmesis rate.  
 
7.2. Statistical Analysis of Cosmetic Outcome 
The rate of physician-reported good/excellent cosmesis will be estimated at baseline and at 6, 12, 24, 
and 36 months. Assuming an observed good/excellent cosmesis rate of about 0.75, an increase in the 
sample size from 40 to 100 will allow the width of the 95% confidence interval (CI) of the rate to be 
decreased by 0.10 units.  Specifically, a rate of 0.75 with samples sizes of 40 and 100 has 95% CI’s of 
0.62
0.88 and 0.67
0.83, respectively.  
 
A true rate of good/excellent cosmesis of ≥ 0.80 would be considered very good, while a rate of ≤0.60 
would be unacceptable.  The table below gives a rough guideline for monitoring the 12 month cosmesis 
rate (the rates at the other time points will not be monitored).  
 
Sample 
size 
Review data if the number 
of patients with 
good/excellent cosmetic 
outcome is: 
30 
≤ 21 (21/30 = 0.70) 
60 
≤ 42 (42/60 = 0.70) 
100 
≤ 70 (70/100 = 0.70) 
 
Simply said, any evidence that the observed cosmesis rate would likely be ≤0.70 would be cause for 
review.  For example, suppose 30 of the first 50 patients (60%) had good/excellent cosmesis. Then even 
if the next 10 patients had acceptable cosmesis (40/60), this would not be enough to avoid a review of 
the data. Therefore, a review would have to be begun when N=50.   The monitoring rules above have 
high probability (i.e., 0.97) of initiating a review of the cosmetic data if the true probability of having 

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good/excellent cosmetic outcome is ≤ 0.60 and a low probability (i.e., 0.14) of initiating a review if the 
true probability of a good/excellent cosmetic endpoint is ≥0.80.  
 
7.3 Statistical Analyses of the Secondary Objectives 
(a) The mean of patient-reported rate of good/excellent cosmesis, and its 95% CI, will be estimated at 
baseline and at 6, 12, 24, and 36 months. 
(b) Quality of life (FACT-B) and patient satisfaction will be measured at baseline and at 6, 12, 24, and 36 
months.  For each scale, the mean and its 95% CI’s will be estimated at each time point; boxplots will be 
used to estimate the distribution of these scales at each time point.  
(c) Time to local or regional failure will be defined as the time from start of treatment to date of local or 
regional failure, whichever comes first; distant failures will be ignored; deaths will be censored. Time to 
distant failure will be defined as the time from start of treatment to date of distant failure; local and 
regional failures will be ignored; deaths will be censored. The Kaplan Meier method will be used to 
estimate both of these distributions.   
 
7.4 Statistical Analyses of the Exploratory Objectives 
(a) Rates of ki-67 at core biopsy and 5-7 weeks post-RT will be estimated with 95% CI’s. 
(b) The analysis of the impact of radiation on gene expression is described in Appendix 1. 
(c)To review  treatment plans, evaluate delivery techniques and assess positioning verification images 
 
 
8.  SAFETY MONITORING AND REPORTING 
The PI is responsible for the identification and documentation of adverse events and serious adverse 
events, as defined below.  At each study visit, the PI or designee must assess, through non-suggestive 
inquiries of the subject or evaluation of study assessments, whether an AE or SAE has occurred.  
Previously, an interim analysis of the first 17 patients was completed. Delayed wound healing, and an 
increase in grade 2 seromas, relative to our Phase I experience, were observed. The PI and study team 
believe that there is an interaction between the radiation and surgery (when completed 6 weeks after 
protocol treatment) that was not seen with our previous practice of 10 days after protocol treatment.  
Therefore, with the current amendment, we are returning to the practice established from our phase 1 
study (Pro00015617) where minimal toxicities were observed.  Whilst adverse events will continue to be 
monitored vigorously, it is not anticipated that that those toxicities will be seen in future enrolled 
subjects given our prior experience.  Therefore, there is no plan to complete an additional interim 
analysis for this study.  
8.1 Adverse Events: 
An adverse event (AE) is any untoward medical occurrence in a subject receiving study therapy and 
which does not necessarily have a causal relationship with this treatment.  For this protocol, the 
definition of AE also includes worsening of any pre-existing medical condition.  An AE can therefore be 
any unfavorable and unintended or worsening sign (including an abnormal laboratory finding), 
symptom, or disease temporally associated with the use of radiation therapy, whether or not related to 
use of the radiation therapy.  Abnormal laboratory findings without clinical significance (based on the 

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PI’s judgment) should not be recorded as AEs.  But laboratory value changes that require therapy or 
adjustment in prior therapy are considered adverse events. 
 
From the time the subject signs the informed consent form through the End of Study visit, all AEs must 
be recorded in the subject medical record and adverse events case report form. 
 
AEs will be assessed according to the CTCAE version 4.0.  If CTCAE grading does not exist for an AE, the 
severity of the AE will be graded as mild (1), moderate (2), severe (3), life-threatening (4), or fatal (5). 
 
Attribution of AEs will be indicated as follows: 
− 
Definite:  The AE is clearly related to the study therapy 
− 
Probably:  The AE is likely related to the study therapy 
− 
Possible:  The AE may be related to the study therapy 
− 
Unlikely:  The AE is doubtfully related to the study therapy 
− 
Unrelated:  The AE is clearly NOT related to the study therapy 
    8.1.1 AEs of Special Interest 
All possible treatment related adverse events/toxicities reported or observed, the 
information should be recorded in the patient’s medical record and on the study’s Toxicity 
Evaluation Form or in the study’s toxicity database.  This should include a description of the 
event, its severity grade, the relationship to the study treatment and the onset date.  
    8.1.2 Reporting of AEs 
  All grade 4 or higher unexpected and possibly related toxicity will be reviewed by the PI 
and study team and reported to the Duke University Health System IRB via the eIRB system. 
    8.2   Serious Adverse Events: 
An AE is considered “serious” if in the opinion of the investigator it is one of the following outcomes: 
− 
Fatal 
− 
Life-threatening 
− 
Constitutes a congenital anomaly or birth defect 
− 
A medically significant condition (defined as an event that compromises subject safety or 
may require medical or surgical intervention to prevent one of the three outcomes above) 
− 
Requires inpatient hospitalization or prolongation of existing hospitalization 
− 
Results in persistent or significant incapacity or substantial disruption to conduct normal life 
functions 
8.3 Safety Oversight Committee (SOC): 
The Duke Cancer Institute SOC is responsible for annual data and safety monitoring of DUHS sponsor-
investigator phase I and II, therapeutic interventional studies that do not have an independent Data 
Safety Monitoring Board (DSMB). The primary focus of the SOC is review of safety data, toxicities and 
new information that may affect subject safety or efficacy. Annual safety reviews includes but may not 
be limited to review of safety data, enrollment status, stopping rules if applicable, accrual, toxicities, 
reference literature, and interim analyses as provided by the sponsor-investigator.  The SOC in concert 
with the DCI Monitoring Team (see Section 12.1 for Monitoring Team description) oversees the conduct 
of DUHS cancer-related, sponsor-investigator greater-than-minimal-risk intervention studies that do not 
have an external monitoring plan, ensuring subject safety and that the protocol is conducted, recorded 
and reported in accordance with the protocol, standing operating procedures (SOPs), Good Clinical 

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Practice (GCP), and applicable regulatory requirements. The DCI Safety Oversight Committee (SOC) will 
perform annual reviews on findings from the DCI Monitoring Team visit and additional safety and 
toxicity data submitted by the Principal Investigator. 
  9.  QUALITY CONTROL AND QUALITY ASSURANCE 
9.1   Monitoring: 
This clinical research study will be monitored both internally by the PI and institutionally by the Duke 
Cancer Institute (DCI).  In terms of internal review the PI will continuously monitor and tabulate adverse 
events.  Appropriate reporting to the Duke University Medical Center IRB will be made.  If an 
unexpected frequency of Grade III or IV events occur, depending on their nature, action appropriate to 
the nature and frequency of these adverse events will be taken.  This may require a protocol 
amendment, dose de-escalation, or potentially closure of the study.  The PI of this study will also 
continuously monitor the conduct, data, and safety of this study to ensure that: 
Stopping rules for toxicity and/or response are met; 
Risk/benefit ratio is not altered to the detriment of the subjects; 
Appropriate internal monitoring of AEs and outcomes is done; 
Over-accrual does not occur; 
Under-accrual is addressed with appropriate amendments or actions; 
Data are being appropriately collected in a reasonably timely manner. 
DCI review and monitoring of this protocol occurs in accordance with the NCI-approved Data and Safety 
Monitoring Plan.  Briefly, protocol review begins with an initial review by the Cancer Protocol 
Committee (CPC), which assesses the ethics and safety of the protocol.  Documentation of these 
assessments will be maintained.  Formal, independent monitoring will be conducted by the DCI 
Monitoring Team after the first 3 subjects are enrolled, followed by annual monitoring of 1-3 subjects 
until the study is closed to enrollment and subjects are no longer receiving study interventions that are 
more than minimal risk.  DCI Monitoring Team reports and additional data/safety/toxicity reports 
submitted by the PI will be reviewed by the Safety Oversight Committee (SOC) on an annual basis.  
Additional monitoring may be prompted by findings from monitoring visits, unexpected frequency of 
serious and/or unexpected toxicities, or other concerns.  Monitoring visits may also be initiated upon 
request by DUHS and DCI Leadership, CPC, SOC, a sponsor, an investigator, or the IRB.     
 
9.2   Audits: 
The Duke School of Medicine Clinical Trials Quality Assurance (CTQA) office may conduct 
confidential audits to evaluate compliance with the protocol and the principles of GCP.  The PI 
agrees to allow the CTQA auditor(s) direct access to all relevant documents and to allocate his/her 

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time and the time of the study team to the CTQA auditor(s) in order to discuss findings and any 
relevant issues. 
 
CTQA audits are designed to protect the rights and well-being of human research subjects. CTQA 
audits may be routine or directed (for cause). Routine audits are selected based upon risk metrics 
generally geared towards high subject enrollment, studies with limited oversight or monitoring, 
Investigator initiated Investigational Drugs or Devices, federally-funded studies, high degree of risk 
(based upon adverse events, type of study, or vulnerable populations), Phase I studies, or studies 
that involve Medicare populations. Directed audits occur at the directive of the IRB or an authorized 
Institutional Official. 
 
CTQA audits examine research studies/clinical trials methodology, processes and systems to assess 
whether the research is conducted according to the protocol approved by the DUHS IRB. The 
primary purpose of the audit/review is to verify that the standards for safety of human subjects in 
clinical trials and the quality of data produced by the clinical trial research are met. The audit/review 
will serve as a quality assurance measure, internal to the institution. Additional goals of such audits 
are to detect both random and systemic errors occurring during the conduct of clinical research and 
to emphasize “best practices” in the research/clinical trials environment. 
10.  ADMINISTRATIVE AND ETHICAL CONSIDERATIONS 
10.1 Regulatory and Ethical Compliance: 
This protocol was designed and will be conducted and reported in accordance with the International 
Conference on Harmonization (ICH) Harmonized Tripartite Guidelines for Good Clinical Practice, the 
Declaration of Helsinki, and applicable federal, state, and local regulations. 
10.2 DUHS Institutional Review Board and DCI Cancer Protocol Committee: 
The protocol, informed consent form, advertising material, and additional protocol-related 
documents must be submitted to the DUHS Institutional Review Board (IRB) and DCI Cancer Protocol 
Committee (CPC) for review.  The study may be initiated only after the Principal Investigator has 
received written and dated approval from the CPC and IRB. 
 
The Principal Investigator must submit and obtain approval from the IRB for all subsequent protocol 
amendments and changes to the informed consent form.  The CPC should be informed about any 
protocol amendments that potentially affect research design or data analysis (i.e. amendments 
affecting subject population, inclusion/exclusion criteria, agent administration, statistical analysis, 
etc.).  
 
The Principal Investigator must obtain protocol re-approval from the IRB within 1 year of the most 
recent IRB approval.  The Principal Investigator must also obtain protocol re-approval from the CPC 
within 1 year of the most recent IRB approval, for as long as the protocol remains open to subject 
enrollment. 
10.3 Informed Consent: 
The informed consent form must be written in a manner that is understandable to the subject 
population.  Prior to its use, the informed consent form must be approved by the IRB. 
 

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The Principal Investigator or authorized key personnel will discuss with the potential subject the 
purpose of the research, methods, potential risks and benefits, subject concerns, and other study-
related matters.  This discussion will occur in a location that ensures subject privacy and in a manner 
that minimizes the possibility of coercion.  Appropriate accommodations will be made available for 
potential subjects who cannot read or understand English or are visually impaired.  Potential 
subjects will have the opportunity to contact the Principal investigator or authorized key personnel 
with questions, and will be given as much time as needed to make an informed decision about 
participation in the study. 
 
Before conducting any study-specific procedures, the Principal Investigator or authorized key 
personnel must obtain written informed consent from the subject or a legally acceptable 
representative.  The original informed consent form will be stored with the subject’s study records, 
and a copy of the informed consent form will be provided to the subject.  The Principal Investigator 
is responsible for asking the subject whether the subject wishes to notify his/her primary care 
physician about participation in the study.  If the subject agrees to such notification, the Principal 
Investigator will inform the subject’s primary care physician about the subject’s participation in the 
clinical study. 
 
10.4 Study Documentation: 
Study documentation includes but is not limited to source documents, case report forms (CRFs), 
monitoring logs, appointment schedules, study team correspondence with sponsors or regulatory 
bodies/committees, and regulatory documents that can be found in the DCI-mandated “Regulatory 
Binder”, which includes but is not limited to signed protocol and amendments, approved and signed 
informed consent forms, FDA Form 1572, CAP and CLIA laboratory certifications, and clinical 
supplies receipts and distribution records. 
 
Source documents are original records that contain source data, which is all information in original 
records of clinical findings, observations, or other activities in a clinical trial necessary for the 
reconstruction and evaluation of the trial.  Source documents include but are not limited to hospital 
records, clinical and office charts, laboratory notes, memoranda, subjects’ diaries or evaluation 
checklists, pharmacy dispensing records, recorded data from automated instruments, copies or 
transcriptions certified after verification as being accurate copies, microfiches, photographic 
negatives, microfilm or magnetic media, x-rays, subject files, and records kept at the pharmacy, at 
the laboratories and at medico-technical departments involved in the clinical trial.  When possible, 
the original record should be retained as the source document.  However, a photocopy is acceptable 
provided that it is a clear, legible, and an exact duplication of the original document. 
 
Electronic case report forms (eCRF) in REDCap will be the primary data collection document for the 
study.  The CRFs will be updated within two weeks of acquisition of new source data.  Only approved 
study staff will be permitted to make entries, changes, or corrections in the CRF.  For paper CRFs, 
errors will crossed out with a single line, and this line will not obscure the original entry.  Changes or 
corrections will be dated, initialed, and explained (if necessary).  The Principal Investigator or 
authorized key personnel will maintain a record of the changes and corrections.  For electronic CRFs, 
an audit trail will be maintained by REDCap. 
 

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10.5 Privacy, Confidentiality, and Data Storage: 
The Principal Investigator will ensure that subject privacy and confidentiality of the subject’s data 
will be maintained.  Research Data Security Plans (RDSPs) will be approved by the appropriate 
institutional Site Based Research group. 
 
To protect privacy, every reasonable effort will be made to prevent undue access to subjects during 
the course of the study.  Prospective participants will be consented in an exam room where it is just 
the research staff, the patient and her family, if desired. For all future visits, interactions with 
research staff (study doctor and study coordinators) regarding research activities will take place in a 
private exam room. All research related interactions with the participant will be conducted by 
qualified research staff who are directly involved in the conduct of the research study. 
 
To protect confidentiality, subject files in paper format will be stored in secure cabinets under lock 
and key accessible only by the research staff. Subjects will be identified only by a unique study 
number and subject initials.  Electronic records of subject data will be maintained using a secure 
online REDCap database. Access to the REDCap database will be limited to essential study 
personnel. Subject data may be stored temporarily on encrypted and password-protected portable 
memory devices such as flash drives and external hard drives, but only when absolutely necessary.  
Data stored on portable memory devices will be de-identified.  Subject data will be deleted from the 
portable memory device at the earliest opportunity.  The security and viability of the IT 
infrastructure will be managed by the DCI and/or Duke Medicine.   
  
Upon completion of the study, research records will be archived and handled per DUHS HRPP policy.     
 
Subject names or identifiers will not be used in reports, presentations at scientific meetings, or 
publications in scientific journals. 
 
 10.6 Data and Safety Monitoring: 
Data and Safety Monitoring will be performed in accordance with the DCI Data and Safety 
Monitoring Plan.  For a more detailed description of the DSMP for this protocol, refer to Section 10 
(Sections 11.6 and 11.7 in particular) along with section 12. 
10.7 Protocol Amendments: 
All protocol amendments must be initiated by the Principal Investigator and approved by the IRB 
prior to implementation.  IRB approval is not required for protocol changes that occur to protect the 
safety of a subject from an immediate hazard.  However, the Principal Investigator must inform the 
IRB and all other applicable regulatory agencies of such action immediately. 
10.8 Records Retention: 
The Principal Investigator will maintain study-related records for the longer of a period of at least six 
years after study completion, per Duke policy. 
 

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18. 
Hall WH, Guiou M, Lee NY, et al: Development and validation of a standardized method 
for contouring the brachial plexus: preliminary dosimetric analysis among patients treated with IMRT for 
head-and-neck cancer. Int J Radiat Oncol Biol Phys 72:1362-7, 2008 
 
19. 
Charaghvandi KR, den Hartogh MD, van Ommen AMLN, et al: The dosimetric feasibility 
of MRI-guided single fraction ablative radiotherapy for early-stage breast cancer: a brachytherapy versus 
VMAT planning study. Radiother Oncol In Press., 2015 
 
20. 
Nichols E, Kesmodel SB, Bellavance E, et al: Preoperative Accelerated Partial Breast 
Irradiation for Early-Stage Breast Cancer: Preliminary Results of a Prospective, Phase 2 Trial. Int J Radiat 
Oncol Biol Phys 97:747-753, 2017 
 

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11. APPENDICES 
 APPENDIX I:  Tissue Studies 
Tissue collected pre and post treatment will be used to explore the biologic response to radiotherapy by 
comparing changes in gene expression pre and post-radiotherapy:   
a.  Assess changes in gene expression following radiation.  
Formalin-fixed paraffin-embedded tissue will be utilized for harvesting of RNA.  Gene expression will 
be assessed using the Affymetrix HTA arrays designed for FFPE samples.  We have previously 
successfully used an FFPE Affymetrix platform on our phase I FFPE samples.    
b. Ki-67  will be assessed in the pre and post radiotherapy tissue samples 
 
Gene Expression 
Optimally tissue will be obtained from outside sources and available as formalin-fixed, paraffin-
embedded (FFPE) tissue from the diagnostic biopsy prior to enrollment on the trial.  FFPE was chosen as 
a tool based on prior experience in our phase I preoperative clinical trial.  In that trial, tumors were very 
small and our attempts to obtain fresh-frozen core biopsies at the time of lumpectomy resulted in a low 
tumor yield.  An approach utilizing fresh-frozen tissue also requires subjects to undergo a second core 
biopsy prior to radiation treatment which would likely decrease accrual.  Furthermore, since we were 
able to successfully utilize a FFPE based gene expression platform with our previous samples, we are 
confident that this approach will yield meaningful data.   
Subjects will receive preoperative treatment and proceed to surgical resection, where a second tumor 
sample will be obtained.  The Biospecimen Repository and Processing Core (BRPC), under the leadership 
of Dr. Shannon McCall, will assist with all aspects of tissue acquisition and processing (including storage 
of tissue obtained from outside sources as outlined above).  Tumor tissue will be identified from the pre- 
and post-radiation samples and sectioned in preparation for RNA extraction using the RNeasy FFPE kit 
from Qiagen.  The extracted RNA will be used with the Human Transcriptome Array 2.0 (HTA 2.0) and 
SensationPlus™ FFPE Amplification and WT Labeling Kit. The Sensation Plus Kit will enable us to prepare 
RNA samples for analysis using the HTA 2.0 arrays. The HTA 2.0 arrays are high-resolution arrays 
with >6.0 million probes that cover coding and non-coding transcripts.  Quantitative PCR will be utilized 
to confirm our findings.  Samples will be batched periodically for assessment of gene expression.  
Processing and analysis will proceed with the assistance of Dr. Holly Dressman, Director of the 
Microarray Facility.  Results will then be directly transmitted to Dr. Owzar, Director of the Bioinformatics 
Shared Resource and lead statistician on this protocol.  Dr. Owzar’s team will query the clinical data 
directly from the REDCap database, ensuring proper chain of custody for this data. 

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Appendix II:  NRG Cosmesis Scale     
                       
1. ____-____-_____DATE EVALUATION DONE 
 
2. PLEASE ASSESS THE COSMETIC RESULTS OF BREAST CONSERVATION THERAPY AT THIS 
TIME. 
(Circle the number next to the word that best describes the cosmetic results.) 
 
1   EXCELLENT: when compared to the untreated breast or the original appearance of the 
treated breast, there is minimal or no difference in the size or shape of the treated breast. The 
way the breast feels (its texture) is the same or slightly different. There may be thickening, scar 
tissue, or seroma within the breast but not enough to change the appearance. 
 
2   GOOD: there is mild asymmetry between the breasts, which means that there is some 
acceptable difference in the size or shape of the treated breast as compared to the opposite 
breast or the appearance of the breast before treatment. There may be some mild reddening or 
darkening of the breast. The thickening or scar tissue within the breast causes a mild change in 
its shape or size. 
 
3   FAIR: moderate deformity of the breast, with an obvious difference in the shape and size of 
the treated breast. This change involves 1/4 or less of the breast. There can be moderate 
thickening or scar tissue of the skin and the breast and there may be obvious color changes. 
 
4   POOR: marked change in the appearance of the treated breast involving more than 1/4 of 
the breast tissue. The skin change may be obvious and detract from the appearance. Severe 
scarring and thickening of the breast which clearly alters its appearance may be present. In 
retrospect, the breast may have been better treated by a mastectomy. 
 
Please circle one (1) number for each of the following treatment effects. 
 
None 
Yes, present but does 
not affect cosmesis 
Yes, present and 
affects cosmesis 
Skin telangiectasia 
0 
1 
2 
Skin atrophy 
0 
1 
2 
Pigment change 
0 
1 
2 
Erythema 
0 
1 
2 
Fat necrosis 
0 
1 
2 
Fibrosis 
0 
1 
2 
Retraction or contour defect 
0 
1 
2 
Volume loss 
0 
1 
2 
Other significant tx effects 
Specify: _______________ 
0 
1 
2 

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APPENDIX III:  Patient Self-Assessment 
 
1.  Please assess the cosmetic outcome of your treatment.  (Circle the number next to the 
word that best describes the appearance of the breast.) 
 
1     Excellent - when compared to the untreated breast, there is minimal or no difference in the 
size, shape or texture of the treated breast. There may be mild thickening or scar tissue within 
the breast or skin, but not enough to change the appearance.  
 
2     Good - there is mild asymmetry in the size or shape of the treated breast as compared to 
the normal breast. The thickening or scar tissue within the breast causes only a mild change in 
the shape.  
 
3     Fair - there is obvious difference in the size and shape of the treated breast. This change 
involves 1/4 or less of the breast.  
 
4     Poor - marked change in the appearance of the treated breast involving more than ¼  of the 
breast tissue.  
 
2.   How satisfied with your treatment are you?   
Extremely satisfied 
 
Very Satisfied  
Satisfied 
Unsatisfied 
 
3.  Would you choose this treatment again?    
Yes  
 
 
No 
 
 

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12.  
APPENDIX IV:  Quality of Life 
 
Below is a list of statements that other people with breast cancer have said are important to their quality of life. 
Please indicate the extent to which you have experienced each of the following statements during the past 7 days 
by circling the appropriate number using the following scale.  
 
0 
1 
2 
3 
4 
not at all 
a little bit 
somewhat 
quite a bit 
very much 
 
During the past week: 
 
PHYSICAL WELL-BEING 
 
1. I have a lack of energy 
0 
1 
2 
3 
4 
 
2. I have nausea 
 
0 
 
1 
 
2 
 
3 
 
4 
 
3. Because of my physical condition, I have trouble meeting                             
the needs of my family 
 
 
 
0 
 
 
1 
 
 
2 
 
 
3 
 
 
4 
4. I have pain 
0 
1 
2 
3 
4 
 
5. I am bothered by side effects of treatment 
 
0 
 
1 
 
2 
 
3 
 
4 
 
6. I feel sick 
 
0 
 
1 
 
2 
 
3 
 
4 
 
7. I am forced to spend time in bed 
 
0 
 
1 
 
2 
 
3 
 
4 
 
 
SOCIAL/FAMILY WELL-BEING 
 
 
 
 
 
 
8. I feel close to my friends 
 
0 
 
1 
 
2 
 
3 
 
4 
 
9. I get emotional support from my family 
 
0 
 
1 
 
2 
 
3 
 
4 
 
10. I get support from my friends  
 
0 
 
1 
 
2 
 
3 
 
4 
 
11. My family has accepted my illness 
 
0 
 
1 
 
2 
 
3 
 
4 
 
12. I am satisfied with family communication about my                                     
illness 
 
 
 
0 
 
 
1 
 
 
2 
 
 
3 
 
 
4 
 
13. I feel close to my partner (or the person who is my main support) 
 
0 
 
1 
 
2 
 
3 
 
4 
 
14. I am satisfied with my sex life 
 
0 
 
1 
 
2 
 
3 
 
4 
 
 
 
 
 
 
 

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EMOTIONAL WELL-BEING 
 
15. I feel sad 
0 
1 
2 
3 
4 
 
16. I am proud of how I am coping with my illness 
 
0 
 
1 
 
2 
 
3 
 
4 
 
17. I am losing hope in the fight against my illness 
 
0 
 
1 
 
2 
 
3 
 
4 
 
18. I feel nervous 
 
0 
 
1 
 
2 
 
3 
 
4 
 
19. I worry about dying 
 
0 
 
1 
 
2 
 
3 
 
4 
 
20. I worry that my condition will get worse 
 
0 
 
1 
 
2 
 
3 
 
4 
 
 
FUNCTIONAL WELL-BEING 
 
 
 
 
 
 
21. I am able to work (include work at home) 
 
0 
 
1 
 
2 
 
3 
 
4 
 
22. My work is fulfilling (include work at home) 
 
0 
 
1 
 
2 
 
3 
 
4 
 
23. I am able to enjoy life 
 
0 
 
1 
 
2 
 
3 
 
4 
 
24. I have accepted my illness 
 
0 
 
1 
 
2 
 
3 
 
4 
 
25. I am sleeping well 
 
0 
 
1 
 
2 
 
3 
 
4 
 
26. I am enjoying the things I usually do for fun 
 
0 
 
1 
 
2 
 
3 
 
4 
 
27. I am content with the quality of my life right now 
 
0 
 
1 
 
2 
 
3 
 
4 
 
 
ADDITIONAL CONCERNS 
 
 
 
 
 
 
28. I have been short of breath 
 
0 
 
1 
 
2 
 
3 
 
4 
 
29. I am self-conscious about the way I dress 
 
0 
 
1 
 
2 
 
3 
 
4 
 
30. My arms are swollen or tender 
 
0 
 
1 
 
2 
 
3 
 
4 
 
31. I feel sexually attractive 
 
0 
 
1 
 
2 
 
3 
 
4 
 
32. I have been bothered by hair loss 
 
0 
 
1 
 
2 
 
3 
 
4 
 
33. I worry about the effect of stress on my illness 
 
0 
 
1 
 
2 
 
3 
 
4 
 
34. I am bothered by a change in weight 
 
0 
 
1 
 
2 
 
3 
 
4 
 
 
 
0 
1 
2 
3 
4 
not at all 
a little bit 
somewhat 
quite a bit 
very much 

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35. I am able to feel like a woman 
 
0 
 
1 
 
2 
 
3 
 
4 
APPENDIX V:  Digital Photographs 
The first photograph should be a close-up encompassing only the treated breast at a 45 degree 
oblique with arms elevated over the head. The second photograph should be a straight frontal 
view of both breasts taken in either a standing or seated position with the patient’s hands 
symmetrically placed on her hips, taking care to exclude her face and framing or focusing on 
both the treated and untreated breast to allow optimal comparison of the breasts for 
symmetry. 
 

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Appendix VI:  Blood Processing 
 
Blood collected pre and post treatment will be used to explore the biologic response to radiotherapy by 
comparing changes in circulating cell-free DNA expression pre and post-radiotherapy:   
 
cfDNA 
 
2 EDTA tubes will be collected prior to radiation and following radiation.  Following collection, 
plasma will be isolated with the following protocol.   
 
1. Spin blood at 3200xg for 12 minutes at room temperature. 
2. Pipette off plasma using a plastic pasteur pipette. Transfer into tube. 
3. Spin NEW plasma tube at 2000xg for 10 minutes at 4°C. 
4. Aliquot into 1ml aliquots in labelled cryovials. 
5. Store at -80°C. 
 
Plasma isolation will be performed in the Clinical Cancer Research Lab and stored as above for future 
biomarker analysis.   
 
Urine samples will be collected before and after treatment. Samples will be stored at -80oC until 
analyzed.  Four isomers of F2-isoprostanes – iPF(2alpha)-III; iPF(2 alpha)-VI; 8,12-iso-iPF(2 alpha)-VI; and 
2,3-dinor-iPF(2 alpha)-III – will be quantified by liquid chromatography-tandem mass spectrometry as 
funding permits.  Allantoin will be quantified using ultra performance liquid chromatography-tandem 
mass spectrometry.  Analysis will also include measuring the marker 8-hydroxydeoxyguanosine (8-
OHdG) levels by HPLC