Implementing Pharmacogenetic Testing in Gastrointestinal Cancers
Phase: NA
Conditions: Gastrointestinal Cancer
Sponsor: Abramson Cancer Center at Penn Medicine

 
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CLINICAL RESEARCH  
 
INVESTIGATIONAL 
PRODUCT(S): 
 
DPYD and UGT1A1 pharmacogenetic test  
STUDY 
NUMBER(S): 
IRB Number 
IRB #844763 (Original approval date 12/18/2020) 
Other Protocol 
Identifiers  
 
NCT 04736472 
UPCC 22220 
PROTOCOL(S) TITLE: 
ImpleMenting PhArmacogenetiC Testing 
in Gastrointestinal Cancers (IMPACT-GI) 
 
 
REGULATORY SPONSORS: 
 
University of Pennsylvania Institutional Review 
Board 
University of Pennsylvania Clinical Trials Scientific 
Review and Monitoring Committee  
FUNDING SPONSOR(S): 
University of Pennsylvania Penn Center for Precision 
Medicine 
 
 
ORIGINAL PROTOCOL DATE: 
30 November 2020 
VERSION NUMBER: 
v 6.0  
VERSION DATE: 
 16 May 16, 2024 
 
 

 
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1 Study Summary ....................................................................................................... 8 
1.1 Synopsis ................................................................................................................. 8 
1.3 Schema ................................................................................................................... 13 
2 Introduction and RationalE .................................................................................. 14 
2.1 Study Rationale ................................................................................................... 14 
2.2 Background ......................................................................................................... 14 
2.2.1 Description of intervention .............................................................................. 16 
3 Study Objectives and Endpoints ........................................................................... 17 
4 Study Plan .............................................................................................................. 18 
4.1 Study Design ....................................................................................................... 18 
4.2 Scientific Rationale for Study Design ................................................................. 18 
4.3 Study Intervention .............................................................................................. 19 
4.4 Dose Adjustments based on Genotype ............................................................... 19 
4.5 Plasma uracil measurements .............................................................................. 21 
4.6 Optional Microbiome Substudy ......................................................................... 21 
5 Study Population and Duration of participation .................................................. 22 
5.1 Inclusion Criteria ................................................................................................ 22 
5.2 Exclusion Criteria ............................................................................................... 22 
5.3 Screen Failures.................................................................................................... 22 
5.4 Participant recruitment ...................................................................................... 23 
5.5 Duration of study participation .......................................................................... 23 
5.6 End of Study Definition ...................................................................................... 24 
6 Study Intervention ................................................................................................. 24 
6.1 Study Intervention(s) Administration ................................................................ 24 
6.1.1 Study Intervention Description ....................................................................... 24 
6.1.2 Dosing and Administration.............................................................................. 24 
6.2 Study Intervention Compliance ......................................................................... 24 
6.3 Discontinuation of Study Intervention ............................................................... 25 
6.4 Participant Discontinuation/Withdrawal from the Study ................................. 25 
6.5 Lost To Follow-Up .............................................................................................. 25 
7 Study Assessment and Procedures ........................................................................ 27 
7.1 Informed Consent (Baseline) .............................................................................. 27 
7.2 Genotyping (0-14 days) ....................................................................................... 27 
7.3 Implementation Metrics (0-14 days) .................................................................. 27 
7.4 Baseline clinical data collection .......................................................................... 27 
7.5 Data collection at each chemotherapy infusion (time 0 to 6 months) ............... 28 
7.6 Patient Survey on attitudes towards pharmacogenetic testing (0-6 months).... 29 
7.7 Plasma uracil assay (PCAM only) ...................................................................... 29 
7.8 Optional Microbiome study (PCAM only)......................................................... 29 
8 Statistical plan........................................................................................................ 29 
8.1 Sample size .......................................................................................................... 29 
8.2 Overview of statistical methods .......................................................................... 30 
 

 
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8.2.1 Implementation Endpoint(s): .......................................................................... 30 
8.2.2 Secondary Endpoint(s): ................................................................................... 31 
8.2.3 Tertiary Endpoint(s): ....................................................................................... 31 
8.3 Microbiome analysis (optional sub-study) ......................................................... 32 
9 Safety and adverse events ...................................................................................... 33 
9.1 Adverse Events and Serious Adverse Events ..................................................... 33 
9.1.1 Definition of Adverse Events (AE) .................................................................. 33 
9.1.2 Definition of Serious Adverse Events (SAE) ................................................... 33 
9.1.3 Classification of an Adverse Event .................................................................. 34 
9.1.4 Time Period and Frequency for Event Assessment and Follow-Up............... 34 
9.1.5 Adverse Event Reporting................................................................................. 35 
9.1.6 Serious Adverse Event Reporting ................................................................... 35 
9.1.7 Reporting of Pregnancy ................................................................................... 36 
9.2 Unanticipated Problems ..................................................................................... 36 
9.2.1 Definition of Unanticipated Problems (UP) .................................................... 36 
10 Supporting Documentation and Operational Considerations ............................ 37 
10.1 Ethical Considerations ...................................................................................... 37 
10.2 Risk/Benefit Assessment ................................................................................... 37 
10.2.1 Known Potential Risks ................................................................................... 37 
10.2.2 Known Potential Benefits .............................................................................. 38 
10.2.3 Assessment of Potential Risks and Benefits .................................................. 38 
10.3 Informed consent .............................................................................................. 38 
10.4 Confidentiality and Privacy .............................................................................. 39 
10.5 Future Use of Stored Data ................................................................................ 39 
10.6 Source Documents............................................................................................. 40 
10.7 Case Report Forms ........................................................................................... 40 
10.8 Records retention .............................................................................................. 40 
10.8.1 Safety Oversight ................................................................................................ 41 
10.8.2 Clinical Monitoring ........................................................................................... 41 
10.8.3 Protocol Deviations ........................................................................................... 41 
10.9 Protocol Amendment History .............................................................................. 42 
11 STUDY FINANCES ............................................................................................. 44 
11.1 Funding Source ................................................................................................. 44 
11.2 Conflict of Interest ............................................................................................ 45 
11.3 Participant Payments ........................................................................................ 45 
12 Publication and data sharing plan ....................................................................... 45 
13 References ............................................................................................................. 45 
14 APPENDIX ........................................................................................................... 49 
14.1 Schedule of Activities (SoA).............................................................................. 49 
14.2 ECOG Performance Status .............................................................................. 51 
14.3 NCI-CTCAE version 5.0 ................................................................................... 51 
14.4 Medication information .................................................................................... 52 

 
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14.4.1 Clinical Pharmacology of 5-FU, capecitabine and irinotecan ...................... 52 
14.4.2 Drug Interactions for 5-FU, capecitabine and irinotecan............................. 54 
14.4.3 Clinical Adverse Event Profile ...................................................................... 55 
14.5 Pharmacogenetic test validation reports (to be attached) ............................... 57 
14.6 Data collection tool for chemotherapy-related adverse events and patient 
reported outcomes (to be attached) ................................................................. 57 
14.7 Participant survey – Pharmacogenetic testing (to be attached) ...................... 57 
14.8 Stool collection kit instructions for optional microbiome substudy (to be 
attached) ........................................................................................................... 57 
14.8.1 Bristol Stool Chart for optional microbiome substudy (to be attached) ...... 57 
 
 
 

 
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PRINCIPAL INVESTIGATOR SIGNATURE 
 
STUDY 
SPONSOR: 
Penn Center for Precision Medicine 
Perelman School of Medicine 
University of Pennsylvania 
STUDY TITLE: 
ImpleMenting PhArmacogenetiC Testing in Gastrointestinal Cancers 
(IMPACT-GI) 
STUDY ID 
PROTOCOL 
VERSION 
 844763v 6.0 
I have read the referenced protocol. I agree to conduct the study in accordance to this protocol, in 
compliance with the Declaration of Helsinki, Good Clinical Practices (GCP), and all applicable 
regulatory requirements and guidelines. 
Principal 
Investigator Name: 
Sony Tuteja, PharmD, MS 
 
Signature 
 
Affiliation: 
4249 - DM-Translational 
Medicine and Human 
Genetics 
 
Date 
 
Co-Investigator: 
 
 
Signature 
 
Affiliation: 
 
 
Date 
 
Co-Investigator: 
Ursina Teitelbaum, MD 
 
 
 
Affiliation: 
Division of Oncology 
 
 
 
 

 
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Abbreviations 
5-FU 
Fluorouracil 
ACC 
Abramson Cancer Center  
AE 
Adverse Event 
CAG 
Center for Applied Genomics  
CHOP 
Children’s Hospital of Philadelphia 
CLIA 
Clinical Laboratory Improvement Amendments 
CDS 
Clinical Decision Support 
CRF 
Case Report Form 
DPYD 
Dihydropyrimidine dehydrogenase 
EHR 
Electronic Health Record 
eCRF 
Electronic Case Report Forms 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GI 
Gastrointestinal 
HIPAA 
Health Insurance Portability and Accountability Act  
HrQoL 
Health Related Quality of Life  
HUP 
Hospital of the University of Pennsylvania  
IB 
Investigator’s Brochure 
ICER 
Incremental Cost-Effectiveness Ratio 
IDE 
Investigational Device Exemption 
IRB 
Institutional Review Board 
NCI-CTCAE 
National Cancer Institute Common Terminology Criteria for Adverse Events 
NCT 
National Clinical Trial 
NIH  
National Institutes of Health 
OHRP 
Office for Human Research Protections 
OS 
Overall survival 
PCAM 
Perelman Center for Advanced Medicine  
PMBB 
Penn Medicine Biobank 
PHI 
Protected Health Information  
PPMC 
Penn Presbyterian Medical Center 
PI 
Principal Investigator 

 
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PGx 
Pharmacogenetic 
PFS 
Progression-free survival 
QA 
Quality Assurance 
QC 
Quality Control 
QALY 
Quality-Adjusted Life Years 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SoA 
Schedule of Activities 
SOC 
System Organ Class 
SOP 
Standard Operating Procedure 
TAT 
Turnaround time  
UGT1A1 
Uridine diphosphate-glucuronosyltransferase isoform 1A1 
US 
United States 
WHO / ECOG 
World Health Organization / Eastern Cooperative Oncology Group 

 
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1 STUDY SUMMARY 
1.1 
Synopsis 
Title:  
ImpleMenting PhArmacogenetiC Testing in Gastrointestinal Cancers  
Short Title: 
IMPACT-GI 
Study 
Description:  
Pharmacogenetic (PGx) variants in the DPYD and UGT1A1 genes are 
associated with fluoropyrimidines and irinotecan induced adverse events. 
However, testing for these variants is not routinely performed in clinical 
practice prior to the initiation of chemotherapy due to lack of a clinical 
assay with rapid turnaround time (TAT) and challenges in integrating 
genetic test results within the electronic health record (EHR). We 
hypothesize that providing clinicians with the ability to order rapid 
turnaround PGx test results along with specific dosing recommendations 
will increase the utilization of PGx tests to guide pharmacotherapy 
decisions and improve patient drug related outcomes. This is a non-
randomized implementation study to determine the feasibility of 
establishing and integrating a PGx test into clinical care to guide 
chemotherapy in patients with gastrointestinal (GI) cancers. Effectiveness 
of the PGx-guided approach will be determined by comparing the 
incidence of severe treatment related adverse events  to historical control 
group of GI cancer patients enrolled into the Penn Medicine Biobank 
(PMBB).  
Objectives:  
Implementation Aims: 
1. To determine the feasibility of returning PGx results prior to the 
first dose of chemotherapy. 
2. To determine the fidelity to the PGx guided dosing 
recommendations. 
3. To determine the rate of testing among providers with patients 
eligible for testing  
Effectiveness Aims: 
4. To determine if providing PGx test results will decrease the 
number of patients severe treatment related events during the first 
six cycles of chemotherapy. 

 
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5. To determine if providing PGx test results will improve patient 
reported outcomes (PRO) during the first six cycles of 
chemotherapy. 
Primary 
Endpoint:  
1. The proportion of PGx test results returned prior to the first dose 
of chemotherapy. [Time Frame: 14 days] 
2. The proportion of dose modifications made in agreement with the 
genotype guided dosing recommendations at the first dose. [Time 
Frame: 14 days] 
3.  The proportion of tests ordered compared to the number of 
patient with eligible for testing. [Time Frame: 14 days] 
Secondary 
Endpoints: 
 
1. The proportion of patients experiencing  severe treatment related 
adverse events (TRAEs) over the first six cycles of chemotherapy.  
[Time Frame: 6 cycles] 
2. The relative dose intensity of 5-FU and irinotecan dosing over the 
first six cycles. [Time Frame: 6 cycles] 
3. Patient reported outcomes (PROs) during the first six cycles of 
chemotherapy. [Time Frame: 6 cycles] 
4. Patient knowledge about and attitudes towards PGx. [Time 
Frame: 6 months] 
5. The incidence of patients of African ancestry experiencing 
TRAEs over the first six cycles of chemotherapy. [Time Frame: 6 
cycles] 
6. The frequency of actionable DPYD and UGT1A1 in various 
ancestry groups. [Time Frame: 6 months] 
7. PFS and OS in patients after genotyping [Time Frame: 6 + 2 
months] 
8. The costs of PGx-guided chemotherapy [Time Frame: 6 cycles] 
Study 
Population: 
Inclusion criteria 
1. Male and female subjects, 18 years or older at time of study 
2. Pathologically confirmed gastrointestinal malignancy for which 
treatment with a fluoropyrimidine and/or irinotecan is indicated 
3. Able and willing to provide informed consent 
4. Willing to undergo blood or saliva sampling for PGx testing and 
comply with all study-related procedures 
5. Life expectancy of at least 6 months 
Exclusion criteria 
1. Prior treatment with irinotecan 
2. DPYD or UGT1A1 genotype already known 

 
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3. Severe renal or hepatic impairment (or unacceptable laboratory 
values) 
4. Women who are pregnant or breast feeding, or subjects who 
refuse to use reliable contraceptive methods throughout the study 
5. Treating physician does not want subject to participate  
Phase: 
N/a 
Description of 
Sites/Facilities  
Penn Medicine sites: 
1. Perelman Center for Advanced Medicine (PCAM)  
2. Penn Presbyterian Medical Center (PPMC)  
3. Lancaster General Hospital (LGH)  
Enrolling 
Participants: 
Approximately 500-800 participants will be enrolled across the Penn 
Medicine sites.  
Description of 
Study 
Intervention: 
Genetic: DPYD and UGT1A1 genotyping 
 
The study utilizes a lab developed test (Center for Applied Genomics 
(CAG), Children’s Hospital of Philadelphia, PA) performed in a  Clinical 
Laboratory Improvement Amendments (CLIA) environment that provides 
identification of a patient’s genotype determined from genomic DNA 
from a blood or saliva sample with a turnaround time of seven business 
days. The alleles identified and reported include DPYD*2A, *5, *6, *8, 
*9A, *10, *12, *13, rs2297595, rs115232898, rs67376798, HapB3 
(rs75017182, rs56038477, rs56276561) and UGT1A1*6, *28. 
This is a nonrandomized, prospective, open label study. Patients with 
gastrointestinal cancers that will be initiated on chemotherapy with 5-
fluorouracil (5-FU), capecitabine, or irinotecan will be consented to 
undergo the PGx test. The PGx test order will be placed by the medical 
oncologist; a blood or saliva sample will be obtained by the phlebotomist 
and sent to CAG for genotyping. Results will be returned in the Precision 
Medicine tab in PennChart. For patients with an actionable genotype 
(variants that would require a dose adjustment of 5-FU, capecitabine or 
irinotecan), clinical decision support (CDS) tools will alert the ordering 
oncologist of the PGx result and the recommended dose adjustment. The 
prescribing oncologist will ultimately decide the chemotherapy dose 
incorporating clinical and/or genetic factors.  
Study Duration: 
2 years 

 
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Participant 
Duration: 
6 months 

 
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Key Roles and Study Governance 
 
Sponsor  
University of Pennsylvania  
Name, degree, title 
Sony Tuteja, PharmD, MS 
Research Assistant Professor of Medicine Director, Pharmacogenomics, Penn 
Medicine Center for Genomic Medicine  
 
Institution Name 
University of Pennsylvania Perelman School of Medicine 
Department of Medicine 
Division of Translational Medicine and Human Genetics 
Address 
3400 Spruce Street 
Maloney Bldg, Room 9013 
Philadelphia, PA 19104-6160 
 
Phone Number 
215-615-8785 
 
Email 
sonyt@pennmedicine.upenn.edu 
 
 

 
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1.3 Schema 
 
 
 
 
 
 
 
 
 
  
Time 0 to 6 months 
 
 
 
 
 
 
 
Time 6 + 2  months  
Total 500-800:  Screen potential participants by inclusion and exclusion criteria 
Obtain informed consent 
Endpoints collected prospectively and/or from medical records for 6 months: 
chemotherapy induced toxicity, grade of toxicity, chemotherapy dose and dose 
reductions, hospitalization rates, reasons for hospitalization, patient reported 
outcomes 
Baseline medical history  
Chemotherapy regimen and dose selected by oncologist 
Agreement to the PGx guided recommendations 
PGx test turn-around time (TAT) 
The rate of testing among providers 
• 
Order PGx test 
• 
Results returned in 
EPIC 
Intervention 
Patient questionnaire regarding attitudes towards PGx testing 
Progression-free survival and overall survival 

 
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2 INTRODUCTION AND RATIONALE 
2.1 
Study Rationale 
There are known pharmacogenetic (PGx) variants in the DPYD and UGT1A1 genes associated 
with altered drug metabolism and prolonged drug exposure resulting in drug-related adverse 
events from fluoropyrimidine and irinotecan therapy. Testing for these variants is not performed 
in routine practice due to barriers in clinical implementation. These obstacles include a lack of 
rapid turnaround times of genotype results to impact clinical care, a lack of a standardized format 
for the return of test results in the electronic health record, inexperience of clinicians on 
interpreting and acting on PGx information, a limited number of prospective, randomized 
genotype-guided clinical outcomes trials, as well as cost considerations and reimbursement. We 
will conduct a non-randomized implementation study to determine the feasibility of establishing 
and integrating a PGx test into clinical care to guide chemotherapy in patients with 
gastrointestinal (GI) cancers. Effectiveness of the PGx guided approach will be determined by 
comparing the incidence of severe TRAEsto historical control group of GI cancer patients 
enrolled into the Penn Medicine Biobank (PMBB).  
2.2 
Background 
Standard first-line systemic chemotherapy for most gastrointestinal malignancies consists of a 
fluoropyrimidine [intravenous 5-fluorouracil (5-FU) or oral capecitabine] in combination with 
irinotecan, oxaliplatin, and/or targeted agents. A unique subset of patients is at an increased risk 
of developing severe, chemotherapy-related adverse events from fluoropyrimidines and 
irinotecan due to germline variants in the DPYD (dihydropyrimidine dehydrogenase) and 
UGT1A1 (uridine diphosphate-glucuronosyltransferase isoform 1A1) genes, respectively.  
Up to 30% of patients develop severe fluoropyrimidine-related toxicity, such as diarrhea, hand-
foot syndrome, mucositis, and myelosuppression at standard doses.1 These events can be fatal in 
1% of treated patients.1 Similarly, as many as 20-35% of patients treated with irinotecan may 
experience severe toxicities, ranging from diarrhea to myelosuppression.2 Given the life-
threatening nature of severe adverse events, hospitalizations are often indicated which result in 
additional resource utilization costs. Subsequently, chemotherapy-related adverse events often 
lead to treatment delays or discontinuations that may impact tumor prognosis.  
The DPYD gene encodes dihydropyrimidine dehydrogenase, or DPD, the metabolic enzyme 
responsible for the catabolism of 5-FU and capecitabine. A partial DPD enzyme deficiency is 
present about 3-5% of individuals of European ancestry while complete deficiency occurs less 
frequently at a rate of 0.2%.3 Four clinically relevant DPYD variants in European ancestry 
individuals and one clinically relevant DPYD variant in African ancestry individuals have been 
identified as resulting in a reduction of DPD enzyme activity of 25 to 50%.1,3-5 These variants 

 
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include *2A (c.1905+1G>A, rs3918290), *13 (c.1679T>G, rs55886062), c.2846A>T 
(rs67376798), and HapB3 (c.1129-5923C>G, rs75017182; c.1236G>A, rs56038477), and 
c.557A>G (rs115232898). Genetic variants associated with reduced UGT1A1 enzyme activity 
include UGT1A1*28 (rs8175347), *6 (rs4148323) (Table 1).6,7 
 
Table 1. Actionable pharmacogenetic variants impacting response to chemotherapy  
Gene 
Variant 
MAF 
Allele Function1,6 
Haplotype 
Nucleotide change 
Protein change 
rsID 
EA 
AA 
DPYD 
*2A 
c.1905+1G>A 
- 
rs3918290 
0.008 
0.003 
No function 
*8 
c.703C>T 
R235W 
rs1801266  
0.0001 
NR 
No function 
*10 
c.2983G>T 
V995F 
rs1801268  
NR 
NR 
No function 
*12 
c.1156G>T 
E386X 
rs78060119  
NR 
NR 
No function 
*13 
c.1679T>G 
I560S 
rs55886062 
0.001 
0.000 
No function 
HapB3 
c.1236G>A 
E412E 
rs56038477 
0.024 
0.003 
Decreased function 
c. 1129-5923C>G 
- 
rs75017182 
Decreased function 
c.483+18G>A 
- 
rs56276561  
Decreased function 
 
c.557A>G 
Y186C 
rs115232898 
0.0001 
0.012 
Decreased function 
 
c.2846A>T 
D949V 
rs67376798 
0.004 
0.003 
Decreased function 
UGT1A1 
*6 
c.211G>A  
G71R 
rs4148323 
0.008 
0.004 
Decreased function 
*28 
c.-41_-40dupTA(TA7) 
- 
rs8175347 
0.316 
0.373 
Decreased function 
 
MAF minor allele frequency, EA European ancestry, AA African ancestry 
The NIH-funded Clinical Pharmacogenetics Implementation Consortium, which issues evidence-
based peer-reviewed guidelines on clinically actionable PGx variants, recommends a 50% dose 
reduction in individuals with one reduced function allele (intermediate metabolizers) and 
avoidance of therapy in those with two reduced function alleles (poor metabolizers).1 Recent 
studies have shown that preemptive genotyping for DPYD variants can significantly reduce 
drug-related adverse events and improve patient safety.8-10 In a 2018 multicenter European study, 
Henricks et al. demonstrated the feasibility of prospective genotype-guided fluoropyrimidine 
dosing in clinical practice. When comparing the safety outcomes in dose-reduced variant carriers 
to a historical control given the standard dose, severe toxicity was found to be higher in the 
standard dose population (39% vs. 23%, p=0.0013). 9 A study conducted by Kleinjan et al. in 
2019 further supports the practice of DPYD genotype-guided dosing, demonstrating that 
performing initial dose reductions of capecitabine in heterozygous DPYD variant carriers 
followed by tolerance-based dose escalation did not lead to higher toxicity compared to patients 
of wild-type status (37.9% vs. 27.3%, p=0.54). 10 There are few studies directly investigating the 
decreased function c.557A>G variant with evidence currently limited to case reports.5  
The FDA drug labeling for irinotecan recommends approximately a 20-40% reduction in the 
starting dose in UGT1A1 *28/*28 homozygous individuals (poor metabolizers) to avoid 
hematological toxicity.11 The Dutch Pharmacogenetics Working Group from the Royal Dutch 
Pharmacists Association recommends an initial dose reduction of 30% in poor metabolizers, with 
subsequent dose escalation guided by patient tolerance and neutrophil counts.12 A 2007 meta-
analysis by Hoskins et al. evaluating a variety of irinotecan-containing regimens found that 

 
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UGT1A1*28 genotyping would be likely to improve rates of severe neutropenia in homozygous 
patients given high doses of irinotecan (>250 mg/m2) (OR 27.8, p=0.05).13 A subsequent 2010 
meta-analysis by Hu et al. reported that the same genotype was also associated with an increased 
risk of neutropenia at doses of 150 mg/m2 to 250 mg/m2 (RR 2.0, p<0.01) and at lower doses 
(<150 mg/m2) (RR 2.4, p<0.01).14 
 
DPYD genotyping has suboptimal sensitivity and positive predictive value (PPV), because DPD 
activity is also impacted at the post-transcriptional level, thus alternative methods have been 
proposed to identify those at risk for fluoropyrimidine-associated toxicity.15 Measuring DPD 
activity is one option, but it is technically and logistically challenging to perform in a clinical 
setting.16 Another method that is being investigated is the measurement of pre-treatment uracil.15 
DPD converts its endogenous substrate uracil into dihydrouracil (DHU). In one study, pre-
treatment uracil was found to be superior to the DHU/uracil ratio as a predictor of severe toxicity 
and high pre-treatment uracil concentrations were strongly associated with overall severe toxicity 
(odds ratio 5.3, p=0.009) severe GI toxicity (OR33.7, p<0.0001), toxicity related hospitalization 
(OR 16.9, p<0.0001), and fatal treatment-related toxicity (OR 44.8, p=0.001).15 In addition, 
genotyping DPYD variants together with the assessment of uracil concentrations improved the 
predictive accuracy of fluoropyrimidine associated toxicity. This study was done in a European 
population and the dynamic range of uracil needs to be confirm in a more ethnically diverse 
population as seen within Penn Medicine. Within the current study we will collect a pretreatment 
plasma sample to retrospectively examine the association of uracil concentrations with 
fluoropyrimidine associated toxicity within our patient population. 
2.2.1 
Description of intervention 
The study utilizes a laboratory developed test for PGx variants in DPYD and UGT1A1, 
performed in a CLIA environment and provides identification of a patient’s genotype determined 
from genomic DNA from a blood or saliva sample (See Section 6.6.1 Study Intervention 
Description and Appendix 14.5 Validation Reports).  
 

 
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3 STUDY OBJECTIVES AND ENDPOINTS 
Hypothesis: 
Providing clinicians with the ability to order a PGx test with a rapid turnaround time for results, 
along with specific dosing recommendations, will increase the utilization of PGx tests to guide 
pharmacotherapy decisions and improve patient drug related outcomes. 
OBJECTIVES 
ENDPOINTS 
Primary 
 
1. To determine the feasibility of returning PGx 
results prior to the first dose of chemotherapy 
2. To determine the fidelity to the PGx guided dosing 
recommendations. 
3. To determine the rate of testing among providers 
with patients eligible for testing  
1. The proportion of tests returned prior to the first 
determined dose of chemotherapy.  
2. The proportion of dose modifications made in 
agreement with the genotype guided dosing 
recommendations at the first dose. 
3. The proportion of tests ordered compared to the 
number eligible for testing.  
Secondary 
 
1. To determine if providing PGx test results will 
decrease the number of patients experiencing 
severe treatment related adverse event (TRAEs)  
during the first six cycles of chemotherapy. 
2. To determine the relative dose intensity of 5-FU 
and irinotecan administered to each patient over 
the first six cycles. 
3. To determine if providing PGx test results will 
improve patient reported outcomes (PRO) during 
the first cycles of chemotherapy. 
4. To assess patient attitudes towards PGx. 
1. The proportion of patients severe TRAEs during 
the first six cycles of chemotherapy. 
2. The relative dose intensity will be calculated as the 
cumulative administered dose divided by the 
anticipated cumulative dose over six cycles 
reported as mg/m2 
3. Patient reported outcomes (PROs) during the first 
six cycles of chemotherapy as assessed on a Likert 
scale. 
4. Patient knowledge about and attitudes towards 
PGx testing as assessed on a Likert scale. 
Tertiary 
 
1. To determine if chemotherapy-induced toxicity 
differs by ancestry group. 
2. To determine the frequency of actionable DPYD 
and UGT1A1 in various ancestry groups. 
3. To determine if PGx testing influences 
progression-free (PFS) and overall survival (OS).  
4. To determine the cost-effectiveness of PGx guided 
chemotherapy dosing. 
5. To determine the association of pre-treatment 
plasma uracil concentrations with severe (Grade 3 
to 5) fluoropyrimidine induced toxicity with the 
first dose.  
1. The proportion of patients experiencing a serious 
treatment relate adverse event during the first six 
cycles of chemotherapy stratified by self-reported 
ancestry. 
2. Minor allele frequency of variants in DPYD and 
UGT1A1 reported by self-reported ancestry. 
3. PFS and OS in patients at 6 + 2  months. 
4. Means and variances of cost in the genotype-
guided group as compared to the historical control 
group (Costs of hospitalizations, treatment, PGx 
test, medical services)  
5. Pre-treatment plasma uracil concentrations as 
measured by HPLC. 

 
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OBJECTIVES 
ENDPOINTS 
Optional Microbiome Substudy at PCAM only 
1. To determine whether the microbiome 
composition impacts the occurrence of 
chemotherapy-induced adverse events 
1. The change in bacterial abundance as measured by 
operational taxonomic units (OTUs) 
2. The change in bacterial composition or beta 
diversity as measured by weighted UniFrac 
distance 
4 STUDY PLAN 
4.1 
Study Design 
This is a non-randomized, prospective, open-label implementation study to determine the 
feasibility of establishing and integrating a PGx test into clinical care. The effectiveness aims 
will be assessed by comparing toxicity outcomes using a historical control group without clinical 
genotyping. The implementation will be deployed across cancer care sites within Penn medicine 
in sequential fashion, starting with PCAM followed by PPMC, and LGH. 
Patients with a GI malignancy initiating chemotherapy with a fluoropyrimidine (5-FU or 
capecitabine) and/or irinotecan will be consented to undergo DPYD and UGT1A1 genotyping, 
the study intervention. The PGx test order will be placed by the research coordinator and signed 
by the medical oncologist; a blood sample will be obtained by the phlebotomist, or saliva self-
collected by the patient in clinic, and sent to CAG for genotyping. Results will be returned in the 
Precision Medicine tab in PennChart. For patients with an actionable genotype (variants that 
would require a dose adjustment of 5-FU, capecitabine or irinotecan), clinical decision support 
(CDS) tools will alert the ordering oncologist of the PGx result and the recommended dose 
adjustment. The prescribing oncologist will ultimately decide the chemotherapy dose 
incorporating clinical and genetic factors. The efficacy and safety of this PGx-guided approach 
will be determined by comparing the incidence of severe treatment related adverse events  to a 
historical control group of GI cancer patients enrolled into PMBB. 
4.2 
Scientific Rationale for Study Design 
This is primarily an implementation study to determine the feasibility of incorporating PGx 
testing as part of clinical care. Secondarily, we will use a historical control of GI cancer patients 
enrolled into PMBB to determine the safety and effectiveness of genotype-guided chemotherapy 
dosing. We performed qualitative interviews of 16 GI oncologists within Penn Medicine, and 6 
(38%) stated that it would be unethical to randomize patients who may be carrying these variants 
to receive full-dose chemotherapy that could result in severe life-threatening toxicity. Five of the 
10 oncologists supported study randomization, but as a clinician acknowledged the challenges in 
consenting a sufficient number of patients to undergo randomized PGx testing as this study 
design is not typically viewed favorably from the patient perspective.  

 
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4.3 
Study Intervention 
The study utilizes a laboratory developed test performed in a CLIA environment for determining 
PGx variants in DPYD and UGT1A1 from genomic DNA isolated from a blood or saliva sample 
(see section 6.1.1 and Appendix 14.5 Validation Reports).  
4.4 
Dose Adjustments based on Genotype 
Genotype-guided dose recommendations will be made according to peer-reviewed, evidence-
based clinical guidelines from the NIH-funded Clinical Pharmacogenetics Implementation 
Consortium (CPIC) for 5-FU and capecitabine and the Dutch Pharmacogenetics Working Group 
(DPWG) for irinotecan (refer to Tables 2 and 3).3,12  
Table 2. Genotype-guided dosing recommendations 
Drug(s) 
Gene 
Genotype 
Gene 
Activity 
Score* 
Phenotype 
Clinical Implication 
Dose Recommendation 
5-FU, 
capecitabine 
DPYD 
See Table 
3 below 
2 
Normal 
Metabolizer 
Patient is predicted to have a 
normal risk of toxicity when 
treated with 5-FU or 
capecitabine. 
Initiate 5-FU or 
capecitabine at the standard 
dose. 
1.5 
Intermediate 
Metabolizer 
Patient is predicted to have 
an increased risk of severe 
toxicity when treated with 5-
FU or capecitabine. 
Reduce starting dose by 
50% followed by dose 
titration based on toxicity. 
5-FU Bolus: if standard 
dose is 400 mg/m2, consider 
200 mg /m2 
5-FU CIV: If standard dose 
is 2400 mg/m2, consider 
1200 mg/m2  
Capecitabine: If standard 
dose is 1000-1250 mg/m2, 
consider 500-625 mg/m2 

 
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1 
Intermediate 
Metabolizer 
Patient is predicted to have 
an increased risk of severe 
toxicity when treated with 5-
FU or capecitabine. 
Reduce starting dose by 
50% followed by dose 
titration based on toxicity. 
5-FU Bolus: if standard 
dose is 400 mg/m2, consider 
200 mg /m2 
5-FU CIV: If standard dose 
is 2400 mg/m2, consider 
1200 mg/m2  
Capecitabine: If standard 
dose is 1000-1250 mg/m2, 
consider 500-625 mg/m2 
0.5 
Poor 
Metabolizer 
Patient is predicted to have 
an increased risk of severe 
toxicity when treated with 5-
FU or capecitabine. 
Avoid use of 5-FU or 
capecitabine-based 
regimens. If alternative 
agents not considered a 
suitable option, 5-FU should 
be administered at a 
strongly reduced dose (i.e. 
<25% of normal starting 
dose) with early therapeutic 
drug monitoring.  
0 
Poor 
metabolizer 
Patient is predicted to have 
an increased risk of severe 
toxicity when treated with 5-
FU or capecitabine. 
Avoid use of 5-FU or 
capecitabine-based 
regimens. 
Irinotecan, 
Liposomal 
irinotecan 
UGT1A1 
*1/*1 
N/A 
Normal 
Metabolizer 
Patient is predicted to have a 
normal risk of toxicity when 
treated with irinotecan. 
Initiate irinotecan at the 
standard dose. 
*1/*28 
*1/*6 
N/A 
Intermediate 
Metabolizer 
Patient is predicted to have a 
normal risk of toxicity when 
treated with irinotecan. 
Initiate irinotecan at the 
standard starting dose. 
*28/*28 
*6/*6 
*6/*28 
N/A 
Poor 
Metabolizer 
 
Patient is predicted to have 
an increased risk of severe 
toxicity when treated with 
irinotecan. 
Irinotecan: 
Reduce starting dose by 
30%. If tolerated, increase 
dose based on the neutrophil 
count.  
Liposomal irinotecan:  
Initiate 50 mg/m2 IV over 
90 minutes. Increase to 70 
mg/m2 IV as tolerated in 
subsequent cycles. 

 
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Table 3. DPYD activity scoring system 
 
DPYD Allele/rsID 
*Activity Value 
Allele Function 
*1 
1 
Normal 
*2A 
0 
None 
*5 
1 
Normal 
*6 
1 
Normal 
*8 
0 
None 
*9A 
1 
Normal 
*10 
0 
None 
*12 
0 
None 
*13 
0 
None 
HapB3 (rs75017182, rs56038477, rs56276561) 
0.5 
Decreased 
rs115232898 
0.5 
Decreased 
rs67376798 
0.5 
Decreased 
rs2297595 
1 
Normal  
Calculating a DPYD activity score 
1. An activity score is used to interpret DPYD genetic test results and assign phenotypes. 
2. Each DPYD variant allele is assigned a value according to its enzyme function: 1 for normal 
function, 0.5 for decreased function, and 0 for no function (or minimal DPD activity). The Allele 
Functionality table can be found at https://cpicpgx.org/guidelines/guideline-for-
fluoropyrimidines-and-dpyd to assign values to alleles.  
3. The activity score is then calculated as the sum of the two DPYD variants with the lowest variant 
activity score to correspond to a phenotype. 
Example: A patient’s DPYD PGx test results are reported as DPYD *1/*2A. The *1 allele has a value 
of 1 and *2A allele has a value of 0, so the sum of these would yield an activity score of 1. This 
patient would then be classified as being an intermediate metabolizer. 
4.5 
Plasma uracil measurements 
A 5 mL venous blood sample for measurement of plasma uracil will be collected in EDTA tubes 
from during the baseline visit if time and resources permit. After collection the blood sample will 
be kept on ice (2-4 °C) and processed to plasma in a timely fashion (processing to begin within 1 
hour of sample procurement) as described below under section 7.7. 
4.6 
Optional Microbiome Substudy 
Participants consenting to the optional microbiome substudy will provide two stool samples, one 
at baseline and a second sample anytime during the 6-month study period. Participants will be 
provided with collection materials, packaging and instructions for collecting the stool at home 
and bringing it to usual clinic visits.  

 
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5 STUDY POPULATION AND DURATION OF PARTICIPATION 
5.1 
Inclusion Criteria 
In order to be eligible to participate in this study, an individual must meet all of the following 
criteria: 
1. Able and willing to provide informed consent 
2. Male or female, aged 18 years or older at the time of study initiation  
3. Pathologically confirmed gastrointestinal malignancy for which treatment with a 
fluoropyrimidine and/or irinotecan is indicated 
4. Willing to undergo blood or saliva sampling for PGx testing and comply with all study-
related procedures 
5. Life expectancy of at least 6 months 
5.2 
Exclusion Criteria 
An individual who meets any of the following criteria will be excluded from participation in this 
study: 
Exclusion criteria 
1. Prior treatment with irinotecan 
2. DPYD or UGT1A1 genotype already known 
3. Severe renal or hepatic impairment (or unacceptable laboratory values), including:  
• Neutrophil count of <1.5 x 109/L, platelet count of <100 x 109/L 
• Hepatic function as defined by serum bilirubin >1.5 x upper limit of normal 
(ULN), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) 
>2.5 x ULN, or in case of liver metastases ALT and AST>5 x ULN 
• Renal function as defined by serum creatinine >1.5 x ULN, or creatinine 
clearance <60 ml/min (by Cockcroft-Gault Equation) 
4. Women who are pregnant or breast feeding, or subjects who refuse to use reliable 
contraceptive methods throughout the study 
5. Treating physician does not want subject to participate 
5.3 
Screen Failures 
Screen failures in this study will be defined as participants who meet criteria for study 
enrollment but decline to participate or the treating oncologist declines participation of their 
patient in the study. A minimal set of screen failure information is required to ensure transparent 
reporting of screen failure participants, to meet the Consolidated Standards of Reporting Trials 
(CONSORT) publishing requirements and to respond to queries from regulatory authorities. 
Minimal information includes demography, screen failure details, and eligibility criteria. 

 
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5.4 
Participant recruitment 
Approximately 1000 cases of GI cancer are treated annually at PCAM, 150 cases at PPMC, and 
200 at LGH. Roughly 100 unique patients receive fluoropyrimidine and/or irinotecan-based 
chemotherapy regimen in a typical month at the PCAM GI cancer clinic. Based on the frequency 
of DPYD and UGT1A1 variants and the number of GI cancer patients seen within Penn 
Medicine, we anticipate that testing 500-800 patients in this multisite study would result in 45-70 
patients with the actionable genotypes (see Table 4). Approximately 20% of the GI cancer 
population at Penn Medicine is of African ancestry. All recruitment will be done through the 
Penn cancer centers and treating oncologists. Clinic schedules will be screened by the clinical 
research coordinator for new patients with GI cancer being evaluated for treatment. Prior to the 
scheduled visit, the research coordinator will notify the treating oncologist about potential 
eligible participants and remind them of the study. The treating oncologist will discuss the study 
with the patient during the evaluation visit and consent will be obtained by the treating GI 
oncology provider (physician or advanced practice provider) or the research coordinator. This 
will occur in person or by remote consent. Patients will be given a copy of the official informed 
consent form and an opportunity to ask questions. Patients will be given sufficient time to 
consider participating in the trial.  
Participants who complete the patient questionnaire regarding attitudes towards PGx testing will 
receive a $25 gift card. The Greenphire ClinCard will be used to disburse funds and mailed to the 
patient.  
Women of childbearing potential who are pregnant or breastfeeding will not be recruited into this 
study due to the risk of fetal harm caused by exposure to 5-FU, capecitabine, or irinotecan and 
the potential for serious adverse reactions in breastfed infants. A pregnancy test is not routinely 
performed in these patients at Penn Medicine thus will not be included as a study procedure.  
Table 4. Anticipated study initiation and estimated participant accrual across sites 
Calendar year  
Site  
Q1 2021 
Q2 2021 
Q3 2021 
Q4 2021 
Q1 2022 
Site totals 
PCAM (20/mo) 
60 
60 
60 
60 
 
240 
PPMC (10/mo) 
 
30 
30 
30 
30 
120 
LGH (20/mo) 
 
60 
60 
60 
60 
240 
Total  
 
 
 
 
 
600 
5.5 
Duration of study participation 
Total involvement for each participant will be 6 months. 

 
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5.6 
End of Study Definition 
A participant is considered to have completed the study if he or she has completed all phases of 
the study including the last visit or the last scheduled procedure shown in the Schedule of 
Activities (SoA), Appendix Section 14.1. 
6  STUDY INTERVENTION 
6.1 
Study Intervention(s) Administration 
6.1.1 
Study Intervention Description 
This study will utilize a laboratory developed test for PGx variants in DPYD and 
UGT1A1performed in a CLIA-approved environment. Samples will be genotyped using the 
Infinium Global Screening Array v2 (Illumina, San Diego, CA), a genome-wide genotyping 
array that contains PGx variants. Genotyping will be performed on Illumina’s iScan System at 
CAG at CHOP. The DPYD SNPs of interest *2A (rs3918290), *5 (rs1801159), *6 (rs1801160), 
*8 (rs1801266), *9A (rs1801265), *10 (rs1801268), *12 (rs78060119), *13 (rs55886062), 
rs2297595, rs115232898, rs67376798, HapB3 (rs75017182, rs56038477, rs56276561) and 
UGT1A1 SNPs *6 (rs4148323) and *28 (rs8175347) will be extracted from the array data. 
The UGT1A1*28 SNP contains a (TA) tandem repeat. Samples will undergo a PCR-based assay 
for amplification and fragment analysis. In the validation report, thirteen samples were processed 
with a fragment analysis assay and compared to previous results obtained using next-generation 
sequencing (NGS) to determine concordance with TA repeat number in the UGT1A1 gene. All 
samples were concordant with the previous results, rendering the assay to be highly sensitive, 
specific, reproducible, and repeatable. Sanger sequencing was used to confirm the DPYD and 
UGT1A1*6 SNPs. All results were concordant showing 100% repeatability and reproducibility. 
6.1.2 
Dosing and Administration 
Dosing for 5-FU, capecitabine and irinotecan will be recommended according to the patients’ 
DPYD and/or UGT1A1 genotype as indicated in Table 2 in Section 4.4.4. Ultimate dosing 
decisions will be determined by the treating oncologists according to their best clinical judgment.  
6.2 
Study Intervention Compliance 
Compliance to the PGx testing will be determined by tracking test orders in PennChart. Central 
laboratory records will be reviewed to determine time of the sample acquisition, time of sample 
receipt in the central lab, time receipt in the genotyping facility (e.g. CAG), and time of results 
posted within PennChart.  Test turnaround time will be determined based on the time from 
sample acquisition to posting of results in PennChart. 

 
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6.3 
Discontinuation of Study Intervention 
If the patient and/or treating oncologist wish to discontinue the PGx test and the sample as 
already been collected, the patient sample will be discarded. Participants will not be contacted 
for surveys.  
6.4 
Participant Discontinuation/Withdrawal from the Study 
Participants are free to withdraw from participation in the study at any time upon request, 
without prejudice to their medical care, and are not obliged to state their reasons. The study 
investigator may discontinue or withdraw a patient from the study at any time for the following 
reasons: 
• Pregnancy 
• Patient transfers care outside of Penn Medicine 
• Treating oncologist wishes patient to withdraw 
The reason for participant discontinuation or withdrawal from the study will be recorded on the 
patient’s Case Report Form (CRF). Subjects who sign the informed consent form but do not 
undergo genotyping may be replaced. Subjects who sign the informed consent form and do 
undergo genotyping, and subsequently withdraw, or are withdrawn or discontinued from the 
study, will not be replaced. 
6.5 
Lost To Follow-Up 
A participant will be considered lost to follow-up if he or she fails to return for completion of 
scheduled chemotherapy infusion appointments. There are no study specific visits. Data is 
collected at the time of usual clinic visit and from the medical record  
The following actions will be taken if a participant fails to return to the clinic for a scheduled 
visit/follow up: 
• The research coordinator will contact the treating oncologist and ensure the reason for not 
returning is not a (serious) adverse event ((S)AE) 
• If patient wishes to discontinue in the study, an attempt will be made to establish that the 
true reason is not an AE (bearing in mind that the patient is not obligated to share his/her 
reasons).  
• If treatment is prematurely discontinued, the primary reasons for discontinuation must be 
recorded in the patient’s file and all efforts will be made to complete and report he 
observations as thoroughly as possible. 

 
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• A complete final evaluation following the patient’s withdrawal will be made, and any 
AEs will be followed up until resolution or a period of 30 days from the last dose of 
chemotherapy has elapsed, whichever is shorter.  
 
 

 
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7 STUDY ASSESSMENT AND PROCEDURES 
7.1 
Informed Consent (Baseline) 
Eligibility for the study test will be determined by study personnel who will screen the clinic 
schedule. Study personnel will inform the treating oncologist of eligible patients by email or in 
person on the day of the evaluation visit. Participants will be consented in-person during the 
same visit or via remote consent (telephone/electronic). Blood or saliva sample will be collected 
on the same day if possible to ensure results will be returned prior to the first dose of 
chemotherapy. 
7.2 
Genotyping (0-14 days) 
Study personnel will place an order for the PGx test in PennChart to be signed by the medical 
oncologist. If saliva is not self-collected by the patient in clinic, the phlebotomist will obtain a 
blood sample that will be sent to the Center for Applied Genomics (CAG) at the Children’s 
Hospital of Philadelphia by courier.  
7.3 
Implementation Metrics (0-14 days) 
The following information if available will be collected to determine the feasibility of PGx test 
implementation and agreement to the PGx guided dosing recommendations: 
• Dates of sample collection, return of PGx test within PennChart, and timing of first dose 
of chemotherapy 
• Intended and prescribed doses of chemotherapy  
• Reasons for not adhering to the PGx guided recommendations  
• The proportion of tests ordered compared to the number eligible for testing. 
7.4 
Baseline clinical data collection 
 
The following information will be obtained at screening and from the patient medical record if 
performed as part of usual care and available in the medical record:  
• Signed informed consent form 
• Inclusion and exclusion criteria 
• Demographic data: age, gender, race/ethnicity 
• Cancer history: GI tumor type, stage, previous cancer treatments, number of lines of 
therapy 
• Routine physical examination: ECOG performance status (see Appendix 14.2), height 
(cm), weight (kg) 
• Vital signs: heart rate, blood pressure 
• Hematology: hemoglobin, hematocrit, white blood cell count, ANC, neutrophils, 
eosinophils, basophils, lymphocytes, monocytes, platelets 

 
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• Clinical chemistry: sodium, potassium, calcium, glucose, creatinine, BUN, AST, ALT, 
alkaline phosphatase, total bilirubin, albumin 
• Creatinine clearance (using Cockcroft-Gault formula) 
• Concomitant medications (including dose, unit, frequency, route of administration and 
indication) 
 
7.5 
Data collection at each chemotherapy infusion (time 0 to 6 cycles) 
The following information will be assessed at each chemotherapy visit by study personnel or 
extracted from the medical record with each chemotherapy treatment during the first six cycles if 
performed as part of usual care and available in the medical record. 
• Routine physical examination: height (cm), weight (kg), calculated body mass index 
(BMI) 
• Vital signs: heart rate, blood pressure 
• Hematology: hemoglobin, hematocrit, white blood cell count, ANC, neutrophils, 
eosinophils, basophils, lymphocytes, monocytes, platelets prior to treatment 
• Clinical chemistry: sodium, potassium, calcium, glucose, creatinine, BUN, AST, ALT, 
alkaline phosphatase, total bilirubin, albumin 
• Creatinine clearance (using Cockcroft-Gault formula) 
• Concomitant medications (including start date, dose, unit, frequency, route of 
administration and indication)  
• Chemotherapy course: dates of treatment, dose of each treatment for first 6 cycles 
• Adverse events: date of reported treatment-related symptoms, date of emergency 
department (ED) visits and/or hospitalizations (if applicable), clinical course and 
symptom duration, ED/hospitalization medical billing information. Severe TRAEs are 
defined as those requiring treatment in the hospital, ED, or Oncology Evaluation Center 
(OEC). 
• Serial questionnaires assessing patient reported outcomes (PROs) for symptoms 
associated with to adverse events will be prospectively collected by the study team at the 
time of each treatment for the first 6 cycles (see data collection tool in Appendix 14.6) 
 
The following information will be extracted from the medical records and/or tumor registry at the 
6-month (+ 2 months) follow-up period if performed as part of usual care and recorded in the 
medical record. 
• Overall patient survival (duration of patient survival from time of treatment initiation)  
• Progression free survival (time from treatment initiation until disease progression or 
worsening)  
• Information regarding tumor response from computed tomography (CT) scans will also 
be collected as available. This is expected to be classified by the treating oncologist as 
complete response (CR), partial response (PR), stable disease (SD), or progressive 

 
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disease (PD) per response evaluation criteria in solid tumors (RECIST) guideline version 
1.1.  
 
7.6 
Patient Survey on attitudes towards pharmacogenetic testing (0-6 months) 
Patients will complete an electronic survey via an emailed/texted link in RedCap to assess their 
knowledge and attitudes towards pharmacogenetics (Appendix 14.7). A paper copy will be made 
available for those without computer access. Patients will be contacted about the survey three 
times, after which time the survey will be recorded as missing data. 
7.7 
Plasma uracil assay (PCAM only) 
If the patient is willing, a plasma sample will be obtained during the baseline visit as described in 
4.5 above. Samples will be marked with a coded study-specific patient de-identifier. Blood 
samples will be centrifuged at 1500 g for 10 minutes in a refrigerated centrifuge (2-4°C) and 
plasma aliquots separated. Plasma will be stored in -80⁰C freezers until analysis.  Plasma uracil 
concentrations will be determined by UPLC-MS/MS (ultra-high performance liquid 
chromatography – dual mass spectrometry), using a previously published and validated assay 
with any necessary minor modifications in collaboration with the clinical pharmacology lab at 
the Norris Cotton Cancer Center at Dartmouth-Hitchcock.17  
7.8 
Optional Microbiome study (PCAM only) 
If participants consent to this portion of the study, participants will be provided a stool collection 
kit during the baseline visit. Participants will be instructed on home stool collection methods and 
will be required to collect a stool sample and bring it with them to their first chemotherapy 
infusion visit and one other clinical visit. Study staff will provide the participant with collection 
materials, packaging and instructions for collecting the stool at home and bringing it to the study 
visits (Appendix 14.8). Participants will be provided with ice packs and container in which to 
store the sample. Immediately after voiding the sample, the participant will rate the stool on the 
Bristol Stool Chart (Appendix 14.8.1). The study coordinator will bring this stool sample to the 
study lab on the 11th floor Smilow Center for Translational Research (SCTR). Lab personnel 
will aliquot the stool sample into 4 spoon-top vials and stored at -80ºC for microbiome 
sequencing and fecal metabolomics. 
8 STATISTICAL PLAN 
8.1 
Sample size 
For the implementation aims, the sample size is based on average GI oncology clinical volume 
and anticipated number of patients that are eligible for testing. We anticipated testing 500-800 
patients during the course of the study at the three Penn Medicine sites. No hypothesis testing 
will be performed. 

 
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For the effectiveness aims, we hypothesize that the chemotherapy-related severe TRAEs will 
decrease from 60% in the variant carriers receiving full dose chemotherapy in the historical 
control group enrolled into the PMBB to 30% in variant carriers receiving genotype guided 
chemotherapy.18 The following table presents the power for different sample sizes per group and 
different expected proportions experiencing severe TRAEs in the PGx group, based on two-sided 
Fisher’s exact test at the alpha level of 0.05 (Table 5). Based on the frequencies of DPYD and/or 
UGT1A1 in the population (~10%), testing 500 patients in each group will result in ~50 patients 
with actionable genotypes.  
Table 5. Power estimate for the reduction in Severe TRAEs  with PGx testing  
Toxicity rate  
 
N in each group with 
actionable variants 
39% in PGx 
35% in PGx 
30% in PGx 
18 
17.8% 
24.8% 
35.6% 
36 
32.3% 
45.8% 
63.6% 
48 
 
 
80% 
54 
49.4% 
66.3% 
83.9% 
70 
 
80% 
 
72 
67.4% 
82.9% 
 
97 
80% 
 
 
 
8.2 
Overview of statistical methods 
Descriptive statistics (mean, SD, median, interquartile range, range, counts, and percentage) will 
be used to describe and compare (t-test or rank sum test for continuous variables and Fisher’s 
exact test for categorical variables) baseline characteristics between the historical control group 
and PGx arms. 
8.2.1 
Implementation Endpoint(s): 
a. We will report the number and proportion of tests returned prior to the first dose of 
chemotherapy.  
b. We will report the proportion of dose modifications made in agreement with genotype-
guided dosing recommendations at the first dose. 
c. The proportion of tests ordered compared to the number eligible for testing. 

 
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8.2.2 
Secondary Endpoint(s): 
1. Clinical endpoints 
a. The proportion of patients experiencing severe TRAEs will be compared in the PMBB 
historical control group vs. the PGx group using Fisher’s exact test.  
Subgroup analyses will be performed by tumor type.   
b. The relative dose intensity (RDI) will be calculated for 5-FU, capecitabine or irinotecan 
as the cumulative administered dose divided by the anticipated cumulative dose over the 
first 6 cycles. RDI will be compared in the PMBB historical control group vs. the PGx 
group using linear regression adjusted for sex, race, BMI, tumor type, cancer stage, line 
of therapy and ECOG performance status.  
Subgroup analyses will be performed by tumor type.  
2. Patient reported outcomes 
Patient reported outcomes as assessed on a Likert scale will be reported as means (SD) 
and compared between the PMBB historical control group vs. the PGx group using linear 
regression adjusting for age, sex, race, tumor type, cancer stage, BMI, line of therapy, 
and ECOG performance status. 
3. Patient attitudes toward PGx testing 
Patient knowledge and attitudes towards PGx testing will be assessed on a Likert scale 
will be reported as means (SD). We will compare results by sex, race, tumor type, and 
insurance status by using linear regression. (See survey in Appendix 14.7) 
8.2.3 
Tertiary Endpoint(s): 
1. Clinical endpoints in minority populations 
The proportion of patients experiencing severe TRAEs will be compared in the PMBB 
historical control group vs. the PGx group using Fisher’s exact tests, stratified by race. 
2. Minor allele frequencies will be reported by ancestry for the DPYD and UGT1A1 genes.  
3. Medical services utilization and costs 
We will obtain data from Data Analytics Center (DAC) on service utilization and costs. 
These will include: number of physician visits; number of emergency department visits; 
number of hospitalizations; length of hospital stay; number of emergency department and 
hospital admissions associated with drug-related adverse events; DPYD and UGT1A1 

 
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genetic testing costs; physician visit cost; emergency department visit costs; 
hospitalization costs; inpatient and physician-administered medication costs; and total 
costs. Care Everywhere will be utilized to obtain information if patients received care 
outside Penn Medicine. Additionally, medical records will be requested for admissions 
that occur outside of Penn Medicine. 
We will compare utilization and costs incurred by the PMBB usual care group with 
utilization and costs incurred the PGx group using Poisson regression methods (for 
number of visits), and linear regression methods with appropriate transformations (e.g,, 
log-transform, winsorization) to account for skewness in utilization and cost distributions. 
4. Survival Analysis 
Overall survival and progression free survival at approximately six months will be 
compared between the PMBB historical control group vs. the PGx group by use of 
Kaplan-Meier estimators and log-rank tests. Cox proportional regression analysis will be 
performed to adjust for clinical covariates including age, sex, race, tumor type, cancer 
stage, BMI, and ECOG performance status. 
5. Pre-treatment uracil and fluoropyrimidine associated toxicity 
First, we will examine the range of pre-treatment uracil concentrations with the 
association of severe toxicity to determine if there is a cut-off whereby toxicity occurs. 
Previous studies have proposed uracil > 16g/ml as highly predictive for severe toxicity, 
but we will validate this cut-off in our patient population.15We will also examine whether 
the pre-treatment uracil levels vary in DPYD variant carriers. Second, we use logistic 
regression models to determine the risk of severe toxicity including a binary factor for 
uracil concentration (above and below cut-off), with adjustment for age, sex and treatment 
regimen. 
8.3 
Microbiome analysis (optional sub-study) 
From the microbiome sequencing, we will obtain tables of OTUs, which will be used to 
determine the relative abundance of taxa in participants with severe TRAEs vs. those without 
severe TRAEs. Weighted UniFrac distance (distance measurement which incorporates 
phylogenetic relationship, weighted by abundance)19,20 is the outcome we will use to examine 
beta diversity. We will compare the change in beta diversity pre and post- chemotherapy. The 
overall difference of the microbiome composition will be testing using permutation distance-
based multivariate analysis of variance (PERMANOVA).21 Non-parametric rank tests will be 
used to detect differences in taxon abundance pre- and post chemotherapy and between 
participants with severe TRAEs vs. those without severe TRAEs . Differential abundance of 
specific taxa will be assessed using nonparametric rank tests or generalized linear mixed effects 
models. To adjust for potential confounders and to evaluate the association between clinical data 
(e.g. age, sex, body mass index, chemotherapy, tumor type, ECOG status) and microbial 

 
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community profiles, we will use the microbiome regression-based kernel association test 
(MiRKAT).22 The association between changes in microbial composition with clinical 
characteristics (sex, race, age, BMI, diet) and outcome (toxicity) will be assessed using 
multivariate modeling. The generalized linear models will be selected when within vs. between-
subject effects will be characterized. False discovery rate (FDR) of 5% will be applied to account 
for multiple comparisons. 
9 SAFETY AND ADVERSE EVENTS  
9.1 
Adverse Events and Serious Adverse Events 
9.1.1 
Definition of Adverse Events (AE) 
 
An adverse event (AE) is any untoward medical occurrence associated with the use of an 
intervention in humans, whether or not considered intervention related. AEs in clinical 
investigation will include those associated with the study intervention (the PGx test). Adverse 
events associated with chemotherapy treatment will be collected as study outcomes, not as study-
related adverse events.   
 
Anticipated AEs may include incidental findings related to the PGx test results and the sharing of 
information to patients. The study team will communicate incidental findings to the treating 
oncologist. The oncologist may choose to return these findings to patients if pertinent for clinical 
care (see Known Potential Risks in Section 10.2.1).  
9.1.2 
Definition of Serious Adverse Events (SAE)  
Serious Adverse Events (SAE) 
Adverse events are classified as serious or non-serious. A serious adverse event is any AE that, 
in the view of the investigator is: 
• fatal 
• life-threatening at the time of the event  
• requires or prolongs hospital stay 
• results in persistent or significant disability or incapacity 
• a congenital anomaly or birth defect 
• an important medical event when the event does not fit the other outcomes, but the event 
may jeopardize the patient and may require medical or surgical intervention (treatment) 
to prevent one of the other outcomes. 

 
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Important medical events are those that may not be immediately life threatening but are clearly 
of major clinical significance. They may jeopardize the subject and may require intervention to 
prevent one of the other serious outcomes noted above. For example, drug overdose or abuse, a 
seizure that did not result in in-patient hospitalization or intensive treatment of bronchospasm in 
an emergency department would typically be considered serious. Likelihood of the SAE being 
attributed to the PGx testing will be documented. 
Unanticipated Adverse Device Effect (UADE) 
A UADE is any serious adverse effect on health or safety, or any life-threatening problem or 
death caused by, or associated with, a device, if that effect, problem, or death was not previously 
identified in nature, severity, or degree of incidence in the investigational plan or application, or 
any other unanticipated serious problem associated with a device that relates to the rights, safety, 
or welfare of subjects. Likelihood of the UADE being attributed to the laboratory developed test 
will be documented. 
 
9.1.3 
Classification of an Adverse Event 
AEs in clinical investigation will include AEs associated with the PGx test since the 
chemotherapy agents that will be administered are standard of care. These will primarily be 
related to HIPAA issues and unexpected findings.   
9.1.3.1 
Relationship to Study Intervention 
All adverse events (AEs) will have their relationship to the PGx test assessed by study personnel 
and/or the clinician who examines and evaluates the participant based on temporal relationship 
and his/her clinical judgment. The degree of certainty about causality will be graded using the 
categories below.  
• Related – The AE is known to occur with the PGx test, there is a reasonable possibility 
that the PGx test caused the AE, or there is a temporal relationship between the PGx test 
and event. Reasonable possibility means that there is evidence to suggest a causal 
relationship between the PGx test and the AE. 
• Not Related – There is not a reasonable possibility that the administration of the PGx test 
caused the event, there is no temporal relationship between the PGx test and event onset, 
or an alternate etiology has been established. 
9.1.4 
Time Period and Frequency for Event Assessment and Follow-Up 
Safety will be assessed by study personnel at the time of PGx test resulting for subjects. 
Chemotherapy-induced toxicity outcomes will be documented using defined parameters 
described in section 7.5.  

 
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As much as possible, each adverse event or follow-up information will be evaluated to 
determine: 
1. Description of adverse event 
2. Date of occurrence 
3. Expectedness to study intervention (PGx test) – [Unexpected (Yes/No)]. 
 
4. Impact on patient care – [Patient informed (Yes/No)] 
Once an adverse event is detected, it should be followed until its resolution or until it is judged to 
be permanent, and assessment should be made at each visit (or more frequently, if necessary) of 
any changes in patient care. 
9.1.5 
Adverse Event Reporting 
AEs encountered during the study will be documented in the patient’s file and reported on the 
Case Report Form (CRF). Likelihood of the AE being attributed to the PGx test will be 
documented. 
 
The information that will be recorded in the patient’s file consists of: 
• Description of the event 
• Date of the event  
• Impact on patient care 
Reporting to the IRB will be done in accordance to the Penn IRB definition of reportable events 
and reporting timelines. 
Reporting Period 
Adverse events will be reported from the time of informed consent until study completion. 
9.1.6 
Serious Adverse Event Reporting  
An SAE must be reported to the study investigators by telephone within 24 hours of the 
event. The investigator will keep a copy of this form on file at the study site. Report SAEs by 
phone to: 
 
 Sony Tuteja, PharmD 
 
Mobile- (484)-431-1002 
 
In the event that Dr. Tuteja cannot be reached, report SAEs to: 
 
 
Ursina Teitelbaum, MD 
Mobile- (215) 796-7413  

 
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At the time of the initial report, the following information should be provided: 
• Study Name 
• Participant number 
• A description of the event 
• Date of onset 
• Current status 
• The reason the event is classified as 
serious 
• Investigator assessment of the 
association between the event and the 
PGx test 
 
Within the following 48 hours, the investigator must provide further information on the 
SAE in the form of a written narrative. Significant new information on ongoing SAEs should be 
provided promptly to the study investigator. 
Reports of all SAEs (including follow-up information) must be submitted to the Ethics 
Committee (EC)/Investigational Review Board (IRB) within 10 working days, unless the SAE 
involves a death, which must be reported within 3 days. Copies of each report and 
documentation of EC /IRB notification and receipt will be kept in the Clinical Investigator’s 
binder. 
9.1.7 
Reporting of Pregnancy 
Pregnancy, in and of itself, is not regarded as an AE unless there is suspicion that study drug or 
process may have interfered with the effectiveness of a contraceptive medication or method. If a 
patient inadvertently becomes pregnant while on treatment, the patient will immediately be 
removed the study and the study investigator will be immediately notified. The outcome of the 
pregnancy will be reported as a SAE or case of death, spontaneous or voluntary termination, 
details of the birth, and the presence or absence of any birth defects, congenital abnormalities, or 
maternal and/or newborn complications. 
9.2 
Unanticipated Problems 
9.2.1 
Definition of Unanticipated Problems (UP) 
The Office for Human Research Protections (OHRP) considers unanticipated problems involving 
risks to participants or others to include, in general, any incident, experience, or outcome that 
meets all the following criteria: 
• Unexpected in terms of nature, severity, or frequency given (a) the research procedures 
that are described in the protocol-related documents, such as the Institutional Review 
Board (IRB)-approved research protocol and informed consent document; and (b) the 
characteristics of the participant population being studied; 
• Related or possibly related to participation in the research (“possibly related” means there 
is a reasonable possibility that the incident, experience, or outcome may have been 
caused by the procedures involved in the research); and 

 
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• Suggests that the research places participants or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized. 
This definition could include an unanticipated adverse device effect, any serious adverse effect 
on health or safety or any life-threatening problem or death caused by, or associated with, a 
device, if that effect, problem, or death was not previously identified in nature.  
10 SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS 
10.1 Ethical Considerations 
This study is to be conducted according to US and international standards of Good Clinical 
Practice (FDA Title 21 part 312 and International Conference on Harmonization guidelines), 
applicable government regulations and Institutional research policies and procedures.  
This protocol and any amendments will be submitted to a properly constituted independent EC/ 
IRB, in agreement with local legal prescriptions, for formal approval of the study conduct. The 
decision of the EC/IRB concerning the conduct of the study will be made in writing to the 
investigator and a copy of this decision will be provided to the sponsor before commencement of 
this study.  
10.2 Risk/Benefit Assessment 
10.2.1 
Known Potential Risks 
 
Blood will be drawn from all participating patients for determining the genotype prior to start of 
chemotherapy. Risks of venipuncture include possible bruising, infection at the site, and in rare 
cases, fainting. These risks are minimized by using trained personnel. The impact on clinical 
oncologic outcomes is unknown. Chemotherapy dose adjustments will be performed by the 
treating oncologist according to his or her clinical judgment.  
 
There can also be a risk in knowing genetic information. New health information about inherited 
traits that may affect participating patients and or their blood relatives may be found during the 
research study. DPD deficiency is an autosomal recessive disease; carriers usually do not have 
related health problems, but they do have an increased risk of complications when treated when 
fluoropyrimidine therapy.23 UGT1A1 plays a role in the metabolism of bilirubin and is associated 
with hereditary hyperbilirubinemia syndromes. The *28 variant is a common cause of Gilbert 
syndrome.6 Individuals with Gilbert syndrome may experience transient elevations in 
unconjugated plasma bilirubin in response to various triggers (e.g., fasting, infection, or 
medications). Genotypes most implicated in Gilbert syndrome are UGT1A1*28/*28 and 
UGT1A1*6/*6. Crigler-Najjar syndrome type I is very rare and results from deleterious 

 
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UGT1A1 mutations that results in hyperbilirubinemia and occur early in childhood therefore the 
PGx testing is unlikely to result in incidental findings.  However, identification of a heterozygous 
state may have implications for prenatal genetic counseling. The treating oncologist may choose 
to return these incidental findings if pertinent for clinical care. For the purposes of this current 
study, variants in the UGT1A1 gene will be interpreted to guide irinotecan drug dosing.24 
 
Additionally, there is the risk of loss of privacy with storing the health and genetic data of 
participating patients. Very rarely health or genetic information could be misused by employers 
or insurance companies; however, in such events, patients may have difficulty finding or 
maintaining a job or insurance. Laws such as the federal Genetic Information Non-
Discrimination Act (GINA) prohibit employers and health insurers from discriminating against 
individuals based on their genetic information. However, GINA does not protect against life 
insurance or long-term care insurance.  
10.2.2 
Known Potential Benefits 
The potential benefit to study participants is having their chemotherapy doses tailored to their 
genetic profile so as to avoid severe life-threatening toxicities. This may prevent hospitalizations 
due to chemotherapy-associated toxicities and improve quality of life for patients. The benefits to 
the health system include decreased hospitalizations and decreased costs in care.  
10.2.3 
Assessment of Potential Risks and Benefits 
The study is considered low risk since the medications of interest in the study are FDA-approved 
for clinical use in GI cancer treatment and dose adjustments are commonly performed according 
to the patient’s tolerance and clinical laboratory values. The study will provide valuable 
information on the best methods for incorporation PGx testing in clinical care to prevent serious 
adverse events.   
10.3 Informed consent 
 
All participants for this study will be provided a consent form describing this study and 
providing sufficient information for participants to make an informed decision about their 
participation in this study. This consent form will be submitted with the protocol for review and 
approval by the EC/IRB for the study. The formal consent of a participant, using the EC/IRB-
approved consent form, must be obtained before that participant is submitted to any study 
procedure. This consent form must be signed by the participant or legally acceptable surrogate, 
and the investigator-designated research professional obtaining the consent. Potential subjects 
and the investigator or a member of her designated research staff will review and sign the 
informed consent form during the baseline visit in the GI cancer clinic. As informed consent is 
an ongoing process, any new information that affects a person’s willingness to continue with the 
trial or risk profile that is received after the trial has been initiated will be provided to all 

 
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subjects, whether participation has been completed or is ongoing.  In order to avoid undue 
influence or coercion, all subjects will be treated equally. 
10.4 Confidentiality and Privacy 
Information about study participants will be kept confidential and managed according to 
the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 
Those regulations require a signed participant authorization informing the participant of the 
following:  
• What protected health information (PHI) will be collected from participants in this 
study  
• Who will have access to that information and why  
• Who will use or disclose that information  
• The rights of a research participant to revoke their authorization for use of their PHI.  
 
In the event that a participant revokes authorization to collect or use PHI, the investigator, 
by regulation, retains the ability to use all information collected prior to the revocation of 
participant authorization. 
 
All data related to this trial will be recorded using the patients’ assigned unique study 
number. Data will be reported only in a confidential manner such that the personal identity of 
any subject will not be identifiable. All study data will be maintained under a double locked 
system, such as a locked closet within a locked office or on a password protected computer in a 
locked office. At the end of the study these data will be electronically archived on a password 
protected computer or other electronic storage device. 
10.5 Future Use of Stored Data 
Data collected for this study will be entered into a RedCap database and analyzed and 
stored within a secure research database housed within the BioMedical Informatics Consortium 
(BMIC) Secure Computing Environment. All PHI within the secure research database will be 
encrypted. Quantifiable data are linked to subjects within the research database using an internal 
patient identifier not derived from any subject information.   
The research database will be accessible only by the PI and designated research staff as 
described to the IRB. Within the research database, designated staff will be able to link data from 
the electronic medical record to data scanned from survey forms. 
With the participant’s approval and as approved by local Institutional Review Boards 
(IRBs), de-identified genome-wide genotyping data (e.g. VCF files) generated at CAG will be 

 
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stored within Penn Medicine Biobank secured servers with the goal of sharing of data with Penn 
Medicine Researchers after appropriate approvals. These data could be used to research the 
genetic causes of medication response and adverse events to medication, risk for various diseases 
such as cancer, cardiovascular disease and diabetes, its complications and to improve treatment. 
The PMBB will also be provided with a code-link that will allow linking the genetic data with 
the phenotypic data from each participant, maintaining the blinding of the identity of the 
participant. 
During the conduct of the study, an individual participant can choose to withdraw consent 
to have data stored for future research.  
10.6 Source Documents 
Source data is all information, original records of clinical findings, observations, or other 
activities in a clinical trial necessary for the reconstruction and evaluation of the trial. Source 
data are contained in source documents. Examples of these original documents, and data records 
include: 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 and complete, 
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. 
10.7 Case Report Forms 
The study case report form (CRF) is the primary data collection instrument for the study. 
All data requested on the CRF must be recorded. All missing data must be explained. If a space 
on the CRF is left blank because the procedure was not done or the question was not asked, write 
“N/D”. If the item is not applicable to the individual case, write “N/A”. All entries should be 
printed legibly in black ink. If any entry error has been made, to correct such an error, draw a 
single straight line through the incorrect entry and enter the correct data above it. All such 
changes must be initialed and dated. DO NOT ERASE OR WHITE OUT ERRORS. For 
clarification of illegible or uncertain entries, print the clarification above the item, then initial and 
date it. 
10.8 Records retention 
Study documents and records will be retained for at least 2 years after the last participant 
has completed the study. 
 
10.8 Study monitoring, auditing, and inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the 
EC/IRB, the sponsor, government regulatory bodies, and University compliance and quality 
assurance groups of all study related documents (e.g. source documents, regulatory documents, 
data collection instruments, study data etc.). The investigator will ensure the capability for 
inspections of applicable study-related facilities (e.g. diagnostic laboratory, etc.).  

 
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Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable University compliance and quality assurance 
offices. 
10.8.1 Safety Oversight 
The Principal Investigator and Co-Investigators will be ultimately responsible for 
assuring the security of all study related materials to minimize risk to participants. Safety data 
such AEs and SAE will be assessed and reviewed in the PGx arm every 3 months after 
enrollment begins. 
This study is expected to be classified as low risk by ACC Risk Categories for Studies. 
The intervention (PGx test) requires a blood sample drawn during routine laboratory blood draw 
(unless a saliva specimen is collected) and thus poses limited risk compared to that experienced 
in daily life. If officially deemed low risk by ACC, we anticipate this protocol will be monitored 
on a “for-cause” basis only.  
10.8.2 Clinical Monitoring 
There is no external sponsor for this study. The PI and study physician will periodically 
review the adverse events that occur during the study to determine their relatedness to the study 
intervention. 
10.8.3 Protocol Deviations 
The PI and the study team should document all scenarios where the protocol is not followed 
and provide, in particular: 
• Who deviated from the protocol 
• What was the deviation 
• When did the deviation occur 
• How did the deviation happen 
• What is the impact of the deviation 
• A root cause analysis of why the deviation occurred 
Not following the genotype guided dose recommendation is NOT considered a protocol 
deviation, but will be recorded as one of the study outcomes. 
If the assessment results in a determination that any of the following are potentially affected, the 
deviation would be considered of significant impact: 
• having the potential to adversely affect subject safety; OR 

 
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• increases risks to participants; OR 
• adversely affects the integrity of the data; OR 
• violates the rights and welfare of participants, OR 
• affects the subject’s willingness to participate in research.  
• there is a potential for an overall impact on the research that should be shared with the 
IRB for consideration and development of next best steps to address it 
10.9 Protocol Amendment History 
Protocol modifications, except those intended to reduce immediate risk to study subjects, 
may be made only by the principal investigator. A protocol change intended to eliminate an 
apparent immediate hazard to subjects may be implemented immediately, provided the IRB/IEC 
is notified within 5 days. 
Any permanent change to the protocol must be handled as a protocol amendment. The 
written amendment must be submitted to the IRB/IEC and the investigator must await approval 
before implementing the changes. The principal investigator will submit protocol amendments to 
the appropriate regulatory authorities. 
If in the judgment of, the sponsor, the IRB/IEC, and/or the investigator, the amendment 
to the protocol substantially changes the study design and/or increases the potential risk to the 
subject and/or has an impact on the subject's involvement as a study participant, the currently 
approved written informed consent form will require similar modification. In such cases, 
informed consent will be renewed for subjects enrolled in the study before continued 
participation. 
The table below is intended to capture changes of IRB-approved versions of the protocol, 
including a description of the change and rationale.  
 
Version 
Date 
Description of Change  
Brief Rationale 
2.0 
 2-3-21 
1. Addition of study personnel 
2. Addition of study procedure 
(serum uracil collection at baseline 
for PCAM patients only) 
3. Revision of fluoropyrimidine dose 
recommendations for DPYD 
p.Y186C variant carriers 
4. Revision to PRO data outcomes 
tool 
1. Study personnel will assist 
with subject recruitment and 
consenting. 
2. Collection of serum uracil at 
baseline will be used as an 
alternative method for 
determining DPYD phenotype. 
Additional study procedure 
included in ICF with patient-
friendly language. 

 
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Version 
Date 
Description of Change  
Brief Rationale 
 
3. Dose revisions to reflect 
current scientific literature, 
clinical guidelines, and expert 
feedback 
4. The NCI PRO-CTCAE™ 
tool has been revised to collect 
information on cardiotoxicity 
symptoms from subjects. 
3.0 
Feb 19, 2021 
1.Oncology providers can obtain 
consent. 
2. Removal of pregnancy test as study 
procedure 
3. Collection of SSN from participants 
 
1. Due to the busy clinic 
volume, the physicians 
wish to be able to consent 
patients for the study and 
not have to wait to study 
staff. 
2. Pregnancy test is not 
performed as part of 
standard of care. 
3. To disburse funds for 
participating in surveys. 
4.0 
Nov 10, 2021 
1. Revision of specimen collection 
to include saliva. 
2. Removal of inclusion criteria of 
ECOG status.   
3. Removal of inclusion criteria of 
prior treatment of 
fluoropyrimidines 
4. Updated timeframe for endpoint 
collection. 
1. Provides an additional 
method of sample 
collection if phlebotomy 
closed for the day. 
2. Patients with higher 
ECOG status (3 or 4) still 
suitable for treatment with 
fluoropyrimidines. 
Oncologist will  determine 
suitability for treatment 
with fluoropyrimidines on 
a case by case basis. 
3. Physicians have expressed 
interest in obtaining 
genotype information 
regardless of a patient’s 
prior treatment status, and 
particularly for individuals 
with previous intolerance 
of fluoropyrimidine to 
guide future treatment 
decisions. 
4. feasibility endpoint time 
frame revised from ‘7 
days’ to ‘prior to the first 
dose of chemotherapy’. 
Seven days is less 

 
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Version 
Date 
Description of Change  
Brief Rationale 
clinically relevant than 
patient-specific treatment 
schedules. adverse event 
data and PRO 
questionnaires to be 
collected over first six 
cycles, not months. It is 
not necessary to collect 
AE data over the longer 
time period for study 
purposes given that 
chemotherapy toxicity is 
typically experienced 
during initial cycles.  
 
5.0 
8.03.2023 
Clarification regarding data collected at 
baseline and with each chemotherapy 
cycle. 
Data elements listed in the protocol 
will be collected if already 
performed as per usual care and 
available in PennChart.  These will 
not be performed for the study. 
6.0 
5.14.2024 
Revised definition severe toxicities from  
≥ Grade 3 toxicities to treatment related 
adverse events requiring treatment in the 
hospital, emergency department, or 
oncology evaluation center.   
Prospective completion of 
chemotherapy related toxicity per 
the National Cancer Institute-
Common Terminology Criteria for 
Adverse Events (NCI-CTCAE) was 
not feasible due to a lack of a 
consistent research coordinator 
throughout the study. In addition, 
the completion rate for the PROs 
was very low therefore we could not 
assign a grade to the adverse event. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
11 STUDY FINANCES 
11.1 Funding Source 
 
This study is financed through a grant from the Penn Center for Precision medicine. 

 
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11.2 Conflict of Interest   
All University of Pennsylvania investigators will follow the University conflict of interest 
policy. 
11.3 Participant Payments 
Participants will be compensated with a $25 gift card for completing the survey on 
attitudes towards PGx testing (Appendix 14.7). Participants will be compensated an 
additional $50 for completing the microbiome sub-study. 
12 PUBLICATION AND DATA SHARING PLAN  
 
Data generated by this study will be shared at scientific meetings and published in 
scientific journals. Investigators actively involved in the execution of the trial will be 
invited to co-author publications. All study investigators will be informed in writing prior 
to any written communication or oral presentation about the study and invited to give 
comments. 
Reasonable request for samples and data will be shared in a de-identified manner. 
13 REFERENCES 
1. Lunenburg CATC, van der Wouden CH, Nijenhuis M, Crommentuijn-van Rhenen MH, de 
Boer-Veger NJ, Buunk AM, Houwink EJF, Mulder H, Rongen GA, van Schaik RHN, van 
der Weide J, Wilffert B, Deneer VHM, Swen JJ, Guchelaar H-J. Dutch Pharmacogenetics 
Working Group (DPWG) guideline for the gene-drug interaction of DPYD and 
fluoropyrimidines. Eur J Hum Genet EJHG. 2020 Apr;28(4):508–517. PMCID: 
PMC7080718 
2. Páez D. Genetics and adverse events with irinotecan treatment: what do we know? 
Pharmacogenomics. 2019 Apr;20(6):393-395. 
3. Amstutz U, Henricks LM, Offer SM, Barbarino J, Schellens JHM, Swen JJ, Klein TE, 
McLeod HL, Caudle KE, Diasio RB, Schwab M. Clinical Pharmacogenetics 
Implementation Consortium (CPIC) Guideline for Dihydropyrimidine Dehydrogenase 
Genotype and Fluoropyrimidine Dosing: 2017 Update. Clin Pharmacol Ther. 2018 
Feb;103(2):210-216. 
4. Offer SM, Lee AM, Mattison LK, Fossum C, Wegner NJ, Diasio RB. A DPYD variant 
(Y186C) in individuals of african ancestry is associated with reduced DPD enzyme activity. 
Clin Pharmacol Ther. 2013 Jul;94(1):158–166. PMCID: PMC3821392 

 
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5. Saif MW, Lee AM, Offer SM, McConnell K, Relias V, Diasio RB. A DPYD variant 
(Y186C) specific to individuals of African descent in a patient with life-threatening 5-FU 
toxic effects: potential for an individualized medicine approach. Mayo Clin Proc. 2014 
Jan;89(1):131–136. PMCID: PMC4071869 
6. Dean L. Irinotecan Therapy and UGT1A1 Genotype. In: Pratt VM, McLeod HL, Rubinstein 
WS, Scott SA, Dean LC, Kattman BL, Malheiro AJ, editors. Med Genet Summ [Internet]. 
Bethesda (MD): National Center for Biotechnology Information (US); 2012 [cited 2020 Apr 
9]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK294473/ PMID: 28520360 
7. Gammal RS, Court MH, Haidar CE, Iwuchukwu OF, Gaur AH, Alvarellos M, Guillemette 
C, Lennox JL, Whirl-Carrillo M, Brummel SS, Ratain MJ, Klein TE, Schackman BR, 
Caudle KE, Haas DW, Clinical Pharmacogenetics Implementation Consortium. Clinical 
Pharmacogenetics Implementation Consortium (CPIC) Guideline for UGT1A1 and 
Atazanavir Prescribing. Clin Pharmacol Ther. 2016 Apr;99(4):363–369. PMCID: 
PMC4785051 
8. Deenen MJ, Meulendijks D, Cats A, Sechterberger MK, Severens JL, Boot H, Smits PH, 
Rosing H, Mandigers CMPW, Soesan M, Beijnen JH, Schellens JHM. Upfront Genotyping 
of DPYD*2A to Individualize Fluoropyrimidine Therapy: A Safety and Cost Analysis. J 
Clin Oncol Off J Am Soc Clin Oncol. 2016 Jan 20;34(3):227–234. PMID: 26573078 
9. Henricks LM, Lunenburg CATC, de Man FM, Meulendijks D, Frederix GWJ, Kienhuis E, 
Creemers G-J, Baars A, Dezentjé VO, Imholz ALT, Jeurissen FJF, Portielje JEA, Jansen 
RLH, Hamberg P, Ten Tije AJ, Droogendijk HJ, Koopman M, Nieboer P, van de Poel 
MHW, Mandigers CMPW, Rosing H, Beijnen JH, Werkhoven E van, van Kuilenburg ABP, 
van Schaik RHN, Mathijssen RHJ, Swen JJ, Gelderblom H, Cats A, Guchelaar H-J, 
Schellens JHM. DPYD genotype-guided dose individualisation of fluoropyrimidine therapy 
in patients with cancer: a prospective safety analysis. Lancet Oncol. 2018;19(11):1459–
1467. PMID: 30348537 
10. Kleinjan JP, Brinkman I, Bakema R, van Zanden JJ, van Rooijen JM. Tolerance-based 
capecitabine dose escalation after DPYD genotype-guided dosing in heterozygote DPYD 
variant carriers: a single-center observational study. Anticancer Drugs. 2019;30(4):410–415. 
PMID: 30628914 
11. Camptosar (irinotecan) [package insert] [Internet]. New York, NY: Pfizer Laboratories Div 
Pfizer Inc; 1996. Available from: 
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e518dfc6-7e93-4fee-a66c-
51e1ab71c056 
12. Annotation of DPWG Guideline for irinotecan and UGT1A1 [Internet]. Dutch 
Pharmacogenetics Working Group, 2020. [Accessed August 2020]. 
<https://www.pharmgkb.org/guidelineAnnotation/PA166104951> 

 
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13. Hoskins JM, Goldberg RM, Qu P, Ibrahim JG, McLeod HL. UGT1A1*28 genotype and 
irinotecan-induced neutropenia: dose matters. J Natl Cancer Inst. 2007 Sep 5;99(17):1290–
1295. PMID: 17728214 
14. Hu Z-Y, Yu Q, Pei Q, Guo C. Dose-dependent association between UGT1A1*28 genotype 
and irinotecan-induced neutropenia: low doses also increase risk. Clin Cancer Res Off J Am 
Assoc Cancer Res. 2010 Aug 1;16(15):3832–3842. PMID: 20562211 
15. Meulendijks D, Henricks LM, Jacobs BAW, Aliev A, Deenen MJ, de Vries N, Rosing H, 
van Werkhoven E, de Boer A, Beijnen JH, Mandigers CMPW, Soesan M, Cats A, Schellens 
JHM. Pretreatment serum uracil concentration as a predictor of severe and fatal 
fluoropyrimidine-associated toxicity. Br J Cancer. 2017 May 23;116(11):1415-1424. 
16. Van Kuilenburg AB, Van Lenthe H, Tromp A, Veltman PC, Van Gennip AH. Pitfalls in the 
diagnosis of patients with a partial dihydropyrimidine dehydrogenase deficiency. Clin 
Chem. 2000 Jan;46(1):9-17. 
17. Jacobs BA, Rosing H, de Vries N, Meulendijks D, Henricks LM, Schellens JH, Beijnen JH. 
Development and validation of a rapid and sensitive UPLC-MS/MS method for 
determination of uracil and dihydrouracil in human plasma. J Pharm Biomed Anal. 2016 Jul 
15;126:75-82. 
18. Cremolini C, Del Re M, Antoniotti C, Lonardi S, Bergamo F, Loupakis F, Borelli B, 
Marmorino F, Citi V, Cortesi E, Moretto R, Ronzoni M, Tomasello G, Zaniboni A, Racca P, 
Buonadonna A, Allegrini G, Ricci V, Di Donato S, Zagonel V, Boni L, Falcone A, Danesi 
R. <i>DPYD</i> and <i>UGT1A1</i> genotyping to predict adverse events during first-
line FOLFIRI or FOLFOXIRI plus bevacizumab in metastatic colorectal cancer. Oncotarget. 
2018 Jan 30;9(8):7859-7866. 
19. Lozupone C, Knight R. Unifrac: A new phylogenetic method for comparing microbial 
communities. Applied and environmental microbiology. 2005;71:8228-8235  
20. Lozupone CA, Hamady M, Kelley ST, Knight R. Quantitative and qualitative beta diversity 
measures lead to different insights into factors that structure microbial communities. Applied 
and environmental microbiology. 2007;73:1576-1585 
21. Anderson MJ. A new method for non-parametric multivariate analysis of variance. Austral 
Ecology. 2001;26:32-46 
22. Zhao N, Chen J, Carroll IM, Ringel-Kulka T, Epstein MP, Zhou H, Zhou JJ, Ringel Y, Li H, 
Wu MC. Testing in Microbiome-Profiling Studies with MiRKAT, the Microbiome 
Regression-Based Kernel Association Test. Am J Hum Genet. 2015 May 7;96(5):797-807. 

 
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23. Dihydropyrimidine dehydrogenase deficiency [Internet]. Genetics Home Reference. 
Available from: https://ghr.nlm.nih.gov/condition/dihydropyrimidine-dehydrogenase-
deficiency 
24. UGT1A1 gene [Internet]. Genetics Home Reference. Available from: 
https://ghr.nlm.nih.gov/gene/UGT1A1#conditions 
 
25. Thorn CF, Marsh S, Carrillo MW, McLeod HL, Klein TE, Altman RB. PharmGKB 
summary: fluoropyrimidine pathways. Pharmacogenet Genomics. 2011 Apr;21(4):237–242. 
PMCID: PMC3098754 
26. Fluorouracil [package insert] [Internet]. Spectrum Pharmaceuticals, Inc.; 1956. Available 
from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/012209s040lbl.pdf 
27. Xeloda (capecitabine) [package insert] [Internet]. San Francisco, CA: Genentech, Inc.; 2001 
Apr. Available from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a1de8bba-
3b1d-4c9d-ab8a-32d2c05e67c8 
28. Whirl-Carrillo M, McDonagh EM, Hebert JM, Gong L, Sangkuhl K, Thorn CF, Altman RB, 
Klein TE. Pharmacogenomics knowledge for personalized medicine. Clin Pharmacol Ther. 
2012 Oct;92(4):414–417. PMCID: PMC3660037 
29. Onivyde (irinotecan liposome injection) [package insert] [Internet]. Basking Ridge, NJ: 
Ipsen Pharmaceuticals, Inc; 1996. Available from: 
https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c8b58efa-1820-48a4-b70d-
62918fc4abfc 
30. Huddart R, Sangkuhl K, Whirl-Carrillo M, Klein TE. Are Randomized Controlled Trials 
Necessary to Establish the Value of Implementing Pharmacogenomics in the Clinic? Clin 
Pharmacol Ther. 2019 Aug;106(2):284-286. 
31. Food and Drug Administration. Table of Pharmacogenomic Biomarkers in Drug Labeling. 
[Internet]. 
2020. Available from: https://www.fda.gov/drugs/science-and-research-drugs/table-
pharmacogenomic-biomarkers-drug-labeling. 
 
 
 

 
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14 APPENDIX  
14.1  Schedule of Activities (SoA) 
 
Study Procedure 
Baseline/ Pre-
treatment 
Cycle 1 
Cycles 1-614 
Follow-up15 
Any point 
during 
months 1-6 
D x 
D 1 
D 1 
 
 
Informed consent 
X 
 
 
 
 
Inclusion and 
exclusion criteria 
X 
 
 
 
 
Demographic data1 
X 
 
 
 
 
Cancer history2* 
X 
 
 
 
 
Physical examination3* 
X 
X 
X 
 
 
Vital signs4* 
X 
X 
X 
 
 
Hematology5* 
X 
X 
X 
 
 
Clinical chemistry6* 
X 
X 
X 
 
 
Creatinine clearance7* 
X 
X 
X 
 
 
Pharmacogenetic test8 
X 
 
 
 
 
Blood sample for 
uracil measurement9 
X 
 
 
 
 
Toxicity assessments10* 
 
X 
X 
 
 
Tumor outcomes11* 
 
 
 
X 
 
Patient reported 
outcomes12 
X 
X 
X 
 
 
Chemotherapy 
 
X 
X 
 
 
Concomitant 
medications13* 
X 
X 
X 
 
 
Patient survey16 
 
 
 
 
X 
Stool collection17 
X 
 
 
 
X 
*if performed as part of usual care and available in PennChart 
1. Demographic data: age, gender, race/ethnicity 
2. Cancer history: GI tumor type, stage, previous cancer treatments, number of lines of 
therapy, ongoing toxicities related to previous therapy  
3. Routine physical examination: WHO performance status, height (cm), weight (kg) 
4. Vital signs: heart rate, blood pressure 

 
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5. Hematology: hemoglobin, hematocrit, white blood cell count, ANC, neutrophils, 
eosinophils, basophils, lymphocytes, monocytes, platelets 
6. Clinical chemistry: sodium, potassium, calcium, glucose, creatinine, BUN, AST, ALT, 
alkaline phosphatase, total bilirubin, albumin 
7. Creatinine clearance (using Cockcroft-Gault formula) 
8. Pharmacogenetic test: screening for SNPs in DPYD (DPYD*2A, DPYD *5, DPYD *6, 
DPYD *8, DPYD *9A, DPYD *10, DPYD *12, DPYD *13, rs2297595, rs115232898, 
rs67376798, DPYD HapB3 (rs75017182, rs56038477, rs56276561) and in UGT1A1  
(UGT1A1*6, UGT1A1*28) 
9. Research blood draw to measure serum uracil (PCAM patients only) 
10. Toxicity assessment: Severe treatment related adverse events requiring hospitalization, 
emergency department visit, or visit to the Oncology Evaluation Center (OEC) will be 
abstracted from medical records and adverse events reported during cycles will be 
documented 
11. Tumor outcomes: progression free survival and overall survival.  
12. Patient reported outcomes per NCI PRO-CTCAE™ and quality of life per FACT-G7 
questionnaire 
13. Concomitant medications: including start date, dose, unit, frequency, route of 
administration and indication 
14. Until cycle 5, or until end of treatment because of tumor progression, unacceptable 
toxicity or any other reason for which treatment with fluoropyrimidines and/or 
irinotecan is discontinued 
15. Follow-up: at 6 + 2 months after treatment initiation 
16. Electronic/paper survey on patient attitudes towards pharmacogenetics will be 
administered once at any point during the study once he/she has undergone 
pharmacogenetic testing.  
17. If patients wish to participate in optional microbiome substudy (PCAM patients only) 
 
 

 
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14.2 ECOG Performance Status 
 
Grade ECOG Description 
 
0 
Fully active, able to carry on all pre-disease performance without 
restriction 
1 
Restricted in physically strenuous activity but ambulatory and able 
to carry out work of a light or sedentary nature, e.g., light house 
work, office work 
2 
Ambulatory and capable of all self-care but unable to carry out any 
work activities; up and about more than 50% of waking hours 
3 
Capable of only limited self-care; confined to bed or chair more 
than 50% of waking hours 
4 
Completely disabled; cannot carry on any self-care; totally confined 
to bed or chair 
5 
Dead 
 
14.3 NCI-CTCAE version 5.0 
 
See: 
https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Quick_R
eference_8.5x11.pdf (Control click to follow link) 
 
The study is no longer grading adverse events using this criteria. 
 
 

 
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14.4 Medication information  
14.4.1 
Clinical Pharmacology of 5-FU, capecitabine and irinotecan 
5-FU is an intravenous fluorine-substituted analogue of uracil that inhibits DNA synthesis to 
result in cytotoxicity and cell apoptosis. Capecitabine is an oral prodrug of 5-FU that is 
converted to 5-FU via a three-step enzymatic cascade. The amount of 5-FU available to exert its 
anticancer effect is directly regulated by its catabolism. Dihydropyrimidine dehydrogenase 
(DPD) is responsible for the initial and rate-limiting step of 5-FU catabolism. The enzyme, 
encoded by DPYD, converts approximately 80% of 5-FU in the liver into its inactive form.25 
When DPD is inactive or harbors reduced activity, the rate of 5-FU clearance decreases, leading 
to the development of severe fluoropyrimidine-related adverse events due to the prolonged 
exposure of 5-FU. 
 
In the event of fluorouracil overdose, uridine triacetate is administered within 96 hours following 
the end of fluorouracil infusion.26 Clinical presentation of acute overdose with capecitabine 
consists of nausea, diarrhea, vomiting, GI irritation and bleeding, and bone marrow depression. 
Medical management should include typical supportive medical interventions to correct the 
observed clinical manifestations. Dialysis may be of benefit in reducing circulating 
concentrations of a low-molecular-weight capecitabine metabolite (5’-DFUR), though there are 
no reported experiences evaluating dialysis for treating capecitabine overdose. Single doses of 
capecitabine were not lethal in animal studies (mice, rats, monkeys) at doses up to 2000 mg/kg 
(>2-9 times larger than the recommended human daily dose).27 See Table 6 for information on 
the pharmacokinetics (PK) of 5-FU and capecitabine.  
 
Irinotecan is a prodrug converted by carboxylesterase enzymes to the active metabolite SN-38 
upon intravenous injection. SN-38 targets topoisomerase I to exert its cytotoxic effects by 
preventing DNA re-ligation of single strand breaks, establishing lethal double-stranded breaks 
that result in irreparable molecular damage and cell apoptosis. Due the lipophilic nature of SN-
38, the metabolite undergoes phase II metabolism (glucoronidation) and becomes inactivated by 
uridine diphosphate-glucoronosyltransferase (UGT) encoded by the UGT1A1 gene. Reduced 
enzymatic activity of UGT1A1 can lead to elevated concentrations of SN-38 and unconjugated 
(indirect) hyperbilirubinemia, which directly relate to the dose-limiting toxicities of febrile 
neutropenia and severe diarrhea.28  
 
Overdose with irinotecan at doses up to approximately twice the recommended therapeutic dose 
have been reported, which may be fatal. The most significant adverse events were severe 
neutropenia and severe diarrhea. In these situations, maximum supportive care should be 
administered to prevent dehydration in the event of diarrhea and/or infectious complications; 
there is no known antidote for irinotecan overdose.11 See Table 7 for information on the 
pharmacokinetics of irinotecan and its liposomal formulation. 

 
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Table 6. Pharmacokinetics of Fluoropyrimidines  
PK 
Parameter 
Fluorouracil (5-FU)27 
Following bolus injection 
Capecitabine (CAPE)27 
Following 1255 mg/m2 PO BID dose 
Absorption 
Not listed in package insert  
 
 
CAPE 
(prodrug) 
5-FU (active 
metabolite) 
Tmax 
1.5 hours 
2 hours 
Cmax 
Lowered by 
60% with food 
Lowered by 
43% with food 
AUC
0-∞ 
Lowered by 
35% with food 
Lowered by 
21% with food 
Distribution 
Distributes throughout the body including the 
intestinal mucosa, liver, cerebrospinal fluid, 
and brain tissue. 
Plasma protein binding: <60% 
Not concentration dependent 
Primarily bound to albumin (35%) 
Metabolism 
Remaining amount of drug following 
excretion is primarily metabolized in liver. 
Extensively bioactivated and metabolized 
enzymatically to 5-FU in liver. In vitro 
studies indicate CAPE and its metabolites do 
not inhibit CYP isoenzymes 1A2, 2A6, 3A4, 
2C19, 2D6, and 2E1. 
Excretion 
Half life (t1/2) 
Urine 
5-20% unchanged in 6 hours; 
metabolites over 3-4 hours 
t1/2 
8-20 min  
Urine 
95.5%; 3% unchanged 
Feces 
2.6% 
t1/2 
0.75 hours (CAPE, 5-FU) 
 
Table 7. Pharmacokinetics of Irinotecan formulations 
PK 
Parameter 
Irinotecan (IRI)11 
Liposomal IRI29  
Following 70 mg/m2 IV dose 
Absorption 
Cmax of SN-38: within 1 hour following end of 
90-min infusion of IRI 
See table 9 in the package insert labeling for 
dose-specific information from studies 
 
IRI 
SN-38 
Cmax 
37.2 mcg/mL 
5.4 ng/mL 
AUC0-∞ 
1364 
h•mcg/mL 
620 
h•ng/mL 
CL 
0.20 L/hr 
N/A 
Distribution 
Plasma protein binding: 30-68% (IRI), 95% 
(SN-38) 
Volume of distribution: 4.1 L (IRI) 
Plasma protein binding: <0.44% (IRI) 
Metabolism 
Glucuronidation of SN-38 to SN-38G via 
UGT1A1; oxidation via CYP3A4. In vitro 
studies indicate IRI and its metabolites do not 
inhibit CYP isoenzymes.  
Glucuronidation of SN-38 to SN-38G via 
UGT1A1; oxidation via CYP3A4 

 
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Excretion 
Half life (t1/2) 
 
IRI 
SN-38 
SN-38G 
Urine 
11-20% 
<1% 
3% 
t1/2 (hr) 
6-12 
10-20 
N/A 
 
IRI 
SN-38 
SN-38G 
Urine 
11-20% 
<1% 
3% 
t1/2 (hr) 
25.8 
67.8 
N/A 
14.4.2 
Drug Interactions for 5-FU, capecitabine and irinotecan 
Fluoropyrimidine Drug-Drug Interactions  
There is a potential for drug interactions with fluoropyrimidines and CYP2C9 substrates and 
anticoagulants such as warfarin. Elevated coagulation times for warfarin have been reported with 
both 5-FU and capecitabine. While there is a lack of pharmacokinetic data to assess the effect of 
5-FU on warfarin, altered coagulation parameters have been observed with capecitabine in 
addition to an increase in warfarin concentrations. These events occurred within several days and 
up to several months after initiation of capecitabine (and within 1 month of discontinuing 
capecitabine in a few cases). The maximum observed INR value increased by 91%; this increase 
in drug concentration is believed to be due to inhibition of CYP2C9 by 5-FU or its metabolites. 
Phenytoin should also be carefully monitored and a dose reduction may be required when 
administering capecitabine. Toxicity associated with elevated phenytoin levels has been reported 
and may be due to CYP2C9 inhibition. Although no formal drug-drug interaction studies have 
been conducted, precautions should taken when capecitabine is coadministered with CYP2C9 
substrates. 
Increased concentrations and toxicity of 5-FU have been reported with leucovorin. Deaths from 
severe enterocolitis, diarrhea, and dehydration have been reported in elderly patients receiving 
weekly leucovorin and 5-FU.  
Administration of infusional 5-FU does not require filter, DEHP-free, or low sorb tubing. 
Standard infusion tubing is used with a closed system transfer device due to the hazardous nature 
of the chemotherapy agent. In the event that only DEHP-free or low sorb tubing is available, 
these materials may still be used for dispensing 5-FU infusions, as they have not shown to be 
incompatible.  
Fluoropyrimidine Drug-Food Interactions  
Food has been shown to reduce both the rate and extent of absorption of capecitabine. In clinical 
trials, patients were instructed to administer capecitabine within 30 minutes after a meal. It is 
recommended that capecitabine be administered with food. There are no drug-food interactions 
listed in the package insert for 5-FU.  
  
Irinotecan Drug-Drug Interactions  

 
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It is recommended to administer 5-FU and leucovorin prior to irinotecan given the slight 
reductions in Cmax and AUC0-24 of SN-38 (14% and 8%, respectively) with 5-FU and leucovorin 
in a phase I clinical study. No formal drug interaction studies have been conducted. 
 
It is recommended to avoid administration of strong CYP3A4 inducers with irinotecan due to 
substantially reduced exposure to irinotecan and SN-38 in adults and children concomitantly 
receiving CYP3A4 enzyme-inducing anticonvulsants (phenytoin, phenobarbital, carbamazepine) 
or St. John’s wort. It is recommended to substitute non-enzyme inducing therapies for at least 2 
weeks prior to starting irinotecan therapy (and its liposomal formulation) and to avoid strong 
CYP3A4 inducers unless there are no therapeutic alternatives. 
 
Concomitant ketoconazole (CYP3A4 and UGT1A1 inhibitors) can increase exposure to 
irinotecan and SN-38. Coadministration of irinotecan with other strong CYP3A4 inhibitors 
(clarithromycin, indinavir, itraconazole, lopinavir, nefazodone, nelfinavir, ritonavir, saquinavir, 
telaprevir, voriconazole) or other UGT1A1 inhibitors (atazanavir, gemfibrozil, indinavir) may 
increase systemic exposure to irinotecan and SN-38. It is recommended to discontinue strong 
CYP3A4 inhibitors at least 1 week prior to starting irinotecan therapy (and its liposomal 
formulation) and to avoid strong CYP3A4 or UGT1A1 inhibitors unless there are no therapeutic 
alternatives.  
Administration of irinotecan does not require filter, DEHP-free, or low sorb tubing. In-line filters 
should not be used during the administration of liposomal irinotecan. Standard infusion tubing is 
used with a closed system transfer device due to the hazardous nature of the chemotherapy agent. 
In the event that only DEHP-free or low sorb tubing is available, these materials may still be 
used for dispensing irinotecan infusions, as they have not shown to be incompatible.  
Irinotecan Drug-Food Interactions  
There are no drug-food interactions listed in the package insert for irinotecan or its liposomal 
formulation.  
14.4.3 
Clinical Adverse Event Profile 
 
Fluorouracil  
 
• Increased risk of serious or fatal 
adverse reactions in patients with 
low or absent DPD activity 
• Cardiotoxicity 
• Hyperammonemic encephalopathy  
• Neurologic toxicity 
• Diarrhea 
• Palmar-plantar erythrodysesthesia 
(hand-foot syndrome) 
• Myelosuppression 
• Mucositis 
• Increased risk of elevated INR when 
administered with warfarin  
 

 
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Capecitabine (occurring in >30% patients) 
• Diarrhea 
• Hand-foot syndrome 
• Nausea 
• Vomiting 
• Abdominal pain 
• Fatigue/weakness 
• Hyperbilirubinemia 
 
Irinotecan (occurring in >30% patients receiving combination therapy) 
• Nausea 
• Vomiting  
• Abdominal pain 
• Diarrhea 
• Constipation 
• Anorexia 
• Mucositis 
• Neutropenia 
• Leukopenia 
• Anemia 
• Thrombocytopenia 
• Asthenia 
• Pain 
• Fever 
• Infection 
• Abnormal bilirubin 
• Alopecia 
 
 
Liposomal irinotecan (occurring in >20% patients) 
• Diarrhea 
• Fatigue/asthenia 
• Vomiting  
• Nausea 
• Decreased appetite 
• Stomatitis 
• Pyrexia 
• Lymphopenia (occurring in >10% patients with Grade 3 or 4 severity) 
• Neutropenia (occurring in >10% patients with Grade 3 or 4 severity) 

 
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14.5 Pharmacogenetic test validation reports (to be attached) 
14.6 Data collection tool for chemotherapy-related adverse events and patient 
reported outcomes (to be attached) 
14.7 Participant survey – Pharmacogenetic testing (to be attached) 
14.8 Stool collection kit instructions for optional microbiome substudy (to be 
attached) 
14.8.1 
Bristol Stool Chart for optional microbiome substudy (to be attached) 
END OF DOCUMENT 

IMPACT-GI Statistical Analysis Plan (SAP) 
Section 1: Administrative 
Section 
Index 
Description 
Title and trial 
registration 
1a 
 
1b 
ImpleMenting PhArmacogenetiC Testing in Gastrointestinal Cancers 
(IMPACT-GI); IRB #844763 (Original approval date 12/18/2020) 
Clinical trials.gov NCT 04736472 (registration date: January 29, 2021) 
SAP version 
2 
SAP Version 1.0 May 2024 
Protocol version 
3 
Protocol Version 6.0 Date 
SAP revision 
4 
n/a 
SAP 
contributors 
5 
Sony Tuteja, PharmD, Co-PI 
Ursina Teitelbaum, MS, Co-PI 
Xingmei Wang, Biostatistician 
Signatures 
6 
Sony Tuteja  
 
Ursina Teitelbaum 
 
Xingmei Wang 
 
Abbreviations 
7 
EHR        electronic health record  
TAT         turnaround time 
TRAE      treatment related adverse event  
 
 
 
 
 
 
 
 
 

Section 2: Introduction 
Section 
Index 
Description 
Background 
and 
introduction 
7 
 There are known pharmacogenetic (PGx) variants in the DPYD and 
UGT1A1 genes associated with altered drug metabolism and 
prolonged drug exposure resulting in drug-related adverse events 
from fluoropyrimidine and irinotecan therapy. Up to 30% of 
patients develop severe fluoropyrimidine-related toxicity, such as 
diarrhea, hand-foot syndrome, mucositis, and myelosuppression at 
standard doses. Similarly, as many as 20-35% of patients treated 
with irinotecan may experience severe toxicities, ranging from 
diarrhea to myelosuppression. Given the life-threatening nature of 
severe adverse events, hospitalizations are often indicated which 
result in additional resource utilization costs. Subsequently, 
chemotherapy-related adverse events often lead to treatment 
delays or discontinuations that may impact tumor prognosis. 
However, testing for these variants is not routinely performed in 
clinical practice prior to the initiation of chemotherapy due to lack 
of a clinical assay with rapid turnaround time (TAT) and challenges 
in integrating genetic test results within the electronic health 
record (EHR). We hypothesize that providing clinicians with the 
ability to order rapid turnaround PGx test results along with 
specific dosing recommendations will increase the utilization of 
PGx tests to guide pharmacotherapy decisions and improve patient 
drug related outcomes. This is a non-randomized implementation 
study to determine the feasibility of establishing and integrating a 
PGx test into clinical care to guide chemotherapy in patients with 
gastrointestinal (GI) cancers. Effectiveness of the PGx-guided 
approach will be determined by comparing the incidence of severe 
treatment related adverse events to historical control group of GI 
cancer patients enrolled into the Penn Medicine Biobank (PMBB).  
Objectives 
and endpoints 
8 
Implementation Aims: 
1. To determine the feasibility of returning PGx results prior 
to the first dose of chemotherapy. 
2. To determine the fidelity to the PGx guided dosing 
recommendations. 
3. To determine the rate of testing among providers with 
patients eligible for testing  
Effectiveness Aims: 
4. To determine if providing PGx test results will decrease the 
number of patients experiencing severe treatment related 
events during the first six cycles of chemotherapy. 

5. To determine if providing PGx test results will improve 
patient reported outcomes (PRO) during the first six cycles 
of chemotherapy. 
Hypothesis 
9 
Providing clinicians with the ability to order a PGx test with a rapid 
turnaround time for results, along with specific dosing 
recommendations, will increase the utilization of PGx tests to 
guide pharmacotherapy decisions and improve patient drug 
related outcomes. 
 
 
 

Section 3: Study Methods 
Section 
Index 
Description 
Trial design 
10 
Non-randomized, prospective, open-label implementation study to 
determine the feasibility of establishing and integrating a PGx test 
into clinical care. 
Randomization 
11 
n/a 
Sample size 
12 
No sample size calculation was performed for this feasibility study 
with pragmatic inclusion of eligible participants recruited over a 
20- month period (Mar 2021- Dec 2022).  
Interim analyses 
13 
No interim analyses planned 
Timing of final 
analysis 
14 
Participants were followed until May 31, 2023, for toxicity 
assessments with an intention of 6-month follow-up for each 
participant. All analyses were performed collectively in May-June 
of 2024. 
Timing of outcome 
assessments 
15 
Serial questionnaires assessing patient reported outcomes (PROs) 
for symptoms associated with to adverse events will be 
prospectively collected by the study team at the time of each 
treatment for the first 6 cycles.  
 
 
 

Section 4: Statistical Principles 
Section 
Index 
Description 
Confidence 
intervals and p-
value 
16 
No hypothesis testing was performed for the primary outcome 
(feasibility) or secondary implementation outcomes (fidelity, 
penetrance). 
Descriptive statistics (mean, SD, median, interquartile range, range, 
counts, and percentage) will be used to describe and compare (t-
test or rank sum test for continuous variables and Fisher’s exact 
test for categorical variables) baseline characteristics between the 
historical control group and PGx arms.  
For the effectiveness aims, significance was set at an alpha=0.05. 
No corrections were made for multiple testing. Confidence 
intervals pertaining to the odds of experiencing a severe TRAE 
were reported. 
Adherence and 
protocol 
deviations 
17 
• 
Removal of inclusion criteria of ECOG status, patients with 
higher ECOG status (3 or 4) still suitable for treatment with 
fluoropyrimidines. Oncologist will determine suitability for 
treatment with fluoropyrimidines on a case-by-case basis. 
• 
Removal of inclusion criteria of prior treatment of 
fluoropyrimidines, physicians have expressed interest in 
obtaining genotype information regardless of a patient’s 
prior treatment status, and particularly for individuals with 
previous intolerance of fluoropyrimidine to guide future 
treatment decisions. Participants that received the PGx 
test after initiation of chemotherapy, due to requests by 
the treating oncologist, were not included as part of the 
primary analysis and were reported/described separately 
and noted as protocol deviations. 
• 
Updated timeframe for endpoint collection, feasibility 
endpoint time frame revised from ‘7 days’ to ‘prior to the 
first dose of chemotherapy’. Seven days is less clinically 
relevant than patient-specific treatment schedules. 
adverse event data and PRO questionnaires to be 
collected over first six cycles, not months. It is not 
necessary to collect AE data over the longer time period 
for study purposes given that chemotherapy toxicity is 
typically experienced during initial cycles. 
• 
Prospective completion of chemotherapy related toxicity 
per the National Cancer Institute-Common Terminology 
Criteria for Adverse Events (NCI-CTCAE) was not feasible 
due to a lack of a consistent research coordinator 
throughout the study. In addition, the completion rate for 
the PROs was very low (22%) therefore we could not 
assign a grade to the adverse event. Revised definition 
severe toxicities from ≥ Grade 3 toxicities to treatment 
related adverse events requiring treatment in the hospital, 
emergency department, or oncology evaluation center.   

 
Analysis 
population 
18 
Modified intent to treat, removing participants that did not meet 
the inclusion criteria (i.e., received PGx test after chemotherapy or 
did not receive qualifying chemotherapy agent). 
 
Section 5: Trial population 
Section 
Index 
Description 
Screening data 
21 
 Clinic schedules will be screened by the clinical research 
coordinator for new patients with GI cancer being evaluated for 
treatment. Screen failures in this study will be defined as 
participants who meet criteria for study enrollment but decline to 
participate or the treating oncologist declines participation of their 
patient in the study. A minimal set of screen failure information is 
required to ensure transparent reporting of screen failure 
participants, to meet the Consolidated Standards of Reporting 
Trials (CONSORT) publishing requirements and to respond to 
queries from regulatory authorities. Minimal information includes 
demography, screen failure details, and eligibility criteria. 
Eligibility 
22 
Inclusion criteria: 
1. Able and willing to provide informed consent 
2. Pathologically confirmed gastrointestinal malignancy for 
which treatment with a fluoropyrimidine and/or 
irinotecan is indicated 
3. Willing to undergo blood or saliva sampling for PGx 
testing and comply with all study-related procedures 
4. Life expectancy of at least 6 months 
Exclusion criteria: 
1. Prior treatment with irinotecan 
2. DPYD or UGT1A1 genotype already known 
3. Severe renal or hepatic impairment (or unacceptable 
laboratory values), including:  
• 
Neutrophil count of <1.5 x 109/L, platelet count of 
<100 x 109/L 
• 
Hepatic function as defined by serum bilirubin 
>1.5 x upper limit of normal (ULN), alanine 
aminotransferase (ALT), and aspartate 
aminotransferase (AST) >2.5 x ULN, or in case of 
liver metastases ALT and AST>5 x ULN 
• 
Renal function as defined by serum creatinine >1.5 
x ULN, or creatinine clearance <60 ml/min (by 
Cockcroft-Gault Equation) 
4. Women who are pregnant or breast feeding, or subjects 
who refuse to use reliable contraceptive methods 
throughout the study 
5. Treating physician does not want subject to participate 
 

Recruitment 
23 
 Prior to the scheduled visit, the research coordinator will notify 
the treating oncologist about potential eligible participants and 
remind them of the study. The treating oncologist will discuss the 
study with the patient during the evaluation visit and consent will 
be obtained by the treating GI oncology provider (physician or 
advanced practice provider) or the research coordinator. This will 
occur in person or by remote consent. Patients will be given a copy 
of the official informed consent form and an opportunity to ask 
questions. Patients will be given sufficient time to consider 
participating in the trial. 
Withdrawal/follow-
up 
24 
 Participants are free to withdraw from participation in the study at 
any time upon request, without prejudice to their medical care, 
and are not obliged to state their reasons. The study investigator 
may discontinue or withdraw a patient from the study at any time 
for the following reasons: pregnancy, patient transfers care outside 
of Penn Medicine, treating oncologist wishes patient to withdraw. 
The reason for participant discontinuation or withdrawal from the 
study will be recorded on the patient’s Case Report Form (CRF). 
Subjects who sign the informed consent form but do not undergo 
genotyping may be replaced. 
A participant will be considered lost to follow-up if he or she fails 
to return for completion of scheduled chemotherapy infusion 
appointments. There are no study specific visits. Data is collected 
at the time of usual clinic visit and from the medical record. The 
research coordinator will contact the treating oncologist and 
ensure the reason for not returning is not a (serious) adverse event 
((S)AE). If treatment is prematurely discontinued, the primary 
reasons for discontinuation must be recorded in the patient’s file 
and all efforts will be made to complete and report the 
observations as thoroughly as possible. 
Information will be extracted from the medical records and/or 
tumor registry at the 6-month (+ 2 months) follow-up period if 
performed as part of usual care and recorded in the medical 
record. 
Baseline patient 
characteristics 
25 
 The following information will be obtained at screening and from 
the patient medical record if performed as part of usual care and 
available in the medical record:  
• 
Signed informed consent form 
• 
Inclusion and exclusion criteria 
• 
Demographic data: age, gender, race/ethnicity 
• 
Cancer history: GI tumor type, stage, previous cancer 
treatments, number of lines of therapy 
• 
Routine physical examination: ECOG performance status 
(see Appendix 14.2), height (cm), weight (kg) 
• 
Vital signs: heart rate, blood pressure 

• 
Hematology: hemoglobin, hematocrit, white blood cell 
count, ANC, neutrophils, eosinophils, basophils, 
lymphocytes, monocytes, platelets 
• 
Clinical chemistry: sodium, potassium, calcium, glucose, 
creatinine, BUN, AST, ALT, alkaline phosphatase, total 
bilirubin, albumin 
• 
Creatinine clearance (using Cockcroft-Gault formula) 
• 
Concomitant medications (including dose, unit, frequency, 
route of administration and indication) 
 
 

Section 6: Analysis 
Section 
Ind
ex 
Description 
Outcome 
definitions 
26 
1. Primary outcome: 
Feasibility: the number and proportion of tests returned prior to the first dose 
of chemotherapy.  
 
2. Secondary outcomes: 
a. Fidelity – proportion of dose proportion of dose modifications made in 
agreement with the genotype guided dosing recommendations at the first 
dose. 
b. Penetrance- proportion of tests orders compared with the number of 
patients treated with study chemotherapy. 
c. Treatment-related adverse events - proportion of patients experiencing a 
serious chemotherapy related toxicity defined as requiring hospitalization, 
visit to the emergency department or oncology evaluation center (OEC). 
d. Relative dose intensity - cumulative dose administered divided by the 
anticipated cumulative dose over six cycles reported as mg/m2. 
e. Patient reported outcomes (PROs) during the first six cycles of chemotherapy. 
f. Patient knowledge and attitudes towards PGx testing. 
 
Analysis 
methods 
27 
1. Primary outcome: 
We will report the number and proportion of tests returned prior to the first 
dose of chemotherapy in the prospective testing arm only as this outcome was 
not relevant for the historical control group. The proportions were compared 
among clinical sites using a chi-square test. The test turn-around time was 
reported as median (interquartile range) and compared using the Wilcoxon 
rank-sum test. 
 
2. Secondary outcomes: 
a. Fidelity- proportion of dose modifications made in agreement with the 
genotype guided dosing recommendations at the first dose was reported, 
no hypothesis testing was performed. 
b. Penetrance- proportion of tests orders divided by the number of patients 
eligible for testing based on pharmacy records indicating the number of 
fluoropyrimidine prescriptions during the enrollment time frame, no 
hypothesis testing was performed. 
c. Treatment-related adverse events (TRAE): proportion of patients 
experiencing a severe treatment related adverse event defined as those 
requiring hospitalization, visit to the emergency department, or visit to the 
oncology evaluation center (OEC). The proportion of patients with severe 
TRAEs in the prospective cohort were compared between the DPYD variant 
carriers vs DPYD wild-type patients. The proportion of patients with TRAEs 
were compared between the prospective and historical control groups 
among DPYD variant carriers. The proportion of patients with TRAEs in the 
prospective cohort were compared between the UGT1A1 poor 
metabolizers vs UGT1A1 normal and intermediate metabolizers. The 

proportion of patients with TRAEs were compared between the 
prospective and historical control groups among UGT1A1 poor 
metabolizers. Chi-square tests were used for all comparisons. Factors 
contributing to having a TRAE were evaluated using a multivariable logistic 
regression model adjusting for age, sex, race, tumor type, ECOG score, 
presence of metastases, intent of treatment, DPYD phenotype, and 
UGT1A1 phenotype using a stepwise approach. 
d. Relative dose intensity for fluoropyrimidines and irinotecan, defined as 
cumulative dose administered divided by the anticipated cumulative dose 
over six cycles reported as mg/m2 was compared between variant carriers 
and wild-type patients (or PM vs. IM/NM for irinotecan) in the prospective 
cohort using t-tests. Relative dose intensity for fluoropyrimidines and 
irinotecan, was compared between the prospective and historical control 
groups in variant carriers (or PM for irinotecan) using t-tests. 
e. Patient reported outcomes (PROs) during the first six cycles of 
chemotherapy were compared in the prospective cohort between DPYD 
variant carriers and wild-type patients using chi-square tests in the subset 
that completed PROs. 
f. 
Patient knowledge and attitudes towards PGx testing were evaluated using 
chi-square and t-tests as appropriate. 
Missing 
data 
28 
a. Prospective completion of chemotherapy related toxicity per the National 
Cancer Institute-Common Terminology Criteria for Adverse Events (NCI-
CTCAE) was not feasible due to a lack of a consistent research coordinator 
throughout the study. In addition, the completion rate for the PROs was 
very low therefore we could not assign a grade to the adverse event.  
b. Revised definition severe toxicities from ≥ Grade 3 toxicities to treatment 
related adverse events requiring treatment in the hospital, emergency 
department, or oncology evaluation center.   
Additional 
analyses 
29 
a. The number of treatment modifications (i.e., delay of treatment or dose 
reduction) and treatment discontinuations in the prospective cohort were 
compared between the DPYD variant carriers vs DPYD wild-type patients using chi-
square tests. These outcomes were also compared between the prospective and 
historical control groups among DPYD variant carriers. These analyses were also 
performed for the UGT1A1 phenotype. 
b. Overall survival at one year was reported for the prospective and historical 
cohorts. 
Harms 
30 
No harms of the genotyping intervention were reported. 
Statistical 
software 
31 
SAS version 9.4 and R version 4.2.3 
References 
32 
1. Henricks LM, Lunenburg CATC, De Man FM, et al. DPYD genotype-guided dose 
individualisation of fluoropyrimidine therapy in patients with cancer: a 
prospective safety analysis. The Lancet Oncology. 2018;19(11):1459-1467. 
doi:10.1016/S1470-2045(18)30686-7 
2. Amstutz U, Henricks LM, Offer SM, et al. Clinical Pharmacogenetics 
Implementation Consortium (CPIC) Guideline for Dihydropyrimidine 

Dehydrogenase Genotype and Fluoropyrimidine Dosing: 2017 Update. Clin 
Pharmacol Ther. 2018;103(2):210-216. doi:10.1002/cpt.911 
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f 
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bl.pdf