The HER Project: Homologous Recombination Deficiency in EGFR-Mutated NSCLC, a Retrospective and Prospective Translational Single-center Study
Conditions: EGFR, Non Small Cell Lung Cancer, Homologous Recombination Deficiency, PARP Inhibitor
Sponsor: IRCCS San Raffaele

 
 
CTC 021OP/1  
 
CONFIDENTIAL 
 
 
 
Page 1 of 26 
 
 
 
 
CLINICAL STUDY PROTOCOL 
 
Study Code: The HER Project 
 
 
Title: The HER Project: Homologous Recombination Deficiency in EGFR-Mutated NSCLC, a retrospective 
and prospective translational single-center study 
 
 
Principal Investigator: Francesca Rita Ogliari, MD 
 
 
 
 
 
 
 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 2 of 26  
CLINICAL STUDY PROTOCOL 
Title: The HER Project: Homologous Recombination Deficiency in EGFR-Mutated NSCLC, a retrospective and 
prospective translational single-center study 
 
 
DISCLAIMER 
This material is strictly private, confidential and property of the Sponsor. Its contents must not be disclosed or used 
except as authorized in writing by the Sponsor. 
 
 
Study Identifier 
The HER Project 
 
RSO number 
N/A 
Other Protocol Codes 
N/A 
Version 
1.0 
Date 
30/SEP/2025 
 
 
Sponsor 
IRCCS Ospedale San Raffaele 
Via Olgettina, 60 
20132 – Milano, Italy 
Authorized 
Sponsor 
Representative 
Prof. Michele Reni 
Head of Medical Oncology Unit 
IRCCS Ospedale San Raffaele 
Authorized Co-Sponsor 
Representative 
N/A 
Funding Source(s) 
Medical Oncology internal Funding (Eredità Buffa) 
 
Principal Investigator 
Francesca Rita Ogliari, MD 
Medical Oncologist 
IRCCS Ospedale San Raffaele 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 3 of 26  
VERSION HISTORY 
 
 
 
Protocol version 
n. 
Reason of changes 
Date issued 
1.0 
First version submitted to the Ethics Committee (EC) 
 
 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 4 of 26  
PROTOCOL SIGNATURE PAGE 
 
Study Title: The HER Project: Homologous Recombination Deficiency in EGFR-Mutated NSCLC, a retrospective 
and prospective translational single-center study  
Study Code: The HER Project 
Protocol Version and Date: Version 1.0 30/SEP/2025 
 
The undersigned has read and understood all the aspects of the protocol detailed within this document and agrees to 
supervise and conduct the study in accordance with the protocol, the Declaration of Helsinki, Guideline for Good 
Clinical Practice ICH E6 (R2), and all applicable regulatory requirements. 
 
 
Dott.ssa Francesca Rita 
Ogliari 
 
 
 
IRCCS Ospedale San 
Raffaele 
 
 
Principal Investigator 
Name 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signature 
 
Affiliation 
 
Date 
 
 
 
 
 
 
 
 
 
 
 
 
Prof. Michele Reni 
 
 
 
IRCCS Ospedale San 
Raffaele 
 
 
Authorized Sponsor 
Representative Name 
 
 
 
Signature 
 
Affiliation 
 
Date 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 5 of 26  
 
TABLE OF CONTENTS 
1. 
KEY STUDY CONTACTS ................................................................................................................................... 7 
2. 
SYNOPSIS ............................................................................................................................................................ 8 
3. 
ABBREVIATIONS AND DEFINITIONS .......................................................................................................... 11 
3.1. 
Abbreviations ......................................................................................................................................... 11 
3.2. 
Definitions .............................................................................................................................................. 11 
4. 
BACKGROUND AND RATIONALE ................................................................................................................ 13 
5. 
OBJECTIVES AND ENDPOINTS ..................................................................................................................... 14 
6. 
STUDY DESIGN ................................................................................................................................................ 15 
6.1. 
Study duration ........................................................................................................................................ 15 
7. 
STUDY POPULATION ...................................................................................................................................... 15 
7.1. 
Study Participants ................................................................................................................................... 15 
7.2. 
Inclusion Criteria .................................................................................................................................... 15 
7.3. 
Exclusion Criteria ................................................................................................................................... 15 
7.4. 
Screening Failures .................................................................................................................................. 15 
8. 
STUDY OBJECT  ............................................................................................................................................... 16 
8.1. 
Study object description ......................................................................................................................... 16 
9. 
STUDY PROCEDURES ..................................................................................................................................... 17 
9.1. 
Informed Consent ................................................................................................................................... 18 
9.2. 
Subject Recruitment and Screening ........................................................................................................ 18 
9.3. 
Subject Identification .............................................................................................................................. 18 
9.4. 
Baseline Assessments ............................................................................................................................. 18 
9.5. 
Visits and Follow Up .............................................................................................................................. 18 
9.6. 
Definition of End of Study ..................................................................................................................... 19 
9.7. 
Premature termination or suspension of a study ..................................................................................... 19 
10. 
DISCONTINUATION AND WITHDRAWAL .............................................................................................. 19 
11. 
SAMPLE HANDLING ................................................................................................................................... 19 
12. 
PATIENT SAFETY ........................................................................................................................................ 20 
13. 
DATA MANAGEMENT ................................................................................................................................ 20 
13.1. 
Definition of source data and source documents .................................................................................... 20 
13.2. 
Documentation of data in Case Report Forms (CRFs) ........................................................................... 20 
13.3. 
Data Recording and Record Keeping ..................................................................................................... 20 
13.4. 
Data Protection ....................................................................................................................................... 21 
14. 
STATISTICS ................................................................................................................................................... 21 
14.1. 
Description of Statistical Methods .......................................................................................................... 21 
14.2. 
Sample Size Determination .................................................................................................................... 21 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 6 of 26  
14.3. 
Analysis Populations .............................................................................................................................. 22 
15. 
ETHICAL AND REGULATORY CONSIDERATIONS ............................................................................... 22 
15.1. 
Responsibilities of the Investigator(s) .................................................................................................... 22 
15.2. 
Ethics Committee (EC) Approvals ......................................................................................................... 23 
15.3. 
Other Ethical Considerations .................................................................................................................. 23 
16. 
GENDER MEDICINE IN RESEARCH PROTOCOL ................................................................................... 23 
17. 
QUALITY ASSURANCE AND QUALITY CONTROL .............................................................................. 23 
17.1. 
Deviation from study protocol ................................................................................................................ 23 
17.2. 
Surveillance for observational studies with additional procedure .......................................................... 23 
18. 
FINANCE AND INSURANCE ...................................................................................................................... 23 
18.1. 
Funding ................................................................................................................................................... 23 
18.2. 
Patient Insurance..................................................................................................................................... 24 
19. 
END OF CLINICAL STUDY ......................................................................................................................... 24 
19.1. 
Summary of the results of the clinical study ........................................................................................... 24 
20. 
INTELLECTUAL PROPERTY ...................................................................................................................... 24 
21. 
PUBLICATION POLICY ............................................................................................................................... 24 
22. 
REFERENCES ................................................................................................................................................ 24 
23. 
APPENDIX A:  AMENDMENT HISTORY .................................................................................................. 25 
24. 
APPENDIX B:  LIST OF CLINICAL SERVICES / LABORATORIES ....................................................... 25 
25. 
APPENDIX C:  LIST OF ENROLLING SITES ............................................................................................. 26 
 
 
 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 7 of 26  
1. KEY STUDY CONTACTS 
 
Sponsor 
Ospedale San Raffaele 
Via Olgettina, 60 
20132 – Milano, Italy 
Authorized Sponsor 
Representative 
Prof. Michele Reni 
Head of Medical Oncology Unit 
IRCCS Ospedale San Raffaele 
reni.michele@hsr.it 
Principal Investigator 
Francesca Rita Ogliari, MD 
Medical Oncologist 
IRCCS Ospedale San Raffaele 
ogliari.francesca@hsr.it 
Study Clinical Unit  
Medical Oncology Unit  
 
Participant Clinical Units  
Pathology Unit, Lung cancer research lab (Experimental Oncology Division) 
Funding source(s) 
Medical Oncology internal Funding (Eredità Buffa) 
Clinical Trial Center 
Email: ctc.firstcontact@hsr.it; ctc.trialstartup@hsr.it; ctc.datamanagement@hsr.it; 
ctc.quality@hsr.it 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 8 of 26  
2. SYNOPSIS 
Study Identifier 
The HER Project 
Study Title 
The HER Project: Homologous Recombination Deficiency in EGFR-
Mutated NSCLC, a retrospective and prospective translational single-center 
study 
Protocol Version and Date 
Ver 1.0 – 30/SEP/2025 
Sponsor  
IRCCS Ospedale San Raffaele 
Via Olgettina, 60 
20132 – Milano, Italy 
Co-Sponsor  
N/A 
Funding Source(s) 
Medical Oncology internal Funding (Eredità Buffa) 
Principal Investigator 
Francesca Rita Ogliari, MD 
Medical Oncologist 
IRCCS Ospedale San Raffaele 
Study Description 
The study aims to evaluate the prevalence of homologous recombination 
deficiency (HRD) in metastatic EGFR-mutated NSCLC and to assess its 
correlation with clinical and molecular features. Based on the hypothesis that 
HRD identifies a distinct EGFRm subgroup with prognostic value and a 
potential sensitivity to PARP inhibitor–based strategies, translational analysis 
will be performed with multiple pre-clinical models, ranging from human 
cancer cells to murine models.  
Study Design 
Observational, retrospective and prospective single-center study  
Primary Objective 
To evaluate prevalence of HRD in 
our internal cohort of metastatic 
EGFRm NSCLC 
Primary Endpoint 
Proportion of EGFRm NSCLC 
with an HRD positive score 
evaluated by AmoyDx HRD 
Panel or similar (GSS ≥ 50). 
 
 Time point(s)  
At T0 on baseline tumour samples 
 
Secondary Objectives 
To assess correlations between 
HRD score (pos/neg) and: 
- 
Clinical variables (PFS, 
OS, metastatic sites) 
- 
Molecular events (type of 
EGFR mutations, VAF, 
drug 
resistance 
mechanisms 
i.e. 
gene 
amplification)  
 
Secondary Endpoints 
 Overall 
survival 
(OS), 
Progression-free 
survival 
(PFS), 
tumour 
genomic 
mutations.  
 
 
Time point(s)  
At T0 on baseline tumour samples 
 
Exploratory Objectives 
- 
To assess the efficacy of  
osimertinib 
and 
olaparib 
combination 
in 
TKI-naïve 
EGFRm NSCLC cell lines 
(HCC-4006, HCC-827, and 
HCC-2935, ranging from low 
to high HRD score); 
- 
To test the drug combination 
in patient-derived models of 
EGFRm tumours (PBMCs, 
organoids, and PDXs); 
Tumor 
growth, 
cellular 
viability, drug toxicity. 
 
N/A 
 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 9 of 26  
- 
To rule out toxicity the drug 
combination 
and 
assess 
treatment response, thanks to 
our 
immune 
competent 
GEMM model of EGFRm16 
and TP53 wt/null. 
Study Population 
Adult patients (≥18 years) with metastatic EGFR-mutated non-small cell lung 
cancer (NSCLC) eligible for treatment with EGFR-TKI according to standard 
clinical practice, with available tumor tissue suitable for HRD testing. 
Inclusion Criteria 
The population of interest will include patients affected by EGFR-mutated 
NSCLC. Individuals must meet all the following inclusion criteria in order to 
be eligible to participate in the study: 
1. Participant is willing and able to give informed consent for participation in 
the study. However, concerning the retrospective cohort, the large sample 
sizes needed and considering that the disease involved in this study affects 
elderly subjects with co-morbidities and presents a significant mortality rate 
based on the stage of the disease, deceased and untraceable patients will also 
be included.  
2. Age ≥18 years old 
3. Have a metastatic histologically confirmed NSCLC  
4. Presence of EGFR common mutations (i.e. ex19del and L858R) 
5. Patients treated in first-line setting with 4th generation EGFR-TKI inhibitors 
(i.e. osimertinib, lazertinib) or beyond 
6. Have archival tumor tissue suitable for HRD testing with AmoyDx Focus 
panel or similar 
7. Survival follow-up available (for retrospective cohort) 
Exclusion Criteria 
All individuals meeting any of the following exclusion criteria at baseline will 
be excluded from the study participation: 
 1. Insufficient baseline tumour tissue (unsuitable for HRD scoring) 
2. Presence of EGFR uncommon mutations (i.e. ex20ins) 
3. Known presence of co-occurring uncommon EGFRm, ALK, ROS1, or 
oncogenic drivers. 
STUDY OBJECT 
DRUG 
Sample Size  
N= 100 Total sample size (N=50 retrospective cohort; N=50 prospective 
cohort) 
Statistical Design 
According to the literature, to obtain an adequate number of patients to allow 
subgroup analyses and explore clinical and molecular correlations, we 
calculated a sample size of 100 patients (50 retrospective; 50 prospective) to 
conduct an exploratory proof-of-concept study, in which we expect to observe 
around 25 HRD-positive cases (the precision of the estimate corresponds to a 
95% confidence interval with a half-width of approximately 8.5 percentage 
points, which is considered clinically relevant). Based on the historical 
caseload at IRCCS Ospedale San Raffaele (≈15 eligible patients/year), 
recruiting the planned sample over 4 years is feasible. For the retrospective 
cohort, we estimate that ≈30% of patients have insufficient residual archival 
tumor tissue, therefore the planned 50 patients will be included considering a 
longer interval (1/1/2020 - 30/09/2025).   
For the Primary and Secondary Objectives, continuous variables will be 
summarized using mean, median, range, and standard deviation. Categorical 
variables will be described using frequency and percentage. To test 
association between categorical variables, chi-squared test will be applied. To 
compare survivals between groups (i.e. HRD positive vs negative, cut-offs to 
be explored) log-rank test will be applied. Time-to-event outcomes will be 
represented using Kaplan-Meier curves.  

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 10 of 26  
 
For the Exploratory Objectives, parametric and non-parametric analyses will 
be used to compare differences in cell lines and phenotypes between groups. 
For the in vivo studies, differences in tumour size and phenotype will be 
evaluated at different timepoints and compared with t-test. For all statistical 
tests, p < 0.05 will be considered statistically significant. 
Duration of the Study 
Duration of enrolment: 4 years, starting from ethical approval 
Duration of total study period: 7 years, including 4 years of enrolment and 3 
years of follow-up (01/01/2026-31/12/2032). Based on historical caseload at 
IRCCS Ospedale San Raffaele, we estimate an average of ≃ 15 EGFRm 
metastatic NSCLC patients eligible per year. 
Retrospective data collection will include patients respecting the eligibility 
criteria from 1/1/2020 to 30/09/2025.  

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 11 of 26  
3. ABBREVIATIONS AND DEFINITIONS 
3.1. Abbreviations 
 
AE 
Adverse event 
CRF 
Case Report Form 
CRO  
Contract Research Organization 
CTC 
Clinical Trial Center 
DPIA 
Data Protection Impact Assessment 
EC 
Ethics Committee 
EGFR 
Epidermal Growth Factor Receptor 
GCP 
Good Clinical Practice 
GSS 
Genomic Scarring Score 
HRD 
Homologous Recombination Deficiency 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonization 
NSCLC 
Non-small cell lung cancer 
OS 
Overall Survival 
OSR 
Ospedale San Raffaele 
PARP inhibitors 
Poly (ADP-ribose) polymerase inhibitors 
PDX 
Patient-derived xenograft 
PFS 
Progression-Free Survival 
PI 
Principal Investigator 
SOP 
Standard Operating Procedure 
TKI 
Tyrosine Kinase Inhibitor 
 
 
 
 
 
 
 
3.2. Definitions 
 
AmoyDx® HRD 
Focus Panel 
A homologous recombination deficiency (HRD) test designed to simultaneously detect 
genetic aberrations of BRCA1 and BRCA2 genes and HRD status [0]. 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 12 of 26  
 
GSS  
A machine learning-based model which assesses genomic instability by analyzing 
different types of copy number events across the genome [0]. It can be calculated as the 
sum of the events of loss of heterozygosity (LOH), large-scale state transition (LST) and 
telomere allele imbalance (TAI) [20]. 
HRD  
A condition linked to an impaired DNA repair mechanism that contributes to genomic 
instability.  
PDX 
A type of cancer model in which tumour tissues or cells from patients are implanted into 
immunodeficient or humanized mice.  
 
 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 13 of 26  
4. BACKGROUND AND RATIONALE 
Introduction  
Lung cancer is the most common diagnosed cancer, with almost 2.5 million new cases per year, and the leading cause 
of cancer-related death (18.7%), according to GLOBOCAN (2022) [1,2]. Non-small cell lung cancer (NSCLC) is the 
most prevalent subtype, accounting for 85% of lung cancers [2]. Epidermal growth factor receptor (EGFR) is a 
transmembrane tyrosine kinase receptor that regulates survival, proliferation and differentiation in mammalian cells 
[3]. EGFR mutations occur in around 30% of patients affected by NSCLC, representing the second most frequent 
targetable oncogenic driver in NSCLC [4,5].  
  
The treatment landscape for metastatic EGFR-mutated (EGFRm) NSCLC has significantly evolved since the 
introduction of 1st generation tyrosine kinase inhibitors (TKIs) in 2010. While osimertinib (a 3rd generation TKI) is 
currently the standard first-line treatment worldwide in the advanced setting, emerging combination strategies, such as 
osimertinib plus chemotherapy (FLAURA2 trial) [6] or lazertinib plus amivantamab (MARIPOSA trial) [7], improved 
progression-free survival (PFS) and overall survival (OS) compared to TKI alone. However, these drug combinations 
often cause increased treatment-related toxicities, impacting both patients' quality of life and healthcare costs [8]. For 
this reason, it becomes crucial to identify predictive biomarkers to guide patient selection for combination therapies. 
For example, post-hoc analyses of FLAURA2 were conducted on poor-risk populations, such as EGFRm patients with 
high tumour burden or TP53 co-mutations [9,10]. Despite better outcomes of chemotherapy plus osimertinib across all 
patient subgroups, only 1 out of 4 patients had baseline tissue samples available for wider genome sequencing. 
Therefore, understanding the role of co-alterations in EGFRm tumours remains to be explored, particularly those 
associated with shorter OS and/or more aggressive clinical presentations. 
  
Targeting HRD pathway with PARP-inhibitors in Non-small cell lung cancer 
Homologous recombination deficiency (HRD) is a condition linked to an impaired DNA repair mechanism that 
contributes to genomic instability in several cancers, including NSCLC. PARP-inhibitors (PARPi), drugs targeting a 
key protein involved in DNA repair, are already available in clinical practice for the treatment of other HRD-positive 
subgroups of solid tumours (e.g. breast, ovarian, prostate cancer) [11]. In NSCLC, however, their clinical benefit 
remains unclear. Previous studies evaluating PARPi in NSCLC, including combinations with chemotherapy or 
immunotherapy, have shown modest or non-significant improvements in PFS and OS [12, 13, 14, 15, 16]. However, a 
significant limitation of these studies is the lack of HRD status assessment, which may have diluted the expected 
benefits in HRD-positive patients.  
Interestingly, emerging evidence suggests that a higher Genomic Scarring Score (GSS), a surrogate for HRD, may 
predict PARPi sensitivity better than the traditional assessment of the mutational status of homologous recombination 
repair (HRR) genes [17]. In this study, the administration of PARPi significantly delayed tumour growth in patient-
derived xenograft (PDXs) with high GSS, half of which carried pathogenic/likely pathogenic somatic HRR mutations 
[17]. Importantly, favourable responses to the PARPi-olaparib were observed regardless of HRR gene mutation status, 
underscoring the potential of GSS as a robust biomarker to more effectively select patients for PARPi-based therapies 
[17]. 
  
HRD in EGFR mutated NSCLC 
In a Chinese cohort of HRD-positive NSCLC, EGFR-mutated tumours are associated with poor TKI response [18], 
which might be explained by gene amplifications like MET, a common resistance mechanism that can be promoted by 
HRD [19]. Studies also showed the co-occurrence of biallelic TP53 mutations and high HRD score in poor-risk 
EGFRm NSCLC, suggesting a link between this tumour genotype and TKI-resistance [20]. In preclinical models of 
NSCLC, osimertinib-resistant EGFRm cell lines exhibited sensitivity to olaparib , leading to increased DNA damage 
and cell death via a pro-oxidant state. Moreover, combining osimertinib with a PARPi in vivo significantly improved 
tumour regression compared to osimertinib alone [21]. Altogether, these findings lead to hypothesize that the HRD 
positive score/GSS may define a patient subgroup that could benefit from PARPi-based combination therapy. 
Clinical trials evaluating EGFR-TKIs with PARPi failed to achieve their primary endpoint of PFS, possibly due to a 
lack of patient selection based on HRD score or other molecular criteria [22]. However, subsequent analyses of the 
GOAL trial found a stronger synergy between gefitinib (a 1st generation TKI) and olaparib in tumours with higher 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 14 of 26  
BRCA1 expression [23], supporting a predictive role for targeting DNA damage repair pathways. In operable NSCLCs, 
the percentage of HRD positive tumours is ~20-30% [24], suggesting that the acquisition of HRD status could be an 
early event. Importantly, a similar incidence was observed in a Chinese cohort of any-stage EGFRm or ALK-
rearranged NSCLC patients in which the cases with high HRD score are ~33% of the total [18]. The sensitivity of 
EGFRm tumours to platinum-based doublets [25], which is a known characteristic of HRD-positive tumours, and a 
larger compendium evidence of chromosomal instability further support exploring the role of HRD in EGFR-mutated 
lung cancer, paving the way for new targeted therapeutic approaches [26].   
The HER Project 
With the HER project, we will investigate the role of HRD and genomic instability (GSS) in EGFRm NSCLC by i) 
defining the fraction of metastatic EGFRm tumours with HRD positive score, ii) correlating HRD score with patient 
outcomes, and iii) assessing the synergic efficacy of EGFR-TKIs plus PARPi based on the HRD score in different 
preclinical settings, ranging from cell lines to a murine model of spontaneous EGFRm lung cancer. We expect that this 
drug combination will be effective in a specific subset of EGFR tumors. However, even if we won’t observe any 
relevant findings by targeting this pathway, our work will increase our knowledge about DNA damage repair and drug 
resistance in EGFRm tumours. 
 
5. OBJECTIVES AND ENDPOINTS 
Objectives 
Endpoints 
Time point(s)  
Primary Objective 
To evaluate prevalence of HRD in 
our internal cohort of metastatic 
EGFRm NSCLC 
 
Primary Endpoint 
Proportion of EGFRm NSCLC with an HRD 
positive score evaluated by AmoyDx HRD 
Panel or similar (GSS ≥ 50). 
 
At T0 on baseline 
tumour samples 
Secondary Objectives 
To assess correlations between HRD 
score (pos/neg) and: 
- 
Clinical variables (PFS, OS, 
metastatic sites) 
- 
Molecular events (type of 
EGFR mutations, VAF, drug 
resistance mechanisms i.e. 
gene amplification)  
 
Secondary Endpoints 
Overall 
survival 
(OS), 
Progression-free 
survival (PFS), tumour genomic mutations.  
 
At T0 on baseline 
tumour samples 
 
Exploratory Objectives 
- 
To 
assess 
the 
efficacy 
of  
osimertinib 
and 
olaparib 
combination 
in 
TKI-naïve 
EGFRm 
NSCLC 
cell 
lines 
(HCC-4006, 
HCC-827, 
and 
HCC-2935, ranging from low to 
high HRD score); 
 
- 
To test the drug combination in 
patient-derived 
models 
of 
EGFRm 
tumours 
(PBMCs, 
organoids, and PDXs); 
Tumor growth, cellular viability, drug toxicity. 
 
N/A 
 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 15 of 26  
 
- 
To rule out toxicity the drug 
combination and assess treatment 
response, thanks to our immune 
competent GEMM model of 
EGFRm16 and TP53 wt/null. 
 
6. STUDY DESIGN 
The study aims to investigate the prevalence of HRD profiles in advanced EGFR-mutated NSCLC patients. The design 
is retrospective/prospetive observational study, and 100 patients will be enrolled (50 in the retrospective cohort and 50 
in the prospective cohort). We plan 4 years of enrollment based on the number of patients with those characteristics 
accessing at OSR Medical Oncology Unit. Moreover, to calculate clinical parameters such as PFS and OS we plan to 
follow-up patients for 3 additional years, based on literature survival analysis.  
 
6.1. 
Study duration  
Duration of enrolment: 4 years, starting from ethical approval. 
Duration of total study period: 7 years, including 4 years of enrolment and 3 years of follow-up (01/01/2026-
31/12/2032). Based on historical caseload at IRCCS Ospedale San Raffaele, we estimate an average of ≃ 15 EGFRm 
metastatic NSCLC patients eligible per year. 
Retrospective data collection will include patients respecting the eligibility criteria from 1/1/2020 to 30/09/2025. 
 
7. STUDY POPULATION 
7.1. Study Participants 
The study population will include adult patients (≥18 years) with metastatic EGFR-mutated non-small cell lung cancer 
(NSCLC). Patients may be included either retrospectively, if already diagnosed and treated with available archival 
tumor tissue, or prospectively, if newly diagnosed and with tumor samples collected prior to treatment initiation. All 
participants must have tumor tissue suitable for HRD testing. 
7.2. Inclusion Criteria 
Individuals must meet all the following inclusion criteria in order to be eligible to participate in the study: 
1. Participant is willing and able to give informed consent for participation in the study. However, since a part of the 
study is retrospective and, considering the large sample sizes required and considering that the disease involved in this 
study affects elderly subjects with co-morbidities and presents a significant mortality rate based on the stage of the 
disease, deceased and untraceable patients will also be included.  
2. Age ≥18 years old 
3. Have a metastatic histologically confirmed NSCLC  
4. Presence of EGFR common mutations (i.e. ex19del and L858R) 
5. Patients treated in first-line setting with 4th generation EGFR-TKI inhibitors (i.e. osimertinib, lazertinib) or beyond 
6. Have archival tumor tissue suitable for HRD testing with AmoyDx Focus panel or similar 
7. Survival follow-up available (for retrospective cohort) 
7.1. 7. Survival follow-up available (for retrospective cohort)Exclusion Criteria 
All individuals meeting any of the following exclusion criteria at baseline will be excluded from the study participation: 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 16 of 26  
 1. Insufficient baseline tumour tissue (unsuitable for HRD scoring) 
2. Presence of EGFR uncommon mutations (i.e. ex20ins) 
3. Known presence of co-occurring uncommon EGFRm, ALK, ROS1, or oncogenic drivers. 
7.2. Screening Failures 
Screen failures are defined as participants who consent to participate in the clinical study but does not meet the criteria 
for participation in the study. A minimal set of screen failure information is required to ensure transparent reporting of 
screen failure participants. Minimal information includes demography, screening failure details, eligibility criteria. 
Based on the study features, we do not expect a high rate of screening failure. 
8. STUDY OBJECT  
The object of the study is to evaluate the prevalence of HRD in metastatic EGFRm NSCLC, investigating any 
correlation with clinical and/or molecular characteristics. As exploratory analysis, the project will assess the 
combination of Osimertinib and Olaparib in different pre-clinical models, ranging from tumour cell lines to GEMM 
animal models.  
 
8.1. Study object description 
N/A 
 
 
 
 
 
 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 17 of 26  
 
9. STUDY PROCEDURES 
Patients will follow normal clinical practice for advanced EGFR-mutated NSCLC. For the purpose of the study, only data on disease progression/death/survival will be collected, 
in addition to molecular analysis about HRD on tumor tissue. The flow-chart below is just representative of a normal path of a patient receiving EGFR-TKI in first-line setting, 
but can be slightly modified according to clinical practice, without any substantial issue.  
Legenda: R=for research purposes, C=per clinical practice, *radiological assessments per clinical practice are accepted every 12-16 weeks 
 
Enrollment 
Screening 
Baseline 
Study Visit 
End of Study Visit 
Follow-Up Visit 
Procedures 
Day 
 
-28 days 
(+/-7) 
0 
As per clinical practice (at least 
once a month) 
At disease progression upon 
first-line treatment 
As per clinical practice (at least every three 
months) 
 
Informed consent 
R 
 
 
 
 
 
Demographics 
C 
 
 
 
 
 
Medical history 
C 
 
C 
 
 
 
Eligibility assessment 
 
R 
 
 
 
 
Physical examination 
(including height and 
weight) 
C 
 
C 
C 
C 
C 
Vital signs 
C 
 
C 
C 
C 
C 
Performance status  
C 
 
C 
C 
C 
C 
Laboratory test  
C 
 
C 
C 
 
 
Availability of tumor 
tissue for HRD testing 
 
R 
 
 
 
 
EGFR-TKI 
administration 
 
 
C 
C 
 
 
Radiologic/Imaging 
assessment (CT-scan 
and brain imaging, CT 
or MRI) 
C 
 
 
C* 
 
 
Adverse event  
 
 
 
C 
 
 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 18 of 26  
9.1. Informed Consent 
Consent forms will be EC-approved, and the participant will be asked to read and review the document. The 
investigator (according to applicable regulatory requirements) or a person designated by the investigator, and under 
the investigator's responsibility, will explain the research study to the participant and answer any questions that may 
arise. A verbal explanation will be provided in terms suited to the participant’s comprehension of the purposes, 
procedures, and potential risks of the study and of their rights as research participants. Participants will have the 
opportunity to carefully review the written consent form and ask questions prior to signing. The participants should 
have the opportunity to discuss the study with their family or surrogates or think about it prior to agreeing to participate. 
The participant MUST sign the informed consent document prior to any procedures being done specifically for the 
study/any data is collected. Participants must be informed that participation is voluntary and that they may withdraw 
from the study at any time, without prejudice. A copy of the informed consent document will be given to the 
participants for their records. The informed consent process will be conducted and documented in the source document 
(including the date), and the form signed, before the participant undergoes any study-specific procedure and any data 
is collected. The rights and welfare of the participants will be protected by emphasizing to them that the quality of their 
medical care will not be adversely affected if they decline to participate in this study. 
However, deceased and untraceable patients will also be included. These patients will be pseudo-anonymized 
according to Institutional procedures. The inclusion of those patients will avoid bias resulting from the exclusion of 
such subjects (patients selected for outcomes) that could compromise the scientific quality of the study and the purpose 
of the research. That is, provided the data controller adopts appropriate measures to protect the rights, freedoms and 
legitimate interests of the individual’s data. 
 
9.2. Subject Recruitment and Screening  
In this single-center study will be enrolled 100 outpatients affected by advanced EGFR-mutated NSCLC, accessing to 
Medical Oncology Unit of IRCCS Ospedale San Raffaele. In the retrospective cohort will be enrolled 50 patients, 
whereas in the prospective cohort we will enroll 50 patients in about 4 years, considering an accrual rate of 15 
patients/years. The patients enrolled in the prospective cohort will follow the normal clinical practice, and no additional 
clinical requirements are needed to be involved in the study. The single parameter that will be investigated in the 
“screening” phase will be the availability of sufficient tumor tissue to perform HRD analysis.   
9.3. Subject Identification 
Starting from the signature of the informed consent by the patient or the patient’s legal tutor, the subject is considered 
enrolled in the clinical study. For the retrospective cohort of the study, deceased and untraceable patients will be 
included as well.  
A subject identification code will be assigned consecutively (e.g.: HER_YYY; where HER is the abbreviation of the 
Protocol Identifier, and YYY is the progressive subject number in increasing order starting from 001). 
A patient identification list will be kept. 
9.4. Baseline Assessments 
Baseline assessment is considered as the visit during which the patient receives EGFR-TKI therapy for the first time 
(Day 0). This time point will serve as the reference for all subsequent evaluations and will be considered the starting 
point for survival analyses (Progression-Free Survival and Overall Survival). At baseline, medical history, physical 
examination (including performance status and vital signs) and routine laboratory data (as per clinical practice) will be 
recorded. 
9.5. Study Visit and Follow Up 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 19 of 26  
For the prospective cohort, study visits will follow routine clinical practice for patients receiving first-line EGFR-TKI. 
 
Treatment visits: patients will be assessed approximately every month (in accordance with standard clinical 
practice), including physical examination and vital signs, performance status, adverse event reporting, and 
laboratory tests as per clinical practice. 
 
Radiological evaluation: imaging (CT-scan of thorax and abdomen plus brain imaging as per clinical practice) 
will be performed every 12 to 16 weeks and as per local use. 
 
Follow-up after treatment discontinuation: patients who discontinue first-line treatment will be followed every 
3 months, until death or study end. 
The retrospective cohort will be followed from the date of diagnosis/first EGFR-TKI treatment until last available 
follow-up or death. 
All patients (retrospective and prospective) will be followed for survival outcomes up to 3 years after the enrollment 
of the last patient, consistent with the study design. 
9.6. Definition of End of Study 
According to the study design, the end of the study is defined as the date on which the last patient completes the last 
visit (approximately 3 years after the last patient enrollment).  
 
9.7. Premature termination or suspension of a study 
As this is an observational, non-interventional study, premature termination or temporary suspension is not expected 
on the basis of patient safety concerns related to study treatment. However, the study may be suspended or terminated 
early by the Sponsor or Principal Investigator if deemed necessary. 
Circumstances that may warrant early termination or suspension include, but are not limited to: 
 
inadequate patient recruitment or follow-up; 
 
data quality concerns, such as incomplete or non-evaluable data; 
 
administrative or financial reasons; 
 
withdrawal of approval by the Ethics Committee or other regulatory authorities. 
In such cases, the Sponsor and the Principal Investigator will ensure that appropriate measures are taken to protect 
participants’ interests. Patients already enrolled will continue to receive standard medical care in accordance with 
institutional clinical practice. 
Written notification documenting the reasons for study suspension or termination will be provided by the Sponsor/PI 
to the Ethics Committee and, if applicable, to participants. 
 
10. DISCONTINUATION AND WITHDRAWAL 
Participants are free to withdraw from participation to the study at any time upon request. 
The reason for participant discontinuation or withdrawal from the study will be recorded on the clinical records and in 
the electronic Case Report Form (eCRF). Subjects who sign the informed consent form and subsequently withdraw, or 
are withdrawn or discontinued from the study, will be replaced.  
11. SAMPLE HANDLING 
Subject included in the study are patients affected by metastatic EGFRm NSCLC, and diagnostic tissue samples are 
taken from each participant to the study protocol as part of the standard of care pathway. Archival tumour samples to 
be used in the study will be those already stored in the Pathology Unit, and tested for HRD status with AmoyDx at the 
Molecular biology laboratory (in the Pathology Unit). HRD testing costs will be covered by research funding as stated 
above. No further analysis are planned for this study, and any further and new research will be approved by the EC. 
The residual material will be stored in the Pathology Unit for 10 years. 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 20 of 26  
12. PATIENT SAFETY 
No additional risks are expected for participants, as this is an observational study and all procedures are part of standard 
clinical practice. 
13. DATA MANAGEMENT   
13.1. Definition of source data and source documents  
Clinical data will be retrieved from patient medical records stored in the electronic medical record system of IRCCS 
Ospedale San Raffaele (e.g.: “Galileo”, “Xero”). These records serve as the primary source documents and include 
hospital charts, laboratory results, diagnostic imaging reports, and other relevant clinical information. 
Source Data: All information in original records and certified copies of original records of clinical findings, 
observations, or other activities in a clinical study necessary for the reconstruction and evaluation of the study. Source 
data are contained in source documents (original records or certified copies). Any data recorded directly on the CRFs 
(i.e., no prior written or electronic record of data), is considered to be source data. 
Source Documents: Original documents, data, and records (e.g., hospital records; clinical and office charts; laboratory 
notes; memoranda; subjects' diaries or evaluation checklists; pharmacy dispensing records; recorded data from 
automated instruments; copies or transcriptions certified after verification as being accurate copies, microfiches, 
photographic negatives, microfilm or magnetic media, x-rays, subject files, or records kept at the pharmacy, at the 
laboratories, and at medico-technical departments involved in the clinical study). 
All parameters asked for in the case report form (CRF) should be documented in the source documents. 
 
A record of patient screen failures will be maintained for patients who do not qualify for enrollment, including the 
reason for the screen failure. 
 
13.2. Documentation of data in Case Report Forms (CRFs)  
Data relevant to the study will be extracted from the source documents and entered into the eCRF CGP (Cohort 
Genomics Platform). The eCRF can be accessed only to the PI and the involved staff, prohibiting access to 
unauthorized third parties. CGP is an electronic data capture system specifically developed around HIPAA-Security 
guidelines.  
The creation of eCRFs is done by a team from the Center for Omics Sciences OSR (COSR) in collaboration with 
Medical Oncology data managers to define the variables and structure. The platform (instance at The OSR clinic 
servers) is accessed via credentials (with institutional hsr email), account configuration is done by the team itself upon 
request. 
The electronic systems used for data handling and storage are validated and comply with established requirements for 
completeness, accuracy, reliability, and consistent performance. 
A record of patient screen failures will be maintained, including the reason for screen failure, and will also be stored 
securely. 
All parameters required for the CRF will be documented in the source documents. 
13.3. Data Recording and Record Keeping 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 21 of 26  
The investigator shall arrange for the retention of Essential Documents for the Conduct of a Clinical study (e.g., patient 
files, other source data, and the Trial Master File/Investigator Site File) after the completion or discontinuation of the 
study according to institutional procedures and applicable laws. 
13.4. Data Protection  
The Investigator (or the Center that will receive the data) undertakes to: 
- use the data only for the purposes of the foreseen analyses and within the limits established by the study and approved 
by the competent EC; 
-  store data in a secure network system; 
-  prohibit unauthorised third parties from accessing data, even partially; 
- guarantees to limit access to and processing of data only to its employees and collaborators who, upon appointment 
as an authorized person: 
1. need to process the data in order to carry out their work in relation to the study; 
2. have undertaken to maintain the confidentiality of the Data and of any information deriving from it or that is 
communicated to them. 
If, within the context of the Study, the Investigator (or the Center that will receive the data) needs to make use of its 
own suppliers, the latter undertakes to appoint these subjects as Data Processors /Responsabili dei Trattamenti with a 
specific agreement or other legal act suitable for this, before the start of any data processing by them, according to 
Regulation (EU) n. 2016/679, art. 28. 
The Investigator (or the Center that will receive the data) also undertakes to adopt suitable measures to facilitate the 
exercise of the rights of the subject provided for by Regulation (EU) n. 2016/679, art. 15 – 22, including the rights of 
access, rectification, cancellation, limitation, opposition and portability, within 30 days of receiving the relative 
request. 
In case the Investigator need to communicate the data outside OSR (the Data Controller /Titolare) in pseudonymized 
form, the Investigator (or the Center that will receive the data) will refrain from carrying out any activity aimed at 
identifying the identity of the subjects to whom such data refer. In the event, however, that the data could not be 
communicated in pseudonymized form by the Data Controller, the Investigator (or the Center that will receive the data) 
undertakes to adopt all the security and organizational measures aimed at protecting the confidentiality of the Data 
Subject). 
Within 30 days following the end of the study, the Investigator (or the Center that will receive the data) undertakes to 
cancel the data communicated by the Data Controller or to make them irreversibly anonymous and to promptly 
communicate it in writing. 
A study specific DPIA (Data Protection Impact Assessment), which includes all these aspects and revised by OSR 
DPO, has been conducted according to applicable data protection law.  
 
14. STATISTICS 
14.1. Description of Statistical Methods 
The statistical analysis will address the primary, secondary, and exploratory objectives of the study. For descriptive 
statistics, continuous variables will be summarized using mean, median, range, and standard deviation, while 
categorical variables will be described using frequency and percentage. Comparisons between groups (e.g., HRD 
positive vs HRD negative) and time-to-event analyses will be performed with appropriate statistical tests, as detailed 
in Section 14.4. Statistical significance will be set at a two-sided p-value < 0.05. Analyses will be performed through 
statistical software such as Microsoft Excel, R, and SPSS. 
14.2. Sample Size Determination 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 22 of 26  
According to the literature, the expected prevalence of HRD positivity in NSCLC ranges from 20–30% in early-stage 
tumours [24]. A similar incidence was observed in a Chinese cohort of any-stage EGFRm or ALK-rearranged NSCLC 
patients in which the cases with high HRD score are ~33% of the total [18].  
Therefore, to obtain an adequate number of patients to allow subgroup analyses and explore clinical and molecular 
correlations, we calculated a sample size of 100 patients (50 retrospective; 50 prospective) to conduct an exploratory 
proof-of-concept study, in which we expect to observe around 25 HRD-positive cases (the precision of the estimate 
corresponds to a 95% confidence interval with a half-width of approximately 8.5 percentage points, which is considered 
clinically relevant). Based on the historical caseload at IRCCS Ospedale San Raffaele (≈15 eligible patients/year), 
recruiting the planned sample over 4 years is feasible. For the retrospective cohort, we estimate that ≈30% of patients 
have insufficient residual archival tumor tissue, therefore the planned 50 patients will be included considering a longer 
interval (1/1/2020 - 30/09/2025).   
14.3. Analysis Populations  
The analysis population will include all patients meeting the eligibility criteria, with available tumour tissue suitable 
for HRD testing. The retrospective cohort will comprise patients already diagnosed and treated with archival tumour 
tissue available; the prospective cohort will include newly diagnosed patients with tumour samples collected prior to 
treatment initiation. Patients with insufficient baseline tumour tissue will be excluded from the analyses. 
14.4 Statistical Design 
For the Primary and Secondary Objectives, continuous variables will be summarized using mean, median, range, and 
standard deviation. Categorical variables will be described using frequency and percentage. To test association between 
categorical variables, chi-squared test will be applied. To compare survivals between groups (i.e. HRD positive vs 
negative, cut-offs to be explored) log-rank test will be applied. Time-to-event outcomes will be represented using 
Kaplan-Meier curves.  
 
For the Exploratory Objectives, parametric and non-parametric analyses will be used to compare differences in cell 
lines and phenotypes between groups. For the in vivo studies, differences in tumour size and phenotype will be 
evaluated at different timepoints and compared with t-test. For all statistical tests, p < 0.05 will be considered 
statistically significant. 
14.5 Potential biases and mitigation strategies 
The study is a pilot investigation with a primarily descriptive intent and will include all advanced lung cancer patients 
with an EGFR mutation treated with TKI inhibitors as standard of care. Retrospective cohort will include patients in 
the interval indicated (1/1/2020 - 30/09/2025) and those who have received at least one dose of treatment and for whom 
survival can be estimated (i.e., at least a date of death available). Only patients for whom insufficient archival tumor 
tissue is available will be excluded, which should not introduce a selection bias. To limit as much as possible bias 
related to sample size, a prospective cohort has been planned, in order to broaden the study while maintaining its 
exploratory nature.  
 
15. ETHICAL AND REGULATORY CONSIDERATIONS 
This clinical study will be conducted in accordance with the principles laid down by the 18th World Medical Assembly 
(Helsinki, 1964) and all applicable amendments established by the World Medical Assemblies, and the ICH guidelines 
for Good Clinical Practice.  
This clinical study will be conducted in compliance with all international laws and regulations; national laws and 
regulations of the country in which the clinical study is performed; as well as any other applicable guidelines. 
15.1. Responsibilities of the Investigator(s) 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 23 of 26  
The Investigator(s) undertake(s) the responsibility to perform the study in accordance with this Protocol, Good Clinical 
Practice, and the applicable regulatory requirements. The Investigator is required to ensure compliance with the 
investigational product schedule, visits schedule, and procedures required by the protocol. The Investigator agrees to 
provide all information requested in the Case Report Form (CRF) in an accurate and legible manner. The investigator 
may implement a deviation from, or a change of, the protocol to eliminate an immediate hazard(s) to study subjects 
without prior EC approval/favorable opinion. As soon as possible, the implemented deviation or change, the reasons 
for it, and, if appropriate, the proposed protocol amendment(s) should be submitted. The investigator must have 
available an adequate number of qualified staff and adequate facilities for the foreseen duration of the study to conduct 
the study properly and safely. 
15.2. Ethics Committee (EC) Approvals  
This clinical study protocol as well as the Informed Consent are to be submitted to the appropriate Ethics Committee, 
and it is mandatory to obtain the written and dated approval, signed by the chairman with Ethics Committee(s) 
composition. 
The clinical study the documents reviewed, the list of voting members and their qualifications, and the date of the 
review should be clearly stated on the written Ethics Committee approval. 
15.3. Other Ethical Considerations 
N/A 
16.  GENDER MEDICINE IN RESEARCH PROTOCOL 
N/A 
17. QUALITY ASSURANCE AND QUALITY CONTROL 
The study will be conducted in accordance with the current approved protocol, GCP, relevant regulations, and standard 
operating procedures. Investigators involved in the study will permit study-related audits, EC review, and regulatory 
inspections by providing direct access to all study records.  
Study audits can be conducted by or on behalf of CTC, according to OSR quality standards. Data will be evaluated for 
compliance with the protocol and accuracy in relation to source documents. Following written standard operating 
procedures, the auditors will verify that the clinical study is conducted and data are generated, documented, and 
reported in compliance with the protocol, GCP, and the applicable regulatory requirements. 
The Investigator should notify the CTC promptly of any inspection scheduled by any regulatory authorities and will 
promptly forward copies of any inspection reports received. 
17.1. Deviation from study protocol 
A deviation from the protocol is an unintended departure from the procedures or processes described in the protocol 
and approved by the EC.  
The Investigator or designee must document and explain in the patient’s source documentation any deviation from the 
approved protocol.  
Every deviation from the study protocol must be specified and documented separately for each patient. The investigator 
should discuss the type and extent of deviation as well as the possible consequences for further participation of the 
patient in the study.  
17.2. Surveillance for observational studies with additional procedure 
 
NA 
18. FINANCE AND INSURANCE 
18.1. Funding 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 24 of 26  
The study is funded by Medical Oncology internal funds (Eredità Buffa). 
18.2. Patient Insurance 
N/A 
19. END OF CLINICAL STUDY 
In accordance with applicable regulation, ICH GCP and SOPs, the PI shall notify the end of the clinical study within 
15 days from the end of the clinical study and the reasons for such action. 
19.1. Summary of the results of the clinical study 
Irrespective of the outcome of a clinical study, within one year from the end of a clinical study, the PI shall submit a 
summary of the results of the clinical study.  
20. INTELLECTUAL PROPERTY  
IRCCS San Raffaele Hospital and the Principal Investigator is the sole owner of data, without prejudice to the 
provisions of the regulations in force regarding the publication of the data.  
21. PUBLICATION POLICY 
The Principal Investigator will have full access to all study data and will have full and total responsibility for:  
1. the preparation of the manuscript(s) and the data collected in this study;  
2. the choice of the journal or conferences to which the manuscript(s) will be submitted;  
3. the final decision on the number, order, and names of contributing authors.  
 
All manuscripts will include an appropriate acknowledgments section, mentioning all researchers who contributed to 
the trial. Prior to submission, all publications (articles, abstracts, presentations) that include data related to the patients 
of this study will be reviewed by all co-authors. The above-mentioned rules are applicable to publications involving 
any patient registered in the trial.  
22. REFERENCES 
[0] https://www.amoydiagnostics.com/products/amoydx-hrd-focus-panel [1] Bray, Freddie et al. “Global cancer 
statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.” CA: a 
cancer journal for clinicians vol. 74,3 (2024): 229-263. doi:10.3322/caac.21834 
[2] Hendriks, Lizza E L et al. “Non-small-cell lung cancer.” Nature reviews. Disease primers vol. 10,1 71. 26 Sep. 
2024, doi:10.1038/s41572-024-00551-9  
[3] Oda, Kanae et al. “A comprehensive pathway map of epidermal growth factor receptor signaling.” Molecular 
systems biology vol. 1 (2005): 2005.0010. doi:10.1038/msb4100014  
[4] Hendriks, L E et al. “Oncogene-addicted metastatic non-small-cell lung cancer: ESMO Clinical Practice Guideline 
for diagnosis, treatment and follow-up.” Annals of oncology : official journal of the European Society for Medical 
Oncology vol. 34,4 (2023): 339-357. doi:10.1016/j.annonc.2022.12.009  
[5] Skoulidis, Ferdinandos, and John V Heymach. “Co-occurring genomic alterations in non-small-cell lung cancer 
biology and therapy.” Nature reviews. Cancer vol. 19,9 (2019): 495-509. doi:10.1038/s41568-019-0179-8  
[6] Planchard, D. et al. Osimertinib with or without Chemotherapy in EGFR -Mutated Advanced NSCLC. New 
England Journal of Medicine 389, 1935–1948 (2023). 
[7] Cho, B. C. et al. Amivantamab plus Lazertinib in Previously Untreated EGFR -Mutated Advanced NSCLC. New 
England Journal of Medicine 391, 1486–1498 (2024) 
[8] Planchard, D. et al. 512MO FLAURA2: Safety and CNS outcomes of first-line (1L) osimertinib (osi) ± 
chemotherapy (CTx) in EGFRm advanced NSCLC. Annals of Oncology 34, S1668 (2023). 
[9] Yang, J. C. et al. MA12.03 FLAURA2: Resistance, and Impact of Baseline TP53 Alterations in Patients Treated 
With 1L Osimertinib ± Platinum-Pemetrexed. Journal of Thoracic Oncology 19, S101–S102 (2024). 
[10] Valdiviezo, N. et al. MA12.04 FLAURA2: Impact of Tumor Burden on Outcomes of 1L Osimertinib ± 
Chemotherapy in Patients with EGFR-mutated Advanced NSCLC. Journal of Thoracic Oncology 19, S102 (2024). 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 25 of 26  
[11] Mekonnen, N., Yang, H. & Shin, Y. K. Homologous Recombination Deficiency in Ovarian, Breast, Colorectal, 
Pancreatic, Non-Small Cell Lung and Prostate Cancers, and the Mechanisms of Resistance to PARP Inhibitors. Front 
Oncol 12, (2022). 
[12] Fennell, Dean A et al. “Olaparib maintenance versus placebo monotherapy in patients with advanced non-small 
cell lung cancer (PIN): A multicentre, randomised, controlled, phase 2 trial.” EClinicalMedicine vol. 52 101595. 11 
Aug. 2022, doi:10.1016/j.eclinm.2022.101595 
[13] Hochmair, Maximilian et al. “Pembrolizumab With or Without Maintenance Olaparib for Metastatic Squamous 
NSCLC That Responded to First-Line Pembrolizumab Plus Chemotherapy.” Journal of thoracic oncology : official 
publication of the International Association for the Study of Lung Cancer vol. 20,2 (2025): 203-218. 
doi:10.1016/j.jtho.2024.10.012 
[14] Ramalingam, Suresh S et al. “JASPER: Phase 2 trial of first-line niraparib plus pembrolizumab in patients with 
advanced non-small cell lung cancer.” Cancer vol. 128,1 (2022): 65-74. doi:10.1002/cncr.33885 
[15] Ahn, Myung-Ju et al. “Durvalumab in Combination With Olaparib Versus Durvalumab Alone as Maintenance 
Therapy in Metastatic NSCLC: The Phase 2 ORION Study.” Journal of thoracic oncology : official publication of the 
International Association for the Study of Lung Cancer vol. 18,11 (2023): 1594-1606. doi:10.1016/j.jtho.2023.06.013 
[16] Clarke, Jeffrey M et al. “Veliparib and nivolumab in combination with platinum doublet chemotherapy in patients 
with metastatic or advanced non-small cell lung cancer: A phase 1 dose escalation study.” Lung cancer (Amsterdam, 
Netherlands) vol. 161 (2021): 180-188. doi:10.1016/j.lungcan.2021.09.004 
[17] Tsilingiri, Katerina et al. “Genomic scarring score predicts the response to PARP inhibitors in non-small cell lung 
cancer.” NPJ precision oncology vol. 8,1 291. 26 Dec. 2024, doi:10.1038/s41698-024-00777-6 
[18] Wang, Y. et al. Clinical and molecular significance of homologous recombination deficiency positive non-small 
cell lung cancer in Chinese population: An integrated genomic and transcriptional analysis. Chin J Cancer Res 36, 
282–297 (2024) 
[19] Fischer, A. et al. Mutational Landscape and Expression of PD-L1 in Patients with Non-Small Cell Lung Cancer 
Harboring Genomic Alterations of the MET gene. Target Oncol 17, 683–694 (2022). 
[20] Feng, J. et al. Combination of genomic instability score and TP53 status for prognosis prediction in lung 
adenocarcinoma. NPJ Precis Oncol 7, 110 (2023) 
[21] Marcar, L. et al. Acquired Resistance of EGFR-Mutated Lung Cancer to Tyrosine Kinase Inhibitor Treatment 
Promotes PARP Inhibitor Sensitivity. Cell Rep 27, 3422-3432.e4 (2019). 
[22] Garcia-Campelo, R. et al. Combination of gefitinib and olaparib versus gefitinib alone in EGFR mutant non-small-
cell lung cancer (NSCLC): A multicenter, randomized phase II study (GOAL). Lung Cancer 150, 62–69 (2020) 
[23] Karachaliou, N. et al. BRCA1 Expression and Outcome in Patients With EGFR-Mutant NSCLC Treated With 
Gefitinib Alone or in Combination With Olaparib. JTO Clin Res Rep 2, 100113 (2021). 
[24] Klinakis, A. et al. 1277P HRD status of patients with early stage non-small cell lung cancer. Annals of Oncology 
34, S737–S738 (2023). 
[25] Wang, Z. et al. Correlation between EGFR mutation status and response to first-line platinum-based chemotherapy 
in patients with advanced non-small cell lung cancer. Onco Targets Ther 1185 (2014) doi:10.2147/OTT.S63665. 
[26] Drews, R. M. et al. A pan-cancer compendium of chromosomal instability. Nature 606, 976–983 (2022). 
 
23. APPENDIX A:  AMENDMENT HISTORY 
 
Amendment 
No. 
Protocol 
Version No. 
Date issued 
Rationale 
Study status 
Details of Changes  
 
 
 
 
 
 
 
24. APPENDIX B:  LIST OF CLINICAL SERVICES / LABORATORIES 
Unit/Service 
Referent 
(name, email and telephone) 
Specific activity  
(study activity, diagnostic 
procedures, lab tests, other)  
 Oncologia Medica 
Francesca Rita Ogliari 
ogliari.francesca@hsr.it 
+39 02-26437627 
Patient 
enrolment 
and 
study 
coordination 

 
The HER Project Protocol 
Date: 30/SEP/2025 
Version: 1.0 
 
CTC 021OP/1  
 
 
CONFIDENTIAL 
 
 
 
Page 26 of 26  
Lung 
Cancer 
Research 
Lab 
(Experimental 
Oncology 
Division) 
Giorgia Foggetti 
foggetti.giorgia@hsr.it  
+39 02-26438011 
Protocol-associated 
pre-clinical 
research 
Anatomia Patologica 
Maria Giulia Cangi 
cangi.mariagiulia@hsr.it +39 02-
26437076 
Histological 
and 
molecular 
analysis 
 
25. APPENDIX C:  LIST OF ENROLLING SITES 
Name and Address 
IRCCS Ospedale San Raffaele 
Via Olgettina, 60 
20132 – Milano, Italy 
Site Role Coordinating site 
Principal Investigator of Site Francesca Rita Ogliari, MD 
Medical Oncologist 
IRCCS Ospedale San Raffaele 
Number of subjects planned  
N=100