Phase II Randomized Trial of Bethesda Protocol Compared to Cambridge Method for Detection of Early Stage Gastric Cancer in CDH1 Mutation Carriers
Phase: PHASE2
Conditions: Gastric Cancer, Gastric Neoplasms, Gastric Adenocarcinoma
Sponsor: National Cancer Institute (NCI)

Abbreviated Title: RCT of CDH1 Surveillance
Version Date: 03/12/2024
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Abbreviated Title: RCT of CDH1 Surveillance
NIH Protocol #: 20C0150
Version Date: 03/12/2024
NCT Number #: NCT04535414
Title: Phase II Randomized Trial of Bethesda Protocol Compared to Cambridge Method for 
Detection of Early Stage Gastric Cancer in CDH1 Mutation Carriers
NCI Principal Investigator:
Jeremy L. Davis, MD
Surgical Oncology Program (SOP), CCR, NCI, NIH
Building 10, Room 4-3742
10 Center Drive
Bethesda, MD 20892
Phone: 240-858-3731
Email: jeremy.davis@nih.gov

Abbreviated Title: RCT of CDH1 Surveillance
Version Date: 03/12/2024
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PRÉCIS
Background:

Hereditary Diffuse Gastric Cancer (HDGC) is most often attributed to inactivating 
germline mutations in the E-cadherin (CDH1) tumor suppressor gene. Mutation carriers 
have a 24-70% lifetime risk of developing gastric adenocarcinoma. 

International consensus guidelines recommend endoscopic screening and surveillance of 
CDH1 mutation carriers who decline risk-reducing total gastrectomy (TG). However, this 
approach lacks sufficient sensitivity for detection of occult, intramucosal foci of signet ring 
cancer cells (SRCC), which are pathognomonic of HDGC. Our team has established a 
systematic endoscopic screening protocol (Bethesda protocol) that demonstrates a higher 
rate of SRCC detection compared to historic controls using the currently recommended 
Cambridge method.
Objective:

Determine if Bethesda protocol provides improved sensitivity for detection of early-stage 
gastric cancer in CDH1 germline mutation carriers compared to the Cambridge method.
Eligibility:

Subjects with pathogenic or likely pathogenic CDH1 germline mutation.

Age >18 years. 

Physiologically able to undergo upper endoscopy
Design:

Phase II randomized study to compare Bethesda protocol and Cambridge method for 
detection of intramucosal SRCC in asymptomatic CDH1 mutation carriers undergoing 
endoscopic screening or surveillance. 

Abbreviated Title: RCT of CDH1 Surveillance
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TABLE OF CONTENTS 
TABLE OF CONTENTS
3
STATEMENT OF COMPLIANCE 10
1
INTRODUCTION
10
1.1
Study Objectives .............................................................................................................10
1.1.1
Primary Objective....................................................................................................10
1.1.2
Secondary Objective................................................................................................10
1.1.3
Exploratory Objectives ............................................................................................10
1.2
Background and Rationale..............................................................................................11
1.2.1
Study Disease...........................................................................................................11
1.2.2
Annual Endoscopic Surveillance.............................................................................13
1.2.3
Adjuncts to Endoscopy............................................................................................14
1.2.4
Molecular and Physiologic Sequelae of Hereditary Diffuse Gastric Cancer 
Syndrome...............................................................................................................................15
2
ELIGIBILITY ASSESSMENT AND ENROLLMENT
16
2.1
Eligibility Criteria ...........................................................................................................16
2.1.1
Initial Enrollment.....................................................................................................16
2.1.2
Re-Enrollment..........................................................................................................16
2.1.3
Recruitment Strategies.............................................................................................16
2.2
Screening Evaluation ......................................................................................................17
2.2.1
Screening Activities Performed Prior to Obtaining Informed Consent...................17
2.2.2
Screening Activities Performed After a Consent for Screening Has Been Signed .17
2.3
Participant Registration and Status Update Procedures..................................................17
2.3.1
Screen Failures.........................................................................................................17
2.3.2
Intervention Assignment Procedures (For Registration Purposes Only).................17
2.4
Baseline Evaluation.........................................................................................................18
3
STUDY IMPLEMENTATION
18
3.1
Study Design...................................................................................................................18
3.1.1
Bethesda Protocol, Arm 1 (Investigational Arm)....................................................18
3.1.2
Cambridge Method Upper Endoscopy, Arm 2 (Control Arm)................................19
3.1.3
Confocal Endomicroscopy of the Gastric Mucosa ..................................................19
3.2
Surgical Guidelines.........................................................................................................19
3.2.1
Preoperative Patient Management ...........................................................................19

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3.2.2
White-light, Upper Endoscopy ................................................................................19
3.2.3
Postoperative Care...................................................................................................19
3.2.4
Discharge .................................................................................................................20
3.3
Follow-Up .......................................................................................................................20
3.3.1
Repeat Endoscopy ...................................................................................................20
3.3.2
Long-Term Sequelae of Total Gastrectomy ............................................................20
3.4
Cost and Compensation ..................................................................................................21
3.4.1
Costs ........................................................................................................................21
3.4.2
Compensation ..........................................................................................................21
3.4.3
Reimbursement........................................................................................................21
3.5
Criteria for Removal from Protocol Interventions and Off Study Criteria.....................21
3.5.1
Criteria for Removal from Protocol Interventions...................................................21
3.5.2
Off-Study Criteria....................................................................................................21
3.5.3
Lost to Follow-Up....................................................................................................22
4
CONCOMITANT MEDICATIONS/MEASURES
22
5
CORRELATIVE STUDIES 23
5.1
Summary and Biospecimen Collection Table for Research ...........................................23
5.1.1
Sample Collection and Processing...........................................................................25
5.2
Samples for Genetic/Genomic Analysis .........................................................................26
5.2.1
Microbiome..............................................................................................................26
5.3
Sample Storage, Tracking and Disposition.....................................................................28
5.3.1
Samples Managed by Dr. Figg’s Blood Processing Core (BPC) ............................28
5.3.2
Laboratory of Pathology..........................................................................................29
5.3.3
Center for Cancer Research Sequencing Facility (CCR-SF)...................................29
5.3.4
Laboratory of Dr. Heller..........................................................................................30
5.3.5
Protocol Completion/Sample Destruction ...............................................................30
5.3.6
Machine Learning for Early Gastric Cancer Detection ...........................................30
6
DATA COLLECTION AND EVALUATION
31
6.1
Data Collection ...............................................................................................................31
6.2
Data Sharing Plans..........................................................................................................31
6.2.1
Human Data Sharing Plan .......................................................................................31
6.2.2
Genomic Data Sharing Plan.....................................................................................32
6.3
Toxicity Criteria..............................................................................................................32

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7
NIH REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN
32
7.1
Definitions.......................................................................................................................32
7.2
OHSRP Office of Compliance and Training / IRB Reporting........................................32
7.2.1
Expedited Reporting ................................................................................................32
7.2.2
IRB Requirements for PI Reporting at Continuing Review ....................................32
7.3
NCI Clinical Director Reporting.....................................................................................32
7.4
NIH Required Data and Safety Monitoring Plan............................................................33
7.4.1
Principal Investigator/Research Team.....................................................................33
8
STATISTICAL CONSIDERATIONS
33
8.1
Statistical Hypothesis......................................................................................................33
8.2
Sample Size Determination.............................................................................................33
8.3
Populations for Analyses ................................................................................................34
8.4
Statistical Analyses .........................................................................................................34
8.4.1
General Approach....................................................................................................34
8.4.2
Analysis of the Primary Endpoint............................................................................34
8.4.3
Analysis of the Secondary Endpoint........................................................................35
8.4.4
Baseline Descriptive Statistics.................................................................................35
8.4.5
Interim Analyses......................................................................................................35
8.4.6
Analysis of the Exploratory Endpoints....................................................................35
9
HUMAN SUBJECTS PROTECTIONS
36
9.1
Rationale for Subject Selection.......................................................................................36
9.2
Participation of Children.................................................................................................36
9.3
Participation of Subjects Unable to Give Consent..........................................................36
9.4
Risk/Benefit Assessment for All Participants.................................................................36
9.4.1
Known Potential Risks ............................................................................................36
9.4.2
Known Potential Benefits........................................................................................37
9.4.3
Assessment of Potential Risks and Benefits............................................................37
9.5
Consent Process and Documentation..............................................................................37
10
REGULATORY AND OPERATIONAL CONSIDERATIONS
38
10.1
Study Discontinuation and Closure.............................................................................38
10.2
Quality Assurance and Quality Control ......................................................................38
10.3
Conflict of Interest Policy ...........................................................................................39

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10.4
Confidentiality and Privacy.........................................................................................39
11
DEVICE INFORMATION
40
12
REFERENCES
41
13
APPENDICES
43
13.1
Appendix 1: Instructions for Completing the Automated Self-Administered 24-Hour 
Dietary Assessment Tool (ASA24) for 24-Hour Food Recall...................................................43
13.2
Appendix 2: Instructions for Completing the Diet History Questionnaire III (DHQIII)
44
13.3
Appendix 3: Stool Specimen Collection Kit Instructions ...........................................45

Abbreviated Title: RCT of CDH1 Surveillance
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STATEMENT OF COMPLIANCE
The trial will be carried out in accordance with International Council on Harmonisation Good 
Clinical Practice (ICH GCP) and the following: 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 
CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812) 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are 
responsible for the conduct, management, or oversight of NIH-funded clinical trials have 
completed Human Subjects Protection and ICH GCP Training.
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the Institutional Review Board (IRB) for review and approval. Approval of both 
the protocol and the consent form must be obtained before any participant is enrolled. Any 
amendment to the protocol will require review and approval by the IRB before the changes are 
implemented to the study. In addition, all changes to the consent form will be IRB-approved; an 
IRB determination will be made regarding whether a new consent needs to be obtained from 
participants who provided consent, using a previously approved consent form.
1
INTRODUCTION
1.1
STUDY OBJECTIVES
1.1.1
Primary Objective

Determine if Bethesda protocol provides improved sensitivity for detection of early-stage 
gastric cancer in CDH1 germline mutation carriers compared to the Cambridge method.
1.1.2
Secondary Objective

Define the false negative rate of SRCC detection using Bethesda protocol and Cambridge 
methods in patients who proceed to risk-reducing total gastrectomy. 

To estimate and compare the difference in crude cancer detection rates between endoscopy 
using the Bethesda protocol and the Cambridge method.
1.1.3
Exploratory Objectives

Determine if confocal endoscopic microscopy (CEM) will afford greater sensitivity for 
detection of SRC foci in CDH1 germline mutation carriers compared to the Cambridge 
method

To characterize gastric tract microbiota of CDH1 germline mutation carriers.

To assess esophageal motility after total gastrectomy (in patients who pursue total 
gastrectomy)

Apply machine learning algorithms to aid early gastric cancer detection using input from 
confocal endoscopic microscopy (CEM) images and histopathology images/results, and 
utilize image-to-image translation to enhance early cancer detection with CEM

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1.2
BACKGROUND AND RATIONALE
1.2.1
Study Disease
Hereditary diffuse gastric cancer (HDGC) accounts for approximately 1-3% of gastric cancers 
globally and is the most common familial form of gastric cancer [1]. Forty percent of HDGC cases 
are linked to inactivating germline mutations in the E-cadherin (CDH1) tumor suppressor gene 
[2]. Estimates of disease penetrance have demonstrated CDH1 mutation carriers have a 
substantially elevated lifetime risk of developing gastric cancer, approximating 37-70% in men 
and 24-56% in women [3, 4]. 
The CDH1 gene encodes the tumor-suppressor protein E-cadherin, which is a glycoprotein 
localized on the surface of epithelial cells at the adherens junctions [5]. E-cadherin functions to 
regulate cell-cell adhesion and intercellular communication, which is critical for cellular migration, 
proliferation, apoptosis and cell differentiation [6-10]. When E-cadherin function is compromised 
there is loss of cell polarity and epithelial architecture, which interferes with the integrity of the 
adherens junctions. CDH1-null epithelial cells may become inappropriately placed in the cellular 
matrix of the lamina propria resulting in the formation of signet ring cancer cells (SRCC) (Figure 
1 and Figure 2) [11]. It is postulated that gastric CDH1-null SRCC can exist for extended periods 
of time allowing for the accumulation of additional molecular alterations that lead to tumorigenesis 
and/or metastasis [12]. It is speculated that a second hit to this gastric mucosa, via mutations in 
Smad4, RHOA, or TP53, ultimately enables tumor cell invasion and metastatic potential [11, 13-
15].
Because of the increased lifetime risk of developing gastric cancer, the International Gastric 
Cancer Linkage Consortium (IGCLC) recommends risk-reducing total gastrectomy to remove all 
gastric epithelium [3]. At the time of total gastrectomy almost all asymptomatic patients with 
CDH1 mutations are found to have SRCC within the stomach. Since 2017, our team has evaluated 
more than 59 total gastrectomy explants and found 86% harbor SRCC (T1a gastric cancers) on 
final pathology. However, there is a scientific lack of understanding of how and why these SRCC 
become invasive cancer. 

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1.2.2
Annual Endoscopic Surveillance 
For patients who decline risk-reducing gastrectomy, annual endoscopic surveillance utilizing the 
Cambridge method is currently recommended by the IGCLC for management patients with 
pathogenic CDH1 variants [3]. This endoscopy technique is performed over 30 minutes, using a 
white light high definition endoscope; it consists of mucosal biopsies of any visible lesions, 
testing for H. pylori, and 30 random mucosal biopsies from the prepyloric area, gastric antrum, 
transitional zone, body, gastric fundus, and gastric cardia. However, this technique is not 
sensitive as it repeatedly has shown to miss early diffuse gastric cancer (DGC) [16-20]. The 
SRCC detection rate with the standard, Cambridge, method ranges from 15-60% with false 
negative rates of 37%-84.6% [21-24]. This form of surveillance is unreliable because 
intramucosal SRCC foci are not visible with standard endoscopy because they make up less than 
2% of the gastric mucosa and often measure less than 1 mm in diameter [17]. 
Our team developed a novel systematic endoscopic screening protocol (Bethesda protocol) that 
was adapted from a method initially described by Yao [25]. Using white-light upper endoscopy, 
the Bethesda protocol consists of 88 mucosal biopsies taken from 22 anatomic areas of the 
stomach. Our group recently compared the sensitivity of SRCC detection using the Bethesda 
protocol to that of the Cambridge method in a retrospective analysis (Figure 3) [21]. 
Figure 3. Sensitivity of SRCC detection comparing the Bethesda protocol to that of the Cambridge 
method in a retrospective analysis.
The analysis consisted of 110 patients with the CDH1 mutation who were evaluated at NIH 
Clinical Center. All 110 patients underwent screening gastroscopy; 29 using the Cambridge 
method and 81 using the Bethesda protocol. Signet ring cancer cells were detected in 4 patients 
(13.8%) using Cambridge method and 29 (35.8%) with the Bethesda protocol. Over half (17/29) 
of the Cambridge method patients underwent prophylactic total gastrectomy, of whom 11 had 
SRCC identified on final pathology. Of those 11, only 2 were positive for SRCC on 
esophagogastroduodenoscopy (EGD) yielding an 82% (9/11) false negative biopsy rate and an 
overall sensitivity of 18% (2/11). Comparatively, 24 patients screened with the Bethesda protocol 
(24/81) later underwent prophylactic total gastrectomy, of whom 22 were found to have SRCC on 
final pathology. Of those 22, 13 were positive for SRCC on EGD giving the Bethesda protocol a 
41% (9/22) false negative biopsy rate and an overall sensitivity of 59% (13/22) for detecting 
SRCC. Based on these data, we conclude the Bethesda protocol is likely better than the Cambridge 
method at detecting SRCC in asymptomatic CDH1 mutation carriers. 

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Our primary objective with this prospective random-assignment study is to compare the Bethesda 
protocol (investigational) to the Cambridge method (control) for detection of early stage gastric 
cancer (e.g. SRCC) in asymptomatic CDH1 mutation carriers.
To fully understand the limitations of endoscopic gastric cancer surveillance, the false-negative 
cancer detection rate should be defined also, which is a secondary aim of the proposed study. This 
can only be done through complete pathologic examination of total gastrectomy explants from 
patients who choose to proceed to prophylactic surgery endoscopic surveillance.
1.2.3
Adjuncts to Endoscopy
Enhanced endoscopic techniques to increase cancer detection rates through improved mucosal 
visualization have been attempted. Confocal endoscopic microscopy (CEM) is a technique that is 
used with a standard endoscope to obtain in vivo histology images of gastrointestinal mucosa. 
Based on data from a Phase II study by our group (18-C-0141), we determined the SRCC detection 
rate of CEM was slightly improved compared to Cambridge method. Our preliminary results, 
which included 34 patients accrued over eight months, demonstrated detection rate of CEM to be 
28.6% with false negative rate of 71.4%, which appeared only slightly better than 14.3% and 
85.7%, respectively, with Cambridge method. It is possible that CEM could improve white light 
endoscopy detection methods when added to the Cambridge method, as in our Phase II study. 
Further exploration of CEM added to gastric surveillance is necessary to answer this question. 
Moreover, interpretation of confocal images obtained during gastric surveillance posed a challenge 
in our Phase II study. Our group is exploring the possible application of artificial intelligence to 
endoscopic and histopathologic findings to improve the sensitivity and specificity of gastric cancer 
diagnosis. Because our use of CEM showed low sensitivity for occult cancer detection, we believe 
that application of machine learning (i.e., computer models) based on the input provided by CEM 
imaging will improve our ability to accurately and reliably detect cancer. By incorporating the 
corresponding histopathology images obtained after gastric biopsy, we will essentially teach the 
computer how to reliably detect occult gastric cancer through an iterative process.
Accurate detection of early gastric cancer from endoscopic biopsies or total gastrectomy explants 
requires expertise in gastrointestinal pathology. Briefly, our NCI pathology colleagues have 
analyzed over 80 gastrectomy specimens and over 1,000 gastric biopsy specimens over the past 3 
years. They have a working system for how they approach all of these patients’ specimens, such 
as the use of initial H&E for screening of gastric biopsies followed by selective use of PAS stain. 
Most often, they are identifying clusters of cells, generally from 100 micrometers up to 1 
centimeter in diameter. It is rare for us to identify single cells, but we have identified small areas 
of carcinoma in situ. The examinations are performed in a systematic manner established by our 
expert gastrointestinal pathologists. It is most frequently our aim to adhere to international gastric 
cancer linkage consortium guidelines for pathologic examination based on availability of resources 
(P. Guilford, personal communication). A Level 1 examination is the minimum suggested to obtain 
sufficient data for appropriate patient care (Figure 4). A Level 3 examination would be considered 
optimal for clinical reporting and support preservation of tissue for future research.

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studies demonstrate a correlation with gastric cancer and opportunistic pathogens within the 
stomach, however the gastric microbiome of CDH1 mutation carriers and the microbiome 
contribution to disease penetrance in this population is unknown [27, 28]. We plan to use pyro-
sequencing techniques to survey microbial diversity in patients’ gastric and fecal samples. Prior to 
stool sample collection dietary recordings and detailed medication history will be collected from 
study participants. The association between specific microbiome maps and the occurrence of 
bacterial translocation will then be analyzed.
2
ELIGIBILITY ASSESSMENT AND ENROLLMENT 
2.1
ELIGIBILITY CRITERIA
2.1.1
Initial Enrollment
2.1.1.1
Inclusion Criteria

An individual who harbors a pathogenic, or likely pathogenic, CDH1 germline variant. 
Note: individuals with CDH1 variant classified as any of the following are not eligible:
o
variant of uncertain significance
o
benign
o
likely benign.

Age >18 years. 

Physiologically able to undergo upper endoscopy.

Ability of subject to understand and the willingness to sign a written informed consent 
document. 
2.1.1.2
Exclusion Criteria

Any clinical contraindication (e.g., known bleeding disorder, thrombocytopenia) to 
endoscopic biopsy.

Unstable angina or recent (within 3 months) myocardial infarction. 

Any clinical contraindication to general anesthesia.
2.1.2
Re-Enrollment
2.1.2.1
Inclusion Criteria

Subject must have previously been enrolled on the study and must have undergone 
endoscopy.  Note: Subject may re-enroll only once after initial endoscopy performed

Subject must have clinical need for a repeat endoscopy

Prior on-protocol endoscopy must have occurred at least 6 months (+/- 2 weeks) and no 
greater than 18 months (+/- 4 weeks) 
2.1.3
Recruitment Strategies
This protocol may be abstracted into a plain language announcement posted on NIH websites and 
on NIH social media platforms. Participants may also be recruited through self-referrals, physician 
referrals, and referrals from the NIH Clinical Center (CC) Office of Patient Recruitment.

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2.2
SCREENING EVALUATION
2.2.1
Screening Activities Performed Prior to Obtaining Informed Consent
Minimal risk activities that may be performed before the subject has signed a consent include the 
following: 

Email, written, in person or telephone communications with prospective subjects 

Review of existing medical records to include H&P, laboratory studies, etc. 

Review of existing MRI, x-ray, or CT images

Review of existing photographs or videos

Review of existing pathology specimens/reports from a specimen obtained for diagnostic 
purposes
2.2.2
Screening Activities Performed After a Consent for Screening Has Been Signed
The following activities will be performed only after the subject has signed the consent for this 
study for screening. Assessments performed at outside facilities or on another NIH protocol within 
the timeframes below may also be used to determine eligibility once a patient has signed the 
consent.
Within 30 days prior to enrollment:

Complete medical history and physical examination, including vital signs.

Review of genetic test results performed in any outside lab if not already completed 
(Section 2.2.1). 
2.3
PARTICIPANT REGISTRATION AND STATUS UPDATE PROCEDURES
Registration and status updates (e.g. when a participant is taken off protocol therapy and when a 
participant is taken off-study) will take place per CCR SOP ADCR-2: CCR Participant 
Registration 
& 
Status 
Updates 
found 
at: 
https://ccrod.cancer.gov/confluence/pages/viewpage.action?pageId=73203825. 
2.3.1
Screen Failures 
Screen failures are defined as participants who consent to participate in the clinical trial but are 
not subsequently assigned to the study intervention or entered 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, eligibility criteria, and any serious adverse event (SAE).
Individuals who do not meet the criteria for participation in this trial (screen failure) because of 
non-conclusive genetic test results may be rescreened.
2.3.2
Intervention Assignment Procedures (For Registration Purposes Only)
2.3.2.1
Cohorts
Number
Name
Description
1
Cohort 1
Subjects with pathogenic, or likely pathogenic, CDH1 germline mutation 

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2.3.2.2
Arms
Number
Name
Description
1
Arm 1
Bethesda protocol (investigational)
2
Arm 2
Cambridge method (control) 
2.3.2.3
Arm Assignment and Randomization
Subjects in Cohort 1 will be randomized by CRO to Arm 1 or Arm 2. No stratification is planned. 
2.4
BASELINE EVALUATION
Within 30 days prior to study procedure (does not need to be repeated if performed during 
Screening within designated time period):

Physical examination, including weight and vital signs. 
3
STUDY IMPLEMENTATION
3.1
STUDY DESIGN
This is a Phase II randomized study designed to compare the efficacy of the Bethesda protocol 
compared to Cambridge method for detecting signet ring cells within gastric mucosa of 
asymptomatic patients with CDH1 mutations.
Upon study enrollment, subjects will be randomized to undergo upper endoscopy by either the 
Bethesda protocol technique (Arm 1) or Cambridge method (Arm 2).
Confocal endomicroscopy (CEM) of the gastric mucosa (Section 3.1.3) will be performed on 
enrolled subjects of both study arms unless otherwise indicated* until sufficient data for 
statistically accurate and reliable application of machine learning (i.e., computer models – refer to 
Section 5.3.6 for details), currently believed to total the first 50 enrolled participants. *CEM will 
not be performed in the following circumstances: participant allergy to the contrast (refer to 
Section 3.1.3), equipment not available or not functioning properly, or due to operating room 
scheduling issues/availability.   
Note: Biopsies will be obtained as indicated below.  
3.1.1
Bethesda Protocol, Arm 1 (Investigational Arm)
Participants will undergo white light endoscopy. The mucosa of the stomach may be thoroughly 
washed before examination with a combination of mucolytics (N-acetylcysteine) and anti-foaming 
agents (simethicone) mixed with sterile water, as medically indicated. Inspection will include 
repeated inflation and deflation to check distensibility and any abnormal appearing areas will 
additionally be biopsied. Eighty-eight non-targeted biopsies from 22 areas of the stomach, four 
mucosal biopsies from each, will be obtained using standard cold endoscopic forceps. This 
technique is estimated to take approximately 45 minutes or less.

Antrum, antegrade view – anterior (1), lesser curve (2), posterior (3), greater curve (4)

lower body, antegrade view – anterior (5), lesser curve (6), posterior (7), greater curve 
(8)

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
middle-upper body, antegrade view – anterior (9), lesser curve (10), posterior (11), 
greater curve (12)

fundus-cardia, retroflex view – anterior (13), lesser curve (14), posterior (15), greater 
curve (16)

middle-upper body, retroflex view – anterior (17), lesser curve (18), posterior (19)

incisura, retroflex view – anterior (20), lesser curve (21), posterior (22)
3.1.2
Cambridge Method Upper Endoscopy, Arm 2 (Control Arm) 
Participants will undergo white light endoscopy. The mucosa of the stomach may be thoroughly 
washed before examination with a combination of mucolytics (N-acetylcysteine) and anti-foaming 
agents (simethicone) mixed with sterile water, as medically indicated. Inspection will include 
repeated inflation and deflation to check distensibility and any abnormal appearing areas will 
additionally be biopsied. A minimum of 30 non-targeted biopsies will be obtained from 6 anatomic 
zones of the stomach: 

pre-pyloric area, 

antrum, 

transitional zone, 

body, 

fundus, and 

cardia.
Five mucosal biopsies will be taken from each zone. Biopsies will be taken using standard, cold 
endoscopic forceps. This technique is estimated to take approximately 30 minutes or less.
3.1.3
Confocal Endomicroscopy of the Gastric Mucosa
Subjects may additionally undergo confocal imaging with fluorescein contrast following white 
light endoscopy (refer to Section 3.1). Confocal imaging of the gastric mucosa will be performed 
using the Cellvizio Real-Time In Vivo Cellular Imaging Platform with Confocal Miniprobes 
(refer to Section 3.1). Focally abnormal areas of gastric mucosa and selected normal-appearing 
anatomic regions will be selected for digital imaging. The overall procedure time for subjects in 
which CEM will also be performed is estimated to increase by approximately ≤ 20 minutes.
3.2
SURGICAL GUIDELINES 
3.2.1
Preoperative Patient Management 
Patients will receive standard preoperative care as appropriate to the planned endoscopic 
intervention and the patient’s underlying health status. This will include sequential compression 
devices placed on the lower extremities prior to induction of general anesthesia.
3.2.2
White-light, Upper Endoscopy 
As described in Sections 3.1.1 and 3.1.2.
3.2.3
Postoperative Care

Patients will be monitored in the post anesthesia care unit (PACU) after their procedure 
prior to being discharged (if outpatient) or transferred to the inpatient ward (if inpatient).

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3.2.4
Discharge

Total hospitalization may be 0-1 day. If patients live in the area they may come in the 
morning of the procedure and leave on the same day providing they have a companion with 
them. If the patient is traveling alone (without companion) then they will spend the night 
in the hospital after the procedure prior to discharge. 
3.3
FOLLOW-UP
Patients will return to the NIH Clinical Center approximately two weeks after the EGD to discuss 
pathology results and any adverse events that they might have experienced. Alternatively, we will 
discuss pathology results and adverse events (AEs) on the phone. 
Gastrectomy is not part of this protocol, but if patient elects to undergo gastrectomy on another 
protocol, we may perform additional correlative studies before, during and after gastrectomy, 
including pathology assessment of stomach tissue.
Participants declining total gastrectomy (TG) may be invited to collect stool samples after study 
intervention as indicated in Section 5.1.
Participants who elect for TG may be invited to collect stool, blood and oropharyngeal swab/saliva 
samples pre-gastrectomy and post-gastrectomy as indicated in Section 5.1.
3.3.1
Repeat Endoscopy 
Endoscopy may be repeated once (per patient) for those with clinical need for repeat endoscopy at 
least 6 months (+/- 2 weeks) and no greater than 18 months (+/- 4 weeks) from the date of initial 
endoscopy on the current study. Patients who have been taken off study will be re-enrolled (refer 
to Section 2.1.2). 
Patient will be randomized for second endoscopy by CRO to Arm 1 or Arm 2.
Baseline assessment will be repeated as explained in Section 2.4.
Endoscopy will be performed as explained in Section  3.2 
Samples for correlative studies will be collected again as explained in Section 5. 
Participants declining TG will be invited to Clinical Center to collect stool samples after second 
endoscopy (refer to Section 5).
3.3.2
Long-Term Sequelae of Total Gastrectomy
Esophageal Dysmotility: Very few studies have evaluated esophageal motility after total 
gastrectomy. The limited data available demonstrate that the majority of post-gastrectomy patients 
(13/20) were symptomatic (with complaints of reflux, dysphagia, or odynophagia) while all 
demonstrated pathological patterns of contraction on esophageal manometry [26]. Because of this 
observation of symptomatic dysphagia in the absence of mechanical abnormality (i.e., esophageal 
stricture), we propose high resolution esophageal manometry studies to understand the functional 
effects of total gastrectomy on the esophagus as part of this endoscopic surveillance protocol.
An esophageal manometry is a test to determine how well the muscles of the esophagus work and 
can help in the evaluation of acid reflux, problems with swallowing, and chest pain that may be 
coming from the esophagus. 

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This high resolution esophageal manometry test typically takes 15 to 20 minutes to complete. 
Patients are asked to stop eating or drinking after midnight on the day of the test. Per standard 
clinical procedure, a small, flexible plastic tube is passed through the naris (i.e., nostril), down the 
back of the throat, and into the esophagus. The esophageal manometry probe contains pressure 
sensors and impedance channels which allow for measurements of the muscle contractions of the 
esophagus and how liquid or viscous materials are propelled through the esophagus during 
swallowing. The patient is asked to swallow small sips of water during the test. Afterwards the 
flexible tube is removed. No activity restriction or dietary restriction is necessary following this 
test.
Participants planning to undergo total gastrectomy at the NIH will also undergo an optional high 
resolution esophageal manometry prior to obtaining baseline esophageal function. Following total 
gastrectomy, additional optional esophageal manometry will be performed at 3 months (+/- 1 
month) and 12 months (+/- 2 months) post-gastrectomy. Results of these high resolution 
esophageal manometry will be shared with participants.
3.4
COST AND COMPENSATION 
3.4.1
Costs
NIH does not bill health insurance companies or participants for any research or related clinical 
care that participants receive at the NIH Clinical Center.  If some tests and procedures are 
performed outside the NIH Clinical Center, participants may have to pay for these costs.  
Medicines that are not part of the study treatment will not be provided or paid for by the NIH 
Clinical Center. 
3.4.2
Compensation
No compensation is offered on this study.
3.4.3
Reimbursement 
The NCI will cover the costs of some expenses associated with protocol participation.  Some of 
these costs may be paid directly by the NIH and some may be reimbursed to the 
participant/guardian as appropriate.  The amount and form of these payments are determined by 
the NCI Travel and Lodging Reimbursement Policy.
3.5
CRITERIA FOR REMOVAL FROM PROTOCOL INTERVENTIONS AND OFF STUDY CRITERIA
Prior to removal from study, effort must be made to have all subjects complete a safety visit 
approximately 14 days following study interventions.
3.5.1
Criteria for Removal from Protocol Interventions

Completion of protocol interventions

Patient requests to be withdrawn from active intervention

A serious or intolerable event related to the intervention occurs 

Investigator discretion
3.5.2
Off-Study Criteria

Completion of 12 months follow up period after last endoscopy procedure (for patients 
who decline total gastrectomy)

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
Completion of 12 months follow up period after total gastrectomy (for patients who opt for 
total gastrectomy)

Investigator discretion

Death

Participant requests to be withdrawn from the study

Lost to follow up

PI decision to close the study

Screen failure
3.5.3
Lost to Follow-Up
A participant will be considered lost to follow-up if he or she fails to return for 4 scheduled visits 
and is unable to be contacted by the study site staff. 
The following actions must be taken if a participant fails to return to the clinic for a required study 
visit:

The site will attempt to contact the participant and reschedule the missed visit within 3 
weeks and counsel the participant on the importance of maintaining the assigned visit 
schedule and ascertain if the participant wishes to and/or should continue in the study.

Before a participant is deemed lost to follow-up, the investigator or designee will make 
every effort to regain contact with the participant (where possible,3 telephone/video 
calls and, if necessary, an IRB approved certified letter to the participant’s last known 
mailing address or local equivalent methods). These contact attempts should be 
documented in the participant’s medical record or study file. 

Should the participant continue to be unreachable, he or she will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up.
4
CONCOMITANT MEDICATIONS/MEASURES
During post-operative period, patients will receive all standard of care supportive measures, 
including pain control and incentive spirometry to prevent atelectasis as indicated. 

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5
CORRELATIVE STUDIES
5.1
SUMMARY AND BIOSPECIMEN COLLECTION TABLE FOR RESEARCH
Specimen / Assay 
Method
Volume 
(approx.)
Type of 
Collection 
Tube*
Collection 
Point(s)**
Location 
of 
Specimen 
Processing/ 
Storage***
Location of 
Specimen 
Analysis
***
Stool/ 
Microbiome by 
DNA + RNA 
Sequence 
Analysis
Stool,
≥ 300 mg/ 
specimen 
(or as 
available)
Stool 
Collection Kit 
(To BPC 
within 24 hrs. 
of collection; 
refer to 
Section 
5.1.1.3)
Participants 
declining TG:  
one-time prior to 
or day of EGD, 
AND post- EGD 
as applicable per 
PI discretion:
6 months (+/- 1 
month) and/or
12-months (+/- 2 
months) after 
study intervention 
Participants who 
elect for TG: 
one-time “pre-
gastrectomy” 
(prior to EGD or 
within 3 months 
prior to TG), 
AND at 
3 months (+/- 1 
month) and 
12 months (+/- 2 
months) post-
gastrectomy
Blood 
Processing 
Core 
(BPC)
CCR 
Sequencing 
Facility 
(CCR-SF)
Serum/ 
Microbiome by 
DNA + RNA 
Sequence 
Analysis 
Blood, 5 mL/ 
specimen
SST 
(red/yellow 
top) tube, or 
similar (per 
BPC)
Participants who 
elect for TG: 
one time “pre-
gastrectomy” 
AND at 
3 months (+/- 1 
month) and 
12 months (+/- 2 
months) post-
gastrectomy 
Blood 
Processing 
Core 
(BPC) 
(As 
indicated 
in Section 
5.1.1.5)
CCR 
Sequencing 
Facility 
(CCR-SF)

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Specimen / Assay 
Method
Volume 
(approx.)
Type of 
Collection 
Tube*
Collection 
Point(s)**
Location 
of 
Specimen 
Processing/ 
Storage***
Location of 
Specimen 
Analysis
***
Gastric Lavage/ 
Microbiome by 
DNA + RNA 
Sequence 
Analysis 
Gastric lavage, 
10 mL/ 
specimen
(as available)
Sterile 
specimen cup 
or conical tube 
(or equivalent) 
(To BPC 
within 2 hrs. of 
collection; as 
indicated in 
5.1.1.1)
One time during 
upper endoscopy 
in all study 
participants (per 
PI discretion at 
time of 
intervention, as 
applicable)
Blood 
Processing 
Core 
(BPC) 
CCR 
Sequencing 
Facility 
(CCR-SF)
Gastric Mucosal 
Biopsy/ 
Microbiome by 
DNA + RNA 
Sequence 
Analysis  
Non-targeted 
gastric biopsy; 
2 biopsies/ 
specimen
(as available)
Sterile conical 
tube (or 
equivalent) 
with normal 
saline (without 
preservative 
fluid)
(To BPC 
within 2 hrs. of 
collection; 
refer to 
5.1.1.2)
One time during 
upper endoscopy 
in all study 
participants (per 
PI discretion at 
time of 
intervention, as 
applicable) 
Blood 
Processing 
Core 
(BPC)
CCR 
Sequencing 
Facility 
(CCR-SF)
Oropharyngeal/ 
Microbiome by 
DNA + RNA 
Sequence 
Analysis 
Oropharyngeal 
swab, 1 swab 
OR
Per salvia 
collection kit 
Cryotube with 
500µl RTF 
buffer (n=1)
OR
Per collection 
kit (or 
equivalent)
(To BPC 
within 2 hrs. of 
collection; 
refer to 
5.1.1.4)
Participants who 
elect for TG: 
one time “pre-
gastrectomy” 
AND at 
3 months (+/- 1 
month) and 
12 months (+/- 2 
months) post-
gastrectomy
Blood 
Processing 
Core 
(BPC)
CCR 
Sequencing 
Facility 
(CCR-SF)
* Tubes/media may be adjusted at the time of collection based upon materials available if approved by the 
PI/laboratory investigator.
** Note: Specimen defined as “pre-gastrectomy” should be collected anytime within the 3 months prior to total 
gastrectomy.
*** Samples will be sent to Blood Processing Core (BPC) for barcoding and initial processing and storage until 
they are distributed for sample analysis, if not otherwise specified in the protocol. Samples will be stored and kept 
frozen in the BPC freezers (e.g., -20/-80°C) according to stability requirements. DNA/RNA extraction in Dr. 
Heller’s lab or per PI discretion at CCR Sequencing Facility (CCR-SF) prior to CCR-SF analysis.

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5.1.1
Sample Collection and Processing 
Standard pathology evaluation of stomach tissue from biopsies and/or gastrectomy will be 
performed in the Laboratory of Pathology (Section 5.3.2).
Note: The handling and processing instructions outlined in the following sections should be 
followed as closely as possible, however handling and processing may be adjusted at the discretion 
of the PI and/or supervising laboratory to ensure sample quality.
5.1.1.1
Gastric Lavage/Microbiome by DNA + RNA Sequence Analysis
Gastric lavage will be obtained during upper endoscopy in all study participants (as indicated in 
Section 5.1) through the working channel of the upper endoscope. In order to avoid potential 
contamination, suctioning of oropharyngeal and esophageal secretion will be minimized upon 
insertion of the endoscope. The gastric lavage will be suctioned into a sterile conical tube.  The 
research study team will be alerted by operating room personnel when the sample is ready for 
pickup. 
The sample will be aliquoted by the study team into approximately 6 smaller containers prior to 
transfer to the Blood Processing Core (BPC) for storage, or as agreed upon with BPC at the time 
of transfer (per PI discretion): one 5 mL tube (n=1) and five 1 mL tubes (n=5), for a total of 10 mL 
(i.e., n=6 total). The samples will be stored at -80°C within 2 hours of collection and kept frozen 
until further analysis. Samples will be initially stored in the Blood Processing Core (BPC) (Section 
5.3.1). 
5.1.1.2
Gastric Mucosal Biopsy/Microbiome by DNA + RNA Sequence Analysis
Gastric mucosal biopsy will be obtained during upper endoscopy in all study participants using a 
sterile standard biopsy forcep (e.g., Standard Radical JawTM biopsy forcep, 2.8mm) as indicated 
in Section 5.1.  Biopsies will be obtained in a standardized fashion, 2 non-targeted biopsies of the 
gastric mucosa placed in a sterile conical tube in normal saline solution. The research study team 
will be alerted by operating room personnel when the sample is ready for pickup.  
The study team may transfer the specimen to cryotubes prior to delivering samples to the BPC for 
storage, or as agreed upon with BPC at the time of transfer (per PI discretion). The specimens will 
be stored at -80°C within 2 hours of collection and kept frozen until further analysis. Samples will 
be initially stored in the Blood Processing Core (BPC). 
5.1.1.3
Stool/Microbiome by DNA + RNA Sequence Analysis
Stool specimens will be collected in all study participants. 
In those who decline total gastrectomy: the participant will be asked to produce a single stool 
specimen, to be collected one time prior to or on the day of study intervention (i.e., EGD), 
followed by potential stool specimen collection twice more post-study intervention (EGD), as 
applicable per PI discretion (refer to the Section 5.1 specimen collection table). 
In those who elect surgery: the participant will be asked to produce a single stool specimen,  
to be collected one-time pre-gastrectomy prior to the endoscopy, then two times post-
gastrectomy (refer to the Section 5.1 specimen collection table). 
Stool specimens will be collected in a standardized manner using a stool collection kit (Appendix 
3). Received participant collection kit stool samples will be aliquoted by the research study team 
into 3 cryotubes containing approximately 300 mg of stool per tube (i.e., n=3 total, if possible 

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based provided specimen volume only). These samples must be stored at -80°C within 24 hours 
after collection and kept frozen until further analysis. Samples will be initially stored in the Blood 
Processing Core (BPC). 
Note: In circumstances in which a participant is unable to produce a stool sample (i.e., unable to 
give stool “on demand”) at the indicated timepoint, one or more additional scheduled stool sample 
collection request(s) are permitted to meet study requirements for the collection of the sample per 
PI discretion.  
5.1.1.4
Oropharyngeal/Microbiome by DNA + RNA Sequence Analysis
Oropharyngeal swab or saliva will be collected only from participants who elect for surgery, 
obtained one time pre-total gastrectomy, and then two times post-gastrectomy (as indicated in 
Section 5.1). 
Samples will be obtained in a standardized manner and placed in a cryotube with 500µl RTF 
buffer, or per saliva collection kit. Samples will be stored at -20°C within 2 hours after collection 
and kept frozen until further analysis. Samples will be initially stored in the Blood Processing Core 
(BPC). 
5.1.1.5
Serum/Microbiome by DNA + RNA Sequence Analysis
Serum for bacterial DNA extraction will be collected only from participants who elect for surgery, 
obtained per the specimen collection table (refer to Section 5.1). Blood Processing Core (BPC) 
personnel will be alerted to pick up the specimen from phlebotomy. Serum specimen tubes will be 
initially processed (spun down) in the BPC and the plasma stored at -20°C and kept frozen in the 
BPC until further analysis.
5.2
SAMPLES FOR GENETIC/GENOMIC ANALYSIS
5.2.1
Microbiome 
The advent of highly sensitive analytical methods in recent years has enabled detailed delineation 
of the gut microbiome in health and disease. Therefore, analysis of the gastric and fecal 
microbiome may aid our understanding of microbiome diversity and possible dysbiosis.  Gastric 
lavage and gastric biopsy can be used to define and characterize the gastric microbiota – luminal 
and mucosal adherent. Recent studies demonstrate a correlation with gastric cancer and 
opportunistic pathogens within the stomach, however the gastric microbiome of CDH1 mutation 
carriers and the microbiome contribution to disease penetrance in this population is unknown 
[27, 28]. We plan to use pyro-sequencing techniques to survey microbial diversity in patients’ 
serum, oropharyngeal, gastric and fecal samples. The association between specific microbiome 
maps and the occurrence of bacterial translocation will then be analyzed.
At the time of analysis, we intend to evaluate the relationship between specific microbiome maps 
and the occurrence of bacterial translocation. In addition, species homology between blood, 
oropharyngeal, gastric, and fecal samples will be determined by deep sequencing. 
Bacterial DNA will be extracted from patient serum, gastric samples, oropharyngeal and stool 
specimens by the CCR Sequencing Facility (CCR-SF).  Metagenomic sequencing techniques 
will be utilized to characterize the gastrointestinal tract microbiome.
Participant dietary history and prescription, herbal and over-the-counter medication and nutrition 
supplementation will also be recorded (see Section 6.1). 

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5.2.1.1
Dietary History
Participants will be asked to complete two types of validated, online questionnaires for collection 
of their dietary history: the Automated Self-Administered 24-Hour Dietary Assessment Tool 
(ASA24) for 24-hour food recall, and the Diet History Questionnaire III (DHQIII) (refer to 
Appendix 1 and Appendix 2).  
For each online questionnaire, the research team will provide each user with a system-generated 
user ID and password that is unique to each respondent for each survey site. A list of 
participants’ respondent user IDs will be kept in a secure drive that is accessible only to the 
research team. The data recorded by the survey site will not include any personal identifiable 
data associated with the study respondents on either questionnaire website. Only this study’s 
investigators and the ASA24 and DHQIII operations teams for NCI (respectively) will have 
access to the participant response data.
Participants will be contacted by registered mail and/or by phone (or other NIH approved remote 
platforms used in compliance with policy, including HRPP Policy 303) as appropriate with 
instructions on how to complete the questionnaires.
Note: Both the ASA24 and DHQIII questionnaires were developed by NCI for research use. 
Automated Self-Administered 24-Hour Dietary Assessment (ASA24) – 24-Hour Food Recall
Participants will be asked to complete the ASA24 questionnaire (which once started requests a 
recall of the last 24 hours from survey start) as follows: 

on the day of each scheduled stool sample collection (Section 5.1.1.3) (+2 days to 
align the stool sample collection date with the day of questionnaire completion if 
needed during the study visit, as the participant may be unable to produce stool at the 
exact timepoint), and

on the day prior to scheduled endoscopy (+2 days to align the stool sample collection 
date with the day of questionnaire completion if needed, as the participant may be 
unable to produce stool at the exact timepoint).
Note: If the participant is unable to produce stool on the day of the scheduled stool sample 
collection but has already completed the 24-hour recall questionnaire earlier that day, per PI 
discretion, the participant may be asked to complete the questionnaire again on the “+1 day” or 
on the “+2 day” as appliable to when the stool sample is produced (in order to capture 
approximately the same 24 hours prior to the actual date of stool sample collection as the 24-
hour recall questionnaire answers). 
Diet History Questionnaire III (DHQIII)
Participants will be asked to complete the DHQIII questionnaire as follows: 

prior to each scheduled stool sample collection (Section 5.1.1.3) (+2 days to align 
with the stool sample collection date with the day of questionnaire completion if 
needed during the study visit, as the participant may be unable to produce stool at the 
exact timepoint), and

within 4 weeks (i.e., +/- 4 weeks) of scheduled upper endoscopy.  

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5.2.1.2
Prescription, Herbal, Over-the-Counter Medication and Nutrition Supplementation 
History
A thorough history of all prescription, herbal and over-the-counter medication and nutrition 
supplementation use will be collected at each outpatient visit, prior to upper endoscopy and prior 
to each of the stool collection periods. If the participant is on any laxatives, probiotic 
supplements, antibiotic medication, stool collection will be deferred until they are off these 
therapies. (See Section 6.1 for data collection.)    
5.3
SAMPLE STORAGE, TRACKING AND DISPOSITION
Samples will be ordered in CRIS and tracked through a Clinical Trial Data Management system. 
Should a CRIS screen not be available, the CRIS downtime procedures will be followed. Samples 
will not be sent outside the National Institutes for Health (NIH) without appropriate approvals 
and/or agreements, if required.
5.3.1
Samples Managed by Dr. Figg’s Blood Processing Core (BPC) 
BPC contact information 
Please e-mail at 
 at least 24 hours before transporting samples (the 
Friday before is preferred).
For sample pickup, page 
For immediate help, call 
 (main blood processing core number) or, if no answer, 
 (main clinical pharmacology lab number).
For questions regarding sample processing, contact 
The samples will be processed, barcoded, and stored in Dr. Figg’s lab until requested by the 
investigator.
5.3.1.1
Sample Data Collection
All samples sent to the Blood Processing Core (BPC) will be barcoded, with data entered and 
stored in Labmatrix utilized by the BPC. This is a secure program, with access to Labmatrix limited 
to defined Figg lab personnel, who are issued individual user accounts. Installation of Labmatrix 
is limited to computers specified by Dr. Figg. These computers all have a password restricted login 
screen. 
Labmatrix creates a unique barcode ID for every sample and sample box, which cannot be traced 
back to participants without Labmatrix access. The data recorded for each sample includes the 
participant ID, name, trial name/protocol number, time drawn, cycle time point, dose, material 
type, as well as box and freezer location. Participant demographics associated with the clinical 
center patient number are provided in the system. For each sample, there are notes associated with 
the processing method (delay in sample processing, storage conditions on the ward, etc.).
5.3.1.2
Sample Storage and Destruction
Barcoded samples are stored in barcoded boxes in a locked freezer at either -20C or -80C 
according to stability requirements.  These freezers are located onsite in the BPC and offsite at 
NCI Frederick Central Repository Services in Frederick, MD. Visitors to the laboratory are 
required to be accompanied by laboratory staff at all times. 

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Access to stored clinical samples is restricted. Samples will be stored until requested by a 
researcher named on the protocol. All requests are monitored and tracked in Labmatrix. All 
researchers are required to sign a form stating that the samples are only to be used for research 
purposes associated with this trial (as per the IRB approved protocol) and that any unused samples 
must be returned to the BPC. It is the responsibility of the NCI Principal Investigator to ensure that 
the samples requested are being used in a manner consistent with IRB approval.
Following completion of this study, samples will remain in storage as detailed above. Access to 
these samples will only be granted following IRB approval of an additional protocol, granting the 
rights to use the material. 
If, at any time, a participant withdraws from the study and does not wish for their existing samples 
to be utilized, the individual must provide a written request. Following receipt of this request, the 
samples will be destroyed (or returned to the participant, if so requested). The PI will record any 
loss or unanticipated destruction of samples as a deviation. Reporting will be per the requirements 
of Section 7.2.
Sample barcodes are linked to participant demographics and limited clinical information. This 
information will only be provided to investigators listed on this protocol, via registered use of the 
Labmatrix. It is critical that the sample remains linked to participant information such as race, age, 
dates of diagnosis and death, and histological information about the tumor, in order to correlate 
genotype with these variables.
5.3.2
Laboratory of Pathology
Tissues designated for clinical diagnostics are transported to the Laboratory of Pathology (LP) 
where they are examined grossly, and relevant portions are fixed, embedded in paraffin and 
sectioned and stained for diagnostic interpretation.  Unutilized excess tissues are stored for up to 
three months, in accordance with College of American Pathologists/Joint Commission on 
Accreditation of Healthcare Organizations (CAP/JCAHO) guidelines, and then discarded.
Following completion of the diagnostic workup, the slides and tissue blocks are either returned to 
the originating pathology department if requested or stored indefinitely in the LP’s clinical 
archives. All specimens are catalogued and retrieved utilizing the clinical laboratory information 
systems, in accordance with CAP/JCAHO regulations. The use of any stored specimens for 
research purposes is only allowed when the appropriate IRB approval has been obtained. In some 
cases, this approval has been obtained via the original protocol on which the participant was 
enrolled.
5.3.3
Center for Cancer Research Sequencing Facility (CCR-SF)
The Center for Cancer Research Sequencing Facility (CCR-SF), frequently referred to as the NCI 
Frederick Sequencing Facility, is a CCR-dedicated sequencing core facility at the Frederick 
National Laboratory for Cancer Research (operated by Leidos Biomedical Research, Inc. and 
sponsored by NCI). The Sequencing Facility processes genomics samples such as DNA or RNA 
from CCR investigators for genomics analysis including mutation analysis such as whole genome 
sequencing, transcript profiling and discovery, DNA/RNA protein interaction, exome sequencing 
or targeted exome sequencing and gene expression analysis.  

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5.3.3.1
Sequencing Facility Established Procedures of Sample Receiving and Storage  

Samples are received with a service request through the secure online request system 
(NAS).

Samples must be coded by the sender to remove any PII. The Sequencing Facility will not 
receive any samples with PII and does not store such information within their electronic 
database system (LIMS). 

Samples are inventoried and stored in freezers or refrigerators which are monitored through 
the alarm system.

The facility’s laboratory is located within a controlled access building. 

Samples are tracked in LIMS in addition to hard copy sample logs.

Sequencing Facility personnel receive annual updated NIH/CIT training and maintain 
standards of computer security.

At the end of the project, leftover samples (if any) will be transferred back to the requestor. 
The Sequencing Facility does not provide long term storage.
5.3.4
Laboratory of Dr. Heller
Samples collected for the purpose of research under this protocol may undergo DNA/RNA 
extraction in Dr. Heller’s lab after Blood Processing Core (BPC) barcoding, initial processing, and 
storage. Samples are stored in freezers at -80°C or -20°C according to stability requirements. 
Samples will be sent on for protocol research analysis as directed by the Principal Investigator.
5.3.5
Protocol Completion/Sample Destruction
All specimens obtained in the protocol are used as defined in the protocol. Any specimens that are 
remaining at the completion of the protocol will be stored in the conditions described in sections 
above. The study will remain open so long as sample or data analysis continues. Samples from 
consenting subjects will be stored until they are no longer of scientific value or if a subject 
withdraws consent for their continued use, at which time they will be destroyed. 
If the patient withdraws consent the participant’s data will be excluded from future distributions, 
but data that have already been distributed for approved research use will not be able to be 
retrieved.
The PI will record any loss or unanticipated destruction of samples as a deviation. Reports will be 
made per the requirements of Section 7.2.1.
5.3.6
Machine Learning for Early Gastric Cancer Detection
Application of artificial intelligence to radiographic and histopathologic tests is being explored to 
improve the sensitivity and specificity of cancer diagnosis. Because the use of CEM in our previous 
Phase II study showed low sensitivity for occult cancer detection, we believe that application of 
machine learning (i.e., computer models) based on the input provided by CEM imaging, and 
endoscopic high-resolution video imaging as applicable, will improve our ability to accurately and 
reliably detect cancer. By incorporating the corresponding histopathology images/results obtained 
after gastric biopsy, we will essentially teach the computer how to reliably detect occult gastric 
cancer through an iterative process.

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This machine learning for early cancer detection is ONLY being applied post-hoc as a research 
tool to improve endoscopic diagnosis for protocol endpoints– it will not be used in any way to 
diagnose or treat patients enrolled on this study.
6
DATA COLLECTION AND EVALUATION 
6.1
DATA COLLECTION
The PI will be responsible for overseeing entry of data into a data capture system provided by the 
NCI CCR and ensuring data accuracy, consistency and timeliness. The principal investigator, 
associate investigators/research nurses and/or a contracted data manager will assist with the data 
management efforts. Primary and final analyzed data will have identifiers so that research data can 
be attributed to an individual human subject participant.
All adverse events, including clinically significant abnormal findings on laboratory evaluations, 
regardless of severity, will be followed until return to baseline or stabilization of event. 
Document AEs from the start of endoscopy through 14 days following study interventions.
An abnormal laboratory value will be recorded in the database as an AE only if the laboratory 
abnormality is characterized by any of the following:

Results in discontinuation from the study

Is associated with clinical signs or symptoms 

Requires treatment or any other therapeutic intervention

Is associated with death or another serious adverse event, including hospitalization. 

Is judged by the Investigator to be of significant clinical impact

If any abnormal laboratory result is considered clinically significant, the investigator will 
provide details about the action taken with respect to the test drug and about the patient’s 
outcome.
Adverse Events related to study interventions will only be recorded if they are serious (all Grades) 
or unexpected (Grades 3 and above).
We will collect information from participants regarding consuming nutritional or dietary 
supplementation, antimicrobial medications, pro- or prebiotics, and/or laxative agents; this 
information may be recorded in the participant’s medical record (in addition to the data capture 
system provided by the NCI CCR) as applicable.  
End of study procedures: Data will be stored according to HHS, FDA regulations, and NIH 
Intramural Records Retention Schedule as applicable. 
Loss or destruction of data: Should we become aware that a major breach in our plan to protect 
subject confidentiality and trial data has occurred, this will be reported expeditiously per 
requirements in Section 7.2.1. 
6.2
DATA SHARING PLANS
6.2.1
Human Data Sharing Plan
The PI will share coded linked human data generated in this research for future research: 

in a NIH-funded or approved public repository clinicaltrials.gov, GenBank 

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
in BTRIS 

in publication and/or public presentations

with approved outside collaborators under appropriate agreements

at the time of publication or shortly thereafter. 
6.2.2
Genomic Data Sharing Plan 
Bacterial gene sequences will be deposited in GenBank.
6.3
TOXICITY CRITERIA
The following adverse event management guidelines are intended to ensure the safety of each 
patient while on the study. The descriptions and grading scales found in the revised NCI Common 
Terminology Criteria for Adverse Events (CTCAE) version 5.0 will be utilized for AE reporting. 
All appropriate treatment areas should have access to a copy of the CTCAE version 5.0. A copy 
of 
the 
CTCAE 
version 
5.0 
can 
be 
downloaded 
from 
the 
CTEP 
web 
site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_50). 
7
NIH REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN
7.1
DEFINITIONS
Please refer to definitions provided in Policy 801: Reporting Research Events found at: 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#HRPPPolicies-
800Series-ComplianceandResearchEventReportingRequirements.
7.2
OHSRP OFFICE OF COMPLIANCE AND TRAINING / IRB REPORTING
7.2.1
Expedited Reporting
Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy 
802: 
Non-Compliance 
Human 
Subjects 
Research 
found 
at: 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#HRPPPolicies-
800Series-ComplianceandResearchEventReportingRequirements. 
7.2.2
 IRB Requirements for PI Reporting at Continuing Review
Please refer to the reporting requirements in Policy 801: Reporting Research Events found at: 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#HRPPPolicies-
800Series-ComplianceandResearchEventReportingRequirements.
7.3
NCI CLINICAL DIRECTOR REPORTING
Problems expeditiously reviewed by the OHSRP in the NIH eIRB system will also be reported to 
the NCI Clinical Director/designee; therefore, a separate submission for these reports is not 
necessary.
In addition to those reports, all deaths that occur within 30 days after receiving a research 
intervention should be reported via email unless they are due to progressive disease. 
To report these deaths, please send an email describing the circumstances of the death to 
within one business day of learning of the death.

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7.4
NIH REQUIRED DATA AND SAFETY MONITORING PLAN
7.4.1
Principal Investigator/Research Team 
The clinical research team will meet weekly when patients are being actively enrolled on the trial 
to discuss each patient. 
All data will be collected in a timely manner and reviewed by the principal investigator or a lead 
associate investigator. Events meeting requirements for expedited reporting as described in Section 
7.2.1 will be submitted within the appropriate timelines. 
The principal investigator will review adverse event and response data on each patient to ensure 
safety and data accuracy. The principal investigator will personally conduct or supervise the 
investigation and provide appropriate delegation of responsibilities to other members of the 
research staff. 
8
STATISTICAL CONSIDERATIONS 
8.1
STATISTICAL HYPOTHESIS
Primary Endpoint: 

Determine if Bethesda protocol provides improved sensitivity for detection of early-stage 
gastric cancer in CDH1 germline mutation carriers compared to the Cambridge method.

Secondary Endpoints:

Define the false negative rate of SRCC detection using Bethesda and Cambridge methods 
in patients who proceed to risk-reducing total gastrectomy.

Estimate and compare the difference in crude cancer detection rates between endoscopy 
using the Bethesda protocol and the Cambridge method. 
8.2
SAMPLE SIZE DETERMINATION
For purposes of sample size determination, it will be of interest to determine if the Bethesda 
protocol provides 60% sensitivity compared to 30% sensitivity for the Cambridge method. For 
background, results from 110 patients enrolled at the NCI (81 receiving Bethesda protocol and 29 
receiving Cambridge evaluations) demonstrated the following. Of the 29 patients who received 
Cambridge, with 4 having SRCCs identified, 17 underwent total gastrectomy of whom 2 had 
SRCCs initially identified by Cambridge. Of the 17, 11 had SRCCs on endoscopic biopsy, so the 
sensitivity of the Cambridge method was 2/11=18%. Similarly, of the 81 patients who received 
Bethesda protocol, 29 were initially found to have SRCC on endoscopic biopsy. Twenty-four of 
the 81 underwent total gastrectomy, of whom 13 had SRCCs initially identified by endoscopic 
biopsy on Bethesda protocol. Of the 24, 22 had SRCCs on endoscopic biopsy, so the sensitivity of 
Bethesda protocol was 13/22=59%. This also means that in practice, approximately 80% of 
patients who underwent a gastrectomy would have SRCCs identified.
Based on these values, it is expected that it would be conservative to try to determine if Bethesda 
protocol would be able to result in 60% sensitivity compared to 30% sensitivity with Cambridge. 
With 48 patients receiving Cambridge endoscopy with positive biopsy followed by gastrectomy 
and 48 receiving Bethesda protocol endoscopy with positive biopsy followed by gastrectomy, on 
a Fisher’s exact test with a 0.05 two-sided significance level we would have 80% power to detect 

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a difference between 30% and 60% sensitivity. In order to yield 48 patients with SRCCs detected 
on endoscopic biopsy, 60 patients with gastrectomy will be required.
Based on the prior experience with surveillance endoscopy, out of 110 patients, only 17+24=41 
(37%) patients underwent a gastrectomy. To provide adequate patients to have a high probability 
of yielding 60 per arm who have a gastrectomy resulting in 48 with SRCCs, the study will 
randomize 175 patients to Bethesda protocol and 175 to Cambridge (350 total patients) in order to 
have 79% probability of obtaining 60 or more patients undergoing each procedure including 
gastrectomy, if the true probability of undergoing a gastrectomy is 37%. In practice, patients will 
continue to be randomized up to the limit of 350 total randomized patients, or until 48 patients on 
each arm have undergone a total gastrectomy and found to have SRCCs.  Re-enrolled subjects will 
be counted separately at each enrollment/randomization. 
All randomized patients who receive an endoscopy will have the crude cancer detection rates 
compared between the two methods. Data from a prior NIH trial indicated that the crude cancer 
detection rate was 15% using the Cambridge method and 36% using the Bethesda method, based 
on 26 and 109 evaluable patients respectively. In the present trial, if all 175 patients are required 
in each arm, then there would be 90.6% power to detect a difference with a two-sided 0.05 
significance level between 15% and 30% crude cancer detection rates on the Cambridge method 
and the Bethesda protocol respectively. If only 135 evaluable patients undergo endoscopy using 
each method, there would be 81.0% power to detect a difference with a two-sided 0.05 significance 
level between 15% and 30% crude cancer detection rates.
Since January 2017 through September 2019, we have enrolled over 240 CDH1 mutation patients 
on protocol 17-C-0043, performed over 145 surveillance endoscopies (12 performed in September 
2019), over 61 risk-reducing gastrostomies (5 performed in September 2019). It is anticipated that 
more than 100 patients per year will be able to enroll onto this trial. Thus, accrual of up to 350 
total subjects is expected to be completed in no more than 3.5 years.
8.3
POPULATIONS FOR ANALYSES
All patients who are randomized on the trial and receive an endoscopy will be used for analysis. 
Those who undergo gastrectomy will be included in the evaluation of the two methods relative to 
the biopsy proven results. 
8.4
STATISTICAL ANALYSES
8.4.1
General Approach
The patients who undergo gastrectomy will have the sensitivity, and false negative rates of 
detection of SRCC determined, while all patients undergoing an endoscopy will be used to estimate 
and compare the crude cancer detection rates for the two methods.
8.4.2
Analysis of the Primary Endpoint
The primary objective of the study is to determine if Bethesda protocol provides improved 
sensitivity for detection of early stage gastric cancer in CDH1 germline mutation carriers compared 
to the Cambridge method. Among patients who undergo gastrectomy, in each of the two arms, the 
fraction of patients who had SRCCs previously identified by endoscopic biopsy out of those who 
had SRCCs detected on final pathologic analysis of gastrectomy explants will be used to determine 
the sensitivity of each arm. These fractions will be reported along with a 95% confidence interval 
and will be compared between the two arms using a two-tailed Fisher’s exact test. This analysis 

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will also be carried out after 24 evaluable participants on each arm have undergone a total 
gastrectomy and found to have SRCCs as an interim evaluation, as indicated below in Section 
8.4.5.
8.4.3
Analysis of the Secondary Endpoint
One secondary endpoint is to define the false negative rate of SRCC detection using Bethesda 
protocol and Cambridge methods in patients who proceed to risk-reducing total gastrectomy. 
Among patients who undergo the gastrectomy in each of the two arms, the fraction of patients who 
had SRCC identified on final pathology but were negative for SRCC on EGD will yield the false 
negative biopsy rate. These fractions will be reported along with a 95% confidence interval and 
will be compared between the two arms using a two-tailed Fisher’s exact test. 
The other secondary endpoint is to estimate and compare the crude cancer detection rates by the 
two methods. The fractions of SRCCs which are found on endoscopy by the two methods will be 
reported along with a 95% confidence interval, and the difference in the fractions will be compared 
using a two-tailed Fisher’s exact test.
8.4.4
Baseline Descriptive Statistics
Baseline demographic characteristics will be reported overall and by arm.
8.4.5
Interim Analyses
Using the Haybittle-Peto approach, after 24 evaluable participants on each arm have undergone a 
total gastrectomy and found to have SRCCs, an interim evaluation will be performed. If at this 
interim point, the difference in the fractions of participants on the two arms with respect to the 
primary sensitivity endpoint is statistically different with p < 0.001, then the trial will stop accrual 
as soon as this can be determined, and the results will be reported based on these participants. As 
a result of selecting the very small 0.001 threshold, if the interim analysis does not find a difference 
at this level, the trial may continue to enroll participants until the intended 48 participants per arm, 
and the final evaluation will take place using the 0.05 significance level threshold (refer to Section 
8.2).
8.4.6
Analysis of the Exploratory Endpoints

Determine if confocal endoscopic microscopy (CEM) will afford greater sensitivity for 
detection of SRC foci in CDH1 germline mutation carriers compared to the Cambridge 
method

To characterize gastric tract microbiota of CDH1 germline mutation carriers.

To access esophageal motility after total gastrectomy (in patients who pursue total 
gastrectomy)

Apply machine learning for early gastric cancer detection via CEM and histopathology, 
and utilize image-to-image translation to enhance early cancer detection with CEM
The exploratory objectives are intended to collect data for use in planning future scientific 
investigations or clinical research. These analyses are expected to be performed primarily using 
descriptive techniques, reporting descriptive statistics including confidence intervals when 
appropriate. If any statistical tests are performed for evaluation of exploratory objectives, they will 
be done without formal adjustment for multiple comparisons, but in the context of the number of 
tests performed. We will tabulate separately by patient the crude cancer detection results for those 

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patients who undergo two procedures, and as an exploratory analysis, compare the results within 
patients and summarize results across patients using descriptive analyses.
9
HUMAN SUBJECTS PROTECTIONS 
9.1
RATIONALE FOR SUBJECT SELECTION
Subjects from all racial/ethnic groups are eligible for this study if they meet the eligibility criteria. 
Efforts will be made to extend accrual to a representative population.
9.2
PARTICIPATION OF CHILDREN
Children are excluded from this study because endoscopic screening for CDH1 mutation carriers 
is not recommended in children. 
9.3
PARTICIPATION OF SUBJECTS UNABLE TO GIVE CONSENT
Adults unable to give consent are excluded from enrolling in the protocol. 
9.4
RISK/BENEFIT ASSESSMENT FOR ALL PARTICIPANTS
9.4.1
Known Potential Risks
9.4.1.1
Risks of Upper Endoscopy
The risks of upper endoscopy include, but are not limited to, temporary throat soreness, 
gastrointestinal bleeding, and rarely gastrointestinal perforation.
9.4.1.2
Risks of Fluorescein Intravenous Administration
The risks of intravenous administration of the contrast agent fluorescein are: nausea, vomiting, 
dizziness, headache, and low blood pressure.
9.4.1.3
Risks of General Anesthesia
The risks of general anesthesia include, but are not limited to, temporary confusion and memory 
loss, dizziness, difficulty passing urine, bruising or soreness from the IV drip, nausea and vomiting, 
shivering and feeling cold, sore throat, heart attack, pneumonia and stroke.
9.4.1.4
Risk of Biopsies 
All care will be taken to minimize risks that may be incurred by tumor sampling. Biopsies will be 
taken during endoscopy. All procedure-related risks (such as bleeding, infection and visceral 
injury) will be explained fully during informed consent.
9.4.1.5
Risks of Esophageal Manometry
The risks of esophageal manometry include discomfort from passing a plastic tube through the 
nostril and possible bleeding. 
9.4.1.6
Risks of Oropharyngeal Swabs and Salvia Collection 
There are no risks or complications associated with an oropharyngeal swab (cheek cells) or saliva 
collection. The oropharyngeal swab test may cause momentary gagging because the back of the 
throat is a sensitive area, but it shouldn’t be painful.
9.4.1.7
Risk of Losing Data 
This includes the risk that data obtained during this study that can be released to members of the 
public, insurers, employers, or law enforcement agencies. Although there are no plans to release 

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results to the patients, family members or health care providers, this risk will be included in the 
informed consent document
9.4.1.8
Risks from Questionnaires
Questionnaires may contain questions that are sensitive in nature. The patients are asked to only 
answer questions they are comfortable with.
9.4.2
Known Potential Benefits
The benefit is detection of gastric cancer at its earliest stage so that it is potentially curable.
9.4.3
Assessment of Potential Risks and Benefits
A number of clinically appropriate strategies to minimize risks to patients have been built into the 
protocol through the means of inclusion/exclusion criteria, monitoring strategies, and management 
guidelines. Overall, the potential benefit of the study interventions in subjects with CDH1 germline 
mutations outweigh the risks associated with study interventions.
The potential benefit to a patient that participates in this study is detection of gastric cancer at its 
earliest stage so that it is potentially curable. 
Potential adverse reactions attributable to the study interventions are discussed in Section 9.4.1. 
All care will be taken to minimize side effects, but they can be unpredictable in nature and severity.
9.5
CONSENT PROCESS AND DOCUMENTATION
The informed consent document will be provided as a physical or electronic document to the 
participant or consent designee(s) as applicable for review prior to consenting.  A designated study 
investigator will carefully explain the procedures and tests involved in this study, and the 
associated risks, discomforts and benefits. In order to minimize potential coercion, as much time 
as is needed to review the document will be given, including an opportunity to discuss it with 
friends, family members and/or other advisors, and to ask questions of any designated study 
investigator. A signed informed consent document will be obtained prior to entry onto the study.
The initial consent process as well as re-consent, when required, may take place in person or 
remotely (e.g., via telephone or other NIH approved remote platforms used in compliance with 
policy, including HRPP Policy 303) per discretion of the designated study investigator and with 
the agreement of the participant/consent designee(s).  Whether in person or remote, the privacy of 
the subject will be maintained. Consenting investigators (and participant/consent designee, when 
in person) will be located in a private area (e.g., clinic consult room). When consent is conducted 
remotely, the participant/consent designee will be informed of the private nature of the discussion 
and will be encouraged to relocate to a more private setting if needed.
Consent will be documented with required signatures on the physical document (which includes 
the printout of an electronic document sent to participant) or as described below, with a manual 
(non-electronic) signature on the electronic document.  When required, witness signature will be 
obtained similarly as described for the investigator and participant.
Manual (Non-Electronic) Signature on Electronic Document:
When a manual signature on an electronic document is used for the documentation of consent 
at the NIH Clinical Center, this study will use the following to obtain the required signatures:

Adobe platform (which is not 21 CFR Part 11 compliant); or,  

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
iMedConsent platform (which is 21 CFR Part 11 compliant)
During the consent process, participants and investigators will view individual copies of the 
approved consent document on screens at their respective locations (if remote consent); the 
same screen may be used when in the same location, but is not required.  
Both the investigator and the participant will sign the document using a finger, stylus or mouse. 
Note: Refer to the CCR SOP PM-2, Obtaining and Documenting the Informed Consent Process 
for additional information (e.g., verification of participant identity when obtaining consent 
remotely) 
found 
at: 
https://ccrod.cancer.gov/confluence/pages/viewpage.action?pageId=73203825.
10 REGULATORY AND OPERATIONAL CONSIDERATIONS 
10.1 STUDY DISCONTINUATION AND CLOSURE
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause. Written notification, documenting the reason for study suspension or 
termination, will be provided by the suspending or terminating party to study participants. If the 
study is prematurely terminated or suspended, the Principal Investigator (PI) will promptly inform 
study participants, the Institutional Review Board (IRB) and will provide the reason(s) for the 
termination or suspension. Study participants will be contacted, as applicable, and be informed of 
changes to study visit schedule.
 Circumstances that may warrant termination or suspension include, but are not limited to:

Determination of unexpected, significant, or unacceptable risk to participants

Insufficient compliance to protocol requirements

Data that are not sufficiently complete and/or evaluable

Determination that the primary endpoint has been met

Determination of futility
Study may resume once concerns about protocol compliance, and data quality are addressed, and 
satisfy the IRB.
10.2 QUALITY ASSURANCE AND QUALITY CONTROL
The clinical site will perform internal quality management of study conduct, data and biological 
specimen collection, documentation and completion. An individualized quality management plan 
will be developed to describe the site’s quality management.
Quality control (QC) procedures will be implemented beginning with the data entry system and 
data QC checks that will be run on the database will be generated. Any missing data or data 
anomalies will be communicated to the site(s) for clarification/resolution.
Following written Standard Operating Procedures (SOPs), the monitors will verify that the clinical 
trial is conducted and data are generated and biological specimens are collected, documented 
(recorded), and reported in compliance with the protocol, International Council on Harmonisation 
Good Clinical Practice (ICH GCP), and applicable regulatory requirements (e.g., Good Laboratory 
Practices (GLP), Good Manufacturing Practices (GMP)). 
The investigational site will provide direct access to source data/documents, and reports for the 
purpose of monitoring and inspection by local and regulatory authorities.

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10.3 CONFLICT OF INTEREST POLICY
The independence of this study from any actual or perceived influence is critical. Therefore, any 
actual conflict of interest of persons who have a role in the design, conduct, analysis, publication, 
or any aspect of this trial will be disclosed and managed. Furthermore, persons who have a 
perceived conflict of interest will be required to have such conflicts managed in a way that is 
appropriate to their participation in the design and conduct of this trial. The study leadership in 
conjunction with the National Cancer Institute (NCI) has established policies and procedures for 
all study group members to disclose all conflicts of interest and will establish a mechanism for the 
management of all reported dualities of interest.
10.4 CONFIDENTIALITY AND PRIVACY
Participant confidentiality and privacy is strictly held in trust by the participating investigators, 
and their staff. This confidentiality is extended to cover testing of biological samples and genetic 
tests in addition to the clinical information relating to participants. Therefore, the study protocol, 
documentation, data, and all other information generated will be held in strict confidence. No 
information concerning the study or the data will be released to any unauthorized third party 
without prior written approval. 
All research activities will be conducted in as private a setting as possible.
The study monitor, representatives of the Institutional Review Board (IRB), and/or regulatory 
agencies may inspect all documents and records required to be maintained by the investigator, 
including but not limited to, medical records (office, clinic, or hospital) and pharmacy records for 
the participants in this study. The clinical study site will permit access to such records.
The study participant’s contact information will be securely stored at the clinical site for internal 
use during the study. At the end of the study, all records will continue to be kept in a secure location 
for as long a period as dictated by the reviewing IRB or Institutional policies.
Study participant research data, which is for purposes of statistical analysis and scientific reporting, 
will be stored at the NCI CCR. This will not include the participant’s contact or identifying 
information. Rather, individual participants and their research data will be identified by a unique 
study identification number. The study data entry and study management systems used by the 
clinical site and by NCI CCR research staff will be secured and password protected. At the end of 
the study, all study databases will be archived at the NIH.
To further protect the privacy of study participants, a Certificate of Confidentiality has been issued 
by the National Institutes of Health (NIH). This certificate protects identifiable research 
information from forced disclosure. It allows the investigator and others who have access to 
research records to refuse to disclose identifying information on research participation in any civil, 
criminal, administrative, legislative, or other proceeding, whether at the federal, state, or local 
level. By protecting researchers and institutions from being compelled to disclose information that 
would identify research participants, Certificates of Confidentiality help achieve the research 
objectives and promote participation in studies by helping assure confidentiality and privacy to 
participants.

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11 DEVICE INFORMATION
The NIH IRB has determined that the use of the devices in this study are not investigational and 
are not the object of the protocol’s investigation; therefore, per NIH IRB’s guidance, no regulatory 
device determination language has been included within the protocol.  

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Karlsson, R., et al., Rho GTPase function in tumorigenesis. Biochim Biophys Acta, 2009. 
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Oliveira, C., et al., E-Cadherin (CDH1) and p53 rather than SMAD4 and Caspase-10 
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Hebbard, P.C., et al., Prophylactic total gastrectomy (PTG) for hereditary diffuse gastric 
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Huntsman DG, et al., Early gastric cancer in young, asymptomatic carriers of germ-line 
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Fujita H, et al., Endoscopic surveillance of patients with hereditary diffuse gastric 
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Curtin, B., The Bethesda Protocol is More Sensitive Compared to Standard Endoscopy 
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Mi, E.Z., et al., Comparative study of endoscopic surveillance in hereditary diffuse 
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Moslim, M.A., et al., Early genetic counseling and detection of CDH1 mutation in 
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Jacobs, M.F., et al., Outcomes of Endoscopic Surveillance in Individuals With Genetic 
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Broll, R. and V. Kreisel, Motilitatsstorungen des Osophagus nach Operationen am 
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Ferreira, R.M., et al., Gastric microbial community profiling reveals a dysbiotic cancer-
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13 APPENDICES
13.1 APPENDIX 1: INSTRUCTIONS FOR COMPLETING THE AUTOMATED SELF-ADMINISTERED 
24-HOUR DIETARY ASSESSMENT TOOL (ASA24) FOR 24-HOUR FOOD RECALL
See Study Instruments Packet
Citation: 
National Cancer Institute, Division of Cancer Control and Population Studies.  Participant Quick 
Start Guide for 24-Hour Recall using ASA24. https://epi.grants.cancer.gov/asa24/resources/asa24-
quick-start-guide-24hr-recall-06062022.pdf. Published June 6, 2022.  Accessed July 24, 2023.

Abbreviated Title: RCT of CDH1 Surveillance
Version Date: 03/12/2024
41
13.2 APPENDIX 2: INSTRUCTIONS FOR COMPLETING THE DIET HISTORY QUESTIONNAIRE III 
(DHQIII)
See Study Instruments Packet
Citation: 
National Cancer Institute, Division of Cancer Control and Population Studies. Diet History 
Questionnaire III (DHQ III). https://epi.grants.cancer.gov/dhq3/. Publication updated March 15, 
2023. Accessed July 24, 2024.  

Abbreviated Title: RCT of CDH1 Surveillance
Version Date: 03/12/2024
42
13.3 APPENDIX 3: STOOL SPECIMEN COLLECTION KIT INSTRUCTIONS
See Study Instruments Packet