Quercetin Chemoprevention for Squamous Cell Carcinoma in Patients With Fanconi Anemia
Phase: PHASE2
Conditions: Fanconi Anemia, Squamous Cell Carcinoma
Sponsor: Children's Hospital Medical Center, Cincinnati

COVER PAGE FOR CLINICALTRIALS.GOV 
Protocol Title: Quercetin chemoprevention for Squamous cell carcinoma 
in patients with Fanconi anemia 
NCT Number: NCT03476330   
Document Version Date: 09/28/2022 

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Quercetin chemoprevention for Squamous cell carcinoma in patients with Fanconi anemia 
PRINCIPAL INVESTIGATOR: 
Parinda A. Mehta, MD 
Professor of Clinical Pediatrics 
Division of Blood and Marrow Transplantation & Immune Deficiency 
Cancer and Blood Diseases Institute 
Cincinnati Children’s Hospital Medical Center 
3333 Burnet Avenue 
Cincinnati, OH  45229 
CO-INVESTIGATORS: 
Stella Davies, MBBS, PhD, MRCP 
Jose Cancelas-Perez, MD 
Jonathan Howell, MD 
Adam Lane, PhD 
Kasiani Myers, MD 
Lindsey Romick-Rosendale, PhD 
David Haslam, MD 
Ahna Pai, PhD 
Ruby Khoury, MD 
Michele Wang, MD 
Jane Koo, MD 
Kimberly Klages, PhD 

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TABLE OF CONTENTS 
 
I.  
PURPOSE OF STUDY 
II.  
SIGNIFICANCE OF STUDY IN RELATION TO HUMAN HEALTH 
III.  
PREVIOUS WORK DONE IN THIS AREA 
IV. 
RESEARCH PLAN 
 
 
1a.  
How many subjects will be studied? 
 
 
1b.  
How will subjects be selected for this study? 
 
 
2a.  
Inclusion Criteria 
 
 
2b.  
Exclusion Criteria 
 
 
3.  
Study Design / Randomization 
 
 
4.  
Procedures 
V.  
EVALUATION CRITERIA 
 
 
1.  
Primary Endpoint 
 
 
2.  
Secondary Endpoint 
 
 
3.  
Correlative Tests 
VI.  
OFF STUDY CRITERIA/CRITERIA FOR WITHDRAWING SUBJECTS 
VII.  
STATISTICAL CONSIDERATIONS 
 
 
1.  
Sample size and Study Duration 
 
 
2.  
Statistical considerations for Data Analysis 
VIII.  
REGULATORY, ETHICAL AND STUDY OVERSIGHT CONSIDERATIONS 
 
 
1.  
Data and Safety Monitoring Plan 
 
 
2.  
Blood Specimens 
3.  
Other Previously Approved Research Studies in Which the Projected Patient Population 
May Also Be Involved 
4.  
Data Collection and Monitoring 
5.  
Facilities Utilized in the Study 
6.  
Special Considerations 
IX.  
POTENTIAL BENEFITS 
X.  
POTENTIAL RISKS, DISCOMFORTS, INCONVENIENCES AND PRECAUTIONS 
1.  
Potential risks, discomforts, inconveniences specific to the study agent administration 
and research evaluations 
2.  
Drug Interactions 
3.  
Carcinogenesis, Mutagenesis, and Impairment of Fertility 
4.  
Pregnancy/Lactation 
5.  
Pediatric Use 
6.  
Adverse Reactions 
7.  
Precautions that will be taken to monitor and avoid the above mentioned risks, 
discomforts, and inconveniences. 
8.  
Adverse Events 
9.  
Risk Assessment Recommendation 
XI.  
CONFIDENTIALITY 
XII.  
PERIOD OF TIME ESTIMATED TO COMPLETE PROJECT AS DESCRIBED 
XIII.  
FUNDING 
XIV.  
PAYMENT FOR STUDIES 
XV.  
METHOD TO BE USED IN PROCURING CONSENT OF SUBJECTS 
XVI.  
SCHUBERT RESEARCH CLINIC SERVICES  
XVII.  REFERENCES 
APPENDIX A 
 

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I. 
PURPOSE OF STUDY 
Primary Objectives: 
1. To determine the efficacy of Quercetin in reducing buccal micronuclei (a surrogate 
marker of DNA damage and susceptibility to squamous cell carcinoma due to genomic 
instability) in post-HCT patients with fanconi anemia (FA). 
 
Correlative studies: 
Measure the impact of Quercetin therapy on additional potential surrogate markers:  
1. Peripheral blood ROS and salivary ROS  
2. Salivary total antioxidant capacity  
3. Biomarkers measured via Exhaled Breath Condensate (EBC) - anti-oxidants, aldehydes 
etc. 
4. Oral microbiome  
5. Skin elasticity  
 
II. 
SIGNIFICANCE OF STUDY IN RELATION TO HUMAN HEALTH 
Fanconi anemia (FA) is an autosomal recessive disease characterized by progressive bone 
marrow failure, variable congenital abnormalities and a predisposition to malignancy, 
particularly acute myeloid leukemia (AML) and squamous cell carcinoma (SCC)1.  The genes 
encoding for 22 subgroups have been identified so far2-5 Cells from FA patients exhibit 
hypersensitivity to alkylating agents such as mitomycin C and diepoxybutane (DEB).  
Currently, FA is diagnosed by testing for chromosome breakage after lymphocyte stimulation 
and exposure to mitomycin C (MMC) or diepoxybutane (DEB)6. Chromosome fragility, defined 
by an increased percentage of chromosome breaks, is diagnostic for FA 7.  Although it is the 
most common form of constitutional aplastic anemia it is quite uncommon and the true 
incidence of FA is not known.  A total of 754 patients from North America with the DEB 
confirmed diagnoses of FA were registered into the International Fanconi Anemia registry 
(IFAR) by 20018. The major cause of morbidity and mortality for children with FA is progressive 
bone marrow failure9 and development of myelodysplastic syndrome (MDS)/leukemia or 
squamous cell carcinoma (SCC) of head and neck (HNSCC)/genitourinary system 1.     
 
Currently, the only curative treatment option for the hematological complications of FA include  
hematopoietic cell transplantation (HCT), with its associated toxicities from the transplant 
conditioning regimens, graft-versus-host disease and increased risk of post-transplant 
malignancy compared to patients without FA (i.e. adding to their baseline increased risk of 
malignancy).  
 
Improved transplant outcomes10-12 are modifying the natural history of Fanconi Anemia. 
Improved transplant survival, no radiation exposure, almost no GVHD, increases the 
importance of addressing later SCC even further. HNSCCs are the most common solid tumor 
in individuals with FA The incidence is 500- to 700-fold higher than in the general population. 
Individuals successfully treated with HCT are also at increased risk (4.4 fold higher risk) for 
solid tumors, in addition to the baseline increased risk related to FA13.  The HNSCCs in FA 
show distinct differences compared to HNSCCs seen in the general population. They occur at 
an earlier age (20-40 years) than in the general population, are most commonly in the oral 
cavity (e.g., tongue), present at an advanced stage, and respond poorly to therapy (<20% 
overall survival). Moreover, individuals with FA are at increased risk for second primary 

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cancers in the skin and genitourinary tract. The pattern of second primaries resembles that 
observed in human papilloma virus (HPV)-associated HNSCC in the general population14.  In 
addition, solid tumors may be the first manifestation of FA in individuals who have no birth 
defects and have not experienced bone marrow failure. These individuals commonly end up 
having significant and at times life threatening complication after treatment with chemotherapy 
and radiation (due to their baseline inability to repair DNA damage) before diagnosis of FA is 
made.  
 
Based on studies in both animals and human subjects indicating that high levels of systemic 
ROS and increased sensitivity of hematopoietic progenitors to ROS plays a key role in 
pathogenesis of bone marrow failure in patients with FA (see section III) and these can be 
reversed by antioxidant Quercetin. We recently completed our pilot study of safety, feasibility 
(of long term administration) and pharmacokinetics (PK) of Quercetin in patients with FA, who 
have not undergone HSCT. Results of our own pilot study of quercetin, a natural anti-oxidant 
showed excellent tolerance, feasibility of long term supplementation and biologically relevant 
blood levels in patients with FA (NCT#01720147) (see section III).  
 
An elevated oxidative status with concomitant depletion of antioxidants has been found in 
breast cancer and head and neck cancer, suggesting their contribution to carcinogenesis15,16.  
 
Recently, ROS were demonstrated to mediate signaling of c-met, the hepatocyte growth factor 
receptor, resulting in increased metastatic capacity17,18. The potential chemotherapeutic 
efficacy of quercetin has also been demonstrated in many types of cancers including SCC19-24.  
 
In fact Quercetin is known to affect various other pathways involved in carcinogenesis in 
addition to its effect on the Redox pathway to cause apoptosis and inhibit proliferation19.  We 
propose to target these key pathways (also known to be involved in pathogenesis of SCC in 
FA) to prevent development and/or early progression of SCC in post-HCT patients with FA.  
 
The results of the proposed project will use important preclinical data (see below) to support 
the development of a novel therapeutic approach for prevention and/or treatment of SCC in 
FA.  We anticipate that quercetin will prevent or delay the development of SCC and associated 
complications, there by ameliorating or delaying the need for potentially lethal treatment with 
chemotherapy and/or radiation therapy for the same. This will be included in standard clinical 
care of patients with FA, potentially for many years.  
 
III. 
PREVIOUS WORK DONE IN THIS AREA 
Studies in both animals and human samples indicate that high levels of systemic reactive-
oxygen species (ROS) and increased sensitivity of hematopoietic progenitors to ROS play a 
key role in the pathogenesis of marrow failure associated with FA and responds to treatment 
with anti-oxidants (Inflammatory reactive oxygen species-mediated hemopoietic suppression in 
Fancc-deficient mice25. Quercetin, a naturally occurring anti-oxidant is the best studied dietary 
flavonol that lacks major side effects26. It has a wide range of biological activities including but 
not limited to free radical scavenging, anti-inflammation, antioxidant and antineoplastic 
properties. 
 
We recently reported results of our Phase 1 open label, single arm, pilot study of safety, 
tolerability and pharmacokinetics (PK) of Quercetin (3, 30, 40, 5, 7-pentahydroxyflavone) in 
patients with FA27 .  

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Standard 3x3 Phase 1 design was used.  
 
Initial treatment phase was 16 weeks followed by an optional continuation phase of 20 more 
months.  
 
Dose limiting toxicity and Stopping rules were defined and an IND was obtained from FDA 
(IND# 113343).  
 
In this prospective, pharmcokinetically guided, stepwise dose finding Phase I study of 
Quercetin in patients with FA, we have shown the following:  
 
1) Quercetin is safe and well tolerated in patients with FA. 
Twelve patients with FA with a median age of 7 years (range: 3-21), were treated with oral 
quercetin twice a day for 16 weeks. Quercetin was well tolerated without attributable 
adverse events. Four patients were noted to have significant weight gain; 4-10 kg over 4 -
18 months. This is a desirable effect in this population as patients with FA usually have 
trouble gaining weight. 
 
2) Long term administration of oral Quercetin is feasible in patients with FA.  
Patients received up to two years of quercetin without hardly missing any doses. Parental 
withdrawal related to inability to administer the study agent was considered to be the 
evidence of lack of feasibility. In addition, if ≥3 out of first 6 patients missed ≥2 weeks of 
therapy/month during first 4 months, we would have concluded that long term oral quercetin 
therapy is not feasible. However both of these stopping rules of lack of feasibility were not 
met. 
 
3) Goal levels of Quercetin were achieved in patients with FA. 
Pharmacokinetic (PK) measurements of Quercetin were performed around 1st dose and 
again at 16 weeks. Quercetin concentration-time profiles were similar to previous reports in 
non-FA individuals (108).  
 
4) Impact of Quercetin on ROS (marker of DNA damage) reduction and preservation of 
stem cell reserve were used as surrogate markers for prevention of progressive 
marrow failure. 
As shown in the Table 1 below, Quercetin dose was adjusted as needed based on serial 
assessments of Quercetin levels (per PK) and change in peripheral blood ROS for each 
cohort of 3 patients. Peripheral Blood ROS levels (marker of DNA damage) were reduced 
after Quercetin therapy; highest reduction children taking the optimized dose (Fig 1).   
Peripheral Blood ROS (surrogate marker of DNA damage) levels were consistently reduced 
at the highest dose tested (last cohort of 3 patients). (Fig 2). 
 

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Table 1. Fourth dose level achieved biologically relevant levels in all 3 patients  
 
 
 

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T
Total ROS normalized to control normal individuals respective to the time. Values at baseline 
compared to ones after 4 months of Quercetin therapy. A. Median total ROS in all 12 patients, 
baseline and 4 months. B. Total ROS levels in individual patients, baseline and 4 months. 
 
Fig 1. Peripheral Blood ROS levels are reduced after Quercetin therapy; highest 
reduction in children taking the optimized dose   
 
 
Fig 2. Peripheral Blood ROS (surrogate marker of DNA damage) levels are 
consistently reduced at the highest dose tested    
 
Final weight adjusted maximum daily dose of 4000mg/day achieved the highest and most 
consistent ROS reduction. We concluded that long-term quercetin therapy is safe, and well 
tolerated in patients with FA and biologically relevant blood levels can be achieved at the 
currently recommended dosing. 
 
Quercetin for chemoprevention of SCC: 
HCT can improve hematological complications of FA (i.e. marrow failure, MDS/AML), however 
these patients still remain at risk of SCC after HCT. Surgery remains the mainstay of treatment 
for SCC in patients with FA due to their chemotherapy and radiation sensitivity. Thus, there is 
A.
B.

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an urgent need to develop a new strategy for its treatment and prevention (See section II, 
SIGNIFICANCE OF STUDY).  
 
• Quercetin inhibits proliferation and induces apoptosis and arrest many types of human 
cancer cells 28-34. 
 
• Saliva has an important role in intraoral oxidative balance. It has been suggested that 
an increase in the amount of intraoral free radicals in saliva may promote the onset of 
oral SCC. Brazil fanconi group measured total oxidant status (TOS) and total 
antioxidant capacity (TAC) by calorimetric methods and showed that ration of TOS/TAC 
was 4.8 times higher in patients with leukoplakia (pre-SCC lesion) group compared to 
FA without leukoplakia and 3.2 when compared to healthy controls35.  These data 
suggest that higher TOS/TAC ratio is associated with transformation and needs 
to be balanced to prevent development of leukoplakia and subsequent SCC.   
 
• Micronuclei (MN) are chromosome fragments that are left behind during anaphase and 
appear in the cytoplasm of the daughter cells as small nuclei. Our collaborator Jordi 
Surrallés’ lab (Barcelona, Spain) recently showed that MN frequency in the buccal 
mucosa is a useful in vivo biomarker of chromosome fragility (ongoing DNA 
damage) in the patients with FA; and patients with FA have a statistically significant 
increase in the MN frequency in buccal epithelial cells compared to the control group 36 
(Fig 3).   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fig 3. Patients with FA have a statistically significant increase in the MN frequency in 
buccal epithelial cells compared to the control group 
 
In collaboration with Dr Surrallés’ lab, we evaluated MN frequencies in 4 patients from above 
Quercetin study before and after Quercetin therapy. Results are shown in the Table 2 below. 
 
Mean ± SD 
FA patients n=11 
Controls n=13 
Mean two cheeks 
FA
No FA
0
2
4
6
8
10
p=0.001
MN/1000  Cells

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Patient 
Time from start of Quercetin 
treatment (days) 
Number of MN/1000cells-buccal 
brushings from both sides 
(Average) (%) 
 
 
 
1 
11 
4.75 
 
109 
2.25 (52.6%) 
 
 
 
2 
31 
3.25 
 
136 
2.25 (31%)   
 
Table 2. Reduction of micronuclei (in vivo marker of chromosome fragility/ongoing DNA 
damage) in the buccal brushings from patients with FA after Quercetin therapy 
 
Quercetin reduced MN frequencies in the buccal brushings from patients with FA, 
suggesting its role in potentially preventing development of SCC in patients with 
FA.  
 
• In fact, a recent report showed that chemoprevention by Quercetin of oral SCC can be 
successfully achieved and is mediated by suppression of the NF-ĸB signaling pathway 
in non-FA DMBA-treated Hamsters 37. 
 
Hamsters fed quercetin developed no tumors or very small tumors compared to larger, 
more invasive tumors in those who did not receive Quercetin.  
 
These results are extremely encouraging especially in reference to FA, as the only 
potentially curative option for SCC in patients with FA is complete surgical excision 
(small tumors are more amenable to complete excision).  
 
• Similarly, our own preliminary data in FA SCC cell lines confirm SCC tumor cell kill by 
Quercetin in a dose dependent manner.  
 
Using a combination of human cell lines deficient (and proficient) for FA, we were able 
to demonstrate that quercetin induces reactive oxygen species (ROS) (Fig 4), 
proliferative arrest (Fig 5), and cell death in cancer cell lines (Fig 6), while non-
cancerous keratinocytes remained unaffected with decreased ROS as expected.  
 
Quercetin has anti-oxidant effects on healthy cells but can cause oxidative stress in 
cancer cells (Fig 4); a well-known mechanism in tumor kill.   
 

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Fig 4. Quercetin has anti-oxidant effects on healthy cells but causes oxidative stress in cancer 
cells 
 
Fig 5. Quercetin diminishes cell number in FA deficient and control cancer cells 

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Fig. 6 Quercetin stimulates cell death in FA deficient and proficient cancer cells 
 
Diminished growth of SCC cells occurred in part through apoptosis induction (Fig 7). 
 
 
Fig 7. Quercetin induces apoptosis in FANCD2 deficient & proficient cancer cell lines 
 
Based on these promising in vitro and in vivo data, we propose Quercetin chemoprevention for SCC 
in post-HCT patients with FA. 
 

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Quercetin 
Quercetin (3, 30, 40, 5, 7-pentahydroxyflavone), is a flavonol that belongs to a group of 
polyphenolic compounds known as flavonoids 38 Flavonoids share a basic three-ring chemical 
structure, with two aromatic centers and a central oxygenated heterocyclic ring39.  Quercetin is 
a common ingredient in dietary supplements and multivitamin preparations, and is a compound 
not generally thought to be harmful (as noted in the review of the compound by the FDA; see 
GRAS 
notices 
on 
the 
FDA 
website: 
http://www.accessdata.fda.gov/scripts/fcn/gras_notices/grn341-1.pdf 
http://www.accessdata.fda.gov/scripts/fcn/gras_notices/grn341-2.pdf).  
 
Its richest dietary sources include onions, apples, tea and red wine40 . Among dietary flavonols, 
quercetin is by far the most abundant, with the average daily intake of quercetin accounting for 
approximately 70% of the total flavonoid intake in Western diet41.  The daily flavonoid intake 
(mainly from onions, apples, grapes, wine, tea, berries, herbs and spices) in the human diet is 
highly variable, estimations ranging from 23 mg/day (only flavonols + flavones), to more than 
500 mg/day, and up to 1 gm/day (total flavonoids)41-45 . 
 
Quercetin has a wide range of biological activities including free radical scavenging, iron 
chelation, anti-inflammation, strong antioxidant, and antineoplastic actions46-50 .  
Epidemiological studies have positively correlated flavonoid intake with decreased incidence of 
coronary heart diseases and common human cancers.  
 
Glutathione (GSH) is a scavenger of free radicals.  Quercetin can directly lower intracellular 
GSH and may cause a pro-oxidative state in cancer cells51 . In vitro and in vivo studies 
showed, that quercetin may exert opposite effects; namely, anti- as well as pro-oxidant, that 
depend on the redox state of a cell52-54. Quercetin acts as a strong antioxidant scavenger of 
free radicals and simultaneously undergoes an oxidation process, giving rise to the formation 
of the semiquinone radical. A labile semiquinone radical undergoes a second oxidation 
reaction that leads to the formation of a quercetinquinone. Quinone reacts strongly with protein 
thiols and it is eliminated by glutathione, which, in turn, results in its clearance 52.  
 
 
Pharmacokinetics of Quercetin 
 
 
Quercetin is found in fruits and vegetables in a water-soluble form in which the quercetin 
molecule is conjugated to a sugar39.  However, when quercetin is consumed, the sugar is 
cleaved off in the small intestine, allowing the lipid-soluble aglycone form of quercetin to 
passively diffuse into the cells lining the intestinal wall 55 . In the liver, aglycone quercetin is 
either methylated, sulfated or glucuronidated. Quercetin predominately circulates in the 
bloodstream  in these conjugate forms, which differ not only from aglycone quercetin, but also 
from the glycosylated forms found in plant foods 56 . 
 
Quercetin is available as both oral and intravenous preparations. It is recommended to store it 
at room temperature, away from heat, moisture, and direct light.  
 
 
 
Quercetin is present in plasma as methyl, glucuronide and sulfate conjugates of quercetin, with 
very little unconjugated quercetin aglycone present 42,57.  
 
 
Moon et al examined the pharmacokinetics of quercetin aglycone as well as its conjugated 
metabolites and developed a population pharmacokinetic model for quercetin that incorporates 

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enterohepatic recirculation. The oral clearance (CL/F) was high (3.5x104 l/h) with an average 
terminal half-life of 3.5 h (range 0.956–12.5 h) for quercetin. The plasma concentration versus 
time curves exhibited re-entry peaks. A one compartment model that included enterohepatic 
recirculation best described the plasma data58.   
 
 
Our study showed similar PK profile and exposure in children and adults with FA treated with 
oral Quercetin (see Table 1). 
 
 
Quercetin has a strong affinity for normal plasma proteins, 99.1% +/- 0.5%. Serum albumin is 
the primary binding serum protein (99.4%). Binding by very low-density lipoproteins or alpha-1-
acid glycoproteins represents less than 0.5% of the total binding 59,60 .  
 
In a human study, orally administered rutin (quercetin rutinoside) and quercetin were not found 
in the urine or plasma in unaltered form, even if given at doses of 50 to 65 milligrams/kilogram. 
Fifty-three percent of quercetin was retrieved in the feces over the first 3 days, the rest was 
assumed to have undergone O-ring cleavage40. Metabolites of quercetin include 3,4,-
dihydroxyphenylacetic acid (homoprotocatechuic acid), metahydroxyphenylaic acid, 4-hydroxy-
3-methoxyphenylacetic acid (homovanillic acid). All are found in small amounts in urine with 
unknown activity61 . Microorganisms in the bowel remove the glycosides and produce ring 
fission, leading to phenolic acids that are demethylated and dehydroxylated62 .  
Potential Toxicities of Quercetin 
Quercetin is commonly used as a dietary supplement and generally not thought to be harmful. 
Studies performed in healthy normal adults as well as several therapeutic adult trials have 
revealed no known immediate toxicities of oral quercetin administration56,63-69 . Planned dosing 
for this study is based on our own pilot study in patients with FA where highest dose level that 
achieved biological effect was tolerated extremely well27 . We will utilize use of an allometric 
power model to calculate pediatric maintenance doses of drugs expressed as a percentage of 
total adult dose of 4000mg/day (Table 1).  
 
In general, oral quercetin is well tolerated without any major side effects. Our study confirmed 
this benign side effect profile in patients with FA treated with Quercetin for up to 2 years. Four 
patients out of 12 gained weight while on Quercetin, a desired effect in most patients with FA, 
as they are usually unable to gain weight. 
   
Similarly while in vitro studies have raised the concern for mutagenicity, extensive in vivo 
studies have not supported this finding. A number of studies concerning quercetin’s effects 
such as DNA damage or its cytotoxic activity, carried out in animal models, have turned out to 
be negative 70,71. In two studies however, after prolonged administration of this flavonoid, a 
significant increase in the rate of bladder and intestinal cancer incidence occurred at very high 
doses in Norway and F344 rats 72,73. Importantly, it is not possible to achieve such high doses 
in humans due to relatively low bioavailability of quercetin. In addition, quercetin is extensively 
metabolized by methylation, glucuronidation and sulfation to non-mutagenic compounds, likely 
contributing significantly to the absence of carcinogenic or mutagenic activity in vivo.  In 
addition to human clinical trials, epidemiologic studies have consistently demonstrated no 
correlation between dietary quercetin intake and cancer incidence. One study demonstrated an 
inverse association between total flavonoid intake (95% of which was determined to be 
quercetin) and overall cancer incidence 74. Thus despite earlier concerns, long-term 
supplementation with high doses of quercetin has not been linked to any adverse effects in 

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rodents or human subjects and quercetin is considered a reasonably safe antioxidant in adults. 
These results are supported by our own data from the pilot study of Quercetin in children and 
adults with FA. 
In terms of genotoxicity or DNA damage, despite concerns by some, most studies show that 
quercetin does not cause DNA damage (an important virtue, especially when considered for 
use in patients with FA)75. Çelik et al in fact showed that quercetin is highly effective in 
reducing the DNA damage caused by the antitumor agents, idarubicin and mitomycin C, 
following bioactivation by P450 reductase76. Our preliminary data show reduction of 
chromosomal fragility (ongoing DNA damage) in the buccal mucosa after Quercetin treatment 
(see Table 2).  
The lack of genotoxicity of quercetin in vivo can be explained again by its low bioavailability 
and by degradation of its aglicone form caused by intestinal bacterial flora or O-methylation, 
glucuronidation and sulphatation in the gastrointestinal tract77. Importantly, quercetin in vivo is 
swiftly metabolized to non-mutagenic forms, i.e. 30-O- and 40-O-methylquercetin78 .  
Drug/food interactions reported with quercetin include the following. Digoxin: increased 
digoxin levels and risk of digoxin toxicity (sudden death, nausea, vomiting, arrhythmias) 
(animal data); and Fluroquinolones: reduced fluoroquinolone effectiveness (in vitro data) have 
been reported to cross react with quercetin.  
Dosing:  
In this study we propose to treat post-HCT children and adults with FA at weight 
adjusted total max dose of 4000mg/day (the highest dose found to be safe and achieve 
biologically meaningful levels in our previous study.  
The results of the proposed project will use these data to support the development of a novel 
therapeutic approach for prevention and/or treatment of SCC in post-HCT patients with FA. We 
hypothesize that quercetin will prevent the development of SCC potentially obviating the need 
for adjuvant therapy with chemotherapy and/or radiation therapy and associated toxicities in 
these high risk patients. If found to be effective, treatment with quercetin can be included in 
standard clinical care of this patient population. 
 
IV. 
RESEARCH PLAN 
1a. 
How many subjects will be studied? 
Potential subjects will be screened and approximately 45 eligible post-transplant 
subjects will be enrolled in this study. Additionally, patients without history of HCT will 
be allowed to participate at the discretion of the Principal Investigator. Approximately 10 
subjects will be included in this second group. In both groups, patients with or without 
existing pre-malignant lesions or history of SCC will be allowed to participate, if they 
wish so and at the discretion of the PI.  Some patients with small tumors may only need 
surgical excision as definitive therapy. These patients will be allowed to participate in 
the study if they wished so, once they recover from surgery, to potentially prevent 
recurrence. Patients receiving radiation therapy, chemotherapy or immunotherapy for 
treatment of SCC will not be eligible. 
 
1b. 
How will subjects be selected for this study? 
Patients attending the CCHMC Fanconi Anemia Comprehensive Care Center who meet 
the eligibility criteria will be offered the opportunity to participate in this research study. 
Patients who are referred by their primary physician from other institutions or are self-

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referred may be offered opportunity for study participation.  The study is open to all 
participants regardless of gender or ethnicity.  Patients starting from 2 years of age, 
including adults who are post-transplant, will be enrolled on the study. Patients should 
be at least 6 months post-HCT as they are expected to have normalization of their 
metabolism and albumin (an important consideration given quercetin’s affinity to bind to 
serum albumin). 
 
2a. 
Inclusion Criteria  
1)   Diagnosis of FA  
2)   Able to take enteral medication 
3)   Patients ≥2 years 
 
2b. 
Exclusion Criteria  
1) Renal failure requiring dialysis 
2) Total bilirubin >3 mg/dl and/or SGPT >200 at time of enrollment 
3) Patients receiving digoxin therapy, who are unable to discontinue treatment due to 
medical reasons 
4) Patients who are pregnant or breastfeeding or are at risk of pregnancy or fathering a 
baby and are unable to use acceptable methods of birth control during the length of 
the study 
5) Patients who have received quercetin supplementation or other antioxidants 
within last 30 days. 
 
 
6)  Patients receiving radiation therapy, chemotherapy or immunotherapy for  
     treatment of SCC. 
 
3. 
Study Design / Randomization 
This study is an open-label, single arm study.  
 
Although randomization will be ideal, due to biological activity shown in our pilot study 
(see preliminary data), this study will not involve randomization. This study will enroll 
approximately 45 post-HCT patients with FA, and approximately 10 patients with FA 
without history of HCT. In both groups, patients with or without evidence of any pre-
malignant lesions concerning for SCC or history of SCC may be allowed to participate if 
they wish so and at the discretion of the PI.  Some patients with small tumors may only 
need surgical excision as definitive therapy. These patients will be allowed to participate 
in the study if they wished so, once they recover from surgery, to potentially prevent 
recurrence. Patients receiving radiation therapy, chemotherapy or immunotherapy for 
treatment of SCC will not be eligible. 
 
All patients will be treated with oral quercetin for a total of 24 months +/- 30 days or until 
the study team receives confirmation from our collaborator Jordi Surrallés’ lab 
(Barcelona, Spain) that the buccal samples collected at the 2 year visit are sufficient for 
analysis.   
 
The quercetin will be administered at an adjusted dose calculated based on weight (see 
Table 3) for a maximum total daily dose of 4000mg/day.  If the patient is 70 kg or more, 
the dose will automatically be assigned at the maximum dose of 4000mg/day.  Patients 
will be followed carefully.  
 

Quercetin in SCC 
Protocol version 09.28.2022 
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We will determine the efficacy of Quercetin in reducing buccal micronuclei (a surrogate 
marker of DNA damage and susceptibility to squamous cell carcinoma due to genomic 
instability) in post-HCT patients with fanconi anemia (FA).  Based on our preliminary 
data – we anticipate improvement (decrease) in number of micronuclei with Quercetin 
treatment.  
Additionally, from our recent pilot study, we have a valid pharmacodynamic endpoint of 
ROS, and we will use reduction in ROS as an indication that the levels achieved have 
biological activity.  Our pre-clinical animal and preliminary clinical data in patients with 
FA support that modification of ROS will modify other surrogate endpoints.   
We will utilize correlative biological studies to Measure the impact of Quercetin therapy 
on additional potential surrogate markers:  
1. 
Peripheral blood ROS and salivary ROS  
2. 
Salivary total antioxidant capacity  
3. 
Biomarkers measured via Exhaled Breath Condensate (EBC) - anti-oxidants, 
aldehydes etc. 
4. 
Oral microbiome  
5. 
Skin elasticity (see Recommended Observation Table). 
 
After completing 24 months (+/- 30 days or until the study team receives confirmation 
from our collaborator Jordi Surrallés’ lab (Barcelona, Spain) that the buccal samples 
collected at the 2 year visit are sufficient for analysis) of therapy, all participants enrolled 
will have an option to continue Quercetin (if elected to do so) as a part of their clinical 
care.  
4. 
Procedures  
Quercetin Administration 
Informed consent from patient/parent will be obtained before screening patients for 
enrollment on this study.  The following tests will be performed to determine patient 
eligibility:   
 
Blood will be drawn for the following: chemistries (liver and renal functions). For females 
of childbearing potential, pregnancy testing will be performed prior to the first dose of 
quercetin.   
 
Tests/procedures that are done as part of routine clinical care will not be repeated for 
the study.  
 
All patients enrolled in this study will be treated with quercetin at an adjusted dose 
calculated, based on weight (see Table 3). Oral quercetin will be administered twice a 
day for 24 months +/- 30 days or until the study team receives confirmation from our 
collaborator Jordi Surrallés’ lab (Barcelona, Spain) that the buccal samples collected at 
the 2 year visit are sufficient for analysis.  
 
The dose utilized in this study is already shown to be safe and well tolerated in children 
and adults with FA.  Moreover it is also known to achieve the desired exposure 27 . 
 
 
 

Quercetin in SCC 
Protocol version 09.28.2022 
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Modified from Holford and Anderson (1997) Pediatric dosages, In:  
 
New ethicals catalogue. Adis International. Auckland, New Zealand, C9.  
Note: The neonatal estimate based on size has been reduced further by 50%  
to account for age-related maturational changes of clearance. 
 
Table 3. Pediatric maintenance doses of drugs expressed as a  
percentage of adult dose using an allometric 34 power model. 
 
 
Preparation and Administration of Study Agent  
Quercetin is routinely available as an over the counter product due to it being a 
nutritional supplement. However, for the purpose of the study, it will be purchased in the 
powder form from PCCA (supplied as 96% Quercetin dehydrate), and stored and 
distributed by the investigational pharmacy at CCHMC using standard operational 
procedures.  The lot number of the investigational product is to be documented 
according to institutional standard of practice in the Investigational Drug Service.  
 
Quercetin is administered as an oral medication, supplied in powder form. Quercetin will 
be stored at room temperature. The product will be dispensed for home administration.  
Each packet will be labeled in accordance with applicable regulatory requirements.  
 
Quercetin should be administered twice a day at approximately the same time of day (± 
4 hours) every day. If any dose of quercetin is missed, every effort should be made to 
resume the original dosing schedule.  Subjects or their caregivers will be instructed by 
study staff on the proper dosing and storage/handling of the study agent.  
 
Compliance in Investigational Product Administration  
When quercetin is dispensed for administration to the subject during the study, the 
investigator or responsible person will determine the level of compliance with the 
administration of the investigational product.   
The subject’s investigational product compliance (e.g., amount used/amount expected 
to be used in interval between visits) will be recorded by review of the dosing 
documentation during follow up communication and at each visit. Ongoing participation 
Approximate 
Age 
Weight (kg) 
Percentage  
of adult dose 
Fraction  
of adult dose 
Birth 
3.2 
5 
1/20 
2 months 
4.5 
13 
1/8 
4 months 
6.5 
17 
12 months 
10 
23 
1/4 
18 months 
11 
25 
5 years 
18 
36 
7 years 
23 
43.5 
10 years 
30 
53 
1/2 
11 years 
36 
61 
12 years 
40 
66 
14 years 
45 
72 
3/4 
16 years 
54 
82 
Adult 
70 
100 
1 

Quercetin in SCC 
Protocol version 09.28.2022 
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will be assessed based on compliance. Patients who are <60% compliant will be 
considered non-evaluable and not included in the final analysis. These patients may be 
replaced at the discretion of the principal investigator to ensure optimal number of 
evaluable patients.  
Additional measures are being introduced to promote adherence as described in detail 
below.   
Measures 
Barriers Assessment Tool (BAT): The BAT is a 20-item scale developed specifically 
to assess barriers specific to pediatric patients and assesses perceived barriers to their 
medication regimen.  There is a patient and parent version of the measure.  From a list 
of barriers, respondents are asked to indicate via checkbox next to each item which 
barriers have gotten in the way of taking their medicine.  The design of the BAT was 
based on prior work in other pediatric sub-specialties (see citations below) and was 
developed so that it could be quickly and easily administered and scored in a clinical 
setting. The types of barriers include logistical issues (e.g., forgetting, inconvenience), 
ingestion difficulties (e.g., swallowing, taste), efficacy (e.g., feel I don’t need it), financial 
difficulties, regimen characteristics (e.g., too many medications, side effects), and 
patient-specific issues (e.g., refusal by child, embarrassment). We modified the BAT 
using an iterative process incorporating feedback from patients and their caregivers, 
healthcare providers, and patient education specialists.  
1. Simons LE, Blount RL. Identifying barriers to medication adherence in 
adolescent transplant recipients. J Pediatr Psychol. 2007;32:831-844.  
2. Simons LE, McCormick ML, Mee LL, Blount RL. Parent and patient 
perspectives on barriers to medication adherence in adolescent transplant 
recipients. Pediatr Transplant. 2009;13:338-347. 
3. Simons LE, McCormick ML, Devine K, Blount RL. Medication barriers predict 
adolescent transplant recipients’ adherence and clinical outcomes at 18-month 
follow-up. J Pediatr Psychol. 2010;35:1038-1048.  
4. Hommel KA, Baldassano RN. Brief report: Barriers to treatment adherence in 
pediatric inflammatory bowel disease. J Pediatr Psychol. 2010;35:1005-1010. 
5. Modi AC, Crosby LE, Guilfoyle SM, Lemanek KL, Witherspoon D, Mitchell MJ. 
Barriers to treatment adherence for pediatric patients with sickle cell disease and 
their families. Child Health Care. 2009;38:107-122. 
6. Modi AC, Monahan S, Daniels D, Glauser TA. Development and validation of 
the pediatric epilepsy medication self-management questionnaire. Epilepsy 
Behav. 2010;18:94-99. 
MedActionPlan is a HIPAA compliant mobile application that allows patients to track 
when they have taken their medications.  The patients access their medications through 
the MyMedSchedule Plus interface. In an objective, peer reviewed assessment of 

Quercetin in SCC 
Protocol version 09.28.2022 
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adherence applications the MedActionPlan app was rated as the top application in 
overall quality, subjective quality and perceived impact (Carmody et al., 2019).  Patients 
will be asked to indicate each time they have taken their medication on the  
MyMedSchedule Plus app. Patients who have not reported taking their medication will 
receive a notification on their phone reminding them to take their medication.  If the 
patient and caregiver choose, the caregiver can also receive a reminder for the patient 
to take their medication. The study team will have access to patient reports of 
medication taken through the HIPAA compliant MedActionPlan provider portal.   
The MedActionPlan app portal will be utilized for logging, tracking, and monitoring 
quercetin dosing.  The MyMedSchedule Plus app will be utilized in place of the drug 
diary, except in rare situations based on individual circumstances and inability to utilize 
the app. Data will be reviewed regularly by the study staff, in consultation with Dr. 
Pai/designee and patients may be contacted in the event of compliance issues to 
determine barriers and provide support to improve adherence.  Patients/caregivers must 
log doses taken twice dailyin the app close to the time taken and must do so 75% to 
meet compliance criteria each month. 
Carmody, J. K., Denson, L. A., & Hommel, K. A. (2019). Content and usability 
evaluation of medication adherence mobile applications for use in pediatrics. 
Journal of Pediatric Psychology, 44(3), 333-342. 
Adherence Support Sessions: The Adherence Support Session will focus on 
providing adherence education and adherence feedback from the MedActionPlan 
application to the patient and if applicable, the caregiver.  Specifically, patients and 
caregivers will be provided with feedback regarding their adherence since the last visit 
using the MedActionPlan data. Next, based on the barriers endorsed by the patients 
and their caregivers individually tailored adherence intervention will be provided 
including problem-solving barriers and setting small goals to overcome those barriers.  
Specifically, the patient and the caregiver will meet with the study psychologist or her 
designee. The psychologist will 1) teach the patient and/or their caregiver to brainstorm 
several creative solutions for overcoming barriers they are encountering with medication 
taking, 2) select the most viable solution for implementation, and 3) develop a specific 
plan to mitigate the impact of the barriers on their adherence. These adherence 
sessions will be conducted by Dr. Ahna Pai or her designee, who will meet with 
participants during/after the study visits (at baseline, 6 months, 1 year, and 2 years) in-
person or virtually, as feasible. If participants are not able to meet with Dr. Pai or her 
designee during the study visit due to scheduling or any other reason, the adherence 
session may be completed virtually up to 30 days after the visit. Additionally, Dr. Pai or 
designee will contact the patient/caregiver to check in after the first month of taking 
quercetin and again at 18 months, to see how the patient is doing and/or give support 
as needed.  In the event a patient demonstrates compliance issues during the course of 
the study, Dr. Pai/designee in conjunction with the study coordinator or nurse will 
contact the patient to assess for barriers and provide support to improve adherence as 
needed. Study staff will do their due diligence to schedule adherence sessions/check 
ins with participants. If participants are unable to complete the sessions/check ins due 
to scheduling or any other reason this will be documented but will not be considered a 
protocol deviation.  

Quercetin in SCC 
Protocol version 09.28.2022 
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During and at the end of study participation, quercetin containers and any remaining 
supply will be returned to investigator or responsible person when subject returns to 
CCHMC for study visits.  Investigator or designee will return containers and remaining 
supply to Investigational Drug Pharmacy at CCHMC who will then log the returned 
amount of drug using standard operational procedures. 
Dosing Schema 
Quercetin (age and wt. appropriate dose – see table 3) will be given orally on a twice a 
day schedule starting with weight adjusted maximum total daily dose of 4000 mg/day.  If 
any of the patients is 70 kg or more, the starting dose will be automatically assigned at 
the maximum dose of 4000 mg/day.   
 
Recommended Observations 
Patients will be monitored as shown in the Recommended Observations table (Table 4). 
Basic blood tests will be allowed to be drawn at local center and results sent to us. For 
some of the specialized blood tests, we will allow shipping in of the blood samples 
(drawn locally), if the patients live long distance. 
 
Table 4.  Recommended Observations 
 
Study visits to be conducted within 30 days (+/-) of listed study dates 
* If a clinical visit occurs within 30 days (+/-) of the time points noted within the table, research samples may be collected at that visit. 
Data from standard of care (SOC) (e.g., ENT or GYN visits) and/or clinical procedures (e.g. CBC, chemistries, endocrine testing, etc.), 
including those done locally, will be collected for the study at all visits, as available. 
# One month research samples when possible to transport, will be accepted by mail. Similarly, in the event study visit/s are cancelled 
(for unforeseen circumstances), other research samples will be obtained via mail if possible. Local patients (living in Tristate or 
surrounding area) may choose to come in person to submit the one month samples. Samples may need to be repeated if there is a 
problem with the quality, transport, and/or shipping of the sample. If a repeat sample is necessary, it may be collected via mail, in 
person (local patients), or in conjunction with an already scheduled visit. 
+ As part of history, we collect information about conditioning regimen for transplant (exposure to radiation vs no radiation), and 
occurrence of mucositis and/or oral/gastrointestinal/vaginal graft vs host disease. 
^ COVID-19 testing may be completed at each timepoint in which buccal samples are collected. This testing will be completed as 
necessary to ensure the safety of patients and those collecting and processing the samples. This testing will be paid for by the study. 
€Patients/caregivers will complete Barriers Assessment Tools during the Adherence Sessions. 
°Patients will be contacted at one month and 18 months via phone or virtual platform for follow up. 
Tests 
Prior to 
First Dose 
1 month 
6 months 
12 months 
(1 Year) 
24 months 
(2 Years) 
30 months 
(Optional)  
     Standard of Care Evaluations 
 History+/PE, including HT&WT, ENT and GYN 
(if applicable) visit  
X 
 
X 
X 
X 
X 
BUN, creatinine, electrolytes 
X 
 
 
 
 
 
ALT, AST,  
X 
 
 
 
 
 
Research Evaluations*# 
 
 
 
 
 
  
Pregnancy testing 
X 
 
 
 
 
 
Adherence Support Sessions 
X€ 
X° 
X€ 
X€ 
X° 
 
PB-ROS assessment  
X 
X 
X 
X 
X 
X 
Salivary ROS assessment  
X 
X 
X 
X 
X 
X 
Antioxidant measurement - Saliva 
X 
X 
X 
X 
X 
X 
Buccal micronuclei^  
X 
X 
X 
X 
X 
X 
Exhaled Breath Condensate - for anti-oxidants, 
aldehydes etc. 
X 
X 
X 
X 
X 
X 
Oral microbiome 
X 
 
X 
X 
X 
X 
Skin elasticity 
X 
 
X 
X 
X 
X 
Extra blood sample (up to 10-12 mL) will be 
collected for additional tests in future (e.g. 
aldehyde load) 
X 
 
X 
X 
X 
X 

Quercetin in SCC 
Protocol version 09.28.2022 
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Follow-up will be at 6, 12, 24 and 30 months (from the start of therapy). Six month visit 
may be research only visit, and 30 month visit will be optional. If standard of care 
procedures are performed clinically around the study visittime points, the results may be 
used for the study.  Up to 10-12 mL blood will be collected for the extra research sample.  
The amount collected will be based on a safe blood volume based on the participant’s 
weight.  All research procedures will be completed as feasible (i.e., if a participant is unable 
to produce enough saliva or is unable to complete the breath test due to physical 
limitations, the tests will be omitted for that visit). 
 
In addition to the above observations, the below questionnaires may be completed by 
patients and/or parents, or the information collected by study staff, prior to the first dose of 
quercetin, and at 6 months, 1 year, and 2 years:  
• PROMIS and Hope scales 
• Exhaled Breath Condensate (EBC) Survey. 
 
PROMIS Profiles assess seven patient quality of life domains: functional mobility, fatigue, 
anxiety, depression, peer relationships, pain intensity and pain interference. The 29-item 
Adult Form will be completed by all adult participants. The 25-item Parent-Proxy Form will 
be completed by all parents of children under the age of 18 years. Children between 8-17 
years of age will also complete the 25-item Pediatric Profile Form to obtain multiple reports 
of the patient’s quality of life. These profiles demonstrate excellent reliability and validity 
both in general and pediatric oncology populations 79-81.  
 
Additionally, we will also measure hope in children using the Children’s Hope Scale (CHS) 
82. Children between 8-17 years of age will complete the six-item Children’s Hope Scale 
that assesses two components of a child’s dispositional hope a) their perception that they 
can take action to move towards a desired goal and b) that they are capable of attaining 
goals. The CHS has good internal consistency (a = .77) and strong construct validity. 
 
For patients with a significant score on the depression section, we will alert the caregiver 
and clinical care team, and inform the patient that their assigned social worker will contact 
them. 
 
An additional quality of life questionnaire will be completed (by the patient or study staff) at 
6 months, 1 year and 2 years.  This questionnaire was developed based on parent 
reporting of changes noted in physical and emotional well-being from our previous dose-
finding pilot study of Quercetin. 
 
These scales or questionnaires will be completed only when feasible.  
 
Study staff will follow up with patients/parents on a monthly basis for the first 6 months of 
treatment with quercetin.  The MedActionPlan app will also be utilized for logging, tracking, 
and monitoring quercetin dosing (as detailed earlier in this section). Dr. Pai/designee will 
contact the patient/parent via phone or virtually to check in after taking quercetin for one 
month and again at 18 months.  After 6 months, communication with patients/parents will 
occur every other month until 1 year.  From 1 year through 30 days post last dose of 
investigational quercetin, communication will occur every 3 months.  The frequency of 
communication may be increased as needed in the event there are compliance or other 

Quercetin in SCC 
Protocol version 09.28.2022 
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issues.   
 
For patients who elect to continue quercetin as a part of their clinical care - we will continue 
to follow and collect data on outcomes. 
 
V. 
EVALUATION CRITERIA 
1. The first primary endpoint of this study is to determine the efficacy of Quercetin in 
reducing buccal micronuclei (a surrogate marker of DNA damage and susceptibility to 
squamous cell carcinoma due to genomic instability) in post-HCT patients with fanconi 
anemia (FA).          
 
Forty-five patients with FA will be treated with twice daily oral quercetin for a total of 24 
months +/- 30 days. Appropriate dosing will be calculated based on body weight as a 
percentage of adult dose, using an allometric power model (to a maximum total adult 
dose of 4000mg/day) which has been shown to be safe and well tolerated in pre-
transplant patients with FA 27. Additionally, it is shown to be safe and well tolerated in 
children and adults with FA also 27.  
 
We will measure the reduction of micronuclei (in vivo marker of chromosome 
fragility/ongoing DNA damage) in the buccal brushings from patients with FA 
after Quercetin therapy. 
 
Buccal brushings from both cheeks at each time point will be collected. These will be 
shipped to Dr Jordi Surrallés’ lab in Barcelona for quantification.  
 
Based on our limited preliminary data, we will utilize average number of total 
micronuclei (average of right and left side) and follow these serially.  
 
We will collect and analyze these at baseline, and again 1 month, 6 months, 1 yr and 2 
yr time points. These samples will be allowed to be mailed in if needed.  
 
Based on our preliminary data – we expect to see improvement (decrease) in number of 
micronuclei from buccal brushings following quercetin treatment. A 20% reduction in 
the average total number of micronuclei will be considered a success of the 
intervention.  
 
Formal sample size calculation was not done due to limited number patients with this 
rare disease. We will try to enroll as many patients as possible, however for now have 
chosen approximately 45 post-transplant patients for the study.    
 
 
 
2. 
The secondary endpoint of this study is to measure the impact of Quercetin therapy 
on additional potential surrogate markers:  
1. 
Peripheral blood ROS and salivary ROS  
2. 
Salivary total antioxidant capacity  
3. 
Biomarkers measured via Exhaled Breath Condensate (EBC) - anti-oxidants, 
aldehydes etc. 
4. 
Oral microbiome  
5. 
Skin elasticity - in patients with FA, who are post HCT. 
 

Quercetin in SCC 
Protocol version 09.28.2022 
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3. 
Correlative tests for the study will be evaluated as follows: 
 
a. Measure the impact of quercetin therapy on ROS (peripheral blood and saliva) and 
total anti-oxidant capacity (saliva).  
 
We will assess this, by prospectively performing serial measurements of ROS levels 
in peripheral blood and saliva from patients treated with quercetin (Drs. Davies, 
Pang and Cancelas-Perez, CCHMC). These will be measured before, during, and at 
the end of therapy at least and when available, post completion of therapy as 
outlined in the Recommended Observations, Table 4. 
 
ROS analysis is known to have significant inter-individual and temporal changes. 
With this limitation in mind, it will be assessed using quantitative measurement.  
 
We anticipate observing decline in ROS levels over time. Based on our preliminary 
data, ≥25% reduction in ROS level compared to baseline will be considered optimal.  
 
Similarly serial measurements of antioxidants (quantitative) will be performed on the 
saliva samples (Table 4) as an assessment of change in oxidant/antioxidant balance 
with Quercetin therapy. 
 
These 
laboratory 
observations 
will 
be 
used 
as 
surrogate 
markers 
for 
delay/prevention of SCC in patients with FA.  
 
 
b. Measure the impact of quercetin therapy on biomarkers collected using Exhaled 
Breath condensation (EBC). Samples will be analyzed for serial measurements of 
anti-oxidants, aldehyde load etc. These samples will be analyzed in collaboration 
with Dr Lindsey Romick-Rosendale’s lab in CCHMC. 
 
c. Oral microbiome changes post Quercetin treatment will be measured serially. 
Despite suggestions that oral microbiome plays a role in pathogenesis of SCC in 
patients with FA, there are limited data on baseline microbiome in these patients, so 
again this will be an exploratory endpoint. These will be measured and analyzed in 
collaboration with Dr David Haslam from Infectious Disease at CCHMC. 
 
d. Skin integrity will be measured at baseline and serially again after quercetin therapy 
(Table 4).  Based on our preliminary data, we know that skin in FA is not normal 
(submitted) and patients with FA will have shorter time to blister compared to 
controls. However, lack of preliminary data on effect of quercetin on skin elasticity 
will make this an exploratory endpoint also.  
 
Additional important assessments include ENT and GYN exams (when indicated 
depending on the age) performed at baseline and at each of the subsequent study visits.  If 
patients are being followed by local ENT and/or GYN physicians, clinical information and 
progress notes from those visits will be allowed for the study.  Although natural history of SCC 
in post-HCT patients remain highly variable, we anticipate that for most patients, we will see 
stable exam and no new lesions. We will look for improvement in the suspicious or pre-
malignant lesions (when present at baseline) after quercetin therapy.  If new suspicious 
lesion/s is/are observed during the span of the study – patients will receive standard 

Quercetin in SCC 
Protocol version 09.28.2022 
Page 24 of 38 
recommended clinical care. His/her continued participation will be determined based on the 
required additional therapy for the lesion and discussion between the patient/parent and the PI.  
 
As we don’t expect to address direct efficacy, above observations will be recorded carefully 
and analyzed in detail, similar to other correlative studies. 
 
In addition we will assess effect of quercetin in improving insulin sensitivity/glucose tolerance 
obtained as a part of their clinical care in post-HCT patients with FA, if available. These results 
will be interpreted with the help of Dr. Jonathan Howell from Division of Endocrinology at 
CCHMC. 
 
Patients without history of HCT will be analyzed separately from the post-transplant patients. 
 
For all patients, PROMIS and Hope scales from 6 months, 1 year and 2 year visits (when 
available) will be compared to baseline assessments (pre-quercetin).  We anticipate that 
average patient quality of life (QOL) and hope at the one and two year time points (post-
Quercetin) will be significantly higher than average baseline QOL and hope (pre-Quercetin). 
 
VI. 
OFF STUDY CRITERIA/CRITERIA FOR WITHDRAWING SUBJECTS 
Subjects (or parents or legal guardians) have the right to withdraw from the study at any 
time and for any reason without prejudice to his or her future medical care by the 
physician or the institution.   
 
Any subject who needs to come off study early due to personal reasons or PI 
recommendation will be asked to discontinue treatment as soon as possible. The 
subject may be asked to complete an end of study visit. Every effort will be made to 
complete this visit in conjunction with an already scheduled clinical visit. If a subject 
decides to discontinue treatment outside of a scheduled clinical visit, the subject may be 
asked to come to CCHMC to provide samples (local subjects) or samples may be 
provided via mail. This visit is not required and will be completed at the convenience of 
the subject only. If the subject does not come to CCHMC for the end of study visit, a 
follow up phone call will be made by the study coordinator to review general health 
status, the reason for withdrawal (if applicable), and plan to return any remaining study 
drug and study diaries. The subject will be followed for at least 30 days after last dose of 
quercetin. 
 
Criteria for Removal from Protocol Therapy: 
Patient withdrawal from protocol therapy  
 
Off Study Criteria: 
 
a) Completion of study endpoints. 
b) Death 
c) Lost to follow-up 
d) Entry into another therapeutic study for FA. 
 
VII.  
STATISTICAL CONSIDERATIONS 
The goal of this study is to assess the impact of oral quercetin therapy in prevention of 
SCC in post-HCT patients with FA, using surrogate markers of efficacy, i.e. reduction of 
micronuclei (marker of DNA damage) in the oral mucosa (buccal brushings) in post-

Quercetin in SCC 
Protocol version 09.28.2022 
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HCT patients with FA. The primary endpoint is the efficacy of oral quercetin therapy 
defined as a 20% reduction in micronuclei from baseline to 1-yr. 
 
We anticipate that the results of our pilot study will show that long term oral quercetin 
therapy decreases micronuclei measured via buccal brushings in post-transplant 
patients with FA. 
 
This study will enroll approximately 45 post-transplant patients.  Data for approximately 
10 patients who have not yet undergone transplant, will be analyzed separately and 
reported using descriptive analyses. 
 
 
1. Sample Size and Study Duration: 
A Simon two-stage design will be used to assess the primary endpoint. The advantage 
of the Simon two-stage design is that it allows for a planned interim analysis for the 
termination of the study if there is no evidence of efficacy. The null hypothesis is that the 
rate of response is 20%. This will be tested against a one-sided alternative that the true 
rate of response is greater than 20%. The first stage will consist of 14 evaluable 
patients. If 3 or fewer patients in the first 14 have an efficacy the trial will stop for futility. 
If 4 or more have an efficacy an additional 31 patients will be enrolled (for a total of 
approximately 45 patients). If 12 or more out of 45 have an efficacy the null hypothesis 
will be rejected in favor of the alternative. This design has a type I error rate less than 
0.05 and a power of 0.80 if the true response rate is 40%.  
 
Due to the length of follow-up required to assess the primary endpoint study enrollment 
will not pause in between stages. However, the determination of stopping for futility will 
be assessed based on the first 14 enrolled chronologically.  
 
 
We follow >140 FA patients at CCHMC. Review of the entry rate into previous FA 
studies along with the fact that quercetin is now shown to be a safe in patients with FA 
except a small possibility of weight gain (usually considered a positive change for 
patients with FA), we anticipate no obstacles in participation. Although no serious 
toxicities have previously been seen and quercetin is generally safe, in patients with FA, 
the expected rate will be low in post-HCT FA patients also. 
 
We anticipate completion of the study within a total of 4-5 years, including data analyses 
and manuscript preparation.  
 
2. Statistical Considerations for Data Analysis: 
The primary endpoint will be assessed by the previously described Simon two-stage 
design.  
 
The secondary endpoint of 25% ROS reduction from baseline will be assessed using a 
Chi-square test under the null hypothesis that the rate of ROS response is 20%.  
 
All other secondary objectives will be descriptive in nature. Summary measures such as 
means or medians for each particular outcome at each time point will be reported. 
 

Quercetin in SCC 
Protocol version 09.28.2022 
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Given the exploratory nature of the quality of life assessments and the proposed sample 
size, descriptive analysis will be calculated to assess changes in quality of life and hope 
between time points when available. 
 
VIII. 
REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS 
The protocol and informed consent document for this study must be approved in writing 
by the Institutional Review Board (IRB) prior to any patient being registered on the 
study. 
 
Changes to the protocol, must also be approved by the IRB. Records of the Institutional 
Review Board review and approval of all documents pertaining to this study must be 
kept on file by the investigator and are subject to FDA inspection at any time during the 
study. Periodic status reports will be submitted to the Institutional Review Board at least 
yearly, as well as notification of completion of the study and a final report within 6-12 
months of study completion or termination. 
 
Informed consent will be obtained prior to the treatment of participants. 
 
This protocol will be performed under our currently existing investigator initiated IND# 
113343. 
 
1. Data Safety Monitoring Plan: 
There are no known toxicities associated with oral quercetin when given to non-FA 
adults, or children and adults with FA except a small possibility of weight gain (usually 
considered a positive change for patients with FA).  
 
The study will be monitored closely by a medical monitor.  This will be a qualified 
physician not associated with this particular protocol.  The monitor will have expertise in 
basic hematology and conduction of clinical trials, and will have prior regulatory 
experience for similar studies.  The monitor will work closely with the PI to monitor the 
participants on study.  He/she will meet with the PI and review study data/progress, 
approximately every 6 months; more often at the discretion of the PI and/or medical 
monitor.  
 
The medical monitor is required to review all unanticipated problems involving risk to 
subjects or others, unanticipated serious adverse events and all subject deaths 
associated with the protocol and provide an unbiased written report of the review.   
 
At a minimum, the medical monitor should comment on the relationship of the event or 
problem, to participation in the study.  Based on the review of these events, the monitor 
should make a recommendation regarding study continuation. Although no serious 
toxicities have previously been seen and quercetin is generally safe, in patients with FA, 
the expected rate will be low in post-HCT FA patients also. However, any unanticipated 
attributable serious adverse event will be discussed with the medical monitor. If there 
are any attributable Serious Adverse Events, the study will stop accrual pending review 
by the medical monitor. The study will resume patient accrual only if written approval is 
given by the medical monitor.   
 
Disease progression (i.e., marrow failure, or development of myelodysplastic syndrome, 

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leukemia or squamous cell carcinoma) will not be captured as adverse events.  These 
complications are part of the natural history of the disease of Fanconi anemia and there 
is no evidence suggesting that quercetin contributes to the development or progression 
of any of these conditions.  However, in effort to do due diligence, we will perform an 
individual assessment of any future incidences of these conditions and discuss them 
with the medical monitor as they occur. 
 
All decisions regarding study continuation, modification, or termination will be reported 
immediately or annually, as appropriate, to the IRB and other appropriate agencies.  
Reports for events determined by either the investigator or medical monitor to be 
possible or definitely related to study participation and reports of events resulting in 
death should be forwarded in compliance with current IRB policy and applicable federal 
regulations. 
 
All reports from Medical monitor will be forwarded to Cincinnati Children's Hospital 
Medical Center IRB and other regulatory agencies as appropriate.   
 
2. Blood Specimens 
Collection volumes listed in Appendix A.  Any research samples will be obtained in 
accordance with institutional standards to ensure patient safety and without compromising 
needed diagnostic/clinical blood samples or patient health.  The total amount of blood 
drawn will not exceed 5ml/kg of body weight in any 24 hour period.  The total volume of 
blood in any 24 hour period will include blood drawn for clinical, research and waste 
samples combined.   
 
Residual clinical samples and/or residual samples obtained for other related research 
studies (e.g. the BMF repository, IRB# 2008-1393 or the FA-HPV Study, IRB # 2010-
3354) may be utilized for this study to avoid an additional needle stick or testing for 
patients consented to those studies.  Any residual samples remaining after study 
procedures have been completed may be placed in the BMF Repository as well.   
 
 
3. Other Previously Approved Research Studies in Which the Projected Patient   
                     Population May Also Be Involved  
Patients eligible for this study are not currently eligible for other open therapeutic 
studies at CCHMC or elsewhere. 
 
 
4. Data Collection and Monitoring: 
Data for the study will be entered into a secure, password protected database by the 
study staff.  
 
Monitoring and auditing procedures will be followed to ensure that the study is 
conducted, documented, and reported in accordance with the IRB approved protocol, all 
applicable federal regulations and guidelines, and applicable regulatory requirements of 
Cincinnati Children’s Hospital Medical Center. 
 
Verification of eligibility will be performed and appropriate documentation of informed 
consent will be documented for all subjects enrolled into the study.  The timeliness of 
Serious Adverse Event reporting will be monitored to ensure regulatory compliance.  All 
case report forms (CRF) for the first subject enrolled into the study will be monitored for 

Quercetin in SCC 
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completeness and quality by comparing data in the case report forms to data in the 
source documents.  Thereafter, a minimum of 10% of enrolled subjects’ CRFs will be 
monitored for completeness and quality by comparing data in the case report forms to 
data in the source documents.  
 
 
 
5. Facilities Utilized in the Study 
Study participants will be cared for by the Division of Bone Marrow Transplantation and 
Immune Deficiency physicians on the Bone Marrow Transplant inpatient and outpatients 
units at Cincinnati Children’s Hospital Medical Center. 
 
 
 
6. Special Considerations 
a) 
Investigational Drugs or Devices: quercetin is a commercially available dietary 
supplement.  However, in this study it will be used under our existing 
investigator-initiated IND for use in pre-HCT patients with FA. 
b) 
IND (Investigational New Drug): In this study, Quercetin will be used under our 
existing investigator-initiated IND for use in pre-HCT patients with FA – IND# 
113343. 
c) 
CCHMC Pharmacy: The Investigational Drug Service at CCHMC will be 
responsible for the purchase, storage and dispensing of quercetin. 
 
IX. 
POTENTIAL BENEFITS 
There may be no benefit to enrollment in this study. Quercetin has the potential to 
prevent SCC and associated complications without the need for chemotherapy and 
radiation treatment.  
 
X. 
POTENTIAL RISKS, DISCOMFORTS, INCONVENIENCES AND PRECAUTIONS 
1. Potential risks, discomforts, inconveniences specific to the study agent 
administration and research evaluations include: 
 
• Drug administration requiring oral ingestion, can be associated with compliance 
issues with long term administration especially in adolescent and young adults.  
Mild to moderate weight gain has been seen in a few subjects currently receiving 
quercetin. This weight gain is generally well tolerated. This is considered a 
positive effect for patients with Fanconi Anemia, who are generally small and 
have difficulty gaining weight. 
• Physical Exams: Physical exams may be associated with minor physical 
discomfort.   
• Laboratory tests requiring venipuncture and buccal brushings: Venipuncture may 
be associated with pain or discomfort at the needle site, bruising, or infection. 
Buccal brushings may be associated with mild discomfort in the cheek area. 
 
 
Every effort will be made to minimize this discomfort based on the participant’s 
developmental stage. 
 
2. Drug Interactions 
Drug/food interactions reported with quercetin include the following. Digoxin: increased 
digoxin levels and risk of digoxin toxicity (sudden death, nausea, vomiting, arrhythmias) 
(animal data); and Fluroquinolones: reduced fluoroquinolone effectiveness (in vitro data) 
have been reported due to cross reactivity with quercetin.  

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Digoxin use is included in the exclusion criteria.  If any of the patients require 
fluoroquinolones, an alternative agent of equivocal potency will be used instead.   
 
3. Carcinogenesis, Mutagenesis, and Impairment of Fertility 
Current available data (from animal and human studies) do not support the carcinogenic   
potential of quercetin. There are no studies addressing its effect on fertility. Mutagenesis 
studies (both in vitro and in vivo) show no confirmed evidence of mutagenic activity. 
 
4. Pregnancy/Lactation  
Pregnancy/lactation: Quercetin is safe in general without any major adverse effects. 
Developmental toxicity studies have been performed in rats and rabbits at doses 
ranging from 60- to 100-fold higher than the human dose and have revealed no 
evidence of harm to the fetus due to quercetin. There are, however, no studies in 
pregnant women. For females of childbearing potential, pregnancy testing will be 
conducted at baseline prior to the first dose of quercetin. It is not known whether 
quercetin is excreted in human milk or absorbed systemically after ingestion. Because 
many drugs and immunoglobulins are excreted in human milk, and the potential for 
unknown adverse reactions in nursing infants, these risks will be discussed in detail 
during consent. 
 
5. Pediatric Use 
Studies performed in healthy normal adults as well as several therapeutic adult trials 
have revealed no known immediate toxicities of oral quercetin administration 56,63-69 . 
Our own experience from our pilot study (including the ongoing expansion cohort) 
showed that quercetin is safe and well tolerated in children and adults with FA 27 . 
Patients from 3 years to 16 years old were enrolled in the study and everyone tolerated 
quercetin well without any major adverse events. Based on our experience and 
additional data of consumption of food containing quercetin by children (see below), we 
expect patients to tolerate quercetin well, even when taken for extended time periods.  
 
Also, as discussed above in section III, among dietary flavonols, quercetin is by far the 
most abundant, with the average daily intake of quercetin accounting for approximately 
70% of the total flavonoid intake in Western diet41 . The daily flavonoid intake (mainly 
from onions, apples, grapes, wine, tea, berries, herbs and spices) in the human diet is 
highly variable, estimations ranging from 23 mg/day (only flavonols + flavones), to more 
than 500 mg/day, and up to 1 gm/day (total flavonoids) 41-45.   
 
Estimates of quercetin intake in normal daily diet have been projected based on data 
included in the National Center for Health Statistics (NCHS), national Health and 
Nutrition Examination Surveys (NHANES) (CDC 2006; USDA, 2009a,b). Within the 
individual population groups, the largest percentage of potential consumers of quercetin 
was identified in children where 55.9% of the population group reported consuming 
foods in which quercetin is present. When heavy consumers (90th percentile) were 
assessed, the estimate for the all-person intake and all-user intake of quercetin was 
observed to be largest in male teenagers at 450mg/person/day and 668 mg/person/day, 
respectively as shown below in Table 5. On a body weight basis, the estimates for the 
all-person and all-user 90th percentile intakes of quercetin were largest in infants with 
values of 12 and 53 mg/kg/day, respectively. 

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Based on these data it is clear that quercetin can be consumed on daily basis without 
any side effects. Similarly, studies in adult volunteers and our previous experience in 
pre-HCT patients with FA 27 ,it is expected that quercetin will be well tolerated without 
any major complications in post-HCT patients with FA. 
 
6. Adverse reactions 
Studies performed in healthy normal adults as well as several therapeutic adult trials 
have revealed no known immediate toxicities of oral quercetin administration. Mild to 
moderate weight gain has been seen in a few subjects in our phase 1 study of 
Quercetin in pre-HCT FA patients. This is generally well tolerated. This is considered a 
positive effect for patients with Fanconi Anemia, who are generally small and have 
difficulty gaining weight.   
 
7. Precautions that will be taken to monitor and avoid the above mentioned risks, 
discomforts, and inconveniences.  
During the clinic visits, any reported new symptoms will be addressed and investigated 
promptly. Patients will be instructed to contact study physician immediately if they 
develop any new signs and symptoms in between visits, to determine whether these are 
related to study agent. 
 
8. Adverse Events 
Unanticipated severe adverse event/s must be reported to the principal investigator who 
is responsible for the reporting to the Cincinnati Children's Hospital Medical Center IRB, 
FDA, and the medical monitor as applicable. Adverse events will be assessed according 
to the Common Terminology Criteria for Adverse Events v5.0 (CTCAE published 
November 27, 2017). 
 
All Adverse Event reporting is to comply with the current CCHMC IRB policy and 
Table 5.  

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applicable federal regulations. If any serious adverse events occur, current guidelines 
will be followed for expedited reporting to the IRB, FDA and/or the medical monitor.   
 
The investigator should notify the IRB of serious adverse events occurring at the site, in 
accordance with local procedures. All serious and medically significant adverse events 
considered related to quercetin by the investigator will be followed until resolved or 
considered stable.   
 
Disease progression (i.e., marrow failure, or development of myelodysplastic syndrome, 
leukemia or squamous cell carcinoma) will not be captured as adverse events.  These 
complications are part of the natural history of the disease of Fanconi anemia and there 
is no evidence suggesting that quercetin contributes to the development or progression 
of any of these conditions.  However, in effort to do due diligence, we will perform an 
individual assessment of any future incidences of these conditions and discuss them 
with the medical monitor as they occur. 
 
Definitions: 
Adverse Event 
An adverse event is any new, undesirable medical occurrence or change of an existing 
condition in a subject that occurs during treatment (which may include a specified post 
treatment period), whether or not considered to be product related.  Abnormal 
laboratory findings considered by the investigator to be clinically significant, e.g. those 
that are unusual or unusually severe for the population being studied, should be 
recorded as adverse events.  
 
Serious Adverse Event 
A serious adverse event is defined by regulatory/clinical criteria.  It is one that suggests 
a significant hazard or side effect, regardless of the investigator’s or sponsor’s opinion 
on the relationship to study material.  This includes, but may not be limited to, any event 
that (at any dose): 
 
• is fatal; 
• is life threatening (places the subject at immediate risk of death); 
• requires in-patient hospitalization or prolongation of existing hospitalization;   
• is persistent and results in significant disability/incapacity; or 
• is a congenital anomaly/birth defect. 
 
Important medical events that may not be immediately life threatening or result in death 
or hospitalization, but may jeopardize the patient or require intervention to prevent one 
of the outcomes listed above, or result in urgent investigation, may be considered 
serious. 
 
If the adverse event is sufficiently severe in the investigator’s judgment, the subject 
should be removed from treatment and a termination assessment performed. The 
subject should be given appropriate care under medical supervision until symptoms 
cease or stabilize.   
 
 
 

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9. Risk assessment recommendation 
 
 
Minimal risk but with direct benefit to participants 
 
 
Minimal risk but without direct benefit to participants 
 
 
More than minimal risk but with potential for direct benefit to participants 
 
 
More than minimal risk but without direct benefit to participant 
 
XI. 
CONFIDENTIALITY 
All records and documents pertaining to the study will be maintained by the Investigator 
and designee(s), and will be available for inspection by the Cincinnati Children's Hospital 
Institutional Review Board and the Medical monitor. All documents will be kept in a locked 
cabinet or on password protected computers in the office of the Clinical Management 
Research Support Core (CMRSC). Access to the files will be limited to the Principal 
Investigator and designees. All information provided to the investigator dealing with the 
study and information obtained during the course of the study will be regarded as 
confidential. 
 
XII. 
PERIOD OF TIME ESTIMATED TO COMPLETE PROJECT AS DESCRIBED 
The period of time to complete enrollment for this study is estimated to be approximately 2-
3 years.  Total time for completion of follow up is estimated to be 5 years.   
 
XIII. 
FUNDING  
1. Name of funding agency or private sponsors 
Research grant support from Fanconi anemia research fund,  Gateway for Cancer 
Research and FDA are used for study expenses.  
 
2. The institution to which funding will be made 
CCHMC 
 
XIV. 
PAYMENT FOR STUDIES 
1. Third party payers 
All costs associated with the routine clinical care of patients will be the responsibility of 
the patient or their insurance carrier.  All other costs and expenses related to the 
conduct of this study will be paid from research grant and/or divisional funds (including 
the study agent quercetin, research labs/expenses related to 6 month study visit). 
Visits/Tests/procedures that are done as part of routine clinical care will not be repeated 
for the study.   The results of these tests will be used for the study.  
 
2. Reimbursement to participants 
To the extent possible, all study visits will be scheduled at the same time clinical visits 
are planned.  All costs and expenses related to the conduct of this study that are 
research related/experimental, will be paid from research grant (including the cost of 
study agent quercetin, research labs at 1 month/other time points and expenses related 
to 6-month study visit) and divisional funds. Travel assistance will be offered for the 6 
month visit. 
Quercetin compliance and reporting will be reviewed approximately monthly, and 
subjects will receive $15 per month if they meet 75% compliance (at Months 1-5, 7-11 
and 13-23). Subjects will be sent payment via ClinCard and the ClinCard will be 
reloaded at each compliance review if the subject meets compliance requirements. 

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Additionally, during the in-person follow up visits (Month 6, 1 Year and 2 Year), subjects 
will receive $50 at the 6-month visit, $60 at the 1-year visit, and $75 at the 2 year visit 
for continued and successful participation in the study including meeting compliance 
requirements (75%) for the month preceding each visit.  
The subject’s quercetin compliance (e.g., amount used/amount expected to be used in 
interval between visits) will be determined by regular review of the MedActionPlan app 
(or drug diary in rare situations).  Patients/caregivers must log doses taken twice daily in 
the app on the date taken and close to the time taken and must do so 75% of the time 
each month to meet compliance criteria.  
ClinCard will be utilized for payment.  If a subject does not have a social security 
number or tax identification number, he/she will be offered gift cards in the amount 
specified above.  Subjects may decline to receive compensation.  This will be 
documented in the subject’s research chart but will not be considered a protocol 
deviation.  
 
XV. 
METHOD TO BE USED IN PROCURING CONSENT OF SUBJECTS 
All prospective patients will have the study explained by a member of the research team.  
All the potential hazards and possible adverse reactions will be explained to patient/parent. 
 
Prior to the initiation of the study, acknowledgement of the receipt of this information and 
the subject's freely tendered offer to participate will be obtained in writing from each subject 
in the study.  Assent for subjects 7-10 years old will not be obtained due to the complex 
nature of the therapy and the limited capability of the minor to reasonably consider all the 
implications associated with this treatment that may be of direct benefit to the subject. 
Assent will be obtained for subjects aged 11 and older. 
 
The consent process may be conducted via telephone according to Clinical Management 
and Research Support Core (CMRSC) SOP. No research procedures will occur prior to 
getting documented consent. The same process will be followed for the assent process for 
subjects aged 11 and older.  
 
This protocol, informed consent, assent form, and any amendments to the protocol will be 
reviewed and approved by the CHMCC IRB prior to initiation.  The study will not be initiated 
without the approval of the IRB. 
 
XVI. 
SCHUBERT RESEARCH CLINIC SERVICES 
The Schubert Research Clinic Services may be utilized for certain study visits as required 
to accommodate better patient flow for the research procedures, as approved by the 
Schubert Research Clinic.  
 
 
 
 
 
 
 
 

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Protocol version 09.28.2022 
Page 38 of 38 
Appendix A: Blood Volumes (Study Visits Screening through End of Treatment) 
 
 
*PB ROS will be collected for subjects seen at CCHMC for study visits only (fresh sample required), as feasible.  If patient unable to 
return to CCHMC for study visit, then we will accept PB ROS sample collected and shipped to CCHMC within approximately 24 hours 
after collection if feasible.  
Data from standard of care (SOC) procedures (e.g. Counts, etc) will be collected for the study, as available (no additional blood will be 
collected).   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tests 
Prior to 
First 
Dose 
1 month 
6 
months 
12 
months 
(1 Year) 
24 
months 
(2 Years) 
30 
months 
(Optional) 
Maximum 
Total 
BUN, creatinine, electrolytes 
1 ml 
 
 
 
 
 
1ml 
ALT, AST,  
1 ml 
 
 
 
 
 
1ml 
PB-ROS assessment  
5-7mls 
5-7mls* 
5-7mls 
5-7mls 
5-7mls  
5-7mls 
42mls 
Additional blood sample for future 
studies 
5-12 mls 
 
5-12 mls 
5-12 mls 
5-12 mls 
5-12 mls 
25-52mls 
Blood Volume Sub-total 
12-21mls 
5-7mls 
10-19mls 
10-19mls 
10-19mls 
10-19mls 
69- 96 mls