A Phase III Clinical Trial Comparing Trastuzumab Given Concurrently With Radiation Therapy and Radiation Therapy Alone for Women With HER2-Positive Ductal Carcinoma In Situ Resected by Lumpectomy
Phase: PHASE3
Conditions: Breast Ductal Carcinoma In Situ
Sponsor: National Cancer Institute (NCI)

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NRG ONCOLOGY 
NSABP PROTOCOL B-43 
ClinicalTrials.gov NCT 00769379 
A Phase III Clinical Trial Comparing Trastuzumab Given Concurrently with 
Radiation Therapy and Radiation Therapy Alone for Women with HER2-Positive 
Ductal Carcinoma In Situ Resected by Lumpectomy 
This trial is part of the National Clinical Trials Network (NCTN) program, which  
is sponsored by the National Cancer Institute (NCI).  The trial will be led by  
NRG Oncology with the participation of the network of NCTN organizations: the Alliance for Clinical 
Trials in Oncology, ECOG-ACRIN Cancer Research Group, NRG Oncology, and SWOG 
NRG Oncology 
Nova Tower 2 
Two Allegheny Center – Suite 1200 
Pittsburgh, PA 15212 
TELEPHONE: 412-339-5300 
 
NRG Oncology Statistics and 
Data Management Center 
One Sterling Plaza 
201 North Craig Street, Suite 500 
Pittsburgh, PA 15213 
TELEPHONE: 412-624-2666 
 
FAX: 412-624-1082 
Clinical Coordinating Department: 1-800-477-7227 
(For clinical questions only) 
KEY STUDY PERSONNEL 
NRG Oncology Chairman: Norman Wolmark, MD 
NRG Oncology Breast Committee Chair Eleftherios Mamounas, MD, MPH 
Protocol Chair: Melody Cobleigh, MD 
Radiation Oncology Protocol Chair: Douglas Arthur, MD 
Protocol Officer: Thomas Julian, MD 
Radiation Oncology Protocol Officer: David Parda, MD 
Protocol Statistician: Stewart Anderson, PhD 
Protocol Pathologists: Soonmyung Paik, MD 
 
Kalliopi Siziopikou, MD, PhD 
 
 
Protocol B-43 (trastuzumab), sponsored by the NCI 
 
STUDY DRUG 
NSC# 
DRUG SUPPLY 
Trastuzumab 
688097 
Genentech, a Member of the Roche 
Group, through the NCI 
 
 
NCI Version Date: June 3, 2016, (Replaces all other versions) 

 
NCI Version Date: 06/03/16 
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NRG ONCOLOGY 
NSABP PROTOCOL B-43 
A Phase III Clinical Trial Comparing Trastuzumab Given Concurrently  
with Radiation Therapy and Radiation Therapy Alone for Women  
with HER2-Positive Ductal Carcinoma In Situ Resected by Lumpectomy 
 
 
Document History 
 
Version/Update Date 
Broadcast Date 
Amendment 8 
June 3, 2016 
TBD 
Amendment 7 
November 14, 2014 
June 15, 2015 
Amendment 6 
April 16, 2014 
July 2, 2014 
Amendment 5 
April 2, 2012 
January 26, 2012 
Amendment 4 
July 18, 2011 
August 11, 2011 
Amendment 3 
September 10, 2010 
September 30, 2010 
Amendment 2 
May 21, 2010 
September 30, 2010 
Amendment 1 
February 16, 2010 
March 23, 2010 
Activation 
May 28, 2008 
October 17, 2008 
 
 
 

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PROTOCOL REVISION RECORD 
Original Version: 
 
May 28, 2008 
Amendment #1: 
 
February 16, 2010 
Sections Changed 
 
Cover Page 
 
Information Resources 
 
Section 1.0 
 
Section 4.0: 
4.1 
 
Section 6.0: 
6.1, 6.2 
 
Section 9.0: 
9.3, 9.5 
 
Section 10.0: 
10.2 
 
Section 12.0: 
12.1 
 
Section 16.0: 
Reference 46 
 
Appendix B: 
3.0, 4.0 
 
Appendix C: 
Cover page, Pages 1, 2, 5 
 
Appendix D: 
Cover page, Pages 1, 2 
Amendment #2: 
 
May 21, 2010 
Sections Changed 
 
Cover Page 
 
Section 10.0: 
10.2 
 
Appendix C: 
Cover page 
 
Appendix D: 
Cover page, Pages 1, 5, 6 
Amendment #3 
September 10, 2010 
Sections Changed 
 
Cover Page 
 
Glossary of Abbreviations and Acronyms 
 
Section 5.0: 
5.0 (Table 3) 
 
Section 8.0: 
8.1, 8.2 (Table 6) 
 
Section 10.0: 
10.1.3, 10.2, 10.3, 10.3.4 (Table 8), 10.3.5 (Table 9), 10.3.6, 10.3.7, 10.5, 10.6 
 
Appendix B: 
5.0, 5.3, 5.4 
 
Appendix C: 
Cover page 
 
Appendix D: 
Cover page, Pages 1, 6 
Amendment #4: 
 
July 18, 2011 
Sections Changed 
 
Cover Page 
 
CTSU Information Resources 
 
Section 1.0 
 
 
Section 2.0: 
2.3 
 
Section 5.0: 
5.0 (Table 3) 
 
Section 6.0: 
6.2 
 
Section 10.0: 
10.3.4 (Table 8), 10.3.5 (Table 9), 10.3.6, 10.6 

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Section 14.0: 
14.3 (Table 10), 14.5, 14.6, 14.7 
 
Section 16.0: 
A new reference, #90, has been added. 
 
Appendix B: 
1.0, 3.0, 4.0, 6.0 
 
Appendix C: 
Cover page, Pages 1, 3, 4, 5 
 
Appendix D: 
Cover page, Pages 1, 2, 8, 9, 10 
Amendment #5: 
 
April 2, 2012 
Sections Changed: 
 
Cover Page 
 
CTSU Information Resources 
 
Glossary of Abbreviations and Acronyms 
 
Section 10.0: 
10.1, 10.2 (Table 7) 
 
Appendix B: 
4.0 
 
Appendix C: 
Cover page, Pages 1, 3, 4 
 
Appendix D: 
Cover page, Pages 1, 5, 6, 8, 10 
Amendment #6: 
 
April 16, 2014 
Sections Changed: 
 
Throughout the protocol, the following have been changed: 
• 
The NSABP and the NSABP Operations Center were changed to NRG Oncology where 
appropriate. 
• 
All references to NSABP Biostatistical Center have been changed to NRG Oncology 
Statistics and Data Management Center (SDMC). 
• 
Division has been changed to Department throughout the protocol where appropriate. 
• 
References to the "Adverse Event Expedited Reporting System (AdEERS)" have been 
changed to "CTEP Adverse Event Reporting System (CTEP-AERS)." 
 
Cover Page 
 
Information Resources 
 
CTSU Information Resources 
 
Glossary of Abbreviations and Acronyms 
 
Section 4.0: 
4.1 
 
Section 5.0: 
5.0 (Table 3) 
 
Section 9.0: 
9.1, 9.3, 9.7, 9.8, 9.9 
 
Section 10.0: 
10.1.1, 10.2 (Table 7), 10.3, new Section 10.3.7 added; subsequent sections 
renumbered, 10.3.8 
 
Section 12.0: 
New Sections 12.1, 12.2, 12.3 added; subsequent sections renumbered, 12.4, 12.7 
 
Section 13.0: 
13.2, 13.5 
 
Section 14.0: 
14.3 (Table 10), 14.5, 14.7 
 
Section 15.0: 
#6 
 
Appendix B: 
Deleted 
 
Pre-Entry Central HER2 Testing Sample Consent Form 
 
Treatment Study Sample Consent Form 
 

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Amendment #7: 
 
November 14, 2014 
Sections Changed: 
 
Cover Page 
 
Section 4.0: 
4.1 
 
Section 10.0: 
10.3.8 
 
Treatment Study Sample Consent Form 
Amendment #8: 
 
June 3, 2016 
Sections Changed: 
 
Cover Page 
 
Information Resources 
 
Cancer Trials Support Unit (CTSU) Information Resources 
 
Section 1.0: 1.0 
 
Section 4.0: 4.0 
 
Section 5.0: 5.0 
 
Section 6.0: 6.1 
 
Section 9.0: 9.1 
 
Section 10.0: 10.2 (Table 7), 10.3.1, 10.3.4 (Table 8), 10.3.5 (Table 9) 
 
Section 12.0: 12.0 
 
Section 13.0: 13.2 
 
 

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[BLANK PAGE] 
 

 
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TABLE OF CONTENTS 
 
Information Resources ................................................................................................................................ 10 
Cancer Trials Support Unit (CTSU) Information Resources ...................................................................... 12 
Glossary of Abbreviations and Acronyms .................................................................................................. 13 
 
1.0 
SUMMARY OF THE STUDY ...................................................................................................... 15 
2.0 
BACKGROUND ........................................................................................................................... 17 
2.1 
Introduction ....................................................................................................................... 17 
2.2 
Prior and ongoing clinical trials in DCIS conducted by the NSABP ................................ 17 
2.3 
Refining therapy for subgroups of patients:  The HER2 alteration in DCIS .................... 19 
2.4 
Refining therapy for subgroups of patients with DCIS ..................................................... 22 
2.5 
Clinical experience with trastuzumab ............................................................................... 23 
2.6 
Rationale for not conducting baseline cardiac evaluations ............................................... 24 
2.7 
Implications for breast cancer prevention ......................................................................... 26 
2.8 
Impact of trastuzumab on ovarian function ...................................................................... 27 
3.0 
STUDY AIMS AND ENDPOINTS .............................................................................................. 28 
3.1 
Primary aim and endpoint ................................................................................................. 28 
3.2 
Secondary aims and endpoints .......................................................................................... 28 
4.0 
PATIENT ELIGIBILITY AND INELIGIBILITY ........................................................................ 30 
4.1 
Patient selection guidelines ............................................................................................... 30 
4.2 
Conditions for patient eligibility ....................................................................................... 30 
4.3 
Conditions for patient ineligibility .................................................................................... 31 
5.0 
REQUIRED ENTRY AND FOLLOW-UP STUDIES .................................................................. 33 
6.0 
PATHOLOGY AND CORRELATIVE STUDIES ....................................................................... 35 
6.1 
Overview of tissue requirements ...................................................................................... 35 
6.2 
Central testing to determine HER2 status ......................................................................... 35 
6.3 
Correlative study hypotheses to be tested ......................................................................... 36 
6.4 
Background and studies leading to the hypotheses ........................................................... 36 
6.5 
Examination of future candidate predictive markers for trastuzumab response ............... 46 
7.0 
TREATMENT REGIMEN ............................................................................................................ 47 
7.1 
Radiation therapy for Group 1 (RT alone) and Group 2 (RT + trastuzumab) .................. 47 
7.2 
Trastuzumab (only Group 2 patients) ............................................................................... 47 
7.3 
Hormonal therapy for all B-43 patients with hormone-receptor positive DCIS ............... 48 
7.4 
Non-protocol therapy ........................................................................................................ 48 
8.0 
TREATMENT MODIFICATIONS ............................................................................................... 49 
8.1 
General instructions .......................................................................................................... 49 
8.2 
Trastuzumab treatment modifications (Group 2 patients) ................................................ 49 
8.3 
Radiation therapy treatment modifications ....................................................................... 49 
9.0 
DRUG INFORMATION ............................................................................................................... 50 
9.1 
Trastuzumab NSC #688097)............................................................................................. 50 
9.2 
Description of trastuzumab (Herceptin®) (NSC #688097) .............................................. 50 
9.3 
Procurement of trastuzumab ............................................................................................. 50 
9.4 
Shipping ............................................................................................................................ 51 
9.5 
Storage/stability ................................................................................................................ 51 

 
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9.6 
Reconstitution and administration .................................................................................... 51 
9.7 
Transfer of trastuzumab .................................................................................................... 52 
9.8 
Return of unused trastuzumab .......................................................................................... 52 
9.9 
Drug accountability ........................................................................................................... 53 
9.10 
Warnings and contraindications ........................................................................................ 53 
10.0 
ADVERSE EVENT REPORTING REQUIREMENTS ................................................................ 55 
10.1 
B-43 definitions for adverse event reporting .................................................................... 55 
10.2 
Adverse events reported for trastuzumab ......................................................................... 55 
10.3 
Expedited reporting of adverse events .............................................................................. 59 
10.4 
Routine reporting of adverse events ................................................................................. 65 
10.5 
Reporting selected adverse events on the B-43 Follow-up Form ..................................... 65 
10.6 
Reporting cancer recurrence, secondary malignancy, and second primary cancer ........... 66 
11.0 
DIAGNOSIS OF BREAST CANCER RECURRENCE AND OTHER CANCER EVENTS ...... 67 
11.1 
Local recurrence ............................................................................................................... 67 
11.2 
Regional recurrence .......................................................................................................... 67 
11.3 
Distant recurrence ............................................................................................................. 67 
11.4 
Second primary breast cancer ........................................................................................... 68 
11.5 
Second primary cancer (non-breast) ................................................................................. 69 
11.6 
Documentation requested following death ....................................................................... 69 
12.0 
REGISTRATION, STUDY ENTRY, AND WITHDRAWAL PROCEDURES .......................... 70 
12.1 
CTEP investigator registration procedures ....................................................................... 70 
12.2 
CTEP associate registration procedures / CTEP-IAM account ........................................ 70 
12.3 
CTSU registration procedures ........................................................................................... 70 
12.4 
Required pre-entry tumor block submission for central HER2 testing ............................. 72 
12.5 
Patient consent form ......................................................................................................... 72 
12.6 
Patient enrollment ............................................................................................................. 72 
12.7 
Oncology Patient Enrollment Network (OPEN) ............................................................... 72 
12.8 
Investigator-initiated discontinuation of study therapy .................................................... 73 
12.9 
Patient-initiated discontinuation of study therapy ............................................................ 73 
12.10 Patient-initiated withdrawal from the study ...................................................................... 73 
13.0 
REQUIRED FORMS AND MATERIALS ................................................................................... 74 
13.1 
Data collection .................................................................................................................. 74 
13.2 
Instruction for completion and submission of B-43 forms and materials ......................... 74 
13.3 
Adverse event reporting .................................................................................................... 74 
13.4 
Pathology specimens ......................................................................................................... 74 
13.5 
Data monitoring for CTEP ................................................................................................ 75 
14.0 
STATISTICAL CONSIDERATIONS ........................................................................................... 76 
14.1 
Endpoints .......................................................................................................................... 76 
14.2 
Stratification and randomization ....................................................................................... 76 
14.3 
Sample size estimation ...................................................................................................... 76 
14.4 
Statistical analysis plan ..................................................................................................... 78 
14.5 
Interim analyses ................................................................................................................ 78 
14.6 
Power considerations for correlative studies .................................................................... 79 
14.7 
Accrual rates ..................................................................................................................... 79 
14.8 
Issues relating to racial and ethnic differences ................................................................. 80 
15.0 
PUBLICATION INFORMATION AND ADMINISTRATIVE AGREEMENTS ....................... 81 
16.0 
REFERENCES .............................................................................................................................. 83 

 
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Figure 1 
B-43 SCHEMA ................................................................................................................. 16 
Figure 2 
Kaplan-Meier plot for recurrence-free survival according to cMYC and treatment ......... 39 
Figure 3 
Survival according to cMYC and treatment ...................................................................... 40 
Figure 4 
Dual signal hypothesis ...................................................................................................... 41 
Figure 5 
Cells with amplification and deregulated expression of cMYC ....................................... 42 
Figure 6 
Cells with cMYC and HER2 co-amplification ................................................................. 42 
Figure 7 
Cells with cMYC and HER2 co-amplification treated with trastuzumab ......................... 43 
 
 
Table 1. 
HER2 expression in DCIS ................................................................................................ 20 
Table 2. 
Trastuzumab (H) impact on LVEF when no anthracyclines  have been administered ..... 26 
Table 3. 
Studies required for study entry and during study therapy and follow-up ........................ 33 
Table 4 
Relative risk of ACTH over ACT and p values from Cox univariate model of  
disease-free survival endpoint for each subset defined by either PathVysion FISH or 
Herceptest IHC or both ..................................................................................................... 37 
Table 5. 
Trastuzumab treatment regimen for Group 2 patients ...................................................... 47 
Table 6. 
Trastuzumab modifications ............................................................................................... 49 
Table 7. 
Comprehensive Adverse Events and Potential Risks list (CAEPR) for trastuzumab ....... 56 
Table 8. 
Phase 2 and 3 trials utilizing an agent under a CTEP IND:  CTEP-AERS expedited 
reporting requirements for adverse events that occur within 30 days1 of the last dose  
of the investigational agent ............................................................................................... 61 
Table 9. 
Phase 2 and 3 trials: CTEP-AERS expedited reporting requirements for adverse events 
that occur within 30 days of the last dose of RT ............................................................... 63 
Table 10. 
Revision of accrual time and time to definitive analysis (see Section 14.7) ..................... 77 
Table 11. 
Rates of ipsilateral invasive and skin cancer and DCIS breast cancer recurrences  
(IIBCR-SCR-DCIS) in selected subsets of NSABP B-24 ................................................ 77 
Table 12. 
Expected racial and ethnic composition of NSABP B-43 ................................................ 80 
 
Appendix A 
Determination Of Pre-Entry Menopausal Status .............................................................. 90 
 
 
 

 
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INFORMATION RESOURCES 
NRG Oncology 
http://www.nsabp.pitt.edu 
NRG Oncology 
Nova Tower 2 
Two Allegheny Center, Suite 1200 
Pittsburgh, PA 15212 
Phone: 412-339-5300 
NRG Oncology Statistics and 
Data Management Center 
(SDMC) 
One Sterling Plaza 
201 North Craig Street, Suite 500 
Pittsburgh, PA 15213  
Phone: 412-624-2666 
Fax: 412-624-1082 
(General office fax) 
Questions/problems regarding 
IRB review & informed consent 
NRG Oncology 
Department of Regulatory Affairs  
Phone: 412-339-5300 
E-mail: regulatory@nsabp.org 
Submission of IRB approval 
CTSU Regulatory Office 
1818 Market Street, Suite 1100 
Philadelphia, PA 19103 
Phone: 1-866-651-2878 
Fax: 215-569-0206 
E-mail:CTSURegulatory@ctsu.coccg.org 
(for regulatory document submission only) 
Questions concerning eligibility 
and clinical aspects of the trial 
NRG Oncology 
Clinical Coordinating Department 
Phone: 1-800-477-7227 
E-mail: ccdpgh@nrgoncology.org 
Information concerning drug 
orders, shipments, transfers, 
and returns  
(see Section 9.0) 
NRG Oncology SDMC (see above) 
For mail (USPS): 
Pharmaceutical Management Branch, 
CTEP, DCTD 
NCI Shady Grove 
Room 5W228, MSC 9725 
9609 Medical Center Drive 
Bethesda, MD 20892-9725 
For express courier: 
Pharmaceutical Management Branch, 
CTEP, DCTD 
NCI Shady Grove 
Room 5W228, MSC 9725 
9609 Medical Center Drive 
Rockville, MD 20850 
Phone: 412-624-2666 
 
 
Phone: 240-276-6575 
Fax: 240-276-7893 
E-mail: PMBAfterHours@mail.nih.gov 
Pre-entry submission of tumor 
blocks (for HER2 testing and, if 
patient is enrolled in  
B-43, for correlative studies); 
when sending blocks, please 
indicate on the package 
"Pathology Specimens 
Enclosed"  
(see Section 6.0) 
Rush University Medical Center 
Department of Pathology 
Jelke Building – 5th Floor 
1750 West Harrison Street 
Chicago, IL  60612 
ATTN: B-43 Pathology Coordinator 
NSABP B-43 TRIAL 
Phone: 312-942-5274 
Refer to the B-43 Pathology Instructions 
in the Members' Area of the NSABP Web 
site or the CTSU Member Web site. 
Questions regarding the results 
of the pre-entry HER2 testing 
Rush University Medical Center 
Department of Pathology 
Phone: 312-942-5274 
Alternate Phone: 312-942-6507 
Arrangement for return of 
blocks 
NRG Oncology Biospecimen Bank-
Pittsburgh 
Phone: 412-697-6611 
E-mail: nrgbiobankpgh@nrgoncology.org 
Note: Information Resources continued on next page. 
 

 
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INFORMATION RESOURCES (continued) 
 
Submission of expedited 
adverse event reports/questions 
concerning expedited adverse 
event reporting (see Section 
10.0) 
NRG Oncology SDMC 
B-43 AE Reporting Nurse 
Phone: 412-383-2557 
Fax: 412-622-2113 
SAEReportingpgh@nrgoncology.org 
Submission of data 
forms/questions concerning 
data management (see Section 
13.0) 
NRG Oncology SDMC 
B-43 Data Manager 
Phone: 412-624-2666 
Data Fax: 412-622-2111 
Refer to the B-43 Data Forms page in the 
Members' Area of the NSABP Web site or 
the CTSU Member Web site. 
 
 

 
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Cancer Trials Support Unit (CTSU) Information Resources 
To submit site registration 
documents: 
 
CTSU Regulatory Office 
1818 Market Street, Suite 1100 
Philadelphia, PA  19103 
 
Phone: 1-866-651-2878 
Fax: 1-215-569-0206 
E-mail: CTSURegulatory 
@ctsu.coccg.org (for submitting 
regulatory documents only) 
 
For patient enrollments: 
 
 
Please refer to the patient 
enrollment section of the 
protocol for instructions on 
using the Oncology Patient 
Enrollment Network (OPEN) 
which can be accessed at 
https://www.ctsu.org/OPEN_ 
SYSTEM/ or 
https://OPEN.ctsu.org. 
Contact the CTSU Help Desk 
with any OPEN-related 
questions at CTSURegulatory 
@ctsu.coccg.org. 
Submit study data directly to 
the NRG Oncology SDMC 
through the Online Data Entry 
function unless otherwise 
specified in the protocol: 
Submit study data online through 
the Online Data Entry function 
located in the Study Management 
Area of Coordinator Online in the 
Members' Area of the NSABP 
Web site.  Contact the Support 
Desk at support@nrgoncology.org 
for an account. 
 
NRG Oncology Statistics and 
Data Management Center 
One Sterling Plaza 
201 North Craig Street, Suite 500 
Pittsburgh, PA 15213 
 
Do not submit study data or forms 
to CTSU Data Operations.  Do 
not copy the CTSU on data 
submissions. 
For clinical questions (i.e. patient eligibility or treatment-related), contact the Clinical 
Coordinating Department at NRG Oncology at 1-800-477-7227. 
For non-clinical questions (i.e. unrelated to patient eligibility, treatment, or clinical data 
submission), contact the CTSU Help Desk by phone or e-mail: 
CTSU General Information Line – 1-888-823-5923, or ctsucontact@westat.com.  All calls and 
correspondence will be triaged to the appropriate CTSU representative. 
The CTSU Member Web site is located at https://www.ctsu.org 
The most current version of the study protocol and all supporting documents must be downloaded 
from the protocol-specific Web page of the CTSU Member Web site located at https://www.ctsu.org.  
Access to the CTSU members' website is managed through the Cancer Therapy and Evaluation 
Program - Identity and Access Management (CTEP-IAM) registration system and requires user log on 
with CTEP-IAM username and password.   
 
 

 
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GLOSSARY OF ABBREVIATIONS AND ACRONYMS 
 
AC 
doxorubicin and cyclophosphamide 
ACT 
doxorubicin and cyclophosphamide followed by paclitaxel 
ACTH 
doxorubicin and cyclophosphamide followed by paclitaxel and trastuzumab 
AE 
adverse event 
AGC 
absolute granulocyte count 
ANC 
absolute neutrophil count 
ASCO 
American Society of Clinical Oncology 
AST (SGOT) 
aspartate aminotransferase 
AUC 
area under the curve 
BP 
blood pressure 
BCIRG 
Breast Cancer International Research Group 
CAEPR 
Comprehensive Adverse Events and Potential Risks 
CCD 
Clinical Coordinating Department (NRG Oncology) 
CE 
cardiac event 
CEF 
cyclophosphamide, epirubicin, and 5-fluorouracil 
CHF 
congestive heart failure 
CI 
confidence interval 
CREC 
Cardiac Review and Evaluation Committee 
CTCAE v3.0 
Common Terminology Criteria for Adverse Events Version 3.0 
CTCAE v4.0 
Common Terminology Criteria for Adverse Events Version 4.0 
CTEP 
Cancer Therapy Evaluation Program 
CTEP-AERS 
CTEP Adverse Event Reporting System 
CTEP-IAM 
CTEP-Identity and Access Management 
CTSU 
Cancer Trials Support Unit 
DCIS 
ductal carcinoma in situ 
DCTD 
Division of Cancer Treatment and Diagnosis 
DFS 
disease-free survival 
DMC 
Data Monitoring Committee 
ECOG 
Eastern Cooperative Oncology Group 
EGFR 
epidermal growth factor receptor 
ER 
estrogen receptor 
FDA 
Food and Drug Administration 
FISH 
fluorescence in situ hybridization 
FSH 
follicle stimulating hormone 
GI 
gastrointestinal 
H&E 
hematoxylin and eosin 
HER2 
human epidermal growth factor receptor 2 
HERA 
Herceptin Adjuvant Trial 
HR 
hazard ratio 
IDC 
infiltrating ductal carcinoma 
IHC 
immunohistochemistry 
IND 
investigational new drug 
IRB 
Institutional Review Board 
IDFS-DCIS 
invasive or DCIS disease-free survival 
IV 
intravenous 
LCIS 
lobular carcinoma in situ 

 
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GLOSSARY OF ABBREVIATIONS AND ACRONYMS (continued) 
 
LV 
left ventricular 
LVEF 
left ventricular ejection fraction 
MAPK 
mitogen-activated protein kinase 
MRI 
magnetic resonance imaging 
NCCTG 
North Central Cancer Treatment Group 
NCI 
National Cancer Institute 
NCTN 
National Trials Clinical Network 
NOS 
not otherwise specified 
NSABP 
National Surgical Breast and Bowel Project 
NSC 
National Service Center 
OPEN 
Oncology Patient Enrollment Network 
OS 
overall survival 
P 
probability (2P indicates probability from a 2-sided test) 
PgR 
progesterone receptor 
PI3K 
phosphatidylinositol 3-kinase 
PMB 
Pharmaceutical Management Branch 
PTEN 
phosphatidylinositol phosphate 3'-phosphatase 
RR 
relative risk 
RT 
radiation therapy 
RT-PCR 
reverse transcriptase polymerase chain reaction 
RUMC 
Rush University Medical Center 
SDMC 
Statistics and Data Management Center 
SPEER 
Specific Protocol Exceptions to Expedited Reporting 
WBC 
white blood cell 
WBI 
whole breast irradiation 
 
 
 

 
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1.0 
SUMMARY OF THE STUDY 
Note: Accrual closed on December 8, 2014, following achievement of the sample size goal. 
The primary aim of this Phase III randomized clinical trial is to determine whether trastuzumab 
given concurrently with radiation therapy (RT) is more beneficial in preventing subsequent 
ipsilateral breast cancer recurrence, ipsilateral skin cancer recurrence, or ipsilateral DCIS, when 
compared with RT alone in women with HER2-positive ductal carcinoma in situ (DCIS) resected 
by lumpectomy.  The secondary aims are to compare the possible benefit of trastuzumab given 
during RT to that of RT alone in preventing subsequent regional or distant recurrence and 
contralateral invasive or DCIS breast cancer.  B-43 will determine if invasive or DCIS  
disease-free survival, recurrence-free interval, and overall survival can be improved with the 
addition of trastuzumab to RT.  The effects of trastuzumab on ovarian function in premenopausal 
women will also be assessed. 
Submission of a representative tumor block to Rush University Medical Center (RUMC) for 
HER2 testing is required prior to randomization.  If the DCIS is found to be HER2-positive and 
the patient is enrolled in B-43, the block will also be used for B-43 correlative studies.  Patients 
whose DCIS is determined to be HER2-negative by testing at RUMC will not be eligible for 
participation in B-43. 
Eligible patients will be randomized to receive either RT alone or two doses of trastuzumab given 
concurrently with RT.  The RT must be whole breast irradiation (with or without a boost) 
delivered over 5-6 weeks or, at the investigator's discretion, accelerated fractionation may be 
used. 
For patients with DCIS that is hormone receptor-positive, hormonal therapy should be given for a 
minimum of 5 years.  Selection of the hormonal therapy agent(s) is at the discretion of the 
investigator. 
The sample size for B-43 will be 2000 patients to be accrued over a period of 7.93 years. 
 
 

 
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Figure 1 
 
B-43 SCHEMA 
 
 
 
 
 
 
 
 
 
 
 
STRATIFICATION 
• Menopausal Status (postmenopausal; not postmenopausal) 
• Plan for Hormonal Therapy (yes; no) 
• Nuclear Grade (low or intermediate; high) 
RANDOMIZATION 
Group 1* 
 
Radiation Therapy 
Group 2* 
 
Radiation Therapy 
+ 
Trastuzumab x 2 doses 
Dose 1: 8 mg/kg IV 
Dose 2: 6 mg/kg IV 
given 3 weeks after Dose 1 
* Patients with ER-positive and/or PgR-positive DCIS should receive a 
 
minimum of 5 years of hormonal therapy. 
DCIS Resected by Lumpectomy  
Determined to be HER2-Positive by Central Testing 

 
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2.0 
BACKGROUND 
2.1 
Introduction 
The American Cancer Society predicts that 184,000 new invasive breast cancers will be 
detected in the United States in the year 2008.  In addition, about 67,770 cases of breast 
carcinoma in situ are expected to be newly diagnosed in 2008.1  Of these, approximately 
85% are expected to be ductal carcinoma in situ (DCIS).2  DCIS gives rise to the majority 
(approximately 85%) of invasive breast cancers3, so it is an important entity to 
understand and to prevent. 
Thus far, treatment of DCIS has been limited to mastectomy or lumpectomy plus 
radiotherapy, with or without tamoxifen in ER-positive cases.  A substantial proportion of 
DCIS is ER-negative and overexpresses HER2.  Targeting HER2 is a promising strategy 
for HER2-overexpressing DCIS.  Trastuzumab, a monoclonal antibody that specifically 
targets the HER2 protein,4,5 was approved by the FDA in 1998 and is now widely 
prescribed for patients with HER2-positive metastatic breast cancer and in combination 
with chemotherapy in the adjuvant setting. 
Preclinical studies have shown that trastuzumab boosts the effectiveness of radiation in 
xenograft models and in cell lines, without producing a detrimental effect on irradiated 
HER2-normal cells.6,7  The first information in humans correlating clinical response with 
molecular markers in trastuzumab-treated patients shows that apoptosis occurs very 
quickly (within one week of beginning single agent trastuzumab) and that there is little 
effect on proliferation.8  This suggests that shorter treatment durations with trastuzumab, 
rather than indefinite or prolonged therapy should be investigated.  Ongoing adjuvant 
trials use trastuzumab during breast irradiation, providing ample evidence of safety. 
Given the accumulated body of evidence, it is reasonable to ask whether trastuzumab, 
administered during radiation therapy, will improve the results of lumpectomy and 
irradiation in women with HER2-positive DCIS.  The view that cancer is a disorder of 
growth and that, ultimately, surgery will be replaced by other methods of re-ordering or 
controlling growth will be further explored in this trial.  This trial will allow us to better 
understand the biology of breast cancer, including its prevention, and to extend the 
benefits of breast-conserving surgery for women with DCIS. 
2.2 
Prior and ongoing clinical trials in DCIS conducted by the NSABP  
Retrospective reports have shown that local recurrence rates after breast-conserving 
surgery for DCIS, with and without radiation therapy, were no greater for DCIS than for 
invasive cancer.9-15  However, mastectomy for DCIS was still the accepted standard 
because there was a risk that recurrence could arise in the form of invasive cancer, which 
could lead to distant metastasis and death, and mastectomy would eliminate the 
possibility of recurrence as invasive breast cancer. 
Two studies carried out by the NSABP have clarified several controversial issues about 
the nature of DCIS and an alternative management approach.  NSABP B-17 compared 
lumpectomy alone with lumpectomy and radiation therapy.  NSABP B-24 evaluated the 
addition of tamoxifen to lumpectomy and radiation therapy.  Together, the two trials 
showed that breast-conserving surgery was an appropriate option for women with 
DCIS.16-20 

 
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Results of NSABP B-17 were published in 1993 and updated in 1995, 1998,18 and 
2001.19  Initially, 818 patients were randomized; there was subsequent follow-up of 814 
patients.  The incidence of invasive breast cancer at 8 years of follow-up was reduced 
with the addition of radiotherapy from 13.4% to 3.9%.  Mortality attributable to breast 
cancer for the entire cohort was only 1.7% at 8 years.  Also, after 8 years of follow-up, 
the addition of radiotherapy continued to show a low cumulative incidence of ipsilateral 
recurrences, both invasive and noninvasive.  Overall long-term survival rates were 
similar to those obtained with total mastectomy in historic retrospective studies.  The 
conclusion was that mastectomy was not generally necessary in women with localized 
DCIS. 
Despite these favorable statistics, others argued that wider local excision could produce 
similar long-term disease control without radiation therapy.21  The idea that wider 
excision is better because it allows the omission of radiation therapy has logic, but is a 
step back toward the Halstedian idea of cancer as a constantly expanding process.  
Another view is that cancer is a disorder of growth and that, ultimately, surgery will be 
replaced by other methods of re-ordering or controlling growth.  NSABP B-24 was 
undertaken to explore the biology of breast cancer and to extend the benefits of  
breast-conserving surgery for women with DCIS. 
Prior NSABP adjuvant trials had shown that tamoxifen decreased the incidence of tumor 
recurrence in the ipsilateral breast and reduced the rate of new primary tumors in the 
contralateral breast,22,23 suggesting that tamoxifen could interfere with the development 
of primary invasive breast cancer or with the progression of DCIS into invasive cancer.  
In NSABP B-24, patients were randomized to receive 5 years of adjuvant tamoxifen or 
placebo after lumpectomy and radiation therapy.  It was postulated that the addition of 
tamoxifen would be more effective than radiotherapy alone in preventing recurrence of 
DCIS or invasive breast cancer.  A total of 1804 women were randomly assigned to 
receive tamoxifen or placebo, and median follow-up was 74 months at the time of the 
primary report.  Women in the tamoxifen group had fewer breast cancer events at 5 years 
than those on placebo (8.2% vs. 13.4%, P=0.00009).16  The cumulative incidence of all 
invasive breast cancers in the tamoxifen group was 4.1% at 5 years vs. 7.2% in the 
placebo group (p=0.004).  There was a reduction in the rate of noninvasive breast cancer, 
but it was not significant.  The benefits of this approach are a reduction in the overall 
incidence of all breast cancer events (ipsilateral, contralateral, and distant) and a 
reduction in the extent and severity of surgery required. 
Margin involvement, a frequently cited predictor of recurrence, was assessed at 5 years of 
follow-up in NSABP B-17.  Positive margins were associated with an increased risk 
(2.33 RR) of ipsilateral breast tumors.20  In NSABP B-24, positive tumor margins were 
associated with increased rates and RR of invasive or noninvasive ipsilateral breast 
tumors.  However, in the tamoxifen-treated group, the risk was 22% lower than the 
untreated group when sample margins were negative and 44% lower when margins were 
positive or unknown.16  The 8-year update of the B-17 study shows that margin status 
was less of an influence (1.48 RR) than indicated in the earlier report.24 
The success of tamoxifen in lowering all rates of recurrence fosters the search for more 
effective and/or less toxic agents to control the stimulation and growth of precancerous 
and cancerous cells in the breast.  This idea formed the rationale for NSABP-35 which 
asked whether anastrozole is more effective than tamoxifen in postmenopausal women 
undergoing breast-conserving treatment for DCIS.  Accrual for B-35 is now completed. 

 
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Young women (age <50) treated with lumpectomy and irradiation are significantly more 
likely to experience an in-breast tumor recurrence or a contralateral breast cancer than 
older women (HR 3.3 vs. 1.3, respectively).16  These women were not eligible for the 
NSABP B-35 trial.  Patients with ER-negative tumors were also ineligible for NSABP  
B-35.  Thus, the current trial complements NSABP B-35 because many of its participants 
will be premenopausal and/or have ER-negative tumors. 
2.3 
Refining therapy for subgroups of patients:  The HER2 alteration in DCIS 
DCIS is more likely than invasive breast cancer to overexpress HER2.  As reported by 
the Intergroup Study 0011, HER2 was overexpressed in 56% of pure DCIS specimens 
(including 77% of the comedo subtype), in 22% of DCIS associated with infiltrating 
ductal carcinoma (IDC), and in only 11% of IDC alone.25,26 
Recently, the expression profiles of nearly 12,000 annotated genes in 25 cases of pure 
DCIS and 25 cases of pure infiltrating ductal cancer were compared.3  HER2 was 
upregulated 3.9-fold in DCIS compared with invasive breast cancer.  HER2 expression in 
DCIS and in invasive breast cancer within the same neoplasm were concordant in 100% 
of cancers tested.27  Thus, interrupting this signal transduction pathway early might 
prevent development of aggressive (HER2-positive) invasive breast cancer and could 
have a major impact on breast cancer mortality. 
A literature review revealed considerable variability in HER2 expression in DCIS, 
ranging from 28% to 65% (Table 1).  Most investigators used immunohistochemical 
(IHC) staining to measure HER2 expression.  The antibodies used, the methods of 
fixation, the duration of tissue storage, and the antigen retrieval techniques are only some 
of the variables that could have affected results.  Only one of the studies performed both 
IHC and fluorescence in-situ hybridization (FISH) testing for HER2 on the same 
specimens.  The investigators, from Rush University Medical Center, evaluated 37 
specimens: Twenty-two were HER2-positive by IHC and nineteen of these were also 
amplified by FISH.  No specimens were FISH-amplified and IHC-negative.28 
 

 
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TABLE 1.  HER2 expression in DCIS 
Author 
N 
Accrual 
Surgery 
HER2 
Test 
HER2+ (%) 
ER+ 
Scoring 
ER+ (%) 
N (%) of 
ER+ Cases 
Which Were 
HER2+ 
Institution 
LeBeau29 
45 
1986-1995 
Any 
3B5a 
21/45 (47) 
 10% 
22/40 (55) 
 
U Munchen, Munchen, 
Germany 
Cornfield30 
151 
1982-2000 
BCT 
nsb 
(33) 
 
(75) 
 
Thomas Jefferson,  
Philadelphia, PA 
Siziopikou K28 
37 
ns 
Any 
CB11c 
& 
FISHd 
22/37 (59) 
19/37 (51) 
 
 
 
Rush, Chicago, IL 
Barnes31 
129 
1979-2004 
Any 
A0485e 
84/129 (65) 
 
 
 
South Manchester U and 
Christie Hospital, England 
Collins32 
148 
2000-2003 
Any 
A0485f 
42/148 (28) 
 10% 
114/148 (77) 
14/114 (12) 
Beth Isreal, Boston 
Provenzano33 
82 
1988-1992 
BCT 
 
17/41 cases (41) 
5/41 controls (12) 
 10% 
14/37 cases (35) 
24/37 controls 
(68) 
 
Victorian Breast Cancer 
Consortium,  
Melbourne, Victoria, 
Australia 
Rodrigues34 
54 
1973-2000 
BCT + RT 
A0485g 
26/54 (48) 
 10% 
45/54 (83) 
18/45 (40) 
Yale, New Haven, CT 
Claus35 
255 
1982-1994 
 
 
(28) 
 
(60) 
(19) 
Yale, New Haven, CT 
Van de Vijver MJ36 
45 
1976-1988 
Any 
3B5h 
19/45 (42) 
 
 
 
The Netherlands Cancer Inst 
Amsterdam 
Perin T37 
49 
1984-1992 
Any 
CB11i 
(55) 
Any 
(54) 
 
C.R.O., Aviano. Italy 
Ringberg A38 
187 
1987-1992 
BCT, no RT 
CB11j 
92/171 (54) 
 10% 
97/163 (60) 
 
South Sweden Breast Cancer 
Groupe 
Bijker N39 
71 
 
BCT 
3B5k 
30/65 (46) in 
primary 
25/65 (38) in 
recur 
 1% 
44/70 (63) in 
primary 
42/66 (63) in 
recur 
 
EORTC 10853 Trial 
Ramachandra S40 
74 
 
 
21N 
44/74 (59) 
 
 
 
The Royal Marsden, U.K. 
Schimmelpenning H41 
107 
 
 
OA-11-
854l 
51/107 (48) 
 
 
 
Karolinska Inst,  
Stockholm, Sweden 
Bobrow L42 
105 
1975-1991 
Any 
21Nm 
47/105 (45) 
 
 
 
ICRF, Guy's Hospital, U.K. 
Leal CB43 
40 
1985-1993 
Any 
seen 
18/40 (45) 
 
23/36 (64) 
 
Instituto Portuges de 
Oncologia Francisco, Porto, 
Portugal 
Somerville JE44 
50 
 
Any 
pAblo 
ICR12o 
23/50 (46) 
 
 
 
Belfast City Hospital,  
Belfast, Ireland 
Poller DN45 
112 
 
Any 
21Np 
62/112 (55) 
Any 
 
 
City Hospital, Nottingham, 
U.K. 

 
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aOncogene Science; any staining considered positive.  bSignet Labs, Dedham, MA.  Positive cases included those with strong membrane staining regardless of the percent of 
cells staining.  Median f/u 65 mo (86 for those w/o recurrence).  42 recurrences w/median TTR of 28.5 mo for those who recurred.  Patients received no RT and no tamoxifen.  
No correlation of markers with recurrence.  cVentana.  2-3+ was considered positive.  This was not otherwise defined.  dVysis.  Barnes: Case-controlled study.  Cytoplasmic 
and membrane staining of HER2 was considered positive.  2+ and 3+ were considered positive.  eHER2-staining was scored 0 (absent) to 3 (maximum cyto-membranous 
staining seen, comparable to a 3+ positive invasive cancer control), with a score 2 considered HER2-positive.  fThe envision double stain system (Dako Cytomation, 
Carpinteria, CA) for simultaneous assessment of ER and HER2 was used.  Only 3+ per HercepTest definition was considered positive.  Provenzano case-control series so ER% 
may be falsely low as half of these patients recurred.  gDako Hercep Test Kit.  2-3+ was considered positive.  hOnly unequivocal membrane staining was considered positive.  
All positive cases were comedo; 66% if comedos stained positively.  A polyclonal Ab against the cytoplasmic domain of HER2.  Cambridge Research Biochemicals, 
Northwich, UK.  iNovocastra Labs, UK.  HER2 was considered positive if any membrane staining was observed.  jNovocastra Labs, UK.  HER2 was considered positive if  
10% membrane staining was observed.  kAny + staining was considered positive.  All cases analyzed were recurrence after BCT.  This was a randomized trial of 1x vs 1x+RT.  
mPolyclonal Ab, Dr. W. Gullick, ICRF, London.  Positive if any strong membrane staining was seen.  nAntibody from Dako (Dakopatts, Denmark).  opAb1, Triton 
Biosciences, Inc., a polyclonal Ab against the c-terminus; ICR12, a monoclonal provided by Dr. C Dean, Institute of Cancer Res; Royal Cancer Hospital, Belmont, Sutton 
Surrey.  Cases that showed strong membrane staining either focal (only affecting some cells) or diffuse (affecting all or most cells) were classified as positive.  pPolyclonal Ab, 
Dr. W.J. Gullick, ICRF, London.  Membrane staining, either homogeneous or heterogeneous was considered positive. 

 
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From NSABP B-24, 100 cases have been examined by HercepTest (IHC) and, if  
2+ or 3+, then by FISH.  Twenty-one cases were 2+ and 26 cases were 3+ by IHC. 
Among the 2+ cases, 12 were found to have gene amplification by FISH, and 22 of the  
26 3+ cases had gene amplification (3 non-evaluable with 1 true non-amplified case).  
Together, 34 cases had HER2 gene amplification.  cMYC was also examined among 
HER2 IHC 2+ or 3+ cases, and 11 of them were found to be amplified (32%).  These data 
suggest that the incidence of HER2 amplification is at least as frequent or more frequent 
in DCIS as compared to invasive breast cancer.46 
This trial will use the following HER2-expression guidelines for eligibility:  From the 
time of study activation until April 4, 2011, central testing was based on IHC for HER2 
(HercepTest) for all cases, with reflex testing by FISH in 1+ and 2+ cases.  An internal 
analysis of B-43 cases determined that the rate of IHC 2+ DCIS found to be  
FISH-positive was 16.8%.  With an IHC score of 1+, the FISH-positive rate was 0.36%.  
Based on these results, it was determined that the rate of identifying FISH-positive 
tumors among patients with DCIS that is IHC 2+ is sufficient to warrant the continued 
practice of reflex FISH for possible participation in the B-43 trial.  However, the very 
low rate of FISH-positive DCIS among IHC 1+ tumors does not justify additional testing, 
and central testing procedures were changed effective April 4, 2011, to discontinue reflex 
FISH following an IHC test result of 1+ (see Section 6.2).  Patients whose tumors are 3+ 
by IHC or amplified by FISH will be eligible. 
2.4 
Refining therapy for subgroups of patients with DCIS 
NSABP B-24 patients were enrolled without regard to estrogen-receptor status.  Further 
data analysis suggested that only ER-positive patients benefited from tamoxifen.47  Thus, 
women with ER-negative DCIS currently have no proven systemic therapeutic options. 
Many patients have DCIS that overexpresses HER2.  Among tumors from 255 women 
presenting to the Yale-New Haven Hospital with DCIS, HER2 expression was inversely 
related to ER status.  Sixty percent of HER2-positive tumors were ER-negative; however, 
expression of HER2 was not limited to ER-negative DCIS.  Nineteen percent of  
ER-positive tumors from patients with DCIS overexpressed HER2.48  It is possible that 
tamoxifen may be deleterious in women with ER-positive, HER2-positive breast 
cancer.49 
HER2-overexpression is frequently associated with large cell, comedo variety DCIS.  Of 
45 patients studied in the Netherlands, 42% had DCIS that overexpressed HER2, and all 
were of the large-cell, comedo growth type.50  This histologic subtype of DCIS is 
generally associated with more aggressive behavior.  For example, subgroup analysis of 
NSABP B-24 revealed that the presence of comedo necrosis was associated with a 
significantly higher relative risk of recurrence than non-comedo histology (2.7 vs. 1.3, 
respectively) in patients treated with lumpectomy and radiation.16 
Other investigators have confirmed the association between high grade DCIS and HER2 
overexpression using classifications systems proposed by Lagios51, modified Lagios52, 
and Holland.53,54  Therefore, the use of trastuzumab to block signal transduction through 
the HER2 pathway is an attractive idea in HER2-overexpressing DCIS. 
 
 

 
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2.5 
Clinical experience with trastuzumab 
Three multicenter clinical trials have shown the safety and efficacy of trastuzumab 
combined with chemotherapy and of trastuzumab monotherapy for patients with 
metastatic breast cancer.4,5,55  Four multicenter adjuvant trials also have been completed 
and underscore the efficacy and safety of this agent. 
The NSABP B-31 trial compared doxorubicin and cyclophosphamide followed by 
paclitaxel every 3 weeks (group 1) with the same regimen plus 52 weeks of trastuzumab 
beginning with the first dose of paclitaxel (group 2) for prolonging DFS.  The North 
Central Cancer Treatment Group (NCCTG) trial N9831 compared three regimens, only 
two of which (group A and group C) were comparable to group 1 and group 2 in B-31: 
doxorubicin and cyclophosphamide followed by weekly paclitaxel (group A), and the 
same regimen plus 52 weeks of trastuzumab initiated concomitantly with paclitaxel 
(group C).  Both studies were amended to address a joint analysis comparing groups 1 
and A (the control group) with groups 2 and C (the trastuzumab group).  Patients in both 
studies with hormone receptor-positive tumors received hormonal therapy for 5 years 
after chemotherapy.56  By March 15, 2005, 394 events had been reported, triggering the 
first scheduled interim analysis.  Of these, 133 were in the trastuzumab group and 261 in 
the control group (HR 0.48; P<0.0001).  This result crossed the early stopping boundary.  
The absolute difference in DFS between the trastuzumab group and the control group was 
12 percent at three years.  Trastuzumab therapy was associated with a 33% reduction in 
the risk of death (p=0.015).  The authors concluded that adjuvant trastuzumab combined 
with paclitaxel given after doxorubicin and cyclophosphamide improves outcomes 
among women with surgically removed HER2-positive breast cancer. 
A second international, multicenter randomized trial, the Herceptin Adjuvant (HERA) 
trial, compared 1 or 2 years of trastuzumab given every 3 weeks with observation alone 
in patients who had HER2-positive, node-negative or node-positive breast cancer and 
who had completed locoregional therapy and at least four cycles of neoadjuvant or 
adjuvant chemotherapy.  Patients with hormone receptor-positive tumors received 
hormonal therapy for 5 years after chemotherapy.57  Data were reported for 1694 women 
assigned to 1 year of trastuzumab and 1693 women assigned to observation.  At the first 
planned interim analysis, 347 events were observed: 127 events in the trastuzumab group 
and 220 in the observation group.  The unadjusted hazard ratio for an event in the 
trastuzumab group, as compared with the observation group, was 0.54 (95% CI, 0.43 to 
0.67; P<0.0001 by the log-rank test, crossing the interim analysis boundary), representing 
an absolute benefit in terms of DFS at 2 years of 8.4 percentage points.  Overall survival 
in the two groups was not significantly different (29 deaths with trastuzumab vs. 37 with 
observation).  The authors concluded that 1 year of treatment with trastuzumab after 
adjuvant chemotherapy significantly improves DFS among women with HER2-positive 
breast cancer. 
In a third international trial, BCIRG 006, patients with HER2-amplified axillary lymph 
node-positive or high risk, node-negative breast cancer were randomized to receive either 
doxorubicin and cyclophosphamide (60/600 mg/m2 q3wk x 4) followed by docetaxel  
(100 mg/m2 q3wk x 4) or two trastuzumab-containing regimens: doxorubicin and 
cyclophosphamide followed by docetaxel with trastuzumab x 1 year or docetaxel and 
carboplatin (75 mg/m2/AUC 6 q3wk x 6) with trastuzumab x 1 year.  Patients with 
hormone receptor-positive tumors received hormonal therapy for 5 years after 
chemotherapy.58  A total of 3222 patients were recruited to the trial.  At a median  

 
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follow-up of 23 months, the two trastuzumab-containing arms both met the DFS endpoint  
(HR 0.49 with doxorubicin and cyclophosphamide followed by docetaxel plus 
trastuzumab, P-value=0.00000048; HR 0.61 with docetaxel plus carboplatin plus 
trastuzumab P-value=0.00015 as compared to doxorubicin and cyclophosphamide 
followed by docetaxel).  The authors concluded that trastuzumab either in combination 
with docetaxel following doxorubicin and cyclophosphamide or combined with docetaxel 
and carboplatin improves outcomes among women with surgically removed  
HER2-positive breast cancer. 
In the final study, the Finland Herceptin (FinHER) trial, 1010 women with either axillary 
node-positive breast cancer or node-negative cancer with tumor > 20 mm were randomly 
allocated to receive either 3 cycles of docetaxel (100 mg/m2) given every 3 weeks or  
8 weekly cycles of vinorelbine (25 mg/m2) as adjuvant therapy.  After single-agent 
docetaxel or vinorelbine, patients from both arms were given 3 cycles of 
cyclophosphamide, epirubicin, and 5-fluorouracil (C-600 mg/m2; E-60 mg/m2;  
F-600 mg/m2) every 3 weeks; tamoxifen was given for 5 years for ER or PgR-positive 
disease.  Patients whose tumors showed HER2 amplification in chromogen in situ 
hybridization (CISH, n=232, 23%) were randomized a second time to receive 9 weekly 
cycles of trastuzumab given concomitantly with either docetaxel or vinorelbine, or no 
trastuzumab.59  Breast cancer recurrence was less frequent among patients treated with 
docetaxel/CEF than among those treated with vinorelbine/CEF (39/502 vs. 68/507;  
HR 0.58; log-rank test, p= 0.0036).  Adjuvant 9-week trastuzumab was effective in 
preventing any breast cancer recurrence (11/115 vs. 26/116, HR 0.46, p for  
recurrence-free survival = 0.0078).  Three-year distant DFS of patients who received 
trastuzumab was 93% and that of patients who did not receive trastuzumab was 76% 
(p=0.0078, 11/115 vs. 26/116 events, HR 0.43).  There was a trend towards superior 
overall survival of patients treated with trastuzumab (6/115 deaths vs. 14/116,  
HR 0.43, p=0.08).  The authors concluded that docetaxel/CEF was more effective than 
vinorelbine/CEF and that trastuzumab was effective in preventing breast cancer 
recurrence when combined with either docetaxel or vinorelbine as adjuvant treatment of 
breast cancer.  Trastuzumab given concomitantly with docetaxel or vinorelbine for  
9 weeks was well tolerated and was not associated with a decrease of left ventricular 
ejection fractions (LVEFs), making monitoring of the LVEFs unnecessary for most 
patients. 
2.6 
Rationale for not conducting baseline cardiac evaluations 
Cardiac events were observed in the pivotal clinical trials that led to the approval of 
trastuzumab.  Cardiotoxicity was most pronounced when trastuzumab was given 
concurrently with anthracyclines.  However, all patients in the Phase III trial and most in 
the Phase II trial for refractory breast cancer had received anthracyclines either 
concurrently with trastuzumab or trastuzumab following an anthracycline. 
Subsequent studies of trastuzumab in metastatic disease, which included less heavily  
pre-treated patients, sparked less concern.  Investigators enrolled 114 patients who had 
HER2-positive metastatic breast cancer and who had not previously received 
chemotherapy for their metastatic breast cancer in a Phase II clinical trial.60  Women with 
current, clinically significant cardiac disease were excluded.  All cardiac events were 
referred to an independent, cardiac review and evaluation committee (CREC).  Three 
women were considered by the CREC to have cardiac dysfunction.  Two of the three 
patients had histories of significant cardiac disease, and one had received adjuvant 

 
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anthracycline therapy.  The cardiac event in the third patient was attributed to underlying 
breast cancer.  After discontinuation of trastuzumab, none of these patients required 
additional intervention for cardiac events. 
In the study by Vogel et al, the two patients who experienced cardiac toxicity did so after 
cumulative doses of 56 and 104 mg/kg of trastuzumab.60  In the adjuvant therapy trials, 
patients would have received at least 32 mg/kg of trastuzumab before beginning radiation 
therapy (RT) and an additional 12 mg/kg during RT.  In the proposed trial, patients will 
receive a total dose of only 14 mg/kg. 
NSABP B-31 compared doxorubicin and cyclophosphamide (AC) followed by paclitaxel 
with AC followed by paclitaxel plus 52 weeks of trastuzumab beginning concurrently 
with paclitaxel in patients with node-positive, HER2-positive breast cancer.  Initiation of 
trastuzumab required normal post-AC LVEF on a multiple-gated acquisition scan.  If 
symptoms suggestive of congestive heart failure (CHF) developed, source documents 
were blindly reviewed by an independent panel of cardiologists to determine whether 
criteria were met for a cardiac event (CE), which was defined as New York Heart 
Association Class III or IV CHF or possible/probable cardiac death.  Frequencies of CEs 
were compared between arms.61 
Among patients with normal post-AC LVEF who began post-AC treatment in NSABP  
B-31, 5 of 814 control patients subsequently had confirmed CEs (4 CHFs and 1 cardiac 
death) compared with 31 of 850 trastuzumab-treated patients (31 CHFs and no cardiac 
deaths).  The difference in cumulative incidence at 3 years was 3.3% (4.1% for 
trastuzumab-treated patients minus 0.8% for control patients; 95% CI, 1.7% to 4.9%).  
Twenty-seven of the 31 patients in the trastuzumab arm have been followed for  6 
months after diagnosis of a CE: 26 were asymptomatic at last assessment, and 18 
remained on cardiac medication.  CHFs were more frequent in older patients and patients 
with marginal post-AC LVEF.  Fourteen percent of patients discontinued trastuzumab 
because of asymptomatic decreases in LVEF; 4% discontinued trastuzumab because of 
symptomatic cardiotoxicity. 
In a more recent publication with four years of follow-up, a comprehensive assessment of 
potential risk factors for CHF in NSABP B-31 patients was conducted.  Left-sided breast 
cancer and radiation therapy was not a risk factor for CHF.62 
In the N9831 trial, NCCTG concluded that concurrent administration of adjuvant RT 
with trastuzumab in early stage breast cancer patients is not associated with an increased 
incidence of acute RT adverse events.  Three thousand five-hundred and five (3505) 
patients were evaluated.63  Women with operable, HER2-positive breast cancer were 
randomized to AC followed by weekly paclitaxel (T): AC→T→trastuzumab (H) or 
AC→TH→H.  Post-lumpectomy breast ± nodal RT was recommended, as was 
postmastectomy chest wall + nodal RT (> 3 positive nodes); internal mammary RT was 
prohibited.  RT started within 5 weeks of completion of T and was allowed to be 
administered concurrently with H.  A total of 1460 patients receiving RT were available 
for analysis of RT-associated AEs.  Also, 1286 patients on trastuzumab arms who 
completed T (908 who received RT and 378 who did not receive RT) were available for 
analysis of clinical CEs. 
Rates of RT-associated AEs were compared across treatment arms, and rates of CEs were 
compared for RT vs. no RT within the trastuzumab arms.  RT did not increase the 

 
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frequency of CEs.  In the AC→T→H arm, the incidence of CEs was 2.2% in patients 
who received RT vs. 2.9% in patients who had not received RT.  In the AC→TH→H 
arm, the incidence of CEs was 1.5% in the RT patients vs. 6.3% in the no-RT patients.  
No difference in CEs was seen between left-sided and right-sided RT fields in the RT 
patients in either group that included trastuzumab. 
The second planned analysis of the BCIRG 006 adjuvant trial revealed that trastuzumab 
does not have cardiac toxicity when it is given to patients who have not received an 
anthracycline: trastuzumab increased the rate of cardiac toxicity only when it was added 
to an anthracycline-containing regimen.64  Table 2 shows the left ventricular function as 
measured by LVEF before, during, and after treatment.  The slope of the LVEF over time 
is not affected by TCH. 
TABLE 2.  Trastuzumab (H) impact on LVEF when no anthracyclines  
have been administered 
 
AC→T 
AC→TH 
TCH 
N 
1043 
1074 
1056 
LVEF slope 
-.78 
-1.77 
+.03 
P-value slope 
.0002 
.00001 
.79 
 
In the FinHer study, wherein patients were randomized to receive only 9 weeks of 
adjuvant trastuzumab, one patient experienced a cardiac infarction and three had cardiac 
failure; none of these four patients had received trastuzumab.  LVEFs were preserved in 
women who received trastuzumab. 
In fact, trastuzumab-treated women had slightly better ejection fractions than those who 
did not receive trastuzumab; in an ANCOVA model, the estimated difference 12 months 
after the completion of chemotherapy was 1.7% (–0.1 to 3.5; p=0.06), and at 36 months it 
was 3.0% (0.7 to 5.4; P=0.01).  Four women who were treated with trastuzumab  
(3.5%) and seven who were not (6.0%) had one or more measurements of ejection 
fraction that were more than 15 percentage points less than the pretreatment value.  A 
decrease by more than 10 percentage points, resulting in an ejection fraction of less than 
50%, occurred in three patients (none of whom had received trastuzumab).65 
Given the fact that patients who enter this trial will not receive an anthracycline and will 
receive only two doses of trastuzumab, it is reasonable not to require baseline cardiac 
evaluation beyond the eligibility criteria, which include no serious cardiac disease and 
New York Heart Association Classification Class I (patients with no limitation of 
activities; they suffer no symptoms from ordinary activities).  This approach is safe 
because no patient will have received prior anthracyclines and the cumulative dose of 
trastuzumab is low. 
2.7 
Implications for breast cancer prevention 
Breast cancer prevention strategies have been limited to inhibiting the binding of estrogen 
to its receptor or to decreasing estrogen levels.  This trial will allow us to study the effect 
of inhibiting the HER2 signal transduction pathway on the contralateral breast. 
 
 

 
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2.8 
Impact of trastuzumab on ovarian function 
DCIS is a precursor to invasive breast cancer and occurs months to years before invasive 
breast cancer.  Many women who enter this trial will be premenopausal and may be 
concerned about the impact of trastuzumab on ovarian function.  This trial will allow us 
to compare menstruation in control and trastuzumab-treated premenopausal women using 
data reported at baseline and at 18 months. 
 
 

 
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3.0 
STUDY AIMS AND ENDPOINTS 
3.1 
Primary aim and endpoint 
The primary aim is to determine the value of trastuzumab given during radiation therapy 
(RT) compared to RT alone in preventing the subsequent occurrence of ipsilateral breast 
cancer recurrence, ipsilateral skin cancer recurrence, or ipsilateral DCIS  
(IIBCR-SCR-DCIS) in women with HER2-positive DCIS resected by lumpectomy. 
The primary endpoint is time from randomization to IIBCR-SCR-DCIS defined as 
ipsilateral invasive breast cancer, ipsilateral skin cancer recurrence, or ipsilateral DCIS.  
An IIBCR-SCR-DCIS event is defined as recurrent tumor in the ipsilateral breast 
parenchyma, skin of the ipsilateral breast or ipsilateral DCIS occurring after lumpectomy.  
In the determination of time to an IIBCR-SCR-DCIS, no statistical censoring will be 
performed with respect to any previous local, regional, distant recurrences or second 
primary cancers. 
3.2 
Secondary aims and endpoints 
3.2.1 
Invasive or DCIS disease-free survival (IDFS-DCIS) 
Aim: Determine the value of trastuzumab given during RT compared to RT alone 
in prolonging IDFS-DCIS. 
Endpoint: Events for analysis of IDFS-DCIS include: local recurrence in the 
ipsilateral breast following lumpectomy, regional recurrence, distant recurrence, 
contralateral breast cancer, second primary cancer (other than squamous and 
basal cell carcinoma of the skin, melanoma in situ, and carcinoma in situ of the 
colon and cervix), or death from any cause prior to recurrence or second primary 
cancer. 
3.2.2 
Invasive or DCIS recurrence-free interval (IRFI-DCIS) 
Aim: Determine the value of trastuzumab given during RT compared to RT alone 
in increasing invasive or DCIS recurrence-free interval. 
Endpoint: Time from randomization to first diagnosis of a local, regional or 
distant recurrence regardless of any intervening contralateral or other second 
primary cancer. 
3.2.3 
Invasive regional or distant recurrence 
Aim: Determine the value of trastuzumab given during RT compared to RT alone 
in improving regional or distant recurrence. 
Endpoint: Time from randomization to first diagnosis of regional or distant 
recurrence. 
 
 

 
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3.2.4 
Contralateral breast cancer (invasive or DCIS) 
Aim: Determine the value of trastuzumab given during RT compared to RT alone 
in improving the incidence of contralateral invasive or DCIS breast cancer. 
Endpoint: Time from randomization to first diagnosis of contralateral invasive or 
DCIS breast cancer. 
3.2.5 
Overall survival (OS) 
Aim: Determine the value of trastuzumab given during RT compared to RT alone 
in improving survival. 
Endpoint: Time from randomization to death from any cause. 
3.2.6 
Ovarian function 
Aim: To explore the effect of trastuzumab on ovarian function. 
Endpoint: The incidence of post-treatment amenorrhea in women who were pre-
menopausal at the time of study entry.  Post-treatment amenorrhea, defined as the 
absence of menstrual period for at least 12 months, will be assessed when the 
patient has been on study for 18 months. 
3.2.7 
Correlative outcomes 
• 
Aim: To determine if the benefit of trastuzumab added to RT will be 
significantly higher in cMYC-amplified tumors than in the cMYC non-
amplified subset. 
• 
Aim: To determine if the benefit of trastuzumab added to RT will be less in 
tumors with mutations in the PI3 Kinase gene than in tumors without PI3 
Kinase gene mutations. 
 
 

 
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4.0 
PATIENT ELIGIBILITY AND INELIGIBILITY 
Note: Accrual closed on December 8, 2014, following achievement of the sample size goal. 
4.1 
Patient selection guidelines 
Although the guidelines in Section 4.1 are not inclusion/exclusion criteria, investigators 
should consider each of these factors when selecting patients for B-43.  Investigators 
should also consider all other relevant factors (medical and non-medical), as well as the 
risks and benefits of the study therapy when deciding whether a patient is appropriate for 
B-43.  These considerations should be weighed carefully, as they may make a patient an 
unsuitable candidate for B-43 and may increase risk to the patient. 
• 
Pre-entry central HER2 testing (see Sections 6.1 and 6.2 and Pre-Entry Sample 
Consent Form) is required for all patients.  The correlative studies are required for all 
patients enrolled in B-43 (see Treatment Study Sample Consent Form).  Therefore, 
submission of a representative tumor block for the B-43 trial is required.  
Submission of alternative tissue samples is NOT permitted.  The local pathology 
department policy regarding release of blocks must be considered when screening 
patients. 
• 
The best representative sample for HER2 central testing may be obtained from the 
lumpectomy specimen or from the core biopsy specimen.  However, the pre-entry 
central HER2 testing consent form must be signed and dated by the patient after her 
lumpectomy but before submission of the representative tumor block. 
• 
Patients with a life expectancy of less than 10 years, excluding the diagnosis of ductal 
carcinoma in situ of the breast.  (Comorbid conditions should be taken into 
consideration, but not the DCIS diagnosis.) 
• 
Women of reproductive potential must agree to use an effective non-hormonal 
method of contraception during therapy and for at least 7 months after completion 
of trastuzumab. 
• 
Psychiatric or addictive disorders or other conditions that, in the opinion of the 
investigator, would preclude the patient from meeting the study requirements. 
4.2 
Conditions for patient eligibility 
A patient cannot be considered eligible for this study unless all of the following 
conditions are met: 
4.2.1 
The patient must have consented to participate and must have signed and dated 
an appropriate IRB-approved consent form that conforms to federal and 
institutional guidelines for the study treatment and for the pre-entry tumor block 
submission for HER2 testing and B-43 correlative studies (see Section 6.1). 
4.2.2 
Patients must be female. 
4.2.3 
Patients must be 18 years of age or older. 

 
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4.2.4 
Patients must have an ECOG performance status of 0 or 1 (0 = fully active, able 
to carry on all pre-disease performance without restriction; 1 = restricted in 
physically strenuous activity but ambulatory). 
4.2.5 
On histologic examination, the tumor must be ductal carcinoma in situ (DCIS).  
(Patients with mixed DCIS and lobular carcinoma in situ [LCIS] are eligible.) 
4.2.6 
The DCIS must be HER2-positive as determined by central testing (see  
Sections 6.1 and 6.2 for details). 
4.2.7 
Estrogen and/or progesterone receptor status must be determined prior to 
randomization.  (Patients with DCIS that is hormone receptor positive or negative 
are eligible.) 
4.2.8 
All DCIS must have been resected by lumpectomy. 
4.2.9 
The margins of the resected specimen must be histologically free of DCIS.  For 
patients in whom pathologic examination demonstrates DCIS present at the line 
of resection, re-excision(s) may be performed to obtain clear margins.  (Patients 
who require mastectomy are not eligible.) 
4.2.10 If axillary staging is performed, nodal staging must be pN0, pN0(i–), pN0(i+) 
which is defined as isolated tumor cells  0.2 mm, regardless of the method of 
detection, i.e., IHC or H&E, pN0(mol–), or pN0(mol+).  Note: Axillary staging 
is not required.  (Refer to AJCC Staging Criteria in the Treatment Trial 
Information section in the Members' Area of the NSABP Web site for TNM 
nomenclature and staging information.) 
4.2.11 The interval between the last surgery for excision of DCIS (lumpectomy or re-
excision of lumpectomy margins) and randomization must be no more than  
120 days. 
4.3 
Conditions for patient ineligibility 
Any patient with one or more of the following conditions will be ineligible for this study: 
4.3.1 
Invasive (including microinvasion staged as T1mic) breast cancer. (Patients with 
DCIS “suspicious” for microinvasion, but not confirmed, are eligible.) 
4.3.2 
Nodal staging of pN1 (including pN1mi).  (Note: Axillary staging is not 
required.) 
4.3.3 
DCIS present in more than one quadrant (multicentric). 
4.3.4 
Masses or clusters of calcification that are clinically or mammographically 
suspicious unless biopsied and proven to be benign.  (If DCIS is found, the 
patient is eligible if the DCIS was in the same quadrant of the ipsilateral breast 
and was resected with clear margins.) 
4.3.5 
Contralateral breast cancer (including DCIS). 
4.3.6 
Whole breast irradiation administered before randomization.  (Partial breast 
irradiation is prohibited.) 

 
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4.3.7 
Prior history of breast cancer, including DCIS.  (Patients with a history of LCIS 
are eligible.) 
4.3.8 
Prior anthracycline chemotherapy for any malignancy. 
4.3.9 
Cardiac disease that would preclude the use of the drugs included in the B-43 
treatment regimens.  This includes but is not confined to: 
Active cardiac disease: 
• 
angina pectoris that requires the use of anti-anginal medication; 
• 
ventricular arrhythmias except for benign premature ventricular contractions 
(PVCs) controlled by medication; 
• 
conduction abnormality requiring a pacemaker; 
• 
supraventricular and nodal arrhythmias requiring a pacemaker or not 
controlled with medication; and 
• 
clinically significant valvular disease. 
History of cardiac disease: 
• 
myocardial infarction documented by elevated cardiac enzymes or persistent 
regional wall abnormalities on assessment of LV function; 
• 
documented congestive heart failure; or 
• 
documented cardiomyopathy. 
4.3.10 Uncontrolled hypertension, i.e., systolic BP greater than 180 mm/Hg and/or 
diastolic BP greater than 100 mm/Hg.  (Patients with hypertension that is well 
controlled on medication are eligible.) 
4.3.11 Other nonmalignant systemic disease that would preclude a patient from receiving 
trastuzumab or radiation therapy or would prevent prolonged follow-up. 
4.3.12 Other malignancies unless the patient is considered to be disease-free for 5 or 
more years prior to randomization and is deemed by her physician to be at low 
risk for recurrence.  Patients with the following cancers are eligible if diagnosed 
and treated within the past 5 years: carcinoma in situ of the cervix, carcinoma in 
situ of the colon, melanoma in situ, and basal cell and squamous cell carcinoma 
of the skin. 
4.3.13 Pregnancy or lactation at the time of study entry.  (Note: Pregnancy testing 
according to institutional standards should be performed for women of child-
bearing potential.) 
4.3.14 Administration of any investigational agent within 30 days before study entry. 
 

 
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5.0 
REQUIRED ENTRY AND FOLLOW-UP STUDIES 
Note: Accrual closed on December 8, 2014, following achievement of the sample size goal. 
TABLE 3.  Studies required for study entry and during study therapy and follow-up 
Required studiesa 
Prior to randomization 
(within 3 months 
unless specified 
otherwise) 
During RT 
with/without trastuzumab 
30 days 
following 
completion 
of RT 
Years 1 through 5 
from 
randomization 
Years 6  
through 10 from 
randomization 
Group 1 
Group 2 
History & physical examb 
X 
  Xc 
Xc 
(before 
trastuzumab 
Dose 2) 
X 
X 
(every 6 months) 
X 
(every 12 
months) 
Radiation oncology evaluation 
X 
 
 
 
 
 
Height and weight 
X 
 
 
 
 
 
Menopausal status (See Appendix A)d 
X  
(within 1 month) 
 
 
 
 
 
Menstrual history 
 
 
 
X 
(only at  
18 months)e 
 
AE assessment 
 
  Xf 
  Xf 
  Xf 
 
 
Bilateral mammogramg 
X  
(within 6 months) 
 
 
 
X  
(every 12 
months)h 
X 
(every 12 
months) 
Pregnancy test 
Xi 
(within 2 weeks) 
 
 
 
 
 
Tumor block submission for central 
HER2 testing 
Xj 
 
 
 
 
 
a 
Physical examination and testing may be performed more frequently at the investigator's discretion. 
b 
Complete H&P prior to randomization; treatment-related assessments (may be performed by physician or other healthcare professional from the 
radiation oncology department and/or department/clinic responsible for administering the trastuzumab) and appropriate follow-up assessments at 
remaining timepoints by physician or other healthcare professional. 
c 
Timing of patient exams should be according to the radiation oncology department's usual practice.  (Group 2 patients must be assessed before 
trastuzumab Dose 2 is administered.) 
d 
An FSH level may be required.  Refer to criteria in Appendix A. 
Note: Table 3 continued on next page. 
 
 

 
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TABLE 3.  Studies required for study entry and during study therapy and follow-up (continued) 
e 
Only for patients who were not postmenopausal at the time of study entry.  (Information collected at 18 months will be more accurate if patients who 
are not postmenopausal at the time of study entry are asked to record the date of onset of their menstrual periods for the first 18 months on study.) 
f 
Expedited AE reporting requirements are addressed in Section 10.3.  AEs requiring routine reporting will be included on one Form AE submitted 30 
days following completion of RT; however, the patient should be assessed for AEs throughout therapy.  (Group 2 patients must be assessed before 
trastuzumab Dose 2 is administered.) 
g 
MRI is not permitted as a substitute for a mammogram. 
h 
The first follow-up mammogram on study should be performed 12 months following the most recent mammogram performed prior to randomization; 
then every 12 months. 
i 
Pregnancy testing according to institutional standards should be performed for women of child-bearing potential (see Section 4.3.13). 
j 
After the B-43 consent form for pre-entry HER2 testing has been signed, tumor blocks for all patients must be submitted for HER2 testing at Rush 
University Medical Center to determine eligibility prior to randomization.  For patients who are subsequently enrolled in B-43, the blocks will also be 
used for correlative studies (see Section 6.0 and the Treatment Study Sample Consent Form). 
 
 

 
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6.0 
PATHOLOGY AND CORRELATIVE STUDIES 
6.1 
Overview of tissue requirements 
NSABP B-43 requires the submission of tumor blocks. 
• 
Submission of a representative tumor block before study enrollment is required for 
central HER2 testing to determine eligibility for B-43.  Note: Submission of 
alternative tissue samples is NOT permitted.  The patient must sign the informed 
consent form for pre-entry HER2 testing, before the submission of her tissue. 
Central testing for HER2 status will be performed at Rush University Medical Center 
(see Information Resources).  Analysis will be performed in a real-time manner, and 
the results will be provided to the patient's study physician. 
Refer to the Members’ Area of the NSABP Web site for the B-43 Pathology 
Instructions for detailed information regarding the B-43 pathology requirements, 
shipment and associated transmittal form, contact information, and receipt of test 
results.  
• 
If the DCIS is determined to be HER2-positive by central testing and the patient is 
enrolled in B-43, the remaining tissue will be forwarded from RUMC to the NRG 
Oncology Biospecimen Bank-Pittsburgh for use in correlative studies for B-43.  By 
signing the B-43 Treatment Study informed consent form, the patient is consenting 
to the use of her tissue for B-43 correlative studies. 
• 
If the DCIS is determined to be HER2-positive by central testing but the patient 
chooses to not enroll on the B-43 study, any tissue remaining after the HER2 testing 
will be returned to the pathology department that submitted the block. 
• 
If the DCIS is determined to be HER2-negative, the patient will be ineligible for  
B-43, and any tissue remaining after the HER2 testing will be returned to the 
pathology department that submitted the block. 
• 
If HER2 testing cannot be performed because of an insufficient or inadequate tumor 
sample, the remaining tumor sample will be returned to the pathology department 
that submitted the block.  If time to randomization permits and if another 
representative tumor block is available, it should be submitted for central HER2 
testing. 
6.2 
Central testing to determine HER2 status 
Central testing for determination of HER2 status will be performed at a central reference 
lab according to the ASCO College of American Pathologists (CAP) guidelines.  HER2 
amplification status for B-43 will be evaluated by IHC using the HercepTest (Dako, 
Carpinteria, CA) for all cases; cases with a 2+ IHC reading will be reflexed to FISH 
(PathVysion®, HER2 DNA probe kit, by Vysis, Inc, Downers Grove, IL).  A 0, 1+, or 3+ 
IHC reading will be considered final for eligibility.  (From the time of study activation 
until April 4, 2011, an IHC 1+ reading was also reflexed to FISH.  This central practice 
was discontinued effective April 4, 2011 [see Section 2.3 for additional information]).  
As part of the correlative science in B-43, FISH testing will also be performed for all 
cases (enrolled patients) at a later date. 

 
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6.3 
Correlative study hypotheses to be tested 
Pre-entry submission of paraffin blocks is mandated in this study.  Collected blocks (for 
those patients who have been enrolled in B-43) will be used to examine mRNA levels 
and DNA copy numbers of HER2, cMYC, and other candidate predictive genes.  
Additionally, we will examine mutation of the PI3K gene as a determinant of resistance 
to trastuzumab.  We will also examine other candidate predictors of trastuzumab response 
as they become available, as well as candidate prognostic markers of DCIS. 
In the NSABP B-35 trial for ER-positive DCIS, we were able to collect blocks from 1907 
out of 2358 cases (80%).  Since, in general, HER2-amplified cases are larger size, 
comedo lesions, we expect to be able to collect at least a similar percentage of blocks. 
We propose the following hypotheses to be tested in this study: 
• 
The benefit from trastuzumab added to radiotherapy will be significantly higher for 
cMYC (8q24)-amplified tumors compared to non-amplified tumors. 
• 
The measurement of HER2 mRNA expression level will provide a better predictive 
assay than HER2 IHC or FISH. 
• 
The benefit from trastuzumab added to radiotherapy will be less significant in tumors 
with mutations in the PI3K gene. 
Since PI3K may be integral to the mechanism of radiosensitization by trastuzumab, 
we hypothesize that an activating mutation in the PI3-Kinase gene will bypass the 
need for HER2 signaling in HER2-overexpressing cells and render them resistant to 
trastuzumab. Dr. Kornelia Polyak at the Dana Farber Cancer Institute will examine, 
by DNA sequencing, the presence of mutations in the PI3-Kinase gene using DNA 
extracted from paraffin blocks.  This study will be complemented by a similar effort 
utilizing tissue blocks from the NSABP B-17 and B-24 trials. 
6.4 
Background and studies leading to the hypotheses 
6.4.1 
Currently used assays to determine HER2 status are not optimal predictors of 
benefit from adding trastuzumab to adjuvant chemotherapy 
In the B-31 trial, we initially allowed local laboratories to perform HER2 testing 
(either IHC or FISH), but, after performing a central review of the HER2 status 
on the initial cohort of patients, we subsequently provided a protocol amendment 
which required that the test be performed by a laboratory that had been pre-
approved by the NSABP.  A central review of all submitted specimens from 
patients entered into B-31 has demonstrated a false-positive rate of 11.5% with 
the PathVysion FISH test and 15.4% with the Herceptest IHC assy.  Table 4 
summarizes the results of the centrally performed HER2 assays, which provided 
an opportunity to address whether HER2 status is a predictor of benefit from 
adjuvant trastuzumab.  We had predicted that there would be no benefit in 
patients with tumors that have either a normal gene copy number or express 
normal levels of HER2 protein.46 
 
 

 
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TABLE 4  Relative risk of ACTH over ACT and p values from Cox univariate model of disease-free 
survival endpoint for each subset defined by either PathVysion FISH or Herceptest IHC or 
both 
XCategory 
RR of ACTH (95% CI) 
p-value from 
Cox model 
N 
Interaction test p-value 
FISH + 
0.47 (0.36-0.61) 
<0.0001 
1588 
0.60 
FISH -  
0.40 (0.18-0.89) 
0.026 
207 
IHC 3+ 
0.48 (0.37-0.63) 
<0.0001 
1488 
0.26 
IHC-( 0-2+) 
0.32 (0.16-0.65) 
0.0017 
299 
FISH-, IHC- 
0.34 (0.14-0.80) 
0.014 
174 
 
Surprisingly, there was no statistical interaction between either HER2 gene copy 
numbers or expression levels and benefit from adding trastuzumab to 
chemotherapy, with a trend for benefit even in patients diagnosed with tumors 
that had 2 or less copies of the HER2 gene or expressed 2+ or 1+ levels of the 
HER2 protein. 
These results indicate that HER2 biology is not as straightforward as expected. 
Response to trastuzumab in the adjuvant setting might be different from the 
response in advanced disease, in that it may not require a high level 
overexpression of HER2 protein. 
Another possibility is that IHC or FISH assays do not provide a linear 
measurement of actual biological expression levels of HER2 protein.  In our 
experience with estrogen receptor (ER), IHC was found to be a highly non-linear 
assay whereas mRNA measurement by RT-PCR was a linear predictor of 
response to tamoxifen.46  Therefore, it will be important in this trial to examine 
mRNA levels of HER2 and other members of the HER family of receptors and 
their ligands as potential predictors of response. 
We also examined other potential predictors.  None of the clinicopathological 
variables examined showed interaction with trastuzumab.46  PTEN loss as 
measured by IHC, Cyclin D1 by FISH, and Topoisomerase II-alpha by FISH all 
failed to predict benefit or lack of benefit from trastuzumab.  Surprisingly, cMYC 
co-amplification turned out to be a strong predictor of benefit from adjuvant 
trastuzumab as described below. 
6.4.2 
cMYC (8q 24) amplification confers poor prognosis in patients with  
HER2-amplified breast cancer treated with AC→T but is a predictor of benefit 
from trastuzumab added to AC→T 
In an effort to develop a prognostic model for identifying potentially cured node-
positive patients treated with standard chemotherapy, we have screened 
commonly amplified chromosomal loci by FISH using tissue microarrays 
constructed from tumor specimens from participants in NSABP B-28, in which 
patients with node-positive breast cancer were randomized to 4 cycles of AC or 
to 4 cycles of AC followed by 4 cycles of paclitaxel.  We hypothesized that since 
gene amplification has a significant role in transcriptional regulation of the 
genome, profiling of commonly occurring amplifications would lead to discovery 
of significant prognostic factors.  Twenty-seven amplicons were selected based 
on their known association with overexpression of genes they transcribe when 
amplified.  This led to identification of HER2 (17q), cMYC (8q), and HTPAP 

 
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(8p) as independently prognostic amplicons in patients treated with 
chemotherapy. Interestingly, amplification of these three genes were independent 
events and there was little overlap between HER2 and HTPAP amplification.  
However, about 25% of HER2-amplified cases had co-amplification of cMYC, 
which conferred a worse prognosis than when either of the two alone were 
amplified.  This prompted us to examine, in an independent patient cohort from 
the NSABP B-31 trial, whether cMYC confers poor prognosis or influences 
response to trastuzumab. 
cMYC gene amplification was predefined as  5 FISH signals on average per 
tumor nucleus after counting 60 tumor nuclei.  We had assay results for cMYC 
available from 1769 cases.  cMYC was amplified in 531 cases (30%).  We 
examined time-to-first recurrence as a primary clinical endpoint.  This was a 
secondary endpoint used in the first reporting of the clinical results.  Overall, the 
addition of trastuzumab to chemotherapy reduced the chance of recurrence by 
53% at 4 years after randomization.  In cases with absence of cMYC 
amplification (n=1238), there was a 38% reduction in recurrence rate in a Cox 
model (HR, 0.62; 95% CI, 0.45 to 0.84; 2P=0.0022).  There were 101 events in 
627 patients assigned to the chemotherapy only arm and 67 events in 611 patients 
randomized to chemotherapy plus trastuzumab.  A Kaplan Meier plot is shown in 
Figure 2 (thin lines).  Of note is that while there is a clear separation of two 
curves, there were continuing failures in both treatment arms during the follow-
up period.  In patients with cMYC amplification (n=531), there was a 74% 
reduction in recurrence rate (HR, 0.26; 95% CI, 0.15 to 0.45; 2P<0.0001) with  
16 events in 269 patients assigned to trastuzumab in contrast to 57 events in 262 
patients who received chemotherapy only.  A Kaplan Meier plot is shown in 
Figure 2 (thick lines).  The four-year recurrence-free rate of cMYC-amplified 
cases is 93% when trastuzumab is added and 66% in the chemotherapy-only arm.  
The formal statistical test for this cMYC-by-trastuzumab interaction was 
significant (2P-value for interaction=0.0058).46 
 
 

 
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Figure 2.  Kaplan-Meier plot for recurrence-free survival according to cMYC and treatment 
 
0
10
20
30
40
50
60
70
80
90
100
0
1
2
3
4
5
Time (Years)
% Recurrence-Free (95% C.I.)
Number at Risk: 
223                 172                110    
45
500                 373                248    
124                  
488                 353                219    
96                  
214                 144                  89   
35                  
cMYC+,ACT
cMYC+,ACTH
cMYC-,ACT
cMYC-,ACTH
Total
269
611
627
262
Recurred
16
67
101
57
Treatment
ACTH
ACTH
ACT
ACT
cMYC
+
-
-
+
Interaction
P-value = 0.0058
 
 
This difference is reflected in the survival endpoint (Figure 3).  There was no 
statistically significant benefit in the cMYC non-amplified cohort in comparison 
to the 72% reduction in death in the cMYC-amplifed cohort when trastuzumab 
was added to chemotherapy.  In the cMYC non-amplified cohort (n=1238), there 
were 31 deaths among 611 patients randomized to the trastuzumab arm compared 
to 35 deaths out of 627 patients in the control arm (HR, 0.85; 95% CI, 0.53 
to 1.39; 2P=0.52).  In the cMYC-amplified cohort (n=531), 8 patients died 
among 269 who were assigned to trastuzumab plus chemotherapy versus 28 
deaths among 262 who were assigned to chemotherapy only (HR, 0.28; 95%  
CI, 0.13 to 0.62, 2P=0.00015).  This interaction between cMYC amplification 
and survival benefit from trastuzumab was also statistically significant (p-value 
for interaction = 0.0175). 
The data remained consistent even when we did an analysis based on a subset of 
patients whose tumors were found to have HER2 gene amplification on central 
assay and who received at least one cycle of trastuzumab (data not shown). 
 
 

 
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Figure 3.  Survival according to cMYC and treatment 
 
0
10
20
30
40
50
60
70
80
90
100
0
1
2
3
4
5
Time (Years)
% Surviving (95% C.I.)
Number at Risk: 
226                 179                111    
46                  
513                 395                268    
136                  
512                 388                256    
120                  
221                 163                109    
47                  
cMYC+,ACT
cMYC+,ACTH
cMYC-,ACT
cMYC-,ACTH
Total
269
611
627
262
Died
8
31
35
28
Treatment
ACTH
ACTH
ACT
ACT
cMYC
+
-
-
+
Interaction
P-value = 0.0175
 
6.4.3 
Why is cMYC important? 
When considering the fact that cMYC amplification was confirmed to be a poor 
prognosticator in the chemotherapy-only arm as observed in the NSABP B-28 
trial, it is remarkable that the addition of trastuzumab to chemotherapy 
completely reverses this trend.  Why should cMYC influence response to 
trastuzumab in such a dramatic way?  One simple hypothesis can be drawn from 
the known role of cMYC for apoptosis, although this model may be somewhat 
oversimplified. 
Although the processes of cell renewal and cell death appear to be opposing and 
mutually contradictory, substantial evidence now indicates that the two are 
linked.66  One of the first oncogenes shown to have proapoptotic activity was 
cMYC.67  cMYC is one of a family of related mammalian genes that encode the 
MYC proteins, transcription factors of the bHLH-zip family.  Deregulated 
expression of MYC genes is frequent in cancer, and substantial evidence 
implicates MYC proteins in the control of cell proliferation.  MYC proteins are 
expressed in proliferating cells but are absent in quiescent cells.  Ectopic 
expression of MYC is sufficient to drive many cells into the cell cycle in the 
absence of external mitogens.  However, in certain circumstances, MYC also 
promotes apoptosis.  The mitogenic and proapoptotic properties of cMYC are 
genetically inseparable.  Both require an intact NH2-terminal transcriptional 
activation domain, DNA binding and dimerization domains, and interaction with 
the MYC partner protein Max.  However, these two processes can be de-linked if 
the apoptotic pathway is suppressed by other factors.  For example, expression of 
the anti-apoptotic protein Bcl-2 specifically abrogates cMYC-induced apoptosis 

 
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without affecting the cMYC mitogenic function.68  The outcome of this de-
linking can be profound in some systems.  In a pancreatic islet cell transgenic 
model, overexpression of cMYC in beta-islet cells induces initial proliferation 
followed by involution of islets due to apoptosis.69  Inhibition of apoptosis by 
introduction of Bcl-xL immediately triggers progression into cancer. In the latter 
model, cMYC alone, when aided by an anti-apoptotic signal, was enough to 
induce all necessary machinery required for expression of the malignant 
phenotype: proliferation, angiogenesis, and invasion.  Downregulation of cMYC 
in this model resulted in regression of tumors.  Unfortunately, the effects of 
withdrawing Bcl-xL on established tumors were never tested in this model since 
Bcl-xL was driven by a constitutive promoter. 
Harrington and Evan proposed a dual signaling hypothesis to explain the 
cooperation between cMYC and survival factors in tumorigenesis.70  In normal 
cells, mitogenic signaling through cMYC will induce both the proliferation and 
the apoptosis pathways.  Therefore, for normal cells to propagate, an apoptotic 
signal induced by mitogenic signaling through cMYC has to be suppressed by 
survival factors (Figure 4). 
Figure 4.  Dual signal hypothesis 
 
In cells with deregulated cMYC expression, a mitogenic signal is no longer 
needed and cells will go through initial proliferation but will soon go through 
apoptosis (Figure 5). 
 
 

 
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Figure 5.  Cells with amplification and deregulated expression of cMYC 
 
 
Only when there is help from overactive survival signals can the cells default to 
proliferation (Figure 6).  We hypothesize that in breast cancer with 
coamplification of cMYC and HER2, HER2 provides an anti-apoptotic signal to 
help cMYC function as a proliferation switch.  Transgenic mouse models have 
demonstrated cooperation between EGFR (a dimerization partner for HER2) and 
cMYC in mammary tumorigenesis, which is mediated by induction of Bcl-xL 
through EGFR activation of Akt, thus suppressing the proapoptotic function of 
cMYC.  Once the apoptotic pathway is de-linked, cMYC becomes a full 
oncogene capable of inducing all hallmarks of the cancer phenotype: 
proliferation, invasion, and angiogenesis. 
Figure 6.  Cells with cMYC and HER2 co-amplification 
 
From a cMYC-centric view of the process, HER2 is only a helper, not the 
instigator of tumorigenesis.  Therefore, while cells primed for malignant 
transformation by cMYC-amplification will be able to escape the fate of 

 
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apoptosis with the help of HER2-amplification, this also makes them dependent 
upon HER2-signaling to survive, making them supersensitive to trastuzumab 
(Figure 7).  Inhibition of the HER2 signal by trastuzumab will trigger the 
proapoptotic function of cMYC in such cancer cells.  In human tumors, studies 
have demonstrated that Bcl-2 and survivin are upregulated by HER2 
overexpression, and trastuzumab was shown to cause apoptosis of HER2-positive 
tumor cells in the preoperative treatment setting.71 
Figure 7.  Cells with cMYC and HER2 co-amplification treated with trastuzumab 
 
 
 
 
 
 
 
 
 
 
 
 
Why is chemotherapy not effective in treating cMYC-amplified tumors?  It could 
be due to the obligatory presence of strong anti-apoptotic signaling from HER2 
(and other survival factor receptors) to suppress cMYC-induced apoptosis in such 
cells.  Therefore, chemotherapy-induced apoptosis is enhanced by suppression of 
the anti-apoptotic signal coming from HER2 in the B-31 study.  Whether cMYC 
alone is sufficient to induce apoptosis or whether cMYC is simply enhancing 
chemotherapy-induced apoptosis is not clear and needs further investigation. 
In this trial, trastuzumab will be tested as a radiosensitizer.  We hypothesize that 
cMYC will have an interaction with radiotherapy similar to its interaction with 
chemotherapy due to an enhancement of the survival pathway in  
cMYC-amplified cells.  We will use the exact same assay methods and scoring 
rates used in the B-31 study.  cMYC gene amplification is predefined as  5 
FISH signals on average per tumor nucleus after counting 60 tumor nuclei. 
Obviously, the above model is somewhat oversimplified since the cMYC 
amplicon is fairly big and there are other genes in that amplicon.  It is possible 
that some of the genes coordinately overexpressed with the 8q24 amplicon may 

 
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be involved in the HER2 signaling pathway, therefore, making tumor cells with 
both HER2 and cMYC amplified tumors overdependent or addicted to the HER2 
signaling pathway.  This would result in sensitivity to trastuzumab. However, the 
expected end result would be the same as that deduced from the apoptosis 
hypothesis, and from the clinical point of view, it should not really matter.  
However, it will have an impact on how we interpret the data and how we 
extrapolate the results from this trial to other studies.  Therefore, it will be 
important to also examine the interaction between trastuzumab and expression 
levels of genes other than cMYC in or around the 8q24 amplicon.  We plan to 
achieve this aim by using real-time reverse transcription polymerase chain 
reaction or the branched DNA amplification method. 
6.4.4 
Role of PI3K in radiosensitization by trastuzumab 
PI3K may have an important role in tumor cell responses to trastuzumab.  
Trastumab-induced inhibition of PI3K is required for the anti-tumor action of 
trastuzumab on HER2-overexpressing breast cancer cells.  Furthermore, genes 
affecting the cell cycle, growth, maintenance, as well as chemosensitivity, are 
preferentially regulated by anti-HER2 antibody through PI3K-Akt signaling.72  
Direct inhibition of PI3K with an inhibitor markedly reduced expression of 14 
genes that were also affected by the anti-HER2 antibody.73  Further evidence that 
PI3K is important in trastuzumab action is demonstrated by its effect on survivin 
expression.  Asanuma et al examined regulation of survivin expression by HER2 
and EGFR: trastuzumab reduced the expression of survivin in  
HER2-overexpressing cells and this reduction of survivin expression was 
blocked by inhibition of PI3K but not by inhibition of MEK1.74 
Liang et al examined the mechanism of radiosensitization of HER2-overexpressing 
breast cancer cells by trastuzumab.  Using six breast cancer cell lines with various 
levels of HER2 (BT474, SKBR3, MDA453, MCF7, ZR75B, and MDA468), the 
investigators found that trastuzumab inhibits breast cancer cell proliferation but 
does not induce apoptosis when used alone; it also enhanced radiation-induced 
apoptosis of the cells in a HER2 level-dependent manner.  They furthered this 
study in MCF7 cells transfected for high levels of HER2 (MCF7HER2).  
Compared with parental or control vector-transfected MCF7 cells, MCF7HER2 
cells showed increased phosphorylation of at least two important HER2 
downstream molecules, protein kinase B/Akt and mitogen-activated protein kinase 
(MAPK), and increased resistance to radiotherapy, as shown by reduced induction 
of apoptosis and increased cell clonogenic survival after radiation.  Exposure of the 
cells to trastuzumab downregulated the levels of HER2, reduced phosphorylation 
levels of Akt and MAPK in MCF7HER2 cells, and sensitized these cells to 
radiotherapy.  When specific inhibitors of the PI3-K and MAPK kinase (MEK) 
pathways were used, we found that exposure of MCF7HER2 cells to the PI3-K 
inhibitor LY294002 inhibited Akt phosphorylation and radiosensitized the cells; 
the radiosensitization effect by the MEK inhibitor PD98059 was relatively weaker, 
even though the phosphorylation of MAPK was reduced by PD98059 treatment.  
These results indicate that the PI3-K pathway might be the major pathway for 
trastuzumab-mediated radiosensitization of breast cancer cells.7 
 

 
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6.4.5 
PI3-Kinase gene mutation in DCIS 
In support of the importance of the PI3-K-Akt pathway in human cancer, genetic 
alterations in several components of the pathway including deletion of PTEN, 
amplification of Akt and PI3-Kinase gene, and somatic mutations of PI3-Kinase 
gene have been reported in various tumor types.  In human breast cancer, 
mutations in PI3-Kinase gene have been reported to occur in 8-40% of tumors, 
making PI3-Kinase gene one of the most frequently mutated genes besides TP53 
in this tumor type.  Expression of cancer derived PI3K mutants in immortalized 
human mammary epithelial cells was sufficient to induce colony formation in 
soft agar and tumorigenicity in vivo, suggesting that mutations in PI3-Kinase 
gene may play a role in the early stages of breast tumorigenesis.  However, 
somatic mutations in PI3-Kinase gene have been reported to occur at higher 
frequency in advanced stage tumors suggesting a role in tumor progression. 
Only two published studies of human breast cancer analyzed PI3-Kinase gene 
mutations in pre-invasive tumors, including DCIS.  In both reports, a limited 
number of DCIS tumors were analyzed.  Campbell et al performed Single-Strand 
Conformational Polymorphism (SSCP) analysis of PI3-Kinase gene exons 1-20 
in 70 breast tumors, including 3 DCIS cases, and detected mutations in 28/67 
invasive tumors and 0/3 DCIS cases; Lee et al analyzed exons 9 and 20 also by 
SSCP in 93 breast tumors and identified mutations in 24/78 of invasive breast 
tumors and only 2/15 for DCIS.  Neither report provided information on the type 
of DCIS that was analyzed (pure or adjacent to invasive tumor, histologic type, 
etc.), but these findings implicate PI3K in the in situ-to-invasive carcinoma 
progression.  Correlating with this, analysis of PTEN expression in DCIS and 
invasive tumors by IHC found down regulation of PTEN only in 2/18 pure DCIS 
and 9/26 DCIS adjacent to invasive cancer.  Importantly, in the 26 DCIS-IDC 
pairs, the expression of PTEN was the same in the in situ and invasive 
components in all but two cases confirming the clonal relatedness of the two 
lesions.  Immunohistochemical analysis of the activity and expression of several 
components of the PI3-K-Akt pathway in breast tumors of different stages also 
detected more frequent loss of PTEN expression, increased S6, AT, mTOR, and 
4E-BP1 expression in invasive tumors compared to preinvasive and premalignant 
lesions.75,76 
To determine if the frequency of PI3-Kinase gene mutations is different in pure 
DCIS compared to DCIS adjacent to invasive cancer, the Polyak laboratory 
sequenced exons 9 and 20 of the PI3-Kinase gene in 22 pure, 1 microinvasive, 
and 5 concomitant (adjacent to invasive cancer) DCIS cases.  Correlating with a 
potential role of PI3K in progression to invasiveness, only 2/22 pure DCIS cases, 
compared to 3/5 DCIS adjacent-to-invasive-tumor cases had mutations in exons  
9 or 20 of the PI3-Kinase gene.  Due to the small number of cases in each group, 
this difference has not reached statistical significance (p=0.085 two-sided 
Fisher’s exact test).  Thus, the analysis of additional cases is necessary. 
 
 

 
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6.5 
Examination of future candidate predictive markers for trastuzumab response 
Many studies to identify predictors of trastuzumab response are ongoing.  By the time the 
accrual for this trial is completed, we will have many candidate markers of response.  We 
may elect to use a real time RT-PCR assay to interrogate the mRNA expression levels of 
such molecules.  One alternative method we are currently developing is based on a 
branched DNA-amplification method and monitored using a luminometer or Luminex® 
bead array.  We may also use IHC and/or variations of the method (such as reverse phase 
protein array) to examine such molecules depending on the availability and reliability of 
the assays.  We are currently exploring a Sequencing by Synthesis approach to parallel 
sequence multiple gene targets at the same time.  If successful, we may sequence 
candidate cancer genes in addition to PI3-Kinase gene in this trial.  Statistical interaction 
between each marker as a continuous variable and trastuzumab-treatment effect will be 
examined.  If multiple genes are examined, appropriate adjustments will be made for 
multiple comparisons.  These studies will be regarded as exploratory in nature. 
 
 

 
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7.0 
TREATMENT REGIMEN 
7.1 
Radiation therapy for Group 1 (RT alone) and Group 2 (RT + trastuzumab) 
All B-43 patients will receive post-lumpectomy whole breast irradiation (WBI) in 
accordance with institutional standards and the NSABP Radiation Therapy Guidelines 
posted on the NSABP Web site. 
7.1.1 
RT treatment schedule 
RT (WBI) must begin following randomization.  Radiation can be delivered in 
25+ fractions or with accelerated fractionation (16-17 fractions). 
7.1.2 
Boost to tumor bed 
RT boost, including brachytherapy, may be administered at the radiation 
oncologist's discretion. 
7.1.3 
Prohibited RT 
• 
Partial breast irradiation 
• 
Regional nodal irradiation 
7.2 
Trastuzumab (only Group 2 patients) 
Administer trastuzumab according to instructions outlined in Table 5. 
TABLE 5.  Trastuzumab treatment regimen for Group 2 patients 
Trastuzumab 
 
Dose* 
and 
Administration 
Treatment Schedule 
RT is planned for  
25+ fractions 
RT is planned for 
16-17 fractions 
(accelerated 
fractionation) 
Dose 1 
8 mg/kg IV over 90 minutes 
Administer within 1 week 
before RT begins or within the 
first 5 days of RT (on or 
before Day 5) 
Administer within 1 
week before RT begins 
or within the first 2 days 
of RT (on or before  
Day 2) 
Dose 2 
6 mg/kg IV over 30 minutes 
(if the patient tolerates the 
initial 90-minute infusion) 
Administer 3 weeks following trastuzumab Dose 1 
* The rounding of trastuzumab doses is optional.  If the treating physician decides to round the dose(s), 
trastuzumab  should be rounded to the nearest 1 mg. 
 
 

 
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7.3 
Hormonal therapy for all B-43 patients with hormone-receptor positive DCIS 
Patients with ER-positive and/or PgR-positive DCIS should receive hormonal therapy, 
which may begin before, during, or after radiation therapy and should be administered for 
a minimum of 5 years.  Choice of the drugs(s) to be used for hormonal therapy is at the 
physician's discretion.  The dose and schedule should be consistent with the drug package 
insert instructions. 
7.4 
Non-protocol therapy 
• 
See Section 7.1.3 for RT techniques that are prohibited. 
• 
Cancer therapy other than that specified in the B-43 protocol is prohibited until the 
time of first cancer recurrence or second primary cancer. 
• 
If a patient is considering participation in another clinical trial (including supportive 
therapy trials), contact the Clinical Coordinating Department (see Information 
Resources). 
 
 
 

 
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8.0 
TREATMENT MODIFICATIONS 
8.1 
General instructions 
• 
The NCI Common Terminology Criteria for Adverse Events Version 3.0  
(CTCAE v3.0) must be used through September 30, 2010, to grade the severity of 
adverse events (AEs).  CTCAE v4.0 will be utilized for AE reporting beginning 
October 1, 2010. 
• 
Treatment decisions should be based on the AE requiring the greatest modification. 
8.2 
Trastuzumab treatment modifications (Group 2 patients) 
• 
If RT is held due to RT-related adverse events, trastuzumab should be administered 
according to the B-43 treatment regimen (see Table 5 in Section 7.2). 
• 
If RT is never initiated, trastuzumab may not be given.  (If Dose 1 was administered 
before the decision to not initiate RT, Dose 2 may not be given.) 
• 
If AEs occur related to trastuzumab, follow trastuzumab treatment modification 
instructions listed in Table 6. 
TABLE 6.  Trastuzumab modifications 
CTCAE v4.0 
Adverse Event 
CTCAE 
Grade 
Action to be Taken 
Cardiac Disorders 
Acute coronary syndrome 
2, 3, 4 
Do not administer trastuzumab Dose 2. 
Heart failure 
2, 3, 4 
Do not administer trastuzumab Dose 2. 
Left ventricular systolic 
dysfunction 
3, 4 
Do not administer trastuzumab Dose 2. 
Myocardial infarction 
3, 4 
Do not administer trastuzumab Dose 2. 
General Disorders 
Infusion-related reaction 
1 
Slow the infusion and assess the patient; management 
is at the investigator's discretion. 
2, 3, 4 
Do not administer trastuzumab Dose 2. 
Immune System Disorders 
Allergic reaction 
1 
Slow the infusion and assess the patient; management 
is at the investigator's discretion. 
2, 3, 4 
Do not administer trastuzumab Dose 2. 
Anaphylaxis 
3, 4 
Do not administer trastuzumab Dose 2. 
Cytokine release syndrome 
2, 3, 4 
Do not administer trastuzumab Dose 2. 
Investigations 
Ejection fraction decreased 
2, 3, 4 
Do not administer trastuzumab Dose 2. 
Other 
Other clinically significant AEs* 
3, 4 
Do not administer trastuzumab Dose 2. 
* Determination of "clinically significant" is at the investigator's discretion and applies to those AEs 
that are attributed to trastuzumab and are not related to RT alone. 
8.3 
Radiation therapy treatment modifications 
Management of adverse events related to RT is at the discretion of the radiation 
oncologist. 

 
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9.0 
DRUG INFORMATION 
9.1 
Trastuzumab (NSC #688097) 
Investigators with an affiliation with either NRG Oncology or the CTSU may request an 
Investigator's Brochure by emailing the Pharmaceutical Management Branch's IB 
Coordinator at ibcoordinator@mail.nih.gov or by calling PMB at 240-276-6575 and 
providing: 
• 
the investigator's full name (first, middle, last) 
• 
the investigator's NCI investigator number 
• 
the agent name (i.e., "trastuzumab") 
• 
the NSC (i.e., "688097") 
• 
the protocol (i.e., "NSABP B-43") 
• 
the requestor's name, email address, and phone number 
9.2 
Description of trastuzumab (Herceptin®) (NSC #688097) 
Trastuzumab is a recombinant DNA-derived humanized monoclonal antibody that 
selectively binds with high affinity in a cell-based assay (Kd=5 nM) to the extracellular 
domain of the human epidermal growth factor receptor 2 protein, HER2.  The antibody is 
an IgG1 kappa that contains human framework regions with the complementarity-
determining regions of a murine antibody (4D5) that binds to HER2. 
The humanized antibody against HER2 is produced by a mammalian cell (Chinese 
Hamster Ovary [CHO]) suspension culture in a nutrient medium containing the antibiotic 
gentamicin.  Gentamicin is not detectable in the final product. 
Trastuzumab is a sterile, white to pale yellow, preservative-free lyophilized powder for 
intravenous (IV) administration.  The nominal content of each trastuzumab vial is 440 mg 
trastuzumab, 400 mg ,-trehalose dihydrate, 9.9 mg L-histidine HCl, 6.4 mg  
L-histidine, and 1.8 mg polysorbate 20, USP.  Reconstitution with 20 mL of the supplied 
Bacteriostatic Water for Injection (BWFI), USP, containing 1.1% benzyl alcohol as a 
preservative, yields a multi-dose solution containing 21 mg/mL trastuzumab, at a pH of 
approximately 6. 
9.3 
Procurement of trastuzumab 
Trastuzumab will be supplied free of charge by Genentech, Inc., and distributed by the 
Pharmaceutical Management Branch (PMB), Cancer Therapy Evaluation Program (CTEP), 
Division of Cancer Treatment and Diagnosis (DCTD), National Cancer Institute (NCI). 
Trastuzumab (NSC #688097) may be requested by the principal investigator (or his/her 
authorized designee[s]) for NSABP B-43 at each participating institution.  
Pharmaceutical Management Branch (PMB) policy requires that trastuzumab be shipped 
to the treating investigator.  The responsible investigator at each participating institution 
must be registered with CTEP, DCTD through the annual submission of an FDA Form 
1572 (Statement of Investigator), a Curriculum Vitae, a Supplemental Investigator Data 
Form (IDF), and a Financial Disclosure Form (FDF). 
Active CTEP-registered investigators and investigator-designated shipping designees and 
ordering designees can submit agent requests through the PMB Online Agent Order 

 
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Processing (OAOP) application (https://eapps-ctep.nci.nih.gov/OAOP/pages/login.jspx).  
Access to OAOP requires the establishment of a CTEP Identity and Access Management 
(IAM) account (https://eapps-ctep.nci.nih.gov/iam/) and the maintenance of an “active” 
account status and a “current” password.  For questions about drug orders, transfers, 
returns, or accountability, call 240-276-6575 Monday through Friday between 8:30 am 
and 4:30 pm (ET) or email ibcoordinator@mail.nih.gov anytime. 
9.4 
Shipping 
Vials of trastuzumab are shipped at room temperature by overnight express delivery 
Monday through Thursday, and must be placed in a 2°- 8°C (36°- 46°F) refrigerator 
immediately upon receipt to ensure optimal retention of physical and biochemical 
integrity. 
9.5 
Storage/stability 
Vials of trastuzumab are stable at 2° - 8°C (36°- 46°F) prior to reconstitution.  Do not use 
beyond the expiration date stamped on the vial.  A vial of trastuzumab reconstituted with 
BWFI, as supplied, is stable for 28 days after reconstitution when stored refrigerated at  
2° - 8°C (36° - 46°F), and the solution is preserved for multiple use.  Discard any 
remaining multi-dose reconstituted solution after 28 days.  If unpreserved SWFI (not 
supplied) is used, the reconstituted trastuzumab solution should be used immediately and 
any unused portion must be discarded.  Do not freeze trastuzumab that has been 
reconstituted.  The solution of trastuzumab for infusion diluted in polyvinylchloride, 
polyethylene, or polypropylene bags containing 0.9% Sodium Chloride Injection, USP, 
may be stored at 2° - 8°C (36° - 46°F) for up to 24 hours prior to use.  Diluted 
trastuzumab has been shown to be stable for up to 24 hours at room temperature  
2° - 25°C.  However, because diluted trastuzumab contains no effective preservative, the 
reconstituted and diluted solution should be stored refrigerated 2° - 8°C. 
9.6 
Reconstitution and administration 
9.6.1 
Reconstitution 
The diluent provided has been formulated to maintain the stability and sterility of 
trastuzumab for up to 28 days.  Other diluents have not been shown to contain 
effective preservatives for trastuzumab.  Each vial of trastuzumab should be 
reconstituted with 20 mL of BWFI, USP, 1.1% benzyl alcohol preserved, as 
supplied, to yield a multi-dose solution containing 21 mg/mL trastuzumab. 
Immediately upon reconstitution with BWFI, the vial of trastuzumab must be 
labeled in the area marked “Do not use after:” with the future date that is 28 days 
from the date of reconstitution. 
Note: When administering trastuzumab to a patient with a known 
hypersensitivity to benzyl alcohol, trastuzumab must be reconstituted with Sterile 
Water for Injection (SWFI), and only one dose per trastuzumab vial should be 
used.  Trastuzumab which has been reconstituted with SWFI must be used 
immediately and any unused portion must be discarded. Use of other 
reconstitution diluents should be avoided. 
Shaking the reconstituted trastuzumab or causing excessive foaming during the 
addition of diluent may result in problems with dissolution and the amount of 

 
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trastuzumab that can be withdrawn from the vial.  Use appropriate aseptic 
technique when performing the following reconstitution steps: 
• 
Using a sterile syringe, slowly inject the 20 mL of diluent into the vial 
containing the lyophilized cake of trastuzumab.  The stream of diluent should 
be directed into the lyophilized cake. 
• 
Swirl the vial gently to aid reconstitution.  Trastuzumab may be sensitive to 
shear-induced stress, e.g., agitation or rapid expulsion from a syringe.  Do 
not shake. 
• 
Slight foaming of the product upon reconstitution is not unusual.  Allow the 
vial to stand undisturbed for approximately 5 minutes.  The solution should 
be essentially free of visible particulates, clear to slightly opalescent and 
colorless to pale yellow. 
9.6.2 
Administration 
See Section 7.2. 
9.7 
Transfer of trastuzumab 
PMB does not permit the transfer of agents between institutions (unless prior approval 
from PMB is obtained).  Trastuzumab may not be used outside the scope of this protocol, 
nor can trastuzumab be transferred or licensed to any party not participating in this 
clinical study.  To obtain an approval for transfer, investigators should complete and 
submit to the PMB (fax number 240-276-7893) a Transfer Investigational Agent Form 
available on the NCI home page (http://ctep.cancer.gov) or call the PMB at  
240-276-6575.  The participating institution should also inform the NRG Oncology 
SDMC of the transfer. 
9.8 
Return of unused trastuzumab 
• 
For U.S. sites 
At the completion of accrual and treatment, all unused (unopened) vials of 
trastuzumab must be returned to the PMB.  When it is necessary to return study 
drug (e.g., unused vials remaining when the protocol is closed to accrual and 
treatment at a participating clinical site, unopened expired vials), investigators should 
return the study drug to the PMB using the NCI Return Agent Form available on the 
NCI home page (http://ctep.cancer.gov) or call the PMB at 240-276-6575. 
• 
For non-U.S. sites 
Undispensed or expired study drug may be destroyed in the Pharmacy department of 
each center as per each center's policy and guidelines or returned to the NCI Clinical 
Repository in cases where it is not possible for the site to destroy the drug locally.  
Sites must contact the PMB at 240-276-6575 or by e-mail 
PMBAfterhours@mail.nih.gov to request and obtain authorization for local 
destruction of undispensed or expired study drug, prior to local destruction of 
undispensed or expired study drug. 
 
 

 
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9.9 
Drug accountability 
The investigator, or a responsible party designated by the investigator, must maintain a 
careful record of the receipt, disposition, and return of all drugs received from the PMB 
using the NCI Investigational Agent Accountability Record Form, available on the NCI 
home page (http://ctep.cancer.gov) or call the PMB at 240-276-6575.  (Refer to the NCI 
Investigator's Handbook for procedures for Drug Accountability and Storage.)  
9.10 
Warnings and contraindications 
9.10.1 Cardiotoxicity 
Administration of trastuzumab can result in the development of ventricular 
dysfunction and congestive heart failure.  Signs and symptoms of cardiac 
dysfunction, such as dyspnea, increased cough, paroxysmal nocturnal dyspnea, 
peripheral edema, S3 gallop, or reduced ejection fraction, have been observed in 
patients treated with trastuzumab.  Congestive heart failure associated with 
trastuzumab therapy may be severe and has been associated with disabling 
cardiac failure, death, and mural thrombosis leading to stroke.  See Section 2.6 
for information related to cardiotoxicity for B-43 Group 2 patients. 
9.10.2 Hypersensitivity reactions including anaphylaxis 
Severe hypersensitivity reactions have been infrequently reported in patients 
treated with trastuzumab. Signs and symptoms include anaphylaxis, urticaria, 
bronchospasm, angioedema, and/or hypotension.  In some cases, the reactions 
have been fatal.  Trastuzumab infusion should be interrupted in all patients 
with severe hypersensitivity reactions.  In the event of a hypersensitivity 
reaction, appropriate medical therapy should be administered, which may include 
epinephrine, corticosteroids, diphenhydramine, bronchodilators, and oxygen.  
Patients should be evaluated and carefully monitored until complete resolution of 
signs and symptoms. 
9.10.3 Infusion reactions 
In the postmarketing setting, rare occurrences of severe infusion reactions 
leading to a fatal outcome have been associated with the use of trastuzumab.  In 
clinical trials, infusion reactions consisted of a symptom complex characterized 
by fever and chills, and on occasion included nausea, vomiting, pain, headache, 
dizziness, dyspnea, hypotension, rash, and asthenia.  These reactions were 
usually mild to moderate in severity. 
However, in postmarketing reports, more severe adverse reactions to trastuzumab 
infusion were observed and included bronchospasm, hypoxia, and severe 
hypotension.  These severe reactions were usually associated with the initial 
infusion of trastuzumab and generally occurred during or immediately following 
the infusion.  However, the onset and clinical course were variable.  Delayed 
post-infusion events with rapid clinical deterioration have also been reported.  
Rarely, severe infusion reactions culminated in death within hours or up to one 
week following an infusion. 

 
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9.10.4 Pulmonary events 
Severe pulmonary events leading to death have been reported rarely with the use 
of trastuzumab in the postmarketing setting.  Signs, symptoms and clinical 
findings include dyspnea, pulmonary infiltrates, pleural effusions,  
non-cardiogenic pulmonary edema, pulmonary insufficiency and hypoxia, and 
acute respiratory distress syndrome.  These events may or may not occur as 
sequelae of infusion reactions.  Patients with symptomatic intrinsic lung disease 
resulting in dyspnea at rest, may be at greater risk of severe reactions. 
Other severe events reported rarely in the postmarketing setting include 
pneumonitis and pulmonary fibrosis. 
 
 

 
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10.0 
ADVERSE EVENT REPORTING REQUIREMENTS 
Please refer to Coordinator Online in the Members' Area of the NSABP Web site for general 
information regarding adverse event reporting. 
10.1 
B-43 definitions for adverse event reporting 
10.1.1 Investigational agent 
The investigational agent administered in NSABP B-43 is trastuzumab.  
Trastuzumab is being made available under an IND sponsored by the National 
Cancer Institute (NCI).  For patients who receive trastuzumab, prior expectedness 
of adverse events is based on the current NCI Specific Protocol Exceptions to 
Expedited Reporting (SPEER) List. 
10.1.2 Investigational combination therapy 
This study includes an investigational agent and radiation therapy (RT).  When 
an investigational agent (trastuzumab) is administered concurrently with RT and 
an adverse event occurs that is expected for RT, but is not listed for trastuzumab, 
the adverse event should be considered expected for the combination.  However, 
if based on clinical judgment, the investigator believes the adverse event is 
possibly, probably, or definitely related to the trastuzumab rather than the RT, the 
adverse event should then be considered unexpected for the combination. 
10.1.3 Adverse event characteristics 
CTCAE term (AE description) and grade: The descriptions and grading scales 
found in the revised NCI Common Terminology Criteria for Adverse Events 
(CTCAE) version 4.0 will be utilized for AE reporting beginning  
October 1, 2010.  All appropriate treatment areas should have access to a copy of 
the CTCAE version 4.0.  A copy of the CTCAE version 4.0 can be downloaded 
from the CTEP web site (http://ctep.cancer.gov). 
10.2 
Adverse events reported for trastuzumab 
The Comprehensive Adverse Event and Potential Risks list (CAEPR) provides a single list of 
reported and/or potential adverse events (AE) associated with an agent using a uniform 
presentation of events by body system.  In addition to the comprehensive list, a subset, the 
Specific Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column 
and is identified with bold and italicized text.  This subset of AEs (SPEER) is a list of events 
that are protocol specific exceptions to expedited reporting to NCI via CTEP-AERS (except as 
noted below).  Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf for 
further clarification.  Frequency is provided based on 4621 patients. 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses 
next to the AE in the SPEER.  If this CAEPR is part of a combination protocol using 
multiple investigational agents and has an AE listed on different SPEERs, use the lower 
of the grades to determine if expedited reporting is required. 
The National Cancer Institute (NCI) holds an IND for trastuzumab, thus, they require the 
entire CAEPR list be included within the protocol document (see Table 7). 
 
 

 
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TABLE 7.  Comprehensive Adverse Events and Potential Risks list (CAEPR) for trastuzumab 
(Herceptin, NSC 688097) 
Version 2.4, April 14, 20161 
 
 Adverse Events with Possible  
 Relationship to Trastuzumab (Herceptin) 
 (CTCAE 4.0 Term) 
[n= 4621] 
 
 
 Specific Protocol Exceptions to 
Expedited Reporting 
(SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
  
 
Anemia 
 
 Anemia (Gr 2) 
 
Febrile neutropenia2 
 
  
CARDIAC DISORDERS 
  
 
Cardiac disorders - Other 
(cardiomyopathy) 
 
  
 
Heart failure 
 
  
 
Left ventricular systolic 
dysfunction 
 
 Left ventricular systolic dysfunction 
(Gr 3) 
 
Pericardial effusion 
 
  
 
Pericarditis 
 
  
 
Sinus tachycardia3 
 
 Sinus tachycardia3 (Gr 2) 
 
Supraventricular tachycardia3 
 
  
EYE DISORDERS 
  
 
Conjunctivitis 
 
  
 
Watering eyes 
 
  
GASTROINTESTINAL DISORDERS 
  
 
Abdominal pain 
 
 Abdominal pain (Gr 2) 
 
Diarrhea 
 
 Diarrhea (Gr 3) 
 
Mucositis oral 
 
 Mucositis oral (Gr 2) 
 
Nausea 
 
 Nausea (Gr 3) 
 
 
Pancreatitis 
  
 
Vomiting 
 
 Vomiting (Gr 3) 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
 
Chills3 
 
 Chills3 (Gr 2) 
 
Edema limbs 
 
  
Fatigue 
 
 
 Fatigue (Gr 3) 
 
Fever3 
 
 Fever3 (Gr 2) 
 
Flu like symptoms 
 
 Flu like symptoms (Gr 2) 
 
Infusion related reaction 
 
 Infusion related reaction (Gr 2) 
 
Non-cardiac chest pain 
 
 Non-cardiac chest pain (Gr 2) 
 
Pain 
 
 Pain (Gr 2) 
IMMUNE SYSTEM DISORDERS 
  
 
 
Allergic reaction4 
  
 
 
Anaphylaxis 
  
INFECTIONS AND INFESTATIONS 
  
 
Infection5 
 
 Infection5 (Gr 3) 
Note: Table 7 is continued on the next page. 
 
 

 
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TABLE 7.  Comprehensive Adverse Events and Potential Risks list (CAEPR) for trastuzumab 
(continued) 
Note: Table 7 is continued on the next page. 
 
 
 
 Adverse Events with Possible  
 Relationship to Trastuzumab (Herceptin) 
 (CTCAE 4.0 Term) 
[n= 4621] 
 
 
 Specific Protocol Exceptions to 
Expedited Reporting 
(SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
INVESTIGATIONS 
  
 
Alkaline phosphatase increased  
 Alkaline phosphatase increased (Gr 
2) 
 
Aspartate aminotransferase 
increased 
 
 Aspartate aminotransferase 
increased (Gr 2) 
 
Cardiac troponin I increased 
 
  
 
Ejection fraction decreased 
 
 Ejection fraction decreased (Gr 3) 
 
GGT increased 
 
 GGT increased (Gr 2) 
 
Neutrophil count decreased2 
 
 Neutrophil count decreased2 (Gr 4) 
 
Weight loss 
 
  
METABOLISM AND NUTRITION DISORDERS 
  
 
Anorexia 
 
 Anorexia (Gr 2) 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
 
Arthralgia 
 
 Arthralgia (Gr 2) 
 
Back pain 
 
 Back pain (Gr 2) 
 
Bone pain 
 
 Bone pain (Gr 2) 
 
Musculoskeletal and connective 
tissue disorder - Other (muscle 
spasms) 
 
  
 
Myalgia 
 
 Myalgia (Gr 2) 
 
Pain in extremity 
 
  
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS 
AND POLYPS) 
  
 
Tumor pain 
 
 Tumor pain (Gr 2) 
NERVOUS SYSTEM DISORDERS 
  
 
Dysgeusia 
 
  
 
Headache 
 
 Headache (Gr 2) 
 
Peripheral sensory neuropathy  
  
PSYCHIATRIC DISORDERS 
  
 
Depression 
 
  
 
Insomnia 
 
  
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
 
Adult respiratory distress 
syndrome3, 4 
  
 
Allergic rhinitis 
 
 Allergic rhinitis (Gr 2) 
 
 
Bronchospasm3, 4 
  
 
Cough 
 
 Cough (Gr 2) 
 
Dyspnea3, 4 
 
 Dyspnea3,4 (Gr 3) 
 
Hypoxia4 
 
 Hypoxia4 (Gr 2) 
 
 
Pneumonitis4 
  
 
 
Pulmonary edema4 
  
 
 
Pulmonary fibrosis 
  
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
 
Alopecia 
 
  
 
Nail loss 
 
  
 
Rash acneiform 
 
 Rash acneiform (Gr 2) 
 
Rash maculo-papular 
 
 Rash maculo-papular (Gr 2) 
 
Urticaria3 
 
 Urticaria3 (Gr 2) 

 
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TABLE 7.  Comprehensive Adverse Events and Potential Risks list (CAEPR) for trastuzumab 
(continued) 
 
1This table will be updated as the toxicity profile of the agent is revised.  Updates will be distributed to all 
Principal Investigators at the time of revision.  The current version can be obtained by contacting 
PIO@CTEP.NCI.NIH.GOV.  Your name, the name of the investigator, the protocol and the agent should 
be included in the e-mail. 
2Fatal event when given in combination with Xeloda® (capecitabine) and Taxotere® (docetaxel). 
3Associated with infusion-related reactions or administration-related reactions (ARRs). 
4Severe hypersensitivity reactions including angioedema and pulmonary adverse events (e.g., hypoxia, 
dyspnea, pulmonary infiltrates, pleural effusion, interstitial lung disease, wheezing, and acute respiratory 
distress syndrome) have been reported. 
5Infection may include any of the 75 sites of infection under the INFECTIONS AND INFESTATIONS 
SOC. 
Adverse events reported on trastuzumab (Herceptin) trials, but for which there is insufficient 
evidence to suggest that there was a reasonable possibility that trastuzumab (Herceptin) caused the 
adverse event: 
Cardiac Disorders - Asystole; Atrial fibrillation; Atrial flutter; Cardiac disorders - Other (edema); Chest 
pain - cardiac; Myocardial infarction; Myocarditis; Palpitations; Sinus bradycardia; Ventricular 
arrhythmia; Ventricular tachycardia 
Ear and Labyrinth Disorders - Hearing impaired; Vertigo 
Eye Disorders - Dry eye; Extraocular muscle paresis 
Gastrointestinal Disorders - Ascites; Constipation; Dyspepsia; Enterocolitis; Esophagitis; Gastritis; 
Gastrointestinal disorders - Other (ischemic bowel); Small intestinal perforation; Typhlitis 
General Disorders and Administration Site Conditions - Injection site reaction; Malaise; Multi-organ 
failure; Sudden death NOS 
Injury, Poisoning and Procedural Complications - Fracture 
Investigations - Alanine aminotransferase increased; Blood bilirubin increased; Creatinine increased; 
Platelet count decreased; Weight gain; White blood cell decreased 
Metabolism and Nutrition Disorders - Dehydration; Hyperkalemia; Hypoalbuminemia; Hypokalemia; 
Hypophosphatemia 
Musculoskeletal and Connective Tissue Disorders - Arthritis; Chest wall pain; Flank pain; Generalized 
muscle weakness; Muscle weakness left-sided; Neck pain 
 
 Adverse Events with Possible  
 Relationship to Trastuzumab (Herceptin) 
 (CTCAE 4.0 Term) 
[n= 4621] 
 
 
 Specific Protocol Exceptions to 
Expedited Reporting 
(SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)   
VASCULAR DISORDERS 
  
 
Hot flashes 
 
  
 
Hypertension3 
 
  
 
Hypotension3 
 
  
 
Lymphedema 
 
  
 
Vascular disorders - Other 
(vasodilation) 
 
  

 
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Nervous System Disorders - Amnesia; Depressed level of consciousness; Dizziness; Encephalopathy; 
Leukoencephalopathy; Paresthesia; Seizure; Syncope 
Psychiatric Disorders - Anxiety; Confusion 
Renal and Urinary Disorders - Acute kidney injury; Proteinuria 
Respiratory, Thoracic and Mediastinal Disorders - Epistaxis; Nasal congestion; Pharyngolaryngeal pain; 
Pleural effusion4; Pulmonary hypertension; Respiratory failure; Respiratory, thoracic and mediastinal 
disorders - Other (oropharyngeal pain); Wheezing4 
Skin and Subcutaneous Tissue Disorders - Dry skin; Erythema multiforme; Hyperhidrosis; Palmar-plantar 
erythrodysesthesia syndrome; Pruritus; Stevens-Johnson syndrome 
Vascular Disorders - Hematoma; Thromboembolic event 
Note: Trastuzumab (Herceptin) in combination with other agents could cause an exacerbation of any 
adverse event currently known to be caused by the other agent, or the combination may result in events 
never previously associated with either agent. 
• 
Additional adverse events from the FDA-approved October 2010 Prescribing Information for 
Herceptin® (trastuzumab) 
− 
General Disorders – edema limbs, edema trunk 
− 
Infections and Infestations – pharyngitis 
− 
Nervous System Disorders – dizziness 
− 
Psychiatric Disorders – depression, insomnia 
− 
Renal and Urinary Disorders – other (glomerulopathy) 
10.3 
Expedited reporting of adverse events 
NRG Oncology follows procedures for centralized reporting of adverse events.  
Centralized reporting requires that adverse events be reported to the NRG Oncology 
SDMC.  NRG Oncology forwards reports to the appropriate regulatory agencies and the 
pharmaceutical company involved in the trial.  Expedited reporting for B-43 utilizes the 
CTEP Adverse Event Reporting System (CTEP-AERS). 
The NRG Oncology is identified in CTEP-AERS as the Lead Group for NRG Oncology 
protocols that require CTEP-AERS reporting.  Expedited AE reporting for this study 
must be submitted to the NRG Oncology Lead Group using CTEP-AERS, accessed 
via the CTEP home page https://eapps-ctep.nci.nih.gov/ctepaers.  In the rare event when 
Internet connectivity is disrupted, a 24-hour notification is to be made to the NCI by 
telephone at: 301-897-7497.  An electronic report must be submitted immediately upon 
re-establishment of the Internet connection. 
10.3.1 Expedited reporting methods 
• 
CTEP-AERS 24-Hour Notification: requires that a CTEP-AERS 24-hour 
notification is electronically submitted to the NCI within 24 hours of learning 
of the adverse event.  Each CTEP-AERS 24-hour notification must be 
followed by either a CTEP-AERS 3 Calendar Day Report (see Table 8) or a 
CTEP-AERS 5 Calendar Day Report (see Table 9). 
• 
CTEP-AERS 3 Calendar Day Report: requires that a complete report is 
electronically submitted to the NRG Oncology Lead Group within 3 
calendar days of submission of the CTEP-AERS 24-hour notification. 

 
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• 
CTEP-AERS 5 Calendar Day Report: requires that a complete  
CTEP-AERS report is electronically submitted to the NRG Oncology Lead 
Group within 5 calendar days of the investigator learning of the adverse 
event. 
• 
Supporting documentation is required for all expedited (CTEP-AERS) 
reports.  Include the protocol number, patient's study number, and  
CTEP-AERS ticket number on each page, and fax supporting 
documentation to the NRG Oncology SDMC (412-622-2113). 
10.3.2 Expedited reporting requirements – CTEP-AERS 24-hour notification,  
CTEP-AERS, and other protocol requirements 
• 
Expedited reporting requirements begin with the first RT treatment or with 
the administration of the first trastuzumab dose.  Expedited reporting 
requirements for all Group 2 patients who receive trastuzumab are provided 
in Table 8.  Expedited reporting requirements for Group 1 patients are 
provided on Table 9. 
• 
There may be protocol specific requirements and exceptions for expedited 
reporting.  Refer to Table 8 and Table 9 for instructions. 
10.3.3 Other recipients of adverse event reports 
Adverse events determined to be reportable must also be reported according to 
the local policy and procedures by the investigator to the Institutional Review 
Board responsible for oversight of the patient. 
10.3.4 Expedited adverse event reporting requirements for Group 2 patients receiving 
the investigational agent (trastuzumab) are listed in Table 8. 
 
 

 
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TABLE 8.  Phase 2 and 3 trials utilizing an agent under a CTEP IND:  CTEP-AERS expedited reporting 
requirements for adverse events that occur within 30 days1 of the last dose of the 
investigational agent 
 
 
 
 
Attribution 
Grade 1 
Grade 2 
Grade 2 
Grade 3 
Grade 3 
Grades 
4 & 52 
Grades 
4 & 52 
Unexpected 
and Expected 
Unexpected 
Expected 
Unexpected 
Expected 
Unexpected 
Expected 
with 
Hospitalization 
without 
Hospitalization 
with 
Hospitalization 
without 
Hospitalization 
Unrelated 
Unlikely 
Not 
Required 
Not 
Required 
Not 
Required 
5 Calendar 
Days 
Not 
Required 
5 Calendar 
Days 
Not 
Required 
5 Calendar 
Days 
5 Calendar 
Days 
Possible 
Probable 
Definite 
Not 
Required 
5 Calendar 
Days 
Not 
Required 
5 Calendar 
Days 
5 Calendar 
Days 
5 Calendar 
Days 
Not 
Required 
24-Hour; 
3 Calendar 
Days 
5 Calendar 
Days 
1 Adverse events with attribution of possible, probable, or definite that occur greater than 30 days after the last dose of treatment 
with an agent under a CTEP IND (trastuzumab) require reporting as follows: 
CTEP-AERS 24-hour notification followed by complete report within 3 calendar days for: 
• Grade 4 and Grade 5 unexpected events  
 
CTEP-AERS 5 calendar day report: 
• Grade 3 unexpected events with hospitalization or prolongation of hospitalization 
• Grade 5 expected events 
2 Although a CTEP-AERS 24-hour notification is not required for death clearly related to progressive disease, a full report is 
required as outlined in the table.   
 
Note: All deaths on study require both routine and expedited reporting regardless of causality.  Attribution to treatment or other 
cause should be provided. 
 
• Expedited AE reporting timelines defined: 
➢“24 hours; 3 calendar days” – The investigator must initially report the AE via CTEP-AERS within 24 hours of learning of the 
event followed by a complete CTEP-AERS report to the NRG Oncology Lead Group within 3 calendar days of the initial 24-hour 
report.  
➢ "5 calendar days" - A complete CTEP-AERS report on the AE must be submitted to the NRG Oncology Lead Group within  
5 calendar days of the investigator learning of the event.  
 
• Any medical event equivalent to CTCAE grade 3, 4, or 5 that precipitates hospitalization (or prolongation of existing hospitalization) 
must be reported regardless of attribution and designation as expected or unexpected with the exception of any events identified as 
protocol-specific expedited adverse event reporting exclusions. 
 
• Any event that results in persistent or significant disability/incapacity, congenital anomaly, or birth defect must be reported via 
CTEP-AERS if the event occurs following treatment with an agent under a CTEP IND. 
 
• Use the NCI protocol number and the protocol-specific patient ID provided during trial registration on all reports. 
 
Please note that Table 8 is continued on the next page. 

 
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TABLE 8.  Phase 2 and 3 trials utilizing an agent under a CTEP IND:  CTEP-AERS expedited reporting 
requirements for adverse events that occur within 30 days1 of the last dose of the 
investigational agent (continued) 
Additional Instructions or Exceptions to CTEP-AERS Expedited Reporting Requirements for Phase 2 and 3 Trials Utilizing an 
Agent under a CTEP-IND: 
a Reports submitted via CTEP-AERS 24-hour notification are available for review by both the NCI and NRG Oncology after submission.  
All other CTEP-AERS reports are first sent to the NRG Oncology Lead Group and then are forwarded to the NCI.  The timelines in the 
table above have been set so that the information can be forwarded to the NCI in a timely manner per the NCI/CTEP’s guidelines. 
b On all reports, use the NCI protocol number, CTEP-AERS ticket number, and the protocol-specific ID provided during the trial 
registration.  Fax supporting documentation to the NRG Oncology SDMC. 
c Hospitalization associated with an adverse event is defined as any hospitalization lasting  24 hours (or a prolongation of an existing 
hospitalization). 
d Refer to Section 10.1.2 for instructions regarding assignment of attribution and expectedness for investigational combination therapy. 
e CTEP-AERS reporting is required for grade 2 unexpected adverse events and grade 3 unexpected adverse events without hospitalization 
only if the adverse event is possibly, probably or definitely related to the investigational agent. 
f Protocol-specific expedited reporting requirements: For this study, the adverse events listed below require expedited reporting via 
CTEP-AERS to the NRG Oncology Lead Group within 5 calendar days of learning of the event. 
• 
Cardiac disorders regardless of attribution:  grade 3 acute coronary syndrome;  grade 2 heart failure;  grade 3 left ventricular 
systolic dysfunction;  grade 3 myocardial infarction (NOTE: Requires expedited reporting via CTEP-AERS from the first dose of 
study therapy until 30 days after the last dose of study therapy.) 
• 
Secondary malignancies as defined in Section 10.3.6 (Note: Secondary malignancies require expedited reporting via CTEP-AERS 
from the first dose of study therapy until the end of the patient's follow-up): 
− 
Leukemia secondary to oncology chemotherapy (e.g., acute myelocytic leukemia [AML]) 
− 
Myelodysplastic syndrome (MDS) 
− 
Treatment-related secondary malignancy 
g Protocol-specific expedited reporting exceptions: For this study, the adverse events listed below, including hospitalizations for these 
events, do not require expedited reporting via CTEP-AERS: 
• 
Neoplasms-malignant (i.e., a second primary malignancy) determined by the investigator to NOT be most probably related or 
definitely related to treatment for malignancy.  (See footnote f and Section 10.6.) 
 
 

 
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10.3.5 Expedited adverse event reporting requirements for Group 1 patients  
(RT alone) are listed in Table 9. 
TABLE 9. 
Phase 2 and 3 trials: CTEP-AERS expedited reporting requirements for adverse events that 
occur within 30 days of the last dose of RT 
Attribution 
Grade 2 
Grade 3 
Grade 4b 
Grade 5a,b 
Protocol-
Specific 
Requirements/ 
Exceptions 
Unexpected 
Unexpected 
Expected 
Unexpected 
Expected 
Unexpected 
Expected 
-See footnote (c) 
for other 
requirements  
-See footnote (d) 
for special 
requirements 
-See footnote (e) 
for special 
exceptions 
Unrelated  
or Unlikely 
 
 
 
CTEP-AERS 
 
CTEP-
AERS 
CTEP-
AERS 
Possible, 
Probable, 
Definite 
 
CTEP-
AERS 
report if 
hospitalized 
 
CTEP-AERS 
24-hour and 
CTEP-AERS 
CTEP-
AERS  
24-hour and 
CTEP-
AERS 
CTEP 24-hour: 
Indicates a CTEP-AERS 24-hour notification must be electronically submitted to the NCI within 24 hours of learning 
of the event. 
CTEP Expedited Report: 
Indicates a complete expedited report must be electronically submitted to the NRG Oncology Lead Group 
within 5 calendar days of learning of the event. 
Hospitalization: Hospitalization associated with an adverse event is defined as any hospitalization lasting > 24 hours (or a prolongation 
of an existing hospitalization). 
All Reports: 
On all reports, use the NCI protocol number, CTEP-AERS ticket number, and the protocol-specific patient ID provided 
during trial registration.  Fax supporting documentation to the NRG Oncology SDMC.   
a All deaths within 30 days of the last RT require expedited reporting regardless of causality. Attribution to treatment or other cause 
should be provided.  Although a CTEP-AERS 24-hour notification is not required for death clearly related to progressive 
disease, a complete CTEP-AERS report is required as outlined in the table. 
b Adverse events that occur greater than 30 days after the last dose of RT with attribution of possible, probable or definite to RT require 
reporting as follows: 
• CTEP-AERS 24-hour notification followed by a complete CTEP-AERS report within 5 calendar days of learning of the event for:   
− grade 4 unexpected events  
− grade 5 unexpected events 
• CTEP-AERS 5-calendar day report for:   
− grade 5 expected events 
c Any event that results in persistent or significant disabilities/incapacities, congenital anomalies, or birth defects must be reported via 
CTEP-AERS if the event occurs following treatment. 
d Protocol-specific expedited reporting requirements: For this study, the adverse events listed below require expedited reporting via 
CTEP-AERS to the NSABP Lead Group within 5 calendar days of learning of the event. 
• Cardiac disorders regardless of attribution:  grade 3 acute coronary syndrome;  grade 2 heart failure;  grade 3 left ventricular 
systolic dysfunction;  grade 3 myocardial infarction (NOTE: Requires expedited reporting via CTEP-AERS from the first dose of 
study therapy until 30 days after the last dose of study therapy.) 
• Secondary malignancies as defined in Section 10.3.6 (Note: Secondary malignancies require expedited reporting via CTEP-AERS 
from the first dose of study therapy until the end of the patient's follow-up): 
− Leukemia secondary to oncology chemotherapy (e.g., acute myelocytic leukemia [AML]) 
− Myelodysplastic syndrome (MDS) 
− Treatment-related secondary malignancy 
e Protocol-specific expedited reporting exceptions: For this study, the adverse events listed below which occur, including 
hospitalizations for these events, do not require expedited reporting via CTEP-AERS: 
• Neoplasms-malignant (i.e., a second primary malignancy) determined by the investigator to NOT be most probably related or 
definitely related to treatment for malignancy.  (See footnote d and Section 10.6.) 
 
 

 
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10.3.6 Reporting a secondary malignancy 
A secondary malignancy is a cancer caused by a treatment for a previous 
malignancy (e.g., treatment with investigational agent/intervention, radiation, or 
chemotherapy).  A secondary malignancy is not considered a metastasis of the 
initial neoplasm. 
All secondary malignancies that occur on NCI-sponsored trials either during or 
following treatment must be reported via CTEP-AERS within 5 days of learning 
of the secondary malignancy (see either Table 8 or Table 9).  Three options are 
available to describe the event: 
• 
Leukemia secondary to oncology chemotherapy (e.g., acute myelocytic leukemia 
[AML]) 
• 
Myelodysplastic syndrome (MDS) 
• 
Treatment-related secondary malignancy 
Supporting documentation, including pathology and cytogenetics reports which 
confirm the secondary malignancy, must be faxed to the NRG Oncology 
SDMC expedited fax at 412-622-2113.  Each page of supporting documentation 
must include the NCI protocol number, the CTEP-AERS ticket number, and the 
protocol-specific patient ID number provided during trial registration. 
Note: All secondary malignancies should also be reported on the B-43 Form F 
(see Section 10.6). 
10.3.7 Second malignancy 
A second malignancy is one unrelated to the treatment of a prior malignancy (and 
is NOT a metastasis from the initial malignancy).  Second malignancies require 
ONLY routine reporting online on the B-43 Form F (see Section 10.6). 
10.3.8 Expedited reporting of pregnancy, fetal death, and death neonatal occurring 
during study therapy 
Any pregnancy, fetal death, or death neonatal occurring while the patient is 
receiving study therapy or within 7 months following the last dose of study 
therapy (trastuzumab) must be reported via CTEP-AERS as a medically 
significant event.  Definitions and reporting instruction for these events are 
provided in the Cancer Therapy Evaluation Program's (CTEP) revised NCI 
Guidelines for Investigators: Adverse Event Reporting Requirements  
(Section 5.5.6) located at the following CTEP website: 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/ 
aeguidelines.pdf). 
Upon learning of a pregnancy, fetal death, or death neonatal that occurs during 
study or within 7 months following the last dose of study therapy (trastuzumab) 
the investigator is required to: 
• 
Call the NRG Oncology Clinical Coordinating Department (see Information 
Resources).  Patients must immediately discontinue receiving study 
(trastuzumab) therapy. 

 
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• 
Within 5 working days of learning of the event, and as required by the NCI 
Guidelines for Investigators: Adverse Event Reporting Requirements 
(Section 5.5.6): 
− 
Create and submit a CTEP-AERS report;  
− 
Complete the Pregnancy Information Form (located in the NSABP 
Members' Area in Protocol B-43 "Forms and Supporting Documents"); 
and 
− 
Fax the completed Pregnancy Information Form with all available 
supporting documentation to the NRG Oncology SDMC's expedited fax 
number at 412-622-2113. 
• 
The pregnancy outcome for patients on study should be reported via CTEP-
AERS at the time the outcome becomes known, accompanied by the same 
Pregnancy Information Form used for the initial report. 
• 
For questions concerning AE reporting, contact the AE Reporting Nurse (see 
Information Resources). 
10.4 
Routine reporting of adverse events 
10.4.1 Online reporting on the B-43 Adverse Event Report Form 
• 
Direct online entry of adverse events is done through the Online Data Entry 
function located in the Study Management Area of Coordinator Online in the 
Members' Area of the NSABP Web site. 
• 
Specified grade 2 AEs and all  grade 3 adverse events not reported via 
CTEP-AERS that occurred during RT and trastuzumab (if given) or during 
the 30 days following completion of RT must be reported on the B-43 
Adverse Event Report Form.  Only one B-43 Adverse Event Report Form 
will be completed and submitted. 
• 
Supporting documentation for each adverse event reported online on the  
B-43 Adverse Event Report Form must be maintained in the patient's 
research record.  When submission of supporting documentation to the NRG 
Oncology SDMC is required, the online software will provide a transmittal 
form that must be printed.  Fax this transmittal form with the supporting 
documentation to 412-622-2111.  Remove patient names and identifiers such 
as social security number, address, telephone number, etc. from reports and 
supporting documentation. 
10.4.2 Submission of the B-43 Adverse Event Report Form 
The B-43 Adverse Event Report Form is submitted online to the NRG Oncology 
SDMC 30 days after completion of RT. 
10.5 
Reporting selected adverse events on the B-43 Follow-up Form 
The selected late adverse events listed below will be reported online on the B-43  
Follow-up Form.  Note: Supporting documentation must be submitted for each adverse 
event listed below and maintained in the patient's research record.  When submission of 
supporting documentation to the NRG Oncology SDMC is required, the online software 
will provide a transmittal form that must be printed.  Fax this transmittal form with the 

 
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supporting documentation to 412-622-2111.  Remove patient names and identifiers such 
as social security number, address, telephone number, etc. from reports and supporting 
documentation. 
• 
 grade 3 acute coronary syndrome 
•  grade 2 heart failure 
• 
 grade 3 left ventricular systolic dysfunction 
• 
 grade 3 myocardial infarction 
10.6 
Reporting cancer recurrence, secondary malignancy, and second primary cancer 
Report breast cancer recurrence, secondary primary malignancies (including leukemia 
secondary to oncology chemotherapy, myelodysplastic syndrome, and treatment-related 
secondary malignancy previously reported through CTEP-AERS), and second primary 
cancer (a malignancy which is unrelated to the treatment of a prior malignancy and which 
is not a metastasis from the initial malignancy) online on the B-43 Follow-up Form.  Fax 
supporting documentation that confirms the breast cancer recurrence or second primary 
cancer diagnosis with the transmittal form (provided by the online software and printed) 
to 412-622-2111. 
 
 

 
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11.0 
DIAGNOSIS OF BREAST CANCER RECURRENCE AND OTHER CANCER EVENTS 
• 
The diagnosis of a first breast cancer recurrence or second primary cancer can be made only 
when both the clinical and laboratory findings meet "acceptable" criteria as defined below.  
Suspicious findings do not constitute criteria for breast cancer recurrence, nor are they an 
indication to alter protocol therapy. 
• 
Please submit a copy of the clinic/office note summarizing the work-up and treatment plan 
for a recurrence or a second primary cancer. 
• 
Treatment of a breast cancer recurrence or second primary cancer will be at the discretion of 
the investigator. 
11.1 
Local recurrence 
Recurrent tumor is defined as evidence of invasive or in situ breast cancer (except LCIS) 
in the ipsilateral breast or skin of the breast.  Patients who develop clinical evidence of 
tumor recurrence in the ipsilateral breast must have a biopsy of the suspicious lesion to 
confirm the diagnosis.  (Note: Invasive includes microinvasion defined as the extension 
of cancer cells beyond the basement membrane into the adjacent tissues with no focus 
more than 0.1 cm in greatest dimension.  When there are multiple foci of microinvasion, 
the size of only the largest focus is used to classify the microinvasion.  The presence of 
multiple foci of microinvasion should be noted, as it is with multiple larger invasive 
carcinoma.77) 
• Acceptable: 
positive histologic biopsy (positive cytology is not acceptable) 
11.1.1 Ipsilateral invasive breast cancer or ipsilateral skin cancer recurrence or DCIS 
(IIBCR-SCR-DCIS) 
An IIBCR-SCR-DCIS event is defined as recurrent tumor in the ipsilateral breast 
parenchyma, skin of the ipsilateral breast, or ipsilateral DCIS occurring after 
lumpectomy. 
11.1.2 Other local recurrence 
Defined as recurrence in the skin of the chest wall (exclusive of the breast) or 
chest wall. 
11.2 
Regional recurrence 
Defined as the development of tumor in the ipsilateral internal mammary, ipsilateral 
supraclavicular, ipsilateral infraclavicular and/or ipsilateral axillary nodes, as well as the 
soft tissue of the ipsilateral axilla, after operation. 
• Acceptable: 
positive cytology or histologic biopsy 
11.3 
Distant recurrence 
Defined as evidence of tumor in any area of the body, with the exception of those 
described in Sections 11.1 and 11.2. 

 
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11.3.1 Skin, subcutaneous tissue, and lymph node (other than local or regional) 
metastases 
• 
Acceptable: 
(i) positive cytology, histologic biopsy, or (ii) radiologic 
evidence of metastatic disease 
11.3.2 Bone marrow metastasis 
• 
Acceptable: 
(i) positive cytology, histologic biopsy, or (ii) MRI scan 
11.3.3 Lung metastasis 
• 
Acceptable: 
(i) positive cytology, histologic biopsy, or (ii) radiologic 
evidence of multiple pulmonary nodules that are judged 
to be consistent with pulmonary metastases 
NOTE:  If a solitary lung lesion is found and no other lesions are present on lung 
tomograms, CT scan, or MRI scan, further investigations such as biopsy or 
needle aspiration must be performed.  Proof of neoplastic pleural effusion must 
be established by cytology or pleural biopsy. 
11.3.4 Skeletal metastasis 
• 
Acceptable: 
(i) x-ray, CT, or MRI evidence of lytic or blastic lesions 
consistent with bone metastasis; or (ii) biopsy proof of 
bone metastases; or (iii) bone scan that is clearly positive 
for bone metastases 
NOTE:  If the diagnosis is equivocal by bone scan or radiologic evaluation, a 
biopsy is strongly recommended.  Any positive bone scan in joints or in a recent 
area of trauma (surgical or otherwise) cannot be used as a criterion for breast 
cancer recurrence. 
11.3.5 Liver metastasis 
• 
Acceptable: 
(i) an abdominal CT scan, liver scan, ultrasound, or MRI 
consistent with liver metastases, or (ii)  liver biopsy 
confirmation of the metastatic disease 
NOTE: If the radiologic findings are not definitive (especially with solitary liver 
nodules), a liver biopsy is recommended; however, if a biopsy is not performed, 
serial scans must be obtained to document stability or progression. 
11.3.6 Central nervous system metastasis 
• 
Acceptable: 
(i)  positive CT scan or MRI scan, usually in a patient 
with neurological symptoms, or (ii)  biopsy or cytology 
(for a diagnosis of meningeal involvement) 
11.4 
Second primary breast cancer 
Defined as evidence of invasive or in situ breast cancer (except LCIS) in the contralateral 
breast or chest wall.  The diagnosis of a second primary breast cancer must be confirmed 

 
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histologically.  (Note: Invasive includes microinvasion defined as the extension of cancer 
cells beyond the basement membrane into the adjacent tissues with no focus more than 
0.1 cm in greatest dimension.  When there are multiple foci of microinvasion, the size of 
only the largest focus is used to classify the microinvasion.  The presence of multiple foci 
of microinvasion should be noted, as it is with multiple larger invasive carcinoma.77) 
• Acceptable: 
positive histologic biopsy 
11.5 
Second primary cancer (non-breast) 
The diagnosis of a second primary non-breast invasive cancer must be confirmed 
histologically whenever possible. 
11.6 
Documentation requested following death 
• 
Autopsy reports should be secured whenever possible and should be submitted to the 
NRG Oncology SDMC.   
• 
A copy of the death certificate should be forwarded to the NRG Oncology SDMC if 
it is readily available or if it contains important cause-of-death information that is not 
documented elsewhere. 
• 
Please submit the last clinic/office note made before the death or the physician's note 
summarizing events resulting in death. 
 
 

 
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12.0 
REGISTRATION, STUDY ENTRY, AND WITHDRAWAL PROCEDURES 
Note: Accrual closed on December 8, 2014, following achievement of the sample size goal. 
12.1 
CTEP investigator registration procedures 
Food and Drug Administration (FDA) regulations and National Cancer Institute (NCI) 
policy require all investigators participating in any NCI-sponsored clinical trial to register 
and to renew their registration annually. 
Registration requires the submission of: 
• 
a completed Statement of Investigator Form (FDA Form 1572) with an original 
signature 
• 
a current Curriculum Vitae (CV) 
• 
a completed and signed Supplemental Investigator Data Form (IDF) 
• 
a completed Financial Disclosure Form (FDF) with an original signature 
Fillable PDF forms and additional information can be found on the CTEP website at 
<http://ctep.cancer.gov/investigatorResources/investigator_registration.htm>.  For 
questions, please contact the CTEP Investigator Registration Help Desk by email at 
<pmbregpend@ctep.nci.nih.gov>. 
12.2 
CTEP associate registration procedures / CTEP-IAM account 
The Cancer Therapy Evaluation Program (CTEP) Identity and Access Management 
(IAM) application is a web-based application intended for use by both Investigators  
(i.e., all physicians involved in the conduct of NCI-sponsored clinical trials) and 
Associates (i.e., all staff involved in the conduct of NCI-sponsored clinical trials). 
Associates will use the CTEP-IAM application to register (both initial registration and 
annual re-registration) with CTEP and to obtain a user account. 
Investigators will use the CTEP-IAM application to obtain a user account only. (See 
CTEP Investigator Registration Procedures above for information on registering with 
CTEP as an Investigator, which must be completed before a CTEP-IAM account can be 
requested.) 
An active CTEP-IAM user account will be needed to access all CTEP and CTSU (Cancer 
Trials Support Unit) websites and applications, including the CTSU members’ website. 
Additional information can be found on the CTEP website at 
<http://ctep.cancer.gov/branches/pmb/associate_registration.htm>.  For questions, please 
contact the CTEP Associate Registration Help Desk by email at 
<ctepreghelp@ctep.nci.nih.gov>. 
12.3 
CTSU registration procedures 
This study is supported by the NCI Cancer Trials Support Unit (CTSU). 
 
 

 
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12.3.1 IRB approval 
Each investigator or group of investigators at a clinical site must obtain IRB 
approval for this protocol and submit IRB approval and supporting 
documentation to the CTSU Regulatory Office before they can be approved to 
enroll patients.  Study centers can check the status of their registration packets by 
querying the Regulatory Support System (RSS) site registration status page of the 
CTSU members’ website by entering credentials at https://www.ctsu.org.  For 
sites under the CIRB initiative, IRB data will automatically load to RSS. 
Sites participating on the NCI CIRB initiative and accepting CIRB approval for 
the study are not required to submit separate IRB approval documentation to the 
CTSU Regulatory Office for initial, continuing or amendment review.  This 
information will be provided to the CTSU Regulatory Office from the CIRB at 
the time the site’s Signatory Institution accepts the CIRB approval.  The 
Signatory site may be contacted by the CTSU Regulatory Office or asked to 
complete information verifying the participating institutions on the study.  Other 
site registration requirements (i.e., laboratory certifications, protocol-specific 
training certifications, or modality credentialing) must be submitted to the CTSU 
Regulatory Office or compliance communicated per protocol instructions. 
12.3.2 Downloading site registration documents 
Site registration forms may be downloaded from the NSABP B-43 protocol page 
located on the CTSU members’ website.   
• 
Go to https://www.ctsu.org and log in to the members’ area using your 
CTEP-IAM username and password 
• 
Click on the Protocols tab in the upper left of your screen 
• 
Click on the NCTN Groupname link to expand, then select trial protocol 
NSABP B-43 
• 
Click on the Site Registration Documents link 
12.3.3 Requirements for protocol number site registration 
• 
CTSU IRB Certification (for sites not participating via the NCI CIRB) 
• 
CTSU IRB/Regulatory Approval Transmittal Sheet (for sites not 
participating via the NCI CIRB) 
12.3.4 Submitting regulatory documents 
Submit completed forms along with a copy of your IRB Approval and Model 
Informed Consent, if applicable, to the CTSU Regulatory Office, where they will 
be entered and tracked in the CTSU RSS. 
 
CTSU Regulatory Office 
 
1818 Market Street, Suite 1100 
 
Philadelphia, PA 19103 
 
Phone: 1-866-651-2878 
 
Fax: 215-569-0206 
 
E-mail: CTSURegulatory@ctsu.coccg.org (for regulatory document 
submission only) 

 
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12.3.5 Checking your site's registration status 
Check the status of your site's registration packets by querying the RSS site 
registration status page of the members' section of the CTSU website.  (Note: 
Sites will not receive formal notification of regulatory approval from the CTSU 
Regulatory Office.) 
• 
Go to https://www.ctsu.org and log in to the members' area using your 
CTEP-IAM username and password 
• 
Click on the Regulatory tab at the top of your screen 
• 
Click on the Site Registration tab 
• 
Enter your 5-character CTEP Institution Code and click on Go 
12.4 
Required pre-entry tumor block submission for central HER2 testing 
Pre-entry HER2 testing will be performed for all patients in order to determine eligibility 
for B-43 (see the Pre-Entry Sample Consent Form).  A representative tumor block must 
be submitted to Rush University Medical Center (see Information Resources).  All tumor 
specimens will be identified by the NSABP Specimen ID for Central Testing (HER2) (a 
unique coded number provided by the NRG Oncology SDMC).  Patients eligible for, and 
consenting to participate in, the B-43 treatment study, must have the NSABP Specimen 
ID for Central Testing (HER2) number recorded on Form ENTRY.  Patients will not be 
able to be enrolled in B-43 until the investigator receives confirmation that the DCIS is 
HER2-positive.  For more information regarding central testing for HER2 status, 
shipment and associated transmittal form, contact information, and receipt of test results, 
refer to Section 6.2 and the "B-43 Pathology Instructions" located in the Members' Area 
of the NSABP Web site. 
12.5 
Patient consent form 
Before the patient is enrolled, the consent form for the Treatment Study, including any 
addenda, must be signed and dated by the patient and the person who explains the study 
to that patient. 
12.6 
Patient enrollment 
Patient registration can occur only after pre-treatment evaluation is complete, eligibility 
criteria have been met, and the study site is listed as ‘approved’ in the CTSU RSS.  
Patients must have signed and dated all applicable consents and authorization forms. 
12.7 
Oncology Patient Enrollment Network (OPEN) 
Patient enrollment will be facilitated using the Oncology Patient Enrollment Network 
(OPEN).  OPEN is a web-based registration system available on a 24/7 basis.  To access 
OPEN, the site user must have an active CTEP-IAM account (check at < https://eapps-
ctep.nci.nih.gov/iam/index.jsp >) and a 'Registrar' role on either the LPO or participating 
organization roster. 
All site staff will use OPEN to enroll patients to this study.  It is integrated with the 
CTSU Enterprise System for regulatory and roster data.  OPEN can be accessed at 
https://open.ctsu.org or from the OPEN tab on the CTSU members’ side of the website at 
https://www.ctsu.org. 

 
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Prior to accessing OPEN, site staff should verify the following: 
• 
All eligibility criteria have been met within the protocol stated timeframes.  (Site 
staff should use the registration forms provided on the NRG Oncology or CTSU Web 
site as a tool to verify eligibility.) 
• 
All patients have signed an appropriate consent form and HIPAA authorization form 
(if applicable). 
• 
DCIS must be determined to be HER2-positive by pre-entry HER2 central testing 
(See Section 6.1 and Section 6.2 and the Pre-Entry Sample Consent Form.) 
Note: The OPEN system will provide the site with a printable confirmation of 
registration, including the Patient ID number for the study, and treatment 
information.  Please print this confirmation for your records.  Additionally, a 
transmittal form to be used when faxing the signed consent form to the NRG 
Oncology SDMC will be provided.  If it is necessary to reprint the randomization 
confirmation or the transmittal form, they can be reprinted through Coordinator 
Online via the View a Patient Entry Report under Patient Entry. 
Further instructional information is provided on the OPEN tab of the CTSU members' 
side of the CTSU Web site at https://www.ctsu.org or at https://open.ctsu.org.  For any 
additional questions contact the CTSU Help Desk at 1-888-823-5923 or 
ctsucontact@westat.com. 
12.8 
Investigator-initiated discontinuation of study therapy 
In addition to the conditions outlined in the protocol, the investigator may require a 
patient to discontinue study therapy if one of the following occurs: 
• 
the patient develops a serious side effect that she cannot tolerate or that cannot be 
controlled with other medications, 
• 
the patient’s health gets worse, 
• 
the patient is unable to meet the study requirements, or 
• 
new information about the study drug or other treatments for breast cancer becomes 
available. 
If study therapy is stopped, study data and other materials should be submitted according 
to the study schedule unless the patient withdraws from the study (see Section 12.10). 
12.9 
Patient-initiated discontinuation of study therapy 
Even after a patient agrees to take part in this study, she may stop study therapy at any 
time.  If study therapy is stopped but she still allows the study doctor to submit 
information, study data and other materials should be submitted according to the study 
schedule. 
12.10 Patient-initiated withdrawal from the study 
If a patient chooses to have no further interaction regarding the study, the investigator 
must provide the NRG Oncology SDMC with written documentation of the patient’s 
decision to fully withdraw from the study. 

 
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13.0 
REQUIRED FORMS AND MATERIALS 
13.1 
Data collection 
A table of required forms and materials is provided in the "Forms and Supporting 
Documents" section in the Members' Area of the NSABP Website for Protocol B-43 
http://www.nsabp.pitt.edu.  (CTSU investigators should also refer to the NSABP B-43 
Web page located on the CTSU Member Web site.) 
Data will be collected on patient characteristics, menstrual history in patients who were 
premenopausal at the time of study entry, DCIS characteristics, trastuzumab therapy, 
radiation therapy, adverse events, ipsilateral breast tumor recurrence, invasive regional 
and distant breast cancer, contralateral breast cancer, second non-breast primary cancer, 
disease-free survival, and overall survival. 
13.2 
Instruction for completion and submission of B-43 forms and materials 
• 
Submit all completed CRFs (with the exception of patient enrollment forms), clinical 
reports, and other documents directly to the NRG Oncology SDMC.  Submission of 
study data directly to NRG Oncology is done through the Online Data Entry function 
located in the Study Management Area of Coordinator Online in the Members' Area 
of the NSABP Web site.  Contact the Support Desk at support@nrgoncology.org for 
an account.  When submission of supporting documentation to the NRG Oncology 
SDMC is required, fax to 412-622-2111.  Remove patient names and identifiers such 
as social security number, address, telephone number, etc. from reports and 
supporting documentation. 
• 
The NRG Oncology SDMC will send query notices and delinquency reports directly 
to the site for reconciliation.  Please send query responses and delinquent data to the 
NRG Oncology SDMC and do not copy the CTSU Data Operations.  If the query is 
sent with fax transmittal form, return the data to the fax number on the transmittal 
form, otherwise fax to 412-624-1082. 
• 
B-43 data form worksheets and specimen transmittal forms, as well as instructions 
for completion and submission of B-43 data and materials, are available in the 
Members' Area of the NSABP Web site, http://www.nsabp.pitt.edu.  (CTSU 
investigators should refer to the NSABP B-43 Web page located on the CTSU 
Member site.)  Sites must use the current form versions and adhere to the instructions 
and submission schedule outlined in the protocol. 
13.3 
Adverse event reporting 
Routine and expedited adverse event reporting requirements are addressed in  
Section 10.0. 
13.4 
Pathology specimens 
See Section 6.0 for required tumor block submission. 
 
 

 
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13.5 
Data monitoring for CTEP 
This study will be monitored by the Clinical Data Update System (CDUS) version 3.0.  
CTEP has assigned abbreviated CDUS reporting: no AE reporting (routine or expedited) 
is required via any of the CDUS mechanism.  Cumulative CDUS data will be submitted 
quarterly by the NRG Oncology SDMC to CTEP by electronic means.  Reports are due 
January 31, April 30, July 31, and October 31. 
 
 

 
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14.0 
STATISTICAL CONSIDERATIONS 
14.1 
Endpoints 
14.1.1 Primary endpoint 
The primary endpoint for analysis is time from randomization to an ipsilateral 
invasive breast cancer, ipsilateral skin cancer recurrence, or DCIS  
(IIBCR-SCR-DCIS).  In the determination of time to an IIBCR-SCR-DCIS, no 
statistical censoring will be performed with respect to any previous local, 
regional, or distant recurrences or second primary cancers.  For example, if a 
patient experiences a regional metastasis then her time to regional metastasis will 
be recorded as her event time for the determination of invasive or DCIS disease-
free survival (IDFS-DCIS), and she will continue to be monitored for 
determining the time to an IIBCR-SCR-DCIS. 
14.1.2 Secondary endpoint 
Secondary endpoints are: a) IDFS-DCIS, b) invasive or DCIS recurrence,  
c) contralateral invasive or DCIS breast cancer, d) overall survival (OS), and 
e) ovarian function via the determination of post-treatment amenorrhea. 
Events for calculation of IDFS-DCIS are any recurrence, whether invasive or 
DCIS, second primary cancer, and death from any cause.  LCIS, basal cell 
carcinoma, squamous cell carcinoma, melanoma in situ, carcinoma in situ of the 
colon, and carcinoma in situ of the cervix will not be included as recurrences or 
second primaries.  For calculation of OS, any death (cancer-related or not) is 
considered an event. 
14.2 
Stratification and randomization 
Assignment of treatment to patients will be balanced with respect to menopausal status 
(postmenopausal, not postmenopausal), hormonal therapy (yes, no), and nuclear grade 
(low or intermediate, high).  Patients will be randomized to Group 1 (radiation therapy 
alone) or Group 2 (radiation therapy plus trastuzumab).  Upon verification of inclusion 
and exclusion criteria, the NRG Oncology SDMC will stratify and randomize the patient 
to either Group 1 or Group 2 using a biased-coin-minimization approach.78 
14.3 
Sample size estimation 
Our design calls for accrual of 2000 patients during a period of roughly 8 years  
(see Table 10).  A definitive analysis of the primary endpoints will be performed when 
163 ipsilateral breast cancer events are observed, which is expected to be achieved 
between 10 and 10.5 years after the start of the protocol.  This number of events affords 
80% power to detect a hazard reduction of 36%, from 1.73 ipsilateral breast cancer events 
per 100 patient-years to 1.11 events per 100 patient-years.  The 36% observed reduction 
in the hazard of IIBCR-SCR-DCIS on the trastuzumab arm is based on a projection of 
40% hazard reduction if the compliance were perfect, with a 10% noncompliance rate.  In 
those 10% of the patients, regardless of when and why they stopped study medication, we 
conservatively assume that no effect would be observed, thus attenuating the hazard 
reduction to 0.9 x 40%=36%.  The power calculations also take into account a 1% loss to 
follow-up in each arm of the study. 
 
 

 
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TABLE 10.  Revision of accrual time and time to definitive analysis (see Section 14.7) 
Accrual Scenario 
1st Year 
Average 
Monthly 
Accrual 
Average 
Subsequent 
Monthly 
Accrual 
Total Years 
of Accrual 
Approximate 
Years From 
the Start of 
the Study to 
Definitive 
Analysis 
Approximate 
Cutoff Date 
for Definitive 
Analysis* 
As originally 
projected in the 
protocol 
30 
60 
3.33 
8.00 
12/31/2016 
Revised using 
observed accrual 
to 12/31/2013 
14.167 
28 
6.03 
11.15 
12/31/2019 
* 
Time of cutoff date estimated based on quarterly generation of summary files. 
 
To estimate the rate of IIBCR-SCR-DCIS in the control arm of the proposed study, we 
used the rates for patients in B-24 with comedo necrosis (as a proxy for HER2+ status).  
Table 11 displays the sub-group proportions and IIBCR-SCR-DCIS event rates for 
patients in B-24.  We also assumed that 80% of hormone receptor-positive patients will 
be treated with tamoxifen, and that no hormone receptor-negative patient will be treated 
with tamoxifen.  Furthermore, it was conservatively assumed that 60% of the patients 
would have comedo necrosis and 40% would not.  To obtain the anticipated rate of breast 
cancer events among hormone receptor-negative patients, we used the rate for  
placebo-treated B-24 patients because hormone receptor status is only known for a subset 
of B-24 patients, and there were too few known hormone receptor-negative patients (with 
comedo necrosis) to allow rate estimation among age groups.  Furthermore, the rates of 
breast cancer events among placebo-treated patients were nearly the same between the 
known hormone receptor-negative and hormone receptor-positive patients. 
TABLE 11.  Rates of ipsilateral invasive and skin cancer and DCIS breast cancer recurrences 
(IIBCR-SCR-DCIS) in selected subsets of NSABP B-24 
Sub-group of 
proposed study 
Percentage 
expected (%) 
Sub-group of B-24 used for rate 
estimation 
Rates* of IIBCR- 
SCR-DCIS 
(per 100 patient-years) 
Pre-menopausal,  
not receiving 
tamoxifen 
15% 
Comedo, age < 50, placebo 
Non-comedo, age  50, placebo 
4.384 
1.967 
Pre-menopausal, 
receiving tamoxifen 
23% 
Comedo, age < 50, tamoxifen 
Non-comedo, age  50, tamoxifen 
2.517 
1.240 
Post-menopausal,  
not receiving 
tamoxifen 
28% 
Comedo, age  50, placebo 
Non-comedo, age  50, placebo 
1.698 
1.022 
Post-menopausal, 
receiving tamoxifen 
34% 
Comedo, age  50, tamoxifen 
Non-comedo, age  50, tamoxifen 
1.244 
0.775 
*  Rate calculated over the first 5 years of follow-up 
The anticipated overall rate in the proposed study is therefore 1.73 IIBCR-SCR-DCIS 
events per 100 patient-years. 

 
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14.4 
Statistical analysis plan 
The intention-to-treat principle will be used for primary analyses of the endpoints.  
Accordingly, the analyses will be performed on all patients with follow-up and will use 
the treatment assignments made at randomization.  As secondary analyses, these analyses 
will be repeated on patients with follow-up who are eligible for the study. 
For all statistical analyses, statistical significance will be determined by a two-sided  
P-value less than or equal to 0.05.  Adjustment will be made to the significance level for 
the primary definitive analysis to account for the interim analyses, as described below. 
Time to IIBCR-SCR-DCIS will be compared across treatment arms using cumulative 
incidence curves,79,80 Cox proportional hazard models,81 and the Kaplan-Meier 
method.82  For formal comparison of cumulative incidence curves, the method by Fine 
and Gray83 will be employed.  In secondary analyses, Cox proportional hazards models81 
will be used to evaluate the effect of treatment on time to any breast cancer event, OS and 
IDFS-DCIS, controlling for the stratification factors as well as other variables including 
comedo necrosis (presence or absence), palpable masses (presence or absence), and 
hormone receptor status (ER+ and/or PgR+ versus neither).  If an imbalance occurs in 
variables (such as the presence or absence of a radiation boost) not included in the 
stratification scheme, we will adjust for that imbalance analytically in a secondary 
analyses.84  The distributions of time to any breast cancer, IDFS-DCIS and OS will be 
estimated by the Kaplan-Meier method82 for each treatment group and will be compared 
between treatments by simple and stratified log-rank tests84,85 (the latter adjusted for 
menopausal status and hormonal therapy).  Invasive breast cancer, ipsilateral recurrence, 
and contralateral breast cancer will be compared across treatment arms using cumulative 
incidence functions.79,80,83  Furthermore, tests for treatment by covariate interactions 
will be performed.86  If the interaction between a covariate and treatment is significant, 
the treatment effect will be reported within each level of the covariate, with 95% 
confidence intervals.  We will test the proportional hazards assumption by creating an 
artificial time-dependent covariate and testing its interaction with other covariates, as 
described in Klein and Moeschberger.87  Confidence intervals for the risk ratios will be 
computed by assuming that the events follow a binomial distribution, conditioning on the 
total number of events and person-years at risk.  Amenorrhea will be summarized by 
treatment arm in terms of incidence rates and the ranges, medians, and quantiles of 
duration. 
14.5 
Interim analyses 
Toxicity and accrual information will be monitored monthly and will be presented at 
every semiannual Data Monitoring Committee (DMC).  Three formal interim analyses 
and one definitive analysis are projected and each will test the equality of proportions of 
patients who are free of ipsilateral invasive breast cancer recurrence, ipsilateral skin 
cancer recurrence, or DCIS (IIBCR-SCR-DCIS) over time between the treatment arms.  
The first analysis will occur at a point when roughly one quarter (41) of the total expected 
number of IIBCR-SCR-DCIS events are observed.  Subsequent interim analyses will 
occur when 82 and 123 IIBCR-SCR-DCIS events are reported with the definitive analysis 
occurring when 163 IIBCR-SCR-DCIS events are reported.  Based on 12/31/2013 data, 
the timing of the interim analyses will most likely be at years 6.5, 8, and 12.25 with the 
definitive analysis most likely being performed between 15 and 15.5 years after the start 
of the study.  If we have not observed 163 events 5 years after the last patient is enrolled, 

 
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we will still analyze the data at that time (projected to be 12/31/2019), using whatever 
events (IBTRs) we have observed.  The file closure and analysis dates for all interim 
analyses may be adjusted to coincide with Data Monitoring Committee meetings.  If early 
results indicate that the treatment is efficacious with respect to IIBCR-SCR-DCIS, then 
Fleming-Harrington-O'Brien -levels88 for the four analyses will be used to make formal 
recommendations to the Data Monitoring Committee.  The corresponding two-sided -
levels for the three interim analyses and the definitive analysis are 0.00167, 0.00194, 
0.00233 and 0.0484, respectively.  Asymmetric stopping boundaries will be employed 
using a modification of the method proposed by Wieand, et al.89  The lower interim 
boundaries are constructed so that if a detrimental effect is rejected at the one-sided 0.025 
level in the first interim analysis or if any detrimental effect (significant or not) is 
observed in any subsequent interim analyses, then the lower boundary would be crossed.  
If the difference in IIBCR-SCR-DCIS results in the upper or lower boundaries as defined 
above being crossed, then the DMC will consider this and any other information relevant 
to the trial to decide if it is appropriate to make a recommendation of early reporting of 
results. 
14.6 
Power considerations for correlative studies 
The main hypothesis to be tested in the correlative science aspect of this trial is that 
cMYC is a predictive marker for benefit from adding trastuzumab to radiotherapy.  We 
conservatively estimate that 80% of the patients accrued to this trial will have cMYC 
information leaving 1600 patients with evaluable information.  Using data from NSABP 
Protocol B-31, we estimate that 70% of the patients will be cMYC negative and 30% will 
be cMYC positive.  Thus, we project that we will have information available for 1120 
cMYC negative patients and 480 cMYC positive patients.  The hazard ratios comparing 
breast cancer related events for the trastuzumab arm versus the placebo arm in B-31 were 
0.62 and 0.26, for the cMYC negative and cMYC positive populations, respectively.  If 
these hazard ratios are observed in this study, then at the time of the definitive analysis  
(10 to 10.5 years after the beginning of the study), using a two-sided =0.05, we would 
have 71.8% power to detect a 38% reduction in the breast cancer related events in cMYC 
negative patients and 95.7% power to detect a 74% reduction in the breast cancer related 
events in cMYC positive patients.  For the IIBCR-SCR-DCIS endpoint, the power for 
detecting the above reductions at the time of the definitive analysis would be 60.1% and 
89.5%, for the cMYC negative and cMYC positive populations, respectively.  All of the 
above calculations assume that there is a 1% loss to follow-up rate among all patients in 
the study.  Other markers are regarded as exploratory in nature. 
14.7 
Accrual rates 
The original estimated rate of accrual to this trial was based on the observed accrual to 
NSABP Protocol B-35, with modifications to account for the expected distribution of 
patients by menopausal and ER status.  We also made modifications to account for the 
proportion of patients who would be HER2-positive using data from DCIS patients 
whose tumors were HER2-positive in the study from the Netherlands.49  This resulted in 
an estimated accrual rate of 60 patients per month.  At this rate, it was originally 
projected that it would require 3 years and 4 months to complete accrual. 
The actual accrual rate experienced in the first years of the trial did not meet our 
expectations and was substantially less than 60 per month.  The reason for this was  
two-fold.  First, the initial accrual rate was based on the estimate from the Netherlands 

 
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study that 42% of DCIS cases would be found to be HER2-positive.  In actuality, the 
proportion was 33.8%.90  Second, our original projections regarding the number of 
patients meeting the eligibility criteria and likely to participate in the trial was optimistic.  
Thus, in accordance with National Cancer Institute requirements for trials accruing at a 
slow rate, with the approval of the Data Monitoring Committee and the National Cancer 
Institute, the protocol was amended to modify the rate and duration of accrual to the 
study.  This change reflects a more realistic goal based on an internal review of  
HER2-positive rates and accrual to date.  The accrual rate was originally changed to  
22 patients per month, but based on 12/31/2013 accrual, was revised to 28 per month and 
the duration was changed to 6.03 years (see Table 10).  The latter calculation was made 
by taking into consideration the accrual rate from 2013 which was just over 38 patients 
per month. 
14.8 
Issues relating to racial and ethnic differences 
TABLE 12.  Expected racial and ethnic composition of NSABP B-43 
 
Ethnic Category 
 
 
Total 
Hispanic or Latino 
86 
Not Hispanic or Latino 
1914 
Ethnic Category: Total of all subjects 
2000 
Racial Category 
 
American Indian or Alaskan Native 
2 
Asian 
52 
Black or African American 
165 
Native Hawaiian or other Pacific Islander 
20 
White 
1761 
Racial Category: Total of all subjects 
2000 
Ethnic 
Hispanic or Latino – a person of Cuban, Mexican, Puerto Rican, South or Central  
Categories: 
American, or other Spanish culture or origin, regardless of race. 
 
Not Hispanic or Latino 
Racial 
American Indian or Alaskan Native – a person having origins in any of the original 
Categories: 
peoples of North, Central or South America, and who maintains tribal affiliations or 
 
community attachment. 
 
Asian – a person having origins in any of the original peoples of the Far East, 
 
Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, 
 
India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and  
 
Vietnam. 
 
Black or African American – a person having origins in any of the black racial 
 
Groups of Africa. 
 
Native Hawaiian or other Pacific Islander – a person having origins in any of the 
 
original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. 
 
White – a person having origins in any of the original peoples of Europe, the Middle 
 
                     East, or North Africa 
 

 
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15.0 
PUBLICATION INFORMATION AND ADMINISTRATIVE AGREEMENTS 
The agent(s) supplied by CTEP, DCTD, NCI used in this protocol is/are provided to the NCI 
under a Collaborative Agreement (CRADA, CTA) between the Pharmaceutical Company(ies) 
(hereinafter referred to as "Collaborator(s)") and the NCI Division of Cancer Treatment and 
Diagnosis.  Therefore, the following obligations/guidelines, in addition to the provisions in the 
"Intellectual Property Option to Collaborator" (http://ctep.cancer.gov/industry) contained within 
the terms of award, apply to the use of the Agent(s) in this study: 
1. Agent(s) may not be used for any purpose outside the scope of this protocol, nor can Agent(s) 
be transferred or licensed to any party not participating in the clinical study.  Collaborator(s) 
data for Agent(s) are confidential and proprietary to Collaborator(s) and shall be maintained 
as such by the investigators. The protocol documents for studies utilizing investigational 
Agents contain confidential information and should not be shared or distributed without the 
permission of the NCI.  If a copy of this protocol is requested by a patient or patient’s family 
member participating on the study, the individual should sign a confidentiality agreement. A 
suitable model agreement can be downloaded from: http://ctep.cancer.gov. 
2. For a clinical protocol where there is an investigational Agent used in combination with (an) 
other investigational Agent(s), each the subject of different collaborative agreements , the 
access to and use of data by each Collaborator shall be as follows (data pertaining to such 
combination use shall hereinafter be referred to as "Multi-Party Data."): 
a. NCI will provide all Collaborators with prior written notice regarding the existence and 
nature of any agreements governing their collaboration with NIH, the design of the 
proposed combination protocol, and the existence of any obligations that would tend to 
restrict NCI's participation in the proposed combination protocol. 
b. Each Collaborator shall agree to permit use of the Multi-Party Data from the clinical trial 
by any other Collaborator solely to the extent necessary to allow said other Collaborator 
to develop, obtain regulatory approval or commercialize its own investigational Agent. 
c. Any Collaborator having the right to use the Multi-Party Data from these trials must 
agree in writing prior to the commencement of the trials that it will use the Multi-Party 
Data solely for development, regulatory approval, and commercialization of its own 
investigational Agent. 
3. Clinical Trial Data and Results and Raw Data developed under a Collaborative Agreement 
will be made available exclusively to Collaborator(s), the NCI, and the FDA, as appropriate 
and unless additional disclosure is required by law or court order. Additionally, all Clinical 
Data and Results and Raw Data will be collected, used and disclosed consistent with all 
applicable federal statutes and regulations for the protection of human subjects, including, if 
applicable, the Standards for Privacy of Individually Identifiable Health Information set forth 
in 45 C.F.R. Part 164. 
4. When a Collaborator wishes to initiate a data request, the request should first be sent to the 
NCI, who will then notify the appropriate investigators (Group Chair for Cooperative Group 
studies, or PI for other studies) of Collaborator's wish to contact them. 

 
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5. Any data provided to Collaborator(s) for Phase III studies must be in accordance with the 
guidelines and policies of the responsible Data Monitoring Committee (DMC), if there is a 
DMC for this clinical trial. 
6. Any manuscripts reporting the results of this clinical trial must be provided to CTEP for 
immediate delivery to Collaborator(s) for advisory review and comment prior to submission 
for publication.  Collaborator(s) will have 30 days from the date of receipt for review.  
Collaborator shall have the right to request that publication be delayed for up to an additional 
30 days in order to ensure that Collaborator’s confidential and proprietary data, in addition to 
Collaborator(s)’s intellectual property rights, are protected.  Copies of abstracts must be 
provided to CTEP for forwarding to Collaborator(s) for courtesy review as soon as possible 
and preferably at least three (3) days prior to submission, but in any case, prior to 
presentation at the meeting or publication in the proceedings.  Press releases and other media 
presentations must also be forwarded to CTEP prior to release.  Copies of any manuscript, 
abstract and/or press release/media presentation should be sent to: 
E-mail: 
ncicteppubs@mail.nih.gov 
The Regulatory Affairs Branch will then distribute them to Collaborator(s).  No publication, 
manuscript or other form of public disclosure shall contain any of Collaborator's confidential/ 
proprietary information. 
 
 

 
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16.0 
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APPENDIX A 
 
DETERMINATION OF PRE-ENTRY MENOPAUSAL STATUS 
 
The following criteria will be used to define postmenopausal: 
• 
A prior documented bilateral oophorectomy, or 
• 
A history of at least 12 months without spontaneous menstrual bleeding, or 
• 
Age 55 or older with a prior hysterectomy, or 
• 
Age 54 or younger with a prior hysterectomy without oophorectomy (or in whom the status 
of the ovaries is unknown), with a documented FSH level demonstrating confirmatory 
elevation in the lab's postmenopausal range. 
Women failing to meet one of these criteria will be classified as not postmenopausal at study 
entry.