A Randomized Phase II Study of Androgen Deprivation Therapy With or Without Palbociclib in RB-Positive Metastatic Hormone-Sensitive Prostate Cancer
Phase: PHASE2
Conditions: Prostate Cancer
Sponsor: University of Michigan Rogel Cancer Center

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UMCC Protocol #: UMCC 2013.117 
Amendment 5: 8/9/2016 
 
 
 
TITLE:  A Randomized Phase II Study of Androgen Deprivation Therapy with or without 
Palbociclib in RB-Positive Metastatic Hormone-Sensitive Prostate Cancer. 
 
 
 
Coordinating Center: 
 
The University of Michigan 
 
 
Overall Study Principal Investigator (PI) and IND Sponsor: 
 
Maha Hussain, MD, FACP, FASCO 
Division of Hematology Oncology 
Northwestern Medicine 
676 N. St. Clair, Suite 850 
Chicago, Illinois 60611 
Phone: 312-695-6180 
Fax: 312-695-4530 
E-mail: maha.hussain@northwestern.edu 
 
 
 
 

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Site Specific and Other Co-Investigators: 
Site Investigator 
Phillip Palmbos, M.D. Ph.D. 
NCRC Bldg 520, Room 1342  
1600 Huron Parkway 
Ann Arbor, MI 48109-2800 
Phone: 734-763-0953 
Fax: 734-647-6977 
 
Email: ppalmbos@umich.edu 
 
Translational Co-Investigator 
Felix Feng, M.D. 
Department of Radiation Oncology  
University of California at San Francisco 
1825 4th Street, First Floor, Rm M2267 
San Francisco, CA 94143  
Email: felix.feng@ucsf.edu 
Site Investigator 
Wm. Kevin Kelly, DO 
Thomas Jefferson University 
1025 Walnut Street 
College Building, Suite 700 
Philadelphia, PA 19107 
Telephone: 215-503-5455 
E-mail: wm.kevin.kelly@jefferson.edu 
  
Translational Co-Investigator 
Karen E. Knudsen, PhD 
Thomas Jefferson University 
233 S. 10th St., Rm 1008 
Philadelphia, PA 19107 
Telephone: 215-503-7595 
E-mail: Karen.Knudsen@jefferson.edu 
 
Site Investigator 
Alicia K. Morgans, MD 
Vanderbilt-Ingram Cancer Center 
2220 Pierce Ave. 
777 PRB 
Nashville, TN 37232 
Telephone: 615-322-4967  
Fax: 615-343-7602 
Email: alicia.morgans@vanderbilt.edu 
 
 
Site Investigator 
Dr. Vivek K. Arora 
Washington University in St. Louis 
Asst Prof of Medicine 
Int Med – Medical Oncology 
660 S. Euclid Ave. CB 8056 
St. Louis, MO 63110 
Telephone: 314-286-1906 
Fax: 314-362-7086 
Email: varora@dom.wustl.edu 
Site Investigator 
Neeraj Agarwal, MD 
Assistant Professor of Medicine, 
Huntsman Cancer Institute, University of Utah. 
2000 Circle of Hope, Ste 2123, 
Salt Lake City, Utah 84112 
Telephone: 801-585-9682 
Fax: 801-585-0124 
Email: Neeraj.Agarwal@hci.utah.edu 
 
Site Investigator 
Emmanuel Antonarakis, M.D 
Sidney Kimmel Comprehensive 
Cancer Center at Johns Hopkins 
Orleans Street, Rm 1M45 
The Bunting-Blaustein Cancer 
Research Building 
Baltimore, MD 21231 
Telephone: 410-502-7528 
Email: eantona1@jhmi.edu 
 
Site Investigator 
Przemyslaw Twardowski, M.D. 
City of Hope Cancer Center 
1500 E. Duarte Road 
Duarte, CA 91010 
Telephone: 626-256-4673 ext 68218 
Fax: 626-301-8898 
Email: ptwardowski@coh.org 
 
Site Investigator 
Benedito Carneiro, MD 
Northwestern University 
233 East Superior Street  
Olson Pavilion, 1st floor  
Chicago, IL 60611 
Telephone: 312-472-1234 
Fax: 312-472-0564 
Email: benedito.carneiro@northwestern.edu   

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Radiology Co-Investigator  
Jon A. Jacobson, M.D. 
University of Michigan 
Taubman Center, Room 2910L 
1500 East Medical Center Dr., SPC 5326 
Ann Arbor, MI 48109 
Phone: 734-936-4365 
Fax: 734-936-9723 
E-mail: jjacobsn@umich.edu 
 
Radiology Co-Investigator   
Matthew S. Davenport, M.D. 
University of Michigan 
1500 East Medical Center Dr. 
Ann Arbor, MI 48109 
Telephone: 734-936-4566 
Fax: 734-764-4230 
E-mail: matdaven@med.umich.edu 
 
Radiology Co-Investigator 
Corrie Yablon, M.D. 
University of Michigan 
Taubman Center, Room 2910Q 
1500 East Medical Center Dr., SPC 5326 
Ann Arbor, MI 48109 
Phone: 734- 232-9402 
E-mail; cyablon@umich.edu 
 
Radiology Co-Investigator 
Elaine Caoili, M.D. 
University of Michigan 
Taubman Center, Room B1D502 
1500 East Medical Center Dr., SPC 5030 
Ann Arbor, MI 48109 
Phone: 734-936-4460 
E-mail: caoili@umich.edu 
 
Biostatistician 
Stephanie Daignault-Newton, M.S. 
2180 SPHII 
1415 Washington Heights 
Ann Arbor, MI, 48109-0473 
Telephone: 734-647-3271 
Email: sfaruzzi@umich.edu 
 
Study Pathologist 
Scott Tomlins, M.D. 
University of Michigan Hospital 
1500 E. Medical Center Drive 
2G332 University Hospital, SPC 5054 
Ann Arbor, MI 48109-5054 
Telephone: 734-763-8261 
 Email: tomlinss@med.umich.edu 
 
 
Administrative Personnel 
University of Michigan Multi-Site Coordinator 
Kathleen Granlund, CCRP 
Cancer Center Clinical Trials Office 
North Campus Research Complex (NCRC) 
Building 300  Main 
Ann Arbor, MI 48109-2800 
Telephone: 734-936-0563 
Fax: 734-232-0744 
Email: kemarsh@med.umich.edu 
 
Ben Wright, CAPM CCRP 
Cancer Center Clinical Trials Office 
North Campus Research Complex (NCRC) 
Building 300  Main 
Ann Arbor, MI 48109-2800 
Telephone: 734-763-0722 
Fax: 734-232-0744 
Email: bdwright@med.umich.edu 
 
Technical Director, Michigan Center for 
Translational Pathology 
Javed Siddiqui, MS, MT(ASCP, CLsp (MB)) 
Room 1138  
2900 Huron Parkway Suite 100 
Ann Arbor, MI 48105 
Telephone (734) 232-0829; Fax (734) 232-0805 
Email: siddiqui@med.umich.edu 
 
 
 
 
Pfizer Supplied Agent 
 
Palbociclib (Ibrance®) 
 

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UMCC Protocol #: UMCC 2013.117 
Amendment 5: 8/9/2016 
 
TITLE:  A Randomized Phase II Study of Androgen Deprivation Therapy with or without 
Palbociclib in RB-Positive Metastatic Hormone-Sensitive Prostate Cancer. 
 
Site Principal Investigator Protocol Signature Page 
 
The signature below constitutes the approval of this protocol and the attachments, and 
provides the necessary assurances that this study will be conducted according to all 
stipulations of the protocol, including all statements regarding confidentiality, and 
according to local legal and regulatory requirements and applicable US federal regulations 
and ICH guidelines.  
 
 
Printed Name: ____________________________________________ 
 
 
Signature:________________________________________________ 
 
 
Date:____________________ 
  
 

5 
 
 
STUDY SCHEMA 
 
 
 
 
 
 
 
 
  
 
Registration  
Biopsy of Metastatic Lesion  
Arm 1: ADT alone, n=20 
Arm 2: ADT + Palbociclib, N=40 
RB Positive (n=60)
RB negative- 
Off Protocol 
New M1 Prostate Cancer 

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TABLE OF CONTENTS 
 
Page 
PI PROTOCOL SIGNATURE PAGE ...................................................................................4 
SCHEMA ..................................................................................................................................5 
1.  OBJECTIVES .....................................................................................................................9 
 
1.1 Primary Objectives ......................................................................................................9 
 
1.2 Secondary Objectives ..................................................................................................9 
 
1.3 Correlative Objectives .................................................................................................9 
 
2.  BACKGROUND ...............................................................................................................10 
     2.1 Metastatic Prostate Cancer and Androgen Signaling .............................................10 
     2.2 Role RB in Metastatic Prostate Cancer ....................................................................10 
     2.3 
Role 
of 
CDK4/6 
Inhibitors 
in 
Prostate 
Cancer 
………………..........................................................................................…………………....10 
     2.4 Palbociclib …………………………………………… ........................……………...12 
     2.5 Rationale for Combination of Palbociclib and ADT ............…… .…………….....16 
     2.6 Correlative Studies Background and Rationale.....………………… …………….17 
 
3.  DRUG INFORMATION ..................................................................................................19 
     3.1 Palbociclib (PD 0332991) ........................................................................................... 19 
     3.2 Bicalutamide (Casodex®) ...........................................................................................28 
     3.3 Goserelin acetate implant (Zoladex®)  .....................................................................29 
     3.4 Leuprolide (Lupron Depot®) .....................................................................................32 
 
4.  PATIENT SELECTION ..................................................................................................35 
 
4.1 Inclusion Criteria  ......................................................................................................35 
 
4.2 Exclusion Criteria ......................................................................................................37 
 
4.3 Inclusion of Women and Minorities .........................................................................38 
 
5. REGISTRATION 
........................................................................................................38 
     5.1 Pretreatment Evaluation ...........................................................................................38 
     5.2 Subject Screening and Registration Procedure ......................................................38 
     5.3 Biopsy and Randomization ……………………………… ………………………..40 
     5.4 Data Management  .....................................................................................................41 
 
6.  STRATIFICATION, RANDOMIZATION AND TREATMENT PLAN....................41 
 
6.1 Stratification and Randomization ............................................................................41 
 
6.2 Agent Administration ................................................................................................42 
     6.3 General Concomitant Medication and Supportive Care Guidelines ....................43 
 
6.4 Duration of Therapy ..................................................................................................44 
 
6.5 Duration of Follow Up ...............................................................................................45 
 
7.  DOSING DELAYS/DOSE MODIFICATIONS .............................................................45 
      7.1 Palbociclib Dose Reductions …………..…………………………… ……………46 
      7.2 Bicalutamide Dose Hold  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 48 
 
8.  ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS .......................49 

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     8.1 Adverse Events and Potential Risks Related to Palbociclib ....................................49 
     8.2 Adverse Event Reporting Requirements ..................................................................49 
     8.3 Definitions ....................................................................................................................50 
     8.4 Adverse Event Characteristics ...................................................................................52 
     8.5 Serious Adverse Event Reporting Guidelines ..........................................................52 
     8.6 Serious Adverse Event Reporting to the FDA ..........................................................54 
      
9.  TISSUE PROCESSING/CORRELATIVE/SPECIAL STUDIES ................................54 
9.1 Tissue/Laboratory Correlative Studies ....................................................................54 
9.2 Description of RB Assessment and Correlative Studies .........................................60 
 
10.  STUDY CALENDAR .....................................................................................................63 
 
11.  MEASUREMENT OF EFFECT ...................................................................................64 
11.1 Definitions .................................................................................................................64 
11.2 Response and Progression Criteria ........................................................................65 
11.3 Methods for Evaluation of Measurable Disease ....................................................67 
11.4 Progression-Free Survival .......................................................................................68 
11.5 Evaluation of Best Overall Response .....................................................................68 
11.6 Duration of Response ...............................................................................................69 
 
12.  DATA MANAGEMENT AND MONITORING ..........................................................70 
      12.1 Data and Safety Monitoring Procedures…………………… ......……………….70 
      12.2 Clinical Monitoring Procedures……………………………… ......……………...70 
      12.3 Quality Assurance and Audits………………………………… ......……………..72 
 
13.  STATISTICAL CONSIDERATIONS ..........................................................................72 
 
13.1 Statistical Design ......................................................................................................72 
 
13.2 Analysis Plan ............................................................................................................73 
 
13.3 Correlative Endpoints Analysis ..............................................................................73 
 
REFERENCES .......................................................................................................................75 
 
APPENDICES 
APPENDIX A 
Performance Status Criteria ........................................................................................78 
APPENDIX B 
 
[Standard Operating Procedure (SOP) for Biopsy of Metastatic Prostate Cancer Lesion 
 
 In Bone……………………………………………………………… .....……………….79 
APPENDIX C 
Standard Operating Procedure (SOP) for Biopsy of Metastatic Prostate Cancer Lesion in 
Soft Tissue……………………………………………………………………………….80 
APPENDIX D 
Standard Operating Procedure (SOP) for Handling Samples ....................................81 
APPENDIX E 
Standard Operating Procedure (SOP) for Shipping of non-CTC Clinical Samples ...83 
APPENDIX F 

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Standard Operating Procedure (SOP) for Shipping of CTC Clinical Samples ..................86 
APPENDIX G 
Patient Medication Diary- Palbociclib .......................................................................88 
APPENDIX H 
Patient Medication Diary- Bicalutamide ....................................................................89 
 
 
 

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1. 
OBJECTIVES 
 
1.1  Primary Objectives 
 
1.1.1 To compare the rate of PSA < 4ng/mL after 28weeks of protocol treatment between 
RB-positive patients with metastatic hormone-sensitive prostate cancer randomized 
to combined androgen deprivation (CAD: LHRH agonist + bicalutamide) versus 
those randomized to CAD + palbociclib.  
 
1.2  
Secondary Objectives 
 
1.2.1 To assess the safety and tolerability of the combination of CAD + palbociclib. 
1.2.2 To assess the rate of undetectable PSA (<0.2ng/mL). 
1.2.3 To assess biochemical and clinical progression-free survival. 
1.2.4 To assess PSA and radiographic response rates.   
 
1.3  
Correlative Objectives  
 
1.3.1 To determine whether cyclin D1, cyclin D1B, p16, CDK4, E2F1, Cyclin A, MCM7, 
or Ki67 levels in pretreatment metastatic tumor biopsy tissue predict a subset of 
tumors responsive to palbociclib or overall response rates. 
 
1.3.2   To evaluate tumor transcriptome and mutational signatures to identify biomarkers 
which predict response to palbociclib. 
  
1.3.3 To create a tissue repository consisting of hormone-sensitive metastatic prostate 
cancer specimens with associated RB status and clinical data which can be used to 
correlate RB status with general clinical outcomes and explore and validate 
important genes identified in 1.3.2. 
 
1.3.4 To assess if the number of circulating tumor cells (CTCs) is associated with 
response to therapy when collected at pre-treatment, week 12, after 28 weeks of 
therapy, and at progression/or coming off protocol treatment. 
 
1.3.5 To assess if CTC heterogeneity, as assessed by the relative distribution of CTC 
phenotypes, predicts either response to palbociclib or overall response rates. 
 
 

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2. BACKGROUND  
 
2.1  
Metastatic Prostate Cancer and Androgen Signaling  
Every year in the United States, about 30,000  men die of metastatic prostate cancer (PCa).1 Since 
the introduction of orchiectomy as the first androgen deprivation therapy (ADT) over seventy years 
ago,2 progress in developing new treatments for patients with metastatic hormone-sensitive 
prostate cancer (mHSPC) has been limited to introducing different modalities of delivering ADT.3  
 
The primary therapeutic maneuver for newly diagnosed metastatic prostate cancer is androgen 
deprivation, which is accomplished by surgical castration or combined androgen deprivation 
therapy using LHRH-agonists/antagonists with or without an antiandrogen such as bicalutamide. 
Although the vast majority of mHSPC will initially respond to ADT, it is well established that the 
quality and duration of response is variable, and most will progress to castration-resistant disease.  
The current median survival of mHSPC is about 4 years.4 At present, all patients with newly 
diagnosed mHSPC are treated with a “one size fits all” approach with no means by which to select 
appropriate therapeutic regimens based on tumor profiling.   
 
2.2 
 Role of RB in Metastatic Prostate Cancer 
Androgens drive proliferation of prostate cancer cells both in initial disease and even after 
progression to castration-resistance. An important mechanism by which androgens drive 
proliferation is up-regulation of cyclin D which complexes with the cyclin-dependent kinase 
(CDK) 4/6, resulting in phosphorylation of RB, a cell-cycle brake. Because RB is a transcriptional 
repressor which binds to the regulatory region of genes whose functions are important for cell 
cycle progression and DNA replication, phosphorylation of RB relieves this repression and allows 
the cell to proceed through the cell-cycle and divide. RB is therefore an important tumor suppressor 
and is lost in early stages in several human malignancies (e.g. breast, cervical, and small cell lung 
cancer).5,6 Because AR signaling is able to inactivate this cell-cycle brake, most early stage prostate 
cancers retain wild-type RB function, and perturbations in this pathway (loss of RB, upregulation 
of cyclin D) are instead felt to promote castration-resistance.7   
 
The relationship between AR and RB is complex.  While AR signaling results in RB 
phosphorylation and cell-cycle progression, expression of the gene encoding the androgen receptor 
(AR) is also under RB control.8 Loss of RB caused de-repression of the AR locus, excessive AR 
production, and castration-resistant (ligand-independent) AR activity that proved sufficient to 
bypass hormone therapy.8 Therefore, AR signaling is closely linked with RB control. 
 
2.3 
 Role of CDK4/6 Inhibitors in Prostate Cancer   
 
CDK4/6 inhibition markedly inhibits prostate cancer growth in vitro and in vivo.  
Exposure of hormone-sensitive prostate cancer cell lines to the CDK4/6 inhibitor, palbociclib (PD 
0332991) significantly decreases active cell cycle progression (through measurement of BrdU 
incorporation kinetics) (Figure 1, top left) and production of factors (cyclins A and E1) necessary 
for cell cycle progression in an RB-dependent manner (Figure 1, top right). These results were 
recapitulated in studies examining human xenograft cultures (Figure 1, bottom) as well as ex vivo 
human tissue model systems. Such decreases in cell cycle progression were accompanied by 
significant decreases in the clinical tumor proliferation marker Ki67 (Figure 2).9 

11 
 
 
RB-proficient prostate cancer cells are preferentially sensitive to CDK4/6 inhibition.  

12 
 
Studies utilizing matched RB-knockdown and control populations have demonstrated a clear 
requirement for the retention of functional RB protein in the response to CDK4/6 inhibition.  
Among populations deficient for RB protein, inhibition of CDK4/6 activity was not able to 
decrease the rate of cells progressing through active cell cycle.9 
 
CDK4/6 inhibitors suppress AR function.  
Previous studies have demonstrated that CDK4/6 directly associates with the androgen receptor 
and enhances transcriptional activity in prostate cancer cells.10 AR activity is coupled to the cell 
cycle machinery primarily through its ability to up-regulate cyclin D protein level (reviewed in8). 
Once produced, cyclin D partners with CDKs 4 and 6, and phosphorylates RB protein, functionally 
inactivating the protein and ultimately relieving the transcriptional repression elicited by RB. This 
results in increased E2F-mediated gene transcription and production of factors that are required 
for cells to progress through the cell cycle and in to S-phase.  In this context, the effect of 
palbociclib administration is stabilization of cyclin D protein levels.11  Results from the Knudsen 
laboratory and others have shown that cyclin D protein is capable of negatively regulating AR 
activity at AR target genes.12  Thus, increases in intracellular cyclin D protein levels are known to 
negatively regulate AR function, and would be hypothesized to decrease AR-driven prostate 
cancer cell growth.  This postulate is supported by recent, unpublished microarray analyses of AR-
positive prostate cancer cells in the presence and absence of PD 0332991 (Karen Knudsen, 
personal communication).  palbociclib selectively suppressed expression of a subset of AR target 
genes known to be critical for castrate-resistant AR activity (eg UBE2C, Rad51, Fen1), while 
having no effect on early-stage AR targets (e.g. PSA, not shown), and little impact on others such 
as Nkx3.1.  Therefore, because palbociclib suppressed AR-dependent gene expression of some 
targets, it may act in concert with standard-of-care (androgen deprivation) to further suppress 
expression of target genes known to promote disease progression/therapeutic response.  
 
2.4 
 Palbociclib 
 
 Palbociclib is a highly selective reversible inhibitor of CDK 4 and 6 currently being evaluated as 
an anti-cancer therapy and approved for the treatment of metastatic breast cancer.13  Palbociclib 
specifically inhibits CDK4-catalyzed phosphorylation of retinoblastoma protein.  It has previously 
been shown to inhibit growth of human xenograft tumors including prostate cancers grown in 
mice.9   
 
Mechanism of Action 
 
Selectivity:  Palbociclib is a highly selective inhibitor of CDK4/cyclinD1 kinase activity (IC50 = 
11 nM; Ki = 2 nM). Palbociclib has selectivity for CDK4/6, with little or no activity against a large 
panel of 34 other protein kinases including other CDKs and a wide variety of tyrosine and 
serine/threonine kinases. CDK6, another enzyme that also complexes with cyclin-D subunits, is 
also commonly expressed in mammalian cells and tumors. CDK6 is highly homologous to CDK4 
and can perform the same function by phosphorylating RB, thus potentially creating a redundant 
mechanism to promote cell cycle progression. Consequently, inhibition of both enzymes is 
necessary to ensure complete suppression of RB phosphorylation and the greatest possible 
spectrum of antitumor activity. Results indicate that palbociclib inhibits CDK6 with equivalent 
potency to CDK4. 
 

13 
 
Inhibition of RB phosphorylation:  The only known natural substrate for CDK4/cyclinD1 is the 
retinoblastoma gene product, RB. Specific CDK4 phosphorylation sites on RB include serine-780 
and serine-795. Therefore, the phosphorylation status of RB at these specific sites in treated tumors 
can serve as an appropriate biomarker for target modulation by palbociclib. The IC50 for reduction 
of RB phosphorylation at serine-780 in the MDA-MB-435 breast carcinoma cell line was 0.066 
M. Palbociclib was equally effective at reducing RB phosphorylation at serine-795 in this tumor 
cell line with an IC50 of 0.063 M. Similar effects on serine-780 and serine-795 phosphorylation 
were obtained in the hormone sensitive prostate cancer cell line VCaP.9 
 
Anti-Proliferative Effects:  Palbociclib inhibits cellular proliferation and prevents cellular DNA 
synthesis by preventing cells from entering S phase of the cell cycle. Palbociclib inhibited 
thymidine incorporation into the DNA of a panel of RB-positive human breast, colon, lung and 
prostate cancers. Palbociclib was also effective in preventing cell cycle progression in human 
leukemias and in nontransformed human epithelial cells and fibroblasts and was equally effective 
in suppressing cell division in human tumor cell lines. 
 
A selective CDK4/cyclinD inhibitor should cause a specific accumulation of cells in G1, but have 
no effect on other phases of the cell cycle, in which cells should continue to progress and eventually 
decline in number. MDA-MB-453 breast carcinoma cells that were exposed to various 
concentrations of palbociclib for 24 hours show a significant increase in the percentage of cells in 
G1 in the presence of as little as 0.04 M palbociclib with a concomitant decline in other phases 
of the cell cycle. Similar results were obtained in panels of prostate cancer cell lines.9 
 
Finally, to provide further evidence of the selectivity of palbociclib, the compound was tested 
against RB-negative tumor cells, which should not be sensitive to a specific CDK4 inhibitor.  
Palbociclib was tested against the MDA-MB-468 human breast carcinoma and the H2009 human 
non-small cell lung carcinoma, both of which have deleted RB. The compound had no anti-
proliferative activity on these cells when assayed at 3 M (highest concentration tested), which is 
1 to 2 orders of magnitude higher than the concentration necessary to inhibit RB-positive tumor 
cells. 
 
Nonclinical Activity 
 
The MTD in SCID mice was 150 mg/kg/day when administered orally, once a day, for 14 days. 
The MTD was defined as the highest dose that was nonlethal (<LD10). At the MTD on this 
regimen, palbociclib has significant antitumor efficacy against multiple human tumor xenograft 
models (including the PC-3 prostate cancer cell line). The Colo-205 model is exquisitely sensitive 
to palbociclib. At doses as low as 12.5 mg/kg, a 13-day growth delay was obtained, indicating a 
90% inhibition of tumor growth rate. Further evidence that the anti-tumor activity observed in RB-
positive tumors is due to inhibition of CDK4/CDK6 protein kinase activity was obtained by testing 
palbociclib in the MDA-MB-468 breast carcinoma and the DU-145 prostate tumor models. These 
are RB-negative tumors; and neither responded to this compound. The lack of efficacy in RB-
negative tumors is consistent with the lack of anti-proliferative activity observed in vitro. Taken 
together, these results support the proposed mechanism of palbociclib (inhibition of CDK4/6-
mediated RB phosphorylation) and the specificity of the compound demonstrated in enzyme 
activity tests. 
 

14 
 
 
Nonclinical Pharmacology and Toxicology 
 
Dosing Schedules:  Further studies investigated whether continuous daily dosing of palbociclib 
was needed for optimal efficacy. Four dosing schedules were employed against the MDA-MB-
435 breast carcinoma model over 14 days of treatment, including continuous daily, every other 
day, every third day, and 3 courses of 3 days dosing followed by 4-day drug holidays. The design 
of this experiment was such that the total compound administered over the 2-week period was 
identical for each treatment schedule. The results show that a similar degree of efficacy was 
attained with all schedules, implying that an intermittent regimen is feasible without compromising 
activity.  
 
Inhibition of RB Phosphorylation:  To determine if palbociclib prevented RB phosphorylation, 
efficacious and non-efficacious doses of palbociclib were given to mice bearing the MDA-MB-
435 breast carcinoma and the phosphorylation status of serine-780 on RB in tumor tissue was 
monitored over time. The results show that while all doses caused a reduction in the biomarker 
shortly after drug administration, phosphorylation returned at the non-efficacious doses (12.5 and 
37.5 mg/kg) over the 24-hour interval before the next dose. However, the highly efficacious dose 
of 150 mg/kg suppressed RB serine-780 phosphorylation during the full 24-hour period. These 
data suggest that complete suppression of RB phosphorylation needs to be maintained between 
drug doses to achieve significant efficacy against this particular tumor model.  
 
Similar experiments with the Colo-205 colon carcinoma xenografts, which are exquisitely 
sensitive to palbociclib, shows that complete suppression of RB phosphorylation between doses 
was found to be unnecessary for producing growth inhibition. However, for maximal effects 
against Colo-205 tumors (i.e., regression), total inhibition had to be maintained.  
 
Comparing results of the efficacy experiments between the highly sensitive colon tumor and the 
moderately sensitive breast tumor reveals a 7 to 8-fold difference in the dose necessary to produce 
comparable efficacy. The pharmacodynamic results show a similar difference between the 2 
tumors in dose requirements necessary to suppress serine-780 phosphorylation on RB, indicating 
that efficacy correlates with modulation of this biomarker. Ki-67, a common marker of cell 
proliferation, was monitored in xenografts by immunohistochemical staining with the MIB-1 
antibody. MDA-MB-435 and Colo-205 xenografts were treated with an efficacious but nontoxic 
dose of palbociclib (130 mg/kg) daily for 7 and 4 days, respectively. Tumor samples were 
harvested at various times after the last dose and analyzed for RB phosphorylation and Ki-67 
expression. Relative to vehicle treated controls, RB phosphorylation and Ki-67 expression were 
both strongly inhibited from 1 to 24 hours after dosing. At 48 and 72 hours after the last dose, RB 
phosphorylation and Ki-67 returned to control levels in MDA-MB-435. In Colo-205, RB 
phosphorylation and Ki-67 expression remained partly suppressed through 72 hours. These results 
are consistent with the anti-proliferative mechanism expected for a specific Cdk4/6 inhibitor. They 
also provide support for the use of Ki-67 as a biomarker of cell proliferation in conjunction with 
palbociclib. 
Clinical Investigations 
 
As of 01 Sep 2015, palbociclib has been investigated in 18 clinical trials and at least 7 ongoing 
trials in humans; 19 phase 1 trials (solid tumors and hematologic malignancy) , three phase 1/2 

15 
 
trials (multiple myeloma and breast cancer) in combination with bortezimib or letrozole and two 
phase 3 trials in breast cancer in combination with letrozole or fulvestrant. 
 
Phase 1 Experience and MTD Determination.  74 patients with a variety of solid tumors were 
treated as part of the Phase 1 trial.  41 patients received palbociclib on a 3-week on, 1-week off 
treatment schedule (3/1) with doses ranging from 25 to 150 mg one daily.  An additional 33 patients 
received daily treatment with 2-week on/1-week off schedule (2/1) at a similar dose range.  The 
MTD doses for Phase 2 investigations was determined to be 125mg daily for the 3/1 schedule and 
200mg daily for the 2/1 schedule.  Common adverse events related to treatment are listed in Section 
3.1 and included fatigue, neutropenia, nausea, diarrhea, and anemia. 
 
Phase 1/2 Experience with Palbociclib in Combination with Letrozole in Women with Breast 
Cancer: Data is available for a Phase 1/2 trial assessing the safety and efficacy of palbociclib 125 
mg QD on Schedule 3/1 in combination with letrozole 2.5 mg QD on a continuous regimen for the 
first-line treatment of female patients with ER-positive, HER2-negative advanced breast cancer.14 
The Phase 1 portion of the study has completed accrual with 12 patients. In the Phase 2 portion of 
the study, patients were randomized to receive either letrozole 2.5 mg QD alone or palbociclib 125 
mg QD on Schedule 3/1 + letrozole 2.5 mg QD. Safety data are available for 95 patients who 
received the combination, which includes 12 patients from Phase 1 and 83 patients from the Phase 
2 portion of the study.  
 
Phase 3 Experience with Palbociclib in Combination with Letrozole in Women with Breast 
Cancer.  In this ongoing study 666 patients were randomized in a double-blind, placebo-controlled 
trial to receive either palbociclib 125mg QD (Schedule 3/1) + letrozole or letrozole alone. The 
most common treatment related adverse events were neutropenia (41.6%), fatigue (28.5%), nausea 
(26.3%), arthralgia (22.5%), and hot flush (21.3%). 
 
Phase 3 Experience with Palbociclib in Combination with Fulvestrant in Women with Breast 
Cancer Whose Disease Progressed after Prior Endocrine Therapy.  This is an ongoing, multicenter, 
randomized, double-blind, placebo-controlled trial comparing palbociclib to placebo in 
combination with fluvestrant with or without goserelin for women whose disease has progressed 
after prior endocrine therapy.  The most common adverse events were neutropenia (39.5%), fatigue 
(33.5%) and nausea (27.5%). 
 
Efficacy:   Results are available from 4 completed studies.  In the Phase 1 trial, stable disease 
was observed for patients with liposarcoma, testicular, kidney, ovarian, breast, appendiceal, 
peritoneal, melanoma, thymoma and lung.  One patient had a partial response (testicular).   
 
Final efficacy results from the Phase 2 portion of the palbociclib/letrozole study demonstrated that 
PFS was significantly longer in the palbociclib plus letrozole arm than in the letrozole alone arm 
(20.2 months vs 10.2 months, respectively with a hazard ratio of 0.488 (95% CI: 0.319-0.748) in 
favor of palbociclib plus letrozole (p=0.0004)).  Palbociclib plus letrozole was also associated with 
higher objective response rates and higher clinical benefit. The efficacy data from palbociclib trials 
led to its FDA approval for use in metastatic breast cancer with letrozole. 
 
2.5  
Rationale for Combination of Palbociclib and ADT in Patients with RB-intact 
Hormone-Sensitive Metastatic Prostate Cancer 

16 
 
 
Androgens drive proliferation of prostate cancer cells 
via up regulation of cyclin D which complexes with 
the kinase CDK4/6, resulting in phosphorylation of 
RB which in turn drives G1/S progression (Fig 3).  
Although most early stage prostate cancers retain 
wild-type RB function, perturbations in this pathway 
(loss of RB, upregulation of cyclin D) are felt to 
promote castration-resistance.   
 
Preclinical data demonstrated that PD 0332991 
(Palbociclib) inhibited proliferation and promoted 
G1 arrest in an RB and Cyclin D-dependent manner 
in prostate cancer cell lines and xenografts.9  Thus, 
this laboratory data support the rationale for treating 
prostate cancers with intact RB function with 
palbociclib.  Currently, the rates of RB loss or 
mutation (as measured by array CGH or exome 
capture) ranges between roughly 1-20% in localized prostate cancer (1% for 2 copy deletion versus 
10-20% for 1 copy deletion)15 to 30-40% in heavily treated metastatic castration-resistant prostate 
cancer16. The reported rates of loss of RB protein expression, by immunohistochemistry, range 
from 0% in prostatectomy series17 to 40% in primary (TURP) tumor specimens in CRPC patients 
(unpublished data, Karen Knudsen, Thomas Jefferson University) to 70% in metastases in CRPC 
patients.7  Although, there is little data examining RB loss in the hormone sensitive metastatic 
population we aim to study here, by extrapolation of existing data, we hypothesize the rate to be 
between 10-20%. 
 
We hypothesize that the addition of palbociclib to initial ADT in patients with newly metastatic 
RB-positive prostate cancer may significantly increase the efficacy of ADT.  We postulate that 
similar to the Phase II trial of palbociclib in breast cancer, responses and survival could be 
predicated on retention of wild-type RB function.  To assess this, we are conducting this 
randomized phase II study of palbociclib in which patients with newly diagnosed mHSPC and RB-
expressing tumors based on metastatic disease biopsy will be randomized (1:2) to ADT or ADT 
plus palbociclib.  We propose to use confirmed PSA response (< 4 ng/mL) after 28 weeks of 
therapy as the primary endpoint because it is an intermediate endpoint that correlates significantly 
with overall survival in hormone-sensitive patients.18,19 
 
 
 

17 
 
2.6 
Correlative Studies Background and Rationale   
 
Targeted Analysis of Potential Predictive Biomarkers.   
As part of the patient selection for this trial, patients will undergo a metastatic disease biopsy which 
will be tested by immunohistochemistry (IHC) for total RB status in a CLIA certified laboratory.7  
Because the RB pathway can be disrupted in human cancers via distinct mechanisms with distinct 
effects, additional correlative studies will be done to assess for potential biomarkers along and 
downstream of the RB pathway.5 For example, the RB protein can be inactivated by 
posttranslational modifications that are the subject of oncogenic (e.g., cyclin D1 or cyclin D1B 
overexpression/amplification) or tumor suppressive (e.g., p16ink4a silencing) alterations. As 
previous studies from our group have defined a signature of RB loss, key RB target genes (such 
as Cyclin A and MCM7) will be assessed as potential biomarkers of response.7  Given that RB 
interactors may also modulate the therapeutic response, the key RB interactor, E2F1, will be 
investigated as a predictive biomarker.  Finally, as RB also plays a critical role in the response to 
many antiproliferative stresses that are engaged by therapeutic agents, the status of Ki-67, a 
common marker of cell proliferation, will be determined.5  Immunohistochemical approaches for 
quantifying these potential biomarkers are described in Section 9. In total, these correlative studies 
will test the hypothesis that distinct alterations in the RB pathway could modulate the response to 
commonly used therapeutic regimens. 
 
While the potential biomarkers to be assessed in the correlative studies (i.e., p16, cyclin D1B, 
E2F1, etc) may modulate, interact with, or be an effector of the RB pathway, each of these 
biomarkers is not completely specific for the RB pathway, and therefore will be assessed as in 
secondary (correlative studies) instead of being included in the primary eligibility criteria.  For 
example, in the case of p16, while RB deficiency causes p16 overexpression, many other biological 
processes (aside from RB deficiency) also cause p16 overexpression.  In general, it appears that 
p16 overexpression is twice as common as RB deficiency. In triple negative breast cancers, there 
is a 25% chance of RB deficiency, but a 50% chance of p16 overexpression.20  In prostate cancers, 
the rate of RB deficiency is estimated to be <10% in the mHSPC population.  However, a study 
using thousands of localized prostate cancer specimens (primarily including Gleason 6/7 disease) 
showed that there was a 20% chance of p16 overexpression in this population,21 suggesting that 
the frequency of p16 overexpression will be at least 20% or higher in the newly metastatic 
population. Therefore, given the fact that p16 is regulated by processes other than RB, and p16 
overexpression is approximately twice as common as RB loss, the status of p16 and other RB 
modulators/interactors/effectors will be assessed in the correlative studies but will not be used to 
exclude patients up front.  
  
Analysis for Additional Predictive Biomarkers using Genomic Methods.  To further uncover 
predictive markers, we will also perform targeted sequencing and expression profiling on biopsy 
tissues. Genes commonly mutated in prostate cancer, those defining basic molecular subtypes, and 
those potentially related to RB will be assessed for point mutations, short insertions/deletions 
[indels] as well as copy number alterations. Transcriptome sequencing and/or qPCR will also be 
performed to assess expression of AR signaling, proliferation, molecular subtyping and RB-related 
genes. Given the challenges of routinely assessing metastatic sites, we will also perform the same 
sequencing on diagnostic specimens to determine concordance between transcriptome/genome 
alterations in primary and metastatic samples. We hypothesize that there may be many additional 
molecular events which determine whether prostate cancers will respond to palbociclib. In 

18 
 
addition, we will also perform exome capture and comprehensive next-generation sequencing on 
biopsy tissues if qualitatively and quantitatively sufficient RNA and DNA are recoverable.  Our 
team has previously initiated one of the first biomarker-stratified randomized trials for patients 
with metastatic castration-resistant disease (NCI 9012), entitled "A Randomized Gene Fusion 
Stratified Phase 2 Trial Of Abiraterone With Or Without ABT888 For Patients With Metastatic 
Castration-Resistant Prostate Cancer."  In the context of this trial, >70 biopsies (stored frozen) of 
metastatic disease were performed over the past 1.5 years, with an 80% success rate of determining 
the status of the biomarker of interest.     
 
While comprehensive sequencing studies have been performed in the context of locally advanced 
prostate cancer22 as well as metastatic end-stage castration-resistant prostate cancer (CRPC),16 
there have been, to our knowledge, no such studies in the context of metastatic hormone-sensitive 
prostate cancer.  Thus, by characterizing the genome and transcriptome in this unstudied space, 
this project will provide a significant contribution to our knowledge regarding the genomic 
landscape of prostate cancer, by providing an extensive look at metastatic, but hormone-sensitive, 
prostate cancer.  This data would represent an extremely valuable resource, which could serve as 
a "baseline" for comparison to subsequent sequencing studies in the CRPC space, as well as an 
opportunity to identify targetable biological concepts that may drive prostate cancer progression. 
 
Analysis of blood specimens for circulating, cell-free tumor DNA  
Recently, it has been demonstrated that patients with a variety of advanced solid tumors shed 
cell-free DNA (cfDNA) into the circulation and that mutations present in tumor tissue can be 
detected by high-throughput sequencing of cfDNA isolated from blood specimens.23 This rapidly 
developing research area has the potential of enabling the so-called "liquid biopsy", in which 
relevant genomic changes which currently need to be sought by biopsy of metastatic sites could 
instead be assayed from a blood specimen. In the current study we will collect the matched blood 
specimens needed to evaluate the efficacy of this approach as a surrogate for molecular analysis 
of tissue biopsy specimens. Once key predictive genomic biomarkers are identified from the 
tissue biopsy analyses above, they can be assayed in blood as well to determine concordance 
between blood and metastatic tissue biopsy. Given that optimal methods for cfDNA analysis are 
rapidly evolving, we plan to use the most current, robust technologies available when the time 
comes for analysis of the collected cfDNA specimens. 
 
Analysis for Additional Predictive Biomarkers in Circulating Tumor Cells 
Assessment of circulating tumor cells potentially represents a “liquid biopsy” approach with the 
potential for identifying biomarkers of treatment response.  To enumerate and characterize 
circulating tumor cells in this study, we will utilize a platform developed by Epic Sciences for 
CTC isolation and identification, which has previously been described.24-28  This platform allows 
for quantification of CTC number, as well as analysis of potential predictive biomarkers.  One 
potential biomarker of response is the heterogeneity of CTCs, as measured by distribution of 
previously characterized CTC subtypes, such as nucleoli CTCs, CTC clusters, CK- CTCs, CK 
speckled CTCs, small CTCs, AR nuclear CTCs, and AR cytoplasmic CTCs.29  The extent of 
CTC heterogeneity has been previously demonstrated to predict for resistance to androgen 
targeting therapeutics.30 Thus, we hypothesize that CTC count and heterogeneity may predict for 
longer-term PSA responses, and will explore this hypothesis in this study. 
 
3. DRUG INFORMATION 

19 
 
 
3.1  
IND Agent:  Palbociclib (Ibrance®) (PD 0332991) (unless otherwise specified, 
information is derived from Investigator’s Brochure). 
 
Chemical 
Name: 
 
6-acetyl-8-cyclopentyl-5-methyl-2-((5-(piperazin-1-yl)pyridin-2-
yl)amino)pyrido[2,3-d]pyrimidin-7(8H)-one 
 
Other Names: Palbociclib, PD-0332991 
 
Classification:  CDK4/6 Kinase Inhibitor 
 
Molecular Formula: C24H29N7O2 
 
M.W.:  447.53 
 
Mode of Action:  Palbociclib is a highly selective inhibitor of CDK 4/6 which blocks 
phosphorylation of the retinoblastoma protein. 
 
How Supplied:   Pfizer will supply Ibrance® for this study.  Ibrance® is supplied as capsules 
containing 75mg, 100mg or 125mg equivalents of palbociclib.  The capsules will be packaged 
in bottles containing 75mg, 100mg or 125mg capsules. 
Note:  Capsules should not be repackaged after they are dispensed.  Capsules should not 
be opened or emptied into another vehicle for oral ingestion.  Capsules should be 
swallowed intact. 
Storage:  Store at controlled room temperature (15-30C, 59-86F) in their original container.
 
 
 
Route(s) of Administration:  Oral 
 
Method of Administration:  Capsules should be swallowed whole without chewing.  
Patients should take doses at approximately the same times each day and record this 
information in the patient diary.  Patients should take palbociclib with food.  Patients will take 
medication daily for 21 days of a 28 day cycle. 
 
Metabolism: The ability of cytochrome P450 enzymes to metabolize palbociclib   was 
evaluated by incubation of palbociclib (6 M) with the 5 major cytochrome P450 (CYP) 
enzymes (CYP1A2, CYP2C9, CYP2C19, CYP2D6, and CYP3A4). CYP3A4 was the only 
enzyme that metabolized palbociclib. Concordantly, metabolism of palbociclib (6 M) in 
human liver microsomes was significantly reduced (>80% decrease) in the presence of the 
CYP3A4 enzyme-specific inhibitor ketoconazole (1 M). These data indicate that CYP3A 
enzymes are the primary enzymes responsible for the metabolism of palbociclib. 
   
Potential Drug Interactions:  Palbociclib is primarily metabolized by CYP3A4.  
Coadministration with strong CYP3A4 inhibitors or inducers may significantly change 
plasma concentrations in humans.  Therefore the concurrent  use of strong inhibitors such 
as amprenavir, atazanavir, boceprevir, clarithromycin, conivaptan, delavirdine, 
diltiazem, erythromycin, fosamprenavir, indinavir, itraconazole, ketoconazole, 
lopinavir, mibefradil, miconazole, nefazodone, nelfinavir, posaconazole, ritonavir, 

20 
 
saquinavir, telaprevir, telithromycin, verapamil, voriconazole, and grapefruit  or strong 
inducers such as carbamazepine, felbamate, nevirapine, phenobarbital, phenytoin, 
primidone, rifabutin, rifampin, rifapentin and St. John’s wort are not allowed. 
 
Excretion:  The excretion balance of radioactivity and radioactivity concentration in the 
collected plasma and blood samples were evaluated following oral administration of [14C] 
palbociclib (ethanesulfonic salt) to intact and bile-duct cannulated (BDC) male and female 
Sprague-Dawley rats at the dose level of 50 mg/kg as salt. The radioactive dose was mainly 
eliminated via the feces (>82%) with minor contribution of urinary excretion (7.8%). The 
percentage of dose eliminated in bile within 72 hours after dosing was 53% in male and 
82% in female BDC rats, suggesting that biliary excretion is the major route of elimination 
in rats.  
 
Toxicology:  The primary palbociclib toxicities in preclinical studies are to the bone 
marrow, lymphoid tissues, and testes. These toxicities occurred in both rats and dogs, and 
are consistent with cell cycle inhibition produced by the intended pharmacology of the 
drug. Bone marrow pancytopenia resulted in decreases in various hematology parameters; 
however, the changes were reversible following cessation of dosing. Reversible 
myelosuppression is anticipated in clinical studies and may be dose-limiting. Palbociclib 
demonstrated a potential for aneugenicity in the in vitro and in vivo micronucleus assays. 
Acute IV administration of palbociclib to anesthetized dogs resulted in significant 
pulmonary effects, including apnea, which were reversible. Effects were transient, 
appeared related to peak plasma concentrations (>2040 ng/mL), and consistent with 
centrally-mediated respiratory depression. No changes in pulmonary function occurred at 
plasma drug concentrations <414 ng/mL. Pulmonary changes were observed in rats to 
which palbociclib was administered orally, which included rales, dyspnea, and atrophy of 
tracheal epithelium. The clinical relevance of these effects is unknown. Results of the 
Purkinje fiber and hERG in vitro assays and cardiovascular study in dogs have indicated a 
potential for prolongation of the QT interval  
 
Additional routine studies in rats revealed that palbociclib could alter glucose metabolism 
and affect the pancreas, eye, teeth, kidney and adipose tissue of some rats. Hyperglycemia, 
glycosuria and pancreatic islet cell changes were observed.  Some rats developed cataracts 
(clouding of the eye lens) after being given palbociclib for 6 months.  It is currently 
unknown what these findings mean for patients treated with palbociclib over time. 
 
Pharmacokinetics in Humans:   
 
As of 10 December 2014, twenty-one clinical studies have evaluated the PK of 
palbociclib.  Four of these trials were conducted in patients with advanced malignant 
disease.  Seventeen Phase 1 clinical pharmacology and biopharmaceutic studies of 
palbociclib were conducted in healthy subjects.  Ten of these 17 clinical trials were 
clinical pharmacology studies conducted to investigate the absorption, distribution, 
metabolism, and excretion of palbociclib as well as examine the potential for a drug-drug 
interaction (DDI) with palbociclib.  The remaining 7 of the 17 clinical trials were 
biopharmaceutic studies conducted to examine the bioavailability, bioequivalence, and 
food effect of the palbociclib formulations.   

21 
 
 
Pharmacokinetic (PK) data from patients with advanced cancer from Study A5481001 
indicate that the plasma pharmacokinetics of palbociclib are low to moderately variable 
with generally dose proportional exposures over the dose range evaluated (25 mg to 225 
mg) following single and multiple doses.  PK data from Studies A5481001, A5481003, 
and A5481010 indicate that palbociclib is slowly absorbed with a median time of 
maximum concentration (Tmax) between 4 and 8 hours post-dose, and is slowly 
eliminated with an elimination half-life (t1/2) ranging from 23.2 hours to 28.8 hours.  
Palbociclib accumulates after repeated daily dosing (median Rac ranged from 1.9 to 2.4), 
which was consistent with its terminal t1/2. In Study A5481010, the median Rss (the 
predicted accumulation to estimate linearity) was 1.1, indicating that palbociclib 
clearance does not change over time.  In Study A5481003, palbociclib was shown to 
achieve steady-state concentrations following 8 days of QD dosing.  The palbociclib 
geometric mean volume of distribution (Vz/F) was 2583 L in women with advanced 
breast cancer (Study A5481003), which is significantly greater than total body water (42 
L), indicating that palbociclib extensively distributes to peripheral tissues. 
 
In humans, metabolism is the major route of elimination of palbociclib. Following a 
single oral administration of [14C]palbociclib to healthy subjects (Study A5481011), the 
overall median recovery of the administered radioactivity in the excreta was 91.6% with a 
median of 17.5% recovered in urine and a median of 74.1% recovered in feces.  
Excretion of unchanged palbociclib in the feces and urine was 2.3% and 6.9% of dose, 
respectively, indicating that excretion plays a minor role in elimination of palbociclib.  A 
study in healthy volunteers (A5481015) indicated that the absolute oral bioavailability of 
palbociclib was approximately 46%.   
 
In vitro data indicate that CYP3A and SULT enzyme SULT2A1 are mainly involved in 
the metabolism of palbociclib.  Palbociclib is a weak time-dependent inhibitor of CYP3A 
following daily 125 mg dosing to steady state in humans.  In vitro, palbociclib is not an 
inhibitor of CYP1A2, 2A6, 2B6, 2C8, 2C9, 2C19, and 2D6, and is not an inducer of 
CYP1A2, 2B6, 2C8, and 3A4 at clinically relevant concentrations. 
 
In vitro evaluations indicated that palbociclib has a low potential to inhibit the activities 
of drug transporters P-glycoprotein (P-gp), breast cancer resistance protein (BCRP), 
organic anion transporter (OAT)1, OAT3, organic cation transporter (OCT)2, organic 
anion transporting polypeptide (OATP)1B1, OATP1B3, and bile salt export pump 
(BSEP) at clinically relevant concentrations. 
 
An itraconazole DDI study in healthy volunteers (Study A5481016) and a rifampin DDI 
study in healthy volunteers (Study A5481017) were conducted to evaluate the potential 
for strong CYP3A inhibitors and inducers, respectively, to alter the PK of palbociclib. 
Coadministration of itraconazole and palbociclib increased palbociclib AUCinf and Cmax 
by approximately 87% and 34%, respectively, relative to those when palbociclib dose 
was given alone.  Coadministration of rifampin and palbociclib decreased palbociclib 
AUCinf and Cmax by approximately 85% and 70%, respectively, relative to palbociclib 
given alone.  Based on this data, the concurrent administration of strong CYP3A 
inhibitors and inducers with palbociclib should be avoided. 

22 
 
 
A midazolam DDI study in healthy volunteers (Study A5481012) was conducted to 
evaluate the potential for palbociclib to act as a time-dependent inhibitor of CYP3A4/5 at 
steady-state.  Plasma midazolam Cmax and AUCinf values increased 37% and 61%, 
respectively, when single oral doses of midazolam were co-administered with multiple 
doses of palbociclib as compared to its administration alone. This is consistent with weak 
time-dependent CYP3A4/5 inhibition mediated by palbociclib at steady-state following 
daily 125 mg dosing. 
 
PK data from the Phase 1 portion of Study A5481003 was analyzed to evaluate the 
potential for a DDI between palbociclib and letrozole at steady-state.  These data indicate 
a lack of a potential for DDIs between palbociclib and letrozole when administered in 
combination.  
 
Data from a DDI study in healthy male subjects indicated that palbociclib exposures were 
comparable when a single dose of palbociclib was coadministered with multiple doses of 
tamoxifen and when palbociclib was given alone. 
 
The effect of food on the exposure of palbociclib when administered as the commercial 
free base capsule was evaluated in healthy subjects (A5481021).  Compared to 
palbociclib given under overnight fasted conditions, the AUCinf and Cmax of palbociclib 
increased by 21% and 38% when given with high-fat food, by 12% and 27% when given 
with low-fat food, and by 13% and 24% when moderate-fat food was given 1 hour before 
and 2 hours after palbociclib dosing.  In addition, food intake significantly reduced the 
intersubject and intrasubject variability of palbociclib exposure.  Based on these results, 
palbociclib commercial free base capsules should be taken with food. 
 
The solubility of the palbociclib free base is pH dependent—palbociclib is water soluble 
at low pH (2.1-4.5), while the solubility dramatically decreases as pH rises above 4.5.  
Concomitant administration of agents which increase gastric pH can alter the solubility 
and absorption of palbociclib free base formulations.  
 
In a drug interaction trial in healthy subjects (A5481038), coadministration of a single 
125 mg dose of commercial free base capsule with multiple doses of the proton pump 
inhibitors (PPI) rabeprazole under fed conditions decreased palbociclib Cmax by 41%, but 
had limited impact on AUCinf (13% decrease), when compared to a single dose of 
palbociclib administered alone.  Given the reduced effect on gastric pH of H2-receptor 
antagonists and local antacids compared to PPIs, the effect of these classes of acid-
reducing agents on palbociclib exposure under fed conditions is expected to be minimal.  
Under fed conditions there is no clinically relevant effect of PPIs, H2-receptor 
antagonists, or local antacids on palbociclib exposure.  In another healthy subject study, 
coadministration of a single dose of commercial free base capsule with multiple doses of 
the PPI rabeprazole under fasted conditions decreased palbociclib AUCinf and Cmax by 
62% and 80%, respectively, when compared to a single dose of palbociclib administered 
alone.  Collectively, these antacid DDI data further support the requirement that the free 
base capsule of palbociclib should be taken with food. 
 

23 
 
Based on a population pharmacokinetic analysis in 183 patients with cancer (50 male and 
133 female patients, age range from 22 to 89 years, and body weight range from 37.9 to 
123 kg), gender had no effect on the exposure of palbociclib, and age and body weight 
had no clinically important effect on the exposure of palbociclib. 
 
Based on a population pharmacokinetic analysis that included 183 patients, where 40 
patients had mild hepatic impairment (total bilirubin ≤ ULN and AST > ULN, or total 
bilirubin >1.0 to 1.5 × ULN and any AST), mild hepatic impairment had no effect on the 
exposure of palbociclib.  The pharmacokinetics of palbociclib have not been studied in 
patients with moderate or severe hepatic impairment (total bilirubin >1.5 × ULN and any 
AST). 
 
Based on a population pharmacokinetic analysis that included 183 patients, where 73 
patients had mild renal impairment (60 mL/min ≤ CrCl <90 mL/min) and 29 patients had 
moderate renal impairment (30 mL/min ≤ CrCl <60 mL/min), mild and moderate renal 
impairment had no effect on the exposure of palbociclib.  The pharmacokinetics of 
palbociclib have not been studied in patients with severe renal impairment. 
 
A pharmacokinetic/pharmacodynamic analysis to evaluate the relationship between 
palbociclib exposure and ECG endpoints (RR and QTc intervals) were developed using 
pooled data from 3 clinical trials in patients with advanced malignant disease (Studies 
A5481001, A5481002, and A5481003).  The study population consisted of 48 men and 
136 women with a median (range) body weight of 73.0 (37.9-123) kg and age of 
61.5 (22-89) years old.  Palbociclib doses ranged from 25 mg to 225 mg QD.  The data 
collected from 184 patients consisted of 569 ECG-palbociclib concentration-matched 
pairs; the observed plasma concentrations had a median (range) of 55.2 (2.51-329) 
ng/mL.  The average heart rate, RR, QT, QT corrected for heart rate according to Bazett 
(QTcB), QT corrected for heart rate according to Fridericia (QTcF), and QTcS (QT 
interval corrected for heart rate according to a study-specific correction factor) at baseline 
for ECG-palbociclib concentration matched data were 76.8 beats per minute, 808 msec, 
380 msec, 425 msec, 409 msec, and 412 msec, respectively. 
 
The results of the analysis indicate that palbociclib does not appear to have a 
concentration-dependent effect on heart rate.  A slight positive linear relationship 
between palbociclib concentration and QTcS was observed; however, at the mean or 
median steady-state palbociclib Cmax following administration of the recommended 
clinical dose of palbociclib (125 mg QD) in patients with cancer, the upper bound of the 
one-sided 95% CI for the increase in QTcS fell below the threshold of 10 msec, 
suggesting that QT prolongation is not a safety concern for palbociclib at the 
recommended clinical dose according to the criteria described in the ICH guidance for 
Industry E14.  Similar results were obtained when QTcF and QTcB were used. 
 
 
Metabolism in Humans:   Assessment of the plasma samples on Day 14 of Cycle 1 
indicated that the glucuronide conjugate of palbociclib and the lactam of palbociclib (PF-
05089326) were the main metabolites present in plasma. Other metabolites observed were 
the glucuronide conjugates of hydroxylated palbociclib and the glucuronide conjugate of 

24 
 
reduced palbociclib. PF-05089326 was also observed in the circulation of rats following 
repeated daily oral administration of palbociclib at the dose levels of 50 and 100 
mg/kg/day. 
 
Safety and Adverse Events: 
 
Phase 1 Trials:13,31 
The most frequently reported treatment-emergent adverse events (TEAEs) (>20% of 
patients) of any grade, regardless of causality were fatigue (52.7% of patients); neutropenia 
(48.4%); nausea (35.2%); diarrhea and anemia (30.8% each); constipation (26.4%); 
decreased appetite (22.0%); and vomiting and thrombocytopenia (20.9% each). The most 
frequently reported TEAEs (>20% of patients) of any grade that were considered to be 
related to the study treatment were neutropenia (46.2% of patients); fatigue (45.1%); 
diarrhea and anemia (25.3% each); and nausea (24.2%). 
 
The most frequently reported Grade > or = 3 TEAEs, all causality, were neutropenia 
(30.8% of patients); anemia (9.9%); leukopenia (7.7%); fatigue (6.6%); and dyspnea and 
disease progression (5.5% each). Grade 3 neutropenia was considered to be related to the 
study treatment for 22.0% of patients. Grade 3 leukopenia and thrombocytopenia were each 
considered related to treatment in 5.5% of patients. 
 
The most frequently reported Grade 4 TEAEs were neutropenia (6 patients; all considered 
to be related to the study treatment) and thrombocytopenia (3 patients; considered to be 
related to study treatment for 2 patients). Grade 4 leukopenia was reported for 2 patients 
and Grade 4 anemia, pulmonary embolism, increased blood uric acid, decreased 
hemoglobin level and hyperglycemia for 1 patient each. Grade 5 events were reported for 
8 patients and included disease progression (5 patients), cardiac arrest (2 patients) and 
failure to thrive (1 patient). No Grade 5 event was considered to be related to palbociclib. 
 
Phase 1/2  Trial:14 
In the Phase 1/2 trial, the most frequently reported TEAEs (>20% of patients) of any grade, 
regardless of causality were neutropenia (71.6% of the patients); leukopenia (41.1%); 
fatigue (40.0%); nausea (27.4%); anemia (26.3%); diarrhea (22.1%); and arthralgia and hot 
flush (20.0% each). All reports of neutropenia and leukopenia were considered to be related 
to the study treatment. Fatigue and anemia were considered to be related to the study 
treatment for 25.3% of patients each, nausea for 18.9%, hot flush for 17.9%, and arthralgia 
for 16.8%. The most frequently reported Grade 3 TEAEs were neutropenia (53.7% of 
patients) and leukopenia (17.9% of patients). All reports of neutropenia and leukopenia 
were considered to be related to the study treatment. The most frequently reported Grade 
4 TEAEs were neutropenia (6.3% of patients; all considered to be related to study 
treatment), fatigue and pulmonary embolism (2.1% of patients each; all considered to be 
unrelated to treatment). As of the 01 September 2012 cutoff, one Grade 5 event (disease 
progression considered unrelated to study treatment) was reported. 
 
Duration of Toxicity: 
An exploratory analysis assessing the duration of neutropenia and thrombocytopenia 
during the first 2 cycles of treatment with palbociclib showed that neutropenia and 

25 
 
thrombocytopenia were dose dependent, with both nadirs observed at the end of the dose 
period. In most patients, both cell counts recover during the off-treatment period at the end 
of the cycle. No significant differences appeared when nadir values during Cycle 1 and 
Cycle 2 were compared, suggesting that myelotoxicity was not cumulative. 11 first cycle 
dose-limiting toxicities (DLTs) were noted, 5 for patients on Schedule 3/1 and 6 for patients 
on Schedule 2/1. All DLTs consisted of neutropenia and/or thrombocytopenia and most 
were categorized as a DLT due to the need for a treatment interruption of longer than 7 
days’ duration. Febrile neutropenia was not reported as a DLT.  
 
Effect on QT interval: 
The results of analysis of 3 clinical trials demonstrates that palbociclib does not appear to 
have a concentration dependent effect on the heart rate.  There was a possible relationship 
between palbociclib and QTc although the increase fell below the threshold of 10 msec 
suggesting that QT prolongation is not a major safety concern at the recommended doses. 
 
Adverse Events with Possible Relationship to Palbociclib 
Likely (>20%) 
Less Likely (<20%) 
Rare but Serious (<3%) 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
Neutropenia 
Lymphopenia 
 
Febrile Neutropenia 
Anemia 
 
Bone Marrow Failure 
Thrombocytopenia 
 
Anemia 
Leukopenia 
 
 
CARDIAC DISORDERS 
 
Palpitations 
Unstable Angina 
Pericarditis 
EYE DISORDERS 
 
Vision Blurred 
Retinal Hemorrhage 
 
Conjunctivitis 
Bilateral Cataracts 
 
Increased Tear Production 
 
GASTROINTESTINAL DISORDERS 
Nausea 
Constipation 
Ischemic Colitis 
Diarrhea 
Vomiting 
Diarrhea 
 
Abdominal Pain 
 
 
Flatulence 
 
 
Abdominal Distension 
 
 
Abdominal Discomfort 
 
 
Dry Mouth 
 
 
Dyspepsia 
 
 
Stomatitis 
 
 
Gum Pain 
 
 
Mouth/Throat Pain 
 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
Fatigue 
Peripheral Edema 
Pyrexia 
 
Pain 
Sudden Death 
 
Pyrexia 
Otitis Media Acute 

26 
 
 
Chills 
 
 
Mucosal Inflammation 
 
 
Chest Pain 
 
 
Asthenia 
 
 
Pain During Urination 
 
INFECTIONS  
 
Upper 
Respiratory 
Tract 
Infection 
Bronchopneumonia 
 
Nasopharyngitis 
Pneumonia 
 
Pneumonia 
Urinary Tract Infection 
 
Bronchitis 
Disseminated Herpes Zoster
 
Viral Infection 
Sepsis 
 
Urinary Tract Infection 
Pyelonephritis 
METABOLISM and NUTRITIONAL DISORDERS 
 
Decreased Appetite 
Dehydration 
 
Hypokalemia 
Metabolic Acidosis 
 
Hyperglycemia 
Elevated Liver Enzymes 
 
 
Hepatic Failure 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
 
Arthralgia 
 
 
Back Pain 
 
 
Muscle Spasms 
 
 
Flank Pain 
 
 
Muscular Weakness 
 
 
Myalgia 
 
 
Pain in Extremity 
 
 
Musculoskeletal Chest Pain 
 
 
Tooth ache 
 
 
Bone Pain 
 
NERVOUS SYSTEM DISORDERS 
 
Neuropathy peripheral 
 
 
Headache 
 
 
Dizziness 
 
 
Dysgeusia 
 
 
Hypoesthesia 
 
 
Falling Down 
 
PSYCHIATRIC DISORDERS 
 
Anxiety 
Suicide Attempt 
 
Depression 
 
 
Insomnia 
 
 
Altered Mood 
 
RESPIRATORY, THORACIC and MEDIASTINAL DISORDERS 
 
Dyspnea 
Allergic Alveolitis 
 
Cough 
Respiratory Failure 
 
Epistaxis 
 

27 
 
 
Rhinorrhea 
 
 
Oropharyngeal Pain 
 
 
Exertional Dyspnea 
 
SKIN and SUBCUTANEOUS TISSUE DISORDERS 
 
Rash 
 
 
Alopecia 
 
 
Pruritus 
 
 
Night Sweats 
 
 
Nail Disorder 
 
 
Dry Skin 
 
VASCULAR DISORDERS 
Hot flush 
Hypertension 
Deep Vein Thrombosis 
 
Hypotension 
 
INVESTIGATIONS 
 
Blood Creatinine Increased 
 
 
Hemoglobin Decreased 
 
 
Neutrophil Count Decreased 
 
 
White Blood Cell Count 
Decreased 
 
 
Blood Potassium Decreased 
 
 
Weight Decreased 
 
 
Weight Increased 
 
 
 
NOTE: Palbociclib in combination with ADT 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.   
 
Special Handling:  Handle palbociclib according to institutional guideline for hazardous 
drugs. 
 
Availability: Palbociclib is an experimental agent supplied by Pfizer. 
 
Drug Accountability:  The investigator, or a responsible party designated by the 
investigator, must maintain a careful record of the inventory and disposition of the 
investigational drug, palbobciclib.   The drug accountability records will capture drug 
receipt, drug dispensing, drug return and final disposition. 
 
***Commercial Agents: For this study, bicalutamide, goserelin acetate and leuprolide acetate or 
equivalent LHRH agonists are commercially available; therefore, Investigator Brochures are not 
applicable to these drugs. Information about commercial drugs is publicly available in the 
Physician’s Desk Reference (PDR), prescribing information and other resources. 
 
 
3.2  Bicalutamide (Casodex®) (NSC-722665) 
 

28 
 
General:   Bicalutamide is an active non-steriodal antiandrogen and its antiandrogen activity 
resides exclusively in the (-) or (R) enantiomer. Unlike flutamide, it is peripherally selective 
and does not cause a rise in serum LH or Testosterone in male rats and dogs. This peripheral 
selectivity may be because it penetrates poorly the CNS and Hypothalamus (the site of negative 
feedback of androgens). In humans, rises in LH, Testosterone and Estradiol concentrations 
were seen. These rises were not dose related. In 90%, testosterone levels remained within 
normal limits. There was no significant rise in mean serum FSH.  
 
Chemistry: Bicalutamide is a racemic mixture containing two enantiomers, (2RS)-4'-Cyano-
3(4-fluorophenylsulphonyl)-2-hydroxy-2-methyl-3'-trifluoromethyl) propionanilide. 
 
Toxicology: In rats, besides antiandrogenic changes, there was evidence of hepatocyte 
hypertrophy and basophilia. In dogs treated for 6 months, there was increased heart rate with 
decreased PR interval, transient decrease in circulating PMNs and increased plasma 
cholesterol. No cardiac pathology was found. In a mouse oncogenicity study, an increased 
incidence of hepatocellular carcinoma was observed in the top dose male group (75 
mg/kg/day). The no effect dose level for hepatocellular carcinoma in this study was 15 
mg/kg/day with steady state blood levels in excess of 10 μg/ml. The mechanism for this tumor 
formation is a non-genotoxic, phenobarbitone-type MFO induction and is not considered to 
represent a risk for humans. A two-year study in rats and female mice at similar 
doses did not show an increased incidence of hepatic tumors. Bicalutamide has been given to 
over 3,500 men in 35 different clinical studies worldwide, in doses up to 600 mg daily. When 
bicalutamide is given in combination with an LHRH analog, the pharmacologic adverse event 
profile is dominated by the LHRH analog and includes hot flashes (53%), gynecomastia (9%) 
and breast pain (6%). Other adverse events reported regardless of 
causality included diarrhea (12%), constipation (22%), nausea (15%) and abdominal pain 
(11%). Other adverse were reported, such as fatigue (22%), pain (35%), back pain (25%), 
pelvic pain (21%), infection (18%), peripheral edema (13%), dyspnea (13%), nocturia (12%), 
hematuria (12%), anemia (11%), dizziness (10%). Bicalutamide has been associated with 
changes in liver function, although these are infrequent (7%) and rarely occur with jaundice. 
Many of these changes improved or resolved despite continuation of bicalutamide therapy. 
There have been no reports of fatal hepatotoxicity associated with bicalutamide therapy. 
 
PHARMACOLOGY: 
 Pharmacokinetics: Animal studies: After oral single dose administration, absorption of the 
compound was slow with peak concentration occurring 3 - 12 hours and plateau between 
2 and 48 hours. There was non-proportional increase in plasma levels with increasing 
doses. Elimination half-life ranges from 17 - 28 hours in male rats, 21 - 29 hours in female 
rats and 5 - 7.5 days in dogs. 91 - 96% of bicalutamide is bound to plasma protein. Human 
studies: After single doses, mean time for peak plasma concentration was 6 hours at 10 and 
30 mg, but at 50 mg, it was 16 hours. Mean plasma elimination half-lives after 12 weeks 
of 10, 30, 50, 100 mg/day was 7 - 10 days. This finding was consistent with single dose 
data. In patients given daily doses of 50 mg, mean plasma concentration was 10 µg/mL at 
12 weeks. After single doses, there was linear increase with doses between 10 and 50 mg, 
but became non-linear at doses of 50 - 100 mg. At 100 mg, the oral bioavailability is 
reduced by 30% but plasma elimination half-life is unchanged. Bicalutamide is extensively 
metabolized and metabolites are excreted by both the biliary and urinary system. 

29 
 
 
 Formulation: Bicalutamide is prepared as round, film-coated green or white tablets 
containing standard recipients and 50 mg of the drug. Storage and stability: All packages 
of bicalutamide should be stored securely in a dry place at room temperature. 
 
 Route of Administration: Bicalutamide is to be administered in tablet form as a once-daily 
oral dose. Patients should be instructed to take one tablet once daily. 
 
 Supplier: Commercial supply of Bicalutamide will be used. Please refer to the Physician 
Desk Reference and package insert for complete information. 
 
3.3 Goserelin acetate implant (Zoladex®) (NSC-606864) 
 
 
PHARMACOLOGY  
 Mechanism of Action: Following initial administration in males, goserelin causes an initial 
increase in serum luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels 
with subsequent increases in serum levels of testosterone. Chronic administration of 
goserelin leads to sustained suppression of pituitary gonadotropins, and serum levels of 
testosterone consequently fall into the range normally seen in surgically castrated men 
approximately 2-4 weeks after initiation of therapy. 
 Absorption: Goserelin 3.6 mg is released slowly in first 8 days, and then rapid and 
continuous release for the remainder of the 28 day dosing period. Time to peak 
concentration for goserelin 3.6 mg is 12-15 days in males and 8-22 days in females. 
Goserelin 10.8 mg exhibits an initial rapid release resulting in a peak concentration at 2 
hours after dosing. From Day 4 until the end of the 12-week dosing interval, the sustained 
release of goserelin produces a reasonably stable systemic exposure.  
 Distribution: Apparent volumes of distribution determined after subcutaneous 
administration of 250 mcg aqueous solution of goserelin were 44.1 and 20.3 liters for males 
and females, respectively. Goserelin is approximately 27% protein bound. 
 Metabolism: Metabolism of goserelin by hydrolysis of the C-terminal amino acids is the 
major clearance mechanism. The half-life elimination (t1/2)) is approximately 4 hours in 
males and 2 hours in females.  
 Elimination: Clearance of goserelin is very rapid and occurs primarily via urinary excretion 
(>90%; 20% as unchanged drug).  
 Drug Interactions: Luteinizing hormone-releasing hormone analogs may diminish the 
therapeutic effect of antidiabetic agents. No formal drug-drug interaction studies have been 
performed. Please refer to the current FDA-approved package insert for additional 
information. 
 
 
 
 
ADVERSE EVENTS- Please refer to package insert or company website for up to date 
information. 
Adverse Events with Possible Relationship to Goserelin 
Likely (>20%) 
Less Likely (<20%) 
Rare but Serious (<3%) 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 

30 
 
 
Anemia 
 
CARDIAC DISORDERS 
 
Congestive Heart Failure 
Cerebrovascular Accident 
 
Hypertension 
Myocardial Infarction 
 
Palpitation 
 
 
Vasodilatation 
 
 
Tachycardia 
 
EYE DISORDERS 
 
Amblyopia 
 
 
Dry Eyes 
 
GASTROINTESTINAL DISORDERS 
 
Anorexia 
 
 
Appetite increase 
 
 
Nausea 
 
 
Abdominal Pain 
 
 
Constipation 
 
 
Diarrhea 
 
 
Dyspepsia 
 
 
Flatulence 
 
 
Ulcer 
 
 
Vomiting 
 
 
Xerostomia 
 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
Sweating 
Injection site reaction 
 
Tumor Flare 
Voice Alterations 
 
IMMUNE SYSTEM DISORDERS 
 
Fever 
 
INFECTIONS  
 
Infection 
 
 
Flu Syndrome 
 
METABOLISM and NUTRITIONAL DISORDERS 
 
Weight gain/loss 
 
 
Hyperglycemia 
 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
Bone 
mineral 
density 
decrease 
Weakness 
 
 
Arthralgia 
 
 
Back pain 
 
 
Hypertonia 
 
 
Bone/Joint Pain 
 
 
Leg Cramps 
 
 
Myalgia 
 
 
Paresthesia 
 
NERVOUS SYSTEM DISORDERS 
Headache 
Dizziness 
 

31 
 
 
Pain 
 
PSYCHIATRIC DISORDERS 
 
Anxiety 
 
 
Depression 
 
 
Insomnia 
 
 
Emotional lability 
 
RENAL and URINARY DISORDERS 
 
Urinary Frequency 
 
 
Urinary Obstruction 
 
 
Urinary Tract Infection 
 
REPRODUCTIVE SYSTEM and BREAST DISORDERS 
Hot flashes/sweats 
Pelvic Symptoms 
 
Libido Decreased 
Breast Enlargement 
 
Sexual Dysfunction 
Erections Decreased 
 
Breast Atrophy 
Libido Increased 
 
 
Breast Pain/Swelling 
 
RESPIRATORY, THORACIC and MEDIASTINAL DISORDERS 
 
Pharyngitis 
 
 
Upper Respiratory Infection 
 
 
COPD 
 
 
Cough 
 
 
Bronchitis 
 
 
Sinusitis 
 
 
Epistaxis 
 
 
Rhinitis 
 
SKIN and SUBCUTANEOUS TISSUE DISORDERS 
Acne 
Hair Disorders 
 
Seborrhea 
Hirsutism 
 
 
Pruritus 
 
 
Rash 
 
 
Skin Discoloration/Bruising 
 
VASCULAR DISORDERS 
Peripheral Edema 
Hemorrhage 
Thromboembolism 
 
 
Adverse effects occurring in <1%, post marketing, and/or case reports: ALT increased, 
anaphylaxis, 
AST 
increased, 
diabetes, 
glucose 
tolerance 
decreased, 
hypercalcemia, 
hypercholesterolemia, hyperlipidemia, hypersensitivity reactions, hypotension, ovarian cyst, 
pituitary apoplexy, psychotic disorders, urticarial. 
 
 
The FDA issued a safety communication in October 2010 based on their ongoing safety review 
of LHRH agonists. The safety communication discusses the potential for an increased risk of 
diabetes and cardiovascular disease (myocardial infarction, sudden cardiac death, stroke) 
associated with these agents. The risk is thought to be low in men receiving LHRH agonists for 
prostate cancer. In this trial, LHRH agonists are being administered for a short period of time. 
FDA recommendations include management of cardiovascular risk factors according to current 
standards of practice. 

32 
 
 
 
DOSING & ADMINISTRATION 
1. Dosing – See Treatment Plan 
2. Goserelin is administered subcutaneously 
 
 
STORAGE & STABILITY: Refer to the current FDA-approved package insert for storage, 
stability and special handling information. 
 
 
HOW SUPPLIED 
1. Goserelin acetate implant is available in a 3.6 mg or 10.8 mg disposable syringe device. 
The unit is sterile and comes in a sealed, light- and moisture-proof, aluminum foil laminate 
pouch containing a desiccant capsule. 
2. Commercial supply of Goserelin will be used. Refer to the current FDA-approved package 
insert for additional information. 
 
 
3.4 Leuprolide (Lupron Depot®) (NSC-377526) 
 
 
PHARMACOLOGY  
 Mechanism of Action: Leuprolide inhibits gonadotropin secretion by acting as an 
luteinizing hormone-releasing hormone (LHRH) agonist. Continuous administration 
results in suppression of ovarian and testicular steroidogenesis due  to  decreased  levels  
of  LH  and  FSH  with  subsequent  decrease  in testosterone (male) and estrogen (female) 
levels. In males, testosterone levels are reduced to below castrate levels. Leuprolide may 
also act directly on the testes as well as act by a different mechanism not directly related to 
reduction in serum testosterone. 
 Absorption: After the initial increase of leuprolide following each injection, mean serum 
concentrations remain relatively constant.  
 Distribution: The mean steady-state volume of distribution of leuprolide following 
intravenous bolus administration to healthy male volunteers was 27 L. In vitro binding to 
human plasma proteins ranged from 43% to 49%. 
 Metabolism: Upon   administration   with   different   leuprolide   acetate formulations, the 
major metabolite of leuprolide acetate is a pentapeptide (M-I) metabolite.  
 Elimination: Less  than  5%  of  the  leuprolide  dose  was  recovered  as parent  and  M-I  
metabolite  in  the  urine  following  the  3.5  mg  depot injection.  
 Drug Interactions: Luteinizing hormone-releasing hormone analogs may diminish the    
therapeutic    effect    of    antidiabetic    agents.    No pharmacokinetic-based drug-drug   
interaction   studies   have   been performed. Because leuprolide is a peptide that is primarily 
degraded by peptidase and not by Cytochrome P-450 enzymes and the drug is only about 
46% protein bound, drug interactions would not be expected to occur. 
 
 
 
ADVERSE EVENTS- Please refer to package insert or company website for up to date 
information. 
 
 
Adverse Events with Possible Relationship to Leuprolide 

33 
 
Likely (>20%) 
Less Likely (<20%) 
Rare but Serious (<3%) 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
 
Edema 
 
CARDIAC DISORDERS 
 
Hyper/Hypotension 
Arrhythmia 
 
Tachycardia 
Atrial Fibrillation 
 
Bradycardia 
Congestive Heart Failure 
 
Angina 
Syncope 
 
Palpitation 
 
GASTROINTESTINAL DISORDERS 
Nausea 
Altered Bowel Function 
Gastrointestinal Hemorrhage 
Vomiting 
Ulcer 
 
 
Intestinal Obstruction 
 
 
Constipation 
 
 
Diarrhea 
 
 
Gastroenteritis/Colitis 
 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
Local 
Injection 
site 
burning/stinging 
Skin reaction 
 
IMMUNE SYSTEM DISORDERS 
 
Flu-like syndrome 
Allergic Reaction 
INFECTIONS  
 
Urinary Tract Infection 
 
 
Infection 
 
INVESTIGATIONS 
 
BUN increase 
 
 
Creatinine increase 
 
 
Bicarbonate decrease 
 
 
Hyperphosphatemia 
 
 
Hyperuricemia 
 
 
Hypoalbuminemia 
 
 
Hypoproteinemia 
 
METABOLISM and NUTRITIONAL DISORDERS 
 
Dehydration 
 
 
Hyperlipidemia 
 
 
Weight gain/loss 
 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
 
Weakness 
 
 
Bone Pain 
 
 
Joint Disorder 
 
 
Myalgia 
 
 
Paresthesia 
 
NERVOUS SYSTEM DISORDERS 
Headache 
Nervousness 
Seizure 
Pain 
Anxiety 
 

34 
 
Insomnia 
Confusion 
 
 
Fatigue 
 
 
Dizziness/vertigo 
 
PSYCHIATRIC DISORDERS 
Depression 
 
 
RENAL and URINARY DISORDERS 
 
Urinary disorders 
 
 
Bladder spasm 
 
 
Urinary retention 
 
REPRODUCTIVE SYSTEM and BREAST DISORDERS 
Hot flashes/sweats 
Gynecomastia 
 
Testicular atrophy 
Breast Tenderness 
 
 
Lactation 
 
 
Testicular Pain 
 
 
Impotence 
 
 
Libido decreased 
 
 
Nocturia 
 
RESPIRATORY, THORACIC and MEDIASTINAL DISORDERS 
 
Emphysema 
 
 
Epistaxis 
 
 
Pleural Effusion 
 
 
Pulmonary Edema 
 
 
Dyspnea 
 
 
Cough 
 
SKIN and SUBCUTANEOUS TISSUE DISORDERS 
 
Acne 
 
 
Alopecia 
 
 
Bruising 
 
 
Cellulitis 
 
 
Pruritus 
 
 
Rash 
 
 
Hirsutism 
 
VASCULAR DISORDERS 
 
Varicose Veins 
 
 
Deep Thrombophlebitis 
 
 
 
<1%, post marketing, and/or case reports: Abdominal pain, anaphylactic/anaphylactoid 
reactions, asthmatic reactions, bone density decreased, coronary artery disease, diabetes; 
fibromyalgia-like symptoms; flushing, hemoptysis, hepatic dysfunction, hypokalemia, 
hypoproteinemia,  injection  site  induration/abscess,  liver  injury, myocardial infarction, pelvic 
fibrosis, penile swelling, peripheral neuropathy, photosensitivity; pituitary apoplexy; prostate pain, 
pulmonary embolism, pulmonary infiltrate, seizure, spinal fracture/paralysis, stroke suicidal 
ideation/attempt (rare), tenosynovitis-like symptoms, thrombocytopenia,   transient   ischemic   
attack,   uric   acid  increased, urticaria, WBC decreased/increased. 
 
 
The FDA issued a safety communication in October 2010 based on their ongoing safety review 

35 
 
of LHRH agonists. The safety communication discusses the potential for an increased risk of 
diabetes and cardiovascular disease (myocardial infarction, sudden cardiac death, stroke) 
associated with these agents. The risk is thought to be low in men receiving LHRH agonists for 
prostate cancer. In this trial, LHRH agonists are being administered for a short period of time. 
FDA recommendations include management of cardiovascular risk factors according to current 
standards of practice. 
 
 
DOSING & ADMINISTRATION 
1. Dosing – See Treatment Plan 
2. Leuprolide is administered intramuscular (Lupron Depot®). Injection sites should be 
varied periodically. 
 
STORAGE & STABILITY: Refer to the current FDA-approved package insert for storage, 
stability and special handling information. 
 
 
HOW SUPPLIED 
1. Leuprolide acetate, 7.5 mg (1 month), 22.5 mg (3 months), 30 mg (4 months) or 45 mg (6 
months) depot formulation kit with accompanying diluent. The prefilled dual-chamber 
syringe contains lyophilized microspheres of leuprolide acetate incorporated in a 
biodegradable lactic acid polymer. 
2. Commercial supply of Leuprolide will be used. Refer to the current FDA-approved 
package insert for additional information. 
 
 
 
4. PATIENT SELECTION 
 
In calculating days of tests and measurements, the day a test or measurement is done is considered 
Day 0. Therefore, if a test is done on a Monday, the Monday 4 weeks later would be considered 
Day 28. This allows for efficient patient scheduling without exceeding the guidelines. If Day 28, 
42, or 56 falls on a weekend or holiday, the limit may be extended to the next working day. 
 
4.1  
Inclusion Criteria  
 
At registration all patients must: 
 
Have pathologic diagnosis of prostate cancer. 
 
 Have hormone-sensitive metastatic disease (M1) as evidenced by soft tissue and/or 
bony metastases.  
 
 
Patients may either be untreated for their newly diagnosed metastatic disease (preferred 
as much as possible) or have started androgen deprivation therapy.  Patients who have 
started androgen deprivation therapy for the treatment of their newly diagnosed metastatic 
disease are eligible as long as the duration of treatment is less than or equal to 2 weeks (14 
days) prior to registration. The start date of androgen deprivation is considered the day the 
patient first received an injection of a LHRH agonist/antagonist (or orchiectomy), not the 
date when an oral antiandrogen started. 
 

36 
 
 
Patients must have a minimum PSA ≥ 5 ng/mL within 60 days of registration or prior 
to the initiation of androgen deprivation for patients who have started androgen deprivation 
therapy. 
 
 
Agree to undergo a biopsy of at least one metastatic site for RB status evaluation 
(Please refer to Appendices B and C for specific procedures).  Adequate metastatic tissue 
from prior biopsy/resection can be used if available in lieu of a biopsy.   
 
 
ECOG performance status of 0-2.   
 
 
Age ≥ 18 years.   
 
 
Patients may have received prior neoadjuvant and/or adjuvant hormonal therapy for 
non-metastatic disease including in combination with salvage radiation therapy for PSA 
relapse, but it must not have lasted for more than 36 months. At least 12 months must have 
elapsed since completion of androgen deprivation therapy in the neoadjuvant and/or 
adjuvant setting.  
 
 
Patients must have adequate organ and marrow function as defined below obtained within 14 
days prior to registration: 
WBC 
 3,000/µl 
ANC 
 1,500/µl 
Platelet count 
 100,000/µl 
Serum Creatinine 
1.5 x the institutional upper limits of 
normal or corrected creatinine clearance 
of  ≥ 50 mg/ml/hr/1.73 m2 BSA 
Bilirubin 
within the institutional limits of normal 
SGOT (AST) 
SGPT (ALT) 
 2 x upper limits of normal 
    2 x upper limits of normal 
 
 Patients must be able to take oral medication without crushing, dissolving or chewing 
tablets. 
 
 Patients may have received prior radiation therapy or surgery. However, at least 14 
days must have elapsed since completion of radiation therapy or surgery and patient 
must have only grade 2 or less adverse effects at the time of registration.  
 
 Patients must agree to use highly effective contraception (details outlined in the consent 
form) during treatment and for a period of 90 days after ending treatment with 
palbociclib.  
 
 Ability to understand and the willingness to sign a written informed consent document 
that is approved by an institutional review board. 
 
4.2 
Exclusion Criteria 
 

37 
 
 Patients who have received androgen deprivation therapy for greater than 14 days 
(LHRH-agonist or antagonist) for the treatment of their newly diagnosed metastatic 
disease prior to enrollment are not eligible for this study. 
 
 Patients who are currently being treated with strong CYP3A4 inhibitors (e.g., 
amprenavir, 
fosamprenavir, 
indinavir, 
itraconazole, 
ketoconazole, 
lopinavir, 
mibefradil, miconazole, nefazodone, nelfinavir, posaconazole, ritonavir, saquinavir, 
telaprevir, telithromycin, verapamil, voriconazole, and grapefruit) or strong CYP3A 
inducers (e.g., carbamazepine, felbamate, nevirapine, phenobarbital, phenytoin, 
primidone, rifabutin, rifampin, rifapentin and St. John’s wort) must either discontinue 
these drugs or are ineligible. 
 
 Grade 3 QTc prolongation (QTc  >500 msec on two separate ECGs). 
 
 Patients with known brain metastases should be excluded from this clinical trial 
because of their poor prognosis and because they often develop progressive neurologic 
dysfunction that would confound the evaluation of neurologic and other adverse events. 
 
 Uncontrolled intercurrent illness including, but not limited to, ongoing or active 
infection, symptomatic congestive heart failure (New York Heart Association Class III 
and IV heart failure), unstable angina pectoris, cardiac arrhythmia, or psychiatric 
illness/social situations that would limit compliance with study requirements. 
 
 Patients with a "currently active" second malignancy other than non-melanoma skin 
cancers are not eligible. Patients are not considered to have a "currently active" 
malignancy if they have completed all therapy and are now considered without 
evidence of disease for 1 year.  
 
 HIV-positive patients on combination antiretroviral therapy are ineligible because of 
the potential for pharmacokinetic interactions with palbociclib.  In addition, these 
patients are at increased risk of lethal infections when treated with marrow-suppressive 
therapy.   
 
 

38 
 
4.3 
Inclusion of Women and Minorities 
This study applies only to men. All races and ethnic groups are eligible for this trial. 
The anticipated accrual in the ethnicity/race categories is shown in the table below.  
 
   Ethnic Category 
Males 
Total 
Hispanic or Latino 
6 
6 
Not Hispanic or Latino 
54 
54 
Total Ethnic 
60 
60 
   Racial Category 
 
 
American Indian or Alaskan Native 
1 
1 
Asian 
2 
2 
Black or African American 
10 
10 
Native Hawaiian or other Pacific Islander 
0 
0 
White  
47 
47 
Racial Category: Total of all Subjects 
60 
60 
 
5. REGISTRATION  
 
5.1    Pretreatment Evaluation 
 
Clinical: (completed within 14 working days prior to registration) 
 Complete history to include all past or current medical conditions, current medications, 
date of diagnosis, and pathological confirmation of prostate carcinoma. 
 Physical Examination including height, weight, ECOG Performance Status and EKG. 
       
      Laboratory: (completed within 14 working days prior to registration) 
 Hematology: Complete blood count, differential and platelet count. 
 Comprehensive Panel: sodium, potassium, chloride, bicarbonate, BUN, creatinine, 
glucose, calcium, AST, ALT, alkaline phosphatase, phosphorous, total bilirubin, 
albumin, total protein and magnesium. 
 PSA. 
 
      Imaging and Diagnostic Studies: (completed within 6 weeks prior to registration or prior 
to initiation of androgen deprivation for patients who have already started ADT prior to 
registration) 
 Chest radiograph (CT or MRI thorax also acceptable) 
 CT or MRI of the abdomen/pelvis 
 Radionuclide Bone Scan 
 
5.2    Subject Screening and Registration Procedure 
 
 
Patient registration and randomization for this trial will be centrally managed by the 
Clinical Trials Office of The University of Michigan Comprehensive Cancer Center 
(UMCC) as described below: 
 
 A potential study subject who has been screened for the trial and who has signed 

39 
 
the Informed Consent document will be initially documented by the participating 
site on the Screening and Enrollment Log provided by the Clinical Trials Office. 
 
 It is the responsibility of the local site investigator to determine patient eligibility 
prior to submitting patient registration request to the multi-site Coordinator of the 
UMCC Clinical Trials Office.  After patient eligibility has been determined, a 
copy of the completed Eligibility Worksheet together with all the pertinent de-
identified source documents will be submitted by the requesting site to the 
Clinical Trials Office, either by fax or by email to : 
 
Ben Wright, CAPM CCRP 
Cancer Center Clinical Trials Office 
North Campus Research Complex (NCRC) 
Building 300 Main 
Ann Arbor, MI 48109-2800 
Phone: 734-763-0722 
Fax: 734-232-0744 
Email: bdwright@med.umich.edu 
 
Kathleen Granlund, CCRP 
Cancer Center Clinical Trials Office 
North Campus Research Complex (NCRC) 
Building 300 Main 
Ann Arbor, MI 48109-2800 
Telephone: 734-936-0563 
Fax: 734-232-0744 
Email: kemarsh@med.umich.edu 
 
 The Multi-Site Coordinator of the Clinical Trials Office, who acts as the registrar, 
will review the submitted documents and process the registration. Sites should 
inform the Multi-Site Coordinator of a potential registration by 5 p.m. on the day 
prior to registration.  Same day registrations cannot be guaranteed.   
 
 An email will be sent by the registrar to the requesting site registrar to confirm 
patient registration and randomization and to provide the study identification 
number and randomization number that has been assigned to the patient. In 
addition, a copy of the completed Eligibility Worksheet signed and dated by the 
registrar, will be emailed back to the requesting site registrar. 
 
 Patients found to be ineligible for participation after being consented will be 
considered screen failures, and documented as such in the Screening and 
Enrollment Log. These patients will not have study identification number 
assigned to them, and will not receive study treatment.  
 
 
 
5.3       Biopsy and Randomization 

40 
 
 
5.3.1 Following registration, patient biopsies must be performed within 10 working days 
(unless archival biopsy tissue is already available from a metastatic site in which case it 
must be provided within 10 working days).   
 
5.3.2 Issues that would cause treatment delays should be discussed with the Principal 
Investigator Dr. Hussain.  If a patient is eligible for treatment, protocol therapy must start 
within 10 working days from the biopsy date or receipt of archival tissue.   
 
5.3.3 Biopsy tissue should be processed and shipped to the Michigan Center for 
Translational Pathology. The coordinator for the Michigan Center for Translational 
Pathology will inform the registrar as well as the participating site whether the patient has 
adequate tissue for RB analysis. 
 
5.3.4 If the patient has adequate tissue which stains positively for RB, the study pathologist 
will also inform the statistician, Stephanie Daignault-Newton at 734-647-3271 or 
sfaruzzi@umich.edu and randomization will be performed.  (See Section 6, Treatment 
Plan).  Randomized patients should begin protocol treatment within 7 working days from 
randomization.  Issues that would cause treatment delays should be discussed with the 
Principal Investigator.  
 
5.3.5 If the patient does not have adequate tissue for RB analysis, he will be removed from 
protocol unless the patient is willing to undergo another biopsy. Repeat biopsy will need 
to be done within 10 working days of initial biopsy as long as patient still fulfills other 
eligibility criteria.  No study labs are needed but safety labs can be done as deemed 
necessary by the managing oncologist.  Patients will be randomized once adequate tissue 
is evaluated and positive for RB staining. 
 
5.3.6 If a patient does not receive protocol therapy following registration, the patient’s 
registration on the study may be canceled. The registrar should be notified of cancellations 
as soon as possible.  
 
5.3.7 If available, diagnostic tissue from prostatectomy or prior biopsy will also be 
requested for correlative studies.   
 If primary prostatectomy is available (preferred): The block with the highest volume of 
representative tumor histology from the index focus should be sent. Up to 12 x 5 micron 
sections will be taken from the block as needed. If blocks cannot be sent, a total of 16 
x 4-5 micron unstained, unbaked sections on glass slides (charged or uncharged) from 
the block with the highest volume of representative tumor histology should be sent. 
 If primary biopsy is available: Three blocks with the highest volume of representative 
tumor histology should be sent. A total of 9 x 10um sections will be taken from one or 
more blocks as needed without exhausting the blocks. If less than three blocks have 
cancer, then all blocks with cancer should be sent. If blocks cannot be sent, a total of 
15 x 4-5 micron unstained sections on glass slides from one or more blocks with the 
highest volume of representative tumor histology should be sent. 

41 
 
  If unstained sections are sent, they should be labeled with the block number/letter. If 
less than three blocks have cancer, then as many unstained 4-5 micron sections (up to 
15) as can be cut from blocks with cancer without exhaustion should be sent.   
 
 
5.4       Data Management 
All information will be recorded locally and entered into Case Report Forms (CRFs) on  
the web-based Velos data management system of the University of Michigan. Online 
access will be provided to each site by the Coordinating Center.  
 
CRFs will be reviewed and source verified by the MSC during annual monitoring visits  
and prior to and between visits. Discrepant, unusual and incomplete data will be queried  
by the MSC. The investigator or study coordinator will be responsible for providing 
resolutions to the data queries, as appropriate. The investigator must ensure that all data 
queries are dealt with promptly.  
 
The data submission schedule is as follows:  
 At the time of registration   
o Subject entry into Velos 
o Subject Status 
o Demographics 
 During study participation 
o All data should be entered online within 10 working days of data 
acquisition. Information on dose limiting toxicity events must be entered 
within one working day. Information on Serious Adverse Events must be 
entered within the reporting timeframe specified in Section 8 of the 
protocol.  
  
Long term data will be collected periodically either by chart review or by contacting the 
patients. 
All study information should be recorded in an appropriate source document (e.g. clinic 
chart). 
 
 
6. 
STRATIFICATION, RANDOMIZATION AND TREATMENT PLAN 
 
 
 
 
 
 
 
6.1        Stratification and Randomization   
 
Stratification:  All patients will be stratified by ADT treatment pre-registration for M1 
disease (yes versus no) and disease extent defined as limited (disease confined to the spine, 
pelvic bones and or lymph nodes) or extensive (ribs, long bones, or visceral organs with or 
without other sites). 
 
Randomization:  All eligible patients with RB-positive tumor will be randomly assigned 
(1:2) to receive ADT (LHRH agonist + biclutamide) alone (ARM 1) or ADT plus 
palbociclib (ARM 2).   
 
 

42 
 
6.2       Agent Administration 
 Patients will only be eligible for protocol therapy if the metastatic disease biopsy 
or prior metastatic disease biopsy/resection tissue has adequate tumor tissue for RB 
analysis and the tissue is RB positive.  
 
 Treatment will be administered on an outpatient basis.  Reported adverse events 
and potential risks are described in Section 3.  Appropriate dose modifications are 
described in Section 7. No investigational or commercial agents or therapies other 
than those described below may be administered with the intent to treat the patient's 
malignancy. 
 
 In both Arms androgen deprivation therapy should be administered after the biopsy 
is done, unless androgen deprivation was started prior to registration. 
 
 In Arm 2 palbociclib  should be administered post randomization as soon as agent 
is available (within 7 working days  from randomization in case time for drug 
shipment is needed)  
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
*LHRH-analogue: Either goserelin or leuprolide dosing to be determined at discretion of 
treating physician. 
** Palbociclib : 125 mg to be taken daily for 21 days with 7 days off during a 28 day cycle.  
Drug should be taken with food.  
 
Arm 1 Treatment 
Agent 
Dose 
Route 
Schedule 
Cycle Length 
LHRH-
analogue*(any 
formulation) 
 
  
Continuously 
 
Bicalutamide 
50 mg 
Oral 
Daily  
Continuously 
4 weeks 
Arm 2 Treatment 
Agent 
Dose 
Route 
Schedule 
Cycle Length 
LHRH- 
analogue*(any 
formulation) 
 
  
 
Continuously 
 
Bicalutamide 
50 mg 
Oral 
Daily Continuously 
4 weeks  
Palbociclib** 
125 mg 
Oral 
Daily, 
Days 1-21 of a 28 
day cycle.   
28 days (4 
weeks: 3 weeks 
of therapy + 1 
week off) 

43 
 
 For patients who have not started ADT D1 is the day palbociclib  + LHRH-a or 
LHRH-a therapy (based on randomization) is started.    
 For patients who have started ADT D1 will be the day of randomization.  “D1 
exam, labs and correlative studies” must be done within 7 working days from 
randomization.  All subsequent labs, imaging and endpoints will be counted 
from this day.  
 For subsequent cycles, the formal “Day 1” of each cycle is defined as the day 
that Palbociclib dosing resumes. 
 Patients will continue treatment until disease progression or other reason for   
discontinuation of protocol treatment. 
 Patient Diary: Bicalutamide and palbociclib compliance will be recorded on the 
Patient Diary (see Appendix G and H). Institutional staff will review and ascertain 
patient adherence with protocol treatment. If a dose of either agent is missed, 
patients are to take the normal dose on the following day.  If more than one daily 
dose is missed, the study doctor or study team must be informed. 
 General rules for palbociclib administration: 
o Palbociclib should be taken with food. 
o Palbociclib capsules should be swallowed whole (do NOT chew, crush or 
open them prior to swallowing). 
o No capsule should be ingested if it is broken, cracked, or otherwise not 
intact. 
o Patients should be encouraged to take their dose at approximately the same 
time each day. 
o Patients who miss a day’s dose entirely must be instructed NOT to “make 
it up” the next day. 
o Patients who vomit any time after taking a dose must be instructed NOT to 
“make it up,” and to resume treatment the next day as prescribed. 
o Patients who inadvertently take 1 extra dose during a day must be 
instructed to skip the next day’s dose.  
 
6.3  
General Concomitant Medication, Treatment and Supportive Care Guidelines 
 
 Patients may continue on a daily Multi-Vitamin, calcium and Vitamin D, but all other 
herbal, alternative and food supplements (i.e. PC-Spes, Saw Palmetto, St John’s Wort, 
etc.) must be discontinued before registration.   
 
 Patients may not receive any other investigational anticancer agents (besides study drug 
and ADT) for this stage of disease. Patients may not undergo concurrent radiation 
therapy. 
 
 Other 
excluded 
treatments 
include 
chemotherapy, 
immunotherapy, 
and 
radiopharmaceuticals or any other therapy intended to treat prostate cancer. 
 
 In case participants develop nausea/vomiting/diarrhea or myelosuppression, supportive 
medications will be allowed according to institutional standards.  
 

44 
 
 Because there is a potential for interaction of palbociclib with other concomitantly 
administered drugs through the cytochrome P450 system, the medical record must 
capture the concurrent use of all other drugs, over-the-counter medications, or 
alternative therapies. The Principal Investigator (Dr. Hussain) should be alerted if the 
patient is taking any agent known to affect or with the potential to affect selected 
CYP450 isoenzymes and the agent should be discontinued or situation discussed with 
her.   
 
 Drugs that Inhibit or Induce CYP3A4 Enzymes (non-comprehensive list): 
 
Patients are not eligible if they are taking one of the agents below.  Similarly if any of 
these agents has to be started for patients randomized to the palbociclib arm then 
patients must come off treatment.  Patients will be followed for progression. 
 
Strong CYP3A4 inhibitors: amprenavir, fosamprenavir, indinavir, itraconazole, 
ketoconazole, 
lopinavir, 
mibefradil, 
miconazole, 
nefazodone, 
nelfinavir, 
posaconazole, 
ritonavir, 
saquinavir, 
telaprevir, 
telithromycin, 
verapamil, 
voriconazole, and grapefruit 
 
Strong CYP3A4  inducers: carbamazepine, felbamate, nevirapine, phenobarbital, 
phenytoin, primidone, rifabutin, rifampin, rifapentin and St. John’s wort. 
 
 Transfusions and hematologic growth factors are allowed in accordance with 
institutional guidelines. 
 
6.4  
Duration of Therapy 
 
In the absence of treatment delays due to adverse event(s), treatment may continue until 
one of the following criteria applies: 
 
 
Disease progression (defined in section 11), 
 
 
Intercurrent illness that prevents further administration of treatment, 
 
 
Unacceptable adverse event(s) (see sections 3 and 8),  
 
 
Therapy delay for more than 4 weeks, 
 
 
Patient decides to withdraw from the study, 
 
 
General or specific changes in the patient's condition render the patient 
unacceptable for further treatment in the judgment of the investigator. 
 
 

45 
 
6.5     Duration of Follow Up 
 
 Patients removed from study treatment for progression will be followed for 4 weeks or 
resolution/stabilization of any therapy related adverse events.    
 
 Once off study treatment for any reason other than progression, follow-up visits will be 
done every 12 weeks.  These visits will include H&P and laboratory assessment 
(CBCPD, Chemistry, PSA).  Imaging will be done q 24 weeks.  Clinical, Laboratory 
and imaging evaluations will be done for 2 years or until progression, whichever comes 
first.  
 
 Patients removed from study treatment for unacceptable adverse event(s) may be 
followed more frequently than every 12 weeks per the investigator’s discretion until 
resolution or stabilization of the adverse event. 
 
 
7. DOSING DELAYS/DOSE MODIFICATIONS 
 
 This study will utilize the CTCAE (NCI Common Terminology Criteria for Adverse 
Events) Version 4.0 for toxicity and Serious Adverse Event reporting.  A copy of the 
CTCAE Version 4.0 can be downloaded from the CTEP home page 
(http://ctep.cancer.gov).  All appropriate treatment areas should have access to a copy 
of the CTCAE Version 4.0. 
 
 Toxicities (including suspected reactions) that meet the serious reporting criteria as 
outlined in section 8.0 of the protocol must be reported to the Coordinating Center Lead 
PI and Multi-site Project Manager and to the IRB per local IRB requirements. 
 
 For treatment or dose modification related questions, please contact Dr. Maha 
Hussain at 312-695-6180 or maha.hussain@northwestern.edu or cto-
multisite@med.umich.edu.  
 
 If a patient experiences several adverse events and there are conflicting 
recommendations, the investigator should use the recommended dose adjustment that 
reduces the dose to the lowest level. 
 
 Combined ADT will be required throughout duration of the study.   
 
 If patient desires to discontinue ADT, he will be removed from study 
treatment.  
 
 If patient develops serious adverse event felt to be related to bicalutamide 
(e.g., liver toxicity) then bicalutamide can be discontinued while continuing 
LHRH agonist/antagonist plus or minus palbociclib. 
 
 
 

46 
 
7.1 
Palbociclib Dose Reductions: 
 
In the event of significant treatment-related toxicity, palbociclib dosing may be interrupted or 
delayed and/or reduced as described below. In the event of multiple toxicities, dose 
modification should be based on the worst toxicity observed.  
Patients are to be instructed to notify Investigators at the first occurrence of any adverse sign 
or symptom. 
 
            Dose levels are defined below: 
 
Dose Level 
Palbociclib 
0 
125 mg daily 
-1 
100 mg daily 
-2 
75 mg daily 
 
o Dose modifications may occur in three ways: 
 Within a cycle: dosing interruption until adequate recovery followed by 
dose reduction, if required. 
 Between cycles: next cycle administration may be delayed due to persisting 
toxicity when a new cycle is due to start. 
 At start of the new cycle: dose reduction may be required in a subsequent 
cycle based on toxicity experienced in the previous cycle. 
 
7.1.1 Palbociclib Dose Modification and Management:  
 
 
Table 1. Palbociclib Dose Modification and Management – Hematologic Toxicitiesa 
CTCAE Grade 
Dose Modifications 
Grade 1 or 2 
No dose adjustment is required. 
Grade 3 
 
Day 1 of cycle: 
Withhold palbociclib, repeat complete blood count monitoring within 
1 week.  
 If recovered to Grade ≤2, resume at the same dose. 
 If Grade 3, hold initiation of next cycle until recovery to 
Grade ≤2. Resume at the same dose. 
 If Grade 4, hold initiation of next cycle until recovery to 
Grade ≤2. Resume at the next lower dose. 
 
Day 14 of first 2 cycles: 
Continue palbociclib at current dose. Repeat complete blood count on 
Day 21. 
 If Grade 3 on Day 21, start subsequent cycles at the same dose. 
 If Grade 4 on Day 21, start subsequent cycles at the next lower 
dose. 
 
Consider dose reduction in cases of prolonged (>1 week) recovery from 

47 
 
Table 1. Palbociclib Dose Modification and Management – Hematologic Toxicitiesa 
CTCAE Grade 
Dose Modifications 
Grade 3 neutropenia or recurrent Grade 3 neutropenia in subsequent 
cycles. 
Grade 3 neutropenia 
with fever ≥38.5 ºC 
and/or infection 
Withhold palbociclib until recovery to Grade ≤2. 
Resume at the next lower dose. 
Grade 4 
 
Withhold palbociclib until recovery to Grade ≤2. 
Resume at the next lower dose. 
Grading according to CTCAE 4.0 (Grade 1: ANC < LLN - 1500/mm3; Grade 2: ANC 1000 - <1500/mm3; 
Grade 3: ANC 500 - <1000/mm3; Grade 4: ANC <500/mm3). 
ANC=absolute neutrophil count; CTCAE=Common Terminology Criteria for Adverse Events; LLN=lower limit 
of normal. 
a 
Table applies to all hematologic adverse reactions except lymphopenia (unless associated with clinical events, 
e.g., opportunistic infections). 
 
Table 2. Palbociclib Dose Modification and Management – Non-Hematologic Toxicities 
CTCAE Grade 
Dose Modifications 
Grade 1 or 2 
No dose adjustment is required. 
Grade ≥3 non-hematologic toxicity (if 
persisting despite medical treatment) 
Withhold until symptoms resolve to: 
 Grade ≤1; 
 Grade ≤2 (if not considered a safety risk 
for the patient) 
Resume at the next lower dose. 
Grading according to CTCAE 4.0. 
CTCAE=Common Terminology Criteria for Adverse Events. 
 
 
7.1.3. A dose reduction of 1 level will be pursued for all Grade 4 toxicities and also for any Grade 
3 toxicity that in the opinion of the investigator will potentially impact the safety of the 
participant.  Dose reductions based on the above criteria can occur at the start of a new 
cycle or at the time of retreatment. 
 
o The dose of palbociclib will not be re-escalated once a dose reduction has occurred.  
 
o Asymptomatic laboratory abnormalities would not be considered a serious adverse 
event unless the treating physician believes it may potentially impact the 
participant’s safety.  
 
o If palbociclib is delayed more than 4 weeks for any reason, or if a dose reduction 
below 75 mg daily is required, patients will be removed from protocol treatment. 
 
o Doses should be held until toxicity resolution. Appropriate follow up assessments, 
as defined by the investigator, should be undertaken until adequate recovery occurs.  
 
 
o Criteria required before treatment can resume are described in the Retreatment 

48 
 
criteria section above. 
 
o Depending on when the adverse event resolved, a treatment interruption may lead 
to the patient missing all subsequent planned doses within that same cycle or even 
to delay in the initiation of the subsequent cycle. 
 
o If the adverse event that led to the treatment interruption recovers within the same 
cycle, then re-dosing in that cycle is allowed. Doses omitted for toxicity are not 
replaced within the same cycle.  
 
o The need for a dose reduction at the time of treatment resumption should be based 
on the criteria defined in the Dose Reductions Section unless an alternative plan is 
expressly agreed upon between the treating physician and the PI.  
 
o If a dose reduction is applied in the same cycle, the patient will need to return to 
the clinic to receive new drug supply. 
 
 
7.2  Bicalutamide Dose Hold  
 
There are no dose reductions for Bicalutamide.    
 
7.2.1. Diarrhea: 
The major toxic effect of bicalutamide is moderate diarrhea which is rarely severe 
(exclusion of other causes of diarrhea should be considered in severe cases). The dose 
modifications for this will be as follows. 
 Grade 2 diarrhea, treat symptomatically with anti-diarrhea drugs. 
 Grade 2 diarrhea unresponsive to symptomatic treatment or Grade 3 or 4 diarrhea - 
discontinue bicalutamide until complete recovery. 
Further tests are up to discretion of treating physician. Restart treatment as per protocol 
when diarrhea resolves to ≤ Grade 1.   
 
7.2.2. Abnormal Liver Function Tests (SGOT/AST, SGPT/ALT, Bilirubin) 
Grade 3 or greater toxicity - Stop bicalutamide. Hepatitis screening (A, B, C) should be 
done in all cases of abnormal LFTs which could be consistent with infectious hepatitis. 
To assess return to normal, abnormal liver function tests should be done weekly or more 
frequently, as per the discretion of the treating physician.   Bicalutamide may be restarted 
after LFTs normalize (< or = Grade 1) if the event is deemed not related to Bicalutamide.  
 
7.2.3. Patients may complain of flatulence, bloating and mild "gas pains" which should 
not result in changes in treatment. Symptomatic treatment should be employed with 
antacids, simethicone, etc.  
 
7.2.4. If patient develops serious adverse event felt to be related to bicalutamide then 
bicalutamide can be discontinued while continuing LHRH agonist/ 
antagonist plus or minus palbociclib (based on arm). 

49 
 
 
7.2.5. For any other Grade 3-4 adverse events which the investigator believes to be 
related to bicalutamide and is clinically significant stop bicalutamide.   
 
7.2.6 Asymptomatic Grade 3 or 4 laboratory findings, which are not considered clinically 
significant may not require dose hold. The decision to hold the dose should be based on 
the investigator’s clinical judgment. 
 
 
8. 
ADVERSE EVENTS  
 
   
8.1 Adverse Events and Potential Risks Related to Palbociclib (see section 3.1). 
 
 For the most recent safety update, please refer to the current Investigator’s Brochure.  
 For contraindications, interactions with other medications and known adverse reactions 
related to palbociclib please see section 3.1. 
 
8.2 Adverse Event Reporting Requirements 
 
8.2.1  Adverse event (AE) monitoring and reporting is a routine part of every 
clinical trial and is done to ensure the safety of subjects enrolled in the studies as 
well as those who will enroll in future studies using similar agents. Data on 
adverse events will be collected from the time of the initial study treatment 
administration through 30 days after the last dose of study treatment. Any serious 
adverse event that occurs more than 30 days after the last study treatment and is 
considered related to the study treatment must also be reported. Serious Adverse 
Events (SAEs) will continue to be followed until: 
 Resolution or the symptoms or signs that constitute the serious adverse 
event return to baseline; 
 There is satisfactory explanation other than the study treatment for the 
changes observed; or  
 Death. 
8.2.2   The investigator is responsible for the detection, documentation, grading 
and assignment of attribution of events meeting the criteria and definition of an 
AE or SAE. The definitions of AEs and SAEs are given below. It is the 
responsibility of the Protocol principal investigator and site investigator to ensure 
that all staff involved in the trial are familiar with the content of this section. 
8.2.3 Any medical condition or laboratory abnormality with an onset date before 
initial study treatment administration is considered to be pre-existing in nature. 
Any known pre-existing conditions that are ongoing at time of study entry should 
be considered medical history. 
8.2.4  All events meeting the criteria and definition of an AE or SAE, as defined 
in Section 8.3, occurring from the initial study treatment administration through 

50 
 
30 days following the last dose of the study treatment must be recorded as an 
adverse event in the patient’s source documents and on the CRF regardless of 
frequency, severity (grade) or assessed relationship to the study treatment.  
8.2.5   In addition to new events, any increase in the frequency or severity (i.e., 
toxicity grade) of a pre-existing condition that occurs after the patient begins 
study treatment is also considered an adverse event. 
8.3 Definitions 
8.3.1 Adverse Event 
 
An adverse event (AE) is any untoward medical occurrence in a patient receiving 
study treatment and which does not necessarily have a causal relationship with 
this treatment. An AE can be any unfavorable and unintended sign (including an 
abnormal laboratory finding), symptom, or disease temporally associated with the 
use of an experimental intervention, whether or not related to the intervention.  
 
Diagnostic and therapeutic non-invasive and invasive (i.e., surgical) procedures 
will not be reported as adverse events. However, the medical condition for which 
the procedure was performed must be reported if it meets the definition of an 
adverse event unless it is a pre-existing (prior to protocol treatment) condition. 
 
 Symptoms of the original or targeted disease will be considered adverse events. 
The following symptoms are indicative of underlying disease (Metastatic Prostate 
Cancer) and will be reported as adverse events. Attribution to underlying disease 
versus therapy must be provided:  
 
o 
Bone Pain 
o 
Urinary Obstruction 
o 
Spinal Cord Compression 
o 
Fractures 
 
 Abnormal laboratory values or test results constitute adverse events if they 
induce clinical signs or symptoms or require therapy. They are to be captured 
under the signs, symptoms or diagnoses associated with them. 
 
 Hy’s Law Cases.  Cases of potential drug‐induced liver injury as assessed by 
laboratory test values (“Hy’s Law Cases”) are also reportable to Pfizer.  If a 
Study subject develops abnormal values in aspartate transaminase (AST) or 
alanine transaminase or both, concurrent with abnormal elevations in total 
bilirubin and no other known cause of liver injury, that event would be 
classified as a Hy’s Law Case. This reporting requirement is further 
explained in the training material provided by Pfizer‐.  As used in this 
Agreement, the term SAE will be understood to also include Hy’s Law 
Cases.” 

51 
 
8.3.2 Serious Adverse Event 
An adverse event is considered “serious” if, in the view of either the Site 
Investigator or the protocol PI it results in any of the following outcomes: 
  
o Death 
If death results from (progression of) the disease, the disease should be 
reported as event (SAE) itself. 
 
o A life-threatening adverse event 
An adverse even is considered ‘life-threatening’ if, in the view of 
either the investigator [or sponsor], its occurrence places the patient or 
subject at immediate risk of death. It does not include an adverse event 
that, had it occurred in a more severe form, might have caused death.  
 
o Inpatient hospitalization or prolongation of existing hospitalization for 
> 24 hours. 
 
o A persistent or significant incapacity or substantial disruption of the 
ability to conduct normal life functions 
 
o A congenital anomaly/birth defect 
 
o Important medical event 
Any event that may not result in death, be life-threatening, or require 
hospitalization may be considered serious when, based upon 
appropriate medical judgment, they may jeopardize the patient and 
may require medical or surgical intervention to prevent one of the 
outcomes listed in this definition of “Serious Adverse Event”. 
Examples of such medical events include allergic bronchospasm 
requiring intensive treatment in an emergency room or at home; 
convulsions that do not result in inpatient hospitalization or the 
development of drug dependency or drug abuse. 
 
o Previously planned (prior to signing the informed consent form) 
surgeries should not be reported as SAEs unless the underlying 
medical condition has worsened during the course of the study. 
Preplanned hospitalizations or procedures for preexisting conditions 
that are already recorded in the patient’s medical history at the time of 
study enrollment should not be considered SAEs. Hospitalization or 
prolongation of hospitalization without a precipitating clinical AE (for 
example, for the administration of study therapy or other protocol-
required procedure) should not be considered SAEs. However, if the 
preexisting condition worsened during the course of the study, it 
should be reported as an SAE. 
 
o Exposure During Pregnancy: 

52 
 
Paternal exposure must be reported if a male has been exposed (e.g., 
due to treatment or environmental exposure) to the investigational 
product prior to or around the time of conception of his child and/or is 
exposed during the partner’s pregnancy. 
 
8.3.3 Expected Adverse Events 
An adverse event (AE) is considered “expected” if: 
 For approved and marketed drugs or devices, those adverse events 
are described in the approved Package Insert (Label).  
 For investigational new drugs, those adverse events are described 
in the FDA Investigator’s Brochure.  
 In clinical research studies, information on expected adverse 
events is also summarized in the protocol and in the consent 
document.  See section 3.1 for the list of expected adverse events 
related to the drug under study. 
8.3.4 Unexpected Adverse Event 
An adverse event (AE) is considered “unexpected” if it is not described in 
the Package Insert, Investigator’s Brochure, in published medical 
literature, in the protocol, or in the informed consent document.  
8.4 
Adverse Event Characteristics 
8.4.1 CTCAE Term 
(AE description) and grade: The descriptions and grading scales found in 
the NCI Common Terminology Criteria for Adverse Events (CTCAE) 
version 4.0 will be utilized for AE reporting. 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 down loaded from the CTEP web site. 
(http://ctep.cancer.gov) 
 
 
 
         8.4.2   Attribution of the AE 
The investigator or co-investigator is responsible for assignment of 
attribution. 
Definite – The AE is clearly related to the study treatment. 
Probable – The AE is likely related to the study treatment 
Possible – The AE may be related to the study treatment. 
Unlikely – The AE is doubtfully related to the study treatment. 
Unrelated – The AE is clearly NOT related to the study treatment. 
8.5 
Serious Adverse Event Reporting Guidelines 
8.5.1 The PI and the Coordinating Center must be notified within 24 hours of first 
awareness of the event (immediately if the event is fatal or life-threatening) 
meeting the criteria and definition of a serious adverse event, regardless of 

53 
 
attribution, occurring from after the first dose of Pfizer Product through 30 
days after the last administration of the Pfizer Product.  In addition, SAEs 
should be submitted any time after the administration of the last dose of the 
Pfizer Product if the Investigator suspects a causal relationship between the 
Pfizer Product and the SAE.  
8.5.2 All serious adverse events must be reported to the Coordinating Center 
within 24 hours of first awareness of the event.  Events should be reported 
using the Medwatch 3500A form.  A copy of the Medwatch 3500A form 
should be sent to the University of Michigan Multi-site Coordinator via fax 
at 734 232 0744 or via email to bdwright@med.umich.edu, 
kemarsh@med.umich.edu or cto-multisite@med.umich.edu. 
8.5.3 All serious adverse events will be reported to the IRB per current 
institutional standards.  
8.5.4 The University of Michigan acting as the Coordinating Center will be 
responsible for reporting to Pfizer by facsimile any Serious Adverse Event 
that occur during the SAE reporting period.  The coordinating center will 
report the SAE within 24 hours of first awareness of the event (immediately 
if the event is fatal or life-threatening). 
8.5.5 Contact information for Principal Investigator for SAE Reporting: 
Maha Hussain, M.D.  
Division of Hematology Oncology 
Northwestern Medicine 
676 N. St. Clair, Suite 850 
Chicago, Illinois 60611 
Phone: 312-695-6180 
Fax: 312-695-4530 
e-mail: maha.hussain@northwestern.edu 
 
 
8.5.6 The Coordinating Center will disseminate information regarding serious 
adverse events to the participating sites within 5 days of review of the 
information by the Principal Investigator (or her designee in the event of 
extended absence) only in the case that the event(s) is believed to be related 
(i.e., possibly, probably, or definitely) to the study medication.  
 
The Coordinating Center, or designee will be responsible for reporting of 
events to the FDA and supporters, as appropriate (outlined in Section 8.6) 
 
 
 
 

54 
 
8.6 SERIOUS ADVERSE EVENT REPORTING TO THE FDA 
 
It is the responsibility of the IND Sponsor to submit an IND for clinical trials conducted 
with investigational agents and to ensure that FDA and all participating investigators are 
promptly informed of significant new AEs or risks with respect to the investigational 
agent. 
 
In this trial, serious unexpected adverse events believed to be definitely, probably or 
possibly related to the study treatment will be reported to the Food and Drug 
Administration via the MedWatch 3500A.  The Coordinating Center, will 
coordinate with the IND Sponsor and/or designee for the reporting of any and all 
IND safety reports to the FDA as per the requirements outlined in 21 CFR 312.32. 
 
 
9. 
TISSUE PROCESSING/CORRELATIVE/SPECIAL STUDIES 
 
9.1 Tissue / Laboratory Correlative Studies 
 
9.1.1. Collection and Handling of Specimens 
 
From each patient, tissue specimens will be collected from: 
 a) A metastatic site of disease (via biopsy) or adequate metastatic tissue from prior 
biopsy or resection. 
 b) Archived prostatectomy or biopsy specimen from the primary prostate tumor (if 
available, via retrieval of previously archived specimens). 
 c) Blood/circulating tumor cells (pre-treatment, week 12, after 28 weeks of therapy, 
and at progression/or coming off protocol treatment). 
 
The rationale, and a brief overview, for collection and handling of these specimens is 
as described below. Further technical details regarding biopsies of metastatic sites and 
handling of these biopsy specimens can be found in Appendices B and C, respectively.   
 
9.1.1a Biopsy of metastatic site: Rationale and Procedure (Appendices B and C) 
 
a. Preclinical and clinical data indicates that palbociclib primarily exerts its effect via 
inhibition of intact RB protein phosphorylation. Therefore, only patients with intact 
RB expression (as assessed by immunohistochemistry) will be randomized to 
palbociclib or control arms.  Thus all patients enrolled in this trial will either 
undergo a biopsy of a metastatic site or have previously underwent a biopsy of 
metastatic disease with evaluable tissue to determine RB status prior to 
randomization. 
 
 
 

55 
 
b. Biopsies must be scheduled for Monday to Thursday to allow for overnight 
shipping to be received by Friday. 
 
c. Patients will be scheduled for a CT-guided biopsy of a bone or soft tissue abnormality 
consistent with prostate cancer metastasis. The site of biopsy will be determined by 
the radiologist after review of available radiographs, CT, MRI, and/or bone scan, 
and will be selected based on whatever site is expected to result in the best access 
and best yield.   
 
 An ultrasound (US) can be used for lymph node or soft tissue biopsies 
provided that the target lymph node or soft tissue mass is visible with the US 
and can be properly accessed. 
 
 Verbal and written informed consent will be obtained after discussion of 
risks (bleeding, infection, soft tissue and bone injury, inconclusive biopsy 
results) of the procedure.   
 
 Standard laboratory tests to assess coagulation and bleeding will also be 
completed prior to the procedure. A standard operating procedure for bone 
biopsy is provided in Appendix B.  A standard operating procedure for 
soft tissue biopsy is provided in Appendix C. 
 
 In order to ensure adequate tumor sample as long as it is deemed safe and 
based on accessibility, target lesion size, specimen integrity, specimen 
appearance, intra-procedural bleeding, tumor biopsy should attempt to obtain: 
 
1. Bone biopsy: 2-8 bone biopsy samples.   In addition, at the time of 
biopsy, it will be determined if a bone marrow aspirate is feasible, and 
if performed, the bone marrow aspirate will be sent to University of 
Michigan for analysis. 
 
2. Lymph node or soft tissue: If obtaining a 1-cm-long 18-gauge core 
specimen, attempts should be made to obtain at least 6 cores.  If 
obtaining a 2-cm-long 18-gauge core specimen, attempts should be 
made to obtain at least 4 cores.   
 
If core biopsy is unsuccessful, a lymph node aspirate can be obtained, 
but is likely to be insufficient to allow Rb status determination and 
randomization. 
 
d.  The biopsy specimens and the aspirate will be collected and will be immediately 
frozen in dry-ice ethanol bath in Tissue-Tek O.C.T Compound (Sakura Finetek, 
Torrance, CA) to ensure the integrity of tissue and proteins for both immunoblotting 
and immunohistological analysis of samples. Upon enrollment of each patient on study, 
sample kits containing necessary reagents for tissue collection (Tissue-Tek standard-
size cryomolds, Tissue-Tek OCT, blue pads, markers, and an insulated bucket) will be 
shipped to the enrolling site coordinator.   

56 
 
 
 It is expected that dry ice and isopentane will be provided by the enrolling site.   
 
In addition, written SOPs, with specific details regarding tissue collection with this kit, 
along with a contact sheet with mailing addresses for sample shipment, will be mailed 
to each site coordinator. 
e.  Each Tissue-Tek cryomold will be labeled with the clinical protocol number, the 
patient’s study registration number,  the tissue type and the biopsy time and date.  In 
addition, a separate information sheet accompanying each specimen will be filled out. 
This information sheet will include various details necessary for quality assurance of 
the specimen, including: 
 
1) Date of collection 
2) Specimen ID 
3) Site from which biopsy obtained (bone versus soft tissue, and then location) 
4) Type of biopsy device 
5) Biopsy diameter: gauge, and length: cm 
6) Time biopsy needle introduced 
7) Time biopsy snap-frozen on dry ice 
8) Time aspirate performed (if applicable) 
9) Time aspirate snap-frozen on dry ice 
 
A standard operating procedure for handling of the biopsy and aspirate 
specimens has been attached to this protocol as Appendix B. 
 
Following biopsy, samples from metastatic sites need to be immediately frozen prior 
to shipment within 24 hours to the University of Michigan, per shipping directions 
described in 9.1.2. 
 
9.1.1b Archived Prostate Cancer Samples: Rationale and Procurement Procedure 
 
Occasionally, newly metastatic prostate cancer is identified by biopsy at the time of 
diagnosis or resection.  This tissue may be utilized for RB status assessment, trial 
enrollment and randomization if it is of adequate quality for IHC analysis of RB status. 
Additionally, previous diagnostic tissue is being requested from all patients to assess 
whether RB status and other correlative markers are maintained between diagnostic 
and metastatic samples with or without previous hormonal therapy.   
 
If resection specimens are available (preferred): The block with the highest volume of 
representative tumor histology from the index focus OR 16 unstained, unbaked sections 
(4-5 microns in thickness) on glass slides (charged or uncharged) should be shipped at 
room temperature to the University of Michigan.  
If biopsy specimens are available: Three blocks with the highest volume of 
representative tumor histology OR 15 unstained, unbaked sections (4-5 microns in 
thickness) on glass slides (charged or uncharged) from up to three blocks should be 
shipped at room temperature to the University of Michigan. If unstained sections are 
sent, they should be labeled with the block number/letter. If less than three blocks have 

57 
 
cancer, then all blocks with cancer OR as many unstained sections as can be cut from 
blocks with cancer without exhaustion should be sent.   
 
 
9.1.1c: Circulating Tumor Cells: Rationale and Sample Collection Procedure  
 
Blood will be collected pre-treatment, week 12, after 28 weeks of therapy, and at 
progression/or coming off protocol treatment.  Blood samples will be drawn into 10-mL 
evacuated blood draw tube (Cell-Free DNA; Streck) (one at each time point). These 
blood samples can be maintained at room temperature, but must be shipped to Epic 
Sciences within 48 hours after collection, per shipping directions described in 9.1.2.  
 
 
9.1.1d: Circulating Tumor DNA: Rationale and Sample Collection Procedure  
 
Blood will be collected pre-treatment, week 12, after 28 weeks of therapy, and at 
progression/or coming off protocol treatment. Blood samples will be drawn into 10-mL 
evacuated blood draw tubes (Cell-Free DNA; Streck) (one at each time point). These blood 
samples can be maintained at room temperature, but must be shipped to University of 
Michigan within 48 hours after collection, per shipping directions described in 9.1.2. 
 
9.1.2 Shipping of Specimens after Collection 
 
All samples, except the blood samples for CTC analysis, must be shipped to the 
University of Michigan, at the following address: 
 
Javed Siddiqui, MS, MT(ASCP, CLsp (MB)) 
Technical Director 
Michigan Center for Translational Pathology 
Room 1138  
2900 Huron Parkway Suite 100 
Ann Arbor, MI 48105 
Phone: (734) 232-0829 
Fax: (734) 232-0805 
siddiqui@med.umich.edu 
 
Shipping must occur only Monday-Thursday, and an e-mail or phone call to the 
contact listed on the laboratory contact sheet, alerting them to the shipment, is 
required.  
 
9.1.2a Biopsies and aspirates from metastatic sites: If biopsies are performed on 
metastatic sites on Monday through Thursday, the biopsy and aspirate samples should 
be shipped overnight, on dry ice, to the University of Michigan.  
 
9.1.2b Archived Primary Prostate Cancer Tissue: The tumor samples can be 
shipped via standard mail, at room temperature, to the University of Michigan.  It is 
requested that efforts be made to ship the primary tumor samples within a month of 
patient enrollment onto the trial. 
 

58 
 
9.1.2c Blood samples NOT for CTC analysis: Blood samples should be obtained on 
Monday through Thursdays, and can be shipped overnight, at room temperature, to 
the University of Michigan.   
 
9.1.2d Blood samples for CTC analysis: The blood samples should be shipped 
overnight, at room temperature, to Epic Sciences, at the following address: 
 
Epic Sciences  
9381 Judicial Drive, STE 200 
San Diego, CA 92121  
858-356-6610  
 
Shipping must occur only Monday-Thursday, and an e-mail should be sent to 
partners@epicsciences.com, alerting to the shipment, the inclusion of the sample 
ID, number of samples, tracking number, and time of blood draw, is required.  
Please note that the Epic Sciences shipping address is to be used ONLY FOR 
THE CTC SAMPLES, and that the remainder of the samples (metastases, 
archived primary tumor, other blood samples) should be sent to the University 
of Michigan address listed above section 9.1.2. 
 
For further details regarding shipping, please refer to Appendix D, E & F which 
are  the standard operating procedures for the shipment of samples.   
 
9.1.3 Sites Performing Correlative Studies  
 
Aside from the circulating tumor cell studies, all correlative studies will be performed at 
the University of Michigan, within the Michigan Center for Translational Pathology 
(MCTP). Dr. Felix Feng, translational co-investigator, and Dr. Scott Tomlins, study 
pathologist, will oversee these correlative studies, with additional consultation provided 
Dr. Karen Knudsen, translational co-investigator. The circulating tumor cell studies will 
be performed by Epic Sciences. 
 
9.1.4 Processing of Specimens after Receipt at the University of Michigan 
 
a. With the receipt of each biopsy specimen, Javed Siddiqui at the University of 
Michigan (or a pre-specified designee) will place the samples in the -80˚C tissue 
repository described below and will record two additional items for further quality 
assurance: 
 
1) The date/time of receipt of the biopsy specimen at the University of Michigan 
 
2) The date/time that the biopsy specimen is placed at -80°C 
 
b. Biopsies from metastatic sites: The frozen tissue samples from either biopsy or from 
preexisting metastatic tissue, obtained for research from patients taking part in this 
protocol will be held in the University of Michigan Prostate Oncology Program Tissue 
Bank.  The Tissue Bank is located in Room 1143, 2900 Huron Parkway, Suite 100, 
University of Michigan, Ann Arbor, Michigan 48105. This laboratory has multiple -
80˚C freezers, one of which will be devoted to the biopsies from this trial. The freezers 

59 
 
have an alarm system and self-dialing emergency system. It is anticipated that at least 
two samples will be obtained from each metastatic biopsy.   
 
From bone biopsies, these metastases may consist of two biopsies or a biopsy and an 
aspirate. One sample from each metastatic biopsy (the biopsy sample in cases where 
there is a biopsy sample and an aspirate) will be fixed in formalin shortly after receipt 
at the University of Michigan.  Eight 5 um section slides will be cut from this formalin 
fixed sample -- one for H&E staining to confirm the presence of tumor, two for 
determination of RB status and the others for correlative studies.  The remaining 
formalin-fixed 
metastatic 
biopsy 
sample 
will 
be 
utilized 
for 
targeted 
transcriptome/genome sequencing.  Where feasible, transcriptome sequencing and 
whole exome capture will be performed on remaining frozen metastatic biopsy 
materials. 
 
c. Primary tumor samples: Retrieved primary tumor samples will be stored at room 
temperature in the University of Michigan Prostate Oncology Program Tissue 
Bank, and will be assessed for RB pathway biomarkers, as well as for genetic 
alterations by focused targeted transcriptome/genome sequencing.  
 
d. Blood samples for circulating tumor DNA studies: Blood samples received will 
have genomic DNA extracted per standard protocols.  Samples will then be stored 
in -80C freezer.  Further analyses of these blood samples will proceed once the 
genomic studies have been performed on the biopsy samples.24-28 
 
e. Blood samples for circulating tumor cell studies:  The Epic Sciences platform will be 
utilized for circulating tumor cell analyses.24-28 Peripheral blood samples will be drawn 
at accruing sites following informed consent and processed following standard 
operating procedures. Using a standardized and ISO-certified shipping process, 
samples are transferred to the Epic Sciences central laboratory. Samples are then 
processed after 48 hours of blood draw. The red blood cells are lysed and the remaining 
nucleated cells are plated on custom glass slides and frozen for storage. As needed, 
blood sample slides are thawed and processed to bind the appropriate cell markers with 
fluorescently labeled antibodies. Depending on peripheral blood counts, up to 16 slides 
are generated from each subject. Two to four processed slides, representing one patient 
test, the identification of CTCs consists of three markers (DAPI-nucleus, cytokeratin – 
epithelial marker, and CD-45 – white blood cell marker) and are imaged on custom-
built automated slide imagers. The resulting images are then automatically processed 
to produce data for technical analysis which consists of removing imaging artifacts and 
selecting potential CTC candidates which are then presented in a web-based report to 
a pathologist for final review. Remaining slides are stored for subsequent analysis.  
These subsequent analyses will include immunofluorescence for the androgen receptor 
(AR), including AR C-terminal and AR N-terminal expression.  
9.2   Description of RB Assessment and Correlative Studies  
 
9.2.1 RB Status Determination  
As part of the patient selection for this trial, patients will undergo 
immunohistochemistry (IHC) for total RB status in a CLIA certified laboratory, per a 
previously published RB IHC protocol.32 IHC will be performed for RB using a mouse-

60 
 
anti-RB monoclonal antibody (BD Biosciences, San Jose, CA, G3-245) using 
automated IHC staining on the Ventana Medical Systems Benchmark Ultra autostainer. 
Slides are pre-treated with CC1 for 40 minutes, incubated with primary antibody for 16 
minutes at 37 C (1:1600 dilution in Ventana diluent 90040). Tumor RB status will be 
determined by assessing staining in at least 100 tumor cells (or all cells if less than 100 
cells are present). Nuclear RB staining intensity in tumor cells will be assessed as 
negative (0), weak (1+), moderate (2+) or strong (3+). Inflammatory, endothelial and/or 
stromal cells will be used as internal positive controls. Based on validation studies 
using samples with known RB retention or deletion, tumor samples with >5% of cells 
showing at least moderate RB expression or 20% of tumor cells showing at least weak 
RB expression will be considered positive and eligible for the trial. For correlative 
studies, RB staining will be quantified in positive patients by multiplying the 
percentage of positive tumor cells by the average intensity of positive tumor cells 
(1=weak, 2=moderate, 3=strong).     
 
9.2.2 Identification of Biomarkers Predictive of Responsiveness to Palbociclib 
The RB pathway can be disrupted in human cancers via multiple mechanisms,5 and 
because alterations in the RB pathway could modulate the response to palbociclib, 
correlative studies will assess for potential biomarkers along the RB pathway via 
multiplexed IHC.  Because the RB protein can be inactivated by posttranslational 
modifications 
that 
are 
the 
subject 
of 
oncogenic 
(e.g., 
cyclin 
D1 
overexpression/amplification) or tumor suppressive (e.g., p16ink4a silencing) 
alterations, IHC for cyclin D1, cyclin D1B (a variant associated with aggressive 
disease), and p16 will be performed.33 Additionally, as RB also plays a critical role in 
the response to many antiproliferative stresses that are engaged by therapeutic agents,5 
immunohistochemistry will also be performed for Ki-67, a common marker of cell 
proliferation.  As previous studies from our group have defined a signature of RB loss,7 
immunohistochemistry will be performed for key RB target genes (such as Cyclin A 
and MCM7).  Finally, we will also assay the status of the RB interactor, E2F1, via IHC. 
In both the primary tumor samples and metastatic biopsies, IHC biomarkers will be 
quantified by multiplying the percentage of positive tumor cells by the average 
intensity of positive tumor cells (0=negative to 3=strong) by experienced pathologists. 
For Ki-67, proliferative index will be determined by quantifying the percentage of 
tumor cells with nuclear staining. Statistical analyses plans for these correlative studies 
are described in Section 13. 
 
 
9.2.3 Targeted DNA sequencing and expression profiling.  While the ultimate goal 
would be to perform comprehensive sequencing (see below) on all the biopsy studies 
from this clinical trial, the tissue limitations regarding tumor quantity may preclude 
comprehensive sequencing on a subset of samples.  Specifically, in patients in which 
only one biopsy core can be obtained, this single core will be converted to a formalin-
fixed paraffin embedded (FFPE) specimen, to allow assessment of the primary 
biomarker (RB) using a validated assay (IHC) in a CLIA-certified laboratory.  While 
comprehensive sequencing cannot be reliably performed on FFPE biopsy specimens, 
targeted sequencing and expression profiling can be performed on these limited FFPE 
tissues. Specifically, we will assess a novel panel of recurrent alterations identified 

61 
 
across prostate cancer profiling studies.  
 
DNA and RNA will be co-isolated using a commercially available kit (Qiagen All Prep 
DNA/RNA FFPE) according to the manufacturer’s instructions. For DNA based 
alterations, a Haloplex custom capture panel (Agilent Technologies) will be utilized 
with Ion Torrent-based sequencing on the PGM/Proton sequencing systems according 
to the manufacturer’s instructions. Our team (S Tomlins) has previously developed a 
Haloplex Custom Design (Agilent) for capture-based targeted sequencing of complete 
coding sequences of 80 genes previously reported as significantly mutated in prostate 
cancer, 46 therapeutic targets, and 50 causal cancer genes; this approach has been 
optimized for 200 ng of genomic DNA.  We will adapt this platform to include potential 
biomarkers of response as identified in Section 9.2.1.  Identified variants will be 
assessed for potential as drivers of resistance to CDK4/6 inhibition or ADT based on 
known roles in oncogenesis and prostate cancer, comparison to Oncomine and 
COSMIC mutational data, and comparison to CRPC tissue expression profiles (as 
previously published by our group and others16,34), and integration with AR chip-seq 
profiles.35  
 
qPCR for targeted gene expression profiling will be performed using a previously 
validated panel of 48 prostate cancer related genes, supplemented with potential 
biomarkers of response as identified in Section 9.2.1. Reverse transcription will be 
performed on 300ng of isolated RNA from each tissue sample using gene specific 
priming with subsequent qPCR using FFPE optimized TaqMan assays. Genes have 
been selected to assess AR signaling status (including both AR induced/repressed and 
neuroendocrine genes), known prostate cancer fusions (through 5’ and 3’ assays for 
ETS genes, FGFR2, RAF/RAS family members, etc), potential therapeutic targets in 
other malignancies (such as 5’ and 3’ assays for ALK and RET over-expression), as 
well as housekeeping genes. qPCR will be performed on the ABI Quantstudio 12K flex 
system using TaqMan Universal PCR Mastermix and 384 well TLDA cards. 
 
9.2.4 Comprehensive next-generation sequencing.  For specimens in which enough 
tumor tissue was present (i.e., additional frozen biopsy specimens), exome sequencing 
and RNA-sequencing using Illumina based technology will be performed as described 
using robust protocols and pipelines previously optimized by our team.16,35-39 Standard 
pipelines will be employed as described to quantify gene expression, and identify gene 
fusions, point mutations, indels and copy number variants.  
 

62 
 
9.2.5 Circulating tumor DNAs as predictive biomarkers of response to androgen 
deprivation therapy alone or in combination with Palbociclib. 
 
Detection of DNA in the serum of patients with metastatic prostate cancer, may allow 
determination of tractable biomarkers of disease status and responsiveness to therapies.  
Here we will collected and analyze serum for circulating tumor DNA to determine if 
we can identify markers of disease state and responsiveness.40  In particular, potential 
biomarkers identified via targeted sequencing and expression profiling of the metastatic 
biopsy samples (see 9.2.3) will be assessed within the blood samples as well, to 
determine if these blood samples can serve as a less invasive approach of querying 
relevant biomarkers. 
 
 
9.2.6 Circulating Tumor Cell (CTC) Count and Heterogeneity as predictive 
biomarkers of response to androgen deprivation therapy alone or in combination 
with Palbociclib.  CTCs will be enumerated using the Epic Sciences System utilizing 
automated fluorescence- based microscopy systems that permit computer-generated 
reconstruction of cellular images. In addition, immunofluoresence-based approaches 
assessing for CK, CD45, DAPI, and AR expression will be used to determine the extent 
of CTC heterogeneity (distribution of CTC phenotypes, such as nucleoli CTCs, CTC 
clusters, CK- CTCs, CK speckled CTCs, small CTCs, AR nuclear CTCs, and AR 
cytoplasmic CTCs).  Associations between outcome and CTC count/heterogeneity will 
be performed as per Section 13.4.  
 
 

63 
 
10. STUDY CALENDAR 
 
 
Cycle 1 
Cycle 2-7 
Subsequent Cycles  
Off 
Treatme
nt g 
Required 
Treatment or 
Studies 
Pre- 
Study 
Day 
1 
Day 
8 
Day 
15 
Day 
21 
Day 
28 
Day 
1 
Day 
8 
Day 
15 
Day 
21 
Day 
28 
ARM 1 ADT 
Alone 
ARM 2 
palbociclib + 
ADTh 
Bicalutamide 
 
X---------------------------------------------------------------------------------X 
Daily 
Daily 
 
LHRH Therapy 
 
X---------------------------------------------------------------------------------X 
Continuous 
Continuous 
 
PD-0332991 (Arm 
2) 3 weeks on /1 
week offh 
 
X-------------------------X 
 
X-------------------------X 
 
NA 
Days 1-21 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
History & Physical 
X 
X 
 
 
 
 
X 
 
 
 
 
Every 12 
weeks 
Every 12 
weeks 
X 
Weight & PS 
X 
X 
 
 
 
 
X 
 
 
 
 
Every 12 
weeks 
Every 12 
weeks 
X 
Height 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Concurrent meds 
X 
X 
 
 
 
 
X 
 
 
 
 
Every 12 
weeks 
Every 12 
weeks 
 
Metastatic disease 
biopsy 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serum PSAa 
X 
X 
 
 
 
 
X 
 
 
 
 
Every 4 weeks 
Every 4 weeks 
X 
CBC w/diff, pltsb 
X 
X 
X 
X 
 
 
X 
 
Xb 
 
 
Every 12 
weeks 
Every 4 weeks 
X 
Serum chemistryc 
X 
X 
X 
X 
 
 
X 
 
 
 
 
Every 12 
weeks 
Every 4 weeks 
X 
PT/PTT/INR 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Correlative Blood 
Samples for 
circulating tumor 
DNA and CTC 
analysisd 
 
X 
 
 
 
 
Xd 
 
 
 
 
Xd 
Xd 
Xd 
EKG e 
X 
 
 
 
 
 
Xe 
 
 
 
 
 
 
 
Archived Tissues 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adverse event 
evaluation 
 
X----------------------------------------------------------------------------------X 
X 
X 
X 
Tumor 
measurement 
X 
Measured  after 28 weeks  +/- 1 week 
Measure every 24 weeks(+/- 1 
week) for 2 years then annually 
unless clinically indicated 
X 
Radiologic 
evaluation f 
X 
X 
a:  For patients who are initiated on ADT prior to registration, pre androgen deprivation PSA should be recorded. 
b:  Arm 2 may consider adding additional interim CBCPD during additional cycles if clinically indicated.  Arm 1 patients do not need repeat CBC during any cycle unless 
medically indicated. 
c:  Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, phosphorus, potassium, total protein, SGOT [AST], SGPT 
[ALT], sodium, magnesium.  Arm 1 patients do not need repeat Chemistry during cycle 1 unless medically indicated. 
d: Pretreatment, week 12, after 28 weeks of therapy, and at progression/or coming off protocol treatment. 
e: EKG should be done on day 1 of cycle 2 for arm 2 patients.  If there is no abnormality, then no additional EKG’s are needed.  If abnormal, then monthly EKG for 7 
cycles can be performed.  Arm 1 patients do not need repeat EKG unless clinically indicated 
f.  Include bone scan, CT/MRI abdomen and pelvis, CT/MRI chest or CXR as appropriate.   All disease sites must be reassessed. 
g:  Follow-up for patients taken off treatment for reasons other than progression will be done every 12 weeks. These visits will include H&P and labs as outlined in 
subsequent cycle arm 1 column.  Imaging will be done q 24 weeks.  Clinical, Lab and imaging will be done for 2 years or until progression whichever comes first. 

64 
 
A cycle is 28 days. For both arms scans to assess disease will be performed after 28 weeks calculated from “Day 1” 
of protocol.  Return visits after initiation of therapy can be done within ± 4 days from actual due date.  Lab draws for 
Arm 2 (CBC w/diff, plts and Serum chemistry) on Cycle 1 (days 8 and 15), and Cycles 2-7 (D15) can be done ± one 
day.  
 
 
h:  For patients coming every 12 weeks appropriate supply of palbociclib can be provided per institutional guidelines and careful instructions regarding the dosing.  
 

65 
 
11. 
MEASUREMENT OF EFFECT 
 
 For the purposes of this study, patients will have a PSA evaluation at the start of each new 
cycle with primary endpoint assessment after 28 weeks of therapy.  Radiologic response 
will be determined after 28 weeks plus or minus 1 week (or as prompted by symptoms) 
and every 24 weeks plus or minus 1 week thereafter while on study for 2 years, then 
annually and otherwise if clinically indicated. 
 
 Response and progression will be evaluated in this study using the new international 
criteria proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) 
guideline (version 1.1).41  Changes in the largest diameter (unidimensional measurement) 
of the tumor lesions and the shortest diameter in the case of malignant lymph nodes are 
used in the RECIST criteria. 
 
11.1 
Definitions 
 
Evaluable for toxicity.  All patients will be evaluable for toxicity from the time of 
their first treatment with ADT with or without palbociclib. 
 
Evaluable for primary endpoint.  All patients randomized to either Arm 1 or Arm 2 
and receive at least one cycle of therapy or are removed from treatment due to 
toxicity are evaluable. Patients who are randomized but do not complete 1 cycle of 
treatment due to reasons other than toxicity will be replaced. 
 
Evaluable for objective response.  Only those patients who have measurable disease 
present at baseline and have had their disease re-evaluated will be considered 
evaluable for response.  These patients will have their response classified according 
to the definitions stated below.   
 
Evaluable non-target disease response.  Patients who have lesions present at 
baseline that are evaluable but do not meet the definitions of measurable disease 
and have had their disease re-evaluated will be considered evaluable for non-target 
disease.  The response assessment is based on the presence, absence, or unequivocal 
progression of the lesions.  
 
Measurable disease.  Measurable lesions are defined as those that can be accurately 
measured in at least one dimension (longest diameter to be recorded) as >20 mm 
by chest x-ray, as >10 mm with CT scan, or >10 mm with CT scan, MRI, or calipers 
by clinical exam.  All tumor measurements must be recorded in millimeters (or 
decimal fractions of centimeters). 
 
Note:  Tumor lesions that are situated in a previously irradiated area might or might 
not be considered measurable.  Decision should be made in consultation with 
primary investigator. 
 
Malignant lymph nodes.  To be considered pathologically enlarged and measurable, 
a lymph node must be >15 mm in short axis when assessed by CT scan (CT 

66 
 
scan slice thickness recommended to be no greater than 5 mm).  At baseline and in 
follow-up, only the short axis will be measured and followed. 
 
Non-measurable disease.  All other lesions (or sites of disease), including small 
lesions (longest diameter <10 mm or pathological lymph nodes with ≥10 to <15 
mm short axis), are considered non-measurable disease.  Bone lesions, 
leptomeningeal disease, ascites, pleural/pericardial effusions, lymphangitis 
cutis/pulmonitis, inflammatory breast disease, and abdominal masses (not followed 
by CT or MRI), are considered as non-measurable. 
 
Note:  Cystic lesions that meet the criteria for radiographically defined simple cysts 
should not be considered as malignant lesions (neither measurable nor non-
measurable) since they are, by definition, simple cysts. 
 
‘Cystic lesions’ thought to represent cystic metastases can be considered as 
measurable lesions, if they meet the definition of measurability described above. 
However, if non-cystic lesions are present in the same patient, these are preferred 
for selection as target lesions. 
 
Target lesions.  All measurable lesions up to a maximum of 2 lesions per organ and 
5 lesions in total, representative of all involved organs, should be identified as 
target lesions and recorded and measured at baseline.  Target lesions should be 
selected on the basis of their size (lesions with the longest diameter), be 
representative of all involved organs, but in addition should be those that lend 
themselves to reproducible repeated measurements.  It may be the case that, on 
occasion, the largest lesion does not lend itself to reproducible measurement in 
which circumstance the next largest lesion which can be measured reproducibly 
should be selected.  A sum of the diameters (longest for non-nodal lesions, short 
axis for nodal lesions) for all target lesions will be calculated and reported as the 
baseline sum diameters.  If lymph nodes are to be included in the sum, then only 
the short axis is added into the sum.  The baseline sum diameters will be used as 
reference to further characterize any objective tumor regression in the measurable 
dimension of the disease. 
 
Non-target lesions.  All other lesions (or sites of disease) including any measurable 
lesions over and above the 5 target lesions should be identified as non-target 
lesions and should also be recorded at baseline.  Measurements of these lesions are 
not required, but the presence, absence, or in rare cases unequivocal progression of 
each should be noted throughout follow-up.  
 
11.2     Response and Progression Criteria 
 
11.2.1  Outcomes based on post-therapy PSA changes  
 
o Primary Endpoint will be stable or declining PSA < 4ng/mL after 28 weeks of 
therapy 
 

67 
 
o Secondary Endpoint will be rate of undetectable PSA  after 28 weeks of therapy 
(<0.2ng/mL) 
 
o These definitions are intended to characterize the PSA changes on study for the 
purpose of reporting of results.    
 
Complete Response (CR): Undetectable PSA (<0.2 ng/ml) that is confirmed by 
another PSA level at no less than 4 weeks interval. 
 
Partial Response (PR): PSA level between 0.2ng/ml and 4ng/ml.. 
 
Stabilization (SD): Patients who do not meet the criteria for PR or PD for at least 
90 days on study (2 cycles of treatment) will be considered stable 
 
Progression (PD): 25% increase over baseline or nadir whichever is lower and an 
increase in the absolute value of PSA level by 2 ng/ml that is confirmed by another 
PSA level at no less than 4 weeks interval. 
 
 
11.2.2  Outcomes based on evaluation of target lesions 
 
 
 
 
 
Complete Response (CR):  Disappearance of all target lesions.  Any pathological 
lymph nodes (whether target or non-target) must have reduction in short axis to <10 
mm. 
 
 
 
 
 
Partial Response (PR):  At least a 30% decrease in the sum of the diameters of 
target lesions, taking as reference the baseline sum diameters. 
 
 
 
 
 
Progressive Disease (PD): 
At least a 20% increase in the sum of the diameters 
of target lesions, taking as reference the smallest sum on study (this includes the 
baseline sum if that is the smallest on study).  In addition to the relative increase of 
20%, the sum must also demonstrate an absolute increase of at least 5 mm.  (Note: 
the appearance of one or more new lesions is also considered progressions). 
 
 
 
 
 
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum diameters while on 
study. 
 
11.2.3  Evaluation of Non-Target Lesions 
 
 
 
 
 
Complete Response (CR): Disappearance of all non-target lesions and 
normalization of tumor marker level.  All lymph nodes must be non-pathological 
in size (<10 mm short axis). 
 
 
 
Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or 
maintenance of tumor marker level above the normal limits. 
 
Progressive Disease (PD):  Appearance of one or more new lesions and/or 

68 
 
unequivocal progression of existing non-target lesions.  Unequivocal progression 
should not normally trump target lesion status.  It must be representative of overall 
disease status change, not a single lesion increase.     
Although a clear progression of “non-target” lesions only is exceptional, the 
opinion of the treating physician should prevail in such circumstances, and the 
progression status should be confirmed at a later time by the review panel (or 
Principal Investigator). 
 
11.2.4  Outcomes based on Radionuclide bone scans  
 
The subjectivity in interpreting serial changes in a radionuclide bone scan is well 
recognized.  Thus, the primary outcome will be whether the scan is stable or 
improved, vs. worse or progression.  Changes in intensity will not be used as an 
outcome measure. 
 
Stable or Improved: A stable or improved classification requires that no new 
lesions appear or that new pain has not developed in an area that was previously 
visualized. 
 
Progression (Non-Response): Appearance of two or more new skeletal lesions. 
An increase in the size or intensity of known skeletal lesions will not be 
considered progression. 
 
    
11.3 Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a ruler or calipers.  
All baseline evaluations should be performed as closely as possible to the beginning of 
treatment and never more than 6 weeks before registration.  
 
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is 
preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be 
imaged but are assessable by clinical exam. 
 
Clinical lesions:  Clinical lesions will only be considered measurable when they are 
superficial (e.g., skin nodules and palpable lymph nodes) and 10 mm diameter as 
assessed using calipers (e.g., skin nodules).  In the case of skin lesions, 
documentation by color photography, including a ruler to estimate the size of the 
lesion, is recommended.  
 
Chest x-ray:  Lesions on chest x-ray are acceptable as measurable lesions when they 
are clearly defined and surrounded by aerated lung.  However, CT is preferable.  
 
Conventional CT and MRI:  This guideline has defined measurability of lesions on 
CT scan based on the assumption that CT slice thickness is 5 mm or less.  If CT 

69 
 
scans have slice thickness greater than 5 mm, the minimum size for a measurable 
lesion should be twice the slice thickness.  MRI is also acceptable in certain 
situations (e.g. for body scans).   
 
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and 
temporal resolution; however, there are many image acquisition variables involved 
in MRI, which greatly impact image quality, lesion conspicuity, and measurement.  
Furthermore, the availability of MRI is variable globally.  As with CT, if an MRI 
is performed, the technical specifications of the scanning sequences used should be 
optimized for the evaluation of the type and site of disease.  Furthermore, as with 
CT, the modality used at follow-up should be the same as was used at baseline and 
the lesions should be measured/assessed on the same pulse sequence.  It is beyond 
the scope of the RECIST guidelines to prescribe specific MRI pulse sequence 
parameters for all scanners, body parts, and diseases.  Ideally, the same type of 
scanner should be used and the image acquisition protocol should be followed as 
closely as possible to prior scans.  Body scans should be performed with breath-
hold scanning techniques, if possible. 
 
 
 
Bone disease:  Bone disease will be evaluated using Radionuclide bone scan. 
 
11.4 
Progression-Free Survival: 
 
Progression-free survival (PFS) is defined as the duration of time from start of treatment 
to time of progression or death, whichever occurs first. 
 
11.5 
Evaluation of Best Overall Response 
 
 
The best overall response is the best response recorded from the start of the treatment 
until disease progression/recurrence (taking as reference for progressive disease the 
smallest measurements recorded since the treatment started).  The patient's best response 
assignment will depend on the achievement of both measurement and confirmation 
criteria. 
 
 
 For Patients with Measurable Disease (i.e., Target Disease) 
 
Target 
Lesions 
Non-Target 
Lesions 
New 
Lesions 
Overall 
Response 
Best Overall Response 
when Confirmation is 
Required* 
CR 
CR 
No 
CR 
>4 wks. Confirmation** 
CR 
Non-
CR/Non-PD 
No 
PR 
>4 wks. Confirmation** 
CR 
Not 
evaluated 
No 
PR 
PR 
Non-
CR/Non-
PD/not 
evaluated 
No 
PR 

70 
 
SD 
Non-
CR/Non-
PD/not 
evaluated 
No 
SD 
Documented at least once 
>4 wks. from baseline** 
PD 
Any 
Yes 
or 
No 
PD 
no prior SD, PR or CR 
Any 
PD*** 
Yes 
or 
No 
PD 
Any 
Any 
Yes 
PD 
* 
See RECIST 1.1 manuscript for further details on what is evidence of a 
new lesion. 
** 
Only for non-randomized trials with response as primary endpoint. 
*** 
In exceptional circumstances, unequivocal progression in non-target 
lesions may be accepted as disease progression. 
Note: Patients with a global deterioration of health status requiring 
discontinuation of treatment without objective evidence of disease 
progression at that time should be reported as “symptomatic 
deterioration.”  Every effort should be made to document the objective 
progression even after discontinuation of treatment. 
 
For Patients with Non -Measurable Disease (i.e., Non Target Disease) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
11.6 
Duration of Response 
 
11.6.1 Duration of overall response:  The duration of overall response is measured from the 
time measurement criteria are met for CR or PR (whichever is first recorded) until the first 
date that recurrent or progressive disease is objectively documented (taking as reference for 
progressive disease the smallest measurements recorded since the treatment started). 
 
The duration of overall CR is measured from the time measurement criteria are first met for 
CR until the first date that progressive disease is objectively documented. 
 
 
Non-Target 
Lesions 
New Lesions 
Overall 
Response 
CR 
No 
CR 
Non-CR/non-PD 
No 
Non-CR/non-
PD* 
Not all evaluated 
No 
not evaluated 
Unequivocal PD 
Yes or No 
PD 
Any 
Yes 
PD 
*  ‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since SD 
is increasingly used as an endpoint for assessment of efficacy in some trials so 
to assign this category when no lesions can be measured is not advised 

7 1 
 
1 1. 6. 2  D urati o n of sta ble disease:  Sta ble disease is meas ure d  fr o m t he start of t he treat me nt 
u ntil  t he  criteria  f or  pr o gressi o n  are met, ta ki n g as refere nce  t he  s mallest  meas ure me nts 
rec or de d si nce t he treat me nt starte d, i ncl u di n g t he baseli ne me as ure me nts.  
 
1 2.   
D A T A M A N A G E M E N T A N D M O NI T O RI N G  
 
1 2. 1   D at a a n d S afet y M o nit ori n g Pr oce d ures 
 
T he Data a n d Safet y M o nit ori n g B oar d ( D S M B) of T he U ni versit y of Mic hi ga n C o m pre he nsi ve 
Ca ncer  Ce nter  ( U M C C C)  is  t he  D S M B  f or  t his  st u d y.    T his  c o m mitt ee  is  res p o nsi ble  f or 
m o nit ori n g t he safet y a n d da ta i nte grit y of t he trial. 
 
Eac h partici pati n g site is re q uire d t o ha ve its o w n Data a n d Sa fet y M o nit ori n g C o m mittee ( D S M C) 
f or t he st u d y.  T his c o m mittee will be c o m p ose d of t he l ocal site pri nci pal i n vesti gat or, site c o-
i n vesti gat or(s),  site  data  ma na ger  or  st u d y  c o or di nat or  a n d  ot her  me m bers  of  t he  st u d y  staff 
i n v ol ve d i n t he c o n d uct of t he trial.  D uri n g t he c o m mittee’s q uarterl y meeti n g, t he site pri nci pal 
i n vesti gat or will disc uss matters relate d t o: 
 
  
E nr oll me nt rate relati ve t o e x pectati o ns, c haracteristics of partici pa nts 
  
Safet y of st u d y partici pa nts ( Seri o us A d verse E ve nt & A d verse E ve nt re p orti n g) 
  
A d here nce t o pr ot oc ol ( pr ot oc ol de viati o ns) 
  
C o m plete ness, vali dit y a n d i nte grit y of st u d y data 
  
Rete nti o n of st u d y partici pa nts 
 
T hese  meeti n gs  are  t o  be  d oc u me nte d  b y  t he  site  data  ma na ger  or   st u d y  c o or di nat or  usi n g  t he 
Pr ot oc ol  S pecific  Data  a n d  Safe t y  M o nit ori n g  Re p ort  ( D S M R),  si gne d  b y  t he  site  pri nci pal 
i n vesti gat or or c o-i n vesti gat or.  Eac h site is re q uire d t o s u b mit t he c o m plete d D S M R t o t he M ulti-
Site C o or di nat or at t he U ni versit y of Mic hi ga n Cli nical Trials Office o n a q uarterl y basis t o get her 
wit h ot her perti ne nt d oc u me nts. 
 
Si milarl y, pr ot oc ol de viati o ns are  t o be d oc u me nte d usi n g t he Notice of Pr ot oc ol De viati o n F or m 
a n d re q uires t he si g nat ures of b ot h t he sites data ma na ger or s t u d y c o or di nat or a n d t he site pri nci pal 
i n vesti gat or or c o-i n vesti gat or. T hese re p orts are t o be se nt t o t he U ni versit y of Mic hi ga n Cli nical 
Trials Office wit hi n 7 cale n dar da ys of a ware ness of t he e ve nt a n d o n a q uarterl y basis wit h t he 
Pr ot oc ol S pecific Data a n d Safet y M o nit ori n g Re p ort. 
 
T he Cli nical Trials Office is res p o nsi ble f or c ollati n g all t he  Data a n d Safet y M o nit ori n g Re p orts 
fr o m all t he partici pati n g sites, a n d pr o vi di n g t he i nf or mati o n t o t he Data Safet y M o nit ori n g B oar d. 
 
1 2. 2   Cli nic al M o nit ori n g Pr oce d ures 
 
Cli nical  st u dies  c o or di nate d  b y  T he  U ni versit y  of  Mic hi ga n  C o m p re he nsi ve  Ca ncer  Ce nter 
( U M C C C) m ust be c o n d ucte d i n acc orda nce wit h t he et hical pri nci ples t hat are c o nsiste nt wit h 
G o o d Cli nical Practices ( G C P) a n d i n c o m plia nce wit h ot her a p pl ica ble re g ulat or y re q uire me nts. 
A d verse  e ve nt  lists,  g ui deli nes,  a n d  i nstr ucti o ns  f or  A E  re p ort i n g  ca n  be  f o u n d  i n  Secti o n  8. 0 
( A d verse E ve nts: List a n d Re p orti n g Re q uire me nts). 
 

72 
 
This study will be monitored by a representative of the Clinical Trials Office (CTO) of the 
UMCCC. Monitoring visits will be made during the conduct of the study and at study close-out. 
 
Prior to subject recruitment, a participating site will undergo site initiation meeting to be conducted 
by the Clinical Trials Office. This will be done as an actual site visit; teleconference, 
videoconference, or web-based meeting after the site has been given access to the study database 
and assembled a study reference binder.  The site’s principal investigator and his study staff should 
make every effort in attending the site initiation meeting. Study–related questions or issues 
identified during the site initiation meeting will be followed-up by the appropriate UMCCC 
personnel until they have been answered and resolved. 
 
Monitoring of this study will include both ‘Centralized Monitoring’, the review of source 
documents at the CTO and ‘On-site Monitoring’, an actual site visit.  The first ‘Centralized’ visit 
should occur after the first subject enrolled completes the first treatment cycle.  The study site will 
send the de-identified source documents to the CTO for monitoring.  ‘Centralized’ monitoring may 
be requested by the CTO if an amendment requires changes to the protocol procedures. The site 
will send in pertinent de-identified source documents, as defined by the CTO for monitoring.  
 
The first annual ‘On-site’ monitoring visit should occur after the first five study participants are 
enrolled or twelve months after a study opens, whichever occurs first.  The annual visit may be 
conducted as a ‘Centralized’ visit if less than three subjects have enrolled at the study site.  The 
type of visit is at the discretion of the CTO.  At a minimum, a routine monitoring visit will be done 
at least once a year, or once during the course of the study if the study duration is less than 12 
months. The purpose of these visits is to verify: 
 
 Adherence to the protocol 
 Completeness and accuracy of study data and samples collected 
 Proper storage, dispensing and inventory of study medication 
 Compliance with regulations 
 
During a monitoring visit to a site, access to relevant hospital and clinical records must be given 
by the site investigator to the CTO representative conducting the monitoring visit to verify 
consistency of data collected on the CRFs with the original source data.  While most patient cases 
will be selected from patients accrued since the previous monitoring visit, any patient case has the 
potential for review.  At least one or more unannounced cases will be reviewed, if the total accruals 
warrant selection of unannounced cases.  
 
The Clinical Trials Office expects the relevant investigational staff to be available to facilitate the 
conduct of the visit, that source documents are available at the time of the visit, and that a suitable 
environment will be provided for review of study-related documents. Any issues identified during 
these visits will be communicated to the site and are expected to be resolved by the site in a timely 
manner.  For review of study-related documents at the CTO, the site will be required to ship or fax 
documents to be reviewed.   
 
Participating site will also undergo a site close-out upon completion, termination or cancellation 
of a study to ensure fulfillment of study obligations during the conduct of the study, and that the 
site Investigator is aware of his/her ongoing responsibilities. In general, a site close-out is 

73 
 
conducted during a site visit; however, site close-out can occur without a site visit if all of the 
following apply: 
 
 No patient has signed the Informed Consent Form and has enrolled into the study 
 Investigational agent has not been dispensed 
 All investigational agent and materials have been returned as defined for the study or 
destroyed and accounted for properly. 
 
12.3 
 Quality Assurance and Audits 
 
The Data Safety Monitoring Board can request a ‘for cause’ audit of the trial if the board identifies 
a need for a more rigorous evaluation of study-related issues. A “for cause” audit would be 
conducted by the Quality Assurance Review Committee (QARC) of the University of Michigan 
Comprehensive Cancer Center. 
 
A regulatory authority (e.g., FDA) may also wish to conduct an inspection of the study, during its 
conduct or even after its completion. If an inspection has been requested by a regulatory authority, 
the site investigator must immediately inform the Clinical Trials Office that such a request has 
been made. 
 
13. 
STATISTICAL CONSIDERATIONS 
 
 
13.1 Statistical Design 
 
The primary analysis will be assessment of the proportion of patients who achieve a 
PSA < 4ng/mL after 28 weeks of treatment in each arm.  For purposes of the primary 
endpoint, day 1 will be the randomization date for patients with pre-registration ADT 
treatment and the treatment start date for patients’ naïve to ADT at registration.  The 
difference in proportions will be reported with the mid p-value test of the 2X2 table 
with a one-sided type I error of 10%.   The binomial proportions with the corresponding 
Wilson score 90% binomial confidence intervals will also be reported by arm.  
 
The primary endpoint of the study is to compare the proportion of patients who have a 
PSA < 4ng/mL after 28 weeks of protocol treatment between patients stratified by pre-
registration ADT treatment and extent of disease and randomized to combined 
androgen deprivation (ADT: LHRH agonist + bicalutamide) and those randomized to 
combined ADT + palbociclib.  ADT alone (Arm 1) is expected to result in 70% of 
patients achieving PSA < 4ng/mL after seven months of protocol treatment.  It is 
hypothesized that the ADT + palbociclib arm (Arm 2) will have a 20% absolute 
increase in proportion to 90% (HA: p2 – p1 > 0).  The null hypothesis is no difference in 
proportions (H0: p2 – p1 ≤ 0).  Patients will be randomized using a 1:2 (Arm 1: Arm 2) 
schema stratified by extent of disease. Up to 95 patients may need to be registered 
(enrolled) in order to obtain the 60 evaluable patients. All patients randomized will be 
evaluable if they receive 1 cycle of treatment or are removed during treatment due to 
toxicity.  Patients who are randomized but do not complete 1 cycle of treatment due to 
reasons other than toxicity will be replaced.  With 20 evaluable patients on ADT alone 
and 40 evaluable patients on combination ADT + palbociclib, there is 64.2% power to 

74 
 
detect a 20% difference in proportions with a one-sided type I error of 0.10 using the 
mid p-value method of the Fisher’s exact test.  
 
With regard to power of the study, the focus of this trial is feasibility and to detect a 
signal, as described by our aims for this small targeted early phase II trial. The 
compromise of the power was done because of the overwhelming benefit to include a 
control population since there is no data on the rate of PSA declines after 28 weeks of 
ADT in the targeted RB positive population. The plan is to use the mid p-value test as 
it is a very close approximation to the one margin condition and is more powerful 
compared to the Fisher’s exact test, which is very conservative due to conditioning on 
both margins.42 
 
13.2 Analysis Plan 
The primary analysis will be assessment of the proportion of patients who achieve a 
PSA < 4ng/mL after 28 weeks of treatment in each arm.  The difference in proportions 
will be reported with the mid p-value method of the Fisher’s exact test of the 2X2 table.  
The binomial proportions with the corresponding Wilson score 90% binomial 
confidence intervals will also be reported by arm. 
 
Secondary endpoints include safety and tolerability.  Frequency of adverse event types 
will be reported for each arm by attribution and grade.  Duration of therapy, dose 
modifications and treatment delays will be reported to describe tolerability within each 
arm. 
 
The proportion of patients who achieve undetectable PSA (<0.2ng/mL), PSA response, 
and radiographic response will be reported by arm using methods described in the 
primary analysis.  Biochemical progression-free survival will begin from treatment 
start until the event of biochemical (PSA) progression (section 11.2) or death, 
whichever occurs first.  Patients who do not have either event will be censored at their 
last known PSA date.  Clinical progression-free survival will begin from treatment start 
until the event of clinical progression or death, whichever occurs first.  Patients who 
do not have either event will be censored at the date of their last known clinical 
measure.  Biochemical PFS and clinical PFS will be described by arm using Kaplan-
Meier methods and log-rank p-values will be reported. 
 
13.3 Correlative Endpoints Analyses 
  
 13.3.1  To determine whether cyclin D1, Cyclin D1B, Cyclin D3, p16, CDK4, 
Cyclin A or MCM7 levels in prebiopsy tissue as measured by IHC predict a subset 
of tumors responsive to palbociclib or overall response rates, logistic models will 
be used.  Logistic models including one marker in each model and response as the 
outcome will be performed.  The models for response rates will explore the one 
marker, treatment group, and the interaction of marker and treatment group to 
determine if the marker is associated with response by palbociclib.  Models of 
response rates with each marker without treatment group will be explored if 
treatment associations are not found. Exploration using multiple markers may be 
investigated using logistic modeling if there is indication that more than one marker 

75 
 
is associated with response.  This is an exploratory aim for discovery so multiple 
testing control will not be included. 
 
13.3.2 Concordance in RB status will be described between primary tumor, and 
metastases within patients using a generalized kappa.  Pairwise concordance will 
be described with proportions, McNemar’s test and kappa statistic. 
 
 13.3.3 To evaluate targeted sequencing and gene expression biomarkers that predict 
response to palbociclib, patients will be classified as responders or non-responders 
and individual biomarkers will be assessed for associations with response by 
Fisher’s exact tests or logistic regression. A comparison of the results for the subset 
of markers tested in 13.3.1 will be reported.  Similar approaches will be used with 
transcriptome/exome sequencing data. 
 
13.3.4 The number of and heterogeneity in circulating tumor cells at baseline, 
during treatment, and after treatment will be described by treatment arm.  Analyses 
will be exploratory. Models may be used to explore baseline CTCs enumeration 
and molecular characterization to predict response.  
 
 
 
 

76 
 
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cyclin-dependent kinase inhibitor, administered in 3-week cycles (Schedule 2/1). Br J Cancer 
104:1862-8, 2011 
 
32. 
Goldhoff P, Clarke J, Smirnov I, et al: Clinical stratification of glioblastoma based 
on alterations in retinoblastoma tumor suppressor protein (RB1) and association with the proneural 
subtype. J Neuropathol Exp Neurol 71:83-9, 2012 
 
33. 
Augello MA, Burd CJ, Birbe R, et al: Convergence of oncogenic and hormone 
receptor pathways promotes metastatic phenotypes. J Clin Invest 123:493-508, 2013 
 
34. 
Taylor BS, Schultz N, Hieronymus H, et al: Integrative genomic profiling of human 
prostate cancer. Cancer Cell 18:11-22, 2010 
 
35. 
Yu J, Mani RS, Cao Q, et al: An integrated network of androgen receptor, 
polycomb, and TMPRSS2-ERG gene fusions in prostate cancer progression. Cancer Cell 17:443-
54, 2010 
 
36. 
Lonigro RJ, Grasso CS, Robinson DR, et al: Detection of somatic copy number 
alterations in cancer using targeted exome capture sequencing. Neoplasia 13:1019-25, 2011 
 
37. 
Palanisamy N, Ateeq B, Kalyana-Sundaram S, et al: Rearrangements of the RAF 
kinase pathway in prostate cancer, gastric cancer and melanoma. Nat Med 16:793-8, 2010 

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38. 
Roychowdhury S, Iyer MK, Robinson DR, et al: Personalized oncology through 
integrative high-throughput sequencing: a pilot study. Sci Transl Med 3:111ra121, 2011 
 
39. 
Wang XS, Shankar S, Dhanasekaran SM, et al: Characterization of KRAS 
Rearrangements in Metastatic Prostate Cancer. Cancer Discov 1:35-43, 2011 
 
40. 
Cheng HH, Mitchell PS, Kroh EM, et al: Circulating microRNA profiling identifies 
a subset of metastatic prostate cancer patients with evidence of cancer-associated hypoxia. PLoS 
One 8:e69239, 2013 
 
41. 
Eisenhauer EA, Therasse P, Bogaerts J, et al: New response evaluation criteria in 
solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer 45:228-47, 2009 
 
42. 
Lydersen S, Fagerland MW, Laake P: Recommended tests for association in 2 x 2 
tables. Stat Med 28:1159-75, 2009 
 
 
 
 

79 
 
APPENDIX A 
 
 
Performance Status Criteria 
 
ECOG Performance Status Scale 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity.  Fully active, able 
to 
carry 
on 
all 
pre-disease 
performance without restriction. 
100 
Normal, no complaints, no 
evidence of disease. 
90 
Able to carry on normal 
activity; 
minor 
signs 
or 
symptoms of disease. 
1 
Symptoms, 
but 
ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able to 
carry out work of a light or 
sedentary 
nature 
(e.g., 
light 
housework, office work). 
80 
Normal activity with effort; 
some signs or symptoms of 
disease. 
70 
Cares for self, unable to carry 
on normal activity or to do 
active work. 
2 
In 
bed 
<50% 
of 
the 
time.  
Ambulatory and capable of all self-
care, but unable to carry out any 
work activities.  Up and about more 
than 50% of waking hours. 
60 
Requires 
occasional 
assistance, but is able to care 
for most of his/her needs. 
50 
Requires 
considerable 
assistance 
and 
frequent 
medical care. 
3 
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care 
and assistance. 
30 
Severely 
disabled, 
hospitalization 
indicated.  
Death not imminent. 
4 
100% bedridden.  Completely 
disabled.  Cannot carry on any self-
care.  Totally confined to bed or 
chair. 
20 
Very 
sick, 
hospitalization 
indicated. 
Death 
not 
imminent. 
10 
Moribund, 
fatal 
processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 
 
 
 
 
 

80 
 
APPENDIX B 
 
Standard Operating Procedures for CT-guided Biopsy of Metastatic Prostate Cancer 
Lesion in Bone 
 
Patients will be scheduled for a CT-guided biopsy of a bone or soft tissue abnormality consistent 
with prostate metastasis.  The site of biopsy will be determined after review of available 
radiographs, CT, MRI, and/or bone scan (where applicable).  The decision regarding which 
metastatic lesion to biopsy should depend on three main factors: 
1) Size of lesion (with preference towards the largest lesion) 
2) Safety (with obvious preference towards least risk to the patient) 
3) For bone lesions, the intensity of lesion activity on bone scan (with preference 
towards the most intense activity) 
Verbal and written informed consent will be obtained after discussion of risks (bleeding, 
infection, soft tissue and bone injury, inconclusive biopsy results) of the procedure.  Standard 
laboratory tests to assess coagulation and bleeding will also be completed prior to the procedure.  
Conscious sedation will be used as necessary using intravenous Fentanyl and Midazolam with 
appropriate nursing support. In order to ensure adequate tumor sample as long as it is deemed 
safe and based on accessibility, target lesion size, specimen integrity, specimen appearance, 
intra-procedural bleeding, tumor biopsy should attempt to obtain   2-8 bone biopsy samples in 
addition to possible bone marrow aspirate, to be determined at the time of biopsy. 
 
 
The patient will be initially scanned with a clinically-available multislice CT scanner for the 
purpose of biopsy planning.  Biopsies will be performed using sterile technique and lidocaine 
local anesthetic. For bone lesions, a clinically-available 11-to-14 gauge bone cutting needle, with 
or without a co-axial trocar, will be used to obtain  two to eight biopsy samples of the selected 
lesion.  Options for obtaining multiple samples of the biopsy can include: 
a) Sequential advancement of needle passes through a fixed trocar, 
such that each needle pass progresses more deeply into the bone 
lesion 
b) Re-insertion and re-direction of the needle and/or trocar through 
another region of the bone lesion  
c) Aspiration of the lesion will be attempted in conjunction with 
biopsy, by attaching a 20 cc sterile syringe to the cannula of the 
biopsy needle and aspirating into this syringe, with repeat 
aspirations as needed. 
 
At the completion of the procedure, CT imaging will be repeated to assess for immediate 
complications.  The patient will be observed for 2 – 4 hours before discharge. 
  
 
 

81 
 
APPENDIX C 
 
Standard Operating Procedures for CT-guided Biopsy of Metastatic Prostate Cancer 
Lesion in Soft Tissue 
 
The patient’s imaging will be reviewed and all soft tissue or nodal lesions deemed suspicious for 
metastasis will be considered. A target for sampling will be selected based on: 1) perceived 
percutaneous access with respect to safety and technical feasibility, and 2) suspected likelihood 
of obtaining malignant tissue. In the cases where both bone and soft tissue lesions are safely 
accessible and have high likelihoods of containing malignant tissue, it would be preferable to 
biopsy the soft tissue lesion.  
 
 For lymph nodes or soft tissue lesions a CT scan will be utilized.  An ultrasound may be 
utilized, provided that the target lymph node or soft tissue mass is visible and accessible. 
    
 In order to ensure adequate tumor sample as long as it is deemed safe and based on 
accessibility, target lesion size, specimen integrity, specimen appearance, intra-
procedural bleeding, tumor biopsy should attempt to obtain: 
o  at least 6 cores if obtaining a 1-cm-long 18-gauge core specimen.   
or 
o at least 4 cores if obtaining a 2-cm-long 18-gauge core specimen.  The needle 
should be directed into the center of the lesion.  
 
Options for obtaining multiple samples include similar principles as described for bone lesions, 
including sequential advancement through the lesion, re-insertion/re-direction, or aspiration 
where appropriate. 
 
Mitigating factors may include but are not limited to: 1) safety of obtaining multiple core 
specimens, 2) friability of the core specimens on visual inspection, 3) target size, 4) perceived 
likelihood of obtaining additional diagnostic tissue by continued sampling. After biopsy is 
performed, the biopsy would be snap frozen, as described in Appendix E.  No aspirate will be 
performed for soft tissue biopsies. 
 
 
 
 

82 
 
Appendix D: Standard Operating Procedure (SOP) for Handling Samples  
 
1.0 PURPOSE  
To standardize the method for handling frozen needle tumor biopsies, to optimize specimen use 
for molecular analyses. 
 
2.0 MATERIALS AND EQUIPMENT REQUIRED  
 
2.1 Sample kit containing: 
Dual sample kit will be sent to each enrolling site immediately following patient 
registration 
A) Cell Free DNA 2 tubes 
B) Sheet for recording biopsy details 
This sample kit will be sent to each enrolling site immediately following patient 
registration. 
 
2.2 Other materials which will be sent to each enrolling site at the initiation of the clinical trial 
(to be kept for use over serial cases):  
a) One box Tissue Tek™ cryomolds 
b) Large bottle of Tissue Tek™ OCT 
c) Blue Pads, Markers  
d) Sterile tweezers  
e) Shipping labels 
f) A supply of additional Cell-Free DNA tubes  
g) Boxes for shipment of Cell-Free DNA samples (see Appendix F) 
 
2.3 Materials that will be provided by the enrolling site: 
a) Dry ice  
b) -80°C freezer (particularly in the case of Friday biopsies) 
 
3.0 OPERATING PROCEDURES  
 
3.1 At least 24 hours prior to the biopsy, the research coordinator is to notify the institutional 
research team involved in this protocol, of the scheduled sample collections.  A laboratory 
technician should pick up the sample kit (see 2.1 above), and prepare cryomolds prior to the 
biopsy, by labeling them, using the provided alcohol-proof marker, with the following 
information:  
             Clinical protocol number 
             Specimen ID  
             Biopsy time and Date       
The research coordinator and the laboratory technician should also confirm, on the day prior to 
biopsy, the availability of materials needed for handling the biopsies, as specified in Section 2 
above. 
 
3.2 The laboratory technician should arrive at the biopsy collection site at least 15 min ahead of 
the scheduled biopsy to allow sufficient time to set up laboratory supplies and ensure rapid 

83 
 
transport of specimens to the laboratory after collection.  He or she should also re-confirm, at 
that time, the availability of all specimens from Section 2.  He should also, immediately before 
the biopsy, fill the insulated bucket with dry ice and isopentane. 
 
3.3  Immediately after the biopsy is performed, the freshly collected specimen should be placed 
in the cryomold.  A single drop  of Tissue Tek™ OCT should be placed on the specimen, and the 
sterile tweezers should be used to gently hold one end of the freshly collected needle biopsy and 
to push the biopsy to the bottom of the cryomold cassette with forceps.  Make sure biopsy is as 
flat as possible. The cryomold should then be filled with OCT, and the cryomold should be 
immediately placed in direct contact with the dry ice/isopentane cocktail until the bottom of the 
OCT freezes and turns white.  Only the bottom of the cryomold should contact the dry 
ice/isopentane--none of the dry ice/isopentane should spill inside the cryomold itself and contact 
the specimen.   
This process can be repeated using separate cryomold cassettes for separate biopsy samples. 
3.4 Once frozen, place cryomolds on dry ice for transport.  The used isopentane should be 
poured back into its bottle using funnel.     
3.5 For bone lesions, an aspirate of the site of bone biopsy may be performed, as described in 
Section C, using a 20 cc sterile syringe.  The contents of this syringe (clotted aspirate) should be 
transferred into a 1.7 mL eppendorf tube.  Several drops of Tissue Tek™ OCT should be added 
to the tube, such that the clotted aspirate is covered by OCT.  The eppendorf tube should then be 
closed, and placed on dry ice for snap freezing. 
3.6 The cryopreserved biopsy and aspirate specimen(s) should be stored at -80°C until shipment.  
Ideally, shipment should occur on the same day as the biopsy, unless the biopsy occurs on a 
Friday, in which case the specimen should be preserved at -80°C until shipment on the following 
Monday. 
  
4. Quality Assurance Process 
After completion of each biopsy, the following information should be recorded on the 
information sheet shipped with each sample kit: 
Biopsy collection 
Date:  
Specimen ID:  
Time guide needle placement confirmed:  
Needle Type:  
Needle diameter: gauge; and length: cm  
Time biopsy needle introduced:  
Time biopsy snap-frozen on dry ice:  
Number of specimens: 
Time aspirate performed (for bone lesions): 
Time aspirate snap-frozen on dry ice: 
Date/time of biopsy specimen(s) (and aspirate specimens, if applicable) placed at -80°C:  
Date/time of biopsy specimen(s) (and aspirate specimens, if applicable) shipped:  
Notes, including any deviations from the standard operating procedure:  
 
 

84 
 
Appendix E: Standard Operating Procedure for Shipment of non-CTC Clinical Samples 
 
I.  Preparing for Shipment 
A. Send an e-mail to Siddiqui@med.umich.edu  prior to shipping to advise recipient of 
scheduled shipping time.  
B. Generate a shipping list recording the number of samples being shipped, type of 
sample (frozen biopsy, blood, or archived formalin-fixed biopsy), and clinical protocol 
number of the patient 
C.  Make sure that the following packing materials are available: 
 Cardboard shipping box with Styrofoam insert.  
--Shipper Boxes 13.38L x 9.25W x 6 in.D;  Outside Dimensions: 15.5L x 
11.5W x 8 in.H;  Wall Thickness: 1 in. Fischer Scientific Catalog # 03-
528-27 
 
Dry ice (amount varies depending on size of Styrofoam insert; usually about 
15 kg’s) 
 
6 in x 6 in cardboard specimen box, with fiberboard box dividers- holds 81, 
16mm vials  
--Revco Fiberboard Storage Boxes, 12/PAK 
--Revco Fiberboard Box Dividers, Holds 81 16mm vials, 12/PAK 
Fischer Scientific Catalog # 11-678-24A, 13-989-218 (resp.) 
 Plastic bag (to go over the cardboard box –in case of leakage) 
 Absorbent strip (to go inside the plastic bag that the boxes are in; can soak up to 
250 cc of liquid) 
--Absorbent Strips 250/Cs 
--Fischer Scientific Catalog # NC9193000 
 UN 3373 label (2 in x 2 in)  
--Labelmaster UN3373 Labels > 2W x 2.75 In. L 
--Labels; Biological Substance; 2W x 2.75 In. L; Paper; 500/RL 
Fischer Scientific Catalog # NC9493045 
 Dry Ice Label with designated UN 1845 diamond (can also be ordered from 
Fischer Scientific) 
--5 1/2 x 5 1/2 in.; complies with DOT (49 CFR 173.217) and IATA 
(Packing Instructions 904)  
--Fischer Scientific Catalog #22-130-065  
 Packing tape 
 
II.  Packaging the specimens 
1. Pull sample tubes from temporary storage freezers and place in dry ice, make sure the 
labels are securely placed on the tube and tubes properly labeled and easy to read. 
2. Ensure that caps are tightly secured and place in 6 in x 6 in cardboard specimen box 
(which should be kept on dry ice during this transfer). 
3. Be sure to check off EACH specimen being shipped  and verify the contents of the 
package match the shipping list 
4. Label the top of the cardboard specimen box with number of samples; clinical 
protocol/specimen number, and contact information of sender, as well as contact of 
receiver. 

85 
 
5. Cover the specimen box, and either tape the sides down or place a rubber band around 
the box, to ensure that the cover will not come off. 
6. Place inside the plastic Ziploc bag with the absorbent strip and seal. Keep on dry ice 
until ready to transfer to the larger shipping box. (can fit two of these specimen boxes 
in a shipper box that is the designated size above) 
7. Fill the shipper box about half way with dry ice (about 1-2 inches in height) and place 
the specimen box inside with shipper. 
8. Add more dry ice to cover the specimen boxes. (about 1 or 2 inches in height again 
and 1-2 inches on the sides the boxes as well).  Note: there should be sufficient dry 
ice to maintain the samples at -20°C for at least 72 h. 
9. DO NOT place dry ice inside the specimen boxes or inside the plastic bag. 
10. Close the Styrofoam box, and tape the packing list to the top. DO NOT seal the 
Styrofoam box with tape.  
11. Ship the specimens with a copy of the shipping list and the completed quality 
assurance record (see Appendix D) for all specimens. Retain copies of the completed 
shipping list and quality assurance record in your records. 
12. Seal the shipping box by taping the flaps of the insulated box along the top edges. 
13. At this point, you should check that your final packaging consists of three 
components (triple packaging): 
 
(a) a primary receptacles (the specimen tubes)  
 
(b) a secondary packaging (6 in x 6 in cardboard specimen box) 
 
(c) a rigid outer packaging (larger cardboard shipping box) 
14. Should you decide to use alternative packaging materials instead of those listed 
above, please note the following requirements: 
The primary receptacles must be packed in secondary packaging in such a way 
that, under normal conditions of transport, they cannot break, be punctured or leak 
their contents into the secondary packaging. Secondary packagings must be 
secured in outer packaging with suitable cushioning material. Any leakage of the 
contents must not compromise the integrity of the cushioning material or of the 
outer packaging. The primary container (i.e. test tube) must be leak proof, as 
should the secondary container. The outer packaging (tertiary container) does not 
have to be leak proof.  Packaging must comply with the IATA packing 
instructions 650 which are summarized below; for further questions, please refer 
to the IATA website: 
http://www.iata.org/SiteCollectionDocuments/DGR51_PI650_EN.pdf 
 
III.  Labelling and sending the shipping box 
A. Fill out the black and white dry ice label to reflect the weight of the dry ice in the box, 
note 2lbs= 1kg. Place completed black and white dry ice label on the shipping box 
B. All shipping boxes must be affixed with two labels: 
“DIAGNOSTIC SPECIMENS PACKED IN COMPLIANCE WITH IATA 
PACKING INSTRUCTION 650” 
and 
“UN 3373 Biological Substance Category B”  
 
 

86 
 
C. Complete the air bill online and attach packing labels to the outside of the shipper. 
Schedule a pick up time and ship overnight to: 
Javed Siddiqui, MS, MT(ASCP, CLsp (MB)) 
Michigan Center for Translational Pathology 
Room 1138  
2900 Huron Parkway Suite 100 
Ann Arbor, MI 48105 
Phone: (734) 232-0829 
Fax: (734) 232-0805 
siddiqui@med.umich.edu 
D. All shipping boxes are required to ship out Priority Overnight (or another comparable 
shipping service that results in delivery by 10:30 AM the following day). 
E. Biopsies on Monday through Thursday should be shipped on the same day as the 
biopsy.  Biopsies on Friday should be stored at -80 degrees Celsius until the following 
Monday, and then should be shipped via Priority Overnight (or a comparable service).   
F.  The sender would need to complete an "air waybill" form 
G.  All diagnostic or investigational specimens shipped on this trial should be classified 
as “Diagnostic Specimens” not “Infectious Substances” when shipping via a standard 
carrier.  (i.e. UPS, FED-EX, DHL/AIRBORNE). Diagnostic Specimens DO NOT 
require a Shipper’s Declaration of Dangerous Goods form.  
 
IV.  Questions 
For any questions regarding shipping, please contact Javed Siddiqui at 
siddiqui@med.umich.edu or phone: (734) 232-0829. 
 
 

87 
 
 
 
 
 

88 
 
 
 
 

89 
 
Appendix G 
PATIENT’S MEDICATION DIARY 
 
Today’s date _____________________     
Agent: Palbociclib 
Patient Name_____________________(initials acceptable)  
 Patient Study ID __________________________ 
INSTRUCTIONS TO THE PATIENT: 
1. 
Complete one form for each cycle of treatment. 
2. 
You will take Palbociclib 
           Dose:   
                                ___75 mg capsules  
                                ___ 100 mg capsules 
                                ___ 125 mg capsules 
 
          Take Palbociclib daily, days 1-21. Take with food.   Do not crush, break, or chew it. 
3. 
Record the date, the number of tablets of each size of tablet that you took, and when you took them.   
4. 
If you have any comments or notice any side effects, please record them in the Comments column.   
5. 
Please bring this form, bottles and extra tablets when you return for each appointment. 
6.      Please record missed or skipped doses.  Do not share your study drug supply, and wash your hands after touching the pills 
 
Day 
 
Date 
Time of Dose 
# of capsules 
taken  
Comments 
1 
 
 
 
 
2 
 
 
 
 
3 
 
 
 
 
4 
 
 
 
 
5 
 
 
 
 
6 
 
 
 
 
7 
 
 
 
 
8 
 
 
 
 
9 
 
 
 
 
10 
 
 
 
 
11 
 
 
 
 
12 
 
 
 
 
13 
 
 
 
 
14 
 
 
 
 
15 
 
 
 
 
16 
 
 
 
 
17 
 
 
 
 
18 
 
 
 
 
19 
 
 
 
 
20 
 
 
 
 
21 
 
 
 
 
 
Patient’s signature_________________________________________________________________________ 
 
 
***FOR CLINIC STAFF USE ONLY*** 
STUDY STAFF 
SIGNATURE: 
 
# of capsules dispensed to 
patient: 
 
DATE: 
 
# of capsules returned: 
 
 
 

90 
 
Appendix H 
PATIENT’S MEDICATION DIARY 
 
Today’s date _____________________     
Agent: Bicalutamide  
Patient Name_____________________(initials acceptable)  
 Patient Study ID __________________________ 
INSTRUCTIONS TO THE PATIENT: 
1. 
Complete one form for each cycle of treatment. 
2. 
You will take Bicalutamide 
           Dose:  50mg 
          Take Bicalutamide daily every day of the month.   Do not crush, break, or chew it. 
3. 
Record the date and when you took it.   
4. 
If you have any comments or notice any side effects, please record them in the Comments column.   
5. 
Please bring this form, bottles and extra tablets when you return for each appointment. 
6.      Please record missed or skipped doses.  Do not share your study drug supply, and wash your hands after touching the pills 
 
Day 
 
Date 
Time of dose  # of tablets taken 
Comments 
 
1 
 
 
 
 
2 
 
 
 
 
3 
 
 
 
 
4 
 
 
 
 
5 
 
 
 
 
6 
 
 
 
 
7 
 
 
 
 
8 
 
 
 
 
9 
 
 
 
 
10 
 
 
 
 
11 
 
 
 
 
12 
 
 
 
 
13 
 
 
 
 
14 
 
 
 
 
15 
 
 
 
 
16 
 
 
 
 
17 
 
 
 
 
18 
 
 
 
 
19 
 
 
 
 
20 
 
 
 
 
21 
 
 
 
 
22 
 
 
 
 
23 
 
 
 
 
24 
 
 
 
 
25 
 
 
 
 
26 
 
 
 
 
27 
 
 
 
 
28 
 
 
 
 
 
 
Patient’s signature_________________________________________________________________________ 
 
STUDY STAFF 
SIGNATURE: 
 
DATE: