Non-Operative Management and Early Response Assessment in Rectal Cancer
Phase: NA
Conditions: Adenocarcinoma of the Lower Rectum
Sponsor: Washington University School of Medicine

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Non-Operative Management and Early Response Assessment in Rectal Cancer (NOM-ERA) 
 
Washington University School of Medicine, Department of Radiation Oncology 
660 S. Euclid Ave., CB 8224, St. Louis, MO 63110 
 
Protocol #: 201904029 
Version date: 09/15/2025  
 
Coordinating Center: 
Washington University School of Medicine 
 
Principal Investigator: 
 
Michael Waters, MD  
Phone: (314) 747-7236  
E-mail:  m.r.waters@wustl.edu  
 
 
Surgery Co-PI: 
 
 
Steven Hunt, M.D. 
Biology Co-PI:  
 
 
David DeNardo, Ph.D. 
 
Sub-Investigators  
 
Institution 
 
 
Modality 
Jeffrey Olsen, M.D.  
 
University of Colorado  
Radiation Oncology 
Christopher Anker, M.D. 
 
University of Vermont  
Radiation Oncology 
Christopher Hallemeier, M.D. 
Mayo Clinic 
 
 
Radiation Oncology 
Pamela Samson, M.D. 
 
Washington University  
Radiation Oncology 
Carl DeSelm, M.D.   
 
Washington University  
Radiation Oncology 
Sean Glasgow, M.D.  
 
Washington University  
Colorectal Surgery 
Paul Wise, M.D. 
 
 
Washington University  
Colorectal Surgery 
Matthew Mutch, M.D. 
 
Washington University  
Colorectal Surgery 
Matthew Silviera, M.D. 
 
Washington University  
Colorectal Surgery 
Patrick Grierson, M.D., Ph.D. 
Washington University  
Medical Oncology 
Kian-Huat Lim, M.D., Ph.D.  
Washington University  
Medical Oncology 
Rama Suresh, M.D.  
 
Washington University  
Medical Oncology 
Benjamin R. Tan, M.D. 
 
Washington University  
Medical Oncology 
Nikolaos Trikalinos, M.D. 
 
Washington University  
Medical Oncology 
Esther Lu, Ph.D. 
 
 
Washington University  
Biostatistics 
 
Clinicaltrials.gov #: NCT03904043 
 
CONFIDENTIAL 
The information contained in this document is regarded as confidential and, except to the extent necessary to obtain 
informed consent, may not be disclosed to another party unless law or regulations require such disclosure.  Persons 
to whom the information is disclosed must be informed that the information is confidential and may not be further 
disclosed by them 
 

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Non-Operative Management and Early Response Assessment in Rectal Cancer (NOM-ERA) 
 
Protocol Revision History 
 
Initial Approval Version 
 
 
 
 
 
 
04/01/19 
Amendment #1 
 
 
 
 
 
 
 
05/11/19 
Amendment #2 
 
 
 
 
 
 
 
03/17/20 
Amendment #3 
 
 
 
 
 
 
 
10/20/20 
Amendment #4 
 
 
 
 
 
 
 
03/16/21 
Amendment #5 
 
 
 
 
 
 
 
05/06/21 
Amendment #6 
 
 
 
 
 
 
 
10/08/21 
Amendment #7 
 
 
 
 
 
 
 
05/23/22 
Amendment #8 
 
 
 
 
 
 
 
02/07/23 
Amendment #9 
 
 
 
 
 
 
 
10/25/23 
Amendment #10                                                                                             09/15/25 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Non-Operative Management and Early Response Assessment in Rectal Cancer (NOM-ERA) 
 
Principal Investigator Signature Page 
 
 
Principal Investigator 
(printed): 
      
Name of Institution:       
  
 
PI Signature 
 
Date 
 
By my signature, I agree to personally supervise the conduct of this study 
and to ensure its conduct in compliance with the protocol, informed 
consent, IRB/HRPO procedures, the Declaration of Helsinki, ICH Good 
Clinical Practices guidelines, and the applicable parts of the United States 
Code of Federal Regulations or local regulations governing the conduct 
of clinical studies. 
 
 

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SCHEMA 
 
 
 
Primary Objective 
To determine the clinical complete response (cCR) rate of patients with Stage I-IIIB (cT1-3, N0-
2a, M0) rectal cancer being treated with sequential short course radiotherapy followed by multi-
drug chemotherapy. 
 
Secondary Objectives: 
1. To determine the 2 year progression free survival (PFS) 
2. To determine the incidence of any grade ≥ 3 toxicity during treatment 
3. To determine the incidence of post chemoradiotherapy grade ≥ 3 toxicity at 1 year 
4. To determine quality of anorectal function at 1 year using the FACT-C questionnaire 
5. To determine the 1 and 2 year organ preservation rate 
 
 
 
Pelvic Radiotherapy 
(5 Gy x 5) 
Optional primary boost to 
30 Gy / 5 fxs 
Extra-mesorectal Node 
SIB (7 Gy x 5) 
FOLFOX x 8 
cycles 
or 
CAPOX x 5 
cycles 
Complete Clinical 
Response: Non-
Operative Management 
Persistent Disease: 
TME 

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Table of Contents  
 
SCHEMA ...................................................................................................................................4 
1 
BACKGROUND ..............................................................................................................7 
1.1 
Stage I-III Rectal Cancer ...............................................................................................7 
1.2 
Short Course Radiation Therapy....................................................................................7 
1.3 
Addition of Chemotherapy ............................................................................................7 
1.4 
Rationale .......................................................................................................................8 
1.5 
Correlative Background ................................................................................................8 
2 
OBJECTIVES ..................................................................................................................9 
3 
ELIGIBILITY CRITERIA.............................................................................................. 10 
3.1 
Inclusion Criteria ........................................................................................................ 10 
3.2 
Exclusion Criteria ....................................................................................................... 11 
3.3 
Inclusion of Women and Minorities ............................................................................ 11 
4 
PATIENT REGISTRATION .......................................................................................... 11 
4.1 
Confirmation of Patient Eligibility .............................................................................. 11 
4.2 
Patient Registration in the Siteman Cancer Center OnCore Database........................... 12 
4.3 
Assignment of UPN .................................................................................................... 12 
5 
EVALUATION STUDIES ............................................................................................. 12 
5.1 
Pre-treatment .............................................................................................................. 12 
5.2 
During Radiotherapy and Chemotherapy ..................................................................... 13 
5.3 
Completion of Chemotherapy/Post-Treatment Evaluation ........................................... 13 
5.4 
Follow-up ................................................................................................................... 14 
6 
RADIATION THERAPY GUIDELINES ....................................................................... 14 
6.1 
Dose, Fractionation and Constraints ............................................................................ 14 
6.2 
Treatment Planning Procedures ................................................................................... 15 
6.3 
Simulation Procedures/Patient Positioning .................................................................. 15 
6.4 
Clinical Target Volume (CTV) and Planning Target Volume (PTV) Definitions and 
Radiation Treatment Planning ............................................................................................... 15 
6.5 
Normal Tissue Contours.............................................................................................. 16 
7 
CHEMOTHERAPY GUIDELINES ............................................................................... 16 
7.1 
Chemotherapy Schedule and Doses ............................................................................. 16 
7.2 
Agent Administration .................................................................................................. 16 
7.3 
Supportive Care Recommendations ............................................................................. 17 
8 
DOSE DELAYS/DOSE MODIFICATIONS .................................................................. 17 
8.1 
Radiotherapy Dosing ................................................................................................... 17 
8.2 
Chemotherapy Dosing ................................................................................................. 18 
8.3 
Dose Modifications for Toxicity Related to FOLFOX-6 .............................................. 18 
8.4 
Dose Modifications for Neurologic Toxicity (Paresthesia or Dysesthesia) Related to 
Oxaliplatin ............................................................................................................................ 19 
8.5 
Dose Modifications for Toxicity Related to CAPOX ................................................... 19 
9 
MR IMAGING GUIDELINES ....................................................................................... 20 
9.1 
Requirements .............................................................................................................. 20 

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10 
ADVERSE EVENT REPORTING ................................................................................. 20 
10.1 WU PI Reporting Requirements .................................................................................. 21 
10.2 Secondary Site Reporting Requirements...................................................................... 22 
10.3 Exceptions to Expedited Reporting ............................................................................. 22 
11 
CORRELATIVE STUDIES ........................................................................................... 23 
11.1 Research Tissue .......................................................................................................... 23 
11.2 Blood for ctDNA ........................................................................................................ 24 
12 
PHARMACEUTICAL INFORMATION ....................................................................... 24 
12.1 Leucovorin .................................................................................................................. 24 
12.2 5-Fluorouracil (5-FU).................................................................................................. 25 
12.3 Oxaliplatin .................................................................................................................. 27 
12.4 Capecitabine ............................................................................................................... 28 
13 
STUDY CALENDAR .................................................................................................... 31 
14 
DATA SUBMISSION SCHEDULE ............................................................................... 33 
14.1 Adverse Event Collection in the Case Report Forms ................................................... 33 
15 
MEASUREMENT OF EFFECT ..................................................................................... 34 
16 
DATA AND SAFETY MONITORING PLAN ............................................................... 34 
17 
AUDITING .................................................................................................................... 35 
18 
STATISTICAL CONSIDERATIONS ............................................................................ 36 
18.1 Study Objectives and Endpoints .................................................................................. 36 
18.2 Study Design and Sample Size Justification ................................................................ 36 
18.3 Interim Analyses and Stopping Rules .......................................................................... 37 
18.4 Definition of Evaluability ............................................................................................ 37 
18.5 Data Analysis .............................................................................................................. 37 
18.6 FAK Expression and Tumor Microenvironment Analysis ........................................... 38 
18.7 Accrual ....................................................................................................................... 38 
19 
MULTICENTER REGULATORY REQUIREMENTS .................................................. 38 
20 
REFERENCES ............................................................................................................... 40 
Appendix A: FACT-C Questionnaire ........................................................................................ 43 
APPENDIX B: PATIENT’S MEDICATION DIARY ............................................................... 46 
APPENDIX C: Definitions for Adverse Event Reporting .......................................................... 47 
APPENDIX D: Reporting Timelines ......................................................................................... 49 
APPENDIX E: Washington University SAE Reporting Cover Sheet ......................................... 51 
APPENDIX F: STUDY SPECIFIC DSM TABLES .................................................................. 52 
 
 
 

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1 
BACKGROUND 
 
1.1 
Stage I-III Rectal Cancer 
 
With the exception of a small group of favorable risk stage I disease, the standard of care 
for stage I-III rectal cancer usually includes a total mesorectal excision (TME). TME in 
the form of an abdominoperineal resection (APR) results in a permanent stoma, which 
may significantly impact the patient’s self-image and quality of life (QOL). TME in the 
form of a low anterior resection (LAR) obviates the need of an ostomy but is associated 
with poorer rectal function. 
 
There are increasing data supporting the use of chemotherapy and radiation therapy for 
non-operative management of rectal cancer1–4. Habr-Gama et al. treated 183 distal rectal 
cancer (T2-4 N0-2) patients with 50.4-54 Gy in 30 fractions and concurrent 5-fluorouracil 
(5FU)/leucovorin and demonstrated an initial complete clinical response (cCR) of 49% 
patients 69% demonstrating a sustained cCR at 5 years1. Appelt et al. treated 55 patients 
(T2-3 N0-1) with 60 Gy in 30 fractions with a 5 Gy brachytherapy boost plus oral tegafur-
uracil2. They reported 78% cCR with 16% local recurrence at 1 year with all local 
recurrences occurring within 2 years at the time of study publication2. Maas et al. found 
that patients with cCR after neoadjuvant chemoradiation therapy have similar oncologic 
outcomes to those with pathologic complete response (pCR)4. The radiation in these trials 
was delivered over 5-6 weeks of daily treatment. 
 
1.2 
Short Course Radiation Therapy 
 
Short course radiation therapy delivered as 25 Gy in 5 fractions is routinely used as 
preoperative therapy in Europe and Australia5–7. The first Polish rectal study demonstrated 
that patients with T3-4 resectable rectal cancer treated with 25 Gy in 5 fractions followed 
by surgery versus 50.4 Gy in 28 fractions with concurrent 5FU followed by surgery had 
similar local recurrence (9% vs 14%), disease free survival (58% vs 56%) and overall 
survival (67% vs 66%)6. There was no difference in severe late toxicity (10% vs 7%). The 
second Polish rectal trial demonstrated that there was no difference in R0 resection and 
pCR rates in patients with T3-4 rectal cancer treated with 25 Gy in 5 fractions followed 
by FOLFOX then surgery compared to 50.4 in 28 fractions with FOLFOX followed by 
surgery7. There was even a 3 year overall survival advantage for short course radiation 
(73% versus 65%), but the reason for this survival advantage in light of a non-significant 
difference in disease free survival is unclear. Important to note is that the dose prescribed 
with pre-operative short course radiation (5 Gy x 5 fractions) has a biologic effective dose 
(BED) of 37.5 Gy (α/β=10) in contrast to the BED of 63.7 Gy when 54 Gy is given in 30 
daily fractions. Increasing the radiation dose to the tumor may further increase the clinical 
complete response (cCR) rate and allow for non-operative management. 
 
1.3 
Addition of Chemotherapy 
 
There are increasing data to support increasing the interval from radiation to surgery. The 

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pCR rate of standard short course radiation followed by surgery 1 week later is 
approximately 1%5,6. Increasing the interval to surgery from 2 to 6-8 weeks may increase 
the pCR rate without compromising oncologic outcomes8–10. The Lyon R90-01 trial 
demonstrated that patients with T2 rectal adenocarcinoma treated with 39 Gy in 13 
fractions had increased pCR if surgery is delayed to 6-8 weeks post-radiation versus 2 
weeks post-radiation (26% vs 10%)8. In the non-inferiority Stockholm III, which evaluated 
short course radiation followed by surgery at 1 versus 4-8 weeks versus long course 
radiation therapy, there were no differences in long term cancer outcomes between the 
three treatment groups11. The GRECCAR-6 trial showed that increasing the interval from 
chemoradiation to surgery from 7 to 11 weeks did not improve pCR. However, 
chemotherapy was not used during the interval between treatments12. The Timing study 
provides evidence that extending the time from radiation to surgery with 3 months of 
chemotherapy increased pCR rates compared to observation and 1-2 months13. Thus 
increasing the interval from radiation completion to surgery, especially with chemotherapy, 
may improve treatment outcomes. 
 
In a phase II trial for patients with cT3-4, any N, any M rectal cancer recently completed 
at Washington University evaluating short-course radiotherapy followed by 4 cycles of 
FOLFOX chemotherapy (5FU, oxaliplatin, and leucovorin), a pCR was seen in 25% of 
patients.  Mean prospective Functional Assessment of Cancer Therapy-Colorectal (FACT-
C) scores for all five categories were not significantly different for pre-treatment (20.6 ± 
5.6), pre-surgery (20.2 ± 5.4), or post-surgery time points (20.0 ± 5.4). Improved patient-
reported functional outcomes were observed for patients undergoing sphincter sparing 
surgery, compared to those requiring an abdominoperineal resection with ostomy, In 
patients with an ostomy, FACT-C scores for functional well-being 1-year post-surgery 
were significantly reduced (lower QOL) compared to patients without ostomy (13.2 vs 
19.2)14. Thus despite the side effect profile associated with radiation and chemotherapy, it 
may provide improved QOL over the sequelae associated with an ostomy and permanent 
stoma.  
 
1.4 
Rationale 
 
Our phase I trial of short course radiation therapy followed by chemotherapy showed 74% 
cCR. Given the promising response rate, we are evaluating short course radiation therapy 
(SCRT) followed by chemotherapy in a multi-institution phase II trial to validate the cCR 
rate of this treatment paradigm. SCRT has not been prospectively evaluated in non-
operative management for patients with non-metastatic rectal adenocarcinoma. 
 
1.5 
Correlative Background 
 
In contrast to the parallel technologies that guide the management of breast15,16 or prostate 
cancer17,18, there are no clinically implemented biomarkers that predict or prognosticate 
outcomes for rectal cancer. Colorectal cancer metastatic potential and aggressive 
proliferative phenotype have been linked to its tumor microenvironment. Cancer-
associated fibroblasts (CAFs) deposit extra-cellular matrix (ECM) proteins resulting in a 
dense fibrotic stroma19 that may confer resistance to chemotherapy, potentiate aggressive 

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phenotype20 and limit infiltration and function of anti-tumor immune cells. FAK 
expression is associated with poorer survival in colorectal cancer patients after 
chemoradiation21,22 and is also associated with fibrosis and poor patient outcomes in 
pancreas adenocarcinoma23. 
 
Cell-free DNA is emerging as a powerful method for quantitating tumor disease burden 
noninvasively24,25. Recently, the Vogelstein group at Johns Hopkins University measured 
circulating tumor DNA (ctDNA), the tumor component of cell-free DNA, in colorectal 
cancer patients treated with surgery and chemotherapy and demonstrated robust ability to 
measure molecular residual disease which was highly prognostic26,27. Similar data are now 
available in breast cancer28, lung cancer29, cervical cancer30, and pancreatic cancer31. 
While the majority of this data is in the setting of surgery, Chaudhuri et al. demonstrated 
that ctDNA can also be measured before and after radiotherapy +/- chemotherapy for lung 
cancer, with post-treatment molecular residual disease (MRD) detection correlating 
significantly with eventual disease progression29. In preliminary data, Chaudhuri et al. 
further showed that mid-treatment ctDNA quantitation during chemoradiation may be 
prognostic for lung cancer patients32. Given these data, our goal is to measure circulating 
tumor DNA pre-, during and post-treatment as part of rectal cancer nonoperative 
management and correlate our findings with clinical and radiographic outcomes. 
 
 
2 
OBJECTIVES 
 
Objectives 
Endpoints 
Justification for 
Endpoints 
Primary 
To determine the clinical 
complete response (cCR) rate 
of patients with stage I-IIIB 
(cT1-3, N0-2a, M0) rectal 
cancer being treated with 
sequential short course 
radiotherapy followed by 
multi-drug chemotherapy. 
cCR at completion of short 
course radiation therapy and 
chemotherapy 
Nonoperative management 
treatment paradigms must 
be effective at eliciting a 
clinical complete response. 
Secondary 
1. To determine the 2 year 
progression free survival 
(PFS) 
2. To determine the incidence 
of any grade ≥ 3 toxicity 
during treatment. 
3. To determine the incidence 
of post chemoradiotherapy 
grade ≥ 3 toxicity at 1 year 
4. To determine quality of 
anorectal function at 1 year 
1. PFS at 2 years 
2. Incidence of any grade ≥ 3 
toxicity during treatment 
3. Incidence of post 
chemoradiotherapy grade ≥ 
3 toxicity  
4. Quality of anorectal 
function as measured by the 
FACT-C questionnaire at 1 
year 
1. Important to assess 
disease recurrence, 
metastasis and death when 
implementing new 
treatment paradigm. 
2. Important to assess acute 
toxicity as there is concern 
that short course radiation 
is associated with 
significantly more acute 
toxicity. 

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using the FACT-C 
questionnaire. 
5. To determine the 1 and 2 
year organ preservation rate 
5. Organ preservation rate at 1 
and 2 years 
3. Important to assess 
toxicity with new treatment 
paradigm, especially if 
rectum is not resected for 
nonoperative patients. 
4. Treatment cannot be so 
toxic that even with 
preserved rectum patient 
QOL is poor.  
5. Patients with cCR may 
still have regrowth of 
primary resulting in 
surgery. Need to assess 
how many patients can 
keep their rectum. 
 
Tertiary/Exploratory 
1. To associate tumor 
microenvironment 
(including FAK 
expression) with cCR and 
other clinical outcomes. 
2. To associate ctDNA levels 
with cCR and other clinical 
outcomes. 
 
 
 
 
3 
ELIGIBILITY CRITERIA 
 
3.1 
Inclusion Criteria 
 
1. Diagnosis of biopsy proven stage I-IIIB (cT1-3, N0-2a, M0) adenocarcinoma of the 
rectum; staging must also be based on multidisciplinary evaluation including MRI 
2. Tumor ≤ 12 cm from anal verge as determined by MRI or endoscopy 
3. Clinically detectable (MR, endoscopy, or DRE) tumor present 
4. ECOG performance status 0-2 
5. At least 18 years of age 
6. Adequate bone marrow function defined as: 
a. ANC > 1,500 cells/mm3 
b. Hgb > 8 g/dl 
c. platelets >100,000 cells/mm3 
7. Women of childbearing potential and men must agree to use adequate contraception 
(hormonal or barrier method of birth control, abstinence) prior to study entry and for 
the duration of study participation.  Should a woman become pregnant or suspect she 
is pregnant while participating in this study, she must inform her treating physician 
immediately. 

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8. Able to understand and willing to sign an IRB-approved written informed consent 
document. 
 
3.2 
Exclusion Criteria 
 
1. Prior radiation therapy, chemotherapy or extirpative surgery for rectal cancer. 
2. Prior oxaliplatin or capecitabine use for any malignancy. 
3. Prior radiation therapy to the pelvis. 
4. A history of other malignancy (except non-melanomatous skin cancers) with the 
exception of malignancies for which all treatment was completed at least 2 years before 
registration and the patient has no evidence of disease. 
5. Currently receiving any investigational agents. 
6. A history of allergic reaction attributed to compounds of similar chemical or biologic 
composition to capecitabine, 5FU, oxaliplatin, or leucovorin. 
7. Uncontrolled intercurrent illness including, but not limited to, ongoing or active 
infection, symptomatic congestive heart failure, unstable angina pectoris, or cardiac 
arrhythmia. 
8. Pregnant and/or breastfeeding.  Women of childbearing potential must have a negative 
serum pregnancy test within 14 days of study entry. 
9. Patients with known history of HIV are eligible unless their CD4+ T-cell counts are < 
350 cells/mcL or they have a history of AIDS-defining opportunistic infection within 
the 12 months prior to registration.  Concurrent treatment with effective ART according 
to DHHS treatment guidelines is recommended. HIV testing for patients without a 
history of HIV is not a protocol requirement. 
 
3.3 
Inclusion of Women and Minorities 
 
Both men and women and members of all races and ethnic groups are eligible for this trial. 
 
 
4 
PATIENT REGISTRATION 
 
Patients must not start any protocol intervention prior to registration through the Siteman 
Cancer Center. 
 
The following steps must be taken before registering patients to this study: 
 
1. Confirmation of patient eligibility by Washington University 
2. Registration of patient in the Siteman Cancer Center OnCore database 
3. Assignment of unique patient number (UPN) 
 
Once the patient has been entered in the Siteman Cancer Center OnCore database, the WUSM 
coordinator will forward verification of enrollment and the UPN via email. 
 
4.1 
Confirmation of Patient Eligibility 
 

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Confirm patient eligibility by collecting the information listed below and scanning and 
emailing it to the research coordinator listed in the Siteman Cancer Center Clinical Trials 
Core Protocol Procedures for Secondary Sites packet at least one business day prior to 
registering patient: 
 
1. Your name and contact information (telephone number, fax number, and email 
address) 
2. Your site PI’s name, the registering MD’s name, and your institution name 
3. Patient’s race, sex, and DOB 
4. Three letters (or two letters and a dash) for the patient’s initials 
5. Currently approved protocol version date 
6. Copy of signed consent form (patient name may be blacked out) 
7. Planned date of enrollment 
8. Completed eligibility checklist, signed and dated by a member of the study team 
9. Copy of appropriate source documentation confirming patient eligibility 
 
4.2 
Patient Registration in the Siteman Cancer Center OnCore Database 
 
Registrations may be submitted Monday through Friday between 8am and 5pm CT. Urgent 
late afternoon or early morning enrollments should be planned in advance and coordinated 
with the Washington University research coordinator.  Registration will be confirmed by 
the research coordinator or his/her delegate by email within one business day. Verification 
of eligibility and registration should be kept in the patient chart. 
 
All patients at all sites must be registered through the Siteman Cancer Center OnCore 
database at Washington University. 
 
4.3 
Assignment of UPN 
 
Each patient will be identified with a unique patient number (UPN) for this study.  Patients 
will also be identified by first, middle, and last initials.  If the patient has no middle initial, 
a dash will be used on the case report forms (CRFs).  All data will be recorded with this 
identification number on the appropriate CRFs. 
 
 
5 
EVALUATION STUDIES 
 
5.1 
Pre-treatment 
 
Within 12 weeks of day of simulation for RT but no later than the first radiation treatment: 
 
• Examination by treating surgeon, medical oncologist, and radiation oncologist 
• CBC with diff, CMP, CEA 
• Staging study to evaluate extent of disease in the chest, abdomen and pelvis: CT w/ 
contrast is preferred to rule out metastatic disease 

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• Rectal protocol MRI pelvis to assess the local extent of the primary tumor, 
including T and N stage.   
• Pregnancy test (for women of childbearing potential) – within 14 days of first 
treatment 
• Colonoscopy (within 6 months is acceptable) 
o If feasible it is strongly recommended that the following physical findings 
should be scored: 
- 
Tumor location (distance in cm from the anal verge to the distal tumor 
margin) 
- 
Circumferential lesion Y/N 
• Research biopsy (see Section 11.1) 
• Blood for ctDNA (see Section 11.2) 
• FACT-C quality of life questionnaire 
 
5.2 
During Radiotherapy and Chemotherapy 
 
Routine standard of care examinations and blood work will be done.   
 
• CMP and CBC with differential prior to each cycle of chemotherapy  
• On treatment assessment by radiation oncologist during the week of radiation 
therapy  
• Assessment by medical oncology physician or nurse with each cycle of 
chemotherapy.   
• Please see Section 6 for radiation therapy guidelines and Section 7 for 
chemotherapy guidelines. 
• Rectal protocol MRI pelvis 8 weeks after completion of radiation (preferably after 
at least 3 cycles of chemotherapy completed) – OPTIONAL. 
 
5.3 
Completion of Chemotherapy/Post-Treatment Evaluation 
 
Three to eight weeks after completion of chemotherapy, patients will have the following 
assessments: 
• CEA 
• FACT-C questionnaire. 
• Surgical assessment w/ endoscopy (sigmoidoscopy preferred, rigid proctoscopy 
acceptable) to evaluate the extent of residual tumor 
• Rectal protocol MRI pelvis to evaluate ycT and ycN stage 
• Digital rectal exam (DRE) to evaluate ycT stage 
  
For patients with a cCR, non-operative management will be pursued. For patients with 
residual disease who do not meet criteria for cCR by 3-8 weeks after completion of the last 
cycle of FOLFOX or CAPOX, further therapy is recommended and at the discretion of the 
treating physicians. At investigator discretion, patients who achieve a near clinical 
complete response33 with equivocal findings concerning for residual disease may be 
followed closely with short interval observation (i.e. 6-8 week MR/endoscopic follow-up), 

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with non-operative management pursued if a subsequent cCR is achieved. Patients whose 
disease is amenable to transanal endoscopic microexcision (TEM) or local excision (LE) 
may undergo TEM/LE to evaluate degree of residual disease.  For those with ypT1 disease 
without LVSI present, non-operative management may continue with evaluation noted 
above.  For those with residual ypT2-3 disease or ypT1 with LVSI, extirpative surgery 
including TME is recommended with treatment at investigators discretion proceeding off-
study. 
 
Post-treatment lymph nodes are to be evaluated by imaging and reviewed in 
muldisciplinary tumor board with a radiologist and classified as progressive, persistent 
disease, indeterminate or benign. Patients with progressive or persistent lymph node 
disease will not be eligible for non-operative management and will undergo additional 
therapy. Patients with indeterminate or benign lymph nodes AND cCR of primary will 
undergo non-operative management. 
 
5.4 
Follow-up 
 
The FACT-C questionnaire and follow-up visit will be done 10-14 months from treatment 
(radiotherapy) start date.  
 
Patients undergoing nonoperative management will be assessed for sustained cCR by rectal 
protocol MRI pelvis, endoscopy (sigmoidoscopy preferred, rigid proctoscopy accepted) 
and DRE every three months (not necessarily on the same day / appointment) for 1 year 
then every 3-4 months for the second year. If patient is unable to receive an MR pelvis 
every 3 months, every 6 months is acceptable as long as endoscopic exam is performed as 
per protocol schedule. CT chest and abdomen with contrast is to be obtained every 6 
months for the first 2 years. Each of the follow-up studies and visits have a permitted 
variation of ±2 weeks. After 2 years of follow-up on study, we recommend off-protocol 
follow-up with the same studies every 4-6 months per treating physician discretion. 
 
 
Once a patient undergoes surgical resection they will undergo imaging and surgical follow-
up as per institutional standard of care. These patients will continue to be followed for data 
collection for during study follow-up. 
 
 
6 
RADIATION THERAPY GUIDELINES 
 
6.1 
Dose, Fractionation and Constraints 
 
When feasible it is strongly recommended that radiotherapy begin on a Monday. It is 
accepted that occasional logistical delays may occur during radiotherapy treatment due to 
machine downtime or other issues.  Radiotherapy as administered during this study may 
take up to 10 business days without being considered a protocol deviation. 
 
Radiotherapy will consist of five fractions, delivered once daily, to a total dose of 25 Gy at 
5 Gy per fraction (PTV2500). An optional simultaneous integrated boost of 30 Gy in 5 

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fractions to the primary tumor is permitted. Monday through Friday treatment is strongly 
recommended. Daily imaging to verify accurate setup is mandatory.  It is required that at 
least 95% of the PTV_2500 receive at least 95% of the prescription dose and that the 
maximum dose be < 115% of the prescription dose. Every effort should be made for 100% 
of the PTV_2500 to be covered by 95% of the prescription dose. For treatment plans to 25 
Gy, this is most reproducibly accomplished via a 3D plan with four fields and optional 
field-in-field technique. The maximum allowed dose to small bowel is 25 Gy (with an 
acceptable deviation of up to 25.5 Gy).  A boost dose of 30 Gy in 5 fractions to the primary 
is strongly recommended for T3 tumors, tumors >4 cm and tumors involving the 
circumferential resection margin. 
 
It is recommended that pelvic lymph nodes outside of the mesorectum determined to be 
clinically suspicious by an experienced radiologist be boosted to 35 Gy in 5 fractions. The 
maximum allowed small bowel dose is 25 Gy (with an acceptable deviation of up to 25.5 
Gy) when a primary or LN boost is given as well. There is no coverage requirement for 
boost doses. SIB plans may be delivered with IMRT (recommended) or multiple field 3D 
planning as long as dose constraints are met.  
 
The following constraints are recommended (IMRT optimization) when boosting lymph 
node(s):  
Bladder V20Gy < 15 cc. Dmax < 38 Gy.  
Penile bulb V30Gy < 3 cc.  
Femoral heads V30Gy < 10 cc.  
Skin V36.5Gy < 10 cc. Dmax < 38.5 Gy. 
  
6.2 
Treatment Planning Procedures 
 
Image-based treatment planning and IMRT are permitted.  Proton therapy is not permitted. 
Dose volume histogram (DVH) information for the target volumes, small bowel, and 
uninvolved colon (defined to be large bowel outside the clinical target volumes) is 
mandatory.  This is to assist in interpreting outcome, including morbidity.  Daily cone beam 
CT to assess for rectal and bladder filling is recommended. 
 
6.3 
Simulation Procedures/Patient Positioning 
 
The prone position with a bowel displacement device incorporated into the immobilization 
cast is generally recommended as the best way to exclude small bowel from the pelvis. The 
exceptions would be patients unable to lay prone or morbidly obese patients whose 
diagnostic supine CT scans demonstrate little or no small bowel in the pelvis.   Those 
patients with good bladder control should be treated with a full bladder per institutional 
practice to further exclude small bowel.  All patients should be simulated with oral small 
bowel contrast.  
 
6.4 
Clinical Target Volume (CTV) and Planning Target Volume (PTV) 
Definitions and Radiation Treatment Planning 
 

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Contouring should be as per the RTOG anorectal contouring atlas. CTV_2500 should 
include rectum and associated mesentery extending caudad at least to two cm below the 
distal edge of palpable disease.  Superiorly it should include the rectum and its mesentery 
to the level of the rectosigmoid or two cm proximal to macroscopic disease, whichever is 
more cephalad.  In addition, the internal iliac, internal obturator, and pre-sacral lymph node 
regions should be included (superiorly to approximately the level of L5/S1, including the 
inferior mesenteric vessels). PTV_2500 is generated by a uniform 0.5-0.7 cm expansion 
about CTV_2500.  CTV_3000 for boost is 0.5 cm expansion off of the GTV. PTV_3000 
is a 0.5-0.7 expansion off of CTV_3000. If a SIB for extra-mesorectal pelvic lymph nodes 
is used, CTV_3500 should be a 0.5 cm expansion from the gross lymph node. PTV_3500 
is a 0.5-0.7 cm expansion from CTV_3500.  
 
It is required that a physician review daily setup images (either pre or post-treatment) for 
each of the five fractions. 
 
Ideally the 95% dose should not extend more than 3-6 mm below or above the PTV 
contour. 
 
6.5 
Normal Tissue Contours 
 
Individual loops of small bowel should be contoured tightly.  Bowel bag is not permitted. 
The CTV is NOT to be extracted from small bowel.  If small bowel lies within a CTV, that 
WILL contribute to the small bowel dose.  Since absolute rather than relative bowel 
volumes are to be tracked, it is not necessary to contour the entire small bowel, only those 
loops caudal to 2 cm above the most cephalad extent of PTV_2500.  
 
 
7 
CHEMOTHERAPY GUIDELINES 
 
7.1 
Chemotherapy Schedule and Doses 
 
Chemotherapy should begin 2 to 4 weeks after completion of radiotherapy and will consist 
of FOLFOX (5FU/leucovorin/oxaliplatin) every other week for 8 courses (16 weeks). 
Leucovorin may be substituted with levoleucovorin (200 mg/m2) if leucovorin is not 
available. Alternatively, CAPOX (capecitabine/oxaliplatin) may be given for 5 cycles over 
15 weeks.  A maximum (total) delay of treatment of 4 weeks is allowed per protocol due 
to factors or adverse events (AEs) listed in this section.  Cumulative delays in excess of 4 
weeks will need to be discussed with the Principal Investigator.  Such cases will need to be 
individualized depending on the clinical scenario.  Patients receiving CAPOX will be given 
a pill diary (Appendix B) to assess compliance for capecitabine. 
 
7.2 
Agent Administration 
 
FOLFOX 
Agent 
Dose  
Route 
Schedule 
Oxaliplatin* 
85 mg/m2 
IV over 2 hours 
On Day 1, Q 14 days 

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Leucovorin* 
400 mg/m2 
IV over 2 hours 
On Day 1, Q 14 days 
5-FU Bolus* 
400 mg/m2 
IV push  
On Day 1, Q 14 days 
5-FU Infusion*  
2400 mg/m2 
IV CIIV 
On Day 1, Q 14 days 
over 46 hours 
*Administer sequentially as written, except oxaliplatin and leucovorin may be administered concurrently 
 
CAPOX 
Agent 
Dose  
Route 
Schedule 
Capecitabine 
1000 mg/m2 
PO 
BID Days 1-14, Q21 days 
Oxaliplatin 
130 mg/m2 
IV over 2 hours 
On Day 1, Q 21 days 
 
Dose calculations for both regimens should be based on actual weight and not corrected 
for obesity. 
 
7.3 
Supportive Care Recommendations 
 
Veno-occlusive disease is a very rare AE associated with the administration of the 
combination of 5-FU and oxaliplatin. VOD disease is characterized by hepatomegaly, 
ascites, and jaundice. These signs and symptoms should prompt consideration of VOD. A 
Doppler ultrasound showing reversal of portal blood flow or other evidence of portal 
hypertension is suggestive of this diagnosis. In addition, standard clinical practice for 
evaluation of VOD should include observation of liver and spleen size, history of or 
gastrointestinal bleeding, development of esophageal varices, ascites, bleeding, or 
jaundice.  All patients on and off therapy who develop signs and symptoms suggestive of 
VOD should be thoroughly evaluated and closely monitored and supported as clinically 
dictated. 
 
Grade 3/4 hypersensitivity, including anaphylactic/anaphylactoid reactions, has been 
observed with oxaliplatin.  These allergic reactions, which can be fatal, can occur within 
minutes of administration, and can occur during any cycle.  There were similar in nature 
and severity to those reported with other platinum-containing compounds, such as rash, 
urticaria, erythema, pruritus, and rarely bronchospasm and hypotension.  These reactions 
are usually managed with standard epinephrine, corticosteroid, and antihistamine therapy, 
and require discontinuation of therapy. 
 
Ice should be avoided during the infusion of oxaliplatin because cold temperatures can 
exacerbate acute neurological symptoms. 
 
 
8 
DOSE DELAYS/DOSE MODIFICATIONS 
 
8.1 
Radiotherapy Dosing 
 
Radiotherapy for this trial may take place over a maximum of 10 business days before it is 
considered a protocol deviation.  There are no dose adjustments (reductions, omissions) 
associated with radiotherapy. 

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8.2 
Chemotherapy Dosing 
 
FOLFOX 
Chemotherapy 
Starting Dose 
Dose Level -1 
Dose Level -2 
Dose Level -3 
Oxaliplatin 
85 mg/m2 
65 mg/m2 
50 mg/m2 
40 mg/m2 
Bolus 5-FU 
400 mg/m2 
300 mg/m2 
200 mg/m2 
100 mg/m2 
Infusion 5-FU 
2400 mg/m2 
1920 mg/m2 
1600 mg/m2 
1360 mg/m2 
Leucovorin 
400 mg/m2 
400 mg/m2 
400 mg/m2 
400 mg/m2 
 
CAPOX 
Chemotherapy 
Starting Dose 
Dose Level -1 
Dose Level -2 
Dose Level -3 
Oxaliplatin 
130 mg/m2 
100 mg/m2 
80 mg/m2 
50 mg/m2 
Capecitabine 
1000 mg/m2 BID 800 mg/m2 BID 650 mg/m2 BID 
500 mg/m2 BID 
 
Dose modifications of the chemotherapy agents may be made independently of each other. 
Patients unable to tolerate one of more drugs due to toxicity may remain on study with the 
other drugs. All toxicities should be graded according to the Common Terminology Criteria 
for Adverse Events (CTCAE), version 4.0.  Dose modifications are based upon dose level 
administered at last treatment day. If the dose level has been reduced due to toxicity, re-
escalation is permitted at the discretion of the primary treating physician.  
 
8.3 
Dose Modifications for Toxicity Related to FOLFOX-6 
 
Dose modifications during FOLFOX chemotherapy are at the discretion of the primary 
treating provider. The use of 5-FU bolus is at the discretion of the treating physician. 
Modifications should be reported to research coordinator. Refer to the tables below for 
guidance regarding suggested dose reductions and treatment delays, consistent with best 
oncologic practices.  
 
Toxicity NCI Grade (Value) 
Worst interval toxicity 
Day of treatment 
Neutropenia (ANC)  
Grade 1 
(ANC < LLN – 1500/mm³) 
Maintain dose level 
If ANC < 1000 on day of treatment, hold 
and check weekly until > 1000 mm3. Then 
treat based on interval toxicity. If ANC < 
1000 after 4 weeks, discontinue therapy. 
 
Grade 2 
(ANC <1499 – 1000/mm³) 
 
Grade 3 
(ANC <999 – 500/mm³) 
Reduce 1 dose level  
Grade 4 
(ANC < 500/mm³) 
Thrombocytopenia 
Grade 1 
(PLT < LLN – 75,000/mm3) 
Maintain dose level 
If PLT < 75,000 on day of treatment, hold 
and check weekly until > 75,000 mm3. 
Then treat based on interval toxicity. If 
PLT < 75,000 after 4 weeks, discontinue 
therapy. 
Grade 2 
(PLT 74,999 – 50,000/mm3) 
Grade 3 
(PLT 49,999 – 25,000/mm3) 
Reduce 1 dose level  

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Grade 4 
(PLT< 25,000/mm3) 
Diarrhea 
Grade 1 
Maintain dose level 
Hold chemotherapy if any grade of 
diarrhea above grade 1 is present with the 
patient not taking antidiarrheal agents 
within 24 hours of treatment. Reduce 5-
FU and oxaliplatin 1 dose level upon 
resolution of diarrhea. If diarrhea has not 
resolved within 4 weeks of scheduled 
treatment day, discontinue therapy. 
Grade 2 
Reduce 
5-FU 
and 
oxaliplatin 1 dose level 
Grade 3 
Grade 4 
Other nonhematologic toxicities 
(except neurologic, alopecia, anorexia, nausea/vomiting if can be controlled by antiemetics) 
Grade 1 
Maintain dose level 
Maintain dose level 
Grade 2 
Grade 3 
Reduce 1 dose level  
Hold until resolved to grade ≤1. 
Reduce 5-FU and oxaliplatin 1 
dose level 
Grade 4 
 
8.4 
Dose Modifications for Neurologic Toxicity (Paresthesia or Dysesthesia) 
Related to Oxaliplatin 
 
Grade 
 
Duration of Toxicity 
1 – 7 Days 
> 7 Days 
Persistent 
Between 
Doses 
Grade 1 
Short duration that resolves and 
does not interfere with function 
No change 
 
No change 
 
No change 
 
Grade 2 
Interfering with function, but not 
activities of daily living (ADL) 
No change 
 
No change 
 
Reduce 
oxaliplatin 1 
dose level 
Grade 3 
With pain or with functional 
impairment that also interferes with 
ADL 
 
1st time: reduce 
oxaliplatin 1 dose 
level 
 
2nd time: reduce 
oxaliplatin another 
dose level 
1st time: reduce 
oxaliplatin 1 dose 
level 
 
2nd time: reduce 
oxaliplatin another 
dose level 
Discontinue 
oxaliplatin 
 
Grade 4 
Persistent symptoms that are 
disabling or life-threatening 
Discontinue 
oxaliplatin 
 
Discontinue 
oxaliplatin 
 
Discontinue 
oxaliplatin 
 
 
8.5 
Dose Modifications for Toxicity Related to CAPOX 
 
Dose modifications may be made as per standard of care following the package inserts or 
standard practice. Based on recent report by Cercek et al., in Lancet Oncology 2018 
(PMID29566109), dose modification of 5-FU or oxaliplatin is quite common, up to 54% 
with oxaliplatin and 25% with 5-FU. However, about 85% were able to complete >75% of 

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planned doses. Therefore, we believe up to 70% of patients requiring dose modification 
would be acceptable.  
 
Specifically, for diarrhea, the following table is recommended for dose modification of 
capecitabine. Standard antidiarrheal agents will be recommended.  
 
Recommended Dose Modification and Toxicity Management Guidelines for Diarrhea 
Attributable to Capecitabine 
 
Toxicity Grades  
During a Course of Therapy  
Dose Adjustment for Next Treatment 
(% of starting dose)  
Grade 1  
Maintain dose level  
Maintain dose level  
Grade 2  
-1st appearance  
Interrupt until resolved to grade 0-1  
100%  
-2nd appearance  
75%  
-3rd appearance  
50%  
-4th appearance  
Discontinue treatment permanently  
-  
Grade 3  
-1st appearance  
Interrupt until resolved to grade 0-1  
75%  
-2nd appearance  
50%  
-3rd appearance  
Discontinue treatment permanently  
-  
Grade 4  
-1st appearance  
Discontinue permanently OR If 
physician deems it to be in the 
patient’s best interest to continue, 
interrupt until resolved to grade 0-1  
50%  
 
 
9 
MR IMAGING GUIDELINES 
 
9.1 
Requirements 
 
• Imaging must be performed with at least 1.5 T (3 T also acceptable). 
• External phased array coils must be used 
• Endorectal coils must not be used 
• 2D fast T2-weighted sequences in the sagittal, axial and coronal planes must be 
obtained. 
• Axial sequence angled perpendicular to the tumor and a coronal sequence angled 
parallel to the tumor for accurate staging 
• DWI sequences should be obtained 
• Contrast agents may be used (should contrast agents be used, imaging without 
contrast must also be obtained) 
 
 
 
10 
ADVERSE EVENT REPORTING 
 
The entities providing oversight of safety and compliance with the protocol require reporting as 
outlined below. Please refer to Appendix C for definitions and Appendix D for a grid of reporting 

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timelines. 
 
Adverse events will be tracked from start of treatment through one year after the start of radiation 
therapy.  All adverse events must be recorded on the toxicity tracking case report form (CRF) with 
the exception of: 
• 
Baseline adverse events, which shall be recorded on the medical history CRF 
• 
Grade 1 or grade 2 events, which will not be captured or reported 
 
Refer to the data submission schedule in Section 14 for instructions on the collection of AEs in the 
EDC. 
 
Reporting requirements for Washington University study team may be found in Section 10.1.  
Reporting requirements for secondary site study teams participating in Washington University-
coordinated research may be found in Section 10.2. 
 
Please note that toxicities will be collected using version 4.0 of the CTCAE for comparison to a 
previous study in this population, HRPO# 201512140. 
 
10.1 
WU PI Reporting Requirements 
 
10.1.1 Reporting to the Human Research Protection Office (HRPO) at 
Washington University 
 
Reporting will be conducted in accordance with Washington University IRB 
Policies. 
 
Pre-approval of all protocol exceptions must be obtained prior to implementing the 
change. 
 
10.1.2 Reporting to the Quality Assurance and Safety Monitoring Committee 
(QASMC) at Washington University 
 
The Washington University PI (or designee) is required to notify the QASMC of 
any unanticipated problems involving risks to participants or others occurring at 
WU or any BJH or SLCH institution that has been reported to and acknowledged 
by HRPO.  (Unanticipated problems reported to HRPO and withdrawn during the 
review process need not be reported to QASMC.) 
 
QASMC must be notified within 10 days of receipt of IRB acknowledgment via 
email to  qasmc@wustl.edu.  Submission to QASMC must include the myIRB form 
and any supporting documentation sent with the form. 
 
For events that occur at secondary sites, the Washington University PI (or designee) 
is required to notify the QASMC within 10 days of Washington University 
notification via email to qasmc@wustl.edu.  Submission to QASMC must include 
either the myIRB form and supporting documentation or (if not submitted to 

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myIRB) the date of occurrence, description of the event, whether the event is 
described in the currently IRB approved materials, the event outcome, 
determination of relatedness, whether currently enrolled participants will be 
notified, and whether the informed consent document and/or any study procedures 
will be modified as a result of this event. 
 
10.1.3 Reporting to Secondary Sites 
 
The Washington University PI (or designee) will notify the research team at each 
secondary site of all unanticipated problems involving risks to participants or others 
that have occurred at other sites within 10 working days of the occurrence of the 
event or notification of the PI (or designee) of the event.  This includes events that 
take place both at Washington University and at other secondary sites, if applicable. 
Refer to Section 19.0 (Multicenter Management) for more information. 
 
10.2 
Secondary Site Reporting Requirements 
 
The research team at each secondary site is required to promptly notify the Washington 
University PI and designee of all serious adverse events (refer to Appendix C, Section D) 
within 1 working day of the occurrence of the event or notification of the secondary site’s 
PI of the event.  This notification may take place via email if there is not yet enough 
information for a formal written report (using FDA Form 3500A (MedWatch) and 
Washington University’s cover sheet (Appendix E)).  A formal written report must be sent 
to the Washington University PI and designee within 4 calendar days (for fatal or life-
threatening suspected adverse reactions) or 11 calendar days (for serious unexpected 
adverse reactions) of the occurrence of the event or notification of the secondary site’s PI 
of the event. 
 
The research team at a secondary site is responsible for following its site’s guidelines for 
reporting applicable events to its site’s IRB according to its own institutional guidelines. 
 
Washington University pre-approval of all protocol exceptions must be obtained prior to 
implementing the change.  Local IRB approval must be obtained as per local guidelines.  
Washington University IRB approval is not required for protocol exceptions occurring at 
secondary sites.   
 
10.3 
Exceptions to Expedited Reporting 
 
Events that do not require expedited reporting as described in Section 10.1 include: 
• planned hospitalizations 
• hospitalizations < 24 hours 
• respite care 
• events related to disease progression 
 
Events that do not require expedited reporting must still be captured in the EDC. 
 

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11 
CORRELATIVE STUDIES 
 
11.1 
Research Tissue 
 
Biopsy samples of the rectal tumor will be taken from the patient tumor prior to treatment 
initiation for tumor microenvironment and FAK expression assessment.  Two samples by 
alligator forceps are recommended.  These biopsies can be obtained at the time of initial 
biopsy or any time prior to initiating treatment. For patients at Washington University who 
co-enrolled in HRPO# 201107221 (Tissue and Blood Acquisition for Genomic Analysis 
and Collection of Health Information for Patients with Gastrointestinal Cancers) pre-
treatment specimens may be requested from the bank and used in lieu of the fresh biopsy 
performed under this protocol. For patients at affiliate sites  who do not have enough tissue 
from the diagnostic biopsy, a repeat pre-treatment biopsy is optional. 
 
Biopsy tissue 1A: 
One biopsy should be split in half with the first half being placed in a cryo vial and snap 
frozen in liquid nitrogen. This will be stored at -80°C until shipment. Shipment should be 
overnight with dry ice. 
 
Biopsy tissue 1B: 
The other half will be placed in formalin with the following processing steps: 
1. Formalin for 24 hours. 
2. Drain the formalin (pour it out of the container), then add 30% ethanol and set on shaker 
for 10-15 minutes. 
3. Repeat with 50% ethanol for 10 minutes. 
4. Repeat with 70% ethanol for 10 minutes. 
5. Store in 70% ethanol at 4 degrees until shipped (within 2 weeks). Please ship overnight 
using wet ice/ice pack. 
 
Blocks will be processed and immunohistochemical analysis performed in the lab of Dr. 
DeNardo. 
 
Alternatively, tissue can be prepared as paraffin embedded blocks per institutional 
standards and stored at room temperature until shipment.  
 
External institutions should ship samples to: 
 
425 S. Euclid Ave, St. Louis MO 63110 
BJC Institute of Health, Room 7207 
Phone: 314-362-9534 (ask for Savannah or Brett) 
 
Biopsy tissue 2: 
The second biopsy tissue will be processed per institutional standard. Biopsy tissue block 
(or 6-10, 10-micron slides) is required for Signatera analysis (below). 
 

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11.2 
Blood for ctDNA 
 
Approximately 20 mL of blood will be collected into STRECK tubes (26 mL for first draw) 
at the following time points: 
• Prior to the start of treatment (purple top and 2 STRECK tubes) 
• Post-RT labs (with SOC CBC/CMP prior to start of Cycle 1 of chemotherapy) 
• Day 1 of Cycle 3 (FOLFOX) or Day 1 of Cycle 2 (CAPOX) (with SOC CBC/CMP) 
• Completion of chemotherapy (3-8 weeks after the end of chemotherapy) 
• 10-14 months after RT (if this visit aligns with a follow-up time point described 
below, one draw can be used to satisfy both time points) 
• Follow-up months (months 3, 6, 9, 12, 16, 20, 24) until salvage surgery or 2 years 
from the completion of chemotherapy, whichever is first 
 
Blood will be collected at the hospital lab collection via Natera specimen acquisition form 
and will be shipped to Natera for processing by the blood collection lab.  
 
Natera, Inc 
201 Industrial Road, Suite 410 
San Carlos, CA 94070 
650-489-9050 
 
 
12 
PHARMACEUTICAL INFORMATION 
 
FOLFOX and CAPOX are standard of care, FDA-approved regimen for the treatment of rectal 
cancer, and treatment will be provided and administered according to standard of care guidelines. 
More detailed information can be found in the products’ package inserts. 
 
12.1 
Leucovorin  
 
12.1.1 Mechanism of action 
 
Leucovorin is a tetrahydrofolate acid derivative that acts as a biochemical cofactor 
for carbon transfer reactions in the synthesis of purines and pyrimidines. 
Leucovorin does not require the enzyme dihydrofolate reductase for conversion to 
tetrahydrofolic acid. Leucovorin potentiates the effects of fluorinated pyrimidines 
like 5-FU. Leucovorin increases the folate pool, increasing the biding of folate 
cofactor and active metabolites of 5-FU.  
 
12.1.2 Pharmacodynamics 
 
Leucovorin is well absorbed after oral administration and is readily converted to 5-
methyltetrahydrofolate after administration. Peak serum concentrations occur 1.7 
to 2.5 hours after an oral dose. Leucovorin is excreted in the urine as metabolites 
and has a half-life of approximately 2-6 hours.  
 

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12.1.3 Availability 
 
Leucovorin calcium is commercially available in: 50 mg, 100 mg, 350 mg vials for 
reconstitution. 
 
12.1.4 Supplier(s) 
 
Leucovorin is commercially available and will not be provided by this study. 
 
12.1.5 Storage and Stability 
 
Intact vials should be stored at room temperature and protected from light. 
Solutions reconstituted with Bacteriostatic Water for Injection (BWI) are stable for 
at least 7 days at room temperature. 
 
12.1.6 Administration 
 
Leucovorin may be reconstituted with BWI or with sterile water. Solutions should 
be further diluted in D5W, 0.9% NaCl or Ringers solution for infusion over two 
hours. 
 
Leucovorin will be administered as a 400 mg/m2 IV infusion over 2 hours. It may 
be given either concurrent with (via a separate infusion line) or following 
oxaliplatin and immediately before fluorouracil. 
 
12.2 
5-Fluorouracil (5-FU) 
 
12.2.1 Mechanism of Action 
 
Fluorouracil, C4H3FN2O2, a pyrimidine antagonist, is an antimetabolite 
antineoplastic agent. Although the precise mechanisms of action of fluorouracil 
have not been fully elucidated, the main mechanism is thought to be the binding of 
the deoxyribonucleotide of the drug (FdUMP) and the folate cofactor, N5-10-
methylenetetrahydrofolate, to thymidylate synthase (TS) to form a covalently 
bound ternary complex, which inhibits the formation of thymidylate from uracil, 
thereby interfering with DNA synthesis. In addition, FUTP can be incorporated into 
RNA in place of uridine triphosphate (UTP), producing a fraudulent RNA and 
interfering with RNA processing and protein synthesis. 
 
12.2.2 Pharmacodynamics/kinetics 
 
Absorption: Following IV administration of fluorouracil, no intact drug is detected 
in plasma after 3 hours. 
 
Distribution: Fluorouracil is distributed into tumors, intestinal mucosa, bone 
marrow, liver, and other tissues. Despite its limited lipid solubility, the drug readily 

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crosses the blood-brain barrier and distributes into CSF and brain tissue. 
Distribution studies in humans and animals have usually shown a higher 
concentration of the drug or its metabolites in the tumor than in surrounding tissue 
or in corresponding normal tissue. It has also been shown that there is a longer 
persistence of fluorouracil in some tumors than in the normal tissues of the host, 
perhaps due to impaired uracil catabolism. From these data, it has been suggested 
that the drug may possibly have some specificity against certain tumors in 
comparison with normal tissues. 
 
Elimination: Following IV administration, the plasma elimination half-life 
averages about 16 minutes (range: 8-20 minutes) and is dose dependent. A small 
portion of fluorouracil is anabolized in the tissues to 5-fluoro-2-deoxyuridine and 
then to 5-fluoro-2-deoxyuridine-5-monophosphate, the active metabolite of the 
drug. The major portion of the drug is degraded in the liver. The metabolites are 
excreted as respiratory carbon dioxide and as urea, α-fluoro-β-alanine, α-fluoro-β-
guanidopropionic acid, and α-fluoro- β-ureidopropionic acid in urine. Following a 
single IV dose of fluorouracil, approximately 15% of the dose is excreted in urine 
as intact drug within 6 hours; over 90% of this is excreted in the first hour. 
 
12.2.3 Availability 
 
Fluorouracil is commercially available as a 50 mg/mL solution for injection in 10 
mL, 20 mL, 50 mL and 100 mL vials. 
 
12.2.4 Supplier 
 
5-FU is commercially available and will not be provided by this study. 
 
12.2.5 Solution Preparation  
 
Inspect for precipitate; if found, agitate or gently heat in water bath. Bolus 
injections are prepared using undiluted drug. Continuous infusions of fluorouracil 
should be prepared for administration via ambulatory infusion pump according to 
the individual institution’s standards. These solutions may be prepared in D5W or 
0.9% NaCl.  
 
12.2.6 Storage and Stability 
 
Intact vials should be stored at room temperature and protected from light. Slight 
yellow discoloration does not usually indicate decomposition. 5-FU is stable in 
syringes for up to 72 hours. Stability in ambulatory pumps varies according to the 
pump, manufacturer of drug, concentration and dilution. Please refer to appropriate 
reference sources for additional information.  
 
12.2.7 Administration 
 

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Fluorouracil will be given as a 400 mg/m2 IV bolus injection followed by 2400 
mg/m2 continuous IV infusion over 46 hours. 
 
12.3 
Oxaliplatin 
 
12.3.1 Mechanism of action 
 
Oxaliplatin is a new platinum derivative with an oxalo ligand group. Although the 
exact mechanism of oxaliplatin’s action remains unclear, the cytotoxicity of 
platinum compounds is thought to result from inhibition of DNA synthesis. 
Intrastrand platinum DNA adducts, the main cytotoxic lesions, are formed by cross-
linking activated platinum species and specific base sequences, notably 2 adjacent 
guanine residues or 2 adjacent guanine-adenine bases. 
 
12.3.2 Pharmacodynamics/kinetics 
 
Time to peak concentration with a single 2-hour infusion of oxaliplatin 85 
milligrams/square meter yielded a peak plasma concentration (Cmax) of 0.814 
micrograms/milliliter. The area under the curve for total plasma platinum was 207-
290 mg/L x hr; ultrafilterable plasma platinum was 11.9-13.6 mg/L x hr. Oxaliplatin 
has 70 to 95% platinum-protein binding while 37% represents total platinum taken 
up by red blood cells (addition of oxaliplatin to whole blood). The volume of 
distribution is 440 liters after a single 2-hour infusion of 85 milligrams/square meter 
oxaliplatin. Oxaliplatin undergoes rapid and extensive (30%) nonenzymatic 
biotransformation.  In vitro studies indicate no cytochrome P450-mediated 
metabolism. Oxaliplatin metabolites include approximately 17 different platinum 
containing derivatives with some being cytotoxic (monochloro DACH platinum, 
dichloro DACH platinum, and monoaquo and diaquo DACH platinum).  Breast 
milk – It is not known whether oxaliplatin is excreted into breast milk. Renal 
clearance is 9.3-17 liters/hour. Elimination half life: intravenous, total plasma 
platinum, alpha half-life (0.2-0.43 hours), beta half-life (15-16.8 hours), gamma 
half-life (252-391 hours). The decline of ultrafilterable platinum levels is 
triexponential with a relatively short alpha and beta half-life (0.43 hours and 16.8 
hours) and a long terminal gamma half-life (391 hours).  
 
12.3.3 Formulation  
 
Molecular formula: C8H14N2O4Pt with the chemical name of cis-[(1R, 2R)-1,2 
cyclohexanediamine-N, N’][oxaloto (2-)-o, o’] platinum. Molecular weight is 
397.3. 
 
12.3.4 Availability 
 
Oxaliplatin is formulated as a white freeze-dried powder in amber glass vials 
containing 50 mg and 100 mg of oxaliplatin in lactose monohydrate.  Each vial is 
sealed with a stopper with a crimped aluminum cap. Drug will be ordered from 

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commercial supply. 
 
12.3.5 Supplier 
 
Oxaliplatin is commercially available and will not be provided by this study. 
 
12.3.6 Solution Preparation  
 
The freeze-dried powder is reconstituted by adding 10 to 20 ml (for the 50-mg vial) 
or 20 to 40 ml (for the 100-mg vials) of sterile water for Injection or 5% dextrose 
solution and then by diluting in an infusion solution of 250 ml or 500 ml of 5% 
dextrose solution.  Avoid performing these manipulations with aluminum needles.  
The reconstitution or final dilution must never be performed with a sodium chloride 
solution. 
 
12.3.7 Storage and Stability 
 
Oxaliplatin freeze-dried powder may be stored at room temperature protected from 
light. Do not combine with alkaline medications or media, which cause oxaliplatin 
to degrade. Do not use needles or intravenous infusion sets containing aluminum 
items (risk of degradation of oxaliplatin upon contact with aluminum) for the 
preparation or administration of oxaliplatin. Do not mix oxaliplatin with sodium 
chloride or other chloride containing solutions. Freeze-dried powder: The 
compound may be stored for 3 years at room temperature protected from light. 
Reconstituted solution:  In 5% dextrose solution or sterile Water for Injection in the 
original vial, the solution may be stored for 24 to 48 hours at 2-80° C. Infusion 
solution:  after dilution in 5% dextrose solution, the shelf-life is 24 hours at room 
temperature.  
 
12.3.8 Administration 
 
Antiemetic premedication (5-HT3 blocker with or without dexamethasone) is 
recommended. Cold temperatures can precipitate/exacerbate neurological 
symptoms-avoid during the infusion of oxaliplatin. Never reconstitute/dilute with 
a chloride-containing solution; avoid aluminum parts when preparing/mixing 
oxaliplatin. Incompatible with alkaline media (i.e., solutions of 5-fluorouracil). 
Prepare oxaliplatin in 250-500 mL D5W. 
 
12.4 
Capecitabine 
 
12.4.1 Mechanism of action 
 
Enzymes convert capecitabine to 5-fluorouracil (5-FU) in vivo. Both normal and 
tumor cells metabolize 5-FU to 5-fluoro-2’-deoxyuridine monophosphate 
(FdUMP) and 5-fluorouridine triphosphate (FUTP). These metabolites cause cell 
injury by two different mechanisms. First, FdUMP and the folate cofactor, N5-10-

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methylenetetrahydrofolate, bind to thymidylate synthase (TS) to form a covalently 
bound ternary complex. This binding inhibits the formation of thymidylate from 2’-
deoxyuridylate. Thymidylate is the necessary precursor of thymidine triphosphate, 
which is essential for the synthesis of DNA, so that a deficiency of this compound 
can inhibit cell division. Second, nuclear transcriptional enzymes can mistakenly 
incorporate FUTP in place of uridine triphosphate (UTP) during the synthesis of 
RNA. This metabolic error can interfere with RNA processing and protein 
synthesis. 
 
12.4.2 Pharmacodynamics/kinetics 
 
Following oral administration of 1255 mg/m2 BID to cancer patients, capecitabine 
reached peak blood levels in about 1.5 hours (Tmax) with peak 5-FU levels 
occurring slightly later, at 2 hours. Food reduced both the rate and extent of 
absorption of capecitabine with mean Cmax and AUC0-∞ decreased by 60% and 
35%, respectively. The Cmax and AUC0-∞ of 5-FU were also reduced by food by 
43% and 21%, respectively. Food delayed Tmax of both parent and 5-FU by 1.5 
hours. 
 
The pharmacokinetics of XELODA and its metabolites have been evaluated in 
about 200 cancer patients over a dosage range of 500 to 3500 mg/m2/day. Over this 
range, the pharmacokinetics of XELODA and its metabolite, 5’-DFCR were dose 
proportional and did not change over time. The increases in the AUCs of 5’-DFUR 
and 5-FU, however, were greater than proportional to the increase in dose and the 
AUC of 5-FU was 34% higher on day 14 than on day 1. The interpatient variability 
in the Cmax and AUC of 5-FU was greater than 85%. 
 
Capecitabine is extensively metabolized enzymatically to 5-FU. 
 
Capecitabine and its metabolites are predominantly excreted in urine. 
 
12.4.3 Formulation  
 
Capecitabine is a fluoropyrimidine carbamate with antineoplastic activity.  The 
chemical name for capecitabine is 5’-deoxy-5-fluoro-N-[(pentyloxy) carbonyl]-
cytidine and has a molecular weight of 359.35.  It’s supplied as biconvex oblong 
film-coated tablets for oral administration. 
 
12.4.4 Availability 
 
Capecitabine is available in 150 mg and 500 mg tablets. 
 
12.4.5 Supplier 
 
Capecitabine is commercially available and will not be provided for this study. 
 

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12.4.6 Storage and Stability 
 
Store at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F). 
 
12.4.7 Administration 
 
Patients will be instructed to take capecitabine with water 30 minutes after a meal 
as described in Section 7.2. 

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13 
STUDY CALENDAR 
 
 
Screening4 
 
During RT 
Day 1 of Each 
Cycle of Chemo8 
Completion of 
Chemo10 
10 to 14 Months 
after RT17 
Follow-
up9 
Informed consent 
X 
 
 
 
 
 
H&P 
X 
X (once) 
X 
X 
X 
 
CBC diff, plts 
X 
 
X 
 
 
 
CMP 
X 
 
X 
 
 
 
CEA 
X 
 
X 
 
 
 
Pregnancy test5 
X6 
 
 
 
 
 
Colonoscopy or barium enema or Hypaque enema 
X11 
 
 
 
 
 
Surgical assessment with proctoscopy or sigmoidoscopy 
 
 
 
X 
 
X15 
Digital rectal exam 
X 
 
 
X 
 
X 
Staging study to evaluate disease in abdomen and pelvis1 
X 
 
 
 
 
X 
Staging study to evaluate disease in lungs2 
X 
 
 
 
 
X 
Imaging study to assess local extent of primary tumor3 
X 
 
X12 
X 
 
X14 
Radiotherapy 
 
X7 
 
 
 
 
FOLFOX / CAPOX 
 
 
X 
 
 
 
Biopsy for research (refer to Section 11) 
X 
 
 
 
 
 
Blood for ctDNA16 
X 
 
X13 
X 
X16 
X16 
FACT-C 
X 
 
 
X 
X 
 
AE assessment 
AEs should be collected through 1 year following the start of RT 
 
Progression and survival 
 
 
 
 
 
X 
1. 
CT with contrast or MRI or PET/CT or PET/MRI; obtain every 6 months during the 2 years of follow-up. Once patients undergo surgical resection they will undergo imaging 
and surgical follow-up as per institutional standard of care. 
2. 
CT of the chest or PET/CT; obtain every 6 months during the 2 years of follow-up. Once patients undergo surgical resection they will undergo imaging and surgical follow-up 
as per institutional standard of care. 
3. 
Rectal protocol (pelvic) MRI (preferred), MRI, CT scan 
4. 
Within 12 weeks of day of simulation for RT but no later than the first radiation treatment 
5. 
Women of childbearing potential only 
6. 
No more than 14 days prior to the first day of treatment 
7. 
5 fractions delivered over the course of no more than 10 business days (preferably starting on a Monday).   
8. 
Chemotherapy should start 2 to 4 weeks after the end of RT.  FOLFOX cycles are 14 days and a total of 8 cycles will be given; CAPOX cycles are 21 days and a total of 5 
cycles will be given. Labs with each chemotherapy may occur up to 3 days prior to Day 1 of the cycle. 
9. 
For patients undergoing nonoperative management, follow-up visits will occur every 3 months for the first year and every 3-4 months for the second year (± 2 weeks). After 2 
years of follow-up we will recommend the same studies every 4-6 months per treating physician discretion. Once patients undergo surgical resection they will undergo imaging 
and surgical follow-up as per institutional standard of care. 
10. 3-8 weeks after the end of chemotherapy 
11. Within 6 months of day of simulation for RT but no later than the first radiation treatment 
12. OPTIONAL; within 8 weeks of completion of RT 
13. Prior to Cycle 1 Day 1 (for FOLFOX and CAPOX) and on Day 1 of Cycle 3 (FOLFOX) and Day 1 of Cycle 2 (CAPOX) 

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14. Rectal protocol MRI pelvis. If patient is unable to receive an MR pelvis every 3 months, every 6 months is acceptable as long as endoscopic exam is performed on schedule. 
15. Sigmoidoscopy preferred, rigid proctoscopy accepted  
16.  Blood for ctDNA will be collected every 3 months after chemotherapy completion until salvage surgery or 2 years from the completion of chemotherapy, whichever is first. 
17. If the 10-14 month after RT visit aligns with a follow-up time point, one visit can be used to satisfy both time points  
 

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14 
DATA SUBMISSION SCHEDULE 
 
Case report forms with appropriate source documentation will be completed according to the 
schedule listed in this section. 
 
Form 
Completion Schedule 
On-Study Form 
Medical History Form 
Time of registration 
Radiation Therapy Form 
Completion of RT 
Chemotherapy Form 
At the end of each cycle of chemotherapy 
Disease Assessment Form 
Baseline 
8 weeks post-RT (OPTIONAL) 
3-8 weeks post-chemoradiation 
Follow-Up Form 
Months 3, 6, 9, 12, 16, 20, and 24 (for subjects who 
have not undergone surgery only) 
FACT-C 
Baseline 
Completion of chemoradiation 
10-14 months after chemoradiation 
Research Tissue Form 
Time of biopsy 
Research Blood Form 
Prior to the start of treatment 
Post-RT (with SOC CBC/CMP) 
Day 1 of Cycle 3 (FOLFOX) or Day 1 of Cycle 2 
(CAPOX)Completion of chemotherapy (3-8 weeks 
after the end of chemotherapy)  
10-14 months after RT 
Follow-up (Months 3, 6, 9, 12, 16, 20, 24) until 
salvage surgery or 2 years from the completion of 
chemotherapy, whichever is first 
Adverse Events Form 
Ongoing 
Progression Form 
Time of disease progression 
Death Form 
Time of death 
 
Any queries generated by Washington University must be responded to within 28 days of receipt 
by the participating site.  The Washington University research team will conduct a regular review 
of data status at all secondary sites, with appropriate corrective action to be requested as needed. 
 
14.1 
Adverse Event Collection in the Case Report Forms 
 
All adverse events that occur beginning with start of treatment (minus exceptions defined 
in Section 10.0) must be captured in the Toxicity Form.  Baseline AEs should be captured 
on the Medical History Form. 
 
Participant death due to disease progression should be reported on the Toxicity Form as 
grade 5 disease progression.  If death is due to an AE (e.g. cardiac disorders: cardiac arrest), 
report as a grade 5 event under that AE.  Participant death must also be recorded on the 

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Death Form. 
 
 
15 
MEASUREMENT OF EFFECT 
 
Criteria for clinical complete response: 
• No residual gross tumor at procto/sigmoidoscopy; or only erythematous scar or ulcer 
• No palpable tumor on DRE 
• No radiographic evidence of tumor on MRI 
• No suspicious mesorectal lymph nodes on MRI 
• Negative biopsy from scar, ulcer, or former tumor site (if necessary according to surgeon’s 
judgment) 
 
Criteria for not clinical complete response (also known as clinical partial response): 
• Does not meet criteria for cCR or progressive disease 
o Residual disease by DRE, endoscopy or MR. 
 
Criteria for progressive disease: 
• Increase in size of primary tumor by RECIST criteria (increase of at least 20% from nadir 
in the sum of the target lesion, with an absolute increase of at least 5 mm) 
• New metastatic disease 
 
 
16 
DATA AND SAFETY MONITORING PLAN 
 
In compliance with the Washington University Institutional Data and Safety Monitoring Plan, the 
Siteman Cancer Center independent standing Data and Safety Monitoring Board (DSMB) will be 
specifically convened for this trial to review toxicity data.  This DSMB will consists of clinical 
investigators with expertise in multiple modalities and at least one biostatistician.  Members of this 
DSMB are subject to the Washington University School of Medicine policies regarding standards 
of conduct.  Individuals invited to serve on the DSMB will disclose any potential conflicts of 
interest to the trial principal investigator and/or appropriate university officials in accordance with 
institution policies.  Potential conflicts that develop during a trial or a member’s tenure on a DSMB 
must also be disclosed. 
 
Until such a time as the first secondary site enrolls its first patient, a semi-annual DSM report to 
be prepared by the study team will be submitted to the Quality Assurance and Safety Monitoring 
Committee (QASMC) semi-annually beginning six months after study activation at Washington 
University (if at least one patient has been enrolled) or one year after study activation (if no patients 
have been enrolled at the six-month mark). 
 
The DSM report for the DSMB will be prepared by the study team with assistance from the study 
statistician, will be reviewed by the DSMB, and will be submitted to the QASMC. The DSMB 
must meet at least every six months beginning six months after enrollment of the first patient at a 
secondary site, no more than one month prior to the due date of the DSM report to QASMC.  This 
report will include: 

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• HRPO protocol number, protocol title, Principal Investigator name, data coordinator name, 
regulatory coordinator name, and statistician 
• Date of initial HRPO approval, date of most recent consent HRPO approval/revision, date 
of HRPO expiration, date of most recent QA audit, study status, and phase of study 
• History of study including summary of substantive amendments; summary of accrual 
suspensions including start/stop dates and reason; and summary of protocol exceptions, 
error, or breach of confidentiality including start/stop dates and reason 
• Study-wide target accrual and study-wide actual accrual including numbers from 
participating sites 
• Protocol activation date at each participating site 
• Average rate of accrual observed in year 1, year 2, and subsequent years at each 
participating site 
• Expected accrual end date, accrual by site 
• Objectives of protocol with supporting data and list the number of participants who have 
met each objective 
• Measures of efficacy 
• Early stopping rules with supporting data and list the number of participants who have met 
the early stopping rules 
• Summary of toxicities at all participating sites 
• Abstract submissions/publications 
• Summary of any recent literature that may affect the safety or ethics of the study  
 
Further DSMB responsibilities are described in the charter. 
 
The study principal investigator and coordinator will monitor for serious toxicities on an ongoing 
basis. Once the principal investigator or coordinator becomes aware of an adverse event, the AE 
will be reported to the HRPO and QASMC according to institutional guidelines (please refer to 
Section 10.0). 
 
Refer to the Washington University Quality Assurance and Data Safety Monitoring Committee 
Policies and Procedures for full details on the responsibilities of the DSMB.  This is located on the 
QASMC 
website 
at 
https://siteman.wustl.edu/research/clinical-research-resources/protocol-
office-prmcqasmc/ 
 
 
17 
AUDITING 
 
As coordinating center of this trial, Washington University (via the Quality Assurance and Safety 
Monitoring Committee (QASMC) will monitor each participating site to ensure that all protocol 
requirements are being met; that applicable federal regulations are being followed; and that best 
practices for patient safety and data collection are being followed per protocol.  Participating sites 
will be asked to send copies of all audit materials, including source documentation.  The audit 
notification will be sent to the Washington University Research Patient Coordinator, who will 
obtain the audit materials from the participating institution. 
 

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Notification of an upcoming audit will be sent to the research team one month ahead of the audit. 
Once accrual numbers are confirmed, and approximately 30 days prior to the audit, a list of the 
cases selected for review (up to 10 for each site) will be sent to the research team. However, if 
during the audit the need arises to review cases not initially selected, the research team will be 
asked to provide the additional charts within two working days. 
 
Items to be evaluated include: 
• Subject screening and enrollment 
• Reporting of adverse events 
• Maintenance of HIPAA compliance 
• Completeness of regulatory documentation 
• Completeness of participant documentation 
• Acquisition of informed consent 
• IRB documentation 
• Issues of protocol adherence 
 
Additional details regarding the auditing policies and procedures can be found at 
https://siteman.wustl.edu/research/clinical-research-resources/protocol-office-prmcqasmc/. 
 
 
18 
STATISTICAL CONSIDERATIONS 
 
18.1 
Study Objectives and Endpoints 
 
The primary objective is to determine the cCR response rate of patients with stage I-IIIB 
(cT1-3, N0-2a, M0) rectal cancer being treated with sequential short course radiotherapy 
followed by multi-drug chemotherapy (either 8 cycles of FOLFOX or 5 cycles of CAPOX). 
The endpoint is cCR at the completion of short course radiation therapy and chemotherapy. 
Secondary endpoints include PFS at 2 years, incidence of any grade ≥ 3 toxicity during 
treatment, incidence of post chemoradiotherapy grade ≥ 3 toxicity, quality of anorectal 
function as measured by the FACT-C questionnaire at 1 year, and 1 and 2 year organ 
preservation rate. Exploratory objectives are to associate tumor microenvironment 
(including FAK expression) and ctDNA levels with cCR and other clinical outcomes.  
 
18.2 
Study Design and Sample Size Justification  
 
The purpose of this phase II study is to determine if the cCR of short course radiation 
therapy followed by multiple agent chemotherapy in rectal adenocarcinoma is at least 50% 
in a multi-institution setting. Given that less than one-third of patients with cCR is deemed 
as an ineffective therapy clinically, our null hypothesis is that cCR rate is 30%. Our phase 
1 data indicated a 74% cCR rate but our retrospective study showed 50%, which is more 
representative of advanced stage and all patients. Therefore, a cCR rate of 50% was 
considered in the alternative hypothesis. A Simon two-stage design1 with a 90% power at 
one-sided 5% type I error will be used to test the null hypothesis. At the first stage, we will 
enroll 24 patients. If the study continues, 39 additional patients will be needed. Study is 
not powered for secondary endpoints. 

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18.3 
Interim Analyses and Stopping Rules 
 
An interim analysis will be performed on the primary endpoint once 24 subjects have been 
enrolled and have completed the evaluation after chemotherapy. If ≤ 8 patients have cCR 
in these 24 patients, the study will be stopped for futility. Otherwise, the additional 39 
patients will be enrolled. The null hypothesis will be rejected if ≥25 patients with cCR are 
observed in 63 patients. 
 
18.4 
Definition of Evaluability 
 
Endpoint 
In order to be evaluable for this endpoint, a 
patient must… 
Primary 
cCR at completion of short course 
radiation therapy and chemotherapy 
Have completed the evaluation after completion 
of radiation therapy and chemotherapy. 
Secondary 
Progression-free survival at 2 years 
Have received at least one fraction of radiation 
therapy and one dose of chemotherapy. 
Incidence of any grade ≥ 3 toxicity 
during treatment 
Incidence of post chemoradiotherapy 
grade ≥ 3 toxicity 
Anorectal function per FACT-C at 1 
year 
Have completed a FACT-C at baseline and at 
least one post-treatment time point. 
1 and 2 year organ preservation rate 
Have received at least one fraction of radiation 
therapy and one dose of chemotherapy. 
Exploratory 
Associate tumor microenvironment 
with cCR and other clinical outcomes 
Have tissue collected at baseline, received at 
least one fraction of radiation therapy and one 
dose of chemotherapy, and completed 
evaluation of their disease. 
Associate ctDNA levels with cCR 
and other clinical outcomes 
Have blood collected at baseline and at least 
one post-dose time point, received at least one 
fraction of radiation therapy and one dose of 
chemotherapy, and completed evaluation of 
their disease. 
 
All eligible enrolled patients that receive any treatment will be included in the intention to 
treat analysis. Patients that complete protocol therapy (both radiation therapy and 
chemotherapy) as prescribed will be included in a per protocol analysis. 
 
18.5 
Data Analysis 
 
Demographic and clinical characteristics of the sample will be summarized using 
descriptive statistics.  Primary endpoint of the cCR rate will be reported as a proportion 
with 95% confidence interval (CI), and a one-sided asymptotic Wald test will be performed 

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to compare the study cohort cCR rate to the null value of 30%. PFS is defined as the time 
from date of treatment to death or progression, which occurs first. The alive patients 
without progression are censored as the last date follow-up. Kaplan-Meier method will be 
used to calculate PFS at 2-year. Proportions of any grade ≥ 3 toxicity during treatment, of 
post chemoradiotherapy grade ≥ 3 toxicity and organ preservation rates at 1 and 2 year will 
be calculated. Their corresponding 95% CIs will also be provided. The quality of anorectal 
function as measured by the FACT-C questionnaire is collected at screening, completion 
of chemo, and 1 year after RT. The generalized estimating equation (GEE) model with 
appropriate link function will be used to analyze this longitudinal data, in which the 
correlation among the repeated measures from the same patient need be considered. The 
autoregressive of first order as working correlation structure will be used and the patients 
with missing values at any time points will be excluded from GEE analysis. Least square 
means for quality of anorectal function at 1 year after RT will be estimated and 95% CI 
calculated within the use of GEE sandwich method when accounting for within-patient 
correlation.  
 
18.6 
FAK Expression and Tumor Microenvironment Analysis 
 
Rectal cancer biopsies will be assessed for total and phosphorylated FAK1 (Tyr-397, p-
FAK1) and PYK2 (FAK2) by immunohistochemistry (IHC) as previously described23. 
Rectal cancer samples will be stratified by high or low epithelial (tumor cell) p-FAK1 
levels using IHC intensity and assessed for tumor-infiltrating CD3+, CD8+ cytotoxic T 
lymphocytes, neutrophil elastase and CD15+ granulocytes. Tumor fibrosis will be assessed 
by total collagen staining by Sirius Red and collagen I, III and IV deposition by IHC. Flow 
cytometry and IHC will be performed as previously reported23,34. To investigate the 
relationship between tumor microenvironment (including FAK expression) or ctDNA 
levels with the outcomes of cCR, incidence of any grade ≥ 3 toxicity during treatment, 
incidence of post chemoradiotherapy grade ≥ 3 toxicity, and organ preservation rates, the 
logistic regression model will be considered. To investigate the relationship between tumor 
microenvironment (including FAK expression) or ctDNA levels with PFS, the Cox 
regression model will be considered. To investigate the relationship between tumor 
microenvironment (including FAK expression) or ctDNA levels with the outcomes of 
quality of anorectal function, the linear regression model will be considered. 
 
18.7 
Accrual  
 
The overall accrual will be 63 patients. The rate of accrual for the study is expected to be 
about 20 patients per year.  It is expected that the accrual period of the study will be 
completed in about 3 years. 
 
 
19 
MULTICENTER REGULATORY REQUIREMENTS 
 
Washington University requires that each participating site sends its informed consent document 
to be reviewed and approved by the Washington University Regulatory Coordinator (or designee) 
prior to IRB/IEC submission.    

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Site activation is defined as when the secondary site has received official written documentation 
from the coordinating center that the site has been approved to begin enrollment.  At a minimum, 
each participating institution must have the following documents on file at Washington University 
prior to study activation: 
• Documentation of IRB approval of the study in the form of a letter or other official 
document from the participating institution’s IRB.  This documentation must show which 
version of the protocol was approved by the IRB. 
• Documentation of IRB approval of an informed consent form. The consent must include 
a statement that data will be shared with Washington University, including the Quality 
Assurance and Safety Monitoring Committee (QASMC), the DSMC (if applicable), and 
the Washington University study team. 
• Documentation of FWA, signed FDA Form 1572 (if applicable), and the CVs of all 
participating investigators. 
• Protocol signature page signed and dated by the investigator at each participating site. 
 
The coordinating center Principal Investigator (or designee) is responsible for disseminating to the 
participating sites all study updates, amendments, reportable adverse events, etc.  Protocol/consent 
modifications and IB updates will be forwarded electronically to the secondary sites within 4 
weeks of obtaining Washington University IRB approval.  Activated secondary sites are expected 
to submit protocol/consent/IB modifications to their local IRBs within 4 weeks of receipt unless 
otherwise noted.  Upon the secondary sites obtaining local IRB approval, documentation of such 
shall be sent to the Washington University study team within 2 weeks of receipt of approval. 
 
Documentation of participating sites’ IRB approval of annual continuing reviews, protocol 
amendments or revisions, all SAE reports, and all protocol violations/deviations/exceptions must 
be kept on file at Washington University. 
 
The investigator or a designee from each institution must participate in a regular conference call 
to update and inform regarding the progress of the trial. 
 
 
 

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20 
REFERENCES 
 
1.  
Habr-Gama A, Gama-Rodrigues J, São Julião GP, et al. Local recurrence after complete 
clinical response and watch and wait in rectal cancer after neoadjuvant chemoradiation: impact of 
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doi:10.1016/j.ijrobp.2013.12.012 
2.  
Appelt AL, Pløen J, Harling H, et al. High-dose chemoradiotherapy and watchful waiting 
for distal rectal cancer: a prospective observational study. Lancet Oncol. 2015;16(8):919-927. 
doi:10.1016/S1470-2045(15)00120-5 
3.  
Martens MH, Maas M, Heijnen LA, et al. Long-term Outcome of an Organ Preservation 
Program After Neoadjuvant Treatment for Rectal Cancer. J Natl Cancer Inst. 2016;108(12). 
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4.  
Maas M, Beets-Tan RGH, Lambregts DMJ, et al. Wait-and-see policy for clinical complete 
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5.  
Ngan SY, Burmeister B, Fisher RJ, et al. Randomized trial of short-course radiotherapy 
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Oncol. 2012;30(31):3827-3833. doi:10.1200/JCO.2012.42.9597 
6.  
Bujko K, Nowacki MP, Nasierowska-Guttmejer A, Michalski W, Bebenek M, Kryj M. 
Long-term results of a randomized trial comparing preoperative short-course radiotherapy with 
preoperative conventionally fractionated chemoradiation for rectal cancer. Br J Surg. 
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7.  
Bujko K, Wyrwicz L, Rutkowski A, et al. Long-course oxaliplatin-based preoperative 
chemoradiation versus 5 × 5 Gy and consolidation chemotherapy for cT4 or fixed cT3 rectal 
cancer: results of a randomized phase III study. Ann Oncol Off J Eur Soc Med Oncol. 
2016;27(5):834-842. doi:10.1093/annonc/mdw062 
8.  
Cotte E, Passot G, Decullier E, et al. Pathologic Response, When Increased by Longer 
Interval, Is a Marker but Not the Cause of Good Prognosis in Rectal Cancer: 17-year Follow-up 
of the Lyon R90-01 Randomized Trial. Int J Radiat Oncol • Biol • Phys. 2016;94(3):544-553. 
doi:10.1016/j.ijrobp.2015.10.061 
9.  
Habr-Gama A, Perez RO, Proscurshim I, et al. Interval between surgery and neoadjuvant 
chemoradiation therapy for distal rectal cancer: does delayed surgery have an impact on outcome? 
Int J Radiat Oncol Biol Phys. 2008;71(4):1181-1188. doi:10.1016/j.ijrobp.2007.11.035 
10.  
Kerr SF, 
Norton 
S, 
Glynne-Jones 
R. 
Delaying 
surgery 
after 
neoadjuvant 
chemoradiotherapy for rectal cancer may reduce postoperative morbidity without compromising 
prognosis. Br J Surg. 2008;95(12):1534-1540. doi:10.1002/bjs.6377 
11.  
Erlandsson J, Holm T, Pettersson D, et al. Optimal fractionation of preoperative 
radiotherapy and timing to surgery for rectal cancer (Stockholm III): a multicentre, randomised, 
non-blinded, 
phase 
3, 
non-inferiority 
trial. 
Lancet 
Oncol. 
2017;18(3):336-346. 
doi:10.1016/S1470-2045(17)30086-4 
12.  
Lefevre JH, Mineur L, Kotti S, et al. Effect of Interval (7 or 11 weeks) Between 
Neoadjuvant Radiochemotherapy and Surgery on Complete Pathologic Response in Rectal 
Cancer: A Multicenter, Randomized, Controlled Trial (GRECCAR-6). J Clin Oncol. 
2016;34(31):3773-3780. doi:10.1200/JCO.2016.67.6049 

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13.  
Garcia-Aguilar J, Chow OS, Smith DD, et al. Effect of adding mFOLFOX6 after 
neoadjuvant chemoradiation in locally advanced rectal cancer: a multicentre, phase 2 trial. Lancet 
Oncol. 2015;16(8):957-966. doi:10.1016/S1470-2045(15)00004-2 
14.  
Myerson RJ, Tan B, Hunt S, et al. Five Fractions of Radiation Therapy Followed by 4 
Cycles of FOLFOX Chemotherapy as Preoperative Treatment for Rectal Cancer. Int J Radiat 
Oncol Biol Phys. 2014;88(4):829-836. doi:10.1016/j.ijrobp.2013.12.028 
15.  
Paik S, Tang G, Shak S, et al. Gene expression and benefit of chemotherapy in women 
with node-negative, estrogen receptor-positive breast cancer. J Clin Oncol Off J Am Soc Clin 
Oncol. 2006;24(23):3726-3734. doi:10.1200/JCO.2005.04.7985 
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Cardoso F, van’t Veer LJ, Bogaerts J, et al. 70-Gene Signature as an Aid to Treatment 
Decisions 
in 
Early-Stage 
Breast 
Cancer. 
N 
Engl 
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2016;375(8):717-729. 
doi:10.1056/NEJMoa1602253 
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Erho N, Crisan A, Vergara IA, et al. Discovery and validation of a prostate cancer genomic 
classifier that predicts early metastasis following radical prostatectomy. PloS One. 
2013;8(6):e66855. doi:10.1371/journal.pone.0066855 
18.  
Ross AE, Feng FY, Ghadessi M, et al. A genomic classifier predicting metastatic disease 
progression in men with biochemical recurrence after prostatectomy. Prostate Cancer Prostatic 
Dis. 2014;17(1):64-69. doi:10.1038/pcan.2013.49 
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Bauer J, Emon MAB, Staudacher JJ, et al. Increased stiffness of the tumor 
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activin A signaling. Sci Rep. 2020;10(1):50. doi:10.1038/s41598-019-55687-6 
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Devarasetty M, Dominijanni A, Herberg S, Shelkey E, Skardal A, Soker S. Simulating the 
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Protocol Amendment v10, 09/15/2025  
 
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Appendix A: FACT-C Questionnaire 
 
Patient ID#:    
 
 
 
Date of Completion:    
 
 
 

Protocol Amendment v10, 09/15/2025  
 
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Patient ID#:    
 
 
 
Date of Completion:    
 
 
 
 

Protocol Amendment v10, 09/15/2025  
 
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Patient ID#:    
 
 
 
Date of Completion:    
 
 
 
 
 
 
 

Protocol Amendment v10, 09/15/2025  
 
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APPENDIX B: PATIENT’S MEDICATION DIARY 
 
Today’s Date:    
 
 
 
 
 
 
Agent:  Capecitabine 
 
Cycle:    
 
 
 
 
 
 
 
Study ID#:   
 
 
 
 
INSTRUCTIONS TO THE PATIENT: 
1. Complete one form for each month.  Take _____mg ( ___pills) of capecitabine twice daily on 
Days 1 through 14 of each cycle, once in the morning and once in the evening.  Take it with a 
glass of water and drink the glass of water in as little time as possible.  Swallow the pills whole 
and do not chew them.   
2. Record the date, the number of pills taken, and when you took them. 
3. If you forget to take dose within 4 hours of the usual time, then do not take that dose.  Restart 
taking it with the next dose. 
4. If you have any questions or notice any side effects, please record them in the comments section.  
Record the time if you should vomit. 
5. Please return the forms to your physician or your study coordinator when you go to your next 
appointment.  Please bring your unused study medications and/or empty bottles with you to each 
clinic visit so that a pill count can be done. 
 
Day 
Date 
What time was dose taken? 
# of tablets taken 
Comments 
AM Dose 
PM Dose 
AM Dose 
PM Dose 
1 
 
 
 
 
 
 
2 
 
 
 
 
 
 
3 
 
 
 
 
 
 
4 
 
 
 
 
 
 
5 
 
 
 
 
 
 
6 
 
 
 
 
 
 
7 
 
 
 
 
 
 
8 
 
 
 
 
 
 
9 
 
 
 
 
 
 
10 
 
 
 
 
 
 
11 
 
 
 
 
 
 
12 
 
 
 
 
 
 
13 
 
 
 
 
 
 
14 
 
 
 
 
 
 
15 
 
 
 
 
 
 
16 
 
 
 
 
 
 
17 
 
 
 
 
 
 
18 
 
 
 
 
 
 
19 
 
 
 
 
 
 
20 
 
 
 
 
 
 
21 
 
 
 
 
 
 
 
 
 

Protocol Amendment v10, 09/15/2025  
 
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APPENDIX C: Definitions for Adverse Event Reporting 
 
A. Adverse Events (AEs) 
 
As defined in 21 CFR 312.32: 
 
Definition: any untoward medical occurrence associated with the use of a drug in humans, 
whether or not considered drug-related. 
 
Grading: the descriptions and grading scales found in the revised NCI Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for all toxicity reporting.  A 
copy of the CTCAE version 4.0 can be downloaded from the CTEP website. 
 
Attribution (relatedness), Expectedness, and Seriousness: the definitions for the terms 
listed that should be used are those provided by the Department of Health and Human Services’ 
Office for Human Research Protections (OHRP).  A copy of this guidance can be found on 
OHRP’s website: 
http://www.hhs.gov/ohrp/policy/advevntguid.html 
 
B. Suspected Adverse Reaction (SAR) 
 
As defined in 21 CFR 312.32: 
 
Definition: any adverse event for which there is a reasonable possibility that the drug caused 
the adverse event.  “Reasonable possibility” means there is evidence to suggest a causal 
relationship between the drug and the adverse event.  “Suspected adverse reaction” implies a 
lesser degree of certainty about causality than adverse reaction, which means any adverse event 
caused by a drug. 
 
C. Life-Threatening Adverse Event / Life Threatening Suspected Adverse Reaction  
 
As defined in 21 CFR 312.32: 
 
Definition: any adverse drug event or suspected adverse reaction is considered “life-
threatening” if, in the view of the investigator, its occurrence places the patient at immediate 
risk of death. It does not include an adverse event or suspected adverse reaction that, had it 
occurred in a more severe form, might have caused death. 
 
D.  Serious Adverse Event (SAE) or Serious Suspected Adverse Reaction 
 
As defined in 21 CFR 312.32: 
 
Definition:  an adverse event or suspected adverse reaction is considered “serious” if, in the 
view of the investigator, it results in any of the following outcomes: 
o Death 
o A life-threatening adverse event 

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o Inpatient hospitalization or prolongation of existing hospitalization 
o A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
o A congenital anomaly/birth defect 
o Any other important medical event that does not fit the criteria above but, based upon 
appropriate medical judgment, may jeopardize the subject and may require medical or 
surgical intervention to prevent one of the outcomes listed above 
 
E. Protocol Exceptions 
 
Definition: A planned change in the conduct of the research for one participant. 
 
F. Deviation 
 
Definition: Any alteration or modification to the IRB-approved research without prospective 
IRB approval.  The term “research” encompasses all IRB-approved materials and documents 
including the detailed protocol, IRB application, consent form, recruitment materials, 
questionnaires/data collection forms, and any other information relating to the research study. 
 
A minor or administrative deviation is one that does not have the potential to negatively impact 
the rights, safety, or welfare of participants or others or the scientific validity of the study. 
 
A major deviation is one that does have the potential to negatively impact the rights, safety, or 
welfare of participants or others or the scientific validity of the study. 
 

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APPENDIX D: Reporting Timelines 
 
Expedited Reporting Timelines 
Event 
HRPO 
QASMC 
Serious AND 
unexpected suspected 
adverse reaction 
 
 
Unexpected fatal or 
life-threatening 
suspected adverse 
reaction 
 
 
Unanticipated problem 
involving risk to 
participants or others 
Report within 10 working days.  If the event 
results in the death of a participant enrolled at 
WU/BJH/SLCH, report within 1 working day. 
Report via email 
after IRB 
acknowledgment 
Major deviation 
Report within 10 working days.  If the event 
results in the death of a participant enrolled at 
WU/BJH/SLCH, report within 1 working day. 
 
A series of minor 
deviations that are 
being reported as a 
continuing 
noncompliance 
Report within 10 working days.   
 
Protocol exception 
Approval must be obtained prior to 
implementing the change 
 
Clinically important 
increase in the rate of a 
serious suspected 
adverse reaction of that 
list in the protocol or 
IB 
 
 
Complaints 
If the complaint reveals an unanticipated 
problem involving risks to participants or others 
OR noncompliance, report within 10 working 
days.  If the event results in the death of a 
participant enrolled at WU/BJH/SLCH, report 
within 1 working day.  Otherwise, report at the 
time of continuing review. 
 
Breach of 
confidentiality 
Within 10 working days. 
 
Incarceration 
If withdrawing the participant poses a safety 
issue, report within 10 working days.   
 
If withdrawing the participant does not represent 
a safety issue and the patient will be withdrawn, 
report at continuing review. 
 
 

Protocol Amendment v10, 09/15/2025  
 
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Routine Reporting Timelines 
Event 
HRPO 
QASMC 
Adverse event or 
SAE that does not 
require expedited 
reporting 
If they do not meet the definition of an 
unanticipated problem involving risks to 
participants or others, report summary 
information at the time of continuing review 
Adverse events will be 
reported in the toxicity 
table in the DSM report 
which is typically due 
every 6 months. 
Minor deviation 
Report summary information at the time of 
continuing review. 
 
Complaints 
If the complaint reveals an unanticipated 
problem involving risks to participants or 
others OR noncompliance, report within 10 
working days.  If the event results in the death 
of a participant enrolled at WU/BJH/SLCH, 
report within 1 working day.  Otherwise, 
report at the time of continuing review. 
 
Incarceration 
If withdrawing the participant poses a safety 
issue, report within 10 working days.   
 
If withdrawing the participant does not 
represent a safety issue and the patient will be 
withdrawn, report at continuing review. 
 
 
Expedited Reporting Timelines for Secondary Sites 
Event 
WU (Coordinating Center) 
Local IRB 
Serious AND unexpected 
suspected adverse reaction 
Report no later than 11 calendar days 
after it is determined that the 
information qualifies for reporting. 
Report all applicable 
events to local IRB 
according to local 
institutional guidelines. 
Unexpected fatal or life-
threatening suspected 
adverse reaction 
Report no later than 4 calendar days 
after initial receipt of the information. 
Unanticipated problem 
involving risk to 
participants or others 
Report no later than 4 calendar days 
after initial receipt of the information. 
Adverse event or SAE 
that does not require 
expedited reporting 
As per routine data entry expectations 
Protocol exception 
Approval must be obtained prior to 
implementing the change. 
 
 
 

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APPENDIX E: Washington University SAE Reporting Cover Sheet 
 
SAE COVER SHEET- Secondary Site Assessment 
 
Washington University HRPO#:  
Sponsor-Investigator:  
Subject Initials:   
Subject ID:  
Treating MD:  
Treating Site:  
EVENT TERM:  
Event Start Date:  
EVENT GRADE: 
Date of site’s first notification: 
 
Treating MD Event Assessment:  
 
 
Is this event possibly, probably, or definitely related study treatment? 
 
 yes 
 
 
 no 
 
If yes, please list which drug (if more than one)______________________________ 
 
       
Explain ______________________________________________________________________ 
 
______________________________________________________________________________ 
 
 
 
_________________________           ___________________________      _________________  
Physician’s Name 
 
 
Physician’s Signature 
 
Date 
 
 
 
 

Protocol Amendment v10, 09/15/2025  
 
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APPENDIX F: STUDY SPECIFIC DSM TABLES 
 
Protocol Objectives and Subject Evaluability 
Objective 
# of patients evaluable for this 
endpoint to date 
Primary 
To determine the clinical complete response rate (cCR) 
rate of patients with stage I-IIIB (cT1-3, N0-2a, M0) rectal 
cancer being treated with sequential short course 
radiotherapy followed by multi-drug chemotherapy. 
 
Secondary 
To determine the 2 year progression free survival (PFS) 
 
To determine the incidence of any grade ≥ 3 toxicity 
during treatment. 
 
To determine the incidence of post chemoradiotherapy 
grade ≥ 3 toxicity at 1 year 
 
To determine quality of anorectal function at 1 year using 
the FACT-C questionnaire. 
 
To determine the 1 and 2 year organ preservation rate 
 
Exploratory 
To associate tumor microenvironment (including FAK 
expression) with cCR and other clinical outcomes. 
 
To associate ctDNA levels with cCR and other clinical 
outcomes. 
 
 
 
Interim Analysis and Early Stopping Rules 
Does the study design include an interim toxicity analysis? 
No 
Does the study design include an interim futility analysis? 
Yes 
If yes, describe. 
An interim analysis will be performed on the primary endpoint once 24 subjects have been 
enrolled and have completed the evaluation after chemotherapy. If ≤ 8 patients have cCR in 
these 24 patients, the study will be stopped for futility. Otherwise, the additional 39 patients will 
be enrolled. The null hypothesis will be rejected if ≥25 patients with cCR are observed in 63 
patients. 
Has the interim futility analysis been conducted? 
 
If yes, describe the results of the interim futility analysis. 
 
Are there early stopping rules that outline circumstances under which the study must be 
suspended or closed? 
Yes 
If yes, describe. 
If ≤ 8 patients have cCR in the first 24 patients, the study will be stopped for futility. 

Protocol Amendment v10, 09/15/2025  
 
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Provide data describing whether the stopping rules have been met. 
 
 
Response Data 
UPN 
Subject Site 
On tx date 
# of cycles 
completed 
Pt replaced? 
Best response 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Aggregated Response Data 
Response 
Completion 
of Chemo 
Non-operative patients only 
3 mon 
6 mon 
9 mon 
12 mon 16 mon 20 mon 24 mon 
cCR 
 
 
 
 
 
 
 
 
PR 
 
 
 
 
 
 
 
 
SD 
 
 
 
 
 
 
 
 
PD 
 
 
 
 
 
 
 
 
NE 
 
 
 
 
 
 
 
 
 
 
Treatment Discontinuation and Survival 
UPN 
Date off tx 
Reason off tx 
Vital status 
If dead, cause 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Summary of Specimen Collections 
Type of specimen 
Time point 
# of patients 
eligible for 
collection at this 
time point 
% of patients who 
have reached this 
time point and had 
the specimen collected 
Tumor tissue 
Screening 
 
 
Blood for ctDNA 
Screening 
 
 
Blood for ctDNA 
Post-RT/prior to C1 
chemo 
 
 
Blood for ctDNA 
C2D1 chemo 
 
 
Blood for ctDNA 
Completion of chemo  
 
Blood for ctDNA 
10-14 mon after 
completion of RT 
 
 
Blood for ctDNA 
3 mon 
 
 
Blood for ctDNA 
6 mon 
 
 
Blood for ctDNA 
9 mon 
 
 

Protocol Amendment v10, 09/15/2025  
 
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Blood for ctDNA 
12 mon 
 
 
Blood for ctDNA 
16 mon 
 
 
Blood for ctDNA 
20 mon 
 
 
Blood for ctDNA 
24 mon