Multimodal Monitoring of Radiotherapy Response in Squamous Cell Cancer in Head & Neck, Lung, Oesophagus, Anal Canal and Uterine Cervix - a Basis for Personalised Radiotherapy
Conditions: Squamous Carcinoma, Head and Neck Cancer, Anal Cancer, Lung Cancer, Esophageal Cancer, Cervix Cancer
Sponsor: Umeå University

 
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Multimodal monitoring of 
radiotherapy response in squamous 
cell cancer in head & neck, lung, 
oesophagus, anal canal and uterine 
cervix – a basis for personalised 
radiotherapy 
MORRIS-study 
 
 
 
 
 
 
 
Sponsor  
 
Björn Zackrisson 
 
 
 
Cancercentrum 
 
 
 
901 85 Umeå 
 
 
 
Sweden 
 
 
 
 
 
 
Protocol date:   
 
2015-03-10  
 

 
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Contacts 
Co-ordinating investigator 
Björn Zackrisson MD Professor 
 
 
 
Cancercentrum  
901 85 Umeå 
bjorn.zackrisson@umu.se 
 
 
Study steering committee 
Karin Söderström MD 
 
 
 
Cancercentrum  
901 85 Umeå 
karin.soderstrom@vll.se 
 
 
 
 
 
Eva Brun, MD, PhD 
 
 
 
Skånes Onkologiska Klinik 
 
 
 
Skånes Universitetssjukhus Lund 
 
 
 
221 85 Lund 
 
 
 
Eva.brun@med.lu.se 
 
 
 
 
 
Tufve Nyholm PhD 
 
 
 
Institutionen för strålningsvetenskaper/radiofysik 
 
 
 
Umeå universitet 
 
 
 
901 85 Umeå 
 
 
 
tufve.nyholm@umu.se 
 
 
 
 
Maria Gebre Medhin MD PhD 
 
 
 
Skånes Onkologiska Klinik 
 
 
 
Skånes Universitetssjukhus, Lund 
 
 
 
221 85 Lund 
 
 
 
maria.gebre-medhin@med.lu.se 

 
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Björn Zackrisson, MD, Professor 
 
 
 
Cancercentrum 
 
 
 
901 85 Umeå 
 
 
 
bjorn.zackrisson@umu.se 
 
Study group 
Clinically active specialists in pathology, oncology, 
gynaecological oncology, surgery, ENT, 
pneumonology, radiology, nuclear medicine, 
radiation chemistry and radiation physics at the 
university hospitals in Lund and Umeå. See 
separate list 
 
Statistician 
 
Kristina Lundqvist 
 
 
 
RCC Norr 
 
 
 
901 85 Umeå 
 
 
 
Kristina.lundqvist@vll.se 
 
Data Center and monitoring Clinical Trial Unit (CTU) 
 
 
 
Norrlands universitetssjukhus 
 
 
 
901 85 UMEÅ 
 
 
 
Telephone: 090-785 8039 
 
 
 
marjaliisa.lammitavelin@vll.se  
 

 
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Protocol Signature Sheet 
Signature coordinating investigator 
 
 
 
 
On behalf of the study group 
 
 
 
 
___________________________ 
 
____________________ 
 
 
 
 
 
Date 
 
 
 
 

 
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1 Synopsis 
Protocol title  
Multimodal monitoring of radiotherapy response in 
squamous cell cancer (SCC) in head & neck, lung, 
oesophagus, anal canal and uterine cervix – a basis for 
personalised radiotherapy 
 
 
Development phase 
Observational study  
Study population 
Patients with previously untreated SCCs aimed for 
radiotherapy with curative intent of the oral cavity, 
oropharynx, uterine cervix, oesophagus, anal canal or 
lung. 
Endpoints 
 
Primary end-point 
Loco-regional control 2 years after completion of 
radiotherapy  
Secondary end points  
1. Loco-regional tumour control (or response) 8 (-2 
- +4) weeks after completion of radiotherapy 
2. Patterns of failure  
3. Progression free survival at 2 years 
4. Overall survival at 2 and 5 years 
5. Changes in imaging and metabolic data 
6. Site specific toxicity at 12 months after 
completion of radiotherapy 
Study design 
Non-randomised, prospective, multi centre, 
observational study. Patients with previously untreated 
SCCs aimed for radiotherapy with curative intent of the 
oral cavity, oropharynx, uterine cervix, oesophagus, 
anal canal or lung are recruited. Multimodal, functional 
imaging data are collected before and during the early 
phase of radiotherapy. In parallel to the imaging data, 
tumour biopsies and blood will be collected for 
molecular analyses that may provide explanatory 
information to the imaging information.    
 
Overall aim  
 
Prediction of short and long term outcome of treatment 
for squamous cell cancer (SCC) by monitoring tumour 
response during early treatment phases. 
 

 
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Specific aims 
 
Correlate changes in imaging bio-markers to 
corresponding changes in tissue or blood bio-markers 
by repeated imaging and biopsies for better 
understanding of the image parameters. 
To correlate data from multiparametric imaging to 
specific outcome 
Validation of early bio-imaging predictors of tumour 
response and patient outcome. 
 
Eligibility criteria  
Inclusion criteria 
1. Morphologically (pathology or cytology) verified, 
previously untreated SCCs of the oral cavity, 
oropharynx, uterine cervix, oesophagus or lung. 
2. The patient should be planned for treatment with 
radiotherapy alone or in combination with 
concomitant medical therapy  
3. The tumour shall be radiologically and/or visually 
identifyable and accessible for biopsy without the 
need for general anaesthesia or other major 
interventions 
4. The patient must be at least 18 years of age, 
able to understand the given information and, 
leave a written informed consent to participate 
Exclusion criteria 
1. The patient is unwilling to participate in the study 
2. Patients with adjuvant post-operative 
radiotherapy (i.e. no visible remaining tumour) 
3. Pregnancy or lactation 
4. Contraindications to investigations with MRI, 
gadolinium contrast or PET-tracers 
5. Patients with an estimated GFR <60 
ml/min/1.73m2. 
6. Severe co-morbidities that are judged to 
significantly compromise survival in a two-years 
perspective.  
  
Duration of study 
The first acquisition of image data and tissue samples is 
performed as close as possible to start of radiotherapy. 
The time for the second acquisition of image data and 
tumour tissue will be after 1-2 weeks of treatment. The 
precise timing will be optimised after the separate 
analysis of the 20-30 first patients. The patients will then 

 
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be followed according to clinical routines for at least two 
years for evaluation of tumour control. In patients with 
remaining tumour or recurrent disease the site of the 
tumour will be recorded and compared with the position 
of the original site. Survival of patients will be followed 
for five years by the Swedish population registry. 
Radiotherapy and 
possible neo-adjuvant, 
concomitant or 
adjuvant therapy 
 
The standard treatment schedules according to clinical 
routines and decisions will be followed irrespective if the 
patient is taking part in the study or not. Specific 
information on all anticancer therapy (doses and timing) 
will be recorded for each patient. The observation will 
commence at start of radiotherapy irrespective when 
and how other supporting therapies are used.  
 
Efficacy evaluation 
1. Loco-regional tumour control (or response) 8 (-2 
- +4) weeks after completion of radiotherapy 
2. Patterns of failure  
3. Progression free survival at 2 years 
4. Overall survival at 2 and 5 years 
5. Changes in imaging and metabolic data 
6. Site specific toxicity at 12 months after 
completion of radiotherapy  
 
Pilot study 
 
 
 
 
 
 
 
 
 
Interim analysis 
The first 30 patients will have the study procedures at 
different time points after start o radiotherapy. Different 
sequencing of biopsy and imaging procedures will be 
employed. This is in order to find the shortest interval 
between start of therapy and imaging to be able to 
detect differences in functional imaging parameters. 
The results will be used for establishing the precise 
schedule for remaining patients. These patients will not 
be included in the final analyses. 
After inclusion of 100 patients for at least two months an 
interim analysis will be performed. The reason is to 
identify parameters that exhibit a rapid change between 
the two assessment times, in a proportion of patients. 
Those parameters that do not exhibit such changes will 
be excluded from further assessments. The protocol will 
subsequently be refined.  
Statistical methods 
To find potentially relevant patterns of response in the 
large amount of data for each patient, chemometric 
methods will be applied 

 
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To estimate the degree of agreement between predicted 
and observed response the Cohen´s Kappa will be 
used. 
 
Criteria for evaluation 
Patients who have undergone per protocol imaging 
sessions before and during therapy  
 
Planned sample size 
412 patients 
Analysis plan 
The primary endpoint will be analysed when median 
follow up is two years. 
Duration of the study  
Three to four years inclusion, five year follow-up after 
inclusion of the last patient. 
 

 
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2 Table of Contents 
Multimodal monitoring of radiotherapy response in squamous cell cancer in head & 
neck, lung, oesophagus, anal canal and uterine cervix – a basis for personalised 
radiotherapy ......................................................................................................................... 1 
Contacts ............................................................................................................................... 2 
1 Synopsis ......................................................................................................................... 5 
Primary end-point ................................................................................................................. 5 
Secondary end points............................................................................................................ 5 
2 Abbreviations .................................................................................................................. 9 
3 Table of Contents ........................................................................................................... 9 
4 Background and introduction ....................................................................................... 11 
4.1 Background............................................................................................................ 11 
5 Aims of the trial............................................................................................................. 13 
5.1.1 Overall aim ...................................................................................................... 13 
5.1.2 Specific aims ................................................................................................... 13 
5.2 End points .............................................................................................................. 13 
5.2.1 Primary end point............................................................................................ 13 
5.2.2 Secondary end points ..................................................................................... 13 
6 Study design ................................................................................................................. 13 
6.1 Study period .......................................................................................................... 14 
7 Study flow chart ............................................................................................................ 14 
8 Overview of study assessments .................................................................................. 14 
9 Patient selection criteria ............................................................................................... 15 
9.1 Inclusion criteria..................................................................................................... 15 
9.2 Exclusion criteria ................................................................................................... 15 
10 Study procedure ......................................................................................................... 15 
10.1 Study entry........................................................................................................... 15 
10.1.1 Mandatory investigations .............................................................................. 15 
10.1.2 Recommended investigations ...................................................................... 17 
10.1.3 Instructions regarding women of childbearing potential .............................. 16 
10.2 Evaluation during treatment ................................................................................ 16 
10.3 Evaluation after completion of treatment ............................................................ 16 
10.4 Surgery ................................................................................................................ 16 
10.5 Follow-up ............................................................................................................. 16 
10.6 End of treatment or follow-up .............................................................................. 17 
11 Radiotherapy .............................................................................................................. 17 
11.1 Patient position and fixation ................................................................................ 17 
11.2 Patient radiotherapy data acquisition ................................................................. 17 
12 Biobank ....................................................................................................................... 17 
13 Statistical plan ............................................................................................................ 18 
13.1 Sample size determination .................................................................................. 18 
13.2 Statistical methods .............................................................................................. 18 
13.3 Subject Population(s) for Analysis ...................................................................... 19 
13.4 Interim analysis ................................................................................................... 19 
14 Quality assurance ...................................................................................................... 19 

 
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14.1 Control of data consistency ................................................................................. 19 
14.2 Site Monitoring ..................................................................................................... 20 
14.3 Direct access to source data/documents............................................................ 20 
15 Data management ...................................................................................................... 20 
15.1 Patient registration procedure ............................................................................. 20 
15.2 Case Report Forms ............................................................................................. 20 
16 Ethical considerations ................................................................................................ 21 
16.1 Patient protection ................................................................................................ 21 
16.2 Patient integrity .................................................................................................... 21 
16.3 Informed consent ................................................................................................. 21 
16.4 Independent ethics committees .......................................................................... 21 
16.5 Risk-benefit analysis ........................................................................................... 22 
17 Participating centres................................................................................................... 23 
18 Ownership of the data ................................................................................................ 23 
18.1 Meetings .............................................................................................................. 23 
18.2 Reporting and Publication ................................................................................... 23 
19 Flow chart study procedures ...................................................................................... 24 
20 References ................................................................................................................. 24 
Addendum x; Handling of biobank samples (Swedish) .................................................... 26 
 

 
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3 Background and introduction 
3.1 Background 
The knowledge of factors determining treatment effect in cancer therapy is important in 
the treatment selection for individual patients. In some cancers impressive progress has 
been made over the years and has resulted in major improvements in disease control, 
e.g. in breast cancer. The basis for treatment selection is usually the assessment of pre-
treatment characteristics of the patient and the individual tumour. Expression of certain 
genes, hormonal status and proliferation parameters are some examples of individual 
tumour properties in clinical routine use. The development in the field of molecular 
biology during recent decades is not reflected in a similar improvement of therapeutic 
results for most cancers. Particularly this is the case with most SCCs. In Sweden about 
2000 SCC are diagnosed every year within lungs, head & neck, anus, cervix and 
esophagus.  
For a large proportion of cancers the knowledge of pre-treatment parameters of 
predictive capacity is sparse. A number of biomarkers or combinations thereof have 
been identified (e.g. HPV, EGFR, …). In the majority of cases they correlate to outcome 
of treatment and can therefore be described as prognostic and not specific enough for 
personalised therapy. In the absence of strong predictors an alternative is to explore the 
early changes after initiating therapy. Such changes have the potential to be relevant in 
the assessment of individual tumour response. It is assumed that the changes will also 
give leads to factors present already before treatment, which are not yet identified. 
Cancer treatments; radiotherapy, chemotherapy and/or targeted therapies are frequently 
administered during an extended time period. The evaluation of effectiveness usually 
takes place a couple of months after end of therapy. Early response is commonly 
evaluated by agreed “Response Evaluation Criteria in Solid Tumors” (RECIST). 
Basically, measuring the diameters of tumour contours on radiological examinations 
makes the assessment. The results given by such end-points will not be able to 
discriminate between different patterns of response as for example, differential 
responses in subsets of the tumour. Furthermore, the time between start of therapy and 
evaluation often comprises the therapeutic interval in which there still exists a possibility 
to adapt or completely change a suboptimal treatment. Structural changes in tumours 
are slow compared with changes in biochemistry and other functions. 
Detection of early response predictors will therefore be an important adjunct to further 
development of cancer therapy. Since many years, in radiotherapy, there are examples 
of early changes that are predictive for outcome. E.g. changes in metabolism measured 
by FDG-PET and labelling index by infusion of halogenated pyrimidines in vivo have 
both shown a strong predictive capacity as early as one week into a 6-7 weeks 
treatment for head and neck cancer e.g. (1,2). It is noteworthy that similar results arise 
from studies of completely different processes. More recent observations in cases such 
as cervical cancer (3,4) and head and neck cancers (5) support the hypothesis that 
treatment effects give rise to complex responses in different cellular processes. Such 
processes may be identified by a number of methods. The combination of different 
methods is likely to be more effective. Functional imaging techniques, as positron 

 
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emission tomography (PET) combined with magnetic resonance imaging (MRI), offer 
complementary information that may assess a multitude of biomarkers in patients with 
SCC. Diffusion, perfusion, metabolism, proliferation are examples of properties that may 
be studied by static and/or dynamic methods. In the present literature usually one or a 
few imaging biomarkers have been analysed at the time and only in small patient 
populations, many with encouraging results e.g. (5-9). They have rarely been further 
validated and thus, not established as a basis for clinical decisions (7,10). 
The imaging biomarkers under study correspond to a number of molecular events in the 
tumour. It is therefore natural to investigate an array of molecular changes in parallel. 
The parallel investigations may also spread light over the influence of tumour 
heterogeneity. The infrastructure of the Department of Oncology in Umeå has access to 
clinical, dedicated MR-PET equipment for research and development. A core facility with 
metabolomics and molecular pathology is also a part in the project. At the radiotherapy 
department in Lund there is presently a MR system available and also availability to 
PET-CT equipment at the hospital for investigation of study patients. Furthermore 
another PET-CT equipment will be installed at the radiotherapy department in Lund in 
near future.  
The concept of metabolomics is the systematic study of the unique chemical fingerprints 
caused by specific cellular processes, where the analysis is expanded to hundreds to 
thousands of metabolites (< 1kDa). This can be compared to traditional metabolic 
studies where only a limited set of molecules is studied. Metabolomics has attracted 
large interest in recent years, since it has the power and scope to resolve fundamental 
biological issues that cannot be readily addressed using other approaches. 
Metabolomics information represents a more complete description of the organism 
closest to the function or phenotype, but also more complex than explanations based on, 
e.g. functional genomics, proteomics and transcriptomics. To model the systems biology 
from genome to function or phenotype (tumour) based on these pieces of information, 
using parametric methods is not realistic today. However, to analyse the systems 
biology by non-parametric methods as applied in metabolomics research is fully feasible. 
Current studies of metabolomics are, however, limited to samples representing the 
whole system or by invasive methods obtained samples and cannot detect 
heterogeneities in tumours or even locate the signalling tissue. In order to move the 
metabolomics from isolated research studies to diagnostic predictive and monitoring 
systems, there is a need for more powerful data collection and data processing tools. 
Both PET and MRI have the capability to measure metabolic activity and system 
vascularity in volume elements of approximately 1-10 mm3. The molar sensitivity of a 
PET system is very high, in the order of 10-15 molar. The combination of the high spatial 
resolution of the MRI technique and the high sensitivity of the PET system will enable 
detection of, e.g. therapy-resistant tumour sub-volumes. Sampling of repeated functional 
images will be an integrated part of the large-scale data sampling. The initial aim of the 
project will be to determine metabolic fingerprints over time from samples and images, 
and correlate these to disease, therapy and outcome. Chemometrics and projection-
based methods such as Principal Component Analysis (PCA), Partial Least Squares 
(PLS) and Orthogonal PLS (OPLS) are well-established methods in metabolomics for 
predictive modelling, powerful data visualization and model interpretation (Holmes & 
Antti 2002, Trygg, Holmes et al. 2007). However, time trends of a biological system are 

 
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not generally considered in metabolomic studies. In the current projects the time aspect 
will be implemented as part of a holistic-system biology approach. This approach is, in 
general, assumed to give more comprehensive information of the metabolic mechanism 
associated with biological functions and disease (Madsen et al. 2010). 
4 Aims of the trial 
4.1.1 Overall aim  
Prediction of short and long term outcome of treatment for squamous cell cancer (SCC) 
by monitoring tumour response during early treatment phases. 
4.1.2 Specific aims 
• Correlate changes in imaging bio-markers to corresponding changes in tissue or 
blood bio-markers by repeated imaging and biopsies for better understanding of 
the image parameters. 
• To correlate data from multiparametric imaging to specific outcome 
• Validation of early bio-imaging predictors of tumour response and patient 
outcome. 
4.2 End points 
4.2.1 Primary end point 
• Loco-regional control 2 years after completion of radiotherapy  
4.2.2 Secondary end points 
• Loco-regional tumour control 8 (-2 - +4) weeks after completion of radiotherapy 
• Patterns of failure  
• Progression free survival at 2 years 
• Overall survival at 2 and 5 years 
• Changes in imaging and metabolic data 
• Site specific toxicity at 12 months after completion of radiotherapy  
 
5 Study design 
The study is prospective, multi-centre, non-randomised observational study for 
investigation and validation of imaging biomarkers for early treatment response. 
Patients are recruited with previously untreated SCCs aimed for radiotherapy with 
curative intent of the oral cavity, oropharynx, uterine cervix, oesophagus, anal canal or 
lung. Multimodal, functional imaging data are collected before and during the early 
phase of radiotherapy. In parallel to the imaging data, tumour biopsies and blood will be 
collected for molecular analyses that may provide explanatory information to the imaging 
information.    
 
 

 
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5.1 Study period 
The inclusion period is calculated to be three to four years. The study ends five years 
after inclusion of the last patient. 
 
6 Study flow chart 
 
 
7 Overview of study assessments 
Patients will be investigated by MR, PET and biopsy/FNAC (fine needle aspiration 
cytology) twice during the study period. 
The first session of imaging will be performed within two weeks from planned start of 
radiotherapy (without reference to any other possible anticancer treatment (e.g. 
chemotherapy). In cases where MR and PET are not performed simultaneously they 
should be performed not more than one week apart. Tissue 
specimens should be obtained as soon as possible before 
imaging. 
The tissue specimen for metabolomics analyses should be 
immediately frozen (within minutes from procedure!). Matching specimen for histological 
verification and future molecular biology studies should also be obtained and handled 
according to addendum. 
 
The second assessment will be performed on Day 8 (+/-1) after start of radiotherapy 
(date of first radiation fraction is defined as Day 1). Adjustments of the timing for the 
second assessment will be determined by using pre-planned variable times for the first 
20-30 patients in the pre-study. Thus, optimising the time interval for different sub-sites. 
In departments where MRI and PET can not be performed simultaneously, the MRI 
should be performed according to protocol. The PET assessment should be performed 
in close connection but not more than 24 h apart from MRI. The biopsy/FNAC should 
preferably be performed after imaging in order to avoid bleeding or edema blunting the 
imaging. It is recommended that the images produced are used as guidance for directing 
the biopsies at volumes assumed to contain active tumour tissue. If this is not practically 

 
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possible the biopsy/FNAC may be performed before imaging under the condition that the 
surgeon provides detailed description of the location of the biopsy in order to allow for 
correcting the results for possible artefacts in the vicinity of the biopsy. 
 
For imaging sessions the patients shall be in therapy position wearing regular fixation 
devices for therapy. E.g. in the head and neck region this means that head coils etc may 
not be used and other coil arrangements with flexible coils will be predominant. In order 
for the patients to avoid higher degrees of discomfort the total time for the imaging 
procedure shall be planned to last not more than 30 minutes. This means that the 
number of protocols used for each imaging session must be carefully optimised. The first 
20-30 patients will be the part of a pre-study where the usefulness of different protocols 
will be evaluated and the procedure optimised.  
8 Patient selection criteria 
8.1 Inclusion criteria 
1. Morphologically (pathology or cytology) verified, previously untreated SCCs of the 
oral cavity, oropharynx, uterine cervix, esophagus, anal canal or lung. 
2. The patient should be planned for treatment with radiotherapy alone or in 
combination with concomitant medical therapy  
3. The tumour shall be radiologically and/or visually identifiable and accessible for 
biopsy without the need for general anaesthesia or other major interventions 
4. The patient must be at least 18 years of age, able to understand the given 
information and, leave a written informed consent to participate 
8.2 Exclusion criteria 
1. The patient is unwilling to participate in the study 
2. Patients with adjuvant post-operative radiotherapy (i.e. no visible remaining 
tumour) 
3. Pregnancy or lactation 
4. Contraindications to investigations with MRI, gadolinium contrast or PET-tracers 
5. Patients with an estimated GFR <60 ml/min/1.73m2. 
6. Severe co-morbidities that are judged to significantly compromise survival in a 
two-years perspective.  
9 Study procedure 
9.1 Study entry 
9.1.1 Mandatory investigations 
1. Adequate clinical assessment with a TNM classification and histology/FNAC 
(showing squamous cell carcinoma).  
2. Body weight and height 
3. ECOG Performance status 
4. P-Creatinine  

 
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5. Tumour biopsy and blood sampling in patients participating in the exploratory part 
of the study. 
6. Registration form including informed consent 
7. The disease specific module of the EORTC QLQ-C30 for reporting late RT effects 
should be offered for the patient to fill out and forward to the data centre in a pre-
stamped envelope. With the exception of sites where no such module is 
available. 
 
Investigations number 1-4 are clinical routine investigations, and are thus not regarded 
as study specific procedures. 
. 
9.1.2 Instructions regarding women of childbearing potential 
Pregnancy must be excluded before a fertile woman can be included in the study.  
 
9.2 Evaluation during treatment 
Concomitant anticancer medication should be recorded with substance, dose and time 
for administration in the CRF. 
9.3 Evaluation after completion of treatment 
At two months after completion of therapy an assessment of tumour control and 
morbidity must be made. Tumour control is assessed by clinical examination together 
with endoscopy, palpation, control biopsies and appropriate imaging as judged indicated 
by the responsible physician.  
 
9.4 Surgery 
If surgery is performed, this must be recorded. 
 
9.5 Follow-up 
• Patients should be seen every three months for two years after completion of 
radiotherapy and a full clinical assessment should be made. 
• One year after end of radiotherapy, the patient will be asked to fill out the disease 
specific module of the EORTC QLQ-C30 for reporting late RT effects. The 
questionnaire will be distributed to the patient at the time of inclusion in the study 
and posted to living patients after one year. One year after completion of 
radiotherapy the questionnaire will be posted to living patients for self-
assessment of late radiotherapy side effects. If not answered, one reminder will 
be distributed.  
• After two years, evaluation of locoregional control should be made every 6 
months up to 5 years. At five years, a last follow-up is recommended at the 
treatment centre with the aim at evaluating late side effects. Any additional follow-
up beyond 5 years is not included in the study protocol, each physician decides 
on further follow-up. 

 
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Patients should be monitored for local recurrence and if symptoms arise that are 
suspicious of distant metastases appropriate investigations must be carried out to 
confirm or exclude their presence. Also, if a locoregional recurrence is found, a 
CT/MR for documentation is mandatory and screening for distant metastases 
should be performed. If distant metastases develop but there is no evidence of local 
recurrence within the irradiated volume, effort should be made to continue to monitor the 
primary site. In all cases histological confirmation should be performed.  
9.6 End of treatment or follow-up 
Follow-up by the protocol ends when any of the events below occurs: 
• If 5 years of follow-up is reached 
• If residual tumour or a locoregional recurrence is diagnosed that cannot be 
treated with curative intent. Survival will then be followed by the Swedish 
population registry 
• In cases of other serious medical conditions, follow-up ends as judged by the 
investigator. Survival will then be followed by the Swedish population registry 
• If the patient dies before 5 years’ follow up 
• Withdrawal of consent 
10 Radiotherapy 
Radiotherapy will be performed according to clinical routines of each participating 
centre. The patients may be treated with X-rays, electrons or protons. 
10.1 Patient position and fixation 
The patient should be treated in supine position, adequately positioned and fixated 
according to the routines at each treatment centre.  
10.2 Patient radiotherapy data acquisition 
Full 3-D treatment plans together with data from the oncology information system will be 
stored in the local research database at each treatment centre. The use of the nationally 
agreed research database for radiotherapy (MIQA) is recommended. The collection of 
data that will be sent to the coordinator of RT-data will be anonymised and assigned the 
patient´s number in the study when the selection of relevant data is analysed. A 
treatment planning imaging (slice thickness  3mm) should be performed with the 
patient in treatment position, adequately fixated. Optionally, a co-registered MRI- or 
PET-scan should also be performed as aid for tumour delineation. 
 
11 Biobank 
As primary biobank, Biobank Norr in Umeå, will be used. Until analysis samples will be 
kept in the local bio-banks at each hospital. 
 

 
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12 Statistical plan 
12.1 Sample size determination 
From the expected number of eligible patients with each diagnose, three separate study 
groups are identified 
1. Lung cancer 
2. Head and neck cancer 
3. Cervix, esofagus and anal carcinoma 
The first two subgroups will be analysed separately as well as aggregated with all other 
groups. In group no 3 the number of patients with each diagnosis is expected to be too 
low to make valid statements for each entity. This group will therefore mainly be 
analysed together with all cases. 
The overall aim of the study is to identify and validate parameters predictive to outcome 
of treatment. To estimate the degree of agreement, the Cohen’s Kappa is commonly 
used. It is defined as the proportion on the main diagonal that exceeds the expected 
number if a random classification is performed. It is normalised to fit the interval (0,1) 
where 0 is a random classification and 1 is a 100% correct classification.  
For personalised therapy purposes a correct classification in 90 % of cases is desired. 
We assume that the proportions of responding patients are either distributed similarly 
(50 %/50 %) or that only 20 % are responders. H0: k =k0, H1: k =k1, k1 >k0. Assuming 
k0 = 0.4 (which is considered to indicate a poor agreement) and k1 = 0.7 (which is 
considered to indicate a good agreement) and if the probability of correct rejection of H0 
is set to 90 % the number of patients needed is 63 or 80 depending on response rates 
(50 % or 20 %). Thus, a number of patients of about 70 for each study group should be 
optimal to answer the study questions. In addition to the 70 patients of each group, the 
data from 30 patients from the head and neck cancers and lung cancers will be used for 
hypothesis generation. Their data will not be re-used for validation. From previous 
experience, a proportion of patients will for medical or other reasons not contribute with 
the second set of data. It is assumed that 20% of patients will have incomplete data 
sets. Thus, the number of included patients in each group will be aimed at 100. 
Additionally, the 30 first patients will be part of a pilot study and not analysed further for 
the study end-points. The total number of patients needed for the study is estimated to 
412 during the three years of accrual. However, each group will be closed earlier for 
further inclusion if 100 evaluable patients are reached .Image and bio-marker analyses 
will be performed only on those with complete data sets from imaging sessions. 
 
12.2 Statistical methods 
Changes in imaging parameters and metabolomics patterns will be used for statistical 
inference. We also intend to apply multivariate data reduction and texture analyses 
techniques on multi-dimensional parametric images from the study population. In this 
part of the project a close collaboration is planned with the project of T Nyholm. All data 
will be stored in communicating databases for future re-analyses when long-term follow-
up data is available and new methods for multiparametric analyses become available. 
Contrary to many studies that result in “promising results” we aim to bring preliminary 
findings to a higher level of validation and thus prepare for large scale clinical studies. In 

 
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the clinical data sampling procedures a pre-determined fraction of the patients will be 
randomised and stored separately for hypothesis validation. 
 
Survival endpoints will be compared by Cox regression stratified for tumor site and 
corrected for all other covariates used in the minimization algorithm – i.e. a multivariate 
Cox regression will be applied with tumour sites as strata as covariates 
 
The primary analysis will be based on the intention-to-treat analysis set. Every effort will 
be made to collect survival data on subjects, including subjects withdrawn from 
treatment for any reason, who are eligible to participate in the study and who have not 
withdrawn consent for survival data collection. OS is defined for each patient as the time 
between radiotherapy start date and death. If a patient has not expired, the patient will 
be censored at the time of last contact (last known alive date). 
12.3 Subject Population(s) for Analysis 
Intention to treat population: Any subject included in the study, regardless of whether 
they received planned treatment. 
Protocol-compliant population: Any subject who was randomized and received the 
planned treatment. 
12.4  Pilot study  
The first 20-30 patients will be part of a pre-study where the timing and protocols for 
investigation are optimised. These patients will not be included in the analysis of the 
main study. One of four patients will be randomly chosen for belonging to the 
“hypothesis generation group” (HGG). Their data will be analysed in the search of a 
number of predictive parameters for outcome. The remaining patients’ data will be used 
for validation of hypotheses. The HGG will not be used in this validation process. The 
first analyses will be performed when the number of study patients is reached. The 
second analysis will be performed two years after including the last patient. The third 
analysis will be performed when five years have passed since the last inclusion of a 
patient.  
13 Quality assurance 
13.1 Control of data consistency 
All patients included in the study are identified by the patient identification number. 
Identification code lists that links patients’ names to the patients’ identification number 
must be stored in the Investigator File.  
Study data will be recorded via using Case Report Forms (CRF). Study data may be 
recorded directly into the CRF, ie the CRF may be the source data. Prior to study start, 
the Investigator and the Monitor must identify and document the expected source 
location of every CRF data. Expected source locations are for example the subject’s 
medical record, laboratory reports and the CRF itself.  
Accurate and reliable data collection will be assured by verification of the CRF against 
the investigator’s records and medical records by the study monitor, as well as study 
integrity, compliance with the protocol and applicable regulations. 

 
MORRIS 2015-03-10 
20 
 
13.2 Site Monitoring 
In consistency with the principles of GCP, the sponsor takes responsibility for monitoring 
of the study. As an external monitor for the study a research nurse or equivalent, not 
involved in any aspects of the study, will be appointed. The external monitor is 
experienced in clinical trials and monitoring, and acting under responsibility of CTU, 
Norrlands universitetssjukhus. 
During the study, the monitor will have regular contacts with the study sites, including 
onsite visits in order to ensure that the study is conducted and documented properly in 
compliance with the protocol, GCP and applicable regulatory requirements. 
 
The trial will be monitored consistent with the demands of the trial and site activity to 
verify that the: 
• Data are authentic, accurate, and complete 
• Safety and rights of subjects are being protected 
• Trial is conducted in accordance with the currently approved protocol and any 
other trial agreements, GCP and all applicable regulatory requirements. 
13.3 Direct access to source data/documents 
The sponsor has the responsibility to maintain adequate and accurate records to enable 
the conduct of the study to be fully documented and the study data to be subsequently 
verified. Investigators files and subjects clinical source documents must be kept for at 
least 10 years after completion or discontinuation of the study. 
14 Data management 
14.1 Patient registration procedure 
Subject eligibility will be established before inclusion. Subjects will be given a 
identification number consecutively, as subjects are eligible for enrolment.  
If a subject discontinues from the study, the subject number will not be reused, and the 
subject will not be allowed to re-enter the study.  
The Data Centre (CTU, Norrlands universitetssjukhus) is responsible for the registration 
procedure. When a patient is found to be eligible and has signed a written informed 
consent, registration will be performed via the study coordinating person.  
A registration form should be filled out before inclusion of each patient. This form will 
contain all relevant data on the patient 
14.2 Case Report Forms 
Study data will be recorded via the CRF. During study treatment the CRF should be 
filled in weekly, and after completion of treatment the CRF should be filled in at each 
time point for follow-up.  
The investigator at the enrolling site is responsible for collection of source data if patient 
visits are decentralized to other clinics. 

 
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14.3 Patient’s questionnaires 
Each patient will be asked to fill out the disease specific module of the EORTC QLQ-
C30 for reporting late RT effects. This procedure will be performed before treatment 
starts and one year after end of radiotherapy. The questionnaire will be distributed to the 
patient at the time of inclusion in the study and posted to living patients after one year. 
One year after completion of radiotherapy the questionnaire will be posted to living 
patients for self-assessment of late radiotherapy side effects. If not answered, one 
reminder will be distributed. The Data Centre will register the completed forms in the 
study database. 
 
15 Ethical considerations 
15.1 Patient protection 
The study is to be performed in accordance with the ethical recommendations of the 
Helsinki declaration and the ICH-GCP guidelines, or the laws and regulations of the 
country, whichever provides the greatest protection of the patient. 
15.2 Patient integrity 
The investigator must assure that the patient’s anonymity will be maintained and that 
their identities are protected from unauthorized parties. On CRFs or other documents 
submitted to the Data Center patients should only be identified by their identification 
code, year and date of birth and initials.  
15.3 Informed consent 
All subjects will receive written and oral information about the aims of the study, 
discomfort inflicted and possible hazards. They will be informed about the strict 
confidentiality of their patient data, but that their medical records may be reviewed for 
trial purposes by authorized individuals other than their treating physician.  
It will be emphasized that the participation is voluntary and that the patient is allowed to 
decline further participation whenever he/she wants. If the patient wishes to withdraw 
from the study, he or she will be offered the standard treatment at the clinic. 
A signed, informed consent must be obtained from the patient before study entry. In the 
cases were the patient declines to participate in the study the conventional procedures 
according to local practice should be offered. 
If new safety information results in significant changes in the risk/benefit assessment, 
the consent form should be reviewed and updated if necessary. All patients (including 
those already being investigated) should be informed of the new information, given a 
copy of the revised form and give their consent to continue in the study. 
15.4 Independent ethics committees 
This protocol and any accompanying material provided to the patient, such as written 
patient information used to obtain informed consent, will be submitted by the investigator 
to the independent Regional Ethical Review Board in Umeå. Approval from the 
committee must be obtained before starting the study, and should be documented in a 

 
MORRIS 2015-03-10 
22 
letter to the investigator specifying the date on which the committee met and granted the 
approval. 
 
15.5 Risk-benefit analysis 
Since the treatment of each patient’s disease will not be affected by the assessment 
procedure or the results of it, the risks are limited to the imaging and biopsy procedures.  
15.5.1 
Imaging procedures 
For the imaging procedure in the cases of simultaneous MRI and PET or a combination 
of PET- CT and MRI the risks are equivalent to those encountered with routine 
examination with each modality alone. They can be divided into three categories 
1. Discomfort. Patients may experience discomfort due to restriction of movements 
etc due to the confined space in the MRI equipment. In severe cases 
claustrophobia may prevent the patient from participating in the study. Patients 
experiencing severe discomfort will be encouraged to refrain from participating or 
to stop the participation. 
2. Reactions towards contrast agents. The routines for Gd-contrast precautions 
at each participating centre will be followed. Gadolineum contrasts with known 
low risk for severe side effects should be used. Patients with an estimated GFR 
<60 ml/min/1.73m2 should not participate.  
3. Radiological hazards. The amount of injected 18F-FDG will be optimised and the 
exposure to a standard dose of FDG (4 MBq/kg) will result in an exposition of 10 
mSv (20 mSv for two examinations). In comparison the exposition in the 
environment in Sweden gives about 3 mSv/year. In the situation of the patients of 
the study, adults subjected to radiotherapy, the risk for long term effects from the 
radiation from the PET tracer, administered twice, may be considered as very 
small. In cases when the combination of PET and CT is used “low-dose CT” will 
be used. The CT examinations adds approximately 1 mSv each.  
 
15.5.2 
Surgical procedures  
The biopsy/FNAC procedure is well known. It may inflict pain and discomfort for the 
patient. The risk for severe complications is low and with proper routines the risk for the 
patient may be considered minimal. Patients will not be subject to general anaesthesia 
for the cause of this investigation but every other method to reduce pain and discomfort 
will be taken. If general anaesthesia is required for this investigation alone, the patient 
will be withdrawn from this part of the study.  
15.5.3 
Potential benefits 
The potential benefit of finding predictive markers for therapy response is vast but will 
not benefit the individual patient in the study. The potential to improve therapy in the 
future, however, is significant. 
The patients in the study are covered by the Swedish Patient Insurance and the 
Swedish Pharmaceutical Insurance. 

 
MORRIS 2015-03-10 
23 
16 Participating centres 
All Swedish hospitals with resources to perform the study will be invited to take part in 
the study.  
Each centre must expect to include a minimum of 5 patients per year. If a centre 
includes less than 2 patients during one year, that centre shall be closed. Previously 
included patients will then be followed according to the protocol but no further inclusion 
is accepted from that centre. 
Centres from other European countries may be accepted as participants in the study as 
decided by the study group. 
17 Ownership of the data 
The Study Group consisting of the investigators at the participating centres owns the 
data. The patient material of the individual centre cannot be extracted for publications to 
answer the questions of this study. The Study Group must approve future research 
projects utilizing data from the present study. In case the Study Group is not active the 
sponsor may make the decisions of the use of data.  
 
17.1 Meetings 
Regular meetings with representatives from all participating centres (Study Group) will 
be held twice per year or when considered necessary. The Study Steering Committee 
will also have separate regular meetings. In the time between Study Group meetings, 
the members of the Study Steering Committee shall act as contact persons and will 
have an executive role. Decisions taken shall be discussed at the meetings of the Study 
Group. The Study Steering Committee shall prepare and arrange the meetings of the 
Study Group. 
17.2 Reporting and Publication 
All presentations of data from the study should only be made after agreement within the 
Study Group. The results of the study will be submitted to an internationally recognized 
medical journal. Apart from the Study Group, each participating centre with at least 20 
patients included will be guaranteed co-authorship for 1 person and if more than 30 
patients, co-authorship for 2 persons is guaranteed when the study is reported. In 
addition to this, persons with special responsibilities within the study may become co- 
authors. The Vancouver declaration will be followed in all publications based on this 
study. 

 
MORRIS 2015-03-10 
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18 Flow chart study procedures 
 
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Addendum 1; Handling of biobank samples (Swedish)  
Addendum 2; Procedures for MRI investigations an data 
collection 
Addendum 3; Procedures for PET imaging and data 
collection