Use of a Proliferation Saturation Index to Determine Personalized Radiotherapy Fractionation for Patients With HPV+ Oropharyngeal Cancers
Phase: NA
Conditions: Oropharyngeal Cancer
Sponsor: H. Lee Moffitt Cancer Center and Research Institute

Use of a Proliferation Saturation Index to Determine Personalized 
Radiotherapy Fractionation for Patients with HPV+ 
Oropharyngeal Cancers 
NCT03656133 
Version 2.3 
July 9, 2021 

 
 
 
 
 
 
Use of a Proliferation Saturation 
Index to Determine Personalized 
Radiotherapy Fractionation for 
Patients with HPV+ 
Oropharyngeal Cancers 
 
Protocol Identifying Number: 
MCC# 19579 
Principal Investigator: Jimmy J. Caudell 
Funded by: Department of Radiation Oncology 
Moffitt Cancer Center 
Version Number: v.2.3 
09 July 2021 

Table of Contents 
 
LIST OF ABBREVIATIONS ....................................................................................................... v 
STATEMENT OF COMPLIANCE .............................................................................................. vi 
STUDY SUMMARY .................................................................................................................. vii 
SCHEMATIC OF STUDY DESIGN .......................................................................................... ix 
1 
KEY ROLES ................................................................................................................ 1 
2 
INTRODUCTION: BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE 1 
2.1 
BACKGROUND INFORMATION .............................................................................. 1 
2.2 
PROLIFERATION SATURATION INDEX ..................................................... 1 
2.3 
RADIOTHERAPY IN HEAD AND NECK CANCER ...................................................... 2 
2.4 
RATIONALE FOR FRACTIONATION SCHEMES USED IN THIS STUDY .................. 4 
2.5 
RATIONALE FOR BIOMARKER STUDIES ................................................................. 4 
2.5.1 EVALUATION OF TUMOR IMMUNE MICROENVIRONMENT (TIM) ....................... 4 
2.5.2 EVALUATION OF HPV DNA VIRAL LOAD IN ORAL GARGLES AND PLASMA ..... 5 
2.6 
POTENTIAL RISKS AND BENEFITS ....................................................................... 5 
2.6.1 KNOWN POTENTIAL RISKS ................................................................................ 5 
2.6.2 KNOWN POTENTIAL BENEFITS ........................................................................ 5 
3 
OBJECTIVES AND PURPOSE ...................................................................... 5 
3.1 
PRIMARY OBJECTIVE ............................................................................................... 5 
3.2 
SECONDARY OBJECTIVES....................................................................................... 5 
3.3 
EXPLORATORY OBJECTIVES .................................................................................. 5 
4 
STUDY DESIGN AND ENDPOINTS ............................................................... 6 
4.1 
DESCRIPTION OF THE STUDY DESIGN ............................................................... 6 
4.2 
STUDY ENDPOINTS ................................................................................................. 6 
5 
STUDY ENROLLMENT AND WITHDRAWAL .......................................................... 7 
5.1 
PARTICIPANT INCLUSION CRITERIA ...................................................................... 7 
5.2 
PARTICIPANT EXCLUSION CRITERIA ..................................................................... 7 
5.3 
PARTICIPANT WITHDRAWAL OR TERMINATION .................................................. 8 
5.4 
PREMATURE TERMINATION OR SUSPENSION OF STUDY ................................. 8 
6 
STUDY AGENT .......................................................................................................... 8 
6.1 
DOSING AND ADMINISTRATION ............................................................................ 8 
6.2 
TREATMENT PLANNING/TARGET VOLUMES .......................................................... 9 
6.3 
DOSES TO NORMAL STRUCTURE .......................................................................... 11 
6.4 
TREATMENT BREAKS .............................................................................................. 12 
6.5 
DEVICE-SPECIFIC CONSIDERATIONS................................................................... 12 
6.5 
DRUG THERAPY ....................................................................................................... 12 
7 
STUDY PROCEDURES AND SCHEDULE ............................................................. 12 
7.1 
STUDY PROCEDURES/EVALUATIONS .................................................................. 12 
7.2 
CORRELATIVE STUD PROCEDURES/EVALUATIONS ........................................ 13 
7.2.1 EVALUATION OF TUMOR IMMUNE MICROENVIRONMENT (TIM) ...................13 
7.2.2 EVALUATION OF HPV DNA VIRAL LOAD IN ORAL GARGLES AND PLASMA .13 

7.2.3 TUMOR SAMPLE SUBMISSION ......................................................................... 13 
7.2.4 ORAL GARGLE SAMPLE SUBMISSION AND PROCESSING ...............................14 
7.2.5 BLOOD SAMPLE SUBMISSION AND PROCESSING ......................................... 14 
7.3 
STUDY SCHEDULE ................................................................................................. 16 
7.4 
CONCOMITANT MEDICATIONS, TREATMENTS, AND PROCEDURES ......... 17 
7.5 
PROHIBITED MEDICATIONS, TREATMENTS, AND PROCEDURES ..................17 
7.6 
PROPHYLACTIC MEDICATIONS, TREATMENTS, AND PROCEDURES ........... 18 
8 
ASSESSMENT OF SAFETY .................................................................................... 18 
8.1 
SPECIFICATION OF SAFETY PARAMETERS ........................................................ 18 
8.1.1 DEFINITION OF ADVERSE EVENTS (AE) .................................................... 18 
8.1.2 DEFINITION OF SERIOUS ADVERSE EVENTS (SAE) .......................... 18 
8.1.3 DEFINITION OF UNANTICIPATED PROBLEMS ............................................. 18 
8.2 
CLASSIFICATION OF AN ADVERSE EVENT ........................................................ 18 
8.2.1 SEVERITY OF EVENT ........................................................................................ 19 
8.2.2 RELATIONSHIP TO STUDY AGENT ................................................................. 19 
8.3 
TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND 
FOLLOW-UP .......................................................................................... 19 
8.4 
REPORTING PROCEDURES ................................................................................... 20 
8.4.1 ADVERSE EVENT REPORTING .......................................................... 20 
8.4.2 SERIOUS ADVERSE EVENT REPORTING ...................................................... 20 
8.4.3 UNANTICIPATED PROBLEM REPORTING ....................................................... 21 
8.5 
STUDY HALTING RULES ......................................................................................... 21 
8.6 
SAFETY OVERSIGHT .............................................................................................. 21 
9 
CLINICAL MONITORING .......................................................................................... 22 
10 
STATISTICAL CONSIDERATIONS........................................................................... 22 
10.1 STATISTICAL AND ANALYTICAL PLANS .................................................. 22 
10.2 DESCRIPTION OF STATISTICAL METHODS ....................................................... 23 
10.2.1 GENERAL APPROACH ....................................................................... 23 
10.2.2 ANALYSIS OF THE PRIMARY EFFICACY ENDPOINT(S) ............................ 23 
10.2.3 ANALYSIS OF THE SECONDARY ENDPOINT(S) .......................................... 23 
10.3 SAMPLE SIZE .......................................................................................................... 23 
11 
SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/DOCUMENTS ... 23 
12 
QUALITY ASSURANCE AND QUALITY CONTROL .............................................. 23 
13 
ETHICS/PROTECTION OF HUMAN SUBJECTS ............................................ 24 
13.1 ETHICAL STANDARD .............................................................................................. 24 
13.2 INSTITUTIONAL REVIEW BOARD ............................................................... 24 
13.3 INFORMED CONSENT PROCESS ......................................................................... 24 
13.3.1 CONSENT/ASSENT AND OTHER INFORMATIONAL DOCUMENTS PROVIDED 
TO PARTICIPANTS ............................................................................................. 24 
13.3.2 CONSENT PROCEDURES AND DOCUMENTATION ...................................... 24 
13.4 PARTICIPANT AND DATA CONFIDENTIALITY ...................................................... 25 

13.5 FUTURE USE OF STORED SPECIMENS .................................................. 25 
14 
DATA HANDLING AND RECORD KEEPING .......................................................... 25 
14.1 DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES .................... 25 
14.2 STUDY RECORDS RETENTION .............................................................................. 25 
14.3 PROTOCOL DEVIATIONS ........................................................................................ 25 
14.3 PUBLICATION AND DATA SHARING POLICY .......................................................... 25 
15 
STUDY ADMINISTRATION ....................................................................................... 25 
15.1 STUDY LEADERSHIP ............................................................................................... 25 
16 
CONFLICT OF INTEREST POLICY ......................................................................... 25 
17 
LITERATURE REFERENCES ................................................................... 25 
APPENDIX ............................................................................................................................... 25 

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AE 
Adverse Event 
CBCT 
Cone Beam Computed Tomography 
CFR 
Code of Federal Regulations 
CLIA 
Clinical Laboratory Improvement Amendments 
CMP 
Clinical Monitoring Plan 
CRF 
Case Report Form 
CRO 
Contract Research Organization 
CT 
Computed Tomography 
CTV 
Clinical Target Volume 
DCC 
Data Coordinating Center 
DHHS 
Department of Health and Human Services 
DSMB 
Data Safety Monitoring Board 
eCRF 
Electronic Case Report Forms 
FDA 
Food and Drug Administration 
FFR 
Federal Financial Report 
GARD 
Genomic-Adjusted Radiation Dose 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practices 
GMP 
Good Manufacturing Practices 
GTV 
Gross Tumor Volume 
GWAS 
Genome-Wide Association Studies 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s Brochure 
ICH 
International Conference on Harmonisation 
ICH E6 
International Conference on Harmonisation Guidance for Industry, Good Clinical 
Practice: Consolidated Guidance 
ICMJE 
International Committee of Medical Journal Editors 
IND 
Investigational New Drug Application 
IRB 
Investigational Review Board 
ISO 
International Organization for Standardization 
LQ 
Linear Quadrant 
LRC 
Locoregional Control 
LSMEAN Least Squares Means 
MRI 
Magnetic Resonance Imaging 
MSDS 
Material Safety Data Sheet 
NIH 
National Institutes of Health 
OHRP 
Office for Human Research Protections 
PET 
Positron Emission Tomography 
PI 
Principal Investigator 
PTV 
Planning Target Volume 
QA 
Quality Assurance 
QC 
Quality Control 
RSI 
Radiosensitivity Index 
RT 
Radiation Therapy 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SMC 
Safety Monitoring Committee 
SOP 
Standard Operating Procedure 
UP 
Unanticipated Problem 
LIST OF ABBREVIATIONS 

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The trial will be conducted in accordance with the ICH E6, the Code of Federal Regulations on 
the Protection of Human Subjects (45 CFR Part 46), and the <NIH IC> Terms of Award. The 
Principal Investigator will assure that no deviation from, or changes to the protocol will take 
place without prior agreement from the sponsor and documented approval from the Institutional 
Review Board, except where necessary to eliminate an immediate hazard(s) to the trial 
participants. All personnel involved in the conduct of this study have completed Human 
Subjects Protection Training. 
 
I agree to ensure that all staff members involved in the conduct of this study are informed of 
their obligation to meet the above commitments. 
 
 
Principal Investigator:    
 
Print/Type Name 
 
 
Signed: 
Date:  
 
STATEMENT   OF   COMPLIANCE 

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Title: 
Use of a Proliferation Saturation Index to Determine Personalized 
Radiotherapy Fractionation for Patients with HPV+ Oropharyngeal 
Cancers. 
 
 
Précis: 
 We will use a mathematical model for each HPV+ oropharyngeal cancer 
patient’s tumor growth characteristics to select radiotherapy fractionation. We 
believe it will most likely to result in a rapid response by week 4 of treatment. 
 
Objectives: 
Primary Objective: 
We hypothesize that by using individual patient proliferation saturation index (PSI) 
to select radiotherapy fractionation (conventional fractionation or 
hyperfractionation) to improve the likelihood of a rapid response (defined as ≥ 
32% reduction in volume at 4 weeks). 
 
Secondary Objectives: 
• 
Rate of complete response by CT at 2 months or PET/CT at 3 months following 
completion of therapy. 
• 
Correlate response and outcome to pre-treatment and during treatment radiomics 
features on PET/CT/MRI. 
• 
Correlate response and outcome to mathematical models of tumor growth and 
death dynamics pre-treatment and during treatment. 
 
Exploratory Objectives: 
• 
Identify potential biomarkers of response to adaptive radiation therapy based on 
evaluation of tumor immune microenvironment and detection of HPV DNA in oral 
gargles and plasma. 
 
Endpoint 
Primary Endpoint: For patients with HPV+ squamous cancer of the oropharynx, fractionation 
of radiation will be individualized based on their PSI. Response will be measured after 4 
weeks of RT as assessed by CT or MRI, as described in section 10.0. Primary objective is to 
increase the rate of response of ≥ 32% at 4 weeks to 63% of patients, above the expected 
49%. 
 
Population: 
Total sample size of 60 patients, which will include men and 
women ≥ 18 years with pathologically (histologically or 
cytologically) proven diagnosis of HPV+ squamous cell 
carcinoma of the oropharynx and no evidence of distant 
metastases. This is a single center study 
Phase: 
2 
Number of Sites 
1 
enrolling participants: 
 
STUDY   SUMMARY 

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Description of Study 
Agent : 
Proliferation Saturation Index – a measure of the carrying capacity 
of the patient for the tumor burden. We will use this to select 
radiotherapy fractionation. 
 
Study Duration: 
~30 months 
Participant Duration: ~33 months 

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SCHEMATIC OF STUDY   DESIGN 
PATIENT POPULATION 
HPV+ Squamous cell carcinoma of the Oropharynx; AJCC 8th edition T0-T2, N0-N1 
(include only 5 or less involved lymph nodes) 
REGISTRATION 
Pre-treatment imaging with CT with contrast at least 1 week apart to calculate the 
Proliferation Saturation Index (PSI) 
Based on PSI, patient will be assigned to: 
1. Standard Fractionation at 2 Gy once daily 
2. Hyperfractionation at 1.2 Gy twice daily (≥ 6 hours apart) 
Assessment at week 4  
Percentage response by CT and/or MRI. 
Radiotherapy completed to standard dose 

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Principal Investigator: 
Jimmy Caudell, MD, PhD 
Department of Radiation Oncology 
Moffitt Cancer Center 
12902 Magnolia Dr. 
Tampa FL 33612 
Phone: 813-745-3547 
Fax: 813-449-8717 
Email: jimmy.caudell@moffitt.org 
 
Co-Investigators: 
Heiko Enderling, PhD 
Christine H. Chung, MD 
Youngchul Kim, PhD, Biostatistician 
 
 
 
With increasing understanding of the complexity of tumor heterogeneity, it would be reasonable to 
hypothesize that cancer therapy should be tailored to individual patients, which is the central 
principle underlying precision medicine. Currently in radiation medicine, decisions for total dose 
and fractionation are based empirically on clinical data, albeit often from randomized trials. 
Current efforts in radiation oncology to personalize radiation therapy mainly address adapting the 
target volume based on response. However, there have been no trials attempting to individualize 
total dose and fractionation. Here we provide one of the first clinical studies to deliver 
personalized radiation fractionation dose therapy for cancer. 
 
 
Tumors are composites of proliferating and growth arrested cells. Overall radiation response 
depends on their respective proportions at irradiation. In multi-compartment mathematical models 
that distinguish between proliferating and growth-arrested cells, we have shown that proliferation 
and oxygenation status-dependent radiation response can be simulated on the cellular level1. 
Tumor growth in vivo can be approximated by logistic dynamics. Initial exponential growth at low 
cell densities when most cells have access to ample resources decelerates when cells at the core 
of the tumor become growth-arrested, mainly due to limited space and exhausted intratumoral 
nutrient supply as resources are consumed by cells closer to the tumor surface. This established 
the notion of a tumor carrying capacity (K) as the maximum tumor volume that can be supported 
by a given environment2. The tumor carrying capacity is patient-specific, depending on the 
established oxygen and nutrients supply through tissue vascularization, removal of metabolic 
waste products, and evasion of immune surveillance. Hence, the tumor volume-to-carrying 
capacity ratio (V/K) describes the saturation in overall tumor cell proliferation as the tumor 
approaches its carrying capacity, which we call a Proliferation Saturation Index (PSI).   Logistic 
growth is modeled as 
 (eqn. 1), where V is the tumor volume at time t, dV/dt is 
the change of tumor volume over time TPOT is the intrinsic potential doubling time.  
 
1 
KEY ROLES 
2 
INTRODUCTION:   BACKGROUND   INFORMATION   AND   SCIENTIFIC   RATIONALE 
2.1 
BACKGROUND INFORMATION 
2.2 
PROLIFERATION SATURATION INDEX 

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Radiation response is modeled as instantaneous volume changes  
(eqn. 2) 
Figure 1. A) Two patients with identical tumor volume but different PSI at treatment begin (day 0) exhibit 
different reduction in tumor volume after fractionated RT. B) Logistic tumor growth and radiation response 
model predicted curves (eqns. 1+2; solid black lines) to four lung cancer patients data (red circles30) with 
growth rate ln2/TPOT=0.045 and radiation-induced death γ2Gy=0.084, and patient-specific carrying capacities 
Ki. PSIi: Proliferation Saturation Index for patient Pi at first treatment (t=0). 
 
at irradiation moments, where 
 represents radiation-induced death after dose d 
following the linear-quadratic model. It follows from (eqns. 1+2) that larger PSI reflect a low 
proliferating cell fraction and, thus, treatment refractory tumors, whereas tumors with low PSI are 
more proliferative and radiosensitive. As such, two patients that present with similar tumor volume 
could have a different tumor growth history and thus a different PSI, which results in different 
responses to the same radiotherapy protocol (Fig. 1A). In a preliminary study of non-small cell lung 
cancer and head and neck cancer patients we have confirmed that PSI varies greatly between 
patients (0.26±0.33; [0.03-0.75]) and correlates inversely with radiotherapy response2. A patient- 
specific pretreatment PSI was sufficient to fit individual patient response data (r2=0.98; Fig. 1B). 
 
 
 
Radiotherapy as definitive treatment for oropharyngeal cancer is a standard of care3. Based on 
multiple clinical trials, standard doses are in the range of 60 – 70 Gy at 2 Gy given once daily or 
60 – 81.6 Gy given twice daily4,5. However, to date the selection of fractionation has been empiric 
in nature. We hypothesize that head and neck cancer represents an ideal opportunity to establish 
a paradigm of individualized radiotherapy dosing based on mathematical models. 
 
We are specifically selecting HPV+ oropharyngeal cancer patients because at an early stage 
(AJCC 8th edition stage T1-2 N0-1 with limited lymph node involvement), radiotherapy alone is a 
standard of care, reducing the variables in question. For example, RTOG H0022 treated patients 
with up to radiographic T1-2 N0-1 (AJCC 7th edition T1-2 N0-2a) oropharyngeal tumors with 
radiotherapy alone, with locoregional control rates of >90%6. Additionally, multiple retrospective 
reports from large institutions such as MD Anderson and Princess Margaret demonstrate >90% 
locoregional control rates for oropharyngeal cancer patients with T1-2 N0-2b (AJCC 7th edition).7,8 
 
However, RTOG 1016, which treated patients with locoregionally advanced HPV+ oropharyngeal 
cancer with 70 Gy of radiotherapy and either cisplatin or cetuximab was recently published. This 
demonstrated the superiority of cisplatin over cetuximab in combination with radiotherapy.9 RTOG 
1016 included overlapping patient population that is eligible for the current trial, specifically patients 
with a single lymph node > 3 cm or multiple lymph nodes in ipisilateral neck. Examination of Forrest 
2.3 
RADIOTHERAPY IN HEAD AND NECK CANCER 

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plots from the trial suggests that patients with a > 10 pack year history of cigarette smoking were 
at higher risk and had a greater benefit from cisplatin. We therefore will exclude patients who are 
locoregionally advanced with a significant smoking history. 
 
Additionally, recent review of Moffitt Cancer Center internal data suggests that patients with greater 
than 5 positive lymph nodes are at a higher risk of regional failure, with locoregional control at 3 
years of 94.9% for 1-5 lymph nodes vs 80.1% for > 5 lymph nodes (p = 0.001). By restricting 
patients to T1-2 N0-1 with 5 or less lymph nodes and a smoking history of 10 pack years or less, 
3-year locoregional control of patients treated with radiation alone at Moffitt Cancer Center was 
94.7% (n=81) compared to 95.9% with concurrent radiotherapy and systemic therapy (n=98) 
(personal communication J. Caudell). 
 
In a retrospective analysis of 44 patients, decrease in nodal size of ≥ 40% was associated with a 
locoregional control (LRC) of 100% at 2 years, compared with 78% for a decrease of < 40%10. 
Retrospective review of a Moffitt cohort (n=49) suggests that a cut point of 32% reduction resulted 
in 100% LRC and DFS (Figure 2A&B)11. Of note, half of these patients were treated with radiation 
alone. 
 
 
100 
 
80 
>32 
<32 
 
60 
 
40 
 
20 
log-rank p = 0.013 
0 
0 
20 
40 
60 
80 
LRC Time (months) 
 
100 
 
80 
>32 
<32 
 
60 
 
40 
 
20 
 
0 
0 
20 
40 
60 
80 
DFS Time (months) 
Figure 2: A) Locoregional Control and B) Disease Free Survival by response at 4 weeks 
 
 
 
 
 
 
 
log-rank p = 0.002 
Percent survival 
Percent survival 

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In the mathematical modeling of radiation treatment response, there is a suggestion of a more 
robust treatment response by hyperfractionation when the PSI is > 0.75 (Figure 3). 
 
 
Figure 3: Model of tumor response at 4 weeks by initial pretreatment PSI. 
 
We therefore hypothesize that by personalizing the fractionation, we will increase the number of 
patients achieving a 32% reduction by week 4. 
 
 
All fractionation schemes are selected are standards of care in H&N cancer. For example, RTOG 
7913 established that the locoregional control rates between these two total dose and fractionation 
schemes were equivalent12. 
 
 
2.5.1 EVALUATION OF TUMOR IMMUNE MICROENVIRONMENT (TIM) 
 
The interplay between the tumor and its TIM is critical in tumor formation, metastasis, and clinical 
outcomes including radiation therapy response13,14. Characterization of lymphoid and myeloid 
immune cells has shown to be prognostic in HNSCC15, but their association with radiation therapy 
benefits has not been clearly evaluated. Significance of the TIM in context of the PSI in HNSCC is 
entirely unknown. The findings from this innovative and highly interdisciplinary project will have a 
significant clinical impact in improving the selection of patients who will gain the most benefit from 
receiving PSI based radiation therapy, offering further biological insight to the mechanisms of 
resistance, and subsequently developing optimal combination therapies for immune modulating 
agents. 
2.4 
RATIONALE FOR FRACTIONATION SCHEMES USED IN THIS STUDY 
2.5 
RATIONALE FOR BIOMARKER STUDIES 

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2.5.2 EVALUATION OF HPV DNA VIRAL LOAD IN ORAL GARGLES AND PLASMA 
 
Detection of HPV DNA in oral gargles and plasma after the completion of treatments has shown to 
associate with recurrence16,17. In a study by Ahn, et al, HPV-16 E6 and E7 DNA were determined 
from plasma and/or saliva samples obtained before and after treatments in 93 patients16. Patients 
with detectable HPV DNA in the posttreatment saliva and either saliva or plasma had reduced 
overall survival. However, significance of persistent HPV DNA detection in saliva and/or plasma in 
context of the PSI in HNSCC is entirely unknown. Evaluation of HPV DNA as a predictive 
biomarker of PSI-based radiation therapy warrants further studies. 
 
 
 
As all interventions are considered standards of care, no additional potential risks would be 
incurred. 
 
 
By selecting the most ideal fractionation scheme, we may be able to improve the 4 week response 
rate which has been associated with improved locoregional control. 
 
 
 
For patients with HPV+ squamous cancer of the oropharynx, fractionation of radiation will be 
individualized based on their PSI. Response will be measured after 20 days of RT as 
assessed by CT or MRI, as described in section 10.0. Primary objective is to increase the rate 
of response of ≥ 32% at 20 days to 63% of patients, above the expected 49%11. 
 
 
• 
Rate of complete response by CT at 2 months or PET/CT at 3 months following completion of 
therapy. 
• 
Correlate response and outcome to pre-treatment and during treatment radiomics features on 
PET/CT/MRI. 
• 
Correlate response and outcome to mathematical models of tumor growth and death dynamics 
pre-treatment and during treatment. 
• 
Correlate RSI/GARD with mid-treatment and post-treatment response. 
• 
Correlate clearance of HPV in serum/oral gargle specimens with mid-treatment and post- 
treatment response. 
 
 
• 
Identify potential biomarkers of response to adaptive radiation therapy based on 
evaluation of tumor immune microenvironment and detection of HPV DNA in oral gargles  
and plasma. 
2.6 
POTENTIAL RISKS AND BENEFITS 
2.6.
KNOWN POTENTIAL 
2.6.2 
KNOWN POTENTIAL BENEFITS 
3 
OBJECTIVES   AND   PURPOSE 
3.1 
PRIMARY OBJECTIVE 
3.2 
SECONDARY OBJECTIVES 
3.3 
EXPLORATORY OBJECTIVES 

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• 
PSI will be calculated according the above formula, where Vdiagnosis is the volume of the 
tumor at first imaging and Vtreatment is the volume of the tumor at second pretreatment 
imaging, t is time, and λ is doubling time. Patients with a PSI ≤ 0.75 will be assigned to 
conventional fractionation group, and PSI > 0.75 will be assigned to the hyperfractionation 
group (Figure 3). 
• 
Each site of disease (primary and each lymph node) will be independently contoured and PSI 
calculated for each. PSI of the lymph nodes will take priority over primary site. PSI of the 
largest lymph node will take priority over smaller lymph nodes. 
• 
Based on PSI, patients will be assigned to one of two cohorts: 
• 
PSI ≤ 0.75: Conventional fractionation – 2 Gy once daily, Monday through Friday. 
• 
**Should patients be assigned to conventional fractionation, and do not meet the predicted 
>32% reduction AND they are not receiving concurrent chemotherapy, their treatment will be 
accelerated via a 6th fraction per week, given as a BID dose once during the week or on a 
Saturday18. 
• 
PSI > 0.75: Hyperfractionation – 1.2 Gy twice daily, at least 6 hours apart, Monday through 
Friday. 
 
 
For the purposes of this study, patients should be evaluated for on-treatment response after 4 
weeks, and re-evaluated at 2 or 3 months post RT (the selection of post-RT timepoint for imaging 
is at physician discretion (either is standard of care; eg if CT is negative a 2 months, no further 
imaging is required. If disease still present at 2 month CT, a 3 month PET will be obtained, or 
simply a 3 month PET). 
 
4.2.1 On Treatment response at 4 weeks during RT 
 
Week 4 CT and/or MRI will be loaded into the treatment planning system or other software for 
volumetric evaluation of tumor size. This will be compared against CT simulation or week 1 
CT/CBCT and/or MRI, whichever is larger. The percent response will be calculated. 
 
4.2.2 Post Treatment response at 2-3 months after RT 
 
A complete response will be defined as resolution of all disease in the head and neck by CT 
at 2 months or PET/CT at 3 months. On CT scan, nodes less than 1 cm in short axis without 
evidence of necrosis will be defined as negative. On PET/CT, resolution of hypermetabolism 
to maximum SUV of 3 or less will be defined as negative, even with evidence of a node larger 
than 1 cm in short axis on CT scan. CT scans or PET scans which do not meet these criteria 
will be reviewed at the Moffitt H&N tumor board for determination of response. 
 
 
 
4 
STUDY DESIGN AND ENDPOINTS 
4.1 
DESCRIPTION OF THE STUDY DESIGN 
4.2 
STUDY ENDPOINTS 

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Men and women of all races and ethnic groups are eligible for this trial. 
 
 
In order to be eligible to participate in this study, an individual must meet all of the following 
criteria: 
• 
Provision of signed and dated informed consent form 
• 
Stated willingness to comply with all study procedures and availability for the duration 
of the study 
• 
Male or female, aged ≥ 18 years 
• 
Pathologically (histologically or cytologically) proven diagnosis of p16+ or HPV+ 
squamous cell carcinoma (including the histological variants papillary squamous cell 
carcinoma and basaloid squamous cell carcinoma) of the oropharynx; cytologic 
diagnosis from a cervical lymph node is sufficient. Patients with unknown primary 
(T0) should be both p16 and HPV positive. Clinical evidence should be documented, 
and may consist of pathology, palpation, imaging, or endoscopic evaluation, and 
should be sufficient to estimate the size of the primary (for T stage). 
• 
AJCC 8th edition staging T0-2 N0-1 M0 (N1 includes clinical tumor involvement in 
only 1-5 lymph nodes) Patients with any smoking history are included if N0 or a 
single involved node size ≤3cm. However, if the number of involved lymph node is 
≥2 or any lymph node size >3 cm, only patients with ≤ 10 pack years of smoking is 
eligible. 
• 
Patients must have clinically or radiographically evident measurable disease at the 
primary site or at nodal stations. 
• 
CT or MRI performed at least 1 week apart. This can consist of diagnostic imaging 
and radiation therapy planning imaging. 
• 
No evidence of distant metastases 
• 
ECOG Performance Status 0 to 2 
 
 
 
An individual who meets any of the following criteria will be excluded from participation in this 
study: 
• 
Age < 18 
• 
Positive urine pregnancy test 
• 
Evidence of distant metastases 
• 
Patients with >10 pack years of smoking is excluded if the number of involved lymph 
node is ≥2 or any lymph node size >3 cm. 
• 
Gross total excision of both primary and nodal disease; this includes tonsillectomy, local 
excision of primary site, and nodal excision that remove all clinically and radiographically 
evident disease
5 
STUDY   ENROLLMENT   AND   WITHDRAWAL 
5.1 
PARTICIPANT INCLUSION CRITERIA 
5.2 
PARTICIPANT EXCLUSION CRITERIA 

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• 
Prior radiotherapy to the region of the study cancer that would result in overlap of 
radiation therapy fields 
• 
Patients with a medical condition or social situation that at the discretion of the PI 
would preclude them from completion of the trial 
 
 
 
Participants are free to withdraw from participation in the study at any time upon request. An 
investigator may terminate participation in the study in the following circumstances: 
 
• 
If any clinically adverse event (AE), laboratory abnormality, or other medical condition 
or situation occurs such that continued participation in the study would not be in the 
best interests of the participant 
• 
If the participant meets an exclusion criterion (either newly developed or not 
previously recognized) that precludes further study participation. 
 
 
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause. Written notification, documenting the reason for study suspension or 
termination, will be provided by the suspending or terminating party to investigators 
and regulatory authorities. If the study is prematurely terminated or suspended, the PI 
will promptly inform the IRB and will provide the reason(s) for the termination or 
suspension. 
 
Circumstances that may warrant termination or suspension include, but are not limited to: 
• 
Determination of unexpected, significant, or unacceptable risk to participants 
• 
Demonstration of efficacy that would warrant stopping 
• 
Insufficient compliance to protocol requirements 
• 
Data that are not sufficiently complete and/or evaluable 
• 
Determination of futility 
 
Study may resume once concerns about safety, protocol compliance, data quality are 
addressed. 
 
 
Not applicable. 
 
 
 
 
 
 
5.3 
PARTICIPANT WITHDRAWAL OR TERMINATION 
5.4 
PREMATURE TERMINATION OR SUSPENSION OF STUDY 
6 
STUDY   AGENT 

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Based on PSI, patients will be assigned to one of two cohorts: 
 
1. Conventional fractionation – 2 Gy once daily, Monday through Friday. 
All disease ≤ 2 
cm 
Any site of 
disease > 2 cm 
but ≤ 4 cm 
Any site of 
disease > 4 cm 
Gross 
Disease 
60 Gy / 30 
fractions 
66 Gy / 33 
fractions 
70 Gy / 35 
fractions 
Elective 
Nodes 
41.4 Gy / 23 
fractions 
41.4 Gy / 23 
fractions 
41.4 Gy / 23 
fractions 
 
**Should patients be assigned to conventional fractionation, and do not 
meet the predicted >32% reduction AND they are not receiving concurrent 
chemotherapy, their treatment will be accelerated via a 6th fraction per 
week (as per standard of care which is one twice daily fraction per week, > 
6 hours apart OR on the weekend). 
 
2. Hyperfractionation – 1.2 Gy twice daily, at least 6 hours apart, Monday 
through Friday. 
All disease ≤ 2 
cm 
Any site of 
disease > 2 cm 
but ≤ 4 cm 
Any site of 
disease > 4 cm 
Gross 
Disease 
60 Gy / 50 
fractions 
64.8 Gy / 54 
fractions 
69.6 Gy / 58 
fractions 
Elective 
Nodes 
41.4 / 36 
fractions 
41.4 / 36 
fractions 
41.4 / 36 
fractions 
 
 
The treatment plan used for each patient will be based on an analysis of the volumetric dose, 
including dose-volume histogram analyses of the planning target volume (PTV) and critical normal 
structures. 
 
Gross tumor volume (GTV) represents the region judged to contain gross primary tumor or 
involved node(s) based on clinical and endoscopic examinations, CT scan, MRI, and PET-CT. 
 
Clinical target volumes (CTV) are defined and contoured in relation to the targets that they are 
intended to encompass and the dose they are intended to receive. For gross targets (GTVs), the 
CTVs are defined by 3D isotropic expansions of 0.5 cm that should then be limited by potential 
barriers to tumor spread such as air cavities, external contours, and bony or fascial planes through 
which tumor spread is not possible or apparent. 
 
Elective clinical target volume consists of elective nodal basins at risk depending on size and 
location of the primary site and grossly involved nodes. In general this consists of levels 2-4 and 
potentially retrostyloid and retropharyngeal ipsilaterally, and levels 2-3 contralaterally. If tonsil 
primary without involvement (or <1 cm involvement) of base of tongue or soft palate, unilateral 
elective neck radiotherapy may be delivered. This will be at the discretion of the treating radiation 
oncologist. 
6.1 
DOSING AND ADMINISTRATION 
6.2 
TREATMENT PLANNING/TARGET VOLUMES 

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PTV represents an additional margin around the GTV to compensate for the variability of treatment 
set up and internal organ motion. The CTVs will be expanded symmetrically 2.5 to 3 mm to 
generate the PTV. 
 
Detailed Organs at Risk Specifications 
 
SpinalCord: The cord begins at the foramen magnum. Superior to this is brainstem and inferior to 
this is cord. The inferior border of the spinal cord volume will be defined at approximately the 
carina (ie, 2-3 cm below the lowest slice level that has PTV on it). The spinal cord shall be defined 
based on the treatment planning CT scan. 
 
SpinalCord_PRV05: Planning Risk Volume (PRV) spinal cord defined as SpinalCord + 5 mm in all 
directions. 
 
BrainStem: The inferior most portion of the brainstem is at the cranial-cervical junction where it 
meets the spinal cord. For the purposes of this study, the superior most portion of the brainstem is 
approximately at the level of the top of the posterior clinoid. The brainstem shall be defined based 
on the treatment planning CT scan. 
 
BrainStem_PRV03: Planning Risk Volume (PRV) brainstem defined as Brainstem + 3 mm in all 
directions. 
 
Parotid_R/L: Parotid glands will be defined in their entirety (superficial and deep lobes) based on 
the treatment planning CT scan. 
 
Pharynx: This will be defined as superior/middle/inferior constrictor muscles. This extends from the 
superior constrictor region (level of the inferior pterygoid plates) to the cricopharyngeal inlet (level 
of the posterior cricoid cartilage). 
 
Esophagus_UP: This will be defined as the cervical or superior (S) esophagus, a tubular structure 
that starts at the bottom of pharynx (cricopharyngeal inlet) and extends to the thoracic inlet. 
 
Larynx: This will be defined as the glottic and supraglottic larynx, including the tip of the epiglottis, 
the epiglottis, the aryepiglottic folds, arytenoids, false cords, and true cords, up to but not including 
the medial border of the thyroid cartilage, and including the cricoid cartilage to the inferior edge of 
the arytenoid cartilage, but not the hypopharynx. 
 
OralCavity: The oral cavity will be defined as a composite structure consisting of the lips, oral 
tongue/floor of mouth, buccal mucosa, and superiorly the palate, and inferiorly to the plane 
containing the tip of the mandible. 
 
Submandibula_R/L: Submandibular glands will be defined in their entirety based on treatment 
planning CT scan. 
 
Mandible: This includes the entire bony structure of the mandible from TMJ through the symphysis. 
Thyroid: Thyroid gland should be contoured in its entirety based on treatment planning CT scan. 
The density-corrected dose distributions shall be calculated, and the dose prescription will be 
based on a dose distribution corrected for heterogeneities. 

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Dosimetry: Intensity-modulated RT, volumetric modulated arc therapy, or tomotherapy planning is 
acceptable. Typically, ≥ 7 beams or ≥ 2 arcs of radiation will be used. 
 
Prescription Isodose Surface Coverage: The prescription isodose surface will be chosen such that 
≥ 95% of the PTV is conformally covered by the dose and 100% of the PTV would be covered with 
the isodose surface that is represented by 95% of the prescription dose. 100% of the GTV should 
be covered by 100% of the prescription dose. 
 
High Dose Spillage: Any dose ≥ 105% of the prescription dose should occur primarily within the 
PTV itself and not within the normal tissues outside the PTV. Therefore, the cumulative volume of 
all tissue outside the PTV receiving a dose > 105% of the prescription dose should be no more 
than 0.03 cc of the PTV volume. 
 
Prioritization for Intensity-Modulated RT Planning: 
1. Spinal cord 
2. Brainstem 
3. Gross target PTV 
4. Elective PTV 
5. Organs at Risk 
a. Parotid gland contralateral to primary tumor site 
b. Larynx 
c. Pharynx 
d. Contralateral submandibular gland 
e. Oral Cavity/Lips 
g. Esophagus 
h. Parotid gland ipsilateral to primary tumor site 
i. Mandible 
6. Unspecified tissue outside the targets 
 
 
Dose limitations to normal structures are described below. For the critical structures of spinal cord 
and brainstem, these are mandatory. For other structures, recommended limits are provided, but 
the doses delivered should always be as low as reasonably achievable without compromising 
doses to PTVs. 
 
• 
Spinal cord: The planning risk volume (PRV) (Spinal cord + 0.5 cm) for spinal cord should 
not exceed 48 Gy to any volume in excess of 0.03 cm3 (approximately 3 mm x 3 mm x 3 
mm). 
• 
Brain stem: The PRV for (brainstem + 0.3 cm) brainstem should not exceed 50 Gy to any 
volume in excess of 0.03 cm3 (approximately 3 mm x 3 mm x 3 mm). In treatment 
planning, the brain stem_03 should be given less priority than the spinal cord, but more 
than the critical structures listed below. 
• 
Oral cavity/Lips: Reduce the dose as much as possible. The mean dose should be <32 
Gy for the oral cavity. Efforts should also be made to avoid hot spots (> 60 Gy) within the 
non-involved oral cavity. 
• 
Parotid glands: The treatment planning goal will be for this individual parotid gland to 
receive a mean dose of < 26 Gy, but efforts should be made to reduce this further if 
possible without compromising dose to PTVs. 
6.3 
DOSES TO NORMAL STRUCTURE 

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• 
Contralateral submandibular gland: If contralateral level Ib is not a target, aim to reduce 
mean contralateral submandibular gland to < 39 Gy. 
• 
Pharynx: Reduce the dose as much as possible. Mean pharynx dose recommended to be 
<50 Gy. 
• 
Esophagus: Reduce the dose as much as possible; recommended (not mandatory) 
treatment goal: mean dose < 30 Gy. 
• 
Larynx: Reduce the dose as much as possible. The larynx mean dose is recommended to 
be ≤ 35 Gy if whole-neck intensity-modulated RT is used. 
• 
Mandible: Reduce the dose as much as possible. Hot spots within the mandible should 
be avoided. It is recommended that maximum dose within the mandible be < 105% of 
prescription dose. 
• 
Unspecified tissue outside the targets (Non-PTV): No more than 1 cm3 of unspecified tissue 
outside the targets can receive ≥ 105% of the prescription dose. 
 
 
 
Treatment breaks must be clearly indicated in the treatment record along with the reason(s) for the 
treatment break(s). Treatment breaks, if necessary, should not exceed 3 treatment days at a time 
and 5 treatment days total. Treatment breaks should be allowed only for resolution of severe acute 
toxicity and/or for intercurrent illness and not for social or logistical reasons. Any treatment break(s) 
exceeding 2 treatment days for reasons other than toxicity/illness will be considered a protocol 
deviation. 
 
 
Photon beams of ≥ 6MV are required with treatment distance ≥ 80 cm source to axis distance for 
isocentric techniques. 
 
Immobilization: Treatment should include use of a thermoplastic head and shoulder mask. 
 
Planning CT scan: CT scan thickness should be ≤ 0.3 cm. If possible, planning CT scan should 
be done with contrast. MRI and/or PET/CT should be fused to the planning CT scan. 
 
Localization: Isocenter or reference point port localization images or volumetric imaging study on 
the linear accelerator couch should be obtained at each treatment on the treatment unit 
immediately before treatment to ensure proper alignment of the geometric center (i.e., isocenter) of 
the simulated fields. 
 
 
There will be no concurrent chemotherapy. Other drug therapy (e.g. lidocaine rinses, skin 
creams, narcotics) as clinically indicated for the management of radiotherapy side effects as per 
standard of care. 
 
 
6.4 
TREATMENT BREAKS 
6.5 
DEVICE-SPECIFIC CONSIDERATIONS 
6.5 
DRUG THERAPY 

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PSI will be calculated according the above formula, where Vdiagnosis is the volume of the tumor 
at first imaging and Vtreatment is the volume of the tumor at second pretreatment imaging, t is 
time, and λ is doubling time. Each site of disease will be contoured individually, and PSI 
calculated. PSI of lymph nodes will have priority over primary site. PSI of the largest lymph 
node will have priority over smaller lymph nodes. Patients with a PSI ≤ 0.75 will be assigned to 
conventional fractionation group, and PSI > 0.75 will be assigned to the hyperfractionation group 
(Figure 3). 
 
• 
Medical history within 90 days of start of treatment, including history, focused physical 
exam of the head and neck, assessment of performance status, and weight. 
 
• 
Imaging will consist of pre-treatment CT and/or MRI, with at least 2 exams one week 
apart. Pre-treatment PET/CT while ideal, is not required. On first day of RT (or within 
5 days of starting RT), CT simulation will be repeated. During week 4 of radiotherapy 
(~fraction 20 for conventionally fractionated patients or ~fraction 40 for 
hyperfractionation patients, CT simulation and MRI will be repeated. At ~8 weeks after 
treatment is complete CT of neck or ~12 weeks PET/CT will be performed for response 
assessment. 
 
 
 
The following samples will be sent to the Moffitt Cancer Center Tissue Core for processing and 
storage for the following analyses in the Chung Laboratory. Detailed sample collection and 
processing are described in Lab Manual. 
 
7.2.1 
EVALUATION OF TUMOR IMMUNE MICROENVIRONMENT (TIM) 
 
An innovative methodology, multiplex immunohistochemical (mIHC) staining, developed in the 
Chung Laboratory allows the analysis of an array of markers from limited sample specimens. The 
evaluation of a complex cellular microenvironment is best accomplished using high mIHC, which 
enables simultaneous detection and measurement of multiple protein antigens on the same tissue 
section allowing accurate classification of cells as well as enumeration and quantification of protein 
signal. This is accomplished by using sequential steps of antigen retrieval followed by primary 
antibody application, and then antibody stripping. The process is repeated using different primary 
antibodies for each antibody target. The result is that up to 18 protein targets can be visualized along 
with the nuclear stain. This complex staining can then be analyzed by imaging systems such as the 
the Aperio FL scanning system. Image analysis software such as Cell Profiler can then be applied 
to enumerate cells and quantify signal. Complex analysis can determine cellular densities and also 
measure co-localized targets. The multiplexing will encompass evaluation of antigen presenting 
cells, T cells, natural killer cells, B cells, and tumor cells using 30 immune cell markers and EGFR. 
The goal is to link a comprehensive clinical characterization and immune microenvironment 
assessment and to correlate these with radiation treatment response and survival. 
7 
STUDY   PROCEDURES   AND   SCHEDULE 
7.1 
STUDY PROCEDURES/EVALUATIONS 
7.2 
CORRELATIVE STUDY PROCEDURES/EVALUATIONS 

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7.2.2 
EVALUATION OF HPV DNA VIRAL LOAD IN ORAL GARGLES AND PLASMA 
 
HPV genotype and viral load will be determined on oral gargle and plasma specimens collected 
before, during, and after treatments using the most updated assay at the time of analyses. 
 
7.2.3 
TUMOR SAMPLE SUBMISSION 
 
Formalin-fixed paraffin-embedded (FFPE) tumor tissue samples will be collected at pre-treatment 
(MANDATORY). The FFPE tumor could be any archived tissue obtained before starting radiation 
therapy. The tumor tissue samples will be submitted to the Moffitt Tissue Core for cataloging and 
storage until the analyses at the Christine Chung's laboratory. 
 
An FFPE tumor block or 10, 4 micron unstained slides should be submitted with the submission 
form. A Pathology Report and one hematoxylin and eosin-stained slide documenting that the 
submitted block or slides contain tumor should also be submitted with the tissue. The report and 
hematoxylin and eosin-stained slide must include the protocol number and patient’s case number. 
The patient’s name and/or other identifying information should be removed from the report. The 
surgical pathology numbers and information must NOT be removed from the report. If the subject 
has multiple archival samples available, samples from various settings may be requested. 
 
7.2.4 ORAL GARGLE SAMPLE SUBMISSION AND PROCESSING 
 
Collection Notification Form (CNF) for each oral gargle and each blood sample will be email to 
Tissue Core Acquisition and Tissue Core SPL groups 24 hours before collection. 
 
Collection sites: 
Moffitt Cancer Center 
 
Oral gargle specimens will be collected using 15 ml of a locally available mouthwash. 
 
Clinical events: 
1. Pre-therapy 
2. During treatment at 1 weeks (+/- 3 days) 
3. During treatment at 2 weeks (+/- 3 days) 
4. During treatment at 3 weeks (+/- 3 days) 
5. During treatment at 4 weeks (+/- 3 days) 
6. End of the treatment (+/- 3 days) 
7. 3 months after the treatment (+/- 14 days) 
8. 6 months after the treatment (+/- 14 days) 
9. 12 months after the treatment (+/- 14 days) 
10. 18 months after the treatment (+/- 14 days) 
11. 24 months after the treatment (+/- 14 days) 
12. Time of disease progression if sooner than 24 months 
13. End of study if the patient is off the study before 24 months with any reasons. 
 
Procedures: The oral gargle samples should be processed within 24 h from collection.         
Oral gargle processing: Refer to Lab Manual. 

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7.2.5 
BLOOD SAMPLE SUBMISSION AND PROCESSING 
 
Collection Notification Form (CNF) for each blood sample will be email to Tissue Core Acquisition 
and Tissue Core SPL groups 24 hours before collection. 
 
 
Collection sites: 
Moffitt Cancer Center 
 
1x 10 ml Lavender EDTA tube of blood and 1x 10ml LBgard blood tube will be collected from each 
clinical event. 
 
 
Clinical events: 
1. Pre-therapy 
2. During treatment at 2 weeks (+/- 3 days) 
3. During treatment at 4 weeks (+/- 3 days) 
4. End of the treatment (+/- 3 days) 
5. 3 months after the treatment (+/- 14 days) 
6. 6 months after the treatment (+/- 14 days) 
7. 12 months after the treatment (+/- 14 days) 
8. 18 months after the treatment (+/- 14 days) 
9. 24 months after the treatment (+/- 14 days) 
10. Time of disease progression if sooner than 24 months 
11. End of study if the patient is off the study before 24 months with any reasons. 
 
Procedures: The blood samples should be processed within 2 h from collection. 
 
Plasma processing: Refer to Lab Manual. 
 
 
 

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Specimen collection summary for correlative studies 
 
Specimens taken  
from patient: 
Collected when: 
Submitted as: 
A paraffin-
embedded tissue of 
archival tissue taken 
before initiation of 
treatment 
 
Pre-treatment 
 
Paraffin-embedded 
tissue block, or 10, 4 
micron unstained 
slides (minimum of 
10 unstained slides) 
Refer to Lab Manual 
for processing and 
storage 
ORAL GARGLE: 
Collected using 15 
ml of a locally 
available 
mouthwash. 
1. Pre-therapy 
2. During treatment at 1 weeks (+/- 3 days) 
3. During treatment at 2 weeks (+/- 3 days) 
4. During treatment at 3 weeks (+/- 3 days) 
5. During treatment at 4 weeks (+/- 3 days) 
6. End of the treatment (+/- 3 days) 
7. 3 months after the treatment (+/- 14 days) 
8. 6 months after the treatment (+/- 14 days) 
9. 12 months after the treatment (+/- 14 days) 
10. 18 months after the treatment (+/- 14 days) 
11. 24 months after the treatment (+/- 14 days) 
12. Time of disease progression if sooner than 
24 months 
13. End of study if the patient is off the study 
before 24 months with any reasons. 
Refer to Lab 
Manual for 
Processing and 
storage 
PLASMA: 
1x 10 mL of 
anticoagulated 
whole blood in 
EDTA tube 
(purple/ lavender 
top). 
 
1. Pre-therapy 
2. During treatment at 2 weeks (+/- 3 days) 
3. During treatment at 4 weeks (+/- 3 days) 
Refer to Lab Manual 
for processing and 
storage 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Specimens taken     
from patient: 
Collected when: 
Submitted as: 
1x 10 mL of 
anticoagulated 
whole blood in 
LBgard blood tube. 
4. End of the treatment (+/- 3 days) 
5. 3 months after the treatment (+/- 14 days) 
6. 6 months after the treatment (+/- 14 days) 
7. 12 months after the treatment (+/- 14 days) 
8. 18 months after the treatment (+/- 14 days) 
9. 24 months after the treatment (+/- 14 days) 
10. Time of disease progression if sooner than 
24 months 
11. End of study if the patient is off the study 
before 24 months with any reasons. 
 
 
 
Refer to Lab  
Manual for  
Processing and 
storage 
PBMC: 
1x10 mL of 
nticoagulated whole 
blood in EDTA tube 
(purple/ lavender 
top). 
1. Pre-therapy 
2. During treatment at 2 weeks (+/- 3 days) 
3. During treatment at 4 weeks (+/- 3 days) 
4. End of the treatment (+/- 3 days) 
5. 3 months after the treatment (+/- 14 days) 
6. 6 months after the treatment (+/- 14 days) 
7. 12 months after the treatment (+/- 14 days) 
8. 18 months after the treatment (+/- 14 days) 
9. 24 months after the treatment (+/- 14 days) 
10. Time of disease progression if sooner than 
24 months 
11. End of study if the patient is off the study 
before 24 months with any reasons. 
Refer to Lab 
Manual for 
Processing and 
storage 
 
 
 
 

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On Treatment 
 
 
 
Assessments 
 
Pre-Study 
(within  90 d. 
of Tx start) 
 
First day, 
prior to RT 
(within5 days 
prior) 
 
Once -a- 
Week Durin g 
RT 
 
 
Week 4 
Durin g RT 
 
End of Tx  
(+/- 3 
days) 
Evaluations 
 
 
 
 
 
Rad Onc Eval H&P, 
ECOG, 
Weight 
 
X 
 
 
X 
 
 
Imaging 
 
 
 
 
 
CT# or MRI of 
primary and neck a,b 
 
Xh 
 
X 
 
 
X 
 
PET/CT 
Xc 
 
 
 
 
Labs 
 
 
 
 
 
Urine Pregnancy Test 
(only Females of 
Child bearing 
potential) 
 
 
X 
 
 
 
 
Tumor Tissue 
for RSI 
X 
 
 
 
 
Oral Gargle for 
HPVe 
X 
 
X 
X 
X 
Plasma for HPVf 
X 
 
X 
X 
X 
 
 
 
From End of Treatment 
 
 
 
Assessments 
4 Wks 
+/- 14 
days 
2-3 mo 
+/- 14 
daysd 
6 mo 
+/- 14 
days 
12 
mo 
+/- 
14 
days 
18 
mo 
+/- 
14 
days 
24 
mo 
+/- 
14 
days 
Time of disease 
progression if 
sooner than 24 
mosg 
End of study if the 
patient is off the 
study before 24 mos 
with any reasonsg 
Evaluations 
Rad Onc Eval 
H&P, ECOG, 
Weight 
 
X 
 
X 
 
X 
 
X 
 
 
 
 
7.3 
STUDY SCHEDULE 

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Assessments 
4 Wks 
+/- 14 
days 
2-3 mo 
+/- 14 
daysd 
6 mo 
+/- 14 
days 
12 
mo 
+/- 
14 
days 
18 
mo 
+/- 
14 
days 
24 
mo 
+/- 
14 
days 
Time of disease 
progression if 
sooner than 24 
mosg 
End of study if the 
patient is off the 
study before 24 mos 
with any reasonsg 
Imaging 
 
 
 
 
 
 
 
 
CT# or MRI of 
primary and 
neck a,b 
 
 
Xc 
 
 
 
 
 
PET/CT 
 
Xc 
 
 
 
 
 
Labs 
 
 
 
 
 
 
 
Urine 
Pregnancy Test 
(only Females 
of Child bearing 
potential) 
 
 
 
 
 
 
 
Tumor Tissue 
for RSI 
 
 
 
 
 
 
 
Oral Gargle for 
HPVe 
 
X 
X 
X 
X 
X 
X 
X 
Plasma for HPVf 
 
X 
X 
X 
X 
X 
X 
X 
 
aInterim MRI or CT for response assessment. 
bCT at day 1 and week 4 may be done using Department of Radiation Oncology CT Simulation cAt 
physician discretion. Pre-treatment PET/CT can be up to 180 days prior to CT simulation. dA CT at 2 
months and/or PET/CT at 3 months may be done at physician discretion. 
eOral Gargle for HPV to be collected at pre-therapy, during treatment at week 1, week 2, week 3, week 4, end 
of treatment, 3 months post-RT, 6 months post-RT, 12 months post-RT, 18 months post-RT, 24 months post-
RT, time of disease progression (if sooner than 24 months), and end of study (if patient discontinues the study 
with any reason sooner than 24 months). See 7.2.4/ 7.2.5 for collection windows. 
fBlood samples to be collected at pre-therapy, during treatment at week 2 and week 4, end of treatment, 3 
months post-RT, 6 months post-RT, 12 months post-RT, 18 months post-RT, 24 months post-RT, time of 
disease progression (if sooner than 24 months), and end of study (if patient discontinues the study with any 
reason sooner than 24 months). See 7.2.4/ 7.2.5 for collection windows. 
gFollowing this visit, patients are considered off the trial and are followed as per standard of care. 
hPre-treatment CT or MRI for PSI calculation can be up to 180 days prior to CT simulation. 
 
 
Not applicable 
 
 
Not applicable 
 
 
 
 
7.6 
PROPHYLACTIC MEDICATIONS, TREATMENTS, AND PROCEDURES 
7.4 
CONCOMITANT MEDICATIONS, TREATMENTS, AND PROCEDURES 
7.5 
PROHIBITED MEDICATIONS, TREATMENTS, AND PROCEDURES 

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Not applicable 
 
 
 
 
 
Adverse event means any untoward medical occurrence associated with the use of an 
intervention in humans, whether or not considered intervention-related (21 CFR 312.32 (a)). 
 
 
Adverse events and suspected adverse reactions are considered "serious" if, in the view of 
either the investigator or sponsor, they result in any of the following outcomes: death, a life- 
threatening adverse event, inpatient hospitalization or prolongation of existing hospitalization, a 
persistent or significant incapacity or substantial disruption of the ability to conduct normal life 
functions, or a congenital anomaly/birth defect. Important medical events that may not result in 
death, be life-threatening, or require hospitalization may be considered serious when, based 
upon appropriate medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. Examples 
of such medical events include allergic bronchospasm requiring intensive treatment in an 
emergency room or at home, blood dyscrasias or convulsions that do not result in inpatient 
hospitalization, or the development of drug dependency or drug abuse. 
 
 
OHRP considers unanticipated problems (UPs) involving risks to participants or others to 
include, in general, any incident, experience, or outcome that meets all of the following 
criteria: 
 
• 
Unexpected in terms of nature, severity, or frequency given (a) the research procedures 
that are described in the protocol-related documents, such as the IRB-approved 
research protocol and informed consent document; and (b) the characteristics of the 
participant population being studied; 
• 
Related or possibly related to participation in the research (“possibly related” means 
there is a reasonable possibility that the incident, experience, or outcome may have 
been caused by the procedures involved in the research); and 
 
• 
Suggests that the research places participants or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously 
known or recognized. 
 
This study will use the OHRP definition of UP. 
 
 
 
8 
ASSESSMENT   OF   SAFETY 
8.1 
SPECIFICATION OF SAFETY PARAMETERS 
8.1.
DEFINITION OF ADVERSE EVENTS 
8.1.2
DEFINITION OF SERIOUS ADVERSE EVENTS 
8.1.3 
DEFINITION OF UNANTICIPATED PROBLEMS 
8.2 
CLASSIFICATION OF AN ADVERSE EVENT 

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All AEs will be graded using the CTCAE 5 criteria. For AEs not included in the protocol-defined 
grading system, the following guidelines will be used to describe severity. 
 
• 
Mild – Events require minimal or no treatment and do not interfere with the participant’s 
daily activities. 
• 
Moderate – Events result in a low level of inconvenience or concern with the 
therapeutic measures. Moderate events may cause some interference with 
functioning. 
• 
Severe – Events interrupt a participant’s usual daily activity and may require 
systemic drug therapy or other treatment. Severe events are usually potentially life- 
threatening or incapacitating.]> 
 
 
 
The clinician’s assessment of an AE's relationship to the study agent (drug, biologic, device) is 
part of the documentation process, but it is not a factor in determining what is or is not reported 
in the study. If there is any doubt as to whether a clinical observation is an AE, the event should 
be reported. All AEs must have their relationship to study agent assessed. In a clinical trial, the 
study product must always be suspect. To help assess, the following guidelines are used. 
 
• 
Attribution of the AE: 
- 
Definite – The AE is clearly related to the study treatment. 
- 
Probable – The AE is likely related to the study treatment. 
- 
Possible – The AE may be related to the study treatment. 
- 
Unlikely – The AE is doubtfully related to the study treatment. 
- 
Unrelated – The AE is clearly NOT related to the study treatment. 
 
 
The occurrence of an AE or SAE may come to the attention of study personnel during study 
visits and interviews with study participants presenting for medical care, or upon review by a 
study monitor. All AEs, including local and systemic reactions not meeting the criteria for 
SAEs, will be captured on the appropriate CRF. Information to be collected includes event 
description, time of onset, clinician’s assessment of severity, relationship to study product 
(assessed only by those with the training and authority to make a diagnosis), and time of 
resolution/stabilization of event. All AEs occurring during the study must be documented 
appropriately, regardless of relationship. All AEs will be followed to adequate resolution. 
 
Any medical condition that is present at the time that the participant is screened will be 
considered as baseline and not reported as an AE. However, if the study participant’s 
condition deteriorates at any time during the study, it will be recorded as an AE. UPs will be 
recorded in the data collection system throughout the study. 
 
Changes in the severity of AEs will be documented to allow an assessment of the duration of the 
event at each level of severity to be performed. AEs characterized as intermittent require 
documentation of onset and duration of each episode. 
 
8.2.
SEVERITY OF 
8.2.2 
RELATIONSHIP TO STUDY AGENT 
8.3 
TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND FOLLOW-UP 

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The PI will record all reportable events with start dates occurring any time after informed consent is 
obtained until 7 (for non-serious AEs) or 30 days (for SAEs) after the last day of study participation. At 
each study visit, the investigator will inquire about the occurrence of AE/SAEs since the last visit. 
Events will be followed for outcome information until resolution or stabilization are achieved. 
 
All Grade 3 or greater AEs will be monitored until resolution or, if the AE is determined to be 
chronic, a cause is identified. If an AE is considered potentially related to study treatment and 
remains ongoing at the conclusion of the study, the event will be followed until resolution, 
stabilization, or initiation of treatment that confounds the ability to assess the event. RT-related AEs 
and SAEs will be collected at follow-up contact 90 days from the end of treatment provided no new 
treatments have been initiated that could confound the ability to assess the event. 
 
 
 
All Grade 3 or greater Adverse Events possibly, probably, or definitely related to radiotherapy up to 
the primary outcome time point (4 weeks) MUST be reported in routine study data submissions. 
Data will be captured in Oncore, Moffitt Cancer Center's clinical trials database. Regulatory 
documents and case report forms will be monitored internally according to Moffitt Cancer Center 
Monitoring Policies. 
 
 
Any clinical adverse event or abnormal laboratory test value that meets the definition of serious 
noted below and occurs in a patient during the course of the study, irrespective of the treatment 
received by the patient, must be reported within 24 hours of the investigator becoming aware of the 
occurrence. Serious adverse event definition and reporting requirements will be in accordance with 
the International Conference of Harmonisation (ICH) Guideline for Clinical Safety Data 
Managements. 
 
Definitions and Standards for Expedited Reporting, Topic E2A: 
An SAE is defined as any untoward medical occurrence that at any dose: 
1. Results in death 
2. Is immediately life-threatening (i.e., in the opinion of the investigator, the AE places the 
patient at immediate risk of death; it does not include a reaction that, had it occurred in a more 
severe form, might have caused death) 
3. Requires inpatient hospitalization or results in prolongation of an existing hospitalization 
4. Results in persistent or significant disability or incapacity 
5. Is a congenital anomaly or birth defect 
6. Is an important medical event that may not be immediately life-threatening, result in death, 
or require hospitalization, but may be considered an SAE when, based upon appropriate 
medical judgment, it jeopardizes the patient or may require medical or surgical intervention to 
prevent one of the outcomes listed above. 
 
Any SAE, whether or not considered to be related to study treatment, will be reported within 24 
hours of the investigator becoming aware of the event. It will be recorded on both the SAE form and 
the CRF AE page. Additional SAE information including medications or other therapeutic measures 
8.4 
REPORTING PROCEDURES 
8.4.
ADVERSE EVENT 
8.4.2 
SERIOUS ADVERSE EVENT REPORTING 

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used to treat the event, action taken with the study drug due to the event, and the outcome / 
resolution of the event will be recorded on the SAE form. Forms for reporting SAEs will be provided 
to the study sites. 
 
Conversely, some hospitalizations, particularly those that are the result of elective or previously 
scheduled surgery for preexisting conditions, which have not worsened after initiation of treatment, 
will not be classified as SAEs. For example, an admission for a drainage of obstructed bile duct 
would not be classified as an SAE. Pre-specified study hospitalizations for observation are not 
considered SAEs. All overdoses, whether or not resulting in an AE, require reporting within 24 
hours. 
 
All Grade 3 and greater AEs and SAEs that occur after the first treatment with RT and through 4 
weeks of treatment will require reporting by the investigational site. SAEs that meet the criteria for 
expedited reporting to the FDA will be reported in accordance with US regulations governing safety 
reporting (Title 21 of the Code of Federal Regulations [CFR] 312.32 and 312.33). Reporting of 
SAEs by the investigator to his or her Institutional Review Board (IRB) will be done in accordance 
with the standard operating procedures and policies of the IRB. Adequate documentation must be 
maintained showing that the IRB was properly notified. 
 
In case of an SAE, the investigator will electronically report to the University of South Florida 
Institutional Review Board via website http://www.research.usf.edu/cs/. 
 
 
Incidents or events that meet the OHRP criteria for UPs require the creation and completion of 
an UP report form. It is the site investigator’s responsibility to report UPs to their IRB and to the 
DCC/study sponsor. The UP report will include the following information: 
 
• 
Protocol identifying information: protocol title and number, PI’s name, and the IRB 
project number; 
• 
A detailed description of the event, incident, experience, or outcome; 
• 
An explanation of the basis for determining that the event, incident, experience, or 
outcome represents an UP; 
• 
A description of any changes to the protocol or other corrective actions that have been 
taken or are proposed in response to the UP. 
 
To satisfy the requirement for prompt reporting, UPs will be reported using the following timeline: 
 
• 
UPs that are SAEs will be reported to the IRB and to the DCC/study sponsor within 
1 day of the investigator becoming aware of the event. 
• 
Any other UP will be reported to the IRB and to the DCC/study sponsor within 7 days of 
the investigator becoming aware of the problem. 
 
 
Not Applicable 
 
 
The Protocol Monitoring Committee (PMC) monitors its assigned ongoing research protocols 
for adverse event reporting, data and safety monitoring, and internal audit findings. The PMC, 
8.4.3 
UNANTICIPATED PROBLEM REPORTING 
8.5 
STUDY HALTING RULES 
8.6 
SAFETY OVERSIGHT 

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upon review of any agenda item, may approve the study for continuation, require revisions, or 
suspend or close a protocol. This study will be reviewed by the PMC for data and safety 
monitoring. The principal investigator will enter into Oncore all adverse events and deviations 
as they occur for review by the PMC. 
 
The Principal Investigator is ultimately responsible for every aspect of the design, conduct, and 
actions of all members of the research team. This includes final analysis of the protocol. 
 
 
This study will be monitored internally by Moffitt Cancer Center using the OnCore reporting system. 
Data will be captured in OnCore, Moffitt’s electronic Clinical Trials Database. For each participant 
enrolled, the electronic CRF must be completed by the assigned data manager or other authorized 
study staff. Any paper forms should be typed or filled out indelible ink and must be legible. Errors 
should be crossed out but not obliterated, the correction inserted, and the change initialed and dated 
by the investigator or his/her authorized delegate. This also applies to records for those patients who 
fail to complete the study. If a patient stops dosing or terminates from the study, the dates and 
reasons must be noted on the CRF. If a patient terminates from the study because of a DLT, 
thorough efforts should be made to clearly document the outcome. The Case Report Forms will be 
reviewed by Moffitt’s Internal Monitors periodically throughout the conduct of the trial. The monitoring 
will include source data verification, utilizing research patients’ medical records. The investigator 
should ensure the accuracy, completeness, legibility, and timeliness of the data reported to the 
protocol monitoring committee. 
Each Scientific Review Committee conducts a formal internal peer review of all clinical protocols and 
general scientific oversight of interventional clinical research. Protocols are reviewed for scientific 
merit, adequate study design, safety, availability of targeted study population, and feasibility of timely 
completion of all proposed research projects to be conducted by its assigned programs at the 
Cancer Center. Each SRC is responsible for evaluating the risk/benefit assessment and 
corresponding data and safety monitoring plan as part of the scientific review and approval process. 
 
No modifications will be made to the protocol without the agreement of the investigators. Changes 
that significantly affect the safety of the patients, the scope of the investigation, or the scientific 
quality of the study will require Scientific Review Committee and Institutional Review Board approval 
before implementation, except where the modification is necessary to eliminate apparent immediate 
hazard to human subjects. Any departures from the protocol must be fully documented in the case 
report form and the source documentation. 
 
 
 
 
Demographic information such as age and race will be tabulated. Descriptive statistics, including 
means, standard deviations, and ranges for continuous parameters, as well as percents and 
frequencies for categorical parameters, will be presented. 
 
The effectiveness of PSI to select fractionation schema will be assessed by percent response at 
the 4th week of treatment. One-sided 95% confidence interval for the percent response at the 4th 
week of treatment will be also reported. A proportion difference test will be performed to test a 
difference of complete response rate from a target of 49%. 
9 
CLINICAL   MONITORING 
10 
STATISTICAL      CONSIDERATIONS 
10.1 
STATISTICAL AND ANALYTICAL PLANS 

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As for secondary endpoints, response will be correlation with pre-treatment and during treatment 
radiomics features on PET/CT/MRI using two sample t-tests and univariate/multivariate logistic 
regression analysis as appropriate. Correlation of response and outcomes to the mathematical 
models of tumor growth and death dynamics pre-treatment and during treatment will be 
performed using logistic regression analysis. 
 
 
 
 
This protocol is a single arm, phase II design with a primary endpoint of 63% of patients achieving 
a ≥ 32% reduction in tumor volume by week 4. This study will test the null hypothesis that the true 
response rate is equal to or less than a historical control of 49%11 versus the alternative 
hypothesis that it is greater than 49%.  
 
Based on Fleming’s 2-stage group sequential design, a total of 60 subjects will provide 
approximately 79% power with a type I error rate of 0.1 to detect a true response rate of 63%. 
The study will enroll subjects in two stages, with 49 subjects in the first stage. One interim 
efficacy/futility analysis will be conducted when the first 49 subjects have completed the study 
treatment and response evaluation. If the number of responsive patients is equal to or less than 
27, the trial will be stopped for futility. If the number of responsive patients is equal to or greater 
than 30, the trial will be stopped for efficacy. Otherwise, the trial will continue to the second stage 
by enrolling 11 additional subjects.  
 
At the final analysis with the total 60 subjects at the second stage, if there are equal to or more 
than 35 responsive patients, it will be concluded that the null hypothesis is rejected and the study 
treatment will be promising. 
 
 
 
The effectiveness of PSI to select fractionation schema will be assessed by percent response at 
the 4th week of treatment. One-sided 95% confidence interval for the percent response at the 4th 
week of treatment will be also reported. A proportion difference test will be performed to test a 
difference of complete response rate from a target of 49%. 
 
 
 
• 
Assess complete response by CT at 2 months or PET/CT at 3 months following 
completion of therapy. This will be compared against historical controls. 
• 
Response correlation with pre-treatment and during treatment radiomics features on 
PET/CT/MRI: 
Radiomics features based on CT, MRI, PET-CT, noted during various imaging scans 
(pre-treatment, at 4 week of RT, and follow-up scan) will be correlated with the overall 
oncological response and outcome 
 
Response correlation at 4 weeks and post treatment imaging with clearance of HPV from 
serum or oral gargle, and RSI/GARD. 
10.2 
DESCRIPTION OF STATISTICAL METHODS 
10.2.1 
GENERAL APPROACH 
10.2.2 
ANALYSIS OF THE PRIMARY EFFICACY ENDPOINT(S) 
10.2.3 
ANALYSIS OF THE SECONDARY ENDPOINT(S) 

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• 
Correlate response and outcome to mathematical models of tumor growth and death 
dynamics pre-treatment and during treatment: 
Mathematical models will be generated based on the pattern of tumor growth and 
response as depicted by tumor volume measurement on various scans. These 
mathematical models will be validated by correlating with the overall response and 
oncological outcome 
 
 
 
One interim efficacy/futility analysis will be conducted when the first 49 subjects have 
completed evaluation of response to the study treatment. If the number of responsive 
patients is equal to or less than 27, the trial will be stopped for futility. If the number of 
responsive patients is equal to or greater than 30, the trial will be stopped for efficacy. 
Otherwise, the trial will continue to the second stage by enrolling 11 additional subjects. 
 
 
 
When the first 33 subjects (55% of the total planned sample size of 60) will complete the study 
treatment, an early interim exploratory data analysis will be performed for data on HPV DNA viral 
load in oral gargle and plasma samples, demographic variables, and basic biometric screening 
results. This exploratory analysis is a pilot proof-of-concept study to evaluate the feasibility and 
consistency of HPV DNA detection in salivary and plasma samples. No analysis of primary and 
secondary safety and efficacy endpoints will be performed in this exploratory data analysis to keep 
trial integrity. 
 
• 
Data for the exploratory analysis will be summarized overall using descriptive 
statistics. Continuous data will be summarized with number of patients (n), 
mean, median, minimum, maximum, and standard deviation. Categorical data 
such as gender, race, and ethnicity will be summarized using frequency counts 
and percentages.  
• 
Cross-tabulation of descriptive statistics of demographic variables and 
biometric screening results with dichotomized HPV DNA viral load results 
(presence/absence of HPV DNA) will be made with Chi-square test and two-
sample t-test as appropriate.  
• 
Pearson’s correlation coefficient, Spearman’s rank correlation coefficient, and 
Kappa statistics will be calculated along with p-values as summary statistics for 
the consistency of HPV viral loads and detection results in oral gargle samples 
and plasma samples. 
 
 
 
60 patients total. Total accrual time is expected to be 30 months. 
 
 
The Investigator is responsible for ensuring the source data are accurate, legible, 
contemporaneous, original, and attributable. 
10.3 
SAMPLE SIZE 
11 
SOURCE DOCUMENTS  AND ACCESS TO SOURCE DATA/DOCUMENTS 
10.2.4 
Interim Efficacy/Futility Analysis 
10.2.5 
Interim Exploratory Data Analysis 

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Regulatory documents and case report forms will be monitored internally according to Moffitt 
Cancer Center Monitoring Policies. Monitoring will be performed regularly to verify data is 
accurate, complete, and verifiable from source documents; and the conduct of the trial is in 
compliance with the currently approved protocol/amendments, Good Clinical Practice (GCP), and 
applicable regulatory requirements. 
 
 
 
The investigator will ensure that this study is conducted in full conformity with Regulations for 
the Protection of Human Subjects of Research codified in 45 CFR Part 46, 21 CFR Part 50, 
21 CFR Part 56, and/or the ICH E6. 
 
 
 
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the IRB for review and approval. Approval of both the protocol and the consent 
form must be obtained before any participant is enrolled. Any amendment to the protocol will 
require review and approval by the IRB before the changes are implemented to the study. All 
changes to the consent form will be IRB approved; a determination will be made regarding 
whether previously consented participants need to be re-consented. 
 
 
 
13.3.1 
CONSENT/ASSENT AND OTHER INFORMATIONAL DOCUMENTS PROVIDED 
TO PARTICIPANTS 
 
Consent forms describing in detail the study agent, study procedures, and risks are given to the 
participant and written documentation of informed consent is required prior to starting 
intervention/administering study product. 
 
 
Informed consent is a process that is initiated prior to the individual’s agreeing to participate in 
the study and continues throughout the individual’s study participation. Extensive discussion of 
risks and possible benefits of participation will be provided to the participants and their families. 
Consent forms will be IRB-approved and the participant will be asked to read and review the 
document. The investigator will explain the research study to the participant and answer any 
questions that may arise. All participants will receive a verbal explanation in terms suited to their 
comprehension of the purposes, procedures, and potential risks of the study and of their rights 
as research participants. Participants will have the opportunity to carefully review the written 
consent form and ask questions prior to signing. 
12 
QUALITY ASSURANCE AND QUALITY CONTROL 
13 
ETHICS/PROTECTION   OF   HUMAN   SUBJECTS 
13.1 
ETHICAL   STANDARD 
13.2 
INSTITUTIONAL REVIEW BOARD 
13.3 
INFORMED CONSENT PROCESS 
13.3.2 
CONSENT PROCEDURES AND DOCUMENTATION 

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The participants should have the opportunity to discuss the study with their surrogates or think about it 
prior to agreeing to participate. The participant will sign the informed consent document prior to any 
procedures being done specifically for the study. The participants may withdraw consent at any time 
throughout the course of the trial. A copy of the informed consent document will be given to the 
participants for their records. The rights and welfare of the participants will be protected by emphasizing 
to them that the quality of their medical care will not be adversely affected if they decline to participate 
in this study. 
 
 
Participant confidentiality is strictly held in trust by the participating investigators, their staff, and 
the sponsor(s) and their agents. This confidentiality is extended to cover testing of biological 
samples and genetic tests in addition to the clinical information relating to participants. 
Therefore, the study protocol, documentation, data, and all other information generated will be 
held in strict confidence. No information concerning the study or the data will be released to 
any unauthorized third party without prior written approval of the sponsor. 
 
The study monitor, other authorized representatives of the sponsor, representatives of the IRB or 
pharmaceutical company supplying study product may inspect all documents and records 
required to be maintained by the investigator, including but not limited to, medical records (office, 
clinic, or hospital) and pharmacy records for the participants in this study. The clinical study site 
will permit access to such records. 
 
The study participant’s contact information will be securely stored at each clinical site for internal 
use during the study. At the end of the study, all records will continue to be kept in a secure 
location for as long a period as dictated by local IRB and Institutional regulations. 
 
Study participant research data, which is for purposes of statistical analysis and scientific 
reporting, will be transmitted to and stored at the Coordinating Center. This will not include the 
participants’ contact or identifying information. Rather, individual participants and their research 
data will be identified by a unique study identification number. The study data entry and study 
management systems used by clinical sites and by the Coordinating Center research staff will 
be secured and password protected. At the end of the study, all study databases will be de- 
identified and archived at the Coordinating Center. 
 
 
Data collected for this study will be analyzed and stored at the Moffitt Cancer Center. 
 
 
 
 
 
 
 
Data collection is the responsibility of the clinical trial staff at the site under the supervision of the 
site PI. The investigator is responsible for ensuring the accuracy, completeness, legibility, and 
13.4 
PARTICIPANT AND DATA CONFIDENTIALITY 
13.5 
FUTURE USE OF STORED SPECIMENS 
14 
DATA HANDLING AND RECORD KEEPING 
14.1 
DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES 

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timeliness of the data reported. 
 
All source documents should be completed in a neat, legible manner to ensure accurate 
interpretation of data. Black ink is required to ensure clarity of reproduced copies. When 
making changes or corrections, cross out the original entry with a single line, and initial and 
date the change. DO NOT ERASE, OVERWRITE, OR USE CORRECTION FLUID OR TAPE 
ON THE ORIGINAL. 
 
Copies of the electronic CRF (eCRF) will be provided for use as source documents and 
maintained for recording data for each participant enrolled in the study. Data reported in the 
eCRF derived from source documents should be consistent with the source documents or the 
discrepancies should be explained and captured in a progress note and maintained in the 
participant’s official electronic study record. 
 
Clinical data (including AEs, concomitant medications, and expected adverse reactions data) and 
clinical laboratory data will be entered into <specify name of data capture system>, a 21 CFR 
Part 11-compliant data capture system provided by Moffitt Cancer Center. The data system 
includes password protection and internal quality checks, such as automatic range checks, to 
identify data that appear inconsistent, incomplete, or inaccurate. Clinical data will be entered 
directly from the source documents. 
 
 
Study documents should be retained for a minimum of 2 years. These documents should be 
retained for a longer period, however, if required by local regulations. No records will be 
destroyed without the written consent of the sponsor, if applicable. It is the responsibility of the 
sponsor to inform the investigator when these documents no longer need to be retained. 
 
 
A protocol deviation is any noncompliance with the clinical trial protocol, GCP or MOP 
requirements. The noncompliance may be either on the part of the participant, the investigator, or 
the site study staff. As a result of deviations, corrective actions are to be developed by the site 
and implemented promptly. 
 
These practices are consistent with ICH E6: 
4.5 Compliance with Protocol, sections 4.5.1-3 
5.1 Quality Assurance and Quality Control section 5.1.1 
5.2 Noncompliance, sections 5.20.1-2 
 
It is the responsibility of the site to use continuous vigilance to identify and report deviations within 
10 working days of identification of the protocol deviation, or within 10working days of the 
scheduled protocol-required activity. All deviations must be addressed in study source documents, 
reported to protocol monitoring committee. Protocol deviations must be sent to the local IRB per 
their guidelines. The site PI/study staff is responsible for knowing and adhering to their IRB 
requirements. Further details about the handling of protocol deviations will be included in the MOP. 
 
 
The study of these patients and results are considered private and confidential. The progress and 
results of this study will not be presented without approval by the principal investigator. 
14.2 
STUDY RECORDS RETENTION 
14.3 
PROTOCOL DEVIATIONS 
14.3 
PUBLICATION AND DATA SHARING POLICY 

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Not applicable. 
 
 
 
 
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical. Therefore any actual conflict of interest of persons who 
have a role in the design, conduct, analysis, publication, or any aspect of this trial will be 
disclosed and managed. Furthermore, persons who have a perceived conflict of interest will 
be required to have such conflicts managed in a way that is appropriate to their participation 
in the trial. The study leadership in conjunction with the study sponsor has established 
policies and procedures for all study group members to disclose all conflicts of interest and 
will establish a mechanism for the management of all reported dualities of interest. 
 
 
16 
CONFLICT   OF INTEREST   POLICY 
15 
STUDY     ADMINISTRATION 
15.1 
STUDY LEADERSHIP 

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1. Enderling H, Anderson ARA, Chaplain MAJ, Beheshti A, Hlatky L, Hahnfeldt P. Paradoxical 
Dependencies of Tumor Dormancy and Progression on Basic Cell Kinetics. Cancer Res. 2009 
Nov 15;69(22):8814–21. 
 
2. Prokopiou S, Moros EG, Poleszczuk J, Caudell J, Torres-Roca JF, Latifi K, et al. A proliferation 
saturation index to predict radiation response and personalize radiotherapy fractionation. Radiat 
Oncol Lond Engl. 2015 Jul 31;10:159. 
 
3. Adelstein D, Gillison ML, Pfister DG, Spencer S, Adkins D, Brizel DM, et al. NCCN Guidelines 
Insights: Head and Neck Cancers, Version 2.2017. J Natl Compr Cancer Netw JNCCN. 2017 
Jun;15(6):761–70. 
 
4. Lacas B, Bourhis J, Overgaard J, Zhang Q, Grégoire V, Nankivell M, et al. Role of radiotherapy 
fractionation in head and neck cancers (MARCH): an updated meta-analysis. Lancet Oncol. 
2017 Sep;18(9):1221–37. 
 
5. Blanchard P, Baujat B, Holostenco V, Bourredjem A, Baey C, Bourhis J, et al. Meta-analysis of 
chemotherapy in head and neck cancer (MACH-NC): A comprehensive analysis by tumour site. 
Radiother Oncol [Internet]. [cited 2011 Jun 18];In Press, Corrected Proof. Available from: 
http://www.sciencedirect.com/science/article/pii/S0167814011002295 
 
6. Eisbruch A, Harris J, Garden AS, Chao CKS, Straube W, Harari PM, et al. Multi-Institutional Trial 
of Accelerated Hypofractionated Intensity-Modulated Radiation Therapy for Early-Stage 
Oropharyngeal Cancer (RTOG 00-22). Int J Radiat Oncol. 2010 Apr;76(5):1333–8. 
 
7. Garden AS, Kies MS, Morrison WH, Weber RS, Frank SJ, Glisson BS, et al. Outcomes and 
patterns of care of patients with locally advanced oropharyngeal carcinoma treated in the early 
21st century. Radiat Oncol Lond Engl. 2013 Jan 29;8:21. 
 
8. O’Sullivan B, Huang SH, Siu LL, Waldron J, Zhao H, Perez-Ordonez B, et al. Deintensification 
candidate subgroups in human papillomavirus-related oropharyngeal cancer according to 
minimal risk of distant metastasis. J Clin Oncol Off J Am Soc Clin Oncol. 2013 Feb 
10;31(5):543–50. 
 
9. Gillison ML, Trotti AM, Harris J, Eisbruch A, Harari PM, Adelstein DJ, et al. Radiotherapy plus 
cetuximab or cisplatin in human papillomavirus-positive oropharyngeal cancer (NRG Oncology 
RTOG 1016): a randomised, multicentre, non-inferiority trial. The Lancet. 2019 Jan 
5;393(10166):40–50. 
 
10. Hu KS, Stewart R, Jacobson A, Persky M, Schantz S, Tran T, et al. Prognostic Value of 
Midtreatment Nodal Response to Chemoradiation in Oropharyngeal Squamous Cell Carcinomas: 
Implications for Treatment Modification. Int J Radiat Oncol • Biol • Phys. 2016 Mar 15;94(4):901. 
 
11. Latifi K, Rishi A, Enderling H, Moros EG, Heukelom J, Mohamed ASR, et al. Mid-treatment Nodal 
Response is Associated With Outcome in Head and Neck Squamous Cell Cancer. Int J Radiat 
Oncol • Biol • Phys. 2017 Oct 1;99(2):E683. 
 
12. Marcial VA, Pajak TF, Chang C, Tupchong L, Stetz J. Hyperfractionated photon radiation therapy 
17 
LITERATURE   REFERENCES 

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in the treatment of advanced squamous cell carcinoma of the oral cavity, pharynx, larynx, and 
sinuses, using radiation therapy as the only planned modality: (Preliminary report) by the 
radiation therapy oncology group (RTOG). Int J Radiat Oncol Biol Phys. 1987 Jan;13(1):41–7. 
 
13. Galon J, Mlecnik B, Bindea G, Angell HK, Berger A, Lagorce C, et al. Towards the introduction of 
the “Immunoscore” in the classification of malignant tumours. J Pathol. 2014 Jan;232(2):199– 
209. 
 
14. Fridman WH, Pagès F, Sautès-Fridman C, Galon J. The immune contexture in human tumours: 
impact on clinical outcome. Nat Rev Cancer. 2012 15;12(4):298–306. 
 
15. Tsujikawa T, Kumar S, Borkar RN, Azimi V, Thibault G, Chang YH, et al. Quantitative Multiplex 
Immunohistochemistry Reveals Myeloid-Inflamed Tumor-Immune Complexity Associated with 
Poor Prognosis. Cell Rep. 2017 04;19(1):203–17. 
 
16. Ahn SM, Chan JYK, Zhang Z, Wang H, Khan Z, Bishop JA, et al. Saliva and plasma quantitative 
polymerase chain reaction-based detection and surveillance of human papillomavirus-related 
head and neck cancer. JAMA Otolaryngol-- Head Neck Surg. 2014 Sep;140(9):846–54. 
 
17. Wang Y, Springer S, Mulvey CL, Silliman N, Schaefer J, Sausen M, et al. Detection of somatic 
mutations and HPV in the saliva and plasma of patients with head and neck squamous cell 
carcinomas. Sci Transl Med. 2015 Jun 24;7(293):293ra104. 
 
18. Overgaard J, Hansen HS, Specht L, Overgaard M, Grau C, Andersen E, et al. Five compared 
with six fractions per week of conventional radiotherapy of squamous-cell carcinoma of head and 
neck: DAHANCA 6&7 randomised controlled trial. The Lancet. 2003 Sep 20;362(9388):933–40. 
 
19. Geraets DT, Struijk L, Kleter B, Molijn A, van Doorn L-J, Quint WGV, et al. The original SPF10 
LiPA25 algorithm is more sensitive and suitable for epidemiologic HPV research than the SPF10 
INNO-LiPA Extra. J Virol Methods. 2015 Apr;215–216:22–9. 
 
20. Cornall AM, Quint WH, Garland SM, Tabrizi SN. Evaluation of an automated SPF10-LiPA25 
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2014 Apr;199:116–8. 
 
 
 

PSI For XRT Fractionation 
 
 
 
 
 
 
 
 
Version 2.3 
Protocol MCC# 19579 
 
 
 
 
 
 
 
 
09 Jul 2021 
 
33 
 
 
Version 
Date 
Significant Revisions 
2.0 
2/09/2018 
Updated inclusion criteria 
Variable dosing based on size 
Added exploratory endpoint examining serum/oral gargle HPV 
pre-treatment, during, and after treatment 
2.1 
11/04/2019 
Updated Inclusion criteria 
Updated calendar: Pre-treatment PET/CT or MRI can be up to 
180 days prior to CT simulation 
2.2 
05/29/2020 
7.2.1 Evaluation of HPV DNA viral load in oral gargles and 
plasma 
HPV genotype and viral load will be determined on oral gargle 
and plasma specimens collected before, during, and after 
treatments using the most updated assay at the time of 
analyses. 
2.3 
07/09/2021 
Updated oral gargle and blood sample time points. Updated 
co-investigator list by removing Drs. Harrison and Trotti.  
Added interim primary endpoint analysis and interim 
exploratory data analyses. 
 
APPENDIX