Karma CREME-1: A Double-blind, Placebo-controlled, Three-armed, Pilot Study of the Effects, Safety and Tolerability of Topical Endoxifen in Women Within the Karma Cohort
Phase: PHASE2
Conditions: Mammographic Breast Density
Sponsor: Atossa Therapeutics, Inc.

Clinical Protocol Version 2.0  
Dated 16Apr2018 
Protocol Title:  Karma Creme-1: A double-blind, placebo-controlled, three-armed, pilot study of the 
effects, safety and tolerability of topical endoxifen in women within the karma cohort 
NCT: 04616430 

 
 
 
 
 
Karma CREME-1: A double-blind, placebo-controlled, three-armed, pilot study of 
the effects, safety and tolerability of topical endoxifen in healthy women 
 
 
 
 
 
Investigational Medical Product: 
Topical endoxifen 
 
 
EudraCT: 
Protocol: 
 
Version: 
 
Principal Investigator: 
2018-000573-72 
ATOS-010 
 
2.0 
 
Per Hall, MD, Professor 
Karolinska Institutet 
Institution for Medical Epidemiology and Biostatistics 
171 77 Stockholm 
Tel: +46733960590 
Email: per.hall@ki.se 
 
Department of Oncology 
Södersjukhuset 
Sjukhusbacken 10 
118 83 Stockholm 
 
 
Sponsor: 
Atossa Genetics Inc. 
107 Spring St, Seattle 
WA 98104, USA 
 
 
 
The information contained herein is confidential and must not be disclosed to unrelated third 
parties without the permission by the investigator and sponsor. 

Protocol ATOS-010: Karma CREME-1: A double-blind, placebo-controlled, three armed, pilot study of the effects, safety and 
tolerability of topical endoxifen in healthy women 
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PROTOCOL REVISION HISTORY 
 
 
Version 
Date 
Revised by 
Description of change 
Refers to 
chapter/page 
1.0 
20180306 
NA 
NA 
2.0 
20180416 
NA 
Revised in response to MPA objections 
NA 

Protocol ATOS-010: Karma CREME-1: A double-blind, placebo-controlled, three armed, pilot study of the effects, safety and 
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PROTOCOL SYNOPSIS 
 
Study Title 
Karma CREME-1: A double-blind, placebo-controlled, three armed, pilot study of the effects, 
safety and tolerability of topical endoxifen in healthy women 
Study code: ATOS-010 
EudraCT No: 2018-000573-72 
Coordinating Investigator/Principle Investigator 
Per Hall 
Study centre 
Karma Study Centre/Breast and Mammography screening unit, Södersjukhuset, Stockholm, Sweden 
Study period 
Estimated date of study open for enrolment: April 2018 
Estimated date of first participant enrolled, May 2018 
Estimated date of last participant completed, March 2019 
Phase of development 
Phase 2 
Objectives and endpoints 
Primary objective:  Breast Density Reduction 
 To determine the effect size of breast density between topical placebo and two 
doses of 
topical endoxifen. The effect size will permit sample size calculations for statistical 
significance in a future phase III 
trial. 
Primary endpoint: 
 Change, on an individual level, in mammographic breast density, measured at 3 and 6 
months after study entry (= baseline screening 
mammography). 
Secondary objective: Tolerability and Safety 
 Assess tolerability and safety of topical 
endoxifen 
Secondary endpoints: 
 Determine dose dependent differences in compliance, side effects and local tolerability 
measured through 
questionnaires 
 Determine dose dependent differences in laboratory assessments such as liver function tests 
(ALAT, ASAT, ALP, Bilirubin), coagulation function (INR, aPTT), sex hormone binding globulin 
(SHBG) 
Tertiary objective: 
 Determine if plasma levels 
of endoxifen influence primary and secondary endpoints 
Tertiary endpoints: 
 Determine if plasma level 
concentrations 
of endoxifen are related to primary and secondary 
endpoints 
Investigational Medicinal Product (IMP) 
The IMP, topical endoxifen and its matching placebo, are formulated from widely used for both 
cosmetics and pharmaceutical topical constituents: Transcutol
TM (2-(2-Ethoxyethoxy)ethanol); 
isopropanol, Crodamol
TM GTCC (a fully saturated emollient triester) and mineral oil. The active IMP 
also contains endoxifen, the strength of which is based on Z-endoxifen content. 

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Study design 
Randomized, double-blinded, three-armed, placebo controlled pilot study 
• 
A daily dose = 2 sachets/day in total which is the equivalent to 1 sachet/breast/day 
Number of participants planned 
90 participants will be randomized to one of three groups with 30 participants per group 
Diagnosis and main eligibility criteria 
Healthy post-menopausal women participating in mammographic screening program at SöS 
Bröstcentrum with a measurable mammographic density, i.e., ≥ 4.5 % density (volumetric) measured 
by Volpara. No history of coagulopathies, cardio-vascular disorders and cancer. 
Duration of treatment 
6 months 
Duration of participants involvement in the study 
6 months of exposure to active compound or placebo 
Efficacy assessments 
Mammographic density after 3 and 6 months. 
Safety assessments 
The safety profile of each individual and dose group will be determined by clinical assessment, 
laboratory findings and participant reports. Laboratory findings and AEs will be followed throughout 
the study period. A Data and Safety Monitoring Board will provide safety oversight of the study. 
Statistical methods 
Karma CREME-1, is a pilot study conducted to aid the design of a larger future trial. As such, the pilot 
study is not powered to show statistical significant reductions in breast density in the treatment 
arms compared to the control arm. Rather, results of the pilot study will be qualitatively presented 
and assessed, which will aid in making decisions about dosing, study length, and sample size for the 
larger trial. 
Efficacy: Assess change in mammographic density from baseline to 3 and 6 months and from 3 to 6 
months of study drug administration. 
Tolerability: Assess the grade, severity and frequency of side effects 
Safety: rank adverse events by severity, grade, interventions, and resolution. 
Group 
IMP 
Assessments 
Dose 
mg/day* 
Frequency 
Duration 
1 
0 
Daily 
6 months 
0, 3, 6 months: 
• 
Safety Labs 
• 
Mammogram 
3, 6 months: 
• Endoxifen levels 
0, 1, 3, 6 months 
• Questionnaires 
2 
10 
Daily 
6 months 
3 
20 
Daily 
6 months 

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Table of Contents 
PROTOCOL REVISION HISTORY ............................................................................................................... 2 
PROTOCOL SYNOPSIS .............................................................................................................................. 3 
1 LIST OF ABBREVIATIONS AND DEFINITION OF TERMS .................................................................. 8 
2 ETHICS ................................................................................................................................................ 9 
2.1 
ETHICAL AND REGULATORY REVIEW ....................................................................................................... 9 
2.2 
ETHICAL CONDUCT OF THE STUDY .......................................................................................................... 9 
2.3 
PARTICIPANT INFORMATION AND CONSENT ............................................................................................ 9 
2.4 
PARTICIPANT DATA PROTECTION ........................................................................................................... 9 
3 ADMINISTRATIVE STRUCTURE ........................................................................................................ 10 
4 INTRODUCTION ............................................................................................................................... 11 
5 STUDY RATIONALE .......................................................................................................................... 11 
5.1 
BACKGROUND .................................................................................................................................. 11 
5.2 
TOPICAL ADMINISTRATION RATIONALE ..................................................................................................... 12 
5.3 
ENDOXIFEN RATIONALE ...................................................................................................................... 12 
5.3.1 
TOPICAL ENDOXIFEN - PHASE 1 DATA ................................................................................................. 12 
5.3.2 
PLASMA ENDOXIFEN LEVELS AFTER EXPOSURE TO ORAL TAMOXIFEN ......................................................... 12 
5.4 
DOSING RATIONALE ................................................................................................................................ 13 
5.5 
MAMMOGRAPHIC DENSITY ................................................................................................................ 13 
5.6 
STUDY DURATION ............................................................................................................................. 14 
5.7 
CONCLUSION .................................................................................................................................... 15 
6 BENEFIT-HARM ASSESMENT ........................................................................................................... 15 
6.1 
BACKGROUND .................................................................................................................................. 15 
6.2 
SAFETY ............................................................................................................................................ 16 
6.2.1 
RISK MITIGATION STRATEGY -SAFETY .................................................................................................. 16 
6.3 
TOLERABILITY ................................................................................................................................... 16 
6.3.1 
LOCAL SIDE EFFECTS ........................................................................................................................ 16 
6.3.2 
SYSTEMIC SIDE EFFECTS ................................................................................................................... 17 
6.4 
BENEFIT-HARM ASSESSMENT OF FREQUENT MAMMOGRAMS ................................................................... 18 
6.5 
POSSIBLE BENEFITS OF PARTICIPATION IN THE TRIAL ............................................................................... 19 
7 SAFETY, TOLERABILITY, EFFICACY AND LABORATORY ASSESSMENTS .......................................... 19 
7.1 
SAFETY ASSESSMENT ......................................................................................................................... 19 
7.2 
TOLERABILITY ASSESSMENTS .............................................................................................................. 20 
7.3 
EFFICACY ASSESSMENTS ..................................................................................................................... 20 
7.4 
LABORATORY ASSESSMENTS ............................................................................................................... 20 
8 STUDY OBJECTIVES AND ENDPOINTS ............................................................................................. 20 
8.1 
PRIMARY OBJECTIVE: BREAST DENSITY REDUCTION ................................................................................... 20 
8.1.1 
PRIMARY ENDPOINT ........................................................................................................................ 20 
8.2 
SECONDARY OBJECTIVE: TOLERABILITY AND SAFETY ............................................................................... 20 
8.2.1 
SECONDARY ENDPOINTS .................................................................................................................. 20 

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8.3 
TERTIARY OBJECTIVE .......................................................................................................................... 21 
8.3.1 
TERTIARY ENDPOINT ....................................................................................................................... 21 
9 STATISTICAL METHODS AND CONSIDERATIONS ............................................................................ 21 
9.1 
STATISTICAL METHODS AND DETERMINATION OF SAMPLE SIZE ................................................................. 21 
9.1.1 
DEMOGRAPHICS AND BASELINE DATA ................................................................................................. 21 
9.1.2 
ANALYSIS OF THE PRIMARY ENDPOINT (EFFECTIVENESS) ......................................................................... 21 
9.1.3 
TRIAL OPERATING CHARACTERISTICS .................................................................................................. 22 
9.1.4 
ANALYSIS OF THE SECONDARY OUTCOME ............................................................................................ 24 
9.1.5 
ANALYSIS OF THE TERTIARY OUTCOME ................................................................................................ 24 
9.1.6 
INTERIM ANALYSIS .......................................................................................................................... 24 
10 INVESTIGATIONAL PLAN ............................................................................................................... 24 
10.1 
THE KARMA STUDY CENTRE .............................................................................................................. 24 
10.2 
SELECTION OF STUDY POPULATION .................................................................................................... 24 
10.3 
INCLUSION CRITERIA ........................................................................................................................ 24 
10.4 
EXCLUSION CRITERIA ....................................................................................................................... 25 
10.5 
OVERALL STUDY DESIGN ................................................................................................................... 26 
10.5.1 
INVITATION ................................................................................................................................. 26 
10.5.2 
PRE-SCREENING OF ELIGIBILITY OF PARTICIPATION .............................................................................. 26 
10.5.3 
BASELINE (MONTH 0) ................................................................................................................... 27 
10.5.4 
1 MONTH AFTER BASELINE (+2/-1 WEEKS) ........................................................................................ 27 
10.5.5 
3 MONTHS AFTER BASELINE (+/- 2 WEEKS) ....................................................................................... 27 
10.5.6 
6 MONTHS AFTER BASELINE (+/- 2 WEEKS), VISIT AT KARMA STUDY CENTRE, END OF STUDY ...................... 27 
10.5.7 
IN BETWEEN REGULAR VISITS AT THE KARMA STUDY CENTRE ................................................................. 28 
10.5.8 
REMINDERS ................................................................................................................................. 28 
10.6 
CRITERIA FOR DISCONTINUATION AND HANDLING OF DROP-OUTS ........................................................... 28 
10.7 
TREATMENTS ................................................................................................................................. 29 
10.7.1 
IDENTITY OF INVESTIGATIONAL MEDICINAL PRODUCT (IMP) ................................................................ 29 
10.7.2 
FLOW OF IMP FROM MANUFACTURING TO INVESTIGATORS SITE ............................................................. 29 
10.7.3 
PACKAGING AND LABELLING OF IMP ................................................................................................ 29 
10.7.4 
STORAGE OF IMP ......................................................................................................................... 30 
10.7.5 
DOSES AND TREATMENT REGIMENS ................................................................................................. 30 
10.7.6 
INVESTIGATIONAL MEDICINAL PRODUCT ACCOUNTABILITY ................................................................... 30 
10.7.7 
METHOD OF ASSIGNING PARTICIPANTS TO TREATMENT GROUPS ........................................................... 30 
10.7.8 
BLINDING .................................................................................................................................... 31 
10.7.9 
PRIOR AND CONCOMITANT THERAPY ................................................................................................ 31 
10.7.10 
PROHIBITED MEDICATIONS ........................................................................................................... 31 
10.7.11 
TREATMENT COMPLIANCE ............................................................................................................ 31 
11 ADVERSE EVENTS .......................................................................................................................... 32 
11.1 
DEFINITIONS .................................................................................................................................. 32 
11.1.1 
ADVERSE EVENT (AE) .................................................................................................................... 32 
11.1.2 
SERIOUS ADVERSE EVENT ............................................................................................................... 32 
11.1.3 
SUSPECTED UNEXPECTED SERIOUS ADVERSE REACTION (SUSAR) ......................................................... 32 
11.2 
REGISTRATION AND ASSESSMENT OF AES ........................................................................................... 32 
11.3 
ELICITING AND RECORDING OF AES .................................................................................................... 33 
11.4 
AES OF INTEREST ............................................................................................................................ 33 
11.4.1 
DEFINITION OF AE OF INTEREST ...................................................................................................... 33 
11.5 
REPORTING OF SAES AND SUSARS TO SPONSOR AND AUTHORITIES ...................................................... 34 
11.5.1 
REPORTING OF SAES ..................................................................................................................... 34 

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11.5.2 
REPORTING OF SUSARS ................................................................................................................ 35 
11.6 
DURATION OF OBSERVATION OF AE/SAE ........................................................................................... 35 
11.7 
FOLLOW-UP OF UNRESOLVED AE ....................................................................................................... 35 
12 DATA QUALITY ASSURANCE .......................................................................................................... 35 
12.1 
ELECTRONIC CASE REPORT FORMS (ECRFS) ........................................................................................ 35 
12.2 
MONITORING ................................................................................................................................. 35 
12.3 
DATA MONITORING AND SAFETY BOARD (DSMB) .............................................................................. 36 
12.4 
SOURCE DATA ................................................................................................................................ 36 
12.5 
AUDIT AND INSPECTIONS ................................................................................................................. 36 
12.6 
CHANGES IN THE APPROVED STUDY PROTOCOL ................................................................................... 36 
12.7 
DATA MANAGEMENT ...................................................................................................................... 36 
13 STUDY MANAGEMENT .................................................................................................................. 36 
13.1 
STUDY TIME TABLE - END OF STUDY ................................................................................................... 36 
13.2 
INSURANCE/INDEMNITY .................................................................................................................. 36 
13.3 
STUDY AGREEMENTS ....................................................................................................................... 37 
13.4 
CRITERIA FOR TERMINATION OF THE STUDY ......................................................................................... 37 
13.5 
REPORTING OF RESULTS AND PUBLICATION POLICY ...................................................................................... 37 
13.6 
RECORD RETENTION .............................................................................................................................. 37 
13.7 
DISCLOSURE AND CONFIDENTIALITY ................................................................................................... 37 
14 EMERGENCY PROCEDURES ........................................................................................................... 38 
14.1 
EMERGENCY CONTACTS ................................................................................................................... 38 
14.2 
EMERGENCY UN-BLINDING FOR SAFETY REASON .................................................................................. 38 
14.3 
PROCEDURES IN CASE OF MEDICAL EMERGENCY ................................................................................... 38 
14.4 
PROCEDURE IN CASE OF OVERDOSE .................................................................................................... 38 
15 REFERENCES ................................................................................................................................... 39 
16 SIGNATURE PAGES ........................................................................................................................ 41 
17 LIST OF APPENDECIES .................................................................................................................... 43 
17.1 
APPENDIX A: SCHEDULE OF EVENTS IN KARMA CREME-1 .................................................................... 44 
17.2 
APPENDIX B: PARTICIPATION CARD ....................................................................................................... 45 

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1 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
Abbreviation or term 
Explanation 
AE 
Adverse event 
BMI 
Body mass index 
CRF 
CRO 
CTA 
eCRF 
DCIS 
DDP 
DMP 
DSMB 
FAP 
GCP 
GMP 
ICF 
Case report form 
Contract Research Organisation 
Clinical Trial Agreement or Clinical Trial Application 
Electronic Case Report Form 
Ductal Carcinoma In Situ 
Data Display Plan 
Data Management Plan 
Data and Safety Monitoring Board 
Full Analysis Population 
Good Clinical Practice 
Good Manufacturing Practices 
Informed Consent Form 
ICH 
International conference on harmonisation 
IEC 
Independent Ethics Committee 
IMP 
IMPD 
MedDRA 
PP 
SAE 
SAP 
SP 
SUSAR 
SöS BC 
QC 
QP 
Investigational medicinal product 
Investigational Medicinal Product Dossier 
Medical Dictionary for Regulatory Activities 
Protocol Population 
Serious adverse event 
Statistical Analysis Plan 
Safety Population 
Suspected Unexpected Serious Adverse Event 
Södersjukhuset Bröstcentrum 
Quality Control 
Qualified Person. A legally defined and certified Quality Assurance 
professional that ensures each lot of product complies with its specification 
and has been made according to good manufacturing practice. 

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2 
ETHICS 
2.1 
Ethical and Regulatory review 
Necessary approvals of the Study Protocol, the Participant Information and Informed Consent Form 
(ICF) must be obtained before enrolment of any participant into the study. Furthermore, it is the 
responsibility of the Sponsor to keep the applicable Independent Ethics Committee (IEC) informed of 
any Suspected Unexpected Serious Adverse Reactions (SUSARs) and any substantial amendments to 
the protocol during the study period. The written approval from the IEC, including a study identification 
and the date of approval, will be filed by the Karma Group at the Karolinska Institutet and at the study 
site at Södersjukhuset Bröstcentrum (SöS BC) together with a list of the IEC members, their titles or 
occupation, and their institutional affiliations. 
2.2 
Ethical conduct of the study 
The study will be conducted according to the protocol and in line with applicable regulations, i.e. LVFS 
2011:19, ICH GCP and the latest version of the declaration of Helsinki. 
2.3 
Participant information and consent 
It is the responsibility of the Investigator to give each participant, adequate verbal and written 
information regarding the objectives and the procedures of the study as well as any risks or 
inconvenience involved before including the participant in the study. The participant should be 
informed that by signing the ICF she authorises monitor(s), auditor(s), the IEC and the Regulatory 
Authorities to have direct access to the participant’s medical records for verification of clinical study 
procedures. The women must be informed about the right to withdraw from the study at any time and 
that participation is on a voluntarily basis. The participant should be allowed sufficient time for 
consideration of the proposal. 
It is the responsibility of the Investigator to obtain signed informed consent from all participants before 
including them in the study. The ICF must be signed and dated before any study-specific procedures 
are performed, including screening procedures. In case of possible future audits/inspections, the 
Investigator must file the signed ICF. 
The final version of the participant information and ICF is submitted to the IEC and concerned 
Regulatory Authorities and must not be changed without permission from Sponsor and the local IEC. 
2.4 
Participant data protection 
The Investigator must file a participant identification list that includes sufficient information to link 
records, i.e., the electronic Case Report Form (eCRF) and clinical records. This list must be preserved 
for possible future inspections/audits. 
The participants will be informed that the data will be stored and analysed by computer, that Swedish 
and local regulations for the handling of computerised data will be followed and that identification of 
individual participant data will only be possible for the Investigator. 
Representatives of the Karma Group including a Contract Research Organisation (CRO), and/or 
regulatory authorities will inform the participants about the possibility of inspections/audits of 
relevant parts of the clinical records. Authorisation to direct access to the participant’s clinical records, 
as described above, is given by signing the ICF. 

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3 
ADMINISTRATIVE STRUCTURE 
Qualified investigators under the sponsorship of Atossa Genetics and the Karma Group will conduct 
the study. The name and contact details of the responsible persons at Karma Group and the CRO will 
be listed in the Investigator Site File provided at the site. 
Role 
Name 
Contact 
Location 
Sponsor 
Steven C. Quay, 
Chairman of the 
Board and Chief 
Executive 
Officer 
Mobile: +1 206. 419.4873 
Telephone: +1.866.893.4927 
steven.quay@atossagenetics.com 
Atossa Genetics Inc. 
Address: 107 Spring Street, 
Seattle, WA 98104, USA 
Janet R. Rea, Sr. 
Vice President 
Regulatory, 
Quality & 
Clinical Affairs 
Mobile: +1.206.799.7186 
janet.rea@atossagenetics.com 
Principal 
Investigator/ 
Responsible 
medical officer 
Per Hall 
+4673-396 05 90 
per.hall@ki.se 
Karolinska Institutet 
/Södersjukhuset /Karma Study 
Centre 
Medical 
doctors / 
Investigators 
Södersjukhuset 
Magnus 
Bäcklund 
Magnus.Backlund@ki.se 
KI/Karma Study Centre SÖS 
Sara Margolin 
Sara.margolin@sll.se 
SöS Onk/Karma Study Centre 
Tommy 
Fornander 
Tommy.fornander@sll.se 
SöS Onk/Karma Study Centre 
Gerhard 
Winblad 
Gerhard.winblad@sll.se 
SöS Onk/Karma Study Centre 
Ellinor Elinder 
Ellinor.elinder@sll.se 
SöS Onk/Karma Study Centre 
Linda Thorén 
Linda.thoren@sll.se 
SöS Onk/Karma Study Centre 
Elin Barnekow 
Elin.Barnekow@sll.se 
SöS Onk/Karma Study Centre 
Jenny Lundin 
Jenny.lundin@sll.se 
SöS Onk/Karma Study Centre 
Head of 
Radiology 
Södersjukhuset 
Karin Leifland 
karin.horstmann-leifland@sodersjukhuset.se 
Dept. of Radiology, 
Södersjukhuset 
Safety 
Monitoring 
Committee 
(Independent 
members) 
Sophia 
Zackrisson 
sophia.zackrisson@med.lu.se 
Dept. of Radiology 
Malmö 
Clinical Trial 
Manager 
Mattias 
Hammarström 
+4673-7121476 
mattias.hammarstrom@ki.se 
Karolinska Institutet /Karma 
Study Centre 
Research 
nurses 
Ann-Sofie 
Andersson 
Agneta Lönn 
+4670-750 2110/08-524 82339 
karmastudien@ki.se 
Karma Study Centre 
Clinical Trial 
Consultant 
Marie Lindahl 
marie.lindahl@yahoo.se 
+46 733 102258 
Stockholm 
Monitor 
KTA, Karolinska 
Trial Alliance 
Lotta Mazouch +4670-0011845 
Lotta Mazouch@KTA.se 
Stockholm 
Holder of 
blinding-code 
(In case of 
emergency and 
blinding needs 
to be broken) 
Apoteket AB 
Linköping 
Weekdays 08:00 – 16:00: 010 – 103 29 62 
All other times: 010 – 103 00 00, require 
pharmacist on call 
Linköping 
SUSAR 
reporting 
KTA, Karolinska 
Trial Alliance 
Lotta Mazouch +4670-0011845 
Lotta Mazouch@KTA.se 
Stockholm 

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4 
INTRODUCTION 
 
Breast cancer is by far the most common cancer among women in the world and a continuing increase 
is seen, particularly so in the developing world. Currently there are few efforts taken to reduce the 
incidence of breast cancer, that is, to prevent the disease. The major research focuses are early 
detection (screening) and therapy. Adjuvant therapy (administrated to patients without a measurable 
tumour burden in order to decrease risk of recurrence of the disease) has been used for decades and 
has dramatically improved survival [Pan, 2017]. Some of the drugs used in the adjuvant setting has also 
been used for prevention. Aromatase inhibitors and selective estrogen receptor modulators (SERMs), 
e.g., tamoxifen, has been shown to reduce the incidence of breast cancer in healthy individuals. Four 
studies have shown that 20 mg of oral tamoxifen in healthy women can reduce the incidence of breast 
cancer by nearly 50% [Visvanathan, 2013]. Tamoxifen has therefore been approved by the FDA for 
prevention since the 1990s. 
Despite the fact that tamoxifen has been found to reduce the incidence of breast cancer in healthy 
women, it is rarely prescribed for this use. The reluctance of physicians to prescribe and for women to 
use oral tamoxifen for prevention is likely due to the perceived and real risks of side effects. Hot flushes, 
and other vasomotor symptoms, which can be severe, are barriers to acceptance. Rare and serious 
side effects are endometrial cancer and venous embolism. 
One possible way of reducing side effects is to lower tamoxifen doses, under the assumption that lower 
dose is required for prevention than for curative treatment. We therefore launched the Karisma-2 trial 
(Karisma-2, Eudra CT 2016-000882-22) in the end of 2016. In short, in the Karisma2 trial we test if lower 
doses of tamoxifen (10, 5, 2.5, 1 mg) has the same effect (measured as a decrease in mammographic 
density, please see below) as the established 20 mg dose. The trial is ongoing and approximately 800 
participants (as of February 2018) of the 1440 women have been recruited. Recruitment is planned to 
end December 2018. 
Another way to reduce side effects is to, instead of using tamoxifen, introducing the tamoxifen 
metabolite endoxifen. As a prodrug, tamoxifen has to be metabolized and endoxifen is considered the 
main active metabolite of tamoxifen [Lim, 2005]. By using endoxifen as a topical application the 
systemic side effects can be reduced [Lee, 2015]. 
In a collaboration with Atossa Genetics Inc., a US company that has developed endoxifen for topical 
application, topical endoxifen will be tested to determine if it reduces mammographic density, 
compared to a placebo group, with acceptable tolerability and safety. 
This pilot study, which is the first launched phase 2 study of topical endoxifen, is named Karma CREME- 
1 and it will be conducted in accordance with the ICH GCP guidelines, the principals of which have their 
origins in the Declaration of Helsinki. 
 
5 
STUDY RATIONALE 
 
5.1 
Background 
Karma CREME-1 will consist of 90 healthy women that will be recruited from the mammography 
screening program at Södersjukhuset, Stockholm. Since 2010, The Karma Group have invited women 
to the Karma project, aiming to reduce breast cancer by a preventive approach. The Karma cohort was 
created between 2010-2013 and consists of 71,000 Swedish women. All women invited for screening 
mammography in Lund, Helsingborg and at Södersjukhuset, were invited to the Karma Study Centers. 
If agreeing to join the study, participants signed an informed consent, donated blood and answered a 
comprehensive questionnaire on lifestyle factors [Gabrielsson, 2017]. 
In the ongoing Karisma 2 trial, all women attending mammography screening at Södersjukhuset are 
invited, not only Karma participants. The Karma CREME-1 trial should be viewed as an extension of the 

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Karisma-2 trial with a possible further reduction of side effects through even lower plasma 
concentrations of the active metabolites of tamoxifen. 
5.2 
Topical administration rationale 
Intravenous, intramuscular and oral administration of a medication gives systemic effects which means 
that the entire body could affected by the drug. In contrast, a topical application has the potential to 
reduce the systemic effect without reducing the local effect. 
There are theoretical reasons for using a topical endoxifen since it has a potential to be enriched in the 
breast tissue. The breast gland has developed from an apocrine gland and could thus be seen as part 
of the skin and any substance would therefore be more likely to penetrate the skin [Ackerman, 2007]. 
Secondly, there is an abundance of lymph and blood vessels in the breast gland that should increase 
the uptake [Suami, 2008]. Thirdly, type of tissue influence the uptake of tamoxifen metabolites. When 
the tamoxifen metabolite afimoxifene was applied in the lower part of the body and over the breast, 
the concentration in the underlying tissue was 10 times higher in the breast than the adipose tissue of 
the belly [Suami, 2008]. Probably an effect of the affinity of afimoxifene to the estrogen receptor. 
5.3 
Endoxifen rationale 
As a prodrug, tamoxifen has to be metabolized and rely on the activity of its metabolites for clinical 
effects. Effects and side effects of tamoxifen is the sum of tamoxifen and all its metabolites. Endoxifen 
has an estrogen receptor affinity exceeding that of the parent drug tamoxifen and is considered the 
main active metabolite of tamoxifen. It has for long been known that the affinity of endoxifen to the 
estrogen receptor is approximately 100 times higher than that of tamoxifen [Katzenellenbogen, 1984]. 
 
5.3.1 
Topical endoxifen - Phase 1 data 
Atossa Genetics Inc., has performed two clinical endoxifen phase 1 studies, one with endoxifen as an 
oral compound and one with endoxifen as a topical compound. The topical phase 1 study is described 
in detail in the Investigators Brochure. 
In the phase 1 topical endoxifen study, 25 healthy individuals received topical endoxifen at doses 0, 2, 
6 and 10 mg/day. None of them experienced side-effects normally linked to tamoxifen, and thereby 
possibly endoxifen, exposure. There were no reports of hot flushes, vaginal discharge, mood swings, 
fatigue or breast pain/tenderness. These symptoms are associated with tamoxifen use and seen in 
more than 50% of the Karisma-2 participants. What was reported in the topical endoxifen phase 1 
study was for tamoxifen atypical, non-dose dependent experiences of abnormal dreams, hypersomnia, 
vomiting and headache. 
In the phase 1 topical endoxifen study, serum concentrations of endoxifen were low even for the 
highest dose group, 10 mg/day of daily topical endoxifen. Most measured samples were below or 
slightly above the limit of detection/quantitation. The mean concentration in the 10 mg group was 1.0 
ng/mL and the maximum 5.0 ng/mL. Concentrations were too low to perform any pharmacokinetic 
analyses. Furthermore, there were no clinically significant safety signals (no measurable influence on 
coagulation system, liver function or sex hormone binding globulin) in any of the subjects receiving 
topical endoxifen. 
In conclusion, topical endoxifen (at doses 0, 2, 6 and 10 mg/day) was well tolerated when administered 
daily for 28 days to 25 healthy volunteers. There were no dose-related or treatment-related trends in 
any of the safety and tolerability endpoints. 
 
5.3.2 
Plasma endoxifen levels after exposure to oral tamoxifen 
Endoxifen concentrations in blood in patients taking oral tamoxifen has been measured in numerous 
studies. Most studies describe a wide variation of plasma concentrations of tamoxifen and its 
metabolites. The inter-individual variation of tamoxifen metabolism is supposedly caused by   genetic 

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factors and different methods used to determine the concentration. In a recent study, concentrations 
of endoxifen were measured in plasma specimens from 281 breast cancer patients treated with 
tamoxifen [Woo, 2017]. The average exposure to 20 mg of tamoxifen was 125 days (range 56 – 340 
days). For endoxifen the mean was 25.0 ng/mL and range 11.4 – 44.8 ng/mL. Most of the variation was 
explained by polymorphisms in key metabolizing genes such as CYP2D6. 
A meta analyses gathered published data covering 13,001 breast cancer patients using tamoxifen 
[Hwang, 2017]. CYP2D6 poor metabolizers were compared to extensive metabolizers and the mean 
endoxifen concentrations were significantly lower in poor metabolizers, 8.8±7.2 versus 
22.3±11.8 ng/mL (p<0.05). In all, 39 women (19 premenopausal and 20 postmenopausal women) on 
adjuvant tamoxifen treatment (20 mg/d) for early breast cancer had endoxifen levels measured using 
ultra-performance liquid chromatography with a mass spectrometry detection [Fotoohi, 2016]. Plasma 
concentrations of endoxifen range from 3.2 to 19 ng/mL, with a mean of 10.4 ng/mL. 
Twenty-four Karma Cohort participants that developed breast cancer during follow up (data not 
published) and were put on 20 mg of tamoxifen had tamoxifen metabolites measured in 2016. The 
average endoxifen plasma levels were 7.4 ng/mL (range 1.8 – 12.2) and the median 9.4 ng/mL. 
From this we assume that the systemic endoxifen concentrations from topical administration of 
endoxifen is approximately 5-10% of the endoxifen plasma levels seen after 20 mg of oral tamoxifen. 
This is most likely the reason why few dose-dependent side effects, typically linked to tamoxifen, were 
seen in the topical endoxifen phase 1 trial. 
5.4 
Dosing Rationale 
If topical endoxifen is actively enriched in the breast tissue and if concentrations are sufficient to 
influence the breast parenchyma, that is, the dense part of a mammogram, has not been studied. The 
influence of another metabolite of tamoxifen, afimoxifene, has been reported in some few studies. It 
should be noted that the affinity of endoxifen to the estrogen receptor is higher than that of another 
tamoxifen metabolite, afimoxifene. 
In a randomised controlled trial 45 breast cancer patients were treated with topical administration of 
afimoxifene in the period between diagnosis and surgery. The effect measure was cell proliferation in 
the breast gland [Rouanet, 2005]. Patients were divided in to five groups, placebo, topical afimoxifene 
in doses 1, 2, and 4 mg/day, and 20 mg of oral tamoxifen. No effect on epithelial cell proliferation was 
seen in patients on placebo and 1 mg/day. These groups did not report any side effects. Proliferation 
was significantly reduced in the groups on 2 and 4 mg/day of afimoxifene and oral tamoxifen 20 mg 
compared to the placebo group. No difference in reduction in proliferation was seen between the three 
groups that responded to therapy. There was no significant difference in side effects in the three 
response groups despite the fact that the plasma concentration of afimoxifene was less than 10% of 
that of oral tamoxifen. 
There are two known studies that tested the effect of topically administrated afimoxifene on 
mammographic density. None of these studies are published but preliminary results show that a 
significant reduction in density was seen without reports on side effects [Bua, 2004; Le Nestour, 2009]. 
Topically administered tamoxifen metabolites seems to influence the breast parenchyma but we do 
not know the dose needed. The tested doses in the topical endoxifen phase 1 trial generated few, if 
any, treatment related side effects and very low concentrations of plasma endoxifen. We therefore 
want to test the breast parenchymal effect of a total daily dose of 10 mg (5 mg/breast) and 20 mg (10 
mg/breast) of topical endoxifen. 
5.5 
Mammographic density 
In a conventional breast cancer prevention study the outcome would be number of breast cancers in 
each arm  given a  predefined time  period.  Such a  study  requires  a long  follow-up and a  very large 

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number of participants. An alternative is to use mammographic density change as a proxy for therapy 
response. 
Mammographic density is the white part of the mammogram and consist of glandular and connective 
tissue. The black, non-radiolucent part is fat. The more glandular and more connective tissues, the 
whiter the breast, and thus, the higher the risk of breast cancer [Boyd, 2007]. Factors that influence 
risk of breast cancer are known to influence density. Hormone replacement therapy increases density 
and risk of breast cancer [Brand, 2013], while tamoxifen has the opposite effect [Li, 2013]. 
In addition to be a excellent marker of risk, mammographic density has been shown to be a reliable 
proxy for therapy response. Mammographic density has been assessed in a nested case-control study 
within the IBIS-1 study, a randomised prevention study of tamoxifen vs. placebo. The density decrease, 
over the first 18 months, in 123 women diagnosed with breast cancer, was compared to 942 women 
without breast cancer [Cuzick, 2011]. Forty-eight per cent of the women treated with tamoxifen 
experienced a 10% or greater reduction in breast density and had a 63% reduction in breast cancer risk 
compared to women in the placebo group. In contrast, those who took tamoxifen but experienced less 
than a 10% reduction in breast density had no risk reduction. 
Within the Karma group a parallel study was conducted including breast cancer patients who were 
treated with adjuvant tamoxifen therapy [Li, 2013]. Forty-eight per cent of the women experienced a 
decrease in density of > 20 % over a 12 month period and had a reduced breast cancer recurrence of 
50%. These findings are fully supported by a very recent finding by a US group [Nyante, 2015]. 
In clinical practice mammographic density is measured using BI-RADS. BI-RADS categorizes breast into 
four categories: entirely fatty (BI-RADS A), scattered areas of fibroglandular density (BI-RADS B), 
heterogeneously dense (BI-RADS C) and extremely dense breast (BI-RADS D). The BI-RADS 
measurement is done by the radiologist by looking at the mammogram. BI-RADS measurements are 
very crude and highly reader dependent. To avoid time consuming and reader dependent measures of 
risk the Karma research group have developed the computerized measurement tool Stratus [Eriksson, 
2018]. 
Stratus is an automated tool that is not dependent on reader skills or experience. The unique features 
of Stratus is that it enables comparison of mammographic density changes over time without being 
restricted to type of mammogram or technical differences between images. An image from one and 
the same women are not always comparable since not the same extent of the breast is seen in the 
image. In order to reduce this technical problem, images has to be aligned before density measures 
are performed. Stratus includes an alignment protocol that makes images from the same individual 
comparable and reduced the non-biological variability between mammograms. Stratus has 
successfully been used in the Karisma trials. In short, Stratus will assess therapy response without being 
influenced by type of image and the alignment protocol will reduce the non-biological variability 
between mammograms. 
Even though Stratus has shown to reduce most of the differences between images through the 
alignment protocol, minute differences could still influence results. In order to reduce any possible 
biological difference between images of the same woman, the study is restricted to postmenopausal 
women that, per definition, have no influence of density related to hormone change during the 
menstruation cycle. 
5.6 
Study duration 
The Karisma-1 pilot trial (Eudra CT2014-005-005-20) preceded the Karisma-2 trial. The major focus of 
the pilot trial was to estimate time to mammographic density change. In all, 32 healthy women 
completed the 6 month trial and were exposed to 10 or 20 mg/day of oral tamoxifen. 
The results of the Karisma-1 trial showed a mammographic density decrease after the full study period 
of 6 months, of about 50% for one quarter of the participants. For another quarter of the participants 

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a ≈ 20% mammographic density decrease was seen. The remaining 50% of the participants did not 
experience any change in mammographic density. 
Table 1 displays the change in mammographic density among the 32 patients seen after 3, 6 and 9 
month of follow up. The biggest decrease is seen the first 3 months and the decrease continues even 
after the treatment was stopped at 6 months. 
-------------------------------------------------------------------------------------------------------------------------------------- 
Table 1. Mean percent dense area and density change from baseline in percent in the Karisma-1 pilot 
study (n=32), in relation to months in study. 
0 month 
3 months 
6 months 
9 months 
Mean % dense area 
17.6 
15.8 
15.3 
14.6 
Mean % change from baseline 
- 
-1.8 
-2.3 
-3.0 
------------------------------------------------------------------------------------------------------------------------------------- 
The results of the Karisma-1 pilot trial show that 3 months of oral tamoxifen exposure is enough to 
significantly influence mammographic density. Since it could be that the uptake of topical endoxifen, 
in contrast to oral tamoxifen, is slower, the treatment period in Karma CREME-1 trial has been set to 6 
months, with mammograms and density measurements performed at 3 and 6 months. 
5.7 
Conclusion 
The ability of oral tamoxifen to reduce breast cancer risk is well-accepted and proven. The tamoxifen 
metabolite endoxifen has the highest affinity for the estrogen-receptor of the tamoxifen metabolites. 
The ability of topical endoxifen to penetrate the skin of the breast was demonstrated in the phase 1 
study of topical endoxifen without safety or tolerability signals. Topical endoxifen, at doses 10 and 20 
mg/day will therefore be tested using mammographic density change as the outcome. The arguments 
for topical endoxifen are: 
1. Endoxifen has the highest affinity of all the tamoxifen metabolites to the estrogen-receptor. 
2. The liver is not required to metabolize endoxifen and interference with the coagulation 
pathway system and liver function is less likely to occur. 
3. From a theoretical pint of view, endoxifen applied to the skin covering the breast could be 
enriched in the breast tissue because the high affinity to the estrogen receptor and the 
vascularisation of the breast epithelium. 
4. Directed delivery to the breast with limited systemic exposure may result in better tolerability 
and compliance. 
 
6 
BENEFIT-HARM ASSESMENT 
 
6.1 
Background 
In a broader sense, ethical considerations in clinical trials should focus on answering the question – 
does knowledge generated through the trial outweigh the possible harms inflicted on the participants? 
The most important task is to take the safety of study participants in to consideration. Breast cancer 
incidence has increased rapidly over the last generations and currently one women per minute is 
diagnosed with breast cancer in Europe. It could therefore be argued that efforts taken to reduce the 
number of breast cancers are much needed. Tamoxifen has been used for adjuvant therapy for breast 
cancer for several decades and the side effects of tamoxifen are well-known. Side effects ranges from 
menopausal symptoms and mood swings to increased risks of endometrial cancer and 
thromboembolism. Tamoxifen has also been found to reduce the number of newly diagnosed cancers 
in perfectly healthy women but is not used to any larger extent due to the risk of bothersome as well 
as potentially very serious side-effects. Little is known about the side effects of endoxifen. Therefore, 
a conservative approach must be to assume that the toxicity of endoxifen is identical to that of 

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tamoxifen and that there is a dose dependency is used. The following sections discuss the potential 
risks associated with exposing healthy volunteers to topical endoxifen and the associated mitigation 
strategies. Possible benefits of participating in the trial are also described, as well as benefit-harm 
assessment of frequent mammograms. 
6.2 
Safety 
The most serious side effects of tamoxifen are thromboembolic events, endometrial cancer, sarcoma 
of the uterus and liver damage such as cirrhosis and steatosis. Markers of the coagulation system, liver 
function and levels of sex hormone binding globulin (SHBG) were therefore tested in the phase I topical 
endoxifen trial. Comparing levels before trial initiation and at 28 days of exposure to the study drug 
revealed no influence on these parameters, not even in the highest dose (10 mg) category. For more 
detailed information on the phase 1 results, please see Investigator Brochure. 
During pregnancy, tamoxifen and its metabolites interact with rapidly growing and developing 
embryonic or foetal tissues. Tamoxifen exposure during pregnancy could lead to congenital 
malformations, spontaneous abortions and even foetal deaths. 
6.2.1     Risk mitigation strategy -Safety 
The phase 1 data does not indicate a systemic influence on the systems but since it cannot entirely be 
ruled out that there is an effect on the coagulation system, liver function or SHBG, markers of their 
function will be measured at 3 and 6 months in this phase 2 study. 
Patients with a previous cardiovascular event will be excluded from the study. Blood pressure will be 
measured before entering the study and women with a blood pressure >140/90 mm Hg will not be 
included in the trial. Possible signs of vaginal bleeding will be addressed immediately. Since only 
postmenopausal women will be included, pregnancy related safety issues are not a concern. 
6.3 
Tolerability 
Theoretically, topical endoxifen could give two kind of side effects, local and systemic. The local 
problems emanate from the application of the solution to the skin of the breast. The systemic effects 
from circulating plasma endoxifen and are measured as experienced side effects through using self- 
reported answers to a Functional Assessment of Cancer Therapy – Endocrine Subscale (FACT-ES) 
questionnaire. The comprehensive questionnaire covers all the well-known side effects seen for 
tamoxifen, such as physical, social, emotional and functional wellbeing. Additional concerns are hot 
flushes, night and cold sweats, vaginal discharge, etc. 
6.3.1 
Local side effects 
Local irritation, redness and itching, were the most commonly reported symptoms in the topical 
endoxifen phase 1 trial, which mostly spontaneously resolved during treatment but in one case lead to 
the discontinuation of the study drug. Mild itching, pain and redness was seen in all dose categories, 
even placebo. Moderate problems were seen in 4 individuals in the highest dose group and in one 
participant in the lowest dose group. No severe skin problems were reported. 
A self-administered assessment was performed daily by the women as to local tolerance. Table 2 shows 
the results of the assessments. As can be seen, most problems were scored as mild, some few 
moderate and none as severe. It turned out that the majority of the reports (41%) of burning, itching, 
and particularly irritation was reported by one study subject. 

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Table 2. Results of Local Tolerance Self-assessment 
 
Parameter 
None 
n (%) 
Mild 
n (%) 
Moderate 
n (%) 
Severe 
n (%) 
Total 
n 
Redness 
662 (98.5) 
10 (1.5) 
0 (0.0) 
0 (0.0) 
672 
Burning 
669 (99.6) 
3 (0.4) 
0 (0.0) 
0 (0.0) 
672 
Pain 
661 (98.4) 
10 (1.5) 
1 (0.1) 
0 (0.0) 
672 
Itching 
651 (96.9) 
16 (2.4) 
5 (0.7) 
0 (0.0) 
672 
Irritation 
651 (96.9) 
20 (3.0) 
1 (0.1) 
0 (0.0) 
672 
6.3.1.1 
Risk mitigation strategy - Local side effects 
It is important that participants are encouraged to only apply the product to intact and not to broken 
skin. Should local symptoms emerge, consultation with the study staff should be made to determine if 
continued participation is warranted. The participants will also be asked to: 
• 
Not expose the treated skin to sunlight (natural or artificial), as the photosensitivity properties 
of the product have not been established 
• 
Avoid skin to skin transfer if possible, at least 30 minutes after application 
• 
Avoid exercise, swimming or bathing for at least 30 minutes after application 
6.3.2 
Systemic side effects 
In the topical endoxifen phase 1 study systemic side effects were measured using the FACT-ES. The 
most common side–effects of tamoxifen and thereby possibly endoxifen are hot flushes, amenorrhea, 
altered menses, vaginal discharge, depression, mood swings, nausea, oedema, fatigue and breast 
pain/tenderness. None of these symptoms were seen among the 25 participants of the phase 1 trial. 
What was seen was abnormal dreams, hypersomnia, vomiting and headache, however, not in a dose- 
dependent manner. The group that had most participants experiencing side effects was the placebo 
group and the most common symptom in this group was headache. As can be seen in Table 3 there 
were reports of mild to moderate symptoms from a variety of organs but, with the exception of skin 
problems, there does not seem to be a dose dependency. The table gives the number of individuals 
reporting problems. 

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Table 3. Number of individuals reporting treatment emergent adverse events by severity and dose in 
the topical endoxifen phase 1 trial 
 
System Organ 
Class, 
Preferred Term 
Severity 
Active Cohort 
Total 
Placebo 
(n = 7) 
All 
Subjects 
(n = 25) 
2 mg 
(n = 6) 
6 mg 
(n = 6) 
10 mg 
(n = 6) 
Total 
Active 
(n = 19) 
Infections and infestations 
Moderate 
1 (14%) 
1 (14%) 
Mild 
1 (17%) 
1 (17%) 
3 (50%) 
5 (28%) 
- 
5 (20%) 
Psychiatric disorders 
Mild 
2 (33%) 
- 
- 
2 (11%) 
- 
2 (8%) 
Nervous system disorders 
Moderate 
- 
1 (17%) 
- 
1 (6%) 
2 (29%) 
3 (12%) 
Mild 
1 (17%) 
- 
1 (17%) 
2 (11%) 
1 (14%) 
3 (12%) 
Vascular disorders 
Mild 
- 
- 
- 
- 
1 (14%) 
1 (4%) 
Gastrointestinal disorders 
Moderate 
- 
1 (17%) 
- 
1 (6%) 
1 (14%) 
2 (8%) 
Mild 
- 
2(33%) 
- 
2 (11%) 
1 (14%) 
3 (12%) 
Skin and subcutaneous tissue disorders 
Mild 
- 
1 (17%) 
2 (33%) 
3 (17%) 
- 
3 (12% 
Reproductive system and breast disorders 
Moderate 
1 (17%) 
- 
- 
1 (6%) 
- 
1 (4%) 
Mild 
- 
- 
- 
- 
1 (14%) 
1 (4%) 
General disorders and administration site conditions 
Mild 
- 
- 
- 
- 
1 (14%) 
1 (4%) 
Investigations 
Mild 
- 
- 
1 (17%) 
1 (6%) 
- 
1 (4%) 
Injury, Poisoning and procedural complications 
Moderate 
- 
1 (17%) 
- 
1 (6%) 
- 
1 (4%) 
Mild 
1 (17%) 
1 (17%) 
- 
2 (11%) 
- 
2 (8%) 
 
6.3.2.1 
Risk mitigation strategy - Systemic side effects 
Participants will be informed to immediately contact the Karma Study Centre if they suspect side 
effects. As within the ongoing dose determination study, Karisma-2 where the aim is to test the effect 
of low dose tamoxifen, participants have the options of reporting side effects via telephone, mail, 
internet or the so called Karmapp. Participants get help at the centre in downloading the app at 
inclusion. Participants are encouraged to report side effects month 1, 3 and 6. They are also 
encouraged to spontaneously report any problems that could be related to the therapy. 
In the Karisma-2 trial, study personal take turns carrying a study mobile phone and participants can 
reach the Karma Trial Centre during office hours. Exactly the same strategy for reporting side effects 
will be used in the topical endoxifen phase 2 trial as in the Karisma-2 trial. Participants reporting severe 
side effects are immediately contacted and discontinuation discussed. So far, 16% of the participants 
of the Karisma-2 trial have left the study because of side effects. 
6.4 
Benefit-harm assessment of frequent mammograms 
Eligible study participants will only be women that have negative screening mammograms before 
entering the study, i.e., no abnormalities have been identified. The participants will have extra 
mammograms taken at 3 and 6 months after study entry. In order to reduce radiation exposure, the 
mammograms consist of 2 images instead of 4, which are standard at a screening examination. The 
examinations are performed on a low-dose screening modality and the total effective radiation  dose 

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is less than 0.2 mSv. The mean value of a conventional x-ray examination is 1 mSv. The Radiation 
Protection Board of Södersjukhuset has approved the Karma CREME-1 study. 
The images will be used for density measurement but radiologist will also screen them for 
abnormalities as in clinical practice. It could be that cancers are diagnosed at these extra visits, which 
should be seen as something that benefits the study participants. 
If a suspected alteration is seen at baseline mammogram, the women will be excluded from the study 
and receive the normal diagnostic routine work-up for a suspected breast cancer, that is, additional 
ultrasound examination and a possible fine needle biopsy. 
6.5 
Possible benefits of participation in the trial 
Participants of the trial will all be Karma Cohort participants and recruited from the national 
mammography screening program at the Breast Centre at Södersjukhuset. In addition to their 
screening mammogram they will have the following examinations: 
• 
Blood pressure will be measured 
o A substantial number of women with hypertension have been found in the Karisma-2 
trial, even women with pressures that needed acute referral for medical attention. 
• 
Markers of coagulation system, liver function and SHBG will be measured 
o If any clinically significant abnormal values are found, participants will discontinue 
their participation in the trial 
• 
Additional two mammograms at months 3 and 6 
o One participant in the Karisma-2 trial had a breast cancer diagnosed at the 6 months 
follow up. According to the radiologist, the mammographic density had decreased in 
a manner that made it possible to identify the cancer. Due to the seriousness of this 
event, the randomization code was broken, revealing that the participant had been 
randomized to a daily dose of 1 mg tamoxifen. 
 
7 
SAFETY, TOLERABILITY, EFFICACY AND LABORATORY ASSESSMENTS 
 
7.1 
Safety Assessment 
• 
Monitoring and recording Adverse Events (AE) and Serious Adverse Events (SAE). Participant 
that reports of adverse events will be followed and appropriate medical action taken, (e.g., 
examination, telephonic contact, etc.) as warranted. Participants can contact Karma Study 
Centre through phone, mail, visit or using the application Karmapp. Reported Adverse Events 
defined as AE of interest, for example, severe intensity grade or signs of severe events (see 
section 10.4 AE of interest) will alert Investigator in the eCRF system for immediate action. This 
approach was successfully used in the Karisma-1 and 2 trials. 
• 
A Data and Safety Monitoring Board (DSMB) will monitor the safety of the study according to 
the guidelines described in the DSMB charter. Monitoring will also be executed by an external 
monitor according to a monitoring plan. 
• 
Blood tests for liver function and coagulation function will be obtained at baseline, 3 and 6 
months (see section below, laboratory assessment, for specific test information). 
• 
Participants will be provided a wallet sized Participant card containing essential information 
about the study and contact information to Karma Study Centre (see appendix). 
• 
Participants will be trained and encouraged to report any symptoms or changes they 
experience. 

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7.2 
Tolerability Assessments 
Tolerability will be assessed as a function of two doses of endoxifen dose or placebo. In Karma CREME- 
1, questionnaires will be used to evaluate general symptoms (Memorial Symptom Assessment Scale), 
specific symptoms of anti-hormonal treatment (FACT-ES), compliance of medicine intake (Morisky 
scale). In addition to the revised FACT-ES questionnaire, specific skin-related questions will also be 
employed to assess local tolerability. Qualitative data will be collected through interviews with some 
of the participants to get their experiences particularly regarding the IMP in order to design next study 
for optimal feasibility. 
7.3 
Efficacy Assessments 
Mammographic density will be measured at baseline and after 3 and 6 months. In the Karma CREME- 
1 study both Volpara and Stratus will be used to analyse the mammographic changes as described in 
chapter 5 Study Rationale; section 5.5 Mammographic density. 
7.4 
Laboratory Assessments 
Blood tests for safety 
Blood tests such as liver function tests (ALT, AST, ASP, Bilirubin), Sex Hormone Binding Globulin (SHBG) 
and coagulation parameters (INR, aPTT), will be analysed. The analyses will be performed within the 
routine care at Karolinska University Laboratory. These blood tests will be performed at baseline and 
at 3 and 6 months following study entry. Abnormal laboratory findings and liver and coagulation 
parameters changing after baseline will call for attention in the eCRF and alert Investigator for 
judgment and possible action. 
Endoxifen in plasma 
It is expected that the topical administration will yield substantially reduced blood levels of endoxifen 
compared to oral tamoxifen dosing (see section 5.3.2 Plasma endoxifen levels after exposure to 
tamoxifen). In the phase 1 study of topical endoxifen, low levels of endoxifen were observed in some 
participants in a dose-dependent manner. The metabolic analyses for Karma CREME-1 will be 
performed at Clinical Pharmacology, Karolinska University Hospital, Huddinge, with a validated method 
also used in the Karisma-2 trial. 
 
8 
STUDY OBJECTIVES AND ENDPOINTS 
 
8.1 
Primary objective: Breast Density Reduction 
• 
Primary objective is to determine the effect size of the breast density change between 
topical placebo and two doses of topical endoxifen. The effect size will permit sample size 
calculations for statistical significance in a future phase III trial. 
8.1.1 
Primary endpoint 
• 
Primary endpoint is to determine change, on an individual level, in mammographic breast 
density, measured at 3 and 6 months after study entry (=baseline screening- 
mammography). 
8.2 
Secondary objective: Tolerability and Safety 
• 
Secondary objective is to assess tolerability and safety of topical endoxifen 
8.2.1 
Secondary endpoints 
• 
Determine dose dependent differences in compliance, side effects and local tolerability 
measured through questionnaires 

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• 
Determine dose dependent differences in laboratory assessments such as liver function 
tests (ALAT, ASAT, ALP, Bilirubin), coagulation function (INR, aPTT), sex hormone binding 
globulin (SHBG) 
8.3 
Tertiary objective 
• 
The tertiary objective is to determine if plasma levels of endoxifen influence primary and 
secondary endpoints 
8.3.1 
Tertiary endpoint 
• 
Tertiary endpoint is to determine if plasma level concentrations of endoxifen are related 
to primary and secondary endpoints 
 
9 
STATISTICAL METHODS AND CONSIDERATIONS 
 
Karma CREME-1 is an exploratory pilot study conducted to aid the planning of a larger phase 2 trial. As 
such, the pilot study is not powered to show statistical significant reductions in breast density in the 
treatment arms compared to the control arm. Rather, the pilot study will give qualitative results, which 
will aid in making decisions about dosing, study length, and sample size for the phase II trial. 
The pilot study’s inclusion criteria will be the same as in the planned full study, but compliance is 
expected to be higher since the population is small and there will be a large number of contact points 
with each study participant. Furthermore, in the pilot study only Karma Cohort participants will be 
invited. The participants have shown that they are more willing to be recruited in the ongoing oral 
tamoxifen Karisma-2 trial than the ordinary screening attendant. Data from this pilot study will be used 
to adequately power a future, larger study. 
9.1 
Statistical methods and determination of sample size 
All analyses will be performed after the study is completed and the database is released. All statistics, 
including tables, figures and listings, will be performed using SAS®, Version 9.3, and R, Version 3.x. The 
statistical analysis are described in detail in the Statistical Analysis Plan (SAP) including a Data Display 
Plan (DDP), which will be in a final draft version prior to study start and finalized and approved before 
database lock. 
9.1.1 
Demographics and baseline data 
All data will be presented using descriptive statistics. Continuous variables will be summarized using 
number of women, mean, standard deviation (for symmetric distributions), interquartile range (for 
skewed distributions), median, minimum and maximum. Categorical variables will be summarized 
using the number and percentage of women. 
9.1.2 
Analysis of the primary endpoint (effectiveness) 
The analysis of the primary endpoint qualitatively and quantitatively summarize difference in density 
change between baseline and at 3 and 6 months follow-up between the three arms. More specifically, 
the difference in density between baseline and at 3 and 6 months follow-up, respectively, for women 
in the placebo arm (ΔDp) and in the two endoxifen arms (ΔDe1 and ΔDe2), will be computed. 
Subsequently, the difference between ΔDp and ΔDe1 as well as ΔDp and ΔDe2 (at both 3 and 6 months) 
will be assessed. 
The primary analysis will be performed on an intention to treat (ITT) basis, and a per protocol (PP) 
analysis will be performed as a secondary analysis. Women who stop using topical endoxifen will be 
encouraged to remain in the study and come in for an exit mammography. The density measured in 
these mammograms will be used in the analyses of the ITT population. Our experience from the 
Karisma-2 study is that virtually all women accept an exit mammography if choosing to withdraw from 
the  study.  However,        women  who  drop  out  of  the  study  and  do  not  come  in  for  additional 

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mammography appointments will be assumed to not have any density reduction for the ITT analysis. 
Sensitivity analyses where density for women who drop out is imputed based on age and density at 
baseline will also be performed. 
Since this is a pilot study, which is not powered for showing statistical significance when testing for 
differences in mammographic density reduction between the treatment arms and the control arm, a 
simple criterion based on the difference in the mean of the density reduction across the two treatment 
arms and the density reduction in the control arm will be used instead. The concept mt is define as the 
mean of the reduction in mammographic density across all women in the two treatment arms (n=60) 
and the mc to be the mean on the reduction in mammographic density in the control arm (n=30). The 
result of the trial as mt minus mc will be summarized. 
9.1.3 
Trial operating characteristics 
Simulations to assess the operating characteristics of the pilot study were performed. The simulations 
aimed at using the best data currently available to estimate the likely outcomes in the pilot study. 
As a basis for the simulations, a dataset of 4,288 women aged 40-74 sampled from the Karma Cohort 
was used. Each woman had Stratus measured density from two mammograms taken at two different 
points in time (approximately two years in between the two time points as this is the screening interval 
in the Swedish national screening program). Summary statistics of the density at the two time points: 
Time point 1: 25.5% (mean), 18.9% (median), IQR 8.3-35.2, 0.1 (min), 99.2 (max) 
Time point 2: 23.3% (mean), 18.7% (median), IQR 8.3-34.4, 0.1 (min), 99.8 (max) 
Women with BI-RADS categories B, C, and D will be invited to the Karma CRÈME-1 study. All women 
with a BI-RADS A density, which corresponds to women with a STRATUS density measures of 2% or 
lower (n=240), were removed from the dataset. The remaining women were used for simulations. 
The following assumptions were used for all simulations: 
• 
Age: 40-74 
• 
BI-RADS: B, C, and D 
• 
The density for women in the control arm is only affected by the natural reduction in density 
that typically comes with increased age. For simulations under the null, this applied also to the 
treatment arms 
• 
65% of the women in the treatment arm are good compliers and are assumed to get the whole 
density reduction that topical application of endoxifen can induce. 
• 
25% of the women in the treatment arm are poor compliers and are assumed to get half of the 
density reduction that topical application of endoxifen can induce. 
• 
10% of the women in each arm drop out of the study. It was assumed that the probability of 
dropout is proportional to the density reduction a given woman gets from the treatment (this 
is consistent with previous data that shows that it primarily is women who get a density 
reduction of tamoxifen who also experience side effects). 
• 
The density reduction that topical application of endoxifen induces is proportional to each 
woman’s density at baseline. 
• 
Comparison between treatment and control arm will be done using a Wilcoxon test in the full 
phase II trial using a two-sided alpha=0.05 to declare statistical significance. 
The assumption about the effect size (anticipated density reduction by using topical endoxifen) was 
then varied in different simulations according to the following: 
• 
No or very little density reduction by using topical endoxifen (null hypothesis): 

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o 0% density reduction 
o 1% density reduction 
o 2% density reduction 
• 
A clinically meaningful density reduction (alternative hypothesis): 
o Best guess. The density reduction by using topical application of endoxifen was 
assumed to the reduction seen in the pilot study of the Karisma-1 (oral tamoxifen, 10 
and 20 mg) trial, i.e. 12% of the baseline density (range 1-19%). 
o Slightly smaller effect size than our best guess. Assuming the density reduction to be 
10% 
o Slightly larger effect size than our best guess. Assuming the density reduction to be 
14% 
Given the dataset from the Karma Cohort and the assumptions listed above, the likely results from the 
pilot trial were simulated. Briefly, a trial cohort of 3x30 women by drawing women from the Karma 
Cohort and applying the density reduction in the treatment arm according to the assumptions above 
was repeatedly (Nsim=1000) simulated. Based on the results from the pilot trial, a decision on how to 
perform a larger, adequately powered study will be taken. Since the pilot study is not designed to show 
statistically significant results in terms of differences in density reductions between the three trial 
arms, a simple criterion based on the differences in mean density reductions between the placebo and 
treatment arms will be used for deciding about performing a larger trial. Whatever criterion picked, 
there will be non-zero probabilities of the pilot leading to false negative or false positive results. Tables 
4 and 5 summarize these probabilities for different choices of criteria. 
 
Table 4. The table shows the probabilities of the pilot trial showing a false negative result based on 
different criteria for declaring a positive result from the pilot study. Simulations performed under the 
alternative hypothesis of a clinically meaningful reduction in density induced by topical application of 
endoxifen. 
 
Criterion 
Density Reduction 
10% 
12% 
14% 
mt-mc > 0% 
10% 
7% 
3% 
mt-mc > 1% 
27% 
20% 
16% 
mt-mc > 2% 
52% 
43% 
33% 
mt-mc > 3% 
74% 
66% 
59% 
 
Table 5. The table shows the probabilities of the pilot trial showing a false positive result based on 
different criteria for declaring a positive result from the pilot study. Simulations performed under the 
null hypothesis of no or only a very small reduction in density induced by topical application of 
endoxifen 
 
Criterion 
Density Reduction 
10% 
12% 
14% 
mt-mc > 0% 
50% 
56% 
57% 
mt-mc > 1% 
24% 
33% 
35% 
mt-mc > 2% 
8% 
16% 
17% 
mt-mc > 3% 
2% 
5% 
5% 

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Based on these simulations of the operating characteristics of the trial, the criterion mt-mc > 0% as a 
criterion for a positive result from the pilot trial and for moving forward with a larger trial with 
adequate power for showing a statistically significant density reduction from topical endoxifen will be 
used. 
9.1.4 
Analysis of the secondary outcome 
Estimate dose dependent differences in compliance, side effects and local tolerability and laboratory 
results. 
9.1.5 
Analysis of the tertiary outcome 
Estimate if plasma level concentrations of endoxifen are related to primary and secondary endpoints. 
9.1.6 
Interim analysis 
No interim analyses will be performed. 
 
10 INVESTIGATIONAL PLAN 
 
10.1 The Karma Study Centre 
Women participating in the Karma CREME-1 study will conduct all study specific activities, except the 
mammography, at the Karma Study Centre. The Karma Study Centre is located in the facilities of 
Södersjukhuset Breast Centre (SöS Bröstcentrum) at Södra station, where mammographic 
examinations are conducted, and is daily staffed with two full time employed nurses and one full time 
employed investigator 
10.2 Selection of study population 
Eligible women will be identified from those women invited for mammography screening at SöS 
Bröstcentrum. 
The rationale to exclude women with the lowest density is based on experience from the Karma 
Group previous study of mammographic density reduction in patients on tamoxifen. In that study 
the researchers had to exclude women with the lowest density since density change was not 
possible to measure in women with very low density. The lower cut off for inclusion is set to 4.5% 
density, measured by Volpara. The 4.5% level corresponds to the clinically used BI-RADS score A. 
The rationale to exclude premenopausal women is to avoid natural fluctuations of mammographic 
density related to the changing hormone levels associated with the menstrual cycle. 
10.3 Inclusion criteria 
To participate, the women must meet the following inclusion criteria: 
• 
Attending the national mammography screening program, i.e., aged 40-74 and have 
performed a screening mammogram maximum 3 months prior to study inclusion 
• 
Mammographic density ≥4.5 % density (volumetric) measured by Volpara, at the screening 
mammogram performed in connection to baseline (maximum 3 months prior to inclusion). The 
threshold value of 4.5% corresponds to the clinically used BI-RADS score A 
• 
Postmenopausal, defined as no period of menstruation during last 12 months independent of 
any hormonal treatment 
• 
Informed consent must be signed before any study specific assessments are performed 

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10.4 Exclusion criteria 
To participate, the women must not meet any of the exclusion criteria listed below at entry of the 
study nor under time of treatment. 
Criteria related to study design 
• 
Any previous or current diagnosis of breast cancer (including carcinoma in situ). 
• 
Any previous diagnosis of cancer with the exception of non-melanoma skin cancer and in situ 
cancer of the cervix. 
• 
A history of major surgery of the breast, e.g., reduction or enlargement, which might affect 
density measurements. 
• 
Mammographic BI-RADS malignancy code 3, or above, at baseline mammography, or at 
mammography during time of treatment. Recall for additional examinations due to technical 
problems with the mammogram is accepted. 
• 
Currently using estrogen and progesterone based hormone replacement therapy (oral or 
patches). Local estrogen treatment is accepted (ex. Vagifem). 
• 
Non-medical approved drugs against hot-flashes including phytoestrogen. 
Criteria related to safety 
• 
A history of thromboembolic disease such as embolus, deep vein thrombosis, stroke, TIA or 
myocardial infarction. 
• 
Known APC (Activated Protein C)-resistance, an inherited haemostatic disorder. 
• 
Women who have an increased risk of venous thrombosis due to immobilization, e.g., using 
wheelchair. 
• 
Known uncontrolled diabetes. 
• 
Hypertension at baseline, defined as systolic pressure higher than 140 mm Hg and diastolic 
higher than 90 mm Hg 
• 
Prescribed and regular use of anticoagulants (defined as substances included in group B01A  
in the ATC-system) 
• 
Not able to understand the study information and/or informed consent. 

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Invitation to 
Karma- 
participants 
invited for 
screening 
mammography 
Invitation to 
Screening 
participants 
Pre-screening 
for eligibility 
 
10.5 Overall study design 
 
 
 
 
Informed consent 
 
 
Randomization 
Visit at Karma Study Centre: activities as per 
protocol including Mammography for density 
measurement and Blood tests for safety and 
and research 
 
 
    Questionnaires: Adverse events, QoL, 
Compliance and Concomitant medications 
 
Inclusion at Karma Study Centre 
IMP treatment period 
 
Screen Mx 
Baseline 
0 
Month post recruiting 
1 
3 
End of trial 
6 
 
 
 
 
 
 
10.5.1 Invitation 
Women invited for ordinary mammography screening to Södersjukhuset Bröstcentrum will receive an 
invitation to participate in Karma CREME-1. The invitation includes a comprehensive study information 
about Karma CREME-1 (see Study file; Studieinformation Karma CREME-1). In connection to the 
screening examination, interested women are invited to visit the Karma Study Centre (located within 
the screening facilities) to declare their interest of participation and to get further information about 
the study 
10.5.2 Pre-screening of eligibility of participation 
At Karma Study Centre: 
• 
Karma nurse checks that the potential participant has read the study information, answers any 
questions, then confirms that potential participant fully understands the information. 
• 
Screening for eligibility commences with blood pressure measurement. 
• 
Volpara density measurement are performed and automatically retrieved from the performed 
mammogram in order to see that women meet inclusion criteria for density (≥4.5 % volumetric 
density). 
• 
If it at this stage turns out that the woman doesn’t meet inclusion criteria or meet any of the 
exclusion criteria, she will be given an explanation from investigator why she can’t participate. 
A record of non-participation is done in the Study file screening-list. 
IC 
R 
Topical Endoxifen 
Total 20 mg/day 
Topical Endoxifen 
Total 10 mg/day 
Placebo 
0 mg/day 
IC 
R 

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10.5.3 Baseline (Month 0) 
Meeting with Investigator 
• 
The investigator will explain the nature and aim of the study, its procedures, possible side 
effects, requirements, restrictions and answer any questions. 
• 
The study participant and the responsible investigator signs and dates the informed consent. 
• 
A woman fulfilling the inclusion and exclusion criteria will be randomized to either placebo or 
any of two active substances. 
• 
The woman will receive a sufficient amount of IMP for daily application for at least 3 months. 
• 
Screening form, randomisation number and other study specific information will be filled in by 
investigator in the eCRF. 
Procedures at baseline 
After meeting with the investigator, the ICF is signed and randomization is performed, the following 
will be obtained: 
• 
A total of 19.2 ml blood will be collected. 9.2 ml blood will be analysed for liver function tests, 
sex hormones and coagulation markers. 10 ml will be stored as a back-up sample for baseline 
measurements 
• 
The participants will be asked to answer Karma CREME-1 baseline web-based questionnaire 
(see Study file; Questionnaires in Karma CREME-1) 
• 
Measurement of weight and length 
• 
Instructions are given on how to apply the topical endoxifen and what restrictions the 
participant shall adhere to (see Study file; Instruktioner Endoxifen kutan lösning) 
• 
Instructions are given on how to report events and how to use the Karmapp 
10.5.4 1 month after baseline (+2/-1 weeks) 
• 
Karma CREME-1 follow up questionnaire including general symptoms, tamoxifen related 
symptoms, skin-related symptoms, compliance and health care contact connected to possible 
side effects 
10.5.5 3 months after baseline (+/- 2 weeks) 
• 
Mammogram (one image per breast only for density measurement purposes) 
• 
A total of 19.2 ml blood will be collected. 9.2 ml blood will be analysed for liver function tests, 
sex hormones and coagulation markers. 10 ml will be used to measure for endoxifen markers 
• 
The women will return empty sachets and secondary boxes for drug accountability. The 
women will receive a sufficient amount of IMP for daily application for at least 3 months 
• 
Karma CREME-1 follow up questionnaire including general symptoms, tamoxifen related 
symptoms, skin-related symptoms, compliance and health care contact connected to possible 
side effects 
10.5.6 6 months after baseline (+/- 2 weeks), visit at Karma Study Centre, end of study: 
• 
Mammogram (one image per breast only for density measurement purposes) 
• 
In total 19.2 ml blood will be collected. 9.2 ml blood will be analysed for liver function tests, 
sex hormones and coagulation markers. 10 ml will be used to measure for endoxifen markers 
in blood. 

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• 
Karma CREME-1 follow up questionnaire including general symptoms, tamoxifen related 
symptoms, compliance and health care contact connected to possible side effects 
• 
Measurement of weight 
• 
The women will return empty sachets and secondary boxes for drug accountability. 
• 
The women will be informed that the study period has ended and she will receive the ordinary 
invitations to mammography within the national screening program in the future. When the 
trial is closed, information will be sent out to all participants with information about study 
results including dose and density change. 
10.5.7 In between regular visits at the Karma Study Centre 
The participants can at any time in between regular visit at the Karma Study Centre contact the Karma 
personal with questions and issues regarding adverse events, compliance and concomitant 
medications. The Karma personal will give participants fast access to health care in case of need. 
Contact channels are phone, mail, visit or the application Karmapp designed for the study. 
10.5.8 Reminders 
Women will receive SMS reminders regarding their upcoming appointment and/or web-questionnaire 
to complete. 
Women not showing up at regular visits at the Karma Study Centre or fail to submit follow-up 
questionnaires will be contacted to ensure compliance and to ensure that no adverse events have 
occurred. 
10.6 Criteria for discontinuation and handling of drop-outs 
The participant should be excluded from the study if, in the opinion of the Investigator, it is medically 
necessary, or if it is the expressed wish of the participant. Women are free to discontinue their 
participation in the study at any time. 
A withdrawn participant is not allowed to re-enter into the study. The criteria for withdrawal are the 
following: 
• 
Participant wishes to discontinue 
• 
Participant fulfil any, in the protocol defined, exclusion criteria 
• 
Unacceptable adverse event/side effect 
• 
Non-compliance with the study protocol 
• 
Participant refuses to cooperate 
• 
Other medical reasons 
Irrespective of the reason for withdrawal and whenever possible, the participant should be encouraged 
to return for a clinical visit at the time of or soon after discontinuation and complete all evaluations 
which may be necessary to assure that the participant is free from any untoward effects and to perform 
appropriate follow-up for any continuing medical event. 
There is also a scientific value to continue investigating the effects of topical endoxifen after the 
participant discontinues her treatment. Women that drop out after 1 week or more, will therefore be 
asked to perform exit examination; follow-up questionnaire, blood sampling and exit-mammogram. 
The time limit of exit exams is set to 2 weeks after the participant has stopped the medication. The 
women are asked, in all cases, to return the remaining IMP to Karma Study Centre. 
Withdrawals will not be replaced. Inclusion stops when 90 participants have been included irrespective 
of numbers of drop outs. 

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10.7 Treatments 
10.7.1 Identity of Investigational Medicinal Product (IMP) 
The IMP, Topical endoxifen and its matching placebo, are formulated from widely used for both 
cosmetics and pharmaceutical topical constituents: TranscutolTM (2-(2-Ethoxyethoxy)ethanol); 
isopropanol, CrodamolTM GTCC (a fully saturated emollient triester) and mineral oil. The active IMP 
also contains endoxifen, the strength of which is based on Z-endoxifen content. 
The formulated product is dispensed into single-dose (a dose defined as one administration per breast) 
and use “sachets”. Each sachet is pliable and consists of laminated plastic and aluminum film. This 
configuration has been used for other topical pharmaceutical dosage units. Each sachet is fully sealed, 
labelled and sufficiently filled to deliver no less than 1.0 mL. Each sachet has a “nozzle” to facilitate the 
delivery of the product directly to the skin. It can be described as similar to a ketchup or mayonnaise 
packet for individual use at a restaurant (please also see more detailed description in the Investigator 
Brochure). 
All investigational product (endoxifen and matching placebo) are manufactured according to Good 
Manufacturing Practice (GMP). 
10.7.2 Flow of IMP from manufacturing to Investigators site 
10.7.3 Packaging and labelling of IMP 
The packaged Active Pharmaceutical Ingredient (API) is tested and released for shipment to 
PharmaProPackaging (PPP), Melbourne AUS, for drug product manufacture. Upon receipt by PPP, the 
identity of the API is confirmed, and used to manufacture the IMP, both the active and the placebo, 
and packaged into individual sachets according to GMPs.  Each IMP is labelled with: 
Each sachet (primary package) is labelled with: 
• 
Atossa Genetics, USA 
• 
1 mL: 10 mg endoxifen or 5 mg endoxifen or placebo 
• 
Topical, 1 sachet/breast /day 
• 
Study: ATOS-010 
API 
•API manufactured by KriSan Biotech, Taiwan 
•Tested, released and shipped for IMP manufacture 
IMP 
•API formulated into topical endoxifen and packaged into sachets by 
PharmaProPackaging ("PPP"), Melbourne, AUS 
•Sachets labeled with subject number and packaged into labeled cartons 
•Cartons packaged for shipment to London for warehousing and distribution 
Release/ 
Distribute 
•IMP received by Renaclinical LTD, London, UK 
•IMP tested, released by QP to Sweden and shipped to Apoteket Kliniska prövningar, 
Solna 
Pharmacy 
•IMP received by Apoteket Kliniska Prövningar, inventoried and dispensed by subject 
number sequential order 

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• 
Rand.id: KCxxxx-x 
• 
Batch Nr: xxx/xxx 
Labelling is performed throughout the manufacturing process to limit the potential for mix-ups, in 
accordance with Good Manufacturing Practices (GMP). 
Secondary packaging is labelled with same information as above with the additional information: 
• 
Only for Clinical trial use 
• 
Contains 184 sachets 1ml/sachet 
• 
Storage instructions 
• 
Sponsor: Atossa Genetics Inc. (contact information) 
• 
Contact information Principal Investigator 
• 
Expiry date: mm/yyyy 
Size of labels and precise Swedish wording is to be found in Enclosure Labels in application to MPA. 
10.7.4 Storage of IMP 
When released the IMP will be stored at Apoteket Kliniska prövningar, Karolinska Sjukhuset, Solna. 
They will store the IMP in the containers in which they are received from the Sponsor’s supplier at 
room temperature. Extreme temperatures (hot, cold) should be avoided and the drug kept away from 
children. 
10.7.5 Doses and treatment regimens 
Participants will be randomized into one of three groups: 
• 
Topical endoxifen, total 20 mg/day (10 mg/breast/day) 
• 
Topical endoxifen, total 10 mg/day (5 mg/breast/day) 
• 
Placebo 0 mg 
Each participant will apply the contents of two sachets to each breast (one sachet/breast) each day for 
6 months. 
10.7.6 Investigational Medicinal Product accountability 
The IMP will be dispensed to the study participant at baseline. A sufficient amount will be provided for 
at least 3 months. The number of sachets given out will be recorded in both CRF and in the Product 
Accountability log in the Study file. Participants are requested to bring back the empty sachets at the 
planned visits by 3 and 6 months or, by discontinuation, at time of exit examination. Any unused 
sachets will be saved for drug accountability and sent for destruction or to the manufacturer for 
analyses if directed by the sponsor. 
10.7.7 Method of assigning participants to treatment groups 
• 
A sequential list of participant identifiers (Rand.id) will be generated by the Investigator, and 
provided to the sponsor. 
• 
Renaclinical LTD London will populate the sequential list of Rand.id and link dose of IMP (0 mg, 
5 mg/sachet or 10 mg/sachet) to Rand.id in a randomized manner. A Randomization list is 
subsequently created. 
• 
Renaclinical will provide the Randomization list directly to the pharmacy (Apoteket AB, 
Sjukhusapoteket Linköping) in a secured fashion, to be opened in case of a safety emergency. 

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• 
Renaclinical will also provide the Randomization list directly to PPP for blinded labelling and 
packaging. 
• 
The IMP will be imported and received by Renaclinical. Once released by the QP, it will be sent 
to Apoteket Kliniska prövningar, Solna. 
• 
IMP will be delivered to study site (Karma Study Centre) already randomized, packed and 
marked in a sequential order. The IMP will be provided to each participant in numerical order. 
• 
The Investigator link the Rand.id to participant in the eCRF and Drug accountability log 
Researchers do not have access to the Randomization list. In case of an emergency, the entire list will 
not be released, rather the treatment assigned for a specifically identified participant. 
10.7.8 Blinding 
The study is a double-blind, placebo controlled randomized study and neither the investigators, 
sponsor nor the participants will know who is on active treatment or placebo. 
The randomization code (emergency envelope) is held by Apoteket AB, Sjukhusapoteket Linköping. 
The treatment code can only be broken if an investigator considers there is a valid medical or safety 
reason to break the blinding (see section 14.2 Emergency un-blinding, for further instructions). The 
Investigator must have a reason to break the blinding, for example when the studied drug is likely to 
have a significant effect on the clinical management of the study participant. When the code is broken 
for an individual participant, a notification must be made in the eCRF, and to the Principle Investigator 
and the Sponsor. 
The study is also blinded for those responsible for mammographic density measurements. 
10.7.9 Prior and concomitant therapy 
All concomitant therapy must be recorded in the eCRF. No other drug under investigation may be used 
concomitantly with the study medication. 
Although endoxifen is one of the first pass metabolites of tamoxifen, conditions that require 
medications metabolized by the P450 pathway should be carefully monitored during this study. 
10.7.10 Prohibited medications 
• 
Estrogen and progesterone based hormone replacement therapy (other than local), are 
not allowed during the study or used at study enrolment. Rationale for prohibition is 
potential interference with outcome measurements. 
• 
Prescribed and regular use of anticoagulants (defined as substances included in group 
B01A in the ATC-system) are not allowed during the study or at time of study enrolment. 
Prescription of anticoagulants indicates that person is at risk of thrombosis. The literature 
and tamoxifen product information also describe concomitant use of tamoxifen and 
warfarin as a contraindication, since this combination may result in an increase in the 
anticoagulation and the risk of bleeding complications. Since the exact mechanism 
triggering this effect is not clear, the Sponsor declares the same precautions regarding 
endoxifen. 
• 
Non-medical approved drugs against hot-flushes including phytoestrogen are not allowed 
during the study or used at study enrolment. Rationale for prohibition is potential 
interference with outcome measurements. 
10.7.11 Treatment compliance 
Compliance will be assessed throughout the study by: i) calculating the number of sachets remaining 
at the visits to the Karma Study Centre and comparing with the expected usage; and ii) by web- 

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questionnaires targeting adherence to therapy. The participant is defined as “compliant” if more than 
80% of the sachets are used. 
A maximum of 14 days of coherent treatment interruption is allowed. Longer time period than that 
must be seen as discontinuation of treatment. 
 
11 ADVERSE EVENTS 
 
11.1 Definitions 
11.1.1 Adverse Event (AE) 
Any untoward medical occurrence in a participant, who has received IMP, will be registered. The 
occurrence does not necessary have to have a causal relationship with the IMP. An AE can therefore 
be any significant change, unfavourable and/or unintended sign (e.g., an abnormal laboratory finding), 
symptom, or disease temporally associated with the use of an IMP, whether or not considered related 
to the IMP. 
11.1.2 Serious Adverse Event 
An SAE is any untoward medical occurrence or event, at any dose, that: 
• 
Results in death 
• 
Is life threatening 
• 
Requires hospitalization or prolongation of existing hospitalization 
• 
Results in persistent or significant disability/incapacity 
or 
• 
Other important medical event (example of such events are convulsions that do not result in 
hospitalization) 
Medical and scientific judgment should be exercised in deciding whether expedited reporting is 
appropriate in other situations, such as important medical events that may not be immediately life- 
threatening or result in death or hospitalization but may jeopardises the participant’s health or may 
require intervention to prevent one of the other outcomes listed in the definitions above. These AEs 
should also usually be considered as serious. 
It is important to distinguish between serious and severe adverse events. Severity is a measure of 
intensity whereas seriousness is defined by the criteria in the previous sections. An adverse event of 
severe intensity need not necessarily be considered serious. For example, nausea, which persists for 
several hours, may be considered severe nausea but not a serious adverse event. On the other hand, 
a stroke resulting only in limited degree in disability may be considered a mild stroke but would be 
considered a serious adverse event. 
11.1.3 Suspected Unexpected Serious Adverse Reaction (SUSAR) 
A SUSAR is a suspected unexpected serious adverse reaction, potentially causally related to the 
investigational medicinal product, and will be reported to the appropriate IEC and Regulatory 
Authorities. 
11.2 Registration and Assessment of AEs 
Adverse Events will be collected through the web-based questionnaire each study participant must 
complete at a regular basis (month 1, 3 and 6) after study entry during the study period. Additionally, 
the participants are encouraged to report AEs anytime (24 hours/day and 7 days/week) to the Karma 

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Study Centre by contacting through phone, mail, visit or using the application Karmapp. All AEs, serious 
and non-serious, will be recorded in the eCRFs. 
11.3 Eliciting and recording of AEs 
Adverse Events will be collected through the web-based questionnaire each study participant must 
complete at a regular basis (month 1, 3 and 6) after study entry during the study period. Additionally, 
the participants are encouraged to report AEs anytime (24 hours/day and 7 days/week) to the Karma 
Study Centre by contacting through phone, mail, visit or using the application Karmapp. All AEs, serious 
and non-serious, will be recorded in the eCRFs. 
11.4 AEs of Interest 
11.4.1 Definition of AE of interest 
AEs reported after study entry via questionnaire (not Baseline questionnaire), telephone, mail, visit or 
via the Karmapp, with high level of intensity ("quite a bit " or "very much") are considered as AE of 
Interest. These AEs are flagged for in the CRM system (eCRF) as a point of action for investigators to 
assess causality to IMP and eventual action for follow-up. 
As an AE of interest is also included: 
• 
All AEs registered in eCRF as free text 
• 
Vaginal bleeding; Intensity grade 3 of 5 (“somewhat”) 
• 
Laboratory measurements (liver function tests and / or coagulation ) outside reference limits 
or major changes since last measurement 
• 
Contact taken with health care 
A total of 52 pre-defined AEs is listed in the eCRF, free text excluded (Se Study file: Sources to 
Questionnaires in Karma CREME-1) 
 
11.4.1.1 Assessment of AE of interest 
In addition to pre-defined AEs, the ability to include free text to capture events outside of the pre- 
defined symptoms. These answers are continuously monitored by Karma staff in order to take 
immediate action if there are any signs of adverse events of interest or possible serious adverse event. 
Potential serious adverse events are signs of thromboembolism or vaginal bleedings. 
An alarm system in the eCRF will alert personnel at the Karma Study Centre when an AE of interest is 
recorded to permit a rapid evaluation and to ensure appropriate follow up is performed throughout 
the study period. 
All AEs of interest will be coded according to Medical Dictionary for Regulatory Activities - MedDRA. 
The Investigator will perform the coding. 
The following evaluations are to be done by the Investigator about the AE of interest: 
• 
Description of the AE. Describe each symptom and if possible include the diagnosis for 
description of the event. 
• 
Intensity (if the intensity changes during the period of the AE the maximum intensity should 
be recorded) 
- Mild - symptoms which are easily tolerated (acceptable) 
- Moderate - symptoms which interfere with usual activity (disturbing) 
- Severe - symptoms which give incapacity to do usual activity (unacceptable) 
• 
Duration of the AE (start - end) 

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• 
Seriousness 
- Yes or No, see definition of a SAE for seriousness, as of above. 
• 
Action taken due to the AE 
- None 
- IMP stopped 
- Additional details on action taken, including diagnostic procedures, will be recorded for any 
women with vaginal bleeding or discharge. Any women who report abnormal vaginal 
bleeding or discharge or pelvic pain or pressure, will be promptly investigated. This also 
applies to participants with suspected signs of thromboembolism. It is not mandatory that 
the study code is broken in such cases, but this may be done if requested by the treating 
physician, necessary for further treatment. 
• 
Causality rating with investigational medicinal product 
- Not related:  Indicates that the AE is definitely not related to the study drug. 
- Unlikely: The adverse onset and the medicinal product administration is such that the 
medicinal product is not likely to have any reasonable association to the AE. 
- Possible: The participant ´s clinical status or the medicinal product could have produced the 
AE. 
- Probable: The AE follows a reasonable temporal sequence from the time of administration 
of the medicinal product, abates upon discontinuation of the medicinal product and cannot 
be reasonably explained by the known characteristics of the participant ´s clinical status. 
- Not assessable: There is not sufficient information to assess causality between the 
medicinal product and the suspected reaction. 
• 
Outcome of the AE – follow until an outcome can be defined 
- Recovered/Resolved 
- Recovered/Resolved with sequelae 
- Recovering/Resolving 
- Not recovered/Not resolved 
- Fatal 
- Unknown 
 
 
11.5 Reporting of SAEs and SUSARs to Sponsor and Authorities 
 
11.5.1 Reporting of SAEs 
All SAEs must be reported by the Investigator using phone, text, email or FAX within 24 hours from the 
Investigator's knowledge of the event to the Sponsor regardless of the time that may have elapsed 
from the time the event occurred to when the Investigator first learns of it. The initial report should 
contain as a minimum the following information: 
• 
Participant identification 
• 
Treatment specification 
• 
Diagnosis or symptoms 

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• 
Name of the original reporter 
• 
Date and time 
An SAE report form must also be completed, signed by the Investigator and submitted to the Sponsor 
within 24 hours after the initial information was received. Additional information can be provided in 
follow-up reports, but it is critical to ensure the initial report is made as soon as possible. Apart from 
the information above, this follow-up report should also contain the following information: 
• 
Assessment of intensity 
• 
Assessment of causality 
 
11.5.2 Reporting of SUSARs 
SAEs that are both unexpected and assessed as related to IMP(s), i.e., SUSARs, should be reported by 
the Sponsor to the appropriate IEC and Regulatory Authorities. In Karma CREME-1, the Karolinska Trial 
Alliance (KTA) has the authorization from Sponsor to report SUSAR to the Investigator, Sponsor, 
regulatory health authorities, the IEC and DSMB 
The Sponsor (or authorised agent) must report all SUSARs that were life threatening or resulted in 
death, to the authority and to the IEC within 24 hours, and if necessary complete the follow up report 
within the following 8 days. Other SUSARs should be reported within 15 days. 
11.6 Duration of observation of AE/SAE 
AE/SAE will be recorded from the moment the participant gives her informed consent to participation 
in the study, until the participant undergoes the final examination planned in the study and results 
from examination are evaluated. AEs reported up to 2 weeks after last day of treatment will be 
assessed according to protocol. AE/SAE that are persisting at the end of the study will be followed up 
and evaluated. 
11.7 Follow-up of unresolved AE 
If a participant is withdrawn due to an AE, or if an AE persists at the end of the study treatment period, 
this should be followed up until the condition has ceased, becomes stable or chronic, or until the 
participant is under professional medical care and a potential causality between IMP and the AE has 
been penetrated. An outcome assessment should be performed when an AE persists. 
 
12 DATA QUALITY ASSURANCE 
 
12.1 Electronic Case Report Forms (eCRFs) 
The site personnel will enter the information required for the study in the eCRF. Data will also be 
imported from web questionnaire, medical records, laboratory findings and measurements of 
mammographic density. 
12.2 Monitoring 
The Karma CREME-1 study will be monitored according to ICH-GCP guidelines, Regulatory 
requirements and the study specific Monitoring plan. The Karma CREME-1 study will be monitored by 
an independent Monitor according to ICH GCP Guidelines. Study conductance, personnel training, 
source data and adherence to the study protocol will be monitored. Findings will be provided to the 
investigator such that corrective measures can be taken. Investigator will grant monitor, or certain 
regulatory personal, access to source data/medical records. 

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12.3 Data Monitoring and Safety Board (DSMB) 
A chartered DSMB will be utilized to provide safety oversight of all study participants. Evaluations and 
assessments of adverse reactions, any safety trends or concerns, etc., will be reviewed as defined in 
the DSMB Charter 
12.4 Source data 
Source data will be handled according to regulatory requirements. A source data location list will be 
kept at the investigational site for definition of source data. 
Mammograms will be retained as interpreted via the software as well as a raw electronic file. 
12.5 Audit and inspections 
The study site may be requested to participate in a quality audit by the Sponsor or someone appointed 
for this task by the Sponsor. A Regulatory Authority may request to inspect the study site. The 
procedures of such a visit would be similar to those of a monitoring visit, and data already checked by 
the Monitor may be checked again. The Investigator is required to inform Karma CREME-1 study staff 
immediately of a request to inspect by a Regulatory Authority. The investigator and other relevant 
personnel must be available during the audit/inspection and must devote sufficient time. 
12.6 Changes in the approved Study Protocol 
Study procedures must not be changed without the agreement of the Investigator and Sponsor and 
indicated as such by an approved amendment to the protocol. 
Any substantial change (e.g., procedure changes increased blood sample volumes or frequencies; 
number of participants, study drug, etc.) to the approved Final Study Protocol will be documented in a 
written, signed, and revision numbered Protocol Amendment. Any proposed substantial change to the 
Final Study Protocol must be discussed with and approved by Sponsor and Investigator before 
submitted to IEC and Regulatory Authority for approval, according to applicable national regulations. 
12.7 Data Management 
A quality control (QC) of data will be performed to ensure that data entry and verification have been 
performed correctly in accordance to pre-defined instructions. The QC will be performed as described 
in the Data Management Plan (DMP). Audit trails will be used to ensure data changes are attributable. 
The QC will be performed  and documented before data is declared clean. 
 
13 STUDY MANAGEMENT 
 
13.1 Study time table - End of study 
The study will be open for inclusion from April 2018 and inclusion will continue for three months (with 
a stop of inclusion during summer vacations), or until 90 participants are enrolled. All attempts will be 
made to fully enrol the study prior to the beginning of summer vacation. If this is not achieved, then 
the last participant would enter into the study by the end of September 2018 and be followed for 6 
months, that is, March 2019. 
End of study is defined as when last participant fulfil study-period (6 months) + 2 weeks window of 
self-reporting of AEs. 
13.2 Insurance/indemnity 
All participants are insured against injuries received in connection with the trial by the Patient Injury 
Act insurance (Patientförsäkringslagen). Atossa Genetics shall maintain commercial liability insurance 
covering injuries to participants that are caused by study drug (equivalent to that of the Swedish 
Pharmaceutical  Insurance  Scheme  “LFF”).   Such  insurance shall  be  underwritten  by  a  nationally- 

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recognized insurance carrier with coverage of at least US $1 million per occurrence and US $2 million 
aggregate. The insurance shall cover Atossa Genetics’ liability under law and generally accepted liability 
standards within the pharmaceutical industry towards any third parties, including participating 
women, as Sponsor of the study. 
Atossa Genetics agrees to indemnify (legal and financial coverage) and hold the Investigator free of 
harm from any claim, whether based on legal principles or on generally accepted liability standards 
within the pharmaceutical industry, made against him by reason of personal injury, including death, to 
any person arising out of or connected with the performance of the study to the extent that the injury 
is not caused by: 
1) Failure by the Investigator to adhere to the terms of the Protocol; 
2) Failure by the Investigator to comply with any applicable governmental regulations; or 
3) Malpractice, negligence or wilful malfeasance by the Investigator. 
The Principal Investigator agrees to notify Atossa Genetics whenever he becomes aware of a claim or 
action, and to co-operate with and to authorize Atossa Genetics to carry out sole management of such 
claim or action. Atossa Genetics will provide the Principal Investigator with application forms in case 
of insurance claims. 
13.3 Study agreements 
The Principal Investigator at the investigational site must comply with all the terms, conditions, and 
obligations of the Clinical Study Agreement (CTA) for this study. 
13.4 Criteria for termination of the study 
The Karma CREME-1 study personnel reserve the right to discontinue the study at any time, but intends 
only to exercise this right for valid scientific or administrative reasons. 
After such a decision, the Principal Investigator must contact all participating women within 2 weeks 
and inform the women as well as perform relevant assessments, preferably according to the scheme 
for the final assessments. All delivered and unused study products and other study materials must be 
returned and all eCRFs completed as far as possible. 
The sponsor (or the authorised agent) will also notify the IEC and the competent authority (Medical 
Products Agency) of any decision of premature termination of the study, within 2 weeks after such a 
decision. 
13.5 Reporting of results and publication policy 
Agreements on publications and dissemination is described in the site clinical trial agreement (CTA). 
13.6 Record retention 
The Investigator must arrange for retention at the investigational site of a list of the women and their 
identifying code, participant files and other study documents. The archiving period must be adapted 
to regulations in force but should not be shorter than ten years after the termination of the study and 
the presentation of the final report. 
It is the responsibility of the Karma CREME-1 study personnel to inform the Investigator/institution as 
to when these documents no longer need to be retained 
13.7 Disclosure and confidentiality 
Agreements on Back- and Foreground Intellectual Property is described in the CTA. 

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14 EMERGENCY PROCEDURES 
 
14.1 Emergency contacts 
In case of a medical emergency, contact Karma CREME-1 study personnel: 
• 
Per Hall, Responsible Medical Officer, Coordinating and Principal Investigator 
Mobile +46733960590, email: per.hall@ki.se 
• 
Mattias Hammarström, Clinical Trial Manager 
Mobile +46737121476, email: Mattias.Hammarstrom@ki.se 
14.2 Emergency un-blinding for safety reason 
The randomization code (emergency envelope) is held by Apoteket AB Linköping, wich provide a 24/7 
service for emergency un-blinding. In case of an emergency where, in the opinion of the Principal 
Investigator, discontinuation of the study treatment is not sufficient and the study treatment must be 
un-blinded in order to evaluate further course of action, the Investigator should contact Apoteket AB, 
Linköping (phone numbers and routines are to be found in the Study Site File) to initiate participant 
un-blinding. In the event the blind is broken, notify the Sponsor as soon as possible. The date, time, 
and reason for un-blinding must be documented in the appropriate section of the eCRF, and in the 
source document. 
14.3 Procedures in case of medical emergency 
The Investigator is responsible for ensuring that there are procedures and expertise available to cope 
with medical emergencies during the study. The study is performed at Södersjukhuset and any acute 
medical illness should be dealt with at the hospital. 
14.4 Procedure in case of overdose 
Overdosing topical endoxifen may increase the pharmacological side effects of the drug. Any study 
participant with a suspected or confirmed overdose of topical endoxifen should contact the Karma 
Study Centre. The Karma personal will in turn contact the Swedish Poison Information Centre. 

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15 REFERENCES 
 
Ackerman AB, Kessler G, Gyorfi T, Tsou HC, Gottlieb GJ. Contrary view: the breast is not an organ per 
se, but a distinctive region of skin and subcutaneous tissue. Am J Dermatopathol. 2007 Apr; 29(2):211- 
8. 
Boyd NF, Guo H, Martin LJ, Sun L, Stone J, Fishell E, Jong RA, Hislop G, Chiarelli A, Minkin S, Yaffe MJ. 
Mammographic density and the risk and detection of breast cancer. N Engl J Med. 2007 Jan 
18;356(3):227-36. 
Brand JS, Czene K, Eriksson L, Trinh T, Bhoo-Pathy N, Hall P, Celebioglu F. Influence of lifestyle factors 
on mammographic density in postmenopausal women. PLoS One. 2013 Dec 9;8(12):e81876. doi: 
10.1371/journal.pone.0081876. eCollection 2013. 
Bua J. Reduction of breast density with 4-hydroxy tamoxifen. US 2004/ 0138314 A12004. Herndon, VA: 
Ascend Therapeutics; 2004. 
Cuzick J, Warwick J, Pinney E, Duffy SW, Cawthorn S, Howell A, Forbes JF, Warren RM. Tamoxifen- 
induced reduction in mammographic density and breast cancer risk reduction: a nested case-control 
study. J Natl Cancer Inst. 2011 May 4;103(9):744-52. doi: 10.1093/jnci/djr079. Epub 2011 Apr 11. 
Eriksson M, Li J, Leifland K, Czene K, Hall P. A comprehensive tool for measuring mammographic density 
changes over time. Breast Cancer Res Treat. 2018 Feb 1. doi: 10.1007/s10549-018-4690-5. [Epub ahead 
of print] 
Fotoohi AK, Karim H, Lafolie P, Pohanka A, Östervall J, Hatschek T, Vitols S. Pronounced Interindividual 
But Not Intraindividual Variation in Tamoxifen and Metabolite Levels in Plasma During Adjuvant 
Treatment of Women With Early Breast Cancer. Ther Drug Monit. 2016 Apr;38(2):239-45 
Gabrielsson M, Eriksson M, Hammarström M, Borgquist S, Leifland K, Czene K, Hall P.Cohort Profile: 
The Karolinska Mammography Project for Risk Prediction of Breast Cancer (KARMA). Int J Epidemiol. 
2017 Dec 1;46(6):1740-1741g. doi: 10.1093/ije/dyw357 
Hwang     GS, Bhat     R, Crutchley     RD, Trivedi      MV.      Impact      of      CYP2D6      polymorphisms 
on endoxifen concentrations and breast cancer outcomes. Pharmacogenomics J. 2017 Aug 1. doi: 
10.1038/tpj.2017.36. [Epub ahead of print] 
Katzenellenbogen BS, Norman MJ, Eckert RL, Peltz SW, Mangel WF. Bioactivities, estrogen receptor 
interactions, and plasminogen activator-inducing activities of tamoxifen and hydroxytamoxifen 
isomers in MCF-7 human breast cancer cells. Cancer Res. 1984;44:112–9 
Lee O, Ivancic D, Allu S, Shidfar A, Kenney K, Helenowski I, Sullivan ME, Muzzio M, Scholtens D, 
Chatterton RT Jr, Bethke KP, Hansen NM, Khan SA. Local transdermal therapy to the breast for breast 
cancer prevention and DCIS therapy: preclinical and clinical evaluation. Cancer Chemother 
Pharmacol. 2015 Dec;76(6):1235-46. doi: 10.1007/s00280-015-2848-y. Epub 2015 Nov 11. 
Le Nestour E. Treatment and prevention of benign breast disease with 4- hydroxy tamoxifen. 
Montrouge, France: Laboratoires Besins International; 2009 
Li J, Humphreys K, Eriksson L, Edgren G, Czene K, Hall P. J Clin Oncol. 2013 Jun 20;31(18):2249-56. 
Lim YC, Desta Z, Flockhart DA, Skaar TC. Endoxifen (4-hydroxy-N-desmethyl-tamoxifen) has anti- 
estrogenic effects in breast cancer cells with potency similar to 4-hydroxy-tamoxifen. Cancer 
Chemother Pharmacol. 2005;55:471–478 
Nyante SJ, Sherman ME, Pfeiffer RM, Berrington de Gonzalez A, Brinton LA, Aiello Bowles EJ, Hoover 
RN, Glass A, Gierach GL. Prognostic significance of mammographic density change after initiation of 
tamoxifen for ER-positive breast cancer. J Natl Cancer Inst. 2015 Feb 6;107(3) 

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Pan H, Gray R, Braybrooke J, Davies C, Taylor C, McGale P, Peto R, Pritchard KI, Bergh J, Dowsett M, 
Hayes DF; EBCTCG. 20-Year Risks of Breast-Cancer Recurrence after Stopping Endocrine Therapy at 5 
Years. N Engl J Med. 2017 Nov 9;377(19):1836-1846. doi: 10.1056/NEJMoa1701830. 
Rouanet P, Linares-Cruz G, Dravet F, Poujol S, Gourgou S, Simony-Lafontaine J, Grenier J, Kramar A, 
Girault J, Le Nestour E, Maudelonde T J. Neoadjuvant percutaneous N-methyl-endoxifen (Afimoxifene) 
decreases breast tumoral cell proliferation: a prospective controlled randomized study comparing 
three doses of N-methyl-endoxifen (Afimoxifene) gel to oral tamoxifen. Clin Oncol. 2005 May 1; 
23(13):2980-7. 
Suami H, Pan WR, Mann GB, Taylor GI. The lymphatic anatomy of the breast and its implications for 
sentinel lymph node biopsy: a human cadaver study. Ann Surg Oncol 2008;15(3):863–71] 
Visvanathan K, Hurley P, Bantug E, Brown P, Col NF, Cuzick J, Davidson NE, Decensi A, Fabian C, Ford 
L, Garber J, Katapodi M, Kramer B, Morrow M, Parker B, Runowicz C, Vogel VG 3rd, Wade JL, Lippman 
SM. Use of pharmacologic interventions for breast cancer risk reduction: American Society of Clinical 
Oncology clinical practice guideline. J Clin Oncol. 2013 Aug 10;31(23):2942-62. doi: 
10.1200/JCO.2013.49.3122. Epub 2013 Jul 8. Review. Erratum in: J Clin Oncol. 2013 Dec 
1;31(34):4383. 
Woo HI, Lee SK, Kim J, Kim SW, Yu J, Bae SY, Lee JE, Nam SJ, Lee SY. Variations in plasma concentrations 
of tamoxifen metabolites and the effects of genetic polymorphisms on tamoxifen metabolism in 
Korean patients with breast cancer. Oncotarget. 2017 Nov 1;8(59):100296-100311. doi: 10.18632/ 
oncotarget.22220. eCollection 2017 Nov 21. 

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16 SIGNATURE PAGES 
 
Principal Investigator 
Study title: 
Karma CREME-1: A double-blind, placebo-controlled, three-armed, pilot study 
of the effects, safety and tolerability of topical endoxifen in healthy women 
 
 
By signing this page I acknowledge that I have read and understood the study protocol “Karma 
CREME-1: A double-blind, placebo-controlled, three-armed, pilot study of the effects, safety and 
tolerability of topical endoxifen in healthy women”. 
 
I also agree by signing this page that I will conduct the study in accordance with the procedures 
specified in the protocol and in line with applicable regulations, i.e. LVFS 2011:19, ICH GCP and the 
latest version of the declaration of Helsinki. 
 
Coordinating Investigator and Principal Investigator, Södersjukhuset 
 
 
 
 
  Per Hall 
 
20180416 
 
Name 
Signature 
Date 

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Sponsor 
 
Study title: 
Karma CREME-1: A double-blind, placebo-controlled, three-armed, pilot study 
of the effects, safety and tolerability of topical endoxifen in healthy women 
 
 
By signing this page I acknowledge that I have read and understood the study protocol “Karma 
CREME-1: A double-blind, placebo-controlled, three-armed, pilot study of the effects, safety and 
tolerability of topical endoxifen in healthy women”. 
 
I also agree by signing this page that the Sponsor will conduct the study in accordance with the 
procedures specified in the protocol, and in line with applicable regulations, i.e. LVFS 2011:19, ICH GCP 
and the latest version of the declaration of Helsinki. 
 
Representative of Sponsor; Atossa Genetics Inc. 
 
 
  Janet R. Rea 
 
  
 
 
   16 April 2018 
 
Name 
Signature 
Date 

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17 LIST OF APPENDECIES 
 
A. Schedule of events 
 
B. Participant card 

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17.1 Appendix A: Schedule of Events in Karma CREME-1 
 
 
Key Tasks 
Months 
0 
1 
3 
6 
ET/W* 
SCREEN 
IMP Administration Period 
(BASELINE) 
Informed Consent 
x 
Physical Exam 
x 
x 
x 
x 
Height 
x 
Weight 
x 
x 
x 
x 
Blood Pressure 
x 
Mammography 
a 
x 
x 
x 
MD Eligibility 
x 
MD Efficacy 
x 
x 
x 
Blood sampling 
x 
x 
x 
x 
Safety** 
x 
x 
x 
x 
Back up sample 
x 
Endoxifen 
metabolites 
x 
x 
x 
Randomise to dose 
group 
x 
Administration of 
IMP 
x 
x 
Questionnaires 
x 
x 
x 
x 
x 
Adverse Event 
Assessment*** 
x 
x 
x 
x 
*ET/W: Early Termination or withdrawal 
a –from routine screening 
 
 
** Blood Sampling Safety: 
• 
Liver function test( ALAT, ASAT, ALP, Bilirubin) 
• 
Coagulation function (INR, aPTT) 
• 
Sex Hormone Binding Globulin (SHBG) 
 
*** Adverse Event Assessment 
• 
Continuously from day 1 of IMP medication 

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17.2 Appendix B: Participation Card 
 
 
 
 
 
Deltagarkort för klinisk forskningsstudie 
Protokoll Karma CREME-1 
Innehavaren av detta kort deltar i en klinisk forskningsstudie där 
Endoxifen-gel för utvärtes bruk utvärderas för förebyggande av 
bröstcancer. Studien innehåller en placeboarm och 2 aktiva armar 
(5mg/bröst/dag och 10mg/bröst/dag). Om information om 
studieläkemedlet är nödvändig för fortsatt vård av patienten ber vi er 
kontakta prövaren (meddelande kan lämnas dygnet runt), 
Tel 08- 524 823 39 
Studieläkemedel: Endoxifen kutan lösning 
Protokoll Karma CREME-1 
Studiedeltagarens namn: 
  
 
Studiedeltagarens födelsedatum:   _  
  
Prövarens namn: 
Prövare kontaktinformation: 
 
 
 
Karma Studiecenter SöS Bröstcentrum 
, Stockholm Sweden. 
Tel: +46-8-524 823 39 
karmastudien@ki.se 
Version 1.0, 20180212