Adipocytokines and Their Relationship to Obesity and Endometrial Cancer
Conditions: Endometrial Cancer, Obesity
Sponsor: University of Surrey

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
STUDY PROTOCOL 
 
FULL/LONG TITLE OF THE STUDY  
Adipocytokines and their relationship to obesity and endometrial cancer 
 
SHORT STUDY TITLE / ACRONYM 
Adipocytokines in endometrial cancer 
 
 
PROTOCOL VERSION NUMBER AND DATE  
Version: 1.1 
Dated: 27/04/2022 
 
 
RESEARCH REFERENCE NUMBERS  
 
IRAS Number 
285863 
NHS REC reference Number  
21/WA/0012 
Sponsor’s Number 
SPON/2020/012/FHMS 
Funder’s Number 
Irene Ray MD 
Clinicaltrials.org 
NCT04697264 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
 
LIST OF CONTENTS 
 
GENERAL INFORMATION 
Page No. 
Title page 
1 
Research reference numbers 
1 
List of contents  
2 
Key study Contacts  
3 
Study summary  
4 
Funding  
4 
Role of sponsor and funder  
4 
Roles and responsibilities of study steering group  
5 
Study flow chart  
6 
Study Protocol  
7 
1. Background  
7 
2. Rationale 
8 
3. Theoretical framework  
8 
4. Research question / Aim(s)  
9 
5. Study design/ methods  
9 
6. Study setting  
11 
7. Sample and recruitment  
11 
8. Ethical and regulatory compliance  
12 
9. Dissemination policy  
15 
10. References  
16 
11. Appendices  
16 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
 
KEY STUDY CONTACTS 
Principal investigator  
Irene Ray  
Post-graduate research student 
Leggett Building, University of Surrey, 
Daphne Jackson Road, Guildford 
GU2 7WG 
i.ray@surrey.ac.uk ; 07490749704  
Academic Supervisor  
Dr. Lisiane Meira 
Lecturer in DNA Damage and Ageing 
Leggett Building, University of Surrey,  
Daphne Jackson Road, Guildford 
GU2 7WG 
l.meira@surrey.ac.uk  
Academic Co-supervisor  
Dr. Agnieszka Michael 
Senior lecturer at University of Surrey 
Consultant, Medical Oncology at Royal 
Surrey NHS Foundation Trust 
Leggett Building, University of Surrey, 
Daphne Jackson Road, Guildford  
GU2 7WG 
a.michael@surrey.ac.uk 
Clinical supervisor  
Miss Patricia Ellis 
Consultant, Department of Gynaecological 
Oncology  
Royal Surrey NHS Foundation Trust  
Egerton Road, Guildford  
GU2 7XX  
patricia.ellis1@nhs.net ; 01483 571122 
Sponsor  
RIGO – University of Surrey 
rigo@surrey.ac.uk 
Funder  
GRACE charity (reg. no. 1189729) 
Department of Gynaecological Oncology  
Royal Surrey NHS Foundation Trust  
Egerton Road, Guildford  
GU2 7XX 
info@grace-charity.org.uk 
Key contributor  
Mr Simon Butler-Manuel  
Consultant, Department of Gynaecological 
Oncology  
Royal Surrey NHS Foundation Trust  
Egerton Road, Guildford  
GU2 7XX  

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
simon.bm@nhs.net ; 01483 571122  
STUDY SUMMARY  
 
STUDY TITLE  
Adipocytokines and their relationship with 
obesity and endometrial cancer  
SHORT TITLE  
Adipocytokines in endometrial cancer  
STUDY DESIGN  
exploratory biomarker study  
STUDY PARTICIPANTS  
Study population - patients presenting to 
Royal Surrey NHS Foundation Trust with 
endometrial cancer, identified at the MDT   
Control population - female patients 
without endometrial cancer, referred for 
benign condition.  
PLANNED SIZE OF SAMPLE  
100-120 
FOLLOW UP DURATION 
N/A 
PLANNED STUDY PERIOD  
36-48 months  
RESEARCH QUESTION /AIM(S) 
To investigate the relationship between 
adipocytokine level in blood and tissue 
(endometrial cancer tissue, adipose tissue 
and lymph node) in patients with 
endometrial cancer and co-relate with BMI 
to identify peripheral biomarkers that can 
be used as prognostic or diagnostic tools 
 
 
 
 
FUNDING AND SUPPORT IN KIND  
 
 
Funders (names and contact details of all 
organisations providing funding and /or 
support in kind for this study  
GRACE (reg. no. 1189729) 
Financial and non-financial support given  
Financial support  
 
 
 
 
ROLE OF STUDY SPONSOR AND FUNDER 
 
 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
The study sponsor is the University of Surrey. The sponsor, along with the Royal Surrey NHS 
Foundation Trust assumes overall responsibility for the initiation and the management of 
the study the funder provides financial support for the study. 
PROTOCOL CONTRIBUTORS  
 
• Irene Ray. Postgraduate research student, University of Surrey, and the Principal 
investigator (PI) of the study. Has been involved in protocol design and will conduct 
the research, data collection and analysis, interpretation of results, manuscript 
writing and dissemination of results. 
 
• Patricia Ellis. Consultant Gynaecological Oncologist at Royal Surrey NHS Foundation 
Trust. Has been involved in protocol design and is also the clinical supervisor for the 
postgraduate research student and co-chief investigator of the study.  
 
• Lisiane Meira. Lecturer in DNA Damage and Ageing, University of Surrey, Guildford. 
Has been involved in protocol design and is also the academic supervisor for the 
postgraduate research student and chief investigator of the study. 
 
• Agnieszka Michael. Consultant Medical Oncologist at Royal Surrey NHS Foundation 
Trust and senior clinical lecturer at University of Surrey. Has been involved in 
protocol design and is also the academic co-supervisor for the post graduate 
research student. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
STUDY FLOWCHART 
 
Figure 1: Pathway for endometrial cancer patients undergoing surgery for endometrial cancer  
 
Figure 2: Pathway for patients undergoing chemotherapy for endometrial cancer  
Patients identified as undergoing 
surgery for endometrial cancer 
at MDT at Royal Surrey NHS 
Foundation Trust
Patients approached at clinic 
appointment /over telephone 
after their clinic visit if PI not able 
to attend clinic to discuss study, 
patient information leaflet given 
Written consent for participation 
in study
Short medical history taking 
(10mins )
Blood test on the day of the 
surgery 
Tissue sample obtained at 
surgery/ after processing in 
histo-pathology
Blood test on day 1 post-surgery
Blood test during 3/6 months 
post-surgery routine follow up 
appointment
Samples stored /analysed in 
oncology lab, Leggett building, 
University of Surrey
Data analysed and results 
reported
Samples stored in Leggett 
building for future research with 
proper consent 
Patients proceeding with 
Chemotherapy identified at MDT 
at Royal Surrey NHS Foundation 
Trust
Patient approached in clinic / 
over telephone after their clinic 
visit if PI not able to attend clinic 
to discuss participation in study, 
patient information leaflet given
Written consent for participation 
in stud 
Short medical history taking 
(10mins )
Baseline blood test before 
starting chemotherapy 
Tissue sample obtained from 
pathology (if pipelle sample 
available and the patient 
consents to the use of that 
tissue) 
Blood test after third cycle of 
chemotherapy (before the fourth 
cycle) 
Blood test after sixth cycle of 
chemotherapy 
Samples stored and analysed in 
oncology lab, Leggett building, 
University of Surrey
Data analysed and results 
reported
Samples stored in Leggett 
building for future research with 
proper consent 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
STUDY PROTOCOL 
 
Adipocytokines and their relationship with obesity and endometrial cancer  
 
KEY WORDS: Endometrial cancer, adiponectin, leptin, TNF α, IL 6, IGF 1, IGF 2, obesity 
 
1.  BACKGROUND 
 
Endometrial cancer is the most common malignancy of the female genital tract. It is the 
fourth most common cancer in the UK with around 9,500 new cases in 2017, current 
lifetime risk being 1 in 36 women1. The number of women diagnosed with endometrial 
cancer continues to rise each year. Since the early 1990s, uterine cancer incidence rates 
have increased by almost three-fifths (55%) in the UK (2015-2017)1. The association 
between endometrial cancer and obesity is well documented. 7.5% of all cancers in women 
in UK are attributable to being overweight / obese (BMI ≥25 kg/m2). For endometrial 
cancer, this risk rises to 34%2. A review of meta-analyses showed endometrial cancer risk is 
16% higher per 5 kg- gained during adulthood, 29% higher per 10cm increase in hip 
circumference and 27% higher per 10cm increase in waist circumference3. This higher 
endometrial cancer risk with raised BMI is present in both pre- and post-menopausal 
women. Moreover, patients who are obese tend to have a poorer outcome with more co-
morbidities than their non-obese counterparts.  
  
In the overweight and obese state, the function of the adipose tissue deteriorates resulting 
in a state of chronic inflammation4. In this inflammatory state, adipocytes and macrophages 
secrete several molecules, adipokines and inflammatory cytokines, which may promote 
tumour development and angiogenesis and stimulate adhesions and migration of cells5.  
Most implicated adipocytokines in the tumorigenesis pathway are adiponectin, leptin, 
tumour necrosis factor-α (TNF‐α), Interleukin-6 (IL‐6) and Insulin-like growth factor 1 and 2 
(IGF 1 and 2).  
 
Adipocytokine related signalling pathways are important in the development of an 
inflammatory microenvironment for tumours. This process is thought to increase the risk of 
endometrial cancer by inducing cell proliferation and preventing cell apoptosis. Adiponectin, 
the most abundant adipokine, has been suggested to have anti-angiogenic, anti-
inflammatory, and anti-apoptotic properties. Raised leptin levels in obese state promotes 
inflammation by stimulating the production of IL-6, TNFα as well as IL-1 and IL-126. Leptin 
and adiponectin secretion is counter-regulated in vivo. A study by Luhn et. al.4 has shown 
adiponectin to have inverse relationship with the risk of endometrial cancer and leptin to 
have a direct co-relation.  
 
Also, in an inflammatory environment, macrophages secrete potent proinflammatory 
cytokines such as TNF‐α and IL‐6, which are known to activate numerous transcription 
factors that regulate the expression of genes involved in immune responses, anti‐apoptosis, 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
angiogenesis, and metastasis7. The mechanisms of tumorigenesis are thought to be involved 
are free-radical production that cause DNA damage and impaired DNA repair.  
 
Research have further suggested that systemic levels of insulin-like growth factor (IGF) is 
dysregulated in obesity either due to increased IGF production or by down-regulation of IGF 
binding protein (IGFBP) prodution8.  IGF 1 is a growth and proliferation promotor and has 
inhibitory effects on cell death and is a major contributor in many neoplastic 
transformation9. 
 
The above biomarkers are physiologically interrelated and are likely to reflect a more 
restricted number of underlying biological pathways10. Possibly, they work in a synergistic 
capacity to modulate the risk of developing endometrial cancer. If specific patterns of 
cytokine expression were found to be predictive of adverse outcome, then the specific 
receptors may be targeted as a therapeutic option for endometrial cancer11. No study so far 
has looked at all these markers together in the serum and tissue samples of the same 
endometrial cancer patients to give a more wholesome idea about their effect on tumour 
genesis, progression and outcome. Therefore, this study is designed to assess the prognostic 
significance of these six biomarkers in the blood and tissue of endometrial cancer patients 
and co-relating the levels with their BMI and tumour type, after adjusting for age, parity, 
smoking status, menopausal status, use of Hormone Replacement Therapy (HRT)/ hormonal 
contraception, and prevalence of diabetes and hypertension. 
 
 
2. RATIONALE 
 
Development of novel biomarkers for a variety of uses including diagnosis, treatment 
monitoring and prognostication is on the Cancer Reform Strategy agenda and actively 
encouraged by the National Cancer Research Institute and Medical Research Council.  
 
Understanding how adipocytokines influence endometrial cancer risk may help to elucidate 
biological mechanisms important for the observed obesity-endometrial cancer association. 
 
 
3. THEORITICAL FRAMEWORK 
 
As the incidence of endometrial cancer continues to rise there is a health need for a better 
diagnostic and prognostic approach. 
 
Studying the different biomarker levels in blood and cancer tissue will enable us to look for 
new targets that may be useful in the treatment and prognostication of this cancer. 
 
Also, if the levels of these markers change significantly post-treatment, we can investigate if 
it will be possible to use these markers to assess response to treatment as follow-up for risk 
of recurrence forms an important part of the treatment protocol. 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
 
 
 
4. RESEARCH QUESTIONS / AIM(S) 
 
4.1. Objectives  
 
To assess the relationship between the endometrial cancer and blood and tissue biomarkers 
in patients referred for endometrial cancer management to Royal Surrey NHS Foundation 
Trust.  
 
 
4.2. Primary Outcomes 
 
1. To assess the circulating levels of adiponectin, leptin, tumour necrosis factor alpha 
(TNFα), interleukin 6 (IL-6), Insulin like growth factors 1 and 2 (IGF 1 and 2) in blood 
and at tissue level (endometrial tissue, adipose tissue, lymph node) from women 
with endometrial cancer (study population) and in the blood +/- endometrial tissue 
(control population) and to compare the results between the two groups.   
2. Additional tests on the samples collected - looking at the cancer tissue 
microenvironment for infiltrating inflammatory cells +/- their secretions or other 
adipocytokines. We may also look at the tumour microbiome to look for any 
commensal bacteria or micro-organism and if available, to compare with tissue 
micro-environment and microbiome of normal endometrial tissue from control 
population. 
3. To determine whether there is a correlation between these markers and obesity 
(classified by WHO category of BMI) after adjusting for confounding factors like age, 
parity, menopause, use of HRT/ hormonal contraception, smoking, diabetes and 
hypertension. 
 
 
4.3. Secondary Outcomes 
 
1. To determine if the markers have any prognostic significance by the 
expression profile with tumour grade, stage and histology.  
2. To determine if the markers could be used as tools to assess effects of treatment. 
 
 
5. STUDY DESIGN and METHODS of DATA COLLECTION AND DATA ANALYSIS 
 
5.1. Study design 
 
All patients being referred to the Royal Surrey NHS Foundation Trust with diagnosed uterine 
cancer will be given the research information leaflet and invited to participate as the study 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
population of the research. Female patients being referred to Royal Surrey NHS foundation 
Trust for benign conditions (specifically not endometrial cancer) will be invited to participate 
as the control population.  
Initially, an invitation letter will be sent alongside the patients’ clinic appointment letter to 
inform them of the study and give them time for preliminary consideration of the study. 
Patients will then be approached in the outpatients’ clinics after the initial consultation by 
the clinician.  Alternatively, patients may be approached over phone and information about 
the study given at that time. The call will be scheduled after the clinic appointment visit so 
that the patient will have received the Invitation Letter that is sent out with the initial 
Appointment Letter, allowing patients sufficient time to consider the study. Patients will be 
given a participant information leaflet detailing the study rationale, methodology and 
analysis in clinic or alternatively the leaflet will be sent by post/ email (in case of telephone 
consultations). Patients who agree to participate in the study will be asked to sign a consent 
form after explanation at a later appointment.  
 
 
Demographic data will be collected at the same time to correlate various risk factors 
associated with the development of uterine cancer. The data collected will include age, 
parity, smoking status, menopausal status, medications used, use of Hormone Replacement 
Therapy (HRT)/ hormonal contraception, and prevalence of diabetes and hypertension. This 
data will be collected by:  
• Taking a medical history from the patient in clinic  
• Patients’ medical notes  
This data will be directly entered into an existing departmental database for Gynaecological 
oncology which is password protected and stored on NHS computers.  
 
Study participants will then have 30mls (2 ½ tablespoons) of venous blood taken on the day 
of the surgery and control participants will also have 30mls of venous blood collection 
alongside their clinic appointment.  
 
Tissue samples from patients undergoing surgery will be collected as follows: For the study 
population, the PI will collect any fresh tissue (adipose tissue) directly from theatre before 
fixing as it is not needed for establishing diagnosis and the uterine cancer tissue and lymph 
node will be collected by the PI after histo-pathological examination from the histo-
pathology department after the diagnosis is established. For the control population, if they 
are having uterine surgery, then the PI will collect some endometrial tissue after histo-
pathological examination from the histo-pathology department after the diagnosis is 
established. All tissue processing will adhere to Human Tissue Authority (HTA) guidelines 
and will be performed at the Oncology laboratory at Leggett building at University of Surrey.  
 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
For study population only - the patients will have repeat blood tests (30mls of venous blood 
taken each time) on day 1 post-surgery and at their 3 or 6 months routine post-surgery 
follow up appointment. Control population will not have any repeat blood tests.  
  
For the study population, women who are recommended chemotherapy, we will also ask 
consent to collect demographic data and baseline blood sample (30mls venous blood) at the 
time of consultation and after 3rd and 6th chemotherapy cycles to assess any changes in the 
markers that may correlate with progression or regression of disease.  
 
We will also obtain archival serum samples and tissue blocks (of uterine cancer patients 
consented from a previous study for use during an appropriate ethics committee approved 
research) to help increase the number of recruitments for this study. Their demographic 
data with identification log will be made available to the PI only to assess for correlation 
between their data and the tissue diagnosis during analysis. 
 
Timing of events including telephone contact events:  
 
1. Send study Invitation Letter with Appointment Letter. 
2. Clinic visit where patient is recruited/ phone call follow-up after clinic visit if the PI is 
not able to attend the clinic.  
3. Enrolment of participant in study after consent.  
4. Collection of blood and tissue sample as described above.  
 
5.2. Study flow-chart for patients undergoing surgery  
 
Procedures 
Pre-study 
 
Treatment period 
Screening 
Day of Sx 
Day 1 Post 
Sx* 
3/6 months 
post-Sx 
FU* 
Visit Number 
1 
2 
3 
4 
Written informed consent 
X 
 
 
 
Demographic data 
X 
 
 
 
Medical history 
X 
 
 
 
Assessment of inclusion/ exclusion 
criteria 
X 
 
 
 
Protocol restriction and continued 
eligibility check 
X 
X 
X 
X 
Concomitant medication 
X 
X 
X 
X 
Taking blood sample 
 
X 
X 
X 
Procuring tissue sample 
 
X 
 
 
Recording AEs 
 
Continuous 
*post surgery bloods relevant for study population only 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
 
 
 
 
5.3. Study flow-chart for patients undergoing chemotherapy (CT) 
 
Procedures 
Pre-study 
 
Treatment period 
Screening 
Before 
starting CT 
After 3rd 
CT cycle 
After 4th 
CT cycle 
Visit Number 
1 
2 
3 
4 
Written informed consent 
X 
 
 
 
Demographic data 
X 
 
 
 
Medical history 
X 
 
 
 
Assessment of inclusion/ exclusion 
criteria 
X 
 
 
 
Protocol restriction and continued 
eligibility check 
X 
X 
X 
X 
Concomitant medication 
X 
X 
X 
X 
Taking blood sample 
 
X 
X 
X 
Recording AEs 
 
Continuous 
 
 
 
5.4. Sample analysis 
 
ELISA will be used to assay bio-marker levels in blood samples. 
 
For tissue analysis we will set up a tissue microarray (TMA).  This will allow more uniform 
staining of the sample for immunohistochemistry with no inter-specimen variation of the 
staining method. Each case will be reviewed, and the area of interest (tumour) marked on 
the slide. Cores from the areas of interest will be used to create the microarray block. 
Sections can then be cut from the microarray block and slides prepared for immune-
staining. The advantage of using this method is that the samples are subjected to the same 
conditions while being stained and the same part of a tumour can be reliably stained for 
several markers. Tissue sections from the TMA will be used for immune-staining and the 
expression of the markers of interest will be scored.  
Some tests have become available at the University of Surrey laboratory that can be done 
from the samples that are already being collected to maximise our information on 
endometrial cancer from the samples already available. These tests will be carried out at the 
University of Surrey laboratory and will not involve any resource implication on Royal Surrey 
NHS Foundation Trust.  

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
The additional tests may include - looking at the cancer tissue microenvironment for 
infiltrating inflammatory cells and / or their secretions or any other adipocytokines. We may 
also look at the tumour microbiome to look for any commensal bacteria or micro-organism 
that may have a role in cancer onset, progression and drug response by secretion of small 
molecules and metabolites. Clinical data which is available on the cases will then be 
correlated with the histological and immunohistochemical results and statistical analysis will 
be carried out. 
 
5.5. Data analysis 
 
Standard statistical analytical tools will be used to analyse the data. Relation between 
different variables will be sought with odds ratio, confidence interval and significance with P 
value (<0.05 significant). The Mann–Whitney U test will be used to assess differential 
expression of immune markers between tissue types –blood and tumour tissue. Correlation 
with clinical characteristics will be determined using univariate log-rank and multivariable 
Cox proportional hazards adjusting for age, stage, grade and histology. Results will be 
compared between the study and the control populations.  
 
6. STUDY SETTING 
 
Study patients will be recruited when attending a clinic in the department of Gynaecological 
Oncology at Royal Surrey NHS Foundation Trust. Private consultation rooms are available 
here for discussing the study, history taking and consenting. 
 
Blood sample will be collected on the day of the surgery when they are in the theatres and 
then repeated on day 1 post-operative in gynaecology ward and at 3 or 6 months post-
surgery follow-up in clinic. 
 
Tissue samples will be obtained from the following areas: 
1. Adipose tissue from the main theatres at Royal Surrey NHS Foundation Trust  
2. Uterine cancer tissue and lymph node from the histopathology department after 
they have finished analysis. 
 
For those women recruited undergoing chemotherapy, blood sample will be procured at 
initial consultation and after 3rd (with the blood test before the fourth cycle of 
chemotherapy) and 6th cycles of chemotherapy. This can be performed in the Department 
of Gynaecological Oncology at Royal Surrey NHS Foundation Trust.  
All samples (blood and tissue) will then be transferred to the Leggett Building at University 
of Surrey for processing and storage following HTA regulations. The samples will be double 
boxed for transfer. The outside box will be an icebox. The PI will personally transport the 
tissues by foot from the hospital to the Leggett building as they are very near geographically 
and it is a short 4 minutes’ walk. 
 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
Control patients will be recruited when they attend a clinic appointment at Royal Surrey 
NHS Foundation Trust for any benign condition. Blood sample will be collected during their 
clinic appointment after written consent. If they are having any uterine surgery, endometrial 
tissue will be collected after histopathological diagnosis from the histo-pathology 
department.     
 
Samples will also be stored anonymised (in case of patients who give consent) in Leggett 
building, University of Surrey following all regulations by HTA) for use in ethics approved 
future research project. 
 
Historical samples / tissue blocks stored in the oncology department in the Leggett building, 
University of Surrey, from a previous study will also be used if appropriate consent is in 
place. 
 
 
7. SAMPLE AND RECRUITMENT 
 
Potential participants will be identified in the Royal Surrey NHS Foundation Trust – either 
seen here or referred here and receiving her treatment here.  
 
7.1. Inclusion criteria 
 
1. Study population- Women diagnosed with endometrial cancer  
2. Control population – Women being seen in clinic for benign conditions 
3. Age 18 or above  
4. Of sound mind so they can give informed consent 
5. Historical tissue sample/ blocks from previous cases in the oncology department in 
the Leggett building also be used if appropriate consent is in place. 
 
7.2. Exclusion criteria 
 
1. Under 18yrs age 
2. Unable to give consent /denies consent 
 
7.3. Sample size 
 
We will aim to recruit 30-60 patients with diagnosed endometrial cancer in the study. This 
sample size will also include archived tissue sample (formerly consented and stored in 
Leggett building for use in future ethical research). We will aim to recruit as many patients 
in the control population as in the study population, aiming for a total (study + control 
population) of 100-120 patients.  
 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
 
7.4. Recruitment  
 
All patients seen or referred with endometrial cancer at the Royal Surrey oncology 
Department will be invited to participate in the study as a part of study population. We will 
aim to get as many control population from the women referred to Royal Surrey NHS 
Foundation Trust with benign conditions.  
   
Patients will not receive any payments for participation in the study. We aim to obtain all 
information and samples at the time of routine visits.  
 
7.4.1. Sample identification  
 
Patients diagnosed with endometrial cancer will be identified through the Gynaecological 
Oncology Multi-Disciplinary Team meeting or by the Gynaecological Oncology or Medical 
Oncology teams. Control population will be identified through the above route or from 
referral letters to Royal Surrey NHS Foundation Trust.  
 
 
7.4.2. Consent  
 
Written consent will be obtained after the patient has received the participant information 
leaflet and had the opportunity to discuss and ask questions about the study. Enough time 
will be given for the purpose. Patients must all have capacity to consent. Consent will be 
undertaken by clinicians on the Gynaecological Oncology team. If necessary, a translator or 
language line can be used. 
 
Consent will also be taken for use of samples (anonymised and stored in Leggett building, 
university of Surrey following all regulations by HTA) for use in future research. However, 
the patient can still take part in this study even if she does not consent to her data/ samples 
to be used in a future study. 
  
 
7.4.3 Withdrawal of consent  
 
Participants are free to withdraw at any time and without giving a reason.  A decision to 
withdraw or not take part will not affect the standard of care they will receive. Anonymised 
data or tissue already collected with consent would be retained and used in the study. 
Anonymised data or tissue already collected with consent would be retained and used in the 
study. This is because once anonymised, samples and data cannot be linked back to a 
participant and therefore we are unable to withdraw a participant’s anonymised data or 
samples. No further data or tissue would be collected, or any other research procedures 
carried out on or in relation to the participant if they withdraw their participation. 
 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
 
 
 
 
 
8. ETHICAL AND REGULATORY CONSIDERATIONS 
 
There is no direct benefit for the patients recruited into this study. They will be part of a 
research study which, in the future, may find ways of improving diagnosis of and survival 
from endometrial cancer. 
 
Patients will not be disadvantaged in any way by participating in this research study – they 
will still receive standard clinical care for their condition.  
 
Informed written consent will be taken from everyone who wishes to participate in the 
study. Written information leaflets will be given to the patients to read before they decide 
whether they wish to participate or not. Consent will be taken by doctors on the 
Gynaecological oncology team who have a clear and good understanding to this research 
and can take a valid informed consent.  
 
All computers used to collect and save data will be stored in a securely locked room on NHS 
computer in NHS or University premises. Access to the computer will be password 
protected. Specific secure passwords will be needed to log onto these computers and this 
information will only be available to the researchers who are also part of the healthcare 
team. All computers will be encrypted to prevent access by any external source to the 
confidential information stored.  
 
All personal information will be anonymised so that researchers except the PI will be blinded 
to this information. Information used for inference of prognostic outcomes will be based on 
generic data collected rather than individual information. At all times, the NHS Code of 
Confidentiality will be followed. Only the PI will have access to the 'key' to the patient 
identifiers. PI will be responsible for this. 
 
All samples (blood and tissue) will then be transferred by the PI to the Leggett Building at 
University of Surrey for processing and storage following HTA regulations. The samples will 
be double boxed for transfer. The outside box will be an ice-box. The PI will personally 
transport the tissues by foot from the hospital to the Leggett building as they are very near 
geographically and it is a short 4 minutes walk. 
 
Samples will be also be stored anonymised (in case of patients who give consent) in Leggett 
building, University of Surrey following all regulations by HTA) for use in future ethics 
approved research project. The patient will still be able to take part in this current study 
even if she does not consent to her data/ samples to be used in a future study. 
 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
 
8.1. Assessment and management of risk 
 
Taking venous blood samples may involve a small amount of discomfort but is often a 
routine part of clinical assessment. 
Tissue samples taken at the time of surgery will add no side-effect, discomfort or distress in 
addition to those of the clinically indicated surgery. 
 
If any concerns are raised during consenting, with regards to the patients’ wellbeing or 
safeguarding, the clinical team will be notified immediately, and appropriate steps will be 
taken to rectify the concerns.  
 
8.2. Research Ethics Committee (REC) and other regulatory review and reports  
 
Before the start of the study, a favourable opinion will be sought from the NHS REC for the 
study protocol, informed consent forms and other relevant documents.  
 
Substantial amendments that require review by NHS REC will not be implemented until that 
review is in place and other mechanisms are in place to implement at site.  
 
All correspondence with the REC will be retained by the PI. It is responsibility of the PI to 
produce the annual reports as required. The PI will notify the REC of the end of the study. 
An annual progress report (APR) will be submitted to the REC within 30 days of the 
anniversary date on which the favourable opinion was given, and annually until the study is 
declared ended. If the study is ended prematurely, the PI will notify the REC, including the 
reasons for the premature termination. Within one year after the end of the study, the PI 
will submit a final report with the results, including any publications/abstracts, to the REC. 
 
8.3. Amendments 
 
Should the protocol undergo any amendments, we will seek advice from the sponsor and 
submit them to the REC/HRA where applicable. Amendments will not be implemented until 
all relevant opinions and approvals have been received. Amendments to the protocol will be 
tracked in the amendments section in appendix. 
 
8.4. Supervisor/ Peer review  
 
The study protocol and other proformas have been reviewed by the clinical supervisor - 
Miss Ellis, consultant gynae-oncologist at the Royal Surrey NHS Foundation Trust and 
academic supervisors - Dr. Meira and Dr. Michael of the University of Surrey, who are all 
senior published authors. The study protocol has also been reviewed by the study sponsor 
(RIGO). The study has also been peer reviewed for enrolment into a public database – 
clinicaltrials.gov (ID No. NCT04697264). 
 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
8.5. Patient and public involvement 
 
This research protocol was discussed with patients from Royal Surrey NHS Foundation Trust 
who also reviewed the patient information sheets and any suggestions/changes were 
incorporated.  
 
8.6. Protocol compliance, adverse events reporting and breaches  
 
The PI will be responsible for the conduct of the research. The research will be monitored by 
the supervisors involved. The sponsor can, at any time, audit the conduct of the study. The 
local R&D office regulations for maintaining research governance will apply.  
Accidental protocol deviations can happen at any time. They must be adequately 
documented on the relevant forms and reported to the PI and sponsor immediately.  
Deviations from the protocol which are found to frequently recur are not acceptable, will 
require immediate action and could potentially be classified as a serious breach. 
 
8.7. Data protection and patient confidentiality 
 
All investigators and study site staff must comply with the requirements of the Data 
Protection Act 2018 with regards to the collection, storage, processing and disclosure of 
personal information and will uphold the Act’s core principles.  
Anonymised data will be stored on encrypted and password protected NHS and University 
computers.  
 
All computers used to collect and save data will be stored in a securely locked room on NHS 
or University premises. Specific secure passwords will be needed to log onto these 
computers and this information will only be available to the researchers (they are also part 
of the healthcare team). 
 
Any emails containing identifiable patient information will be sent to/from encrypted 
servers such as NHS mail.  
 
All personal information will be anonymised so that the researchers will be blinded to this 
information. Information used for inference of prognostic outcomes will be based on 
generic data collected rather than individual information.  
 
Only the principal investigator will have access to the ‘key’ to the patient identifiers.  
Data from the interview will be directly entered into an existing departmental database for 
Gynaecological oncology which is password protected and stored on NHS computers. A file 
containing a copy of patient demographic data proformas that are completed at the initial 
interview will be stored in a locked office within the Leggett building, University of Surrey to 
be made available for source data verification, if required. The principal investigator will be 
the data custodian. All data will be stored for 10 years. 
 

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
8.8. Indemnity and insurance 
 
The University of Surrey (sponsor) has in force all relevant insurance for the design, conduct 
and the management of the study. The sponsor has arrangements in place for payment of 
compensation in the event of harm to the research participants where no legal liability 
arises. 
 
8.9. Access to final study dataset 
 
The final dataset will be accessible by the research team.  
Study investigators and the sponsor may seek access to the data after approval.  
 
 
9. DISSEMINATION POLICY 
 
9.1. Dissemination policy 
 
The study results will be published in international journals and presented at relevant 
conferences.  
It will also be published as the MD thesis for the PI.  
GRACE charity (funder) will be acknowledged in all publications as the funder of the 
research. 
 
 
9.2. Authorship eligibility guidelines any intended use of professional writers  
 
The PI will be the lead author on the final study report and any publications. The supervisors 
are senior authors and will take responsibility for the published data. Other protocol 
contributors will be listed as co-authors. 
 
 
10. REFERENCES 
 
1. Cancer Research UK Uterine Cancer Statistics 
http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-
by-cancer-type/uterine-cancer/incidence#heading-One. Accessed Oct 2020 
2. Brown KF, Rumgay H, Dunlop C, et al. The fraction of cancer attributable to known 
risk factors in England, Wales, Scotland, Northern Ireland, and the UK overall in 
2015. British Journal of Cancer. 118, 1130-1141 (2018). 
3. Kyrgiou M, Kalliala I, Markozannes G, et al. Adiposity and cancer at major anatomical 
sites: umbrella review of the literature. BMJ 2017;356:j477. 
4. Luhn P, Dallal CM, Weiss JM, et al. Circulating adipokine levels and endometrial 
cancer risk in the prostate, lung, colorectal, and ovarian cancer screening 
trial. Cancer Epidemiol Biomarkers Prev. 2013;22(7):1304–1312.  

                                                                                                
 
 
 
Protocol version 1.1 27/04/2022                                                                         Adipocytokines in endometrial cancer  
5. Nieman KM, Kenny HA, Penicka CV, Ladanyi A, Buell-Gutbrod R, Zillhardt MR, 
Romero IL, Carey MS, Mills GB, Hotamisligil GS, Yamada SD, Peter ME, Gwin K, 
Lengyel E. Adipocytes promote ovarian cancer metastasis and provide energy for 
rapid tumor growth. Nat Med. 2011 Oct 30;17(11):1498-503. 
6. Carbone F, La Rocca C, Matarese G. Immunological functions of leptin and 
adiponectin. Biochimie. 2012 Oct;94(10):2082-2088. 
7. Shacter E, Weitzman SA. Chronic inflammation and cancer. Oncology (Williston 
Park). 2002 Feb;16(2):217-26, 229; discussion 230-2. 
8. Carlson, M. J., Thiel, K. W., Yang, S., & Leslie, K. K. Catch it before it kills: 
progesterone, obesity, and the prevention of endometrial cancer. Discovery 
medicine, 2012 September; 14(76), 215–222. 
9. Gunter MJ, Hoover DR, Yu H, et al. A prospective evaluation of insulin and insulin-like 
growth factor-I as risk factors for endometrial cancer. Cancer Epidemiol Biomarkers 
Prev. 2008;17(4):921–929.  
10. Dossus, L., Lukanova, A., Rinaldi, S., Allen, N., Cust, A. E., Becker, S., Tjonneland, A., 
Hansen, L., Overvad, K., Chabbert-Buffet, N., Mesrine, S., Clavel-Chapelon, F., 
Teucher, B., Chang-Claude, J., Boeing, H., Drogan, D., Trichopoulou, A., Benetou, V., 
Bamia, C., Palli, D.,Kaaks, R. (2013). Hormonal, metabolic, and inflammatory profiles 
and endometrial cancer risk within the EPIC cohort--a factor analysis. Am J 
Epidemiol. 2013; 177(8): 787–799. 
11. Wang T, Rohan TE, Gunter MJ, et al. A prospective study of inflammation markers 
and endometrial cancer risk in postmenopausal hormone nonusers. Cancer 
Epidemiol Biomarkers Prev. 2011;20(5):971–977.  
 
 
12. PROTOCOL HISTORY 
Amendment 
No. 
Protocol 
version no. 
Date issued 
Author(s) of 
changes 
Details of changes made 
1 
0.9 
28/06/2021 
Irene Ray 
(PI) 
Provision for telephone consultation 
added 
2. 
1.0 
16/09/2021 
Irene Ray 
(PI) 
1. Control population added. 
2. Provision for performing other 
relevant tests from the samples 
collected. 
3. 
1.1 
27/04/2022 
Irene Ray 
(PI) 
1. Increase in number of control 
population recruitment. 
2. Extension of study duration to 36-
48 months.