Clinical trial NCT04011410
Conditions: Prostate Cancer Recurrent
Keywords: Prostate Cancer Oligometastatic Prostate Cancer Limited Metastatic Disease Metastatic Prostate Cancer
Sponsor: Patrick Hensley
Start date: 2019-12-03; Completion date: 2024-03-08
Enrollment: 20 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
Treatment of recurrent oligometastatic prostate cancer may be enhanced by the addition of Hydroxychloroquine to the current treatment regimens. Potential benefits of Hydroxychloroquine include delayed disease progression and delayed initiation of androgen deprivation therapy (ADT), thus lessening morbidity, distressing side effects, and improving functioning and quality of life in men with recurrent prostate cancer.

Building on prior research at Markey, patients recently diagnosed with recurrent oligometastatic prostate cancer will be approached about participating in this study. Per standard of care, these patients undergo either surgery or radiation, in addition participants of this clinical trial will also receive Hydroxychloroquine (400 mg per day, oral medication) for 3 months.

It is expected that a participant will exhibit a 50% increase of tumor suppressor PAR-4, as well as few, if any, negative side effects from Hydroxychloroquine.

Detailed description:
This investigator-initiated clinical trial (IIT) builds on and extends research on autophagy in prostate cancer with PAR-4 and HCQ conducted by a transdisciplinary investigative team, and is sponsored by funding from Markey Cancer Center.

Prostate cancer is the most common cancer in men and the 2nd most common cause of cancer death in men. Secondary to the greying of the U.S. population and increasing life expectancy, metastatic prostate cancer (mPCa) rates are increasing. Androgen deprivation therapy (ADT) has been the primary treatment for metastatic prostate cancer. The survival benefit of ADT is juxtaposed against significant adverse effects including cardiovascular morbidity, skeletal fractures, diabetes, sexual dysfunction, and a decrease in cognitive function. Recent studies have indicated a potential benefit to treatment of metastatic lesions in men with limited metastatic disease and have identified a potential delay in initiation of ADT in men whose limited metastatic lesions were treated with stereotactic radiotherapy. Prostate apoptosis response-4 (PAR-4) is a tumor suppressor protein that facilitates apoptosis in numerous types of cancer cells. Hydroxychloroquine (HCQ) has been found to induce PAR-4 expression and subsequently promote apoptosis of cancer cells and inhibit metastatic progression. HCQ has also been reported to both inhibit and enhance immune responses via changes in Th1, Th2, Th17 and Treg subsets and reduce inflammatory markers. It also acidifies lysosomes which potentially inhibits antigen presentation by antigen-presenting cells, and can be measured with LysoSensor Yellow/Blue DND-160 by flow cytometry and induces autophagy which can be detected by measuring up-regulation of the microtubule associated protein LC3B. Treatment of oligometastatic prostate cancer may be enhanced by the addition of Hydroxychloroquine to either surgical resection or radiation treatment of metastatic lesions. Potential benefits of Hydroxychloroquine include delayed disease progression and delayed initiation of ADT, lessening morbidity and increasing quality of life in men with oligometastatic prostate cancer.

A single-arm, open-label phase II trial will be conducted in a population of men with recurrent oligometastatic prostate cancer following primary treatment of localized disease. The oligometastatic sites will be treated with either surgical resection or stereotactic radiation per standard of care, in addition to 400 mg of Hydroxychloroquine per day for a period of 3 months.

Sample Size:

Based on an ongoing Phase I trial of HCQ, the proportion of patients who will exhibit a 50% induction in PAR-4 from baseline levels is equal to 0.50, compared to a null hypothesis of 0.20. A sample of 18 patients will provide 84% power to detect this hypothesized difference in proportion based on a two-sided test with 5% significance level. Prior studies at Markey Cancer Center in this population have demonstrated an attrition rate of less than a 10%. Thus, a total of 20 patients will be enrolled into the study.

Specific and Secondary Aims:

The primary objective is to assess the rate of attainment of a 50% increase in tumor suppressor PAR-4 levels from baseline in patients treated with 3-months of hydroxychloroquine (HCQ), in combination with radiation or surgery for recurrent, oligometastatic prostate cancer.

Secondary aims of the trial include assessment of: median progression-free survival; 1- and 3-year ADT-free survival; treatment toxicity and quality of life.

Correlative studies of the trial comprise assessment of immunological effect of Hydroxychloroquine by analyzing peripheral blood mononuclear cells (PBMC's).

Statistical Analytic Plan:

Descriptive statistics will be calculated to summarize PAR-4 levels at each time point of follow-up. Percent change from baseline compared to each follow-up time point will likewise be calculated. The proportion of patients who exhibit a 50% induction in PAR-4 compared to baseline within the 3-month therapy period will be calculated and a one-sample test for proportion will be performed. Secondary analyses of the primary endpoint will also be performed. Continuous changes in PAR-4 levels will also be assessed using paired t-test or nonparametric analog. Linear mixed models will be employed to analyzed repeatedly measured levels of PAR-4 and association with clinical parameters as well as PSA levels.

* Other secondary analyses will include summary of the PAR-4 induction profile over the 3-month treatment period and after end of therapy period. PSA levels will be assessed and PSA doubling time will be calculated. Association of PSA levels with PAR-4 levels will be determined using Spearman or Pearson's correlation coefficient. Quality of life as measured by the EORTC QLQ-C30 supplemented with QLQ-PR25 will be evaluated and descriptive statistics of QOL scores will be calculated. Association of QOL with PAR-4, PSA and other clinical endpoints will be determined in an exploratory manner using correlations and survival analysis models.
* All participants who received HCQ will be included in the safety analysis. Frequency and incidence tables of toxicity and AEs will be generated.
* Immune outcome endpoints including markers of immune function/activation and systemic inflammation will be summarized at each time point of follow-up. Linear mixed models will be utilized to model these repeatedly measured immune endpoints to determine changes over time. Associations between markers and PAR-4 levels will be assessed via calculation and comparison of correlation coefficients. Data processing, data analysis pipelines and bioinformatics methods for NGS data will be employed in collaboration with MCC Shared Resource Facilities. False discovery rate (FDR) q values will be calculated for multiple comparison adjustment, with threshold significance set to 0.05.

Arms: arm 1: Hydroxychloroquine (HCQ)

DOSAGE FORM: 200 mg tablet, oral route

DOSAGE: 200 mg BID by mouth, for a total daily dose of 400 mg

FREQUENCY: HCQ is taken twice daily (morning and night) with food.

DURACTION OF HCQ: 90-days
Interventions: intervention 1: Hydroxychloroquine Sulfate 200Mg Tab
Intervention descriptions: intervention 1: Twice daily for 90-days, administered two weeks prior to radiation/surgery of oligometastatic lesions

Protocol documents:
Prot_SAP_000.pdf: 
Document Coversheet 
 
 Study Title: Phase 2 Study of Hydroxychloroquine to Increase Tumor Suppressor PAR-4 Levels 
in Oligometastatic Prostate Cancer  
Institution/Site:  
University of Kentucky 
Document (Approval/Update) Date: 
6/16/2023 
NCT Number: 
NCT04011410 
IRB Number 
50146 
Coversheet created: 
3/4/2025 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           1 
     Amendment 4, 16JUN2022 
 
 
 
 
 
 
SUMMARY OF CHANGES  
 
 
MCC Study ID No.: MCC-19-GU-72 
   Date: 06/16/2023 
 RE: Submission of Amendment 4 (pvd 16JUN2023) 
 
The approved protocol (Amendment 3, pvd 05JAN2022) is being revised for PI reassignment.  
Dr. James (PI) is transitioning to a new institution and is being reassigned as external Co-Principal 
Investigator.  Dr. Patrick Hensley is assuming the role of co-PI at Markey. We added Dr. Zhengyan Huang 
as co-statistician; we removed Dr. Peng Wang from the personnel list. The revised protocol is 
Amendment 4, protocol version date 16JUN2023.  
 
Additional administrative edits comprising:  
- All pages: new version date updated in footer. 
- Cover Page: updates to Protocol Version and Version Date. 
- Protocol History: updated the table.  
  
 
 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           2 
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MCC Protocol #:  19-MCC-GU-72 
ClinicalTrials.gov Identifier:  NCT04011410 
 
 
Phase 2 Study of hydroxychloroquine to increase tumor suppressor PAR-4 levels 
in oligometastatic prostate cancer 
 
 
 
Short Study Title: HCQ on PAR-4 in Oligometastatic Prostate Cancer 
 
 
 
Co-Principal                 Patrick Hensley, MD 
Investigator:                 Patrick.hensley@uky.edu 
                                      Urology, UK College of Medicine 
 
External Co-Principal     Andrew James, MD 
Investigator:                 Texas Urology Group, San Antonio, TX  
                                      Andrew.James@ 
 
Co-Investigators:       Vivek Rangnekar, PhD 
                                            Co-Director, Cancer Cell Biology and Signaling Research Program 
                                             Professor, Radiation Medicine, UK College of Medicine 
                                              vmrang01@uky.edu  
                                     Don Cohen, PhD 
                                             Director, Flow Cytometry and Cell Sorting SRF  
                                              Professor, Immunology, Department of Microbiology 
                                              don.cohen@uky.edu  
                                     Stephen Strup, MD – Urology, UK College of Medicine 
                                     William St. Clair, MD – Radiation Medicine, UK College of Medicine 
                                     Donglin Yan, PhD – co-statistician, Biostatistics and Bioinformatics SRF 
                                     Zhengyan Huang – co-statistician, Biostatistics SRF 
                                               
 
Commercially Available Agent: Hydroxychloroquine   
IND Status:  Study Exempt from IND Requirements per 21 CFR 312.2(b).   
 
Funding Source: Internal Markey CCSG Pilot Award, 11/1/2018 
 
Protocol Version # / Version Date:  Amendment 3, 05.January.2022 
                                                            Amendment 4, 16.June.2023 
 
 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           3 
     Amendment 4, 16JUN2022 
 
Protocol History -- Summary of Changes from Original Version to Current Version: 
 
Version 
No. & Date 
Revision(s) 
 
Original, 
1/22/2019 
First full draft, January 22, 2019 (aka “V1”) ;  
 2/4/19: Reviewed by FRC, Approved, minor edits.  
2/7/19: PI responses to FRC. FRC OK’d move to PRMC.  
2/22/19: Reviewed by PRMC, Approved. PRMC OK’d proceed to IRB with 
incorporations of edits from FRC and PRMC. 
 
Original, 
Revision 1, 
3/8/2019 
Revision to original.   
Dosing schedule and imaging clarified; size of CPT to collect PBMCs 
clarified; Study Calendar completely rearranged & revised to improve clarity 
re: research-related tests (versus standard of care).  
3/21/2019 
PRMC approved revision dated 3/8/2019.  
3/12/2019 
IRB Submission – review of Version Date 3.8.2019 
     4/29/2019 
5/03/2019 
IRB Meeting  
    Notification of IRB withheld approval – requested edits to Informed Consent form 
5/7/2019 
Changes made to informed consent form, resubmitted to IRB 
      5/13/2019 
Medicare coverage analysis returned.  
      5/20/2019 
IRB initial approval received.  
Original, 
Revision 2, 
6/27/2019 
Minor clarifications to Study Calendar from the Medicare Coverage Analysis findings.  
Budget updated to include MCC member discount to SRF fees, and research-related 
costs. 
7/3/2019 
PRMC approved Revision 2, dated 27 June 2019.  
10/15/2019 
PRMC approved Protocol Version Date 9/ 27 /19 
12/3/2019 
OPEN TO ACCRUAL 
Amendment 1, 
11/18/2020 
Protocol revised to relax eligibility criteria (cataracts, and 5 lesions for 
oligomets).  
Amendment 2, 
6/7/2021 
Protocol revised to clarify follow-up timepoints post-treatment.   
Amendment 3, 
01/05/2022 
Protocol revised to include PSMA scan.  
Amendment 4, 
06/14/2023 
PI changed to Dr. Hensley; Dr. James noted as external co-PI. Dr. Zhengyan 
Huang added as co-statistician; Dr. Peng Wang removed from the personnel 
list 
Amendment 5, 
Add date 
Placeholder for future amendment.  
Amendment 6, 
Add date 
Placeholder for future amendment.  
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           4 
     Amendment 4, 16JUN2022 
 
Figure 1. SCHEMA  
 
 
  
 
 
 
Inclusion Criteria:  
- 
Men ages 18 and older with 
recurrent prostate cancer 
following primary treatment of 
localized disease with either 
surgery or radiation 
- 
Recurrence defined as PSA ш 0.2 
ng/dl following prostatectomy   
OR a PSA increase ш2 above 
nadir following radiotherapy of 
primary tumor 
- 
V\QFKURQRXVPHWDVWDWLF
lesions on CT C/A/P and/or 
fluciclovine or prostate-specific 
membrane antigen scan 
- 
ECOG 0-2 
Anticipated sample size, 
N = 20 
Eligibility Screening 
Exclusion Criteria:  
- 
Brain or CNS mets 
- 
Prior XRT/surgery to a metastatic site; 
orchiectomy 
- 
Prior ADT for metastatic disease or as 
adjuvant therapy in past two years 
- 
Hx of fracture or spinal cord 
compression 
- 
Currently treated with abiraterone, 
enzalutamide, apalutamide, 
chemotherapy, immunotherapy or 
radioisotopes 
- 
Macular degeneration 
- 
Serum testosterone less than 50 ng/ml 
- 
Receipt of HCQ in the past 6 months 
                                                    STUDY ENDPOINTS 
Primary: 3-mos PAR-4 levels  
Secondary:  
          Median Progression-Free Survival and 1-yr ADT-Free Survival up to 3 years 
           HCQ Toxicity and Tolerability 
           Quality of Life  
Correlatives: PBMCs (days 0, 30, 60 of HCQ treatment), immune function and  
    
                     activation, systematic inflammation, and autophagy induction 
Study Enrollment 
2-weeks HCQ, followed by SBRT or surgery 
+ 400 mg HCQ (200 mg BID, 3-months) 
On-Study Follow-Up -   3-mos, 6-mos & 12-mos, then followed per standard of care up to 3 years  


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           5 
     Amendment 4, 16JUN2022 
 
TABLE OF CONTENTS 
Pages 
Title Page  /  Protocol History & Summary of Changes 
1  /  3  
SCHEMA 
4 
Table of Contents  
5-6 
1. STUDY OBJECTIVES 
      Primary Objective 
      Secondary Objectives 
Exploratory Endpoints 
 
7 
7 
7 
2. BACKGROUND 
     Prostate Cancer and its Treatment 
Oligometastatic Prostate Cancer 
PAR-4 tumor suppressor protein 
Hydroxychloroquine 
 
7 
7 
7 
7 
Study Rationale 8 
Study Hypotheses 8 
3. PATIENT ELIGIBILITY  
Inclusion Criteria  
Exclusion Criteria 
Statement about NIH-defined special populations 
 
9 
9 
10 
4. STUDY REGISTRATION 
 PRMC and IRB  
Enrollment 
Informed Consent 
Compliance with Laws and Regulations 
 
10 
10 
11 
11 
5.TREATMENT PLAN 
Enrollment and Screening 
Metastatic site-directed treatment 
HCQ Administration 
General Concomitant Medication and Supportive Care 
Duration of Therapy 
Duration of Follow-up 
 
12 
12 
12 
13 
13 
13 
6. HCQ: DOSING DELAYS AND DOSE MODIFICATIONS 
Modifications for non-hematologic toxicities 
Modifications for hematologic toxicities 
13 
14 
15 
7. ADVERSE EVENTS 
Expected toxicities for HCQ 
Adverse Event Characteristics 
Expedited Adverse Event Reporting 
Expedited reporting to hospital risk management 
Routine Adverse Event reporting  
 
15 - 17 
18 
18 - 19 
20 
20 
8. HCQ:  PHARMACEUTICAL INFORMATION 
HCQ Molecular Structure 
HCQ Storage Requirements & Stability  
Route of Administration of HCQ 
Contra-indications for HCQ 
HCQ Precautions 
HCQ Overdose – Symptoms and Overdose Treatment  
 
20 
21 
21 
21 
21 
21-22 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           6 
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9. IMMUNOLOGICAL EFFECT OF HCQ 
22 
10. STUDY CALENDAR 
24 – 25 
11. HCQ: MEASUREMENT OF EFFECT 
11.1 Primary Objective:  
Compliance with HCQ regimen and PAR-4 increase  
11.2 Secondary Objectives:  
11.2.1 HCQ and treatment toxicity 
11.2.3 HCQ immunologic effect on PAR-4 Levels 
11.2.3 HCQ and Quality of Life 
11.3 Types of Progression 
11.4 Definition of Disease Assessments  
 
 
25 
25 
25 
25 
25-26 
26 
27 
12. DATA REPORTING AND REGULATORY GUIDANCE 
Method of Data Reporting 
Responsibility for Data Submission and Oversight 
 
28 
28 
13. METHODOLOGY & STATISTICAL ANALYSIS 
Design of the Study, Sample Size and Accrual Rate 
Interim Monitoring for Efficacy 
Analysis of Primary and Secondary Endpoints 
Data Management 
 
29 
29 
30 
31 
14. REFERENCES  
32 – 33 
15. APPENDICES 
34 – 52 
Appendix A: Performance Status Scales  
35 
Appendix B: Medications known to interact with HCQ 
36 
Appendix C:  Instructions for taking HCQ 
37 
Appendix D: Pill Dairy (sample / patient version) 
38 - 40  
Appendix E: Lab Manual for FCIM – assays 
40 – 44 
Appendix F: Clavien-Dindo Classification 
45 
Appendix G: EORTC Quality of Life Measures 
    Summary of the two complimentary QOL measures 
EORTC QLQ - C30 
EORTC QLQ-PR25 
Scoring Instructions for the QLQ-PR25  
46 - 52 
46 
47-48 
49-51 
52 
Appendix H: Response Criteria - Disease Assessment 
                H.1 RECIST v1.1 for soft-tissue lesions 
H.2 MDAnderson bone-specific response criteria 
53 
 
 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           7 
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1. STUDY OBJECTIVES 
1.1 Primary Objective 
Assess the rate of attainment of a 50% increase in tumor suppressor PAR-4 levels from baseline 
in patients treated with 90-days of hydroxychloroquine (HCQ) in combination with radiation or 
surgery for recurrent, oligometastatic prostate cancer.  
      
We hypothesize the successful attainment of a 50% increase from baseline will occur 
 
among 50% or more of study participants within the three-months administration period of 
 
HCQ. 
1.2 Secondary Objectives 
- 
Median Progression-Free Survival (time to clinical progression)  
- 
1- and 3-year Androgen Deprivation Therapy (ADT) Free Survival 
- 
HCQ Treatment toxicity (AEs and SAEs during HCQ administration) and radiation toxicity 
to be assessed and recorded utilizing the CTCAE v5.0. Surgical Complications will be 
scored using the Clavien-Dindo Classification (Appendix F).  
- 
Immunological effect of HCQ by analyzing peripheral blood mononuclear cells (PBMCs)  at 
 
day 0 and Day 30 of treatment, and also, Day 60 (+ 6 weeks) of treatment.   
- 
Quality of life as measured by the EORTC QLQ-C30 + QLQ-PR25 
 
2. BACKGROUND 
2.1 Prostate Cancer and its Treatment  
Among men in the U.S., prostate cancer is the most common cancer and the second most common 
cause of cancer mortality.1 In 2018, an estimated 164,960 men will be diagnosed with this disease, 
representing 19% of all new cancer cases and 9% of male cancer-specific mortality.1 The 
prevalence of prostate cancer is projected to rapidly rise over the next 15 years, stemming from “the 
greying of the U.S. population.”  Given the link between increasing age and cancer, aging baby 
boomers will significantly increase cancer incidence and mortality.  For the first time in two decades, 
there was an increase in rates of prostate cancer deaths from 2017 to 2018.2   
Early stage prostate cancer has few symptoms while men with more advanced disease may 
experience significant dysfunction, including weak or interrupted urine flow, urinary urgency, 
frequency and pain and bloody urine.2 Initial treatment options include surgery, external beam 
radiation or brachytherapy.2-4 
2.2 Oligometastatic Prostate Cancer 
Advanced prostate cancer commonly spreads to the bones, which can cause pain in the hips, spine, 
ribs or other areas.2,4-6 For advanced disease (metastases or recurrence), hormonal therapy in 
conjunction with surgery or radiation is used.7-9  Historically, treatment of these patients has 
comprised primarily androgen deprivation therapy (ADT), guided by the premise that aggressive 
treatment of the primary tumor and metastatic lesions conferred considerable morbidity and was 
unlikely to result in cure.4,7-8   The survival benefit of ADT is juxtaposed against significant sequelae 
including cardiovascular morbidity, skeletal fractures, diabetes, sexual dysfunction, and a decrease 
in cognitive function.10 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           8 
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Advancements in molecular testing have highlighted distinctly different mutations in the lesions of 
patients with limited metastatic prostate disease as compared to those of patients with diffuse 
metastatic disease, possibly explaining the different biologic behavior of these tumors.11-13  Among 
men with limited metastatic disease, there is a potential benefit to treatment of oligometastatic 
prostate lesions.14 Previous studies have identified a potential delay in the initiation of ADT in men 
treated with stereotactic radiotherapy.15,16 Additionally, a prospective, multicenter trial showed that 
metastasis-directed therapy delayed initiation of ADT in patients with oligometastatic disease.17  
Given increased rates of metastatic disease and projected increases in incidence and mortality, 
innovative enhancement of current prostate cancer treatment regimens is vital. Novel therapeutic 
approaches for oligometastatic prostate cancer are needed, given ADT-induced sequelae such as 
cardiovascular morbidity, diabetes, cognitive deficits and sexual dysfunction.   
 
2.3 Prostate Apoptosis Response-4 (PAR-4): tumor suppressor protein 
Prostate apoptosis response-4 (PAR-4) is a tumor suppressor protein that facilitates apoptosis in 
numerous types of cancer cells.18 PAR-4 is ubiquitously expressed in normal cells and tissues, but 
it is often inactivated, down-regulated or mutated in several types of cancer cells.18,19 PAR-4 
sensitizes cells to the action of diverse therapeutic agents.18  The loss of PAR-4 in tumors 
contributes to recurrence and decreased overall patient survival. The baseline levels of PAR-4 
secreted by normal cells are generally inadequate to cause massive apoptosis in cancer cells. Given 
the apoptosis-PAR-4 association, drugs that successfully bolster PAR-4 secretion constitute an 
important therapeutic advance. 
 
2.4 Hydroxychloroquine (HCQ) 
Chloroquine [CQ; (RS)-N'-(7-chloroquinolin-4-yl)-N, N-diethyl-pentane-1, 4-diamine] is an 
antimalarial drug introduced into clinical practice in 1947 for the prophylactic treatment of malaria 
and has been repurposed to treat inflammatory diseases such as rheumatoid arthritis and lupus. 
Hydroxychloroquine (HCQ) differs from chloroquine by the presence of a hydroxyl group at the N-
ethyl substituent is beta-hydroxylated, but has similar pharmacokinetics to CQ, with quick 
gastrointestinal absorption and is eliminated by the kidney with minimal side effects on short term 
treatments.  
Both CQ and HCQ are potent inhibitors of autophagy, a cellular survival process during starvation 
to maintain cellular energy by degradation of unnecessary or dysfunctional components through the 
actions of lysosomes. CQ and HCQ are lysosomotropic agents, which inhibit autophagy by raising 
the lysosomal pH, leading to inhibition of both fusion of autophagosome with lysosome and 
lysosomal protein degradation. Moreover, by inhibiting autophagy, CQ activates caspases and 
sensitizes the cells to apoptosis. These apoptosis-sensitizing features of HCQ or CQ enhance the 
anti-tumor effects of a broad range of cancer therapeutics.20,21 Institutional experiences with 
chloroquine administered concurrently with conventional therapy in adjuvant setting provided longer 
survival.22 These studies provide a basis for the hypothesis that hydroxychloroquine can elevate 
PAR-4 levels and thus provide tumor suppression systemically. Accordingly, HCQ and CQ are being 
studied either pre-operatively or in conjunction with chemotherapeutic agents or radiation.23 
Chloroquine has been found to induce PAR-4 expression and subsequently promote apoptosis of 
cancer cells and inhibit metastatic progression.23,24   


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           9 
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2.5 Study Rationale  
Treatment of oligometastatic prostate cancer may be enhanced by the addition of 
hydroxychloroquine to either surgical resection or radiation treatment of metastatic lesions.  
Potential benefits of hydroxychloroquine include delayed disease progression and delayed initiation 
of ADT, lessening morbidity and increasing quality of life in men with oligometastatic prostate 
cancer. Our recent studies identified several small molecules that show robust secretion of PAR-4 
in cell culture and mouse models, and secreted PAR-4 induces apoptosis of cancer cells.19,24 
However, these small molecules are not FDA-approved for human use. We therefore sought to 
identify FDA-approved small molecule drugs that show robust secretion of PAR-4 in normal cells 
and can be repurposed for treatment of cancer. These studies (unpublished) identified HCQ as a 
potent inducer of PAR-4 secretion from normal cells under conditions that show no normal cell 
death.  
As normal cells in any patient far outnumber cancer cells, FDA-approved PAR-4 secretagogues 
may play a valuable role in elevating systemic and local levels of PAR-4 protein, thereby inducing 
paracrine apoptosis in primary and metastatic prostate tumors. Systemic PAR-4 is also expected to 
induce apoptosis in circulating cancer cells that contribute to metastasis. PAR-4 produces apoptosis 
and HCQ is expected to produce elevated levels of PAR-4 secretion that will prevent the growth of 
tumors.  HCQ has also been reported to both inhibit and enhance immune responses via changes 
in Th1, Th2, Th17 and Treg subsets and reduce inflammatory markers.  It also acidifies lysosomes 
that potentially inhibits antigen presentation by antigen-presenting cells and can be measured with 
LysoSensor Yellow/Blue DND-160 by flow cytometry. HCQ blocks autophagy by preventing the 
fusion of the autophagosome with the lysosome, and auto- phagosome cargo protein 
p62/Sequestosome-1 (also known as the ubiquitin-binding protein), and microtubule-associated 
protein LC-3II levels (analyzed by Western blot analysis or IHC) are elevated in the normal cells, as 
well as tumor cells in the patient.    
 
2.6 Study Hypothesis:  In men who develop recurrent oligometastatic disease following primary 
treatment of prostate cancer, treatment with surgery or radiation in combination with administration 
of hydroxychloroquine (400 mg per day for a 90-day period) will induce an elevation of PAR-4 
expression among a majority of participants within three months of HCQ administration.  
We hypothesize successful attainment of a 50% increase in PAR-4 from baseline levels 
among 50% or more of participants within the 90-day administration period of HCQ.  


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           10 
     Amendment 4, 16JUN2022 
 
3. PATIENT SELECTION – ELIGIBILITY  
3.1 Inclusion Criteria 
 
3.1.1 Males age 18 and over 
3.1.2 Histologically confirmed prostate cancer that has recurred following primary definitive  
 
      treatment of localized prostate cancer (either surgery, radiotherapy or both) 
 
PSA biochemical recurrence defined as either:  
 
     PSA ш 0.2 ng/dl following radical prostatectomy 
 
     36$LQFUHDVHng/mL above PSA nadir value following radiotherapy of primary tumor 
3.1.3 Five or fewer synchronous metastatic lesions (on imaging) with no evidence of residual  
 
local disease 
3.1.4 ECOG performance status 0 – 2    (see Appendix A)   
3.1.5 Approval by screening eye exam (disqualifying baseline conditions listed in 3.2.2, below)  
3.1.6 Ability to provide informed consent 
 
3.2 Exclusion Criteria 
 
3.2.1 Hydroxychloroquine-specific rule-outs:  
 
3.2.1a. Receipt of HCQ within the past 6 months 
 
3.2.1b. History of allergic reactions attributed to compounds of similar chemical or  
 
 
biologic composition to hydroxychloroquine 
 
3.2.1c. Use of contraindicated medications, including but not limited to combination  
 
 
antiretroviral therapy and enzyme-inducing anti-epileptics (see Appendix B)  
3.2.2 Macular degeneration or concurrent macular disease. Eligibility in the presence of other eye 
/ visual impairments (cataracts, severe retinopathy, severe visual impairment at baseline, 
presence of only one functional eye) will be at the discretion of the treating physician based 
on eye exam by ophthalmologist.   
 
 
3.2.3 Prior treatment with ADT including:  
 
 
ADT for treatment of metastatic disease 
 
 
ADT as adjuvant therapy prior to surgery/radiation within 1 year of enrollment  
3.2.4 Previous history of radiation or surgery to a metastatic site 
3.2.5 Previous treatment with any of the following:  
 
 
-Abiraterone       -Enzalutamide 
   -Apalutamide       -antiretroviral therapy 
 
 
-chemotherapy      -immunotherapy     -radioisotopes      
3.2.6 Serum testosterone less than 50 ng/ml 
3.2.7   History of orchiectomy 
3.2.8 History of pathologic fracture or spinal cord compression 
3.2.9 Brain or CNS metastases 
3.2.10  History of G-6-PD (glucose-6-phosphate dehydrogenase) deficiency  
3.2.11 Uncontrolled intercurrent illness including but not limited to the following:  
 
 
-ongoing or active infection 
 
-symptomatic congestive heart failure  
 
 
-unstable angina pectoris 
 
-cardiac arrhythmia 
3.2.12 Psychiatric illness and/or social situations that would limit compliance with study   
 
 
requirements. 
3.2.13  Patients taking other investigational agents 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           11 
     Amendment 4, 16JUN2022 
 
 
 
3.3 Inclusion of Women, Minorities and Children 
 
Prostate cancer does not occur in women nor in male children; as such, these groups are 
excluded from this study. No eligible male participants will be excluded from this study on the 
basis of race or ethnicity.  
 
 
4. STUDY REGISTRATION PROCEDURES 
 
4.1 Protocol Review and Monitoring Committee and Institutional Review Board Review 
 
Before implementing this study, the protocol must be reviewed by the Markey Cancer Center’s 
Protocol Review and Monitoring Committee.  The protocol, the proposed informed consent form and 
other information to subjects must be reviewed by the University of Kentucky Institutional Review 
Board (IRB). A signed and dated UK IRB initial review approval memo must be maintained in the 
Markey Cancer Center Clinical Research Office (MCC CRO) regulatory binder. Any amendments 
to the protocol, other than administrative ones, must be reviewed and approved by the PRMC, study 
sponsor, and the UK IRB.   
 
4.2 Enrollment Guidelines 
 
Patients who have received previous treatment for prostate cancer with the intent to cure who have 
biochemical recurrence will undergo metastatic evaluation with imaging at baseline including 
fluciclovine or prostate-specific membrane antigen (PSMA) PET scan (preferred), bone scan, 
PET/CT and/or CT of the chest, abdomen, and pelvis as needed to assess for metastatic disease.   
 
Biochemical recurrence for patients who have previously undergone radical prostatectomy is 
defined as D 36$  QJGO  Patients who have biochemical recurrence following radical 
prostatectomy should have received postoperative radiotherapy to the prostate bed if no evidence 
of metastatic disease.   
 
For patients who have previously undergone primary treatment of their prostate cancer with 
radiotherapy, biochemical recurrence is defined as an increase of 2 or more ng/dl above the nadir.   
Patients who have undergone primary radiotherapy will have pelvic MRI to rule out local disease as 
part of the requisite baseline imaging.  Suspicious lesions within prostate bed will be assessed by 
biopsy.  
 
Patients with 1-3 metastatic lesions on metastatic evaluation will be further screened per inclusion 
and exclusion criteria as noted above, Section 3.  Initial localization of metastases will be recorded 
(node vs bone vs visceral).  
Eligible patients will be identified by the principal investigator and co-investigators of this study. 
Potentially eligible patients will be screened in the University of Kentucky Markey Cancer Center 
clinics by the investigators, study personnel, and the Principal Investigator (PI). Upon obtaining 
proper consent, patients will be enrolled into the study.   


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           12 
     Amendment 4, 16JUN2022 
 
4.3 Informed Consent 
The goal of the informed consent process is to provide people with sufficient information so they 
can make informed choices about whether to begin or continue participation in clinical research.  
The process involves a dynamic and continuing exchange of information between the research team 
and the participant throughout the research experience.  It includes discussion of the study's 
purpose, research procedures, risks and potential benefits, and the voluntary nature of participation. 
 
The informed consent document provides a summary of the clinical study and the individual's rights 
as a research participant.  The document acts as a starting point for the necessary exchange of 
information between the investigator and potential research participant.  Also, research participants 
and their families may use the consent document as an information resource and reference 
throughout participation in the trial.  The informed consent document is often considered the 
foundation of the informed consent process; it does not, however, represent the entirety of the 
process.  Nor is the informed consent document a risk-management tool for the investigator and/or 
institution. 
 
The investigator must explain to each subject the nature of the study, its purpose, the procedures 
involved, the expected duration, the potential risks and benefits involved and any discomfort it may 
entail. Each subject must be informed that participation in the study is voluntary and that he may 
withdraw from the study at any time and that withdrawal of consent will not affect his subsequent 
medical treatment or relationship with the treating physician. 
 
This informed consent should be given by means of a standard written statement, written in non-
technical language. The subject should read and consider the statement before signing and dating 
it, and should be given a copy of the signed document. No patient can enter the study before his 
informed consent has been obtained.  The informed consent form is considered to be part of the 
protocol, and must be submitted by the investigator with the protocol at the time of IRB review. 
 
4.4 Compliance with Laws and Regulations 
 
The study will be conducted in accordance with U.S. Food and Drug Administration (FDA) and 
International Conference on Harmonization (ICH) Guidelines for Good Clinical Practice (GCP), the 
Declaration of Helsinki, any applicable local health authority, and Institutional Review Board (IRB) 
requirements.  The study PI or designee will be responsible for obtaining continuing and not less 
than annual IRB re-approval throughout the duration of the study.  Copies of the Investigator’s 
annual report to the IRB and copies of the IRB continuance of approval must maintained by the 
MCC CRO.  The study PI or designee is also responsible for notifying the Data and Safety 
Monitoring Committee of the MCC and the UK IRB of any significant adverse events that are serious 
and/or unexpected, as per SOP’s of those entities. The MCC DSMC will review all adverse events 
of this IIT as per its SOP. 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           13 
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5. TREATMENT PLAN 
 
5.1 Enrollment and Screening Process 
 
Prior to any study-required tests, subjects must first provide written informed consent to participate 
 
in this study.  
All lab tests, ophthalmologic exam and radiographic studies should be completed within eight 
 
weeks prior to initiation of HCQ treatment.  
Complete history, physical examination, and evaluation of performance status will also be 
 
performed during this 8-week timeframe.   
Required lab work will include:  
 
complete blood count (CBC); serum chemistry tests to include alkaline phosphatase, 
 
glucose, creatinine, electrolytes, AST (SGOT), total testosterone, and total bilirubin.   
 
 
5.2 Metastatic site-directed treatment and hydroxychloroquine administration 
 
Modality of site-directed treatment of oligometastatic lesions will be decided by multidisciplinary 
team consisting of urologic surgery, radiation oncology, and medical oncology in consultation with 
the patient.  
 
 
5.3 HCQ Administration 
Hydroxychloroquine will be administered daily on an outpatient basis beginning 2 weeks before 
metastasectomy or initiation of radiation treatment to metastatic lesions.  HCQ administration will 
be held the day of surgery for those patients undergoing surgical resection of their metastatic site(s) 
and will resume on post-operative day 1, and the missed dose will not be made up.  
Hydroxychloroquine will be administered orally at a total daily dose of 400 mg (200 mg BID) for 90-
days. Tablets of HCQ are available in 200 mg strength.  
 
Instructions on taking HCQ (patient version) are located in Appendix C.  
 
To minimize nausea, HCQ is recommended to be administered in divided doses (one 200-
mg tablet twice per day). The divided doses should be taken with meals, once in the morning and 
once at night. Should a subject have emesis and regurgitate the HCQ within 30 minutes of taking it, 
the dose may be repeated once, but if vomiting occurs longer than 30 minutes after ingestion, the 
dose should not be repeated. 
 
Study participants will be required to keep a medication diary and to present the completed diary at 
the end of the treatment (Appendix D). Additionally, at the PI’s discretion, study staff will call the 
participants periodically on an as-needed basis to monitor ongoing completion of the pill diaries 
while patient is on-study, e.g., if a patient misses a clinic visit.  
 
Appropriate dose modifications are described in Section 6.  
 
Adverse events and potential risks are described in Section 7.  
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           14 
     Amendment 4, 16JUN2022 
 
5.4 General Concomitant Medication and Supportive Care Guidelines  
Because there is a potential for interaction of hydroxychloroquine with other concomitantly 
administered drugs through the cytochrome P450 system, the case report form must capture the 
concurrent use of all other drugs, over-the-counter medications, or alternative therapies. The PI 
should be alerted if the patient is taking any agent known to affect or with the potential to affect 
selected CYP450 isoenzymes. Appendix B presents guidelines for identifying medications/ 
substances that could potentially interact with hydroxychloroquine. While not strictly prohibited, 
these medications should be avoided if at all possible. Hydroxychloroquine should also be used with 
caution in patients taking medicines that may cause adverse ocular or skin reactions.  
 
5.5 Duration of Therapy 
 
In the absence of treatment delays due to adverse event(s), hydroxychloroquine treatment will 
continue for 3 months or until one of the following criteria applies:  
• 
Disease Progression, assessed by standard of care and defined as either:  
          - PSA progression (an increase in PSA > 25% above baseline at study entry), or 
          - Symptomatic progression (increasing pain from metastatic lesion), or  
          - Progression of baseline-detected lesions (soft-tissue lesions as assessed by 
  
 
RECIST and bone lesions as assessed by the MDA criteria (respectively,  
 
 
Appendix H.1 and Appendix H.2).  
 
 
Additionally, CT C/A/P and/or fluciclovine or PSMA PET scans may be 
                        performed at the time of either Symptomatic or PSA Progression at  
                        discretion of the treating physician. 
 
- Appearance of new metastatic lesions 
• 
Intercurrent illness that prevents further administration of treatment 
• 
Unacceptable adverse event(s) 
• 
Patient decides to withdraw from the study 
• 
General or specific changes in the patient's condition that render the patient unacceptable 
 
 for further treatment in the judgment of the investigator 
 
 
5.6 Duration of Follow-up  
 
Patients will be followed for up to three years post-therapy or until death, whichever occurs first. 
Patients removed from study for unacceptable adverse event(s) will be followed until resolution or 
stabilization of the adverse event.   
 
 
6. DOSING DELAYS AND DOSE MODIFICATIONS 
 Dose schedule and dose reduction schedule for hydroxychloroquine (HCQ): 
 
Dose Level    HCQ Dose 
1 
 200 mg, twice a day (total daily dose, 400 mg) 
-1 
 200 mg, daily 
 
 If a participant is unable to tolerate 200 mg per day of HCQ, he will be removed from the study. 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           15 
     Amendment 4, 16JUN2022 
 
6.1 HCQ Dose Modifications for Non-Hematologic Toxicities that are deemed     
                Possibly, Probably or Definitely related to Hydroxychloroquine 
 
Nausea and/or 
Vomiting 
Management/Next Dose for Hydroxychloroquine 
Grade 1 
No change in dose 
Grade 2 
Hold XQWLOGrade 1.Resume at same dose level. 
Grade 3 or 4 
Hold* until < Grade 2. Resume at one dose level lower, if indicated. 
*Patients requiring a delay of >2 weeks should go off protocol therapy. 
Recommended management: Re-educate patient to take with meals and anti-emetics. Adjunct 
anti-nausea therapy is permitted and should be recorded when used. 
 
Diarrhea 
Management/Next Dose for Hydroxychloroquine 
Grade 1 
No change in dose 
Grade 2 
Hold XQWLOGrade 1.Resume at same dose level. 
Grade 3 or 4 
Hold* until < Grade 2. Resume at one dose level lower, if indicated. 
*Patients requiring a delay of >2 weeks should go off protocol therapy. 
Recommended management: Loperamide antidiarrheal therapy 
Dosage schedule:4 mg at first onset, followed by 2 mg with each loose bowel movement  
        until diarrhea-free for 12 hours (maximum dosage:16 mg/24 hours) 
Adjunct anti-diarrheal therapy is permitted and should be recorded when used. 
 
Visual Changes 
Management/Next Dose for Hydroxychloroquine 
Grade 1 
No change in dose 
Grade 2 or greater 
Permanently discontinue. 
The methods recommended for early diagnosis of "chloroquine retinopathy" consist of 
(1) fundoscopic examination of macula for fine pigmentary disturbances or loss of foveal reflex &   
(2) examination of the central visual field with a small red test object for pericentral or paracentral 
scotoma or determination of retinal thresholds to red. 
 
Pustular or Bullous 
Dermatitis 
Management/Next Dose for Hydroxychloroquine 
Grade 1 
No change in dose 
Grade 2 
Hold XQWLOGrade 1.Resume at same dose level. 
Grade 3 or 4 
Hold* until < Grade 2.Resume at one dose level lower, if indicated. 
*Patients requiring a delay of >2 weeks should go off protocol therapy. 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           16 
     Amendment 4, 16JUN2022 
 
6.2 HCQ Dose Modifications for Hematologic Toxicities 
Neutropenia 
Management/Next Dose for Hydroxychloroquine 
Grade 1 
No change in dose 
Grade 2 
Hold XQWLOGrade 1.Resume at same dose level. 
Grade 3 or 4 
Hold* until < Grade 2.Resume at one dose level lower, if indicated. 
 
*Patients requiring a delay of >2 weeks should go off protocol therapy. 
 
Thrombocytopenia 
Management/Next Dose for Hydroxychloroquine 
Grade 1 
No change in dose 
Grade 2 
Hold XQWLOGrade 1.Resume at same dose level. 
Grade 3 or 4 
Hold* until < Grade 2.Resume at one dose level lower, if indicated. 
*Patients requiring a delay of >2 weeks should go off protocol therapy. 
 
NOTE:  All other grade 3 or 4 toxicities should be discussed with the study PIs. 
 
7. ADVERSE EVENTS – LIST AND REPORTING REQUIREMENTS 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial. The following list 
of AEs (Section 7.1) and the characteristics of an observed AE (Section 7.2) will determine if the 
event requires expedited reporting (via Medwatch Forms) in addition to routine reporting. 
 
7.1 Expected Toxicities for Hydroxychloroquine 
 
7.1.1 Precautions 
 
Dermatologic Reactions to hydroxychloroquine sulfate tablets may occur and, therefore, proper 
care should be exercised when they were administered to any patient receiving a drug with a 
significant tendency to produce dermatitis. 
 
Hydroxychloroquine Retinitis is both dose- and duration-dependent with increased risk occurring 
at doses exceeding 5mg/kg of actual body weight and chronic use exceeding 5 years.  This trial 
uses an FDA-approved dose of hydroxychloroquine and is 90 days in duration. Thus, risks of 
hydroxychloroquine retinitis are small (less than 1%) and will be 
further minimized by baseline 
screening for retinal abnormalities, (see eligibility criteria 3.1.5 and 3.2.2), monthly assessment of 
adverse effects, repeat visual examinations for ocular toxicity and permanent discontinuation of 
hydroxychloroquine for any grade 2 or greater ocular toxicity (see 6.1, Visual Changes. The methods 
recommended for early diagnosis of "chloroquine 
retinopathy" consist of (1) fundoscopic 
examination of the macula for fine pigmentary disturbances or loss of the foveal reflex and (2) 
examination of the central visual field with a small red test object for pericentral or paracentral 
scotoma or determination of retinal thresholds to red. Any unexplained visual symptoms, such as 
light flashes or streaks, should also be regarded with suspicion as possible manifestations of 
retinopathy. 
 
If serious toxic symptoms occur from HCQ Overdosage or Sensitivity, it is suggested that 
ammonium chloride (8 g daily in divided doses) be administered orally three or four days a week for 
several months after therapy has been stopped, as acidification of the urine increases renal excretion 
of the 4-aminoquinoline compounds by 20-90%. However, caution must be exercised in patients 
with impaired renal function and/or metabolic acidosis. See Section 8.7 for details.  


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           17 
     Amendment 4, 16JUN2022 
 
7.1.2 Adverse Reactions 
 
 
The Council for International Organizations of Medical Sciences (CIOMS) frequency rating is 
 
used as follows, when applicable:  
 
 
CIOMS Frequency Rating       (expected % of population experiencing adverse reactions) 
Inadequate data Not Known  
0.1%  - 0.9%  Uncommon 
10% or greater = 
Very Common  
0.01 – 0.09%  Rare 
1%  – 9%  Common 
Less than 0.01%  Very Rare  
 
 
Eye Disorders 
 
Common: Blurring of vision due to a disturbance of accommodation, which is dose  
 
 
dependent and reversible. 
 
Uncommon:  
 
-Maculopathies, which may be irreversible. 
 
-Retinopathy with changes in pigmentation and visual field defects. In its early form, it  
 
   appears reversible upon discontinuation of the drug. If allowed to develop however,           
 
   there may be a risk of progression even after treatment withdrawal. 
 
-Patients with retinal changes may be asymptomatic initially, or may have scotomatous 
 
   vision with paracentral, pericentral ring types, temporal scotomas, abnormal color    
 
   visions, reduction in visual acuity, night blindness, difficulty reading and skipping words. 
 
- Corneal changes including edema and opacities. They are either symptomless or may 
 
   cause disturbances, i.e., halos around lights especially at night, blurring of vision or     
 
    photophobia. They may be transient or are reversible upon discontinuation of therapy. 
          Not known: Macular degeneration, which may be irreversible. 
 
Gastrointestinal Disorders 
 
Very common: Abdominal pain, nausea 
 
Common: Diarrhea, vomiting 
         These symptoms usually resolve immediately upon reducing the dose or upon stopping treatment. 
 
Skin and subcutaneous tissue disorders 
 
Common: Skin rash, pruritus 
 
Uncommon: Pigmentary changes in skin and mucous membranes, bleaching of hair,  
 
 
alopecia. These usually resolve readily upon cessation of therapy. 
 
Not known: Bullous eruptions (including urticarial, morbilliform, lichenoid, maculopapular, 
 
 
purpuric, erythema annularecentrifugum), toxic epidermal necrolysis, erythema  
 
 
multiforme, Stevens-Johnson syndrome, Drug Rash with Eosinophilia and Systemic 
 
 
Symptoms (DRESS syndrome), photosensitivity, exfoliative dermatitis, acute  
 
 
generalized exanthematouspustulosis (AGEP) 
        AGEP has to be distinguished from psoriasis, although HYDROXYCHLOROQUINE may    
 
precipitate attacks of psoriasis. It may be associated with fever and hyperleukocytosis. 
      Outcome is usually favorable after discontinuation of drug. 
 
Metabolism and nutrition disorders 
 
Common: Anorexia (usually resolves immediately upon reducing dose or stopping  
 
 
treatment). 
 
Not known: hypoglycemia 
         HYDROXYCHLOROQUINE may exacerbate porphyria. 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           18 
     Amendment 4, 16JUN2022 
 
 
7.1.2 Adverse Reactions from HCQ – CONTINUED  
 
Nervous system disorders  
 
Common: Headache 
 
Uncommon: Dizziness 
 
Not known: Convulsions 
 
Psychiatric disorders  
 
Common: Affect lability  
 
Uncommon: Nervousness 
 
Not known: Psychosis, suicidal behavior 
 
Blood and lymphatic system disorders 
 
Not known: Bone marrow depression, anemia, aplastic anemia, agranulocytosis,   
 
 
leucopenia, and thrombocytopenia. 
 
Cardiac disorders 
 
Not known: Cardiomyopathy, which may result in cardiac failure and in some cases a fatal 
 
 
outcome. 
Chronic toxicity should be considered when conduction disorders (bundle branch block/ 
atrioventricular heart block) as well as biventricular hypertrophy are found. Drug 
discontinuation may lead to recovery. 
 
Immune system disorders 
 
Not known: Urticaria, angioedema, bronchospasm 
 
Ear and labyrinth disorders 
 
Uncommon: Vertigo, tinnitus 
 
Not known: Hearing loss including cases of irreversible hearing loss. 
 
Hepatobiliary disorders 
 
Uncommon: Abnormal liver function tests 
 
Not known: Fulminant hepatic failure 
 
Musculoskeletal and connective tissue disorders 
 
Uncommon: Sensory motor disorders 
 
Not known: Skeletal muscle palsies or skeletal muscle myopathy or neuromyopathy leading 
 
 
to progressive weakness and atrophy of proximal muscle groups. Depression of  
 
 
tendon reflexes, abnormal results of nerve conduction tests. Myopathy may be  
 
 
reversible after drug discontinuation, but recovery may take many months. 
 
 
For a comprehensive list of adverse reactions, 
please refer to the HCQ package insert. 
 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           19 
     Amendment 4, 16JUN2022 
 
7.2   Adverse Event Characteristics 
 
7.2.1 CTCAE v.5.0: For AE reporting, descriptions and grading scales of the NCI Common 
Terminology Criteria for Adverse Events CTCAE version 5.0 will be utilized. All appropriate 
treatment areas have access to a copy of the CTCAE version 5.0.  
Additionally, a copy of the CTCAE version 5.0 can be downloaded from the CTEP web site   
          http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
 
7.2.2 For expedited reporting purposes only: 
           AEs for HCQ noted in Section 7.1 should be reported only if the adverse event varies in 
nature, intensity or frequency from the expected toxicity information which is provided.  
 
Other AEs that do not require expedited reporting are outlined in Expedited Adverse Event 
Reporting (Section 7.3). 
 
 
 
7.2.3 Attribution of the Adverse Event (AE): 
 
Definite – The AE is clearly related to the HCQ. 
 
Probable – The AE is likely related to the HCQ. 
 
Possible – The AE may be related to the HCQ. 
 
Unlikely – The AE is doubtfully related to the HCQ. 
 
Unrelated – The AE is clearly NOT related to the HCQ. 
 
 
7.3    Expedited Adverse Event Reporting 
 
7.3.1 For MCC Investigator-Initiated Trials (IITs), study investigators and staff must report to the 
 
Overall PI any serious adverse event (SAE) that occurs after the initial dose of HCQ, 
 
during the 90-day HCQ administration (study treatment), or within 30 days of the last dose  
 
of HCQ on the SAE form.  
 
 
This applies to the following categories: 
x 
Grade 2 ocular or visual changes – any changes, regardless of attribution to the HCQ 
x 
Grade 3 (severe) Medical Events – Only events that are Unexpected and Possibly,  
  
Probably or Definitely Related / Associated with the HCQ. 
x 
ALL Grade 4 (life threatening or disabling) Medical Events – Unless expected AND  
  
specifically listed in protocol as not requiring reporting. 
x 
ALL Grade 5 (fatal) Events regardless of study phase or attribution. 
 
Note: If subject is in Long-Term Follow-Up, death is reported at continuing review.  
 
 
Note: Abnormal laboratory values are not considered medical events, unless determined to be 
         causative of SAE by the investigator or are a grade 5. 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           20 
     Amendment 4, 16JUN2022 
 
7.3.2    The following table outlines the required forms and reporting structure for clinical trials. 
 
Study type 
Expedited 
reporting to 
MCC 
Expedited 
reporting to 
External 
Agency 
Non- 
expedited 
AE 
 
Form 
 
IRB 
 
IIT by MCC 
investigator of 
HCQ,  
a commercially 
available agent  
(non-IND and 
non-IDE) 
Grade 2 eye/visual 
changes, any 
attribution.  
 
Grade 3 – Unexpected 
AE PLUS Possibly, 
Probably or Definitely 
Related 
 
ALL Grade 4 Unless 
expected AND listed 
in protocol as not 
requiring reporting.  
 
 
ALL Grade 5 events 
(fatal) 
 
FDA: 
Suspected AE 
that is serious 
and 
unanticipated 
(not listed in 
IDB or in the 
consent) 
 
OnCore and 
DSMC 
reporting 
only 
 
Voluntary 
Medwatch 
3500 for 
Serious and 
unanticipated 
 
 
OnCore for 
all 
AEs, 
including 
SAEs 
Yes if it 
meets the 
IRB reporting 
requirements: 
Unanticipated 
Problem 
and/or 
Serious AE 
(use IRB AE 
reporting 
form for all 
corresponden
ce with IRB 
 
7.3.3  MCC Expedited Reporting Guidelines for MCC IITs 
 
Investigators within MCC will report SAEs directly to the MCC DSMC per the MCC DSMC SOP 
 
and the University of Kentucky IRB reporting policy. 
 
 
Attribution 
MCC Reportable AEs 
Gr. 2 AE 
Expected 
    Gr. 3 AE 
Unexpected 
Gr. 4 AE 
Expected 
Gr. 4 AE 
Unexpected 
Gr. 5 AE 
Expected  
or 
Unexpected 
Unrelated 
Unlikely 
Only for 
eye/visual 
changes 
 
Not required 
 
5 calendar days# 
 
5 calendar days 
 
24 hours* 
Possible 
Probable 
Definite 
Only for 
eye/visual 
changes 
 
5 calendar days 
 
5 calendar days# 
 
5 calendar days 
 
24 hours* 
# If listed in protocol as Expected and Not Requiring expedited reporting, the adverse event does not need to be  
    reported. 
* For participants enrolled and actively participating in the study or for SAEs occurring within 30 days of the 
    last intervention, the SAE should be reported within 24 business hours of learning of the event. 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           21 
     Amendment 4, 16JUN2022 
 
 
 
7.4   Expedited Reporting to Hospital Risk Management 
 
Participating investigators will report to the UK Office of Risk Management any participant 
safety reports or sentinel events that require reporting according to institutional policy.  
 
 
7.5   Routine Adverse Event Reporting  
 
All AEs must be reported in routine study data submissions to the PI on the OnCore case 
report forms. AEs reported through expedited processes (e.g., reported to the IRB) must also be 
reported in routine study data submissions. 
 
 
 
8. PHARMACUETICAL INFORMATION  
A list of the adverse events and potential risks associated with HCQ administered in this study is 
found in Section 7.1.  
8.1 Hydroxychloroquine 
 
Description:  Hydroxychloroquine sulfate, USP is a colorless crystalline solid, soluble in water to at 
least 20 percent; chemically the drug is 2-[[4-[(7-Chloro-4-quinolyl) amino]pentyl] ethylamino] ethanol 
sulfate (1:1). Hydroxychloroquine sulfate, USP has the following structural formula: 
 
 
Molecular Formula: C18H26ClN3O.H2SO4 Molecular Weight of 433.95 
 
Each tablet, for oral administration, contains 200 mg hydroxychloroquine sulfate, USP (equivalent to 
155 mg base). In addition, each tablet contains the following Inactive Ingredients: colloidal silicon 
dioxide, dibasic calcium phosphate, hypromellose, 
macrogol/PEG 3350, magnesium stearate, 
polysorbate 80, pre-gelatinized starch, talc, and titanium dioxide. 
Hydroxychloroquine sulfate tablets, USP are white, to off-white, capsule-shaped tablets, debossed 
with "HCQS" on one side and plain on the reverse side and are available in bottles of 10, 100, 500 
and 1000. 
NDC 63304-296-0 
Bottles of 10 
NDC 63304-296-01 
Bottles of 100 
NDC 63304-296-05 
Bottles of 500 
NDC 63304-296-10 
Bottles of 1000 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           22 
     Amendment 4, 16JUN2022 
 
8.2 HCQ Storage Requirements: 
 
 8.2.1  Dispense in a tight, light-resistant container as defined in the USP/NF. 
 8.2.2   Store at 20° - 25°C (68° - 77°F) excursions permitted to 15° - 30°C (59° - 86°F) [See  
 
 
USP Controlled Room Temperature]. 
 8.2.3 Store out of the reach of children. 
 
8.3 HCQ Stability: 
 
When stored as listed above and light-resistant containers, hydroxychloroquine is stable 
 
for 3 years from manufacture date. 
 
8.4  Route of Administration for HCQ: 
 
Hydroxychloroquine is taken orally twice a day, each dose to be taken with a meal or a glass 
of milk. If patients miss the dose, take if within 2 hours. Outside of this 2-hour window, just skip the 
dose and take the next dose at the regular scheduled time. See Appendix C.   
 
8.5 HCQ Contraindications 
 
Use of HCQ is contraindicated in:  
 
(1) presence of retinal or visual field changes attributable to any 4-aminoquinoline  
 
 
compound,  
 
(2) patients with known hypersensitivity to 4-aminoquinoline compounds, and  
 
(3) for long-term therapy in children. 
 
 
8.6   HCQ Precautions: General 
 
Antimalarial compounds should be used with caution in patients with hepatic disease or  alcoholism 
or in conjunction with known hepatotoxic drugs. Periodic blood cell counts should be made if patients 
are given prolonged therapy. If any severe blood disorder appears which is not attributable to the 
disease under treatment, discontinuation of the drug should be considered. The drug should be 
administered with caution in patients 
having G-6-PD (glucose-6-phosphate dehydrogenase) 
deficiency. 
 
 
8.7  HCQ Overdose: Symptoms of Overdose and Treatment for HCQ Overdose 
 
Overdose with the 4-aminoquinolines is dangerous particularly in infants, as little as 1-2 
 
grams having proved fatal. 
 
 
8.7.1 Symptoms of HCQ Overdose: 
 
The 4-aminoquinoline compounds are very rapidly and completely absorbed following 
 
ingestion and in accidental overdosage, toxic symptoms may occur within 30 minutes.  
 
These consist of:  
 
 
 headache, drowsiness, visual disturbances, cardiovascular collapse,  
 
 
 
hypokalemia and convulsions, rhythm and conduction disorders, including QT  
 
 
prolongation, torsade de pointes, ventricular tachycardia and ventricular fibrillation, 
 
 
followed by sudden potentially fatal respiratory and cardiac arrest.  
 
Immediate medical attention is required, as effects may appear shortly after overdose.  
 
The ECG may reveal atrial standstill, nodal rhythm, prolonged intraventricular conduction 
 
 
time, and progressive bradycardia leading to ventricular fibrillation and/or arrest. 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           23 
     Amendment 4, 16JUN2022 
 
8.7.2  Treatment of HCQ Overdose: 
 
Treatment is symptomatic and must be prompt with immediate evacuation of the stomach by emesis 
(at home, before transportation to the hospital), or gastric lavage until the stomach is completely 
emptied. If finely powdered activated charcoal is introduced by the stomach tube, after lavage and 
within 30 minutes after ingestion of the tablets, it may inhibit further intestinal absorption of the drug. 
To be effective, the dose of activated charcoal should be at least five times the estimated dose of 
ingested hydroxychloroquine. Convulsions, if present, should be controlled before attempting gastric 
lavage. If due to cerebral stimulation, cautious administration of an ultrashort-acting barbiturate may 
be tried but, if due to anoxia, convulsions should be corrected by oxygen administration, artificial 
respiration or, in shock with hypotension, by vasopressor therapy. Because of the importance of 
supporting respiration, tracheal intubation or tracheostomy, followed by gastric lavage, has also been 
advised. Exchange transfusions have been used to reduce the level of 4-aminoquiolines in the blood. 
Consideration should be given to administering diazepam parenterally since studies have reported it 
beneficial in reversing 
chloroquine cardiotoxicity. A patient who survives the acute phase and is 
asymptomatic should be closely observed for at least 6 hours. Fluids may be forced, and sufficient 
ammonium chloride may be administered for a few days to acidify the urine to help promote urinary 
excretion. If serious toxic symptoms occur from over dosage or sensitivity, it is suggested that 
ammonium chloride (8 g daily in divided doses for adults) three or four days a week be administered 
for several months after therapy has been stopped, as acidification of the urine increases renal 
excretion of the 4-aminoquinoline compounds by 20 to 90 percent. However, caution must be 
exercised in patients with impaired renal function and/or metabolic acidosis. 
 
 
9.  IMMUNOLOGICAL EFFECT OF HCQ  
To assess the immunological effect of HCQ therapy in patients, we will analyze peripheral blood 
mononuclear cells (PBMCs) at days 0 and 30 of treatment, and also, Day 60 (+ 6-week study visit 
window) of treatment.  PBMC and plasma separation and storage will be handled by the Biospecimen 
Procurement and Translational Pathology Shared Resource Facility, per their standard processes 
until samples are ready for analysis.  
 
Changes in markers of immune function/activation will be determined by measuring the percentage 
and absolute number of activated, naïve, and memory T cell subsets within CD4 helper, CD8 
cytotoxic, and Treg subsets using cell marker antibodies to: CD4, CD8, CD45RA, CD45RO, CD25, 
and Foxp3.  Th1, Th2 and Th17 subsets will be identified in the CD4 T cell subset by intracellular 
staining for IFN- ܵ, IL-10 and IL-17 in ex vivo activated PBMCs. Markers for systemic inflammation 
(C-reactive protein, IFN-gamma and TNFa) will be quantified in plasma samples. As a lysomotrophic 
compound, HCQ reduces pH in lysosomes which can promote antigen retention and can promote 
autophagy.  The pH levels in intracellular vesicles will be evaluated by flow cytometry in CD4 and 
CD8 T cell subsets and in monocytes using LysoSensor Yellow/Blue DND-160.  Induction of 
autophagy will be monitored in CD4 and CD8 T cell subsets and in monocytes by evaluating 
expression levels of the autophagy marker, LC3B. 
 
To assess PAR-4 levels we will analyze plasma (or serum) at Day 0, 2 weeks prior to surgery or 
initiation of radiation treatment (corresponds to roughly Day 14 of HCQ therapy); 30-, 60- and 90-days 
post-HCQ initiation; and at the 6-month and 12-month follow-up timepoints (that correspond to a 
standard of care clinic visit 6- and 12-months after cessation of HCQ therapy).  
 
See Study Lab Manual for additional details – a draft of the lab manual is Appendix E


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           24 
     Amendment 4, 16JUN2022 
 
10. Study Calendar / Schedule of Activities   
 
Baseline evaluations are to be conducted within 8 weeks prior to start of HCQ. Scans and ophthalmologic exam must 
be completed less than 8 weeks prior to the start of HCQ regimen. In the event the patient’s condition is deteriorating, 
laboratory evaluations should be repeated more frequently, as clinically indicated and at the discretion of the treating 
physician.  At PSA progression or symptomatic progression: PSA, history and physical/toxicity assessment, CT C/A/P 
and/or fluciclovine or PSMA PET scans to be performed at discretion of treating physician, per standard of care.  
 
Study Calendar  
Procedures 
Pre-study Screening 
 
Enrollment/Baseline Visit 1, Day 0 
Day 14 post-HCQ initiation  
Day 30 post-HCQ initiation 
Day 60 post-HCQ  initiation 
 90 days post-HCQ initiation 
6-months post-HCQ cessation   
 
1 Year Post- HCQ cessation  
2 Years Post-HCQ cessation 
3 Years Post-HCQ cessation 
 Off-Study  
HCQ Drug Dispensing  
 
R 
 
R 
R 
R 
 
 
 
 
 
Adverse Event Evaluation  
 
R 
R 
R 
R 
R 
 
 
 
 
 
HCQ compliance (pill diary) 
 
 
 
R 
R 
R 
 
 
 
 
 
PAR-4 blood sample 1 
 
R 
R 
R 
R 
R 
R 
R 
 
 
 
PBMCs blood collection 2 
 
R 
 
R 
R  
 
 
 
 
 
 
Quality of Life 3 
 
R 
 
 
 
R 
R 
R 
 
 
 
Informed Consent 
R 
 
 
 
 
 
 
 
 
 
 
Demographics 
R 
 
 
 
 
 
 
 
 
 
 
Ophthalmologic Exam 4 
R 
Å ---------------- S ** -------------------Æ  
 
 
 
 PSA  (serum, one tube) 5 
S 
R 
 
R 
 
S 
S 
S 
 
 
 
Imaging 6 
Fluciclovine or PSMA PET or PET/CT scan 
6a  S** 
 
 
 
 
 
 
 
 
 
 
Bone scan 6a S**  
 
 
 
 
 
 
 
 
 
CT chest, abdomen, pelvis 6a  S** 
 
 
 
 
 
 
 
 
 
 
MRI of pelvis 6b S * 
 
 
 
 
 
 
 
 
 
 
Assessment of Disease Progression 6c  
 
S * , ** 
CBC w/ differential 
S 
* 
* 
S 
S 
S 
** 
** 
 
 
 
CMP ** 
S 
* 
* 
S 
S 
S 
** 
** 
 
 
 
 Concomitant Medications 7 
S 
S 
S 
S 
S 
S 
 
 
 
 
 
 Medical History 
S 
 
 
 
 
 
 
 
 
 
 
Height 8 
 
S 
 
 
 
 
 
 
 
 
 
Physical Exam with vitals (including weight) 
and ECOG Performance status 
S 
 ** 
S** 
S 
S 
S 
** 
** 
 
 
 
Survival Status 
 
 
 
 
 
 
 
 
R 
R 
R 
Record date of ADT initiation 9 
 
 
 
 
 
 
 
 
 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           25 
     Amendment 4, 16JUN2022 
 
Study Calendar  
Procedures 
Pre-study Screening 
 
Enrollment/Baseline Visit 1, Day 0 
Day 14 post-HCQ initiation  
Day 30 post-HCQ initiation 
Day 60 post-HCQ  initiation 
 90 days post-HCQ initiation 
6-months post-HCQ cessation   
 
1 Year Post- HCQ cessation  
2 Years Post-HCQ cessation 
3 Years Post-HCQ cessation 
 Off-Study  
 
NOTES:      * per standard of care                     ** at the discretion of the treating physician.  
  Legend: S = standard of care; R = research;  PSA, prostate-specific antigen; PET, positron emission tomography 
                scan; HCQ, hydroxychloroquine; PAR-4, prostate apoptosis response-4; PSMA, prostate-specific membrane antigen PET scan 
   1: Blood (1 tube) will be drawn at each of the 7 noted timepoints for PSA and PAR-4 levels; plasma is preferred (serum is acceptable). 
Timepoints may be +/- 72-hour window at Pre-study and Enrollment.  
        For Day 14, Timepoints may be +/- 120-hour window.  
        Timepoints may be +/- 28-day window at the 3-, 6- and 12-month f/u, coinciding with a clinic visit. 
 
2: for collection of PBMCs (peripheral blood mononuclear cells): one tube per collection timepoint, slated for Day 0, Day 30 
   and Day 60. Day 0 and Day 30 timepoints have a +/- 14-day window. Day 60 has a +6 week window. This is explicated in 
   greater detail in study lab manual.   
 
3: QOL is assessed via EORTC QLQ-C30 + QLQ-PR25 at 4 timepoints 
       - at a clinic visit prior to initiation of HCQ   
       - at a clinic visit; either the end of HCQ administration OR when HCQ is discontinued (if stop it early)  
      - at 6-mos and 12-mos post-treatment. These final two QOL timepoints can be +/- 8 weeks, and conducted during a regularly scheduled,  
            standard of care clinic visit.      
 
  4: Requisite pre-study eye exam; Eye exam may be repeated during HCQ administration if vision complaints. 
  5: One tube of blood will be drawn at each of the 6 noted timepoints for serum PSA; this is standard of care for baseline and every 3 months (4 of 
the 6 draws), with two additional draws scheduled. Timepoints may be +/- 72-hour window at screening and enrollment. 
 
 
 6:  Imaging at baseline, pre-study: Patients who have confirmed recurrent disease of the prostate are deemed ineligible for this trial. As such, all 
eligible patients will undergo standard of care imaging to identify metastases (initial evaluation of status/extent of recurrent disease), including:   
      6a: All eligible patients will undergo standard of care imaging to assess extent of metastatic disease at baseline; fluciclovine or PSMA PET 
scans are preferred; other scans (PET/CT scan, bone scan and/or CT of the chest, abdomen and pelvis) may be performed as needed at 
baseline to assess extent of metastatic disease, per standard of care. 
      6b: Additionally, eligible patients who have undergone radiation prior to study enrollment will have an MRI of pelvis (in addition to previously 
named imaging studies) to assess for recurrent local disease. Suspicious lesions of the prostate seen on MRI will be biopsied.  
       
     6c: Imaging on Study as work-up for disease progression: Once a patient is enrolled on-study, imaging to assess disease progression will  
          proceed per standard of care, based on clinical indicators such as rising PSA and/or other clinical symptoms. Per RECIST  
        1.1, tumor re-evaluation scheduled every 6-8 weeks at the discretion of the treating physician based on clinical indicators. Notably, a rising  
        PSA and/or other clinical symptoms could trigger a scan/imaging in an earlier timeframe.  
  7: Concomitant Medications will be assessed per standard of care at the discretion of the treating physician; during HCQ administration, Con 
Meds will be assessed with a particular focus on medications contraindicated for use with HCQ.  
  8: Height will be evaluated once while on-study. Height can either be assessed via the patient’s medical record, and/or assessed directly (in  
         conjunction with vital signs during a clinic visit) 
  9: ADT initiation: record date and reason for ADT initiation. Reasons for ADT initiation include: PSA/biochemical progression, Symptomatic 
Progression, Local Progression of baseline-detected lesions (either soft-tissue or bone lesions), or Appearance of new metastatic lesions.  
 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           26 
     Amendment 4, 16JUN2022 
 
11. MEASUREMENT OF HCQ EFFECT 
11.1 PRIMARY OBJECTIVE  
 
To assess the effect of HCQ on PAR-4, first compliance with HCQ planned dose regimen should be ascertained.  
 
HCQ regimen compliance: pill diaries (Appendix D) and/or patient-reported HCQ compliance will be 
evaluated to assess participant adherence to HCQ daily regimen at follow-up clinic visits with study staff. 
Additionally, study staff may institute a telephone check with study participants on a PRN basis, should compliance 
to the HCQ regimen need to be monitored outside regular clinic visit schedule.  
 
Participants who completed 80% of the planned HCQ doses will be considered evaluable for the Primary Endpoint, 
PAR-4 increase.   
 
PAR-4 level will be assessed for each participant at the following timepoints:  
 
Enrollment/Baseline visit 
 
Day 14 post- HCQ initiation  
 
Day 30 of HCQ 
 
Day 60 of HCQ  
 
Day 90 of HCQ 
 
6-month follow-up (during a standard of care visit) 
 
12-month follow-up (during a standard of care visit) 
 
It is expected that HCQ will induce an elevation of PAR-4 expression among 50% of the participants within the 
90-day administration of HCQ. The elevation is expected to be a 50% increase from baseline PAR-4 levels 
among half of the study participants.  
 
 
11.2 SECONDARY OBJECTIVES:  
 
11.2.1 HCQ safety analysis and Treatment Toxicity: frequency and incidence tables of toxicity and AEs will be 
generated. Toxicity will be assessed using Common Terminology Criteria for Adverse Events V5.0 (for HCQ and 
for radiation therapy), as well as the Clavien-Dindo classification of surgical complications in the case of patients 
who underwent surgery (Appendix F). All patients will be evaluable for toxicity (HCQ) from the time of their first 
treatment with Hydroxychloroquine.  
 
 
 
11.2.2 HCQ immunologic effect on PAR-4 Levels: as measured by serum (or plasma) blood collected at multiple 
timepoints. PAR-4 secretion is expected to come primarily from normal cells of the patient. The contribution of the 
tumor cells to serum levels of PAR-4 is expected to be minimal, but this has not been directly tested. Association 
between PAR-4 levels and clinical stage will be assessed.  
 
 
 
11.2.3  Quality of Life: This is assessed by two validated patient-reported outcomes measures, the EORTC QLQ-
C30 and QLQ-PR25 questionnaires. All items assessing symptoms and functional domains employ a 4-point Likert 
scale, with responses ranging from “Not At All”, “A Little”, “Quite a Bit” and “Very Much.” Study participants will be 
instructed to choose one response per item. The EORTC QLQ-C30 is a 30-item questionnaire assessing multiple 
domains of global health-related quality of life in cancer populations. It includes one global QOL rating, 5 functioning 
scales (physical, cognitive, emotional, role and social) and 9 symptom-specific subscales (fatigue, N/V, pain, 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           27 
     Amendment 4, 16JUN2022 
 
dyspnea, insomnia, constipation, diarrhea, appetite loss). The EORTC QLQ-PR25 is a prostate cancer module 
meant for use among patients with prostate cancer in varying in disease stage and treatment modality (i.e., surgery, 
chemotherapy, radiotherapy, etc.), which complements the QLQ-C30. The QLQ-PR25 module comprises 25 items 
assessing disease symptoms, treatment side effects, sexual functioning and sexual activity. The functional scales 
are sexual activity and sexual functioning; the 4 symptom scales are urinary symptoms, bowel symptoms, hormonal 
treatment-related symptoms, and incontinence aid. All participants will complete items 1-19 as well as items 20-21 
(which query current sexual activity). Completion of Items 22-25 are conditional on being sexually active (and 
comprise the Sexual Functioning subscale), and thus will only be completed by a subgroup of study patients. For 
interpretation of scores on the two EORTC QOL questionnaires, all of the scales and single-item measures range 
in score from 0 – 100. A high scale score represents a higher response level – so that a higher score represents a 
higher (“better”) level of functioning OR a higher (“worse) level of symptoms. See Appendix G for additional details 
and the patient self-report questionnaires.  
 
 
 
11.3  Four Types of Disease Progression 
 
 
1. PSA or Biochemical Progression: defined as a PSA increase of  25% DQGQJP/LI36$ 
  
ZDVQJP/from baseline 25D36$LQFUHDVHRILI36$ZDVQJP/DWVWXG\ 
  
enrollment).  
 
 
 
2. Symptomatic Progression: defined as increasing pain from baseline-detected metastatic lesion.  
 
Time to first symptomatic event will be calculated from study enrollment until the event of 
  
symptoms due to metastatic disease.  
 
 
3. Local Progression of baseline-detected lesions depend on site:   
- 3a. soft-tissue metastatic lesion: local progression is defined DVDQLQFUHDVHRILQWKH
 
largest tumor dimension with a minimum absolute increase of 5 mm. All lesions are 
 
considered target lesions, irrespective of size, if they are suspicious on choline PET-CT. 
 
See Appendix H.1 for RECIST v1.1.  
 
- 3b. bone metastases: local progression is assessed using the MD Anderson Cancer Center-
 
criteria26-27, and defined as DLQFUHDVHLQVL]HRIDPHDVXUDEOHOHVLRQor D
 
increase in the size of ill-defined lesions on CT considered to be progression.  
 
MDA bone-specific response criteria in Appendix H.2.   
 
 
 
 
 
 
4. Distant Progression: appearance of new metastatic lesions 
 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           28 
     Amendment 4, 16JUN2022 
 
11.4 Definition of Disease Assessments to evaluate Progression-Free Survival and ADT-
Free Survival 
 
11.4.1  ADT-Free Survival 
Indications to start Androgen Deprivation Therapy include appearance of new metastases (i.e., 
progression to more than the three baseline-detected metastases, “distant progression”), or local 
progression of baseline-detected metastases.  
ADT initiation can be considered at Symptomatic Progression or at PSA Progression. Additionally, 
CT C/A/P and/or fluciclovine or PSMA PET scans may be performed at the time of either 
Symptomatic or PSA Progression at discretion of the treating physician. 
 
Date of ADT initiation will be recorded for each participant, accompanied by the reason for 
initiation.  
    
ADT-free Survival is defined as the time between study enrollment until the start of ADT or death 
as a result of any cause. Patients who do not start ADT at the time of last follow-up will be 
censored at that time point.  
- 
Initiation of ADT will be recorded if it occurs after initiation of HCQ. This will also be 
recorded for enrolled patients who have ADT initiation occurring after completion of 
surgery/radiation but prior to HCQ initiation (as this is exclusion criterion, the patient will be 
removed from the study).  
- 
After HCQ administration is completed, survival status will be assessed at ongoing clinic 
visits for one year post-enrollment, and afterwards, annually for up to 2 additional years (i.e., 
at Year 2 post-enrollment and at Year 3 post-enrollment).  
 
11.4.2  Progression-Free Survival (time to clinical progression)  
Four types of progression are defined in 11.3. Progression is calculated from time of study 
enrollment until progression (per the 4 specified definitions) or death. Events for PFS are:  
1. PSA or biochemical progression: defined as a PSA increase of  25% DQGQJP/LI
36$ZDVQJP/IURPEDVHOLQH) 
2. Symptomatic progression: increasing pain from metastatic lesion  
3. Local progression of baseline-detected lesions: each metastasis is a target lesion 
  
independently assessed as:  
 
- soft-tissue lesions assessed per RECIST v1.1 (Appendix H.1)  
 
- bone lesions assessed per MDA bone-specific response criteria (Appendix H.2) 
4. Distant progression: appearance of new metastatic lesions.  
 
If an event is identified, then the time to the event will be recorded as the first instance where any 
of the above four situations occur. 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           29 
     Amendment 4, 16JUN2022 
 
12. DATA REPORTING AND REGULATORY REQUIREMENTS 
 
   Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.  
 
12.1 Method of Data Reporting  
This study will require data submission and reporting via the OnCore Database, which is the official 
database of the MCC CRO. Instructions for submitting data are listed in the Data Management Plan created 
by the Markey Data Management staff in conjunction with the MCC CRO and the QA Office, per their SOPs 
(see S13.4, below).  
 
12.2 Responsibility for Data Submission and Oversight 
Study staff is responsible for submitting study data and/or data forms to OnCore as per the MCC CRO 
SOP’s. This trial will be monitored by the MCC DSMC on a schedule determined by the PRMC at the initial 
PRMC review. The CRO SRF staff is responsible for compiling and submitting data for all participants and 
for providing the data to the PI for review. 
 
13. STATISTICAL CONSIDERATIONS  
13.1 Study Design, Sample Size Considerations and Accrual Rate  
 
13.1.1 Study Design  
 
A single-arm, Phase II trial will be employed to obtain initial assessment of the effect of HCQ in 
modulation of PAR4 levels among patients with oligometastatic prostate cancer treated with surgery or 
radiation.  The primary endpoint is based on obtaining a 50% increase in PAR-4 levels from baseline within 
the 3-month period of HCQ administration.  
 
13.1.2 Sample size justification  
 
Based on an ongoing Phase I trial of HCQ, we will assume that the proportion of patients who will 
exhibit a 50% induction in PAR-4 from baseline levels is equal to 0.50 compared to a null hypothesis of 0.20.  
A sample of 18 patients will provide 84% power to detect this hypothesized difference in proportion based on 
a two-sided test with 5% significance level. Assuming no more than a 10% drop out rate, we will enroll a total 
of 20 patients into the study. No patients dropped out of our Phase 1 study, which ascertained 200 mg daily 
as the optimal biological dose.25  
 
13.1.3 Accrual Rate 
 
The accrual rate is estimated to be one patient per month. Based on this enrollment rate, we will 
complete the accrual of 20 patients in about 18 months.  
 
13.2 Interim Monitoring for Efficacy 
We propose to assess the proportion of patients who will exhibit induction levels in PAR-4 after half of the 
patients have been enrolled into the trial.  Bayesian interim monitoring methods using posterior probabilities, 
credible intervals and predictive probabilities will be calculated based on proportion of patients exhibiting a 
50% induction in PAR-4 levels.  Briefly, a beta distribution will be assumed for the proportion of PAR-4 
response and uninformative and neutral prior distributions will be utilized.   
After half of the participants are enrolled on-study (n = 10-11), the proportion of patients with PAR-4 induction 
will again be estimated and posterior distributions and predictive posterior distributions will be calculated.  
Accrual will continue during interim analysis.   Based on posterior probabilities and credible intervals from the 
interim analysis, we will then determine whether to continue or stop accrual efforts to attain the planned 
sample size of 20.   
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           30 
     Amendment 4, 16JUN2022 
 
13.3 Analysis of Primary and Secondary Endpoints 
To be considered “evaluable” a patient must have completed 80% of the 90-day planned dose of HCQ.  
 
13.3.1 PAR-4 Levels  
Patient compliance with planned HCQ regimen will be assessed by the treating physician and the patient-
reported pill diary will be reviewed. For each evaluable patient, descriptive statistics will be calculated to 
summarize PAR-4 levels at each time point of follow-up.  Percent change from baseline PAR-4 compared to 
each follow-up time point will likewise be calculated.  The proportion of patients who exhibit a 50% induction 
in PAR-4 compared to baseline within the 3-month therapy period will be calculated and a one-sample test 
for proportion will be performed.   
Secondary analyses of the primary endpoint will also be performed.  Continuous changes in PAR-4 levels will 
also be assessed using paired t-test or nonparametric analog.  Linear mixed models will also be employed to 
analyzed repeatedly measured levels of PAR-4 and association with clinical parameters as well as PSA levels.  
Other secondary analyses will include summary of the PAR-4 induction profile over the 3-month treatment 
period and after end of therapy period.  
 
13.3.2 Analysis of Secondary Endpoints 
Clinical Endpoints.  
Progression-free survival (PFS) will be estimated using the Kaplan-Meier method and estimates of median 
PFS and PFS rates at specific time points will be calculated.   
Likewise, median, 1-year and 3-year ADT-free survival will be estimated using the Kaplan-Meier method.   
Exploratory analysis for association of PFS and ADT-free survival with PAR-4 and PSA levels will be assessed 
using the Cox regression model.  
Correlative and QOL endpoints.  PSA levels will be assessed according to the schedule described by the 
study calendar above and PSA doubling time will be calculated.  Association of PSA levels with PAR-4 levels 
will be determined using Spearman or Pearson’s correlation coefficient. Quality of life (QOL) measured by the 
EORTC QLQ-C30 supplemented with QLQ-PR25 will be evaluated and descriptive statistics of QOL scores 
will be calculated.  Association of QOL with PAR-4, PSA and clinical endpoints will be determined in an 
exploratory manner using correlations and survival analysis models.  
 
Safety analysis.   All patients who received study drug will be included in the safety analysis.  Frequency and 
incidence tables of toxicity and AEs will be generated in the overall patient group. We will generate a safety 
report for review by the Markey Cancer Center’s Data Safety and Monitoring Committee (DSMC) based on 
an intent-to-treat population.  
 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           31 
     Amendment 4, 16JUN2022 
 
13.4 Data Management 
Data management will be performed by cross-team members at MCC, including members from the Cancer 
Research Informatics (CRI) SRF and BB SRF, who will work\ closely with the MCC CRO. A protocol-specific 
Data Management Plan (DMP) will be authored by a senior data manager in collaboration with the 
biostatistician and CRO, each team will be expected to review and sign off on the DMP prior to finalization. In 
order to maintain best clinical practices in data management, the DMP may include, but not be limited to 
CRF/eCRF design, database build and design, database training, edit check/validation specifications, study 
database testing/ release, data and paper workflow, 
report, metrics, query/discrepancy management, 
management of external (including lab) data, medical coding, SAE handling/reconciliation, data transfers and 
database lock. The protocol-specific DMP will additionally define the schedule at which data will be accessed 
by study statisticians to perform statistical programming for conduct of data 
quality, data control, data 
management, generation of interim reports and statistical analysis. Furthermore, the CRI will utilize the Labkey 
system to develop a web-based data entry system for the PAR-4 and other correlative biomarkers that will be 
evaluated using western blot and ELISA assays from Dr. Rangnekar’ s laboratory. The study statistician will 
access to both Oncore clinical databases and Labkey system. Cross-team members will collaborate to 
establish procedures and timelines for quality control, audits, query resolution, interim safety and final data 
analysis. 
 
 
The study statistician and staff from the Biostatistics and Bioinformatics Shared Resource (BB SRF) of the 
Markey Cancer Center (MCC) will work closely with the study team, the Clinical Research Office (CRO) at 
MCC and the Cancer Research Informatics (CRI) Shared Resource at MCC to develop the Data Management 
Plan (DMP) for this trial. The DMP will provide details for development of eCRFs in the OnCore system, trial-
specific processes for data entry, generation of reports, data management and statistical analysis. 
Specifically, the statistician will attend several meetings including the eCRF development meeting, Data 
Management and Development meeting and the Protocol Initiation meeting. Appropriate and accurate 
collection of primary and secondary study endpoints and inclusion of valid values and range checks for data 
fields will be designed for the eCRFs. The OnCore clinical trial management system, managed by Markey’s 
CRO and CRI, will be the primary database repository of clinical data from all patients enrolled into this trial. 
Furthermore, the CRI at MCC has established workflows for receipt, storage and secure access of high-
throughput bioinformatics data (next generation sequencing) using the university’s high performance 
computing facility. The study statistician and Dr. Chi Wang from the BB SRF have access to both OnCore 
clinical databases and bioinformatics data. Data will be accessed by the study statistician on a regularly-
scheduled basis as defined in the DMP to perform statistical programming for conduct of data quality control, 
data management, generation of interim reports and statistical analysis. In collaboration with the study team, 
procedures will be developed for timelines for data quality control, resolution of data queries, interim safety 
reporting and final data analysis. 
 
A Data Management Specialist (DMS) from CRI SRF will be assigned to build the study-specific calendar and 
appropriate eCRF for data collection. User Acceptance Testing (UAT) will be performed and reviewed by 
study team members, Data Management Specialist Sr, (DMSr), CRA, and export files by statistician, to assure 
all data collection tools are appropriate for the study data capture and all data export formatting is appropriate 
for analysis; eCRF’s will be updated and retested as needed. Additional data management study start-up 
activities, (i.e. writing of Data Management Plan, data validation programs, reporting and review tools) will be 
conducted concurrent to database build and testing. 
 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           32 
     Amendment 4, 16JUN2022 
 
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(Version 3.2018).      www.nccn.org/professionals/physician_gls/pdf/prostate 
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7. Sharifi N, Gulley JL, Dahut WL. Androgen deprivation therapy for prostate cancer. JAMA. 2005;294:  
 
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8. Tosoian JJ, Gorin MA, Ross AE, Pienta KJ, Tran PT, Schaeffer EM. Oligometastatic prostate cancer: 
 
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9. Perlmutter MA, Lepor H. Androgen deprivation therapy in the treatment of advanced prostate cancer. 
 
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11. Tamoto E, Tada M, Murakawa K, et al. Gene-expression profile changes correlated with tumor 
 
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PMID: 15173069 
12. Wuttig D, Baier B, Fuessel S, et al. Gene signatures of pulmonary metastases of renal cell carcinoma 
 
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474-82. PMID: 19391132 
13. Lussier YA, Xing HR, Salama JK, et al. MicroRNA expression characterizes oligometastasis(es). PLoS 
 
One. 2011;6: e28650. PMC3236765 
14. Ost P, Bossi A, Decaestecker K, et al. Metastasis-directed therapy of regional and distant recurrences  
 
after curative treatment of prostate cancer: A systematic review of the literature. Eur Urol. 2015;67: 
 
852-63. PMID: 25240974 
15. Berkovic P, De Meerleer G, Delrue L, et al. Salvage stereotactic body radiotherapy for patients with 
 
limited prostate cancer metastases: Deferring androgen deprivation therapy. Clin Genitourin Cancer. 
 
2013;11: 27-32. PMID: 23010414 
16. Decaestecker K, De Meerleer G, Lambert B, et al. Repeated stereotactic body radiotherapy  for 
 
oligometastatic prostate cancer recurrence. Radiat Oncol. 2014;9: 135. PMC4066290 
17. Ost P, Reynders D, Decaestecker K, et al. Surveillance or metastasis-directed therapy for 
 
oligometastatic prostate cancer recurrence: A prospective, randomized multi-center phase II trial. J 
 
Clin Oncol. 2018; 36: 446-53. PMID: 29240541 
18. Hebbar N, Wang C, Rangnekar VM. Mechanisms of apoptosis by tumor suppressor PAR-4. J Cell  
 
Physiol. 2012;227: 3715-21. PMC3414654 
19. Burikhanov R, Shrestha-Bhattarai T, Hebbar N, et al. Paracrine apoptotic effect of p53 mediated by 
 
tumor suppressor PAR-4. Cell Rep. 2014;6: 271-7.  PMC3922895 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           33 
     Amendment 4, 16JUN2022 
 
20. MacLean KH, Dorsey FC, Cleveland JL, Kastan MB. Targeting lysosomal degradation induces p53-
 
dependent cell death and prevents cancer in mouse models of lymphomagenesis. J Clin Invest. 
 
2008;118: 79-88. PMC2148253 
21. Kimura T, Takabatake Y, Takahashi A, Isaka Y. Chloroquine in cancer therapy: A double-edged sword 
 
of autophagy. Cancer Res. 2013;73: 3-7.  PMID: 23288916 
22. Rojas-Puentes LL, Gonzalez-Pinedo M, Crismatt A, et al. Phase II randomized, double-blind, placebo-
 
controlled study of whole-brain irradiation with concomitant chloroquine for brain metastases. Radiat 
 
Oncol. 2013;8: 209. PMC3848663 
23. Ratikan JA, Sayre JW, Schaue D. Chloroquine engages the immune system to eradicate irradiated 
 
breast tumors in mice. Int J Radiat Oncol Biol Phys. 2013;87: 761-8. PMID: 24138918 
24. Burikhanov R, Hebbar N, Noothi S, et al. Chloroquine-inducible PAR-4 secretion is essential for tumor 
 
cell apoptosis and inhibition of metastasis. Cell Rep. 2017;18: 508-19. PMC5264245 
25. Wang P, Burikhanov R, Jayswal R, et al. Neoadjuvant administration of hydroxychloroquine in a phase 1 
  
clinical trial induced plasma Par-4 levels and apoptosis in diverse tumors. Genes Cancer. 2018; 9 (5- 
 
6): 190-97. PMC6305107 
26. Hamoaka T, Madewell J, Podoloff D, et al. Bone imaging in metastatic breast cancer. J Clin Oncol.  
      2004; 22(14): 2942-53. PMID: 15254062 
27. Costelloe C, Chuang H, Madewell J, et al. Cancer response criteria and bone metastases: RECIST 1.1,  
            MDA and PERCIST. J Cancer. 2010; 1; 80-92. PMC2938069 
28.  Clavien P, Barkun J, doe Oliveria M, et al. The Clavien-Dindo Classification of Surgical Complications:  
 
Five-Year Experience. Annals Surgery. 2009; 250(2): 187-96. PMID: 19638912 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           34 
     Amendment 4, 16JUN2022 
 
16. APPENDICES 
 
 
 
Appendix A: Performance Status Scales  
Appendix B: Medications known to interact with HCQ 
Appendix C:  Instructions for taking HCQ 
Appendix D: Pill Dairy (sample / patient version) 
Appendix E: Lab Manual for FCIM – assays 
Appendix F: Clavien-Dindo Classification 
Appendix G: EORTC Quality of Life Measures 
    Summary of the two complimentary QOL measures 
EORTC QLQ - C30 
EORTC QLQ-PR25 
Scoring Instructions for the QLQ-PR25  
Appendix H: Response Criteria - Disease Assessment 
                H.1 RECIST v1.1 for soft-tissue lesions 
H.2 MDAnderson bone-specific response criteria 
 
 
 


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Appendix A.  PERFORMANCE STATUS CRITERIA  
 
 
 
ECOG Performance Status Scale 
 
Karnofsky Performance Scale 
Grade 
Description 
Percent 
Description 
 
0 
Normal activity.  Fully active, able to 
carry on all pre-disease performance 
without restriction. 
100 
Normal, no complaints, no evidence of 
disease. 
90 
Able to carry on normal activity; minor 
signs or symptoms of disease. 
 
 
1 
Symptoms, but ambulatory. Restricted 
in physically strenuous activity, but 
ambulatory and able to carry out work 
of a light or sedentary nature (e.g., 
light housework, office work). 
 
80 
Normal activity with effort; some signs 
or symptoms of disease. 
 
70 
Cares for self, unable to carry on normal 
activity or to do active work. 
 
 
2 
In bed <50% of the time. Ambulatory 
and capable of all self-care, but unable 
to carry out any work activities.  Up and 
about more than 50% of waking hours. 
 
60 
Requires occasional assistance, but is 
able to care for most of his/her needs. 
50 
Requires considerable assistance and 
frequent medical care. 
 
3 
In bed >50% of the time.  Capable of 
only limited self-care, confined to bed or 
chair more than 50% of waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated.  Death not imminent. 
 
4 
100% bedridden. Completely 
disabled.  Cannot carry on any self-
care.  Totally confined to bed or chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly. 
 
5 
 
Dead. 
 
 
0 
 
Dead. 
 
 
 


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Appendix B.  POSSIBLE DRUG INTERACTIONS WITH HYDROXYCHLOROQUINE 
 
Proper Name 
Effect/clinical comment 
Any medication known to cause Adverse ocular reactions  AND/OR  Adverse skin reactions  
Agalsidase 
 theoretical risk of inhibition of intra-cellular Į-galactosidase activity when HCQ is 
co-administered with agalsidase. 
 
Amiodarone 
There may be an increased risk of inducing ventricular arrhythmias if HCQ is used 
concomitantly with other arrhythmogenic drugs. 
 
Antacids 
As with chloroquine, antacids may reduce absorption of HCQ so it is advised that a 
four-hour interval be observed between HCQ and antacid dosing. 
Anti-diabetics 
May enhance the effects of a hypoglycemic treatment, a decrease in doses of 
antidiabetic drugs may be required. 
Anti-epileptics 
The activity of antiepileptic drugs might be impaired if co-administered with HCQ. 
Anti-malarials  
known to lower the 
convulsion threshold 
HCQ can lower the convulsive threshold. Co-administration of HCQ with other 
anti-malarials known to lower the convulsion threshold (e.g., mefloquine) may 
increase the risk of convulsions. 
 
Mefloquine 
HCQ can lower the convulsive threshold. Co-administration of HCQ with other 
antimalarials known to lower the convulsion threshold (e.g., mefloquine) may 
increase the risk of convulsions. 
Arrhythmogenic 
drugs 
There may be an increased risk of inducing ventricular arrhythmias if HCQ is used 
concomitantly with other arrhythmogenic drugs. 
Cyclosporine 
An increased plasma ciclosporin level was reported when ciclosporin and HCQ 
were co-administered. 
Digoxin 
May result in increased serum digoxin levels; serum digoxin levels should be 
closely monitored in patients receiving concomitant treatment. 
Insulin 
May enhance the effects of a hypoglycemic treatment, a decrease in doses of 
insulin may be required. 
Moxifloxacin 
There may be an increased risk of inducing ventricular arrhythmias if HCQ is used 
concomitantly with other arrhythmogenic drugs. 
 
Due to its similarity in structure and pharmacokinetics with chloroquine, a similar effect may be 
expected for HCQ with the following medications and their derivatives, although specific reports 
have not appeared regarding their use with HCQ  
Praziquantel 
  Chloroquine has been reported to reduce the bioavailability of praziquantel. A   
  similar effect may be expected for HCQ. 
Pyridostigmine 
 Potential antagonism of effect of pyridostigmine. 
Human diploid cell 
rabies vaccine 
  Reduction of the antibody response to primary immunization with intradermal  
  human diploid cell rabies vaccine. 
Neostigmine 
 Antagonism of effect of neostigmine. 
Aminoglycoside 
antibiotics 
 Potentiation of its direct blocking action at the neuromuscular junction by  
  aminoglycoside antibiotics. 
 
Cimetidine 
  Inhibition of its metabolism by cimetidine, which may increase plasma  
  concentration of the antimalarial. 
 
 


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Appendix C.  Oral hydroxychloroquine administration 
 
Hydroxychloroquine should be taken with a meal or a glass of milk. Try to take your hydroxychloroquine 
at about the same time every day.  
 
Please record any side effects from HCQ in the medication diary given to you by your study team. 
 
x Use of nausea medicines (Phenergan, Compazine, or Zofran) may be helpful, and these 
medicines are best given about 30-60 minutes before the hydroxychloroquine. Please discuss 
this with your doctor. 
 
x If you are unable to take the medicine, call your doctor for further instructions. 
 
x If you vomit within 30 minutes of taking the medicine, you may take a second dose of the 
medication. Do not take more than two doses of medication in the same day. 
 
x If you vomit longer than 30 minutes after taking the medicine, do not take any more 
hydroxychloroquine that day. 
 
x If you have any questions, call Dr. Andrew James at (859) 257-4488  or Dr. Peng Wang at (859) 
323-6522 for further instructions.  
 
 
Common hydroxychloroquine side-effects 
What can I do if I experience this? 
Feeling sick, stomach pain, loss of appetite, 
diarrhea 
Remember to take the tablets after food or with a 
drink of milk. Stick to simple foods-avoid spicy or 
rich meals. 
Headache 
Ask your doctor or pharmacist to recommend a 
suitable painkiller. 
Eye problems (for example, blurred vision or 
sensitivity to light) 
Let your doctor know about this as soon as 
possible. 
Skin rash or itching 
If this becomes troublesome, speak with your 
doctor. 
 
If you have any other symptoms that you think may be due to this medicine, speak with Dr. Andrew James 
or Dr. Peng Wang (after business hours or on weekends call 859-323-5321),  or your pharmacist. 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           38 
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Appendix D.  PILL DIARY (HCQ oral administration log) – sample draft 
 
Day of 
course 
 
Date 
 
AM 
 
PM 
 
Side effects 
1 
 
 
 
 
2 
 
 
 
 
3 
 
 
 
 
4 
 
 
 
 
5 
 
 
 
 
6 
 
 
 
 
7 
 
 
 
 
8 
 
 
 
 
9 
 
 
 
 
10 
 
 
 
 
11 
 
 
 
 
12 
 
 
 
 
13 
 
 
 
 
14 
 
 
 
 
15 
 
 
 
 
16 
 
 
 
 
17 
 
 
 
 
18 
 
 
 
 
19 
 
 
 
 
20 
 
 
 
 
21 
 
 
 
 
22 
 
 
 
 
23 
 
 
 
 
24 
 
 
 
 
25 
 
 
 
 
26 
 
 
 
 
27 
 
 
 
 
28 
 
 
 
 
29 
 
 
 
 
30 
 
 
 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           39 
     Amendment 4, 16JUN2022 
 
Day of 
course 
 
Date 
 
AM 
 
PM 
 
Side effects 
31 
 
 
 
 
32 
 
 
 
 
33 
 
 
 
 
34 
 
 
 
 
35 
 
 
 
 
36 
 
 
 
 
37 
 
 
 
 
38 
 
 
 
 
39 
 
 
 
 
40 
 
 
 
 
41 
 
 
 
 
42 
 
 
 
 
43 
 
 
 
 
44 
 
 
 
 
45 
 
 
 
 
46 
 
 
 
 
47 
 
 
 
 
48 
 
 
 
 
49 
 
 
 
 
50 
 
 
 
 
51 
 
 
 
 
52 
 
 
 
 
53 
 
 
 
 
54 
 
 
 
 
55 
 
 
 
 
56 
 
 
 
 
57 
 
 
 
 
58 
 
 
 
 
59 
 
 
 
 
60 
 
 
 
 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           40 
     Amendment 4, 16JUN2022 
 
Day 
of course 
Date 
AM 
PM 
Side effects 
61 
 
 
 
 
62 
 
 
 
 
63 
 
 
 
 
64 
 
 
 
 
65 
 
 
 
 
66 
 
 
 
 
67 
 
 
 
 
68 
 
 
 
 
69 
 
 
 
 
70 
 
 
 
 
71 
 
 
 
 
72 
 
 
 
 
73 
 
 
 
 
74 
 
 
 
 
75 
 
 
 
 
76 
 
 
 
 
77 
 
 
 
 
78 
 
 
 
 
79 
 
 
 
 
80 
 
 
 
 
81 
 
 
 
 
82 
 
 
 
 
83 
 
 
 
 
84 
 
 
 
 
85 
 
 
 
 
86 
 
 
 
 
87 
 
 
 
 
88 
 
 
 
 
89 
 
 
 
 
90 
 
 
 
 
 
 


HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           41 
     Amendment 4, 16JUN2022 
 
 
APPENDIX E. Lab Manual and summary of work from Flow Cytometry & Immune Monitoring SRF 
 
Personnel: 
Don Cohen, PhD (Director of Flow Cytometry and Immune Monitoring SRF) (FCIM) 
MS419, UK Medical Center, Lexington KY 40536 
don.cohen@uky.edu; 859-323-5131 
 
Jerold G. Woodward, PhD (Co-director of Flow Cytometry and Immune Monitoring SRF) 
MN426, UK Medical Center, Lexington KY 40536  
Jwood1@uky.edu; 859-323-5538 
 
Siva k Gandhapudi, PhD (Manager of Immune Monitoring Lab) 
MN421, UK Medical Center, Lexington KY 40536 
skgand2@uky.edu; 859-323-5584 
 
Jennifer Strange, BS (Manager of Flow Cytometry Lab) 
MS408, UK Medical Center, Lexington KY 40536 
jstra1@uky.edu ; 859-323-6859 
 
Immune monitoring procedures and assays to be performed: 
Overview:  Blood from HCQ-treated patients will be drawn into BD Vacutainer® CPT™ Mononuclear Cell 
Preparation Tube ( 8ml ) containing Sodium Heparin at days 0, 30, and 60 of treatment. At each time 
point, de-identified blood samples in CPT tubes will be sent to FCIM for immediate separation of plasma 
and peripheral blood mononuclear cells (PBMCs) and cryopreservation. All cryopreserved blood samples 
will be assayed in bulk following collection of all patient samples. At that time, PBMCs will be assessed for 
immune phenotypes and function as detailed in the following section.  Plasma will be assessed for 
cytokine levels as detailed below. 
 
PBMC assays 
1. Immunophenotyping of T cell subsets 
2. Intracellular cytokine (IL-10, IL-17, and IFN-ܵ) in T cell subsets 
3. Lysosomal acidification in T cell subsets 
4. Expression of autophagy in T cell subsets 
Plasma assays 
1. Concentration of IFNܵ in plasma 
2. &RQFHQWUDWLRQRI71)ĮLQSODVPD 
3. Concentration of C-reactive protein in plasma


 
 
HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           42 
     Amendment 4, 16JUN2022 
 
Appendix E, continued                                           PBMC Assays 
 
Immunophenotyping of T cell subsets: 
1. Freshly thawed aliquots of each PBMC sample (2 x 106 cells/vial) will be resuspended in FACS 
staining Buffer (100μl) containing Human IgG Fc-receptor blocking antibody for 20 min. 
2. After  blocking,  antibody  cocktail  (T  cell  cocktail)  (50μl)  will  be  added  to  each  tube  and 
incubated @ 4oC for 60 min in the dark. 
 
Table 1:  T cell antibody cocktail (fluorochromes are tentative) 
# 
Antibody 
Fluorochrome 
Dilution (final) 
1 
Anti-human CD3 
FITC 
Optimal dose determined by titration. 
2 
Anti-human CD4 
BV420 
Optimal dose determined by titration. 
3 
Anti-human CD8 
PercP 
Optimal dose determined by titration. 
4 
Anti-human CD45RA 
APC 
Optimal dose determined by titration 
5 
Anti-human CD45RO 
PE 
Optimal dose determined by titration. 
6 
Anti-human CD25 
Texas-red 
Optimal dose determined by titration. 
NOTE: Single antibody controls will be prepared with each of the above antibodies using 
OneComp eBeads (eBioscience). Appropriate FMO controls will be run to identify some cell 
subsets. 
3. Cells will be washed twice by adding 4 ml of PBS and centrifuging cells @1400 RPM for 5 min. 
4. Cells then will be fixed using 100ul of paraformaldehyde (4% in PBS) and incubated for 
15 min @4oC. 
5. Cells will be washed twice with PBS and resuspended in FACS buffer for flow cytometric 
analysis. 
 
Intracellular cytokine staining for detection of IL-10, IL-17, and IFN-ܵ: 
1. Freshly thawed aliquots of each PBMC sample (2 x 106 cells/vial) will be resuspended in 1 ml 
of cell culture media (1X106 cells/ml). 
2. PBMCs will be cultured in IL-2 containing media overnight to allow for recovery of cells from 
thawing. 
3. PBMCs will be cultured in the presence of PMA/ionomycin (60ng/3μM) for 6hrs in a cell culture 
media supplemented with BD GolgiStop. 
4. After incubation, cells will be washed twice with FACS cell staining buffer and resuspended in 
FACS staining buffer (100μl) containing Human IgG Fc-receptor blocking antibody for 20 min. 
5. After blocking, antibody cocktail (Intracellular cytokine cocktail) (50μl) will be added to each tube 
and incubated @ 4oC for 60 min in the dark. 
 
Table 2:  Intracellular cytokine cocktail (flurochromes are tentative) 
 
# 
Antibody 
Fuorochrome 
Dilution (final) 
1 
Anti-human CD3 
FITC 
Optimal dose determined by titration. 
2 
Anti-human CD4 
BV420 
Optimal dose determined by titration. 
3 
Anti-human CD8 
PerCP 
Optimal dose determined by titration. 
NOTE: Single antibody controls will be prepared with each of the above antibodies using 
OneComp eBeads (eBioscience). Appropriate FMO controls will be run to identify cell 
subsets and cytokine expression. 


 
HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           43 
     Amendment 4, 16JUN2022 
 
6. Cells will be washed twice by adding 4 ml of PBS and centrifuging cells @1400 RPM for 5 min. 
7. Cells will be fixed using 100ul of fix/perm buffer for 30 min in the dark to permeabilize cells 
8. Cells will be resuspended in 50 μl perm buffer containing APC-Cy7 anti-human IL-17, PE-Cy7 anti-
human IFN-ܵ and APC anti-human IL-10 and incubated for 45 min in dark @4oC. 
9. Cells will be washed twice with perm wash buffer and resuspend in FACS buffer for flow analysis. 
 
 
Detection of lysosomal acidification: 
1. Freshly thawed aliquots of each PBMC sample (2 x 106 cells/vial) will be resuspended in 1 ml of 
cell culture media (1X106 cells/ml). 
2. Lyso sensor yellow/blue DND-10 will be added to each sample as defined by manufacturer. 
3 .  Cells will be washed in FACS cell staining buffer containing sodium azide and resuspended in 
FACS staining buffer (100μl) containing Human IgG Fc-receptor blocking antibody for 20 min. 
4. After blocking, antibody cocktail (Lysosomal cocktail) (50μl) to each tube and incubate cells @ 4oC 
for 30 min in the dark. 
 
Table 1:  Lysosomal cocktail (flurochromes are tentative) 
 
# 
Antibody 
Fluorochrome 
Dilution (final) 
1 
Anti-human CD3 
FITC 
Optimal dose determined by titration. 
2 
Anti-human CD4 
PE 
Optimal dose determined by titration. 
3 
Anti-human CD8 
PerCP 
Optimal dose determined by titration. 
4 
Anti-human CD14 
APC 
Optimal dose determined by titration. 
NOTE: Single antibody controls will be prepared with each of the above antibodies using 
OneComp eBeads (eBioscience). Appropriate FMO controls will be run to identify cell 
subsets and lysosomal acidification. 
 
5. Cells will be washed twice by adding 4 ml of PBS and centrifuging cells @1400 RPM for 5 min. 
6. Cells then will be fixed using 100ul of paraformaldehyde (4% in PBS) and incubated for 
15 min @4oC. 
7. Cells will be washed twice with PBS and resuspended in FACS buffer for flow 
cytometric analysis. 
 
 
Detection of cell autophagy: 
1. Freshly thawed aliquots of each PBMC sample (2 x 106 cells/vial) will be resuspended in  FACS 
staining Buffer (100μl) containing Human IgG Fc-receptor blocking antibody for 20 min. 
2. After  blocking,  antibody  cocktail  (Autophagy  cocktail)  (50μl)  will  be  added  to  each  tube  
and incubated @ 4oC for 60 min in the dark. 
 
 
 
 


 
HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           44 
     Amendment 4, 16JUN2022 
 
 
Table 1:  Autophagy cocktail (flurochromes are tentative) 
 
 
# 
Antibody 
Fluorochrome 
Dilution (final) 
1 
Anti-human CD3 
FITC 
Optimal dose determined by titration. 
2 
Anti-human CD4 
PE 
Optimal dose determined by titration. 
3 
Anti-human CD8 
PerCP 
Optimal dose determined by titration. 
4 
Anti-human CD14 
APC 
Optimal dose determined by titration. 
5 
Anti-human LC3B 
(autophagy marker) 
PE-Cy7 
Optimal dose determined by titration. 
6 
Anti-SQSTM1 / p62 
antibody 
(autophagy marker) 
APC-Cy7 
Optimal dose determined by titration. 
NOTE: Single antibody controls will be prepared with each of the above antibodies using 
OneComp eBeads (eBioscience). Appropriate FMO controls will be run to identify cell 
subsets and autophagy. 
 
3. Cells will be washed twice by adding 4 ml of PBS and centrifuging cells @1400 RPM for 5 min. 
4. Cells will be fixed using 100ul of fix/perm buffer for 30 min in the dark to permeabilize cells 
5. Cells will be resuspended in 50 μl perm buffer containing Autophagy cocktail #2 and incubated for 
45 min in dark @4oC. 
6. Cells will be washed twice with perm wash buffer and resuspend in FACS buffer for flow analysis. 
 
Table 2:  Autophagy cocktail #2 (flurochromes are tentative) 
 
# 
Antibody 
Fluorochrome 
Dilution (final) 
1 
Anti-human LC3B 
(autophagy marker) 
PE-Cy7 
Optimal dose determined by titration. 
2 
Anti-SQSTM1 / p62 
antibody 
(autophagy marker) 
APC-Cy7 
Optimal dose determined by titration. 
NOTE: Single antibody controls will be prepared with each of the above antibodies using 
OneComp eBeads (eBioscience). Appropriate FMO controls will be run to identify cell 
subsets and autophagy. 
 
 
Cytokine detection by ELISA 
1. Frozen aliquots of plasma samples will be allowed to thaw at room temperature and then vortexed 
to mix. 
(/,6$DVVD\VIRU,)1ܵ 71)Į and CRP will be performed as described in the manufacturer 
protocols and measured in a multiwall plate reader.  
 
 
 
 


 
HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           45 
     Amendment 4, 16JUN2022 
 
APPENDIX F.  Clavien-Dindo Classification of Surgical Complications 28 
Grades 
Definition 
 
Grade I: 
Any deviation from the normal postoperative course without the need for 
pharmacological treatment or surgical, endoscopic and radiological interventions. 
Acceptable therapeutic regimens are: drugs as antiemetics, antipyretics, analgetics, 
diuretics and electrolytes and physiotherapy. This grade also includes wound infections 
opened at the bedside. 
 
Grade II: 
Requiring pharmacological treatment with drugs other than such allowed for Grade 
I complications. 
Blood transfusions and total parenteral nutrition are also included. 
 
Grade III: 
Requiring surgical, endoscopic or radiological intervention 
Grade III-a: 
intervention not under general anesthesia 
Grade III-b: 
intervention under general anesthesia 
Grade IV: 
Life-threatening complication (including CNS complications)‡ requiring IC/ICU-
management 
Grade IV-a: 
single organ dysfunction (including dialysis) 
Grade IV-b: multi organ dysfunction 
Grade V: 
Death of a patient 
 
Suffix ’d’: 
If the patient suffers from a complication at the time of discharge (see examples in 
Appendix B, http://Links.Lww-.com/SLA/A3), the suffix “d” (for ‘disability’) is 
added to the respective grade of complication. This label indicates the need for 
a follow-up to fully evaluate the complication. 
 
 
‡ brain hemorrhage, ischemic stroke, subarrachnoidal bleeding, but excluding transient ischemic attacks (TIA);  
IC: Intermediate care;  
ICU: Intensive care unit 
www.surgicalcomplication.info 
  
 
 
 
 


 
HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           46 
     Amendment 4, 16JUN2022 
 
APPENDIX G.  Quality of Life: EORTC’s Validated, Patient-Report Questionnaires  
Quality of Life: This is assessed by two validated patient-reported outcomes measures, the EORTC QLQ-C30 and 
QLQ-PR25 questionnaires. All items assessing symptoms and functional domains employ a 4-point Likert scale, with 
responses ranging from “Not At All”, “A Little”, “Quite a Bit” and “Very Much.” Study participants will be instructed to 
choose one response per item.  The EORTC QLQ-C30 is a 30-item questionnaire assessing multiple domains of 
global health-related quality of life in cancer populations. It includes one global QOL rating, 5 functioning scales 
(physical, cognitive, emotional, role and social) and 9 symptom-specific subscales (fatigue, N/V, pain, dyspnea, 
insomnia, constipation, diarrhea, appetite loss). The EORTC QLQ-PR25 is a prostate cancer module meant for use 
among patients in varying in disease stage and treatment modality (i.e., surgery, chemotherapy, radiotherapy, etc.), 
which complements the QLQ-C30. The QLQ-PR25 module comprises 25 items assessing disease symptoms, 
treatment side effects, sexual functioning and sexual activity. The functional scales are sexual activity and sexual 
functioning; the 4 symptom scales are urinary symptoms, bowel symptoms, hormonal treatment-related symptoms, 
and incontinence aid. All participants will complete items 31-49 as well as items 50-51 (which query current sexual 
activity).  
For interpretation of scores on the two EORTC QOL questionnaires, all of the scales and single-item measures range 
in score from 0 – 100. A high scale score represents a higher response level – so that a higher score represents a 
higher (“better”) level of functioning OR a higher (“worse) level of symptoms.  
EORTC 
Item / Scale 
# of  
Items 
Responses 
Item No.s 
Score Interpretation  
QLQ-C30 
Global QOL 
2 
1 - 7 
29, 30 
Higher score = better global QOL 
QLQ-C30 
Physical Functioning  
5 
 
 
1  -  4 
1-5 
 
 
Higher score =  better functioning  
Cognitive Functioning 
2 
20, 25 
Emotional Functioning  
4 
21-24 
Role Functioning  
2 
6, 7 
Social Functioning 
2 
26, 27 
 
QLQ-C30  
Symptoms 
Fatigue 
3 
 
 
 
1  -  4 
10, 12, 18 
 
 
Higher score = 
more/worse symptoms 
Nausea / Vomiting 
2 
14, 15 
Pain 
2 
9, 19 
Dyspnea 
1 
8 
Insomnia 
1 
11 
Appetite Loss 
1 
13 
Constipation 
1 
16 
Diarrhea 
1 
17 
Financial Difficulties 
1 
28 
QLQ-PR25 
Sexual Activity  
2 
1  -  4 
50, 51 
Higher score = better functioning 
Sexual Functioning * 
4 
52-55 
 
 
QLQ-PR25 
Symptoms 
Urinary Symptoms 
8 
 
 
1 – 4  
31-37, 39 
 
Higher score = 
more/worse symptoms 
Bowel Symptoms 
4 
40-43 
Hormonal Treatment-
related Symptoms 
6 
44-49 
Incontinence Aid 
1 
 
 
* Completion of Items 52-55 are conditional on being sexually active (and comprise the Sexual Functioning subscale), 
and thus, these 4 items will only be completed by a subgroup of study patients. Response to item #52 keeps original 
scoring, while responses to items 53-55 are reverse-scored. Specifically, for items 53-55, a response of “4” is recoded 
as “1”,  a response of “3” is recoded as “2”, a response of “2”  is recoded as “3”, and a response of “1” is recoded as 
“4”). This reverse-scoring preserves the Functional scale property, where a higher response indicates higher 
functioning.  
 
 


 
HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           47 
     Amendment 4, 16JUN2022 
 
EORTC QLQ-C30 (version 3) 
We are interested in some things about you and your health. Please answer all of the questions yourself by 
circling the number that best applies to you. There are no "right" or "wrong" answers. The information that 
you provide will remain strictly confidential. 
 
Please fill in your initials: 
 
 
Your birthdate (Day, Month, Year): 
 
Today's date (Day, Month, Year): 
 
 
 
 
1. 
Do you have any trouble doing strenuous activities, 
Not at 
All 
A 
Little 
Quite 
a Bit 
Very 
Much 
like carrying a heavy shopping bag or a suitcase? 
1 
2 
3 
4 
2. 
Do you have any trouble taking a long walk? 
1 
2 
3 
4 
3. 
Do you have any trouble taking a short walk outside of the house? 
1 
2 
3 
4 
4. 
Do you need to stay in bed or a chair during the day? 
1 
2 
3 
4 
5. 
Do you need help with eating, dressing, 
washing yourself or using the toilet? 
 
1 
 
2 
 
3 
 
4 
During the past week: 
 
Not at 
 
A 
 
Quite 
 
Very 
 
All 
Little 
a Bit 
Much 
6. 
Were you limited in doing either your work or other daily activities? 
1 
2 
3 
4 
7. 
Were you limited in pursuing your hobbies or 
other leisure time activities? 
 
1 
 
2 
 
3 
 
4 
8. 
Were you short of breath? 
1 
2 
3 
4 
9. 
Have you had pain? 
1 
2 
3 
4 
10. Did you need to rest? 
1 
2 
3 
4 
11. Have you had trouble sleeping? 
1 
2 
3 
4 
12. Have you felt weak? 
1 
2 
3 
4 
13. Have you lacked appetite? 
1 
2 
3 
4 
14. Have you felt nauseated? 
1 
2 
3 
4 
15. Have you vomited? 
1 
2 
3 
4 
16. Have you been constipated? 
1 
2 
3 
4 
Please go on to the next page


 
HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           48 
     Amendment 4, 16JUN2022 
 
During the past week: 
Not at 
All 
A 
Little 
Quite 
a Bit 
Very 
Much 
17. Have you had diarrhea? 
1 
2 
3 
4 
18. Were you tired? 
1 
2 
3 
4 
19. Did pain interfere with your daily activities? 
1 
2 
3 
4 
20. Have you had difficulty in concentrating on things, 
like reading a newspaper or watching television? 
 
1 
 
2 
 
3 
 
4 
21. Did you feel tense? 
1 
2 
3 
4 
22. Did you worry? 
1 
2 
3 
4 
23. Did you feel irritable? 
1 
2 
3 
4 
24. Did you feel depressed? 
1 
2 
3 
4 
25. Have you had difficulty remembering things? 
1 
2 
3 
4 
26. Has your physical condition or medical 
treatment interfered with your family life? 
 
1 
 
2 
 
3 
 
4 
27. Has your physical condition or medical 
treatment interfered with your social activities? 
 
1 
 
2 
 
3 
 
4 
28. Has your physical condition or medical 
treatment caused you financial difficulties? 
 
1 
 
2 
 
3 
 
4 
 
 
For the  following  questions  please  circle  the  number  between   1  and  7  that   
best applies to you 
29. How would you rate your overall health during the past week? 
 
1 
2 
3 
4 
5 
6 
7 
 
     Very poor 
Excellent 
 
 
30. How would you rate your overall quality of life during the past week? 
 
1 
2 
3 
4 
5 
6 
7 
 
      Very poor 
Excellent 
 
 
Please go on to the next page 
 
 


 
HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           49 
     Amendment 4, 16JUN2022 
 
 
 
EORTC QLQ - PR25 
Patients sometimes report that they have the following symptoms or problems. Please indicate 
the extent to which you have experienced these symptoms or problems during the past week. 
Please answer by circling the number that best applies to you. 
 
 
During the past week 
Not 
A 
Quite 
Very 
at all 
little 
a bit 
much 
31. Have you had to urinate frequently during the day? 
1 
2 
3 
4 
32. Have you had to urinate frequently at night? 
1 
2 
3 
4 
33. When you felt the urge to pass urine, did you 
have to hurry to get to the toilet? 
 
1 
 
2 
 
3 
 
4 
34. Was it difficult for you to get enough sleep, because 
you needed to get up frequently at night to urinate? 
 
1 
 
2 
 
3 
 
4 
35. Have you had difficulty going out of the house 
because you needed to be close to a toilet? 
 
1 
 
2 
 
3 
 
4 
36. Have you had any unintentional release (leakage) of urine? 
1 
2 
3 
4 
37. Did you have pain when you urinated? 
1 
2 
3 
4 
38. Answer this question only if you wear an incontinence 
aid. Has wearing an incontinence aid been a problem for 
you? 
 
1 
 
2 
 
3 
 
4 
39. Have your daily activities been limited by your urinary problems? 
1 
2 
3 
4 
40. Have your daily activities been limited by your bowel problems? 
1 
2 
3 
4 
41. Have you had any unintentional release (leakage) of stools? 
1 
2 
3 
4 
42. Have you had blood in your stools? 
1 
2 
3 
4 
43. Did you have a bloated feeling in your abdomen? 
1 
2 
3 
4 
44. Did you have hot flushes? 
1 
2 
3 
4 
45. Have you had sore or enlarged nipples or breasts? 
1 
2 
3 
4 
46. Have you had swelling in your legs or ankles? 
1 
2 
3 
4 
 
 
 
Please go to the next page 
 
 
 
 
 
 
5 


 
HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           50 
     Amendment 4, 16JUN2022 
 
 
 
 
During the last 4 weeks… 
Not 
A 
Quite 
Very 
at all 
little 
a bit 
much 
47. Has weight loss been a problem for you? 
1 
2 
3 
4 
48. Has weight gain been a problem for you? 
1 
2 
3 
4 
49. Have you felt less masculine as a result of your 
illness or treatment? 
 
1 
 
2 
 
3 
 
4 
 
 
 
 
 
 
50. To what extent were you interested in sex? 
1 
2 
3 
4 
51. To what extent were you sexually active 
(with or without intercourse)? 
 
1 
 
2 
 
3 
 
4 
 
 
PLEASE ANSWER THE NEXT FOUR QUESTIONS ONLY IF YOU HAVE BEEN SEXUALLY ACTIVE OVER THE LAST 4 WEEKS 
 
52. To what extent was sex enjoyable for you? 
1 
2 
3 
4 
53. Did you have difficulty getting or maintaining an erection? 
1 
2 
3 
4 
54. Did you have ejaculation problems (eg dry ejaculation)? 
1 
2 
3 
4 
55. Have you felt uncomfortable about being sexually intimate? 
1 
2 
3 
4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
© Copyright 1999 EORTC Quality of Life Group. All rights reserved. (phase IV module) 
 


 
HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           51 
     Amendment 4, 16JUN2022 
 
 
 
Scope 
The prostate cancer module is meant for use among patients with prostate cancer varying in disease stage 
and treatment modality (i.e. surgery, chemotherapy, radiotherapy, etc.). It should always be 
complemented by the QLQ-C30.  
Scoring 
Scale  
name 
Number 
of items 
Item 
range 
QLQ-C30+PR25  
Item numbers 
QLQ-PR25 
item numbers 
Functional scales 
 
 
 
 
Sexual activity 
PRSAC 
2 
3 
50, 51 
20, 21 
Sexual functioning 
PRSFU 
4 
3 
52-55 
(reverse code 
responses to 
53-55) 
22 – 25 
(reverse code 
responses to 
 23-25) 
Symptom scales 
 
 
 
 
Urinary symptoms 
PRURI 
8 
3 
31-37, 39 
1 – 7, 9 
Bowel symptoms 
PRBOW 
4 
3 
40-43 
10 – 13 
Hormonal treatment-
related symptoms  
PRHTR 
6 
3 
44-49 
14 – 19 
Incontinence aid 
PRAID 
1 
3 
38 
8 
Remarks 
 
x Items 20 and 21 can be completed by all patients 
x Items 22-25 are conditional on being sexually active, and thus will only be completed by a subgroup of patients. This 
will require reversing the response categories of questions 23-25 but not of 22. 
x If reporting scale level data, it is highly recommended that some basic psychometric analyses be carried out. Minimally, 
one would want to look at the internal consistency of the scales (using a reliability program of a statistical software 
package that calculates a Cronbach’s alpha coeffieient). This coefficient should preferably be above 0.70 for purposes 
of group comparisons. You do not need to recode the items to perform the reliability analysis. 
 
Reference 
 
van Andel G, Bottomley A, Fosså SD, et al. An International Field Study of the EORTC QLQ-PR25: a 
Questionnaire for Assessing the  Health-Related  Quality  of  Life of Patients with Prostate Cancer. Eur 
J Cancer 44:2418-2424, 2008. 
 
 
Prostate cancer module: QLQ-PR25 


 
HCQ on PAR-4 in Oligometastatic Prostate Ca                                                                                                           52 
     Amendment 4, 16JUN2022 
 
APPENDIX H 1-2  – Response Criteria for Disease Progression  
 
- 
H.1  RECIST v1.1 for soft-tissue metastatic lesions 
- 
H.2  MDA Criteria for bone-specific response criteria  
 
 H.1    Response Evaluation Criteria in Solid Tumors (RECIST 1.1)* to be used for soft-tissue metastatic lesions 
Response category Criteria 
Complete  
response 
Disappearance of all target lesions 
Reduction in short axis of target lymph nodes to < 10 mm 
Partial response 
Decrease in target lesion diameter sum > 30%† 
 
Progressive 
disease 
Increase in target lesion diameter sum > 20%‡ 
> 5 mm increase in target lesion diameter sum 
New, malignant FDG uptake in the absence of other indications of progressive disease or an anatomically
stable lesion, and confirmed on contemporaneous or follow-up CT 
Unequivocal progression of nontarget lesions 
Stable disease 
Does not meet other criteria‡ 
*Measurements are based on the sum of the unidimensional measurement of the greatest diameter of a maximum 5 lesions. 
   †Reference standard: baseline sum.   ‡Reference standard: smallest recorded sum. Table modified from Eisenhauer et al. 
 
 H.2   MD Anderson Cancer Center-Criteria for bone response criteria for bone metastases * 
Response category Criteria 
 
Complete 
response 
Complete sclerotic fill-in of lytic lesions on XR or CT 
Normalization of bone density on XR or CT 
Normalization of signal intensity on MRI 
Normalization of tracer uptake on SS 
 
Partial  
response 
Development of a sclerotic rim or partial sclerotic fill-in of lytic lesions on XR or CT. 
Osteoblastic flare - Interval visualization of lesions with sclerotic rims or new sclerotic lesions in the setting of 
other signs of PR and absence of progressive bony disease 
GHFUHDVHLQPHDVXUDEOHOHVLRQVRQ;5&7RU05, 
VXEMHFWLYHGHFUHDVHLQWKHVL]HRILOO-defined lesions on XR, CT, or MRI 
VXEMHFWLYHGHFUHDVHLQWUDFHUXSWDNHRQ66 
 
Progressive 
disease 
> 25% increase in size of measurable lesions on XR, CT, or MRI 
> 25% subjective increase in the size of ill-defined lesions on XR, CT, or MRI 
> 25% subjective increase in tracer uptake on SS 
New bone metastases 
 
Stable 
disease 
No change 
< 25% increase or < 50% decrease in size of measurable lesions 
< 25% subjective increase or < 50% subjective decrease in size of ill-defined lesions 
No new bone metastases 
*Measurements are based on the sum of a perpendicular, bidimensional measurement of the greatest diameters of each individual lesion. 
Abbreviations: XR, radiography; CT, computed tomography; SS, skeletal scintigraphy; MRI, magnetic resonance imaging.  
Table modified from Hamaoka et al. (27).