Clinical trial NCT01324141
Conditions: Anal Cancer
Keywords: Anal Cancer Radioprotector Topical Radiation Dermatitis
Sponsor: National Cancer Institute (NCI)
Start date: 2011-03-18; Completion date: 2015-04-15
Enrollment: 6 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
Background:

\- Radiation and chemotherapy treatments for anal cancer can cause irritation of the skin that can lead to redness and tenderness, and in some cases can be so severe that it results in blistering or peeling of the skin during treatment. These conditions cause discomfort and may require breaks from radiation treatment. Researchers are interested in determining whether MTS-01, a drug that protects cells and tissues from the effects of radiation, can be given before radiation treatment to prevent these side effects and reduce the irritation of the skin during chemotherapy and radiation for anal cancer.

Objectives:

\- To determine the safety and effectiveness of topical MTS-01 given before radiation in the groin and gluteal cleft of patients receiving combined radiation and chemotherapy for anal cancer.

Eligibility:

\- Individuals at least 18 years of age who have been diagnosed with cancer of the anal canal and are eligible to receive radiation and chemotherapy treatments.

Design:

* Participants will be screened with a physical examination, medical history, blood tests, imaging studies and physical examination of the anal canal, and biopsies as needed to evaluate eligibility for treatment.
* Participants will be scheduled for radiation and chemotherapy treatments on the following schedule:
* Radiation given 5 days per week for 6 weeks, with topical MTS-01 treatment on the skin in the groin areas and between the buttocks before each treatment
* Mitomycin C given intravenously on days 1 and 29 of treatment
* 5-Fluorouracil given intravenously over 4 days (first week and fifth week) during radiation treatment
* Participants will be monitored throughout the treatment for side effects, with photographs of the treatment area and frequent blood tests.
* Following the end of radiation, participants will have followup visits for 1 year with blood tests and imaging studies to evaluate the response to treatment.

Detailed description:
Background:

* Patients with non-metastatic carcinoma of the anal canal are treated with concurrent mitomycin C (MMC), 5-fluorouracil (5-FU), and radiotherapy (RT) in the curative setting in an attempt to preserve the anal sphincter.
* Radiation dermatitis is a uniform complication of this therapy which frequently results in treatment delay due to pain and discomfort. High grade dermatitis may also become superinfected in the setting of decreased blood counts from chemotherapy and diarrhea from radiation proctitis, further delaying therapy. Approaches that decrease toxicity may be particularly important in patients infected with human immunodeficiency virus (HIV).
* MTS-01 (tempol, 4-hydroxy-2,2,6,6-tetramethylpiperidine-1-oxyl) is a piperidine nitroxide known to act as a chemical radioprotector with selective protection of normal versus tumor tissue.
* Tempol gel (tempol 70 mg/mL plus water, ethanol, and hydroxypropyl cellulose) has been evaluated as a topical radioprotector in pilot trials that included a variety of sites.

Objectives:

* Primary Objective: To determine the safety and tolerability of topical MTS-01 on a daily basis prior to irradiation in the groin and gluteal cleft of patients receiving combined therapy with MMC, 5-FU, and RT for carcinoma of the anal canal.
* Secondary Objectives will include evaluation of the following endpoints in a preliminary fashion:

  * To describe the rates and severity of skin toxicity in patients treated with this regimen
  * To describe the need for toxicity related treatment breaks with this regimen
  * To describe the opiate requirements in patients treated with this regimen
  * To describe 12-month progression-free survival, disease-free survival, and overall survival in patients treated with concurrent chemotherapy, radiation therapy, and MTS-01
  * Evaluate the effects of antiretroviral therapy, 5-fluorouracil, mitomycin C, and radiation on low level persistent HIV viremia and HIV genetic diversity during therapy and recovery
  * To evaluate the feasibility of collecting HIV ribonucleic acid (RNA) and mononuclear cells from rectal associated lymphoid tissue for correlative studies
  * Collect and store anal cytology and core needle biopsies of tumor for future human papillomavirus infection (HPV) and tumor based analyses

Eligibility:

* Age greater than or equal to 18 years.
* Eastern Cooperative Oncology Group (ECOG) performance status less than or equal to 2.
* Histologically confirmed carcinoma of the anal canal without evidence of distant metastases
* No contraindications to definitive chemoradiotherapy for carcinoma of the anal canal

Design:

This is a pilot trial of topical MTS-01 in patients receiving MMC, 5-FU, and intensity-modulated radiation therapy (IMRT) for definitive management of carcinoma of the anal canal. Fifteen patients will be enrolled. MMC will be delivered at a dose of 10mg/m(2) on days 1 and 29. 5-FU will be delivered as 1000mg/m(2)/day as 96 hour continuous infusion beginning on day 1 and 29. RT will be delivered to a total dose of 50-54 Gy based on tumor characteristics. Tempol gel will be applied to the bilateral groins and the gluteal cleft, avoiding a 3 cm radius from the anal verge, immediately prior to each fraction of RT. Radiation Therapy Oncology Group (RTOG) grading will be used to evaluate skin toxicity in both the groin and gluteal cleft weekly during treatment and at 4 weeks, 3 months and 6 months after completion of treatment. The duration of treatment, number of treatment breaks, opiate requirements, and level of pain will be evaluated weekly during treatment and at 4 weeks and 3 months after the completion of treatment. Disease control will be assessed at 4 weeks, 3 months, 6 months, 9 months, and 12 months of follow-up.

Arms: arm 1: Chemo + Radiation
Interventions: intervention 1: Tempol intervention 2: 5-Fluorouracil intervention 3: Mitomycin-C intervention 4: Radiation Therapy
Intervention descriptions: intervention 1: Tempol gel will be applied to the bilateral groins and the gluteal cleft, avoiding a 3 cm radius from the anal verge, immediately prior to each fraction of radiation therapy (RT). intervention 2: 5-FU will be delivered as 1000mg/m(2)/day as 96 hour continuous infusion beginning on day 1 and 29. intervention 3: Mitomycin-C (MMC) will be delivered at a dose of 10mg/m(2) on days 1 and 29 intervention 4: Radiation therapy (RT) will be delivered to a total dose of 50-54 Gray (Gy) based on tumor characteristics.

Protocol documents:
Prot_SAP_000.pdf: 
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/;<=29>?.@/	.A
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.//1	3		2/;<=0829
;<=3		/	./122//	0108
29.22./	9
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	1/23		.2/	2
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, 42.0	/2		3		2C/2
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?2		012/2	/2
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, 42	.23		/	2		.		012
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05	00	,0///4
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>?U VWCOXCEFIJILYQJQLFEZCJP[FZ\Z]^FZGI_LIDEZR
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7.5006/005-		-00/
5	123
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55	5004/0-		
7b055	/5	505/
/7804		506/	0
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6-0//706/5	05
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	67
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123
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44550
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g,/4	45	6-		4-0123
7
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05	6//	5	
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11		/12//,0	72/
/1/		-	0/,4/,0
/1		8<6:2//=		>1	?	8@A:-
B4,C	5D74/7/-
/	0/,1/,1-
EFGFH JKLMNMOP
11		078:	R0
7//		,/	48:-B	11	
,/7,/782//		7/7	:/2/,7
S	74-A3,		1		201=/,2/
1		-./	22/				02//

 /1/1	/7/	/4	,	1
	7-@/T///		/	7-
97		-	,8			:-./
1,	,,	/		,,7/4	
1=	/3-C/11		/	/7	
//		7481,/>>
		,/	,/:0	/7,/0
83:	/7	7	1	3/3737
	7/7				/	-<18,	,	
//:8,	,	//:2/
1-A11	14-
EFGFV WKXYZ[\OMK]\]^_X`_\X\OMK]
56370		57S	
5
	0			1
		2,001=	2/,<R,,4	-2/
/4-,	2/a5b-156/		/
037040-
EFGFc dO\eM[MOP\]^fOKX\g`
	/7/56			7/	77/,1
0	11-a,8 hih:,1	7/-1,,
4,	2,		>/7
 j8:2/
07/37k		2	,17-1i/0	
,-1		2	3/,-a	
5b 1T,	7,-,	1,,0
56	1,l,,	2,-


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@@AB
C			@
DDEFAAAAADGHIA	JF		DDFA
JKL MABJ	EHNJJ
JK@L A
	@JKHDJADA		
@H	LLOHPQ@D	FA
AD	LFALH
,-.-R S5=:3<974T4U474>6
D	FA		VDAWA			@D	G
XDD	@	JDL	
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_		L		HNA		AF		_
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FAA	L	AAA@G	BEJD@
HNA			@@J		HAJA@A
J			dDA	DDHDAD@A
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fH
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g	VHNOAPh@
iJ	j
kH@j@iJJ
JHLHAG	
FH JK	
HkJK	HPJK	DL	H	
@@D		A	L	AF		HNA
@	L	DD	AG		V	
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	DAF	L		FAD@G
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2	03	/42525/26-
/	-	0-4-	/7	/8
26/9	-6:-5	62
2/2	2	6;<20,--	
/	/2	/20	:74=28	2
/	-2>	52-2?
55/22		-	03
6				.	525-	-2
5:65?0
ABCBD FGHIJKLMNGOLOQRHSRLHLMNGO
T26	2U5	
55
	 50<	4-?
	 	/6	
-0U5/	0,2=	60-/	6	
		4/2=6	4/4-
	01		//		0-252
7
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ABCBV WMLXNKNMYLOQZMGHL[S

8\3	-2		-2/=50,
/06:6276 ]8=/4-	520
813	-
 -5^/
7/_80`5220U5>	5//-0
_8/	42Ua,15b		6060-	
/- 5/	
cdFKJNQ
WMLXNKNMY
Ue:?
_2
0e,2	?

2
,;?
 2
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0-000-.
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89:9P =>?@A?BCD=LQGBICDRBGSG
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-0	1/	/00			
	-.1
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	+1
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LMNOPQRSQTUTWSXMYMNMZPOX.+
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ICF_001.pdf: 
MEDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• 
Adult Patient or 
• Parent, for Minor Patient 
INSTITUTE: 
National Cancer Institute 
STUDY NUMBER: 
11-C-0129 
PRINCIPAL INVESTIGATOR: 
Deborah E. Citrin, M.D. 
STUDY TITLE:  
 
A Pilot Trial Assessing the Feasibility of Delivering Topical MTS-01 to Reduce 
Dermatitis in Patients Receiving Intensity Modulated Radiation with Concurrent 5-
Fluoruracil and Mitomycin-C for Stage I-III Carcinoma of the Anal Canal 
Continuing Review Approved by the IRB on 07/22/13 
Amendment Approved by the IRB on 04/02/14 (D) 
                   Date Posted to Web: 4/11/14 
Standard Consent 
PATIENT IDENTIFICATION 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• 
Adult Patient or 
• Parent, for Minor Patient 
NIH-2514-1 (07-09) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent (1) 
 
 
INTRODUCTION 
We invite you to take part in a research study at the National Institutes of Health (NIH). 
First, we want you to know that: 
 
Taking part in NIH research is entirely voluntary.  
You may choose not to take part, or you may withdraw from the study at any time.  In 
either case, you will not lose any benefits to which you are otherwise entitled.  However, 
to receive care at the NIH, you must be taking part in a study or be under evaluation for 
study participation. 
You may receive no benefit from taking part.  The research may give us knowledge that 
may help people in the future. 
 
Second, some people have personal, religious or ethical beliefs that may limit the kinds of 
medical or research treatments they would want to receive (such as blood transfusions).  If you 
have such beliefs, please discuss them with your NIH doctors or research team before you agree 
to the study. 
 
Now we will describe this research study.  Before you decide to take part, please take as much 
time as you need to ask any questions and discuss this study with anyone at NIH, or with family, 
friends or your personal physician or other health professional.   
 
Why is this study being done?  
 
The purpose of this study is to find out what effects, good or bad, MTS-01 has on your skin 
during chemotherapy and radiation treatment for anal cancer.  Treatment with radiation and 
chemotherapy for anal cancer can cause irritation of the skin that can lead to redness and 
tenderness.  In some patients the skin irritation can be severe and lead to blistering or peeling of 
the skin during treatment, causing discomfort and requiring breaks from radiation treatment.  


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  2  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
MTS-01 is a drug that protects cells and tissues from the effects of radiation.  The purpose of this 
study is to determine if treatment with MTS-01 every day before radiation treatment can reduce 
the irritation of the skin during chemotherapy and radiation for anal cancer. 
 
How many people will take part in this study?  
 
A total of 15 people will take part in this study.  The dose of MTS-01 applied to the skin will be 
the same for every patient.  All patients will receive similar doses of radiation and chemotherapy. 
Description of Research Study 
 
What will happen if you take part in this research study?   
 
Before you begin the study, you will need to have the following exams, tests, or procedures to 
find out if you can be in the study.  These exams, tests, or procedures are part of regular cancer 
care and may be done even if you do not join the study. If you have had some of them recently, 
they may not need to be repeated.  This will be up to your study doctor. 
• History and Physical examination 
• Biopsy of tumor 
• CT scan of the chest, abdomen, and pelvis 
• PET scan 
• MRI or ultrasound of the anal tumor 
• Basic laboratory tests including blood counts and measurement of kidney function, liver 
function, and electrolytes in the blood. 
• Urine pregnancy test for females 
 
During the study, you will need the following tests and procedures.  They are part of regular 
cancer care.  
• Radiation treatment planning and daily radiation treatments for six weeks 
• Treatment with chemotherapy (mitomycin-C and 5-fluorouracil) during the radiation 
treatment 
• Blood tests every week to check blood cell counts, blood electrolytes, and blood 
chemistries. 
• Weekly visits with the radiation oncologist during treatment. 
You will need these tests and procedures that are either being tested in this study or being done 
to see how the study is affecting your body. 
• Sigmoidoscopy with biopsies (optional, see below) 
• Treatment with the study drug, MTS-01 gel, on the skin in the groin area and between the 
buttocks each day prior to radiation treatment.  A small area near your belly button will 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  3  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
also be treated to see how your skin responds to MTS-01 without radiation (this area 
does not receive radiation). 
• Pictures of the skin receiving treatment with MTS-01 will be taken before treatment and 
at each weekly visit during treatment. 
• You will fill out a pain questionnaire every week. 
• If you have HIV, tests of the levels of virus in your blood will be performed every week 
during treatment. 
 
When you are finished with your radiation and chemotherapy treatment, you will continue to be 
seen weekly for the first month after treatment for blood tests and an examination and then every 
three months by the radiation oncologist.  You will stop being treated with MTS-01 the same day 
you complete radiation and chemotherapy.  You will undergo repeated physical examination, 
blood testing, and x-rays to see how your tumor responds to treatment.   
 
Study Chart 
Another way to find out what will happen to you during the study is to read the chart below.  
Start reading at the top and read down the list, following the lines and arrows.  


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  4  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
 
 
 
 
 
 
 
 
 
                                                               
 
 
                                                                    
 
 
 
 
 
 
Treatment  
Planning 
• 
Radiation Treatment Simulation (planning session) 
• 
Chemotherapy planning, placement of temporary catheter in vein in arm (PICC) 
Therapy 
• 
MTS-01 gel will be applied to your skin in the groin areas and between the 
buttocks daily before each radiation treatment. 
• 
Radiation Monday through Friday (5 days per week for ≈ 6 weeks). 
• 
Mitomycin C by intravenous injection twice (Day 1 and Day 29)   
• 
5-Fluorouracil given by intravenous infusion over four days twice,(first week and 
fifth week) during radiation treatment beginning the first week of radiation 
treatment.  
Monitoring 
• 
Review of Side Effects 
• 
Photos of Treatment Area 
• 
Blood Studies 
Screening and Enrollment 
• 
Medical History and Physical Exam 
• 
Biopsy 
• 
Imaging Studies to Stage Cancer 
• 
Blood Studies, Including HIV Test 
• 
Optional Anoscopy, Sigmoidoscopy, Cytology, 
and Biopsies 
After Treatment 
• 
Clinic Appointments for 1 year 
• 
Blood tests 
• 
Follow-up imaging to document response 
• 
Follow-up sigmoidoscopy and biopsies and/or 
cytology(Optional) 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  5  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
 
What does this study involve? 
 
Standard of Care Treatment: 
 
Treatments covered under this study include 5-fluorouracil and Mitomycin-C (chemotherapies) 
and radiation to treat your cancer. These treatments will not be experimental. Your doctors will 
describe your treatment plan to you in detail before asking you to sign this consent form. You 
may be asked to sign a separate consent form for any treatment procedures not outlined in this 
consent. 
 
Birth Control 
 
If you are a woman who is breast feeding or pregnant, you may not take part in the study because 
we don’t know how this medicine would affect your baby or your unborn child. If you are a 
woman who can become pregnant, or are the partner of a woman who can become pregnant, you 
will need to practice an effective form of birth control before starting study treatment, during 
study treatment, and for six months after you finish study treatment.  If you think that you or 
your partner is pregnant, you should tell your study doctor or nurse at once.   
 
Effective forms of birth control include:  
• Abstinence  
• intrauterine device (IUD) 
• hormonal [birth control pills, injections, or implants] 
• tubal ligation 
• vasectomy 
 
Alternative Approaches or Treatments 
 
What other choices do I have if I do not take part in this study?  
 
Instead of being in this study, you have these options: 
• Getting treatment or care for your cancer without being in a study 
• Taking part in another study 
 
Please talk to your doctor about these and other options. 
 
Risks or Discomforts of Participation 
 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  6  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
You may have side effects while on the study.  Everyone taking part in the study will be watched 
carefully for any side effects.  However, doctors don’t know all the side effects that may happen.  
Side effects may be mild or very serious.  Your health care team may give you medicines to help 
lessen side effects.   
 
What side effects or risks can I expect from being in this study?  
Possible side effects of MTS-01 
Likely 
Less Likely 
Rare but Serious 
• Skin irritation 
• Rash 
• Itching of the skin in 
the area being treated 
• Low blood sugar 
• Nausea 
• Diarrhea 
• Low blood potassium 
level 
• Dizziness 
• Blood clots 
Several laboratory tests are always conducted on new drugs to determine if the drugs have the 
potential to alter or otherwise damage the genetic material (DNA) in the body’s cells.  These 
tests are conducted to help determine if the drug may cause cancer in humans.  MTS-01 caused 
damage to DNA in some test-tube tests.  This type of damage to DNA has been associated with 
the development of cancer; however, these laboratory test findings do not necessarily mean that 
MTS-01 could cause genetic damage in humans or increase your risk of developing cancer. 
 
It is unknown whether MTS-01 can interfere with the effectiveness of radiation therapy in the 
treatment of your cancer. 
 
Possible side effects from 5-fluorouracil and mitomycin C 
Likely 
Less Likely 
Rare but Serious 
• Mild 
Nausea 
and/or 
vomit 
• Loss of Appetite 
• Diarrhea 
• Mouth Sores 
• Changes in taste 
• Gastrointestinal 
discomfort 
• Low white blood cell 
count 
• Rash 
• Infections 
• Anemia 
• Low Platelet counts 
• Pain 
• Itchy Skin 
• Dehydration (too much 
water loss from body) 
• Blood clots 
• Severe decreases in 
blood cell counts 
(platelets, red blood 
cells, and white blood 
cells) 
• Changes in mental 
status (i.e. confusion 
and lack of 
coordination) 
• Chest Pain 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  7  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
• Nail problems 
• Hair loss 
• Headache 
• Fatigue 
• Allergic reactions 
• Kidney damage 
• Severe skin damage at 
infusion site 
• Death 
 
Additional Side Effects from Radiation 
Some additional aide effects may occur with radiation to the pelvic area.  These side effects are 
listed below.  Your doctor will discuss these with you.  It is important to let your doctor know if 
you develop these side effects because changes may need to be made to your treatment.  The 
short term side effects of radiation tend to go away a few weeks after treatment is completed. 
 
Likely 
Less Likely 
• Skin irritation in the area radiated 
(pelvis) 
• Fatigue 
• Diarrhea 
• Hair loss in the area treated with 
radiation 
• Burning 
with 
urination 
or 
urgent 
urination 
• Decrease in blood counts 
• Pain in the pelvis area 
 
 
Late Side Effects of Radiation 
 
Some side effects of radiation can happen many months or years after treatment.  It is impossible 
to predict who will develop long term side effects.  Your doctor will discuss these risks with you.  
The possible long term side effects of radiation to the pelvis can include: 
 
Common:  increased tendency to develop gas or diarrhea, more frequent or urgent bowel 
movements, infertility 
 
Uncommon:  bleeding from the rectum, bleeding from the bladder, scarring of the vagina in 
females, decreased sexual function in males 
 
Extremely rare:   injury to the hips that could result in a fracture of bone, life-threatening tumor 
caused by radiation. 
 
Potential Benefits of Participation 
 
Are there benefits to taking part in this study?  


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  8  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
 
The aim of this study is to see if MTS-01 will prevent or lessen skin irritation from 
chemotherapy and radiation as treatment for anal cancer.  By reducing skin irritation, it is 
possible that MTS-01 may reduce the need for breaks from treatment due to pain or infection, 
which may improve the efficacy of treatment.  Because there is not much information about the 
drug’s effect on the skin, we do not know if you will benefit from taking part in this study.  The 
information from this study may help doctors learn more about MTS-01 as a treatment for 
radiation skin damage.  This information could help future cancer patients.  
 
Research Subject’s Rights 
 
What are the costs of taking part in this study?  
 
If you choose to take part in the study, the following will apply, in keeping with the NIH policy: 
• 
You will receive study treatment at no charge to you. This may include 
surgery, medicines, laboratory testing, x-rays or scans done at the 
Clinical Center, National Institutes of Health (NIH), or arranged for you 
by the research team to be done outside the Clinical Center, NIH if the 
study related treatment is not available at the NIH.  
• 
There are limited funds available to cover the cost of some tests and 
procedures performed outside the Clinical Center, NIH.  You may have 
to pay for these costs even if they are not covered by your insurance 
company. 
• 
Medicines that are not part of the study treatment will not be provided or 
paid for by the Clinical Center, NIH. 
• 
Once you have completed taking part in the study, medical care will no 
longer be provided by the Clinical Center, NIH. 
 
Stopping Therapy 
 
Your doctor may decide to stop your therapy for the following reasons: 
• if he/she believes that it is in your best interest 
• if your disease grows during treatment 
• if you have side effects from the treatment that your doctor thinks are too severe 
• if new information shows that another treatment would be better for you 
 
In this case, you will be informed of the reason therapy is being stopped. 
 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  9  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
You can stop taking part in the study at any time. However, if you decide to stop taking part in 
the study, we would like you to talk to the study doctor and your regular doctor first. 
If you decide at any time to withdraw your consent to participate in the trial, we will not collect 
any additional medical information about you. However, according to FDA guidelines, 
information collected on you up to that point may still be provided to Mitos Pharmaceuticals or 
designated representatives. If you withdraw your consent and leave the trial, any samples of 
yours that have been obtained for the study and stored at the NCI can be destroyed upon request. 
However, any samples and data generated from the samples that have already been distributed to 
other researchers or placed in the research databases cannot be recalled and destroyed. 
 
 
Conflict of Interest 
 
The National Institutes of Health (NIH) reviews NIH staff researchers at least yearly for conflicts 
of interest.  The following link contains details on this process 
http://ethics.od.nih.gov/procedures/COI-Protocol-Review-Guide.pdf.  You may ask your 
research team for a copy of the Protocol Review Guide or for more information.  Members of the 
research team who do not work for NIH are expected to follow these guidelines but they do not 
need to report their personal finances to the NIH. 
 
Members of the research team working on this study may have up to $15,000 of stock in the 
companies that make products used in this study.  This is allowed under federal rules and is not a 
conflict of interest.  
 
Optional Biopsies and/or Cytology: 
You are being given the option of having 1) biopsies of tumor, and/or  2) biopsies of normal cells 
from the rectum and anus, and 3) collection of cell from the anus using a small brush (Cytology) 
before and one year after your treatment. You may consent to 0, 1 , 2, or 3 of these procedures, 
and participation in optional biopsies does not affect your ability your eligibility to receive 
treatment for your anal cancer. 
 
For the two separate types of biopsies, your doctor will remove some small pieces of tumor 
and/or 15-30 small pieces of healthy tissue from the rectum and anal canal to do some research 
tests.  
 
These biopsies will be performed via endoscopy. Gastrointestinal endoscopy and biopsy is a 
standard procedure performed in a designated endoscopy room by a qualified gastroenterologist. 
You will be prepared for flexible sigmoidoscopy with a gut-clearing agent (e.g., Golytely, 
Magnesium Citrate) and eating nothing after midnight the night before; you can still take 
medications.  Medications to decrease anxiety and discomfort of endoscope insertion are not 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  10  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
routinely given to patients for flexible sigmoidoscopy, but can be given upon special request by 
you. A flexible tube will be inserted into the rectum that allows the operator to visualize the gut 
mucosa and/or to project an image of the mucosal surface onto a TV screen. At various places in 
the gut surface and tumor surface, small pieces of tissue will be plucked out by manipulation of 
tissue collecting devices at the tip of the endoscope.  
 
The procedure itself generally lasts 15 to 30 minutes. The biopsy procedure has multiple risks.  
The most common side effects are minor bleeding not requiring treatment (3/100 procedures) 
and local pain (3/100 procedures).  Rare but serious side effect include: the risk of the sedatives 
(if given) causing slowing or cessation of breathing (your breathing and blood oxygen level is 
constantly monitored, and some of the sedative effects can be reversed with other drugs); making 
a tear (perforation) in the lining of the bowel (1/10,000 procedures); and death (1/10,000 
procedures). Any complication will be identified as soon as possible and treated appropriately 
which may include hospitalization, antibiotics, blood transfusion, or surgery. The endoscope is 
sterilized prior to use so there is minimal risk of infection from the endoscope. This procedure 
will be further explained to you in much greater detail during a separate informed consent. 
 
Cytology will be performed separately.  A small brush will be inserted into the anus by a doctor 
or nurse to collect cells. 
 
The results of these tests will not be used to plan your care. This tissue will be used to allow us to 
study possible viral causes of anal cancer (Human Papilloma Virus, HPV).  If you have HIV, 
these tests will also be used to see how the HIV virus changes with treatment. 
 
The biopsy to be performed is exclusively for research purposes and will not benefit you.  It 
might help other people in the future.  Even if you sign "yes" to have the biopsy you can change 
your mind at any time.  Please read each sentence below and think about your choice. After 
reading each sentence, circle and initial the answer that is right for you. The decision to 
participate in this part of the research is optional, and no matter what you decide to do, it will not 
affect your care.  
 
I agree to have the anal or rectal biopsies for the research tests in this study.  
 
Yes              No               Initials_________ 
 
I agree to have anal cytology for the research tests in this study.  
 
Yes              No               Initials_________ 
 
Consent for the HPV-Related Cancer Genomic Study 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  11  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
 
Purpose of the Project 
 
We would like to invite you to participate in a research project to discover genetic changes 
associated with cancer, thus potentially leading to better prevention, detection and treatment of 
cancer, and perhaps other diseases as well.  This project is being sponsored by the National 
Cancer Institute (NCI), part of the government agency known as the National Institutes of Health 
(NIH).  If you choose to participate in this aspect of the study, a piece of a biopsy from your 
cancer as well as a blood sample will be included in this study.  You do not need to participate 
in the HPV-Related Cancer Genomic Study in order to participate in the larger treatment 
study. 
 
Bodily tissues are made up of cells containing DNA, which is part of the unique genetic material 
carrying the instructions for your body’s development and function.  Cancer can result from 
changes in this genetic material, thereby causing cells to divide in an uncontrolled way and 
possibly to travel to other organs.  Some of the genetic changes leading to cancer are currently 
known, however many remain to be discovered. 
 
The HPV-Related Cancer Genome Project is designed to identify genetic changes that can cause 
cancer in humans.  As such, we would like to study the genetic material obtained from your 
tumor tissue as part of this project.  We will compare the genetic material from your cancerous 
tissue with the genetic material from your normal tissue to find any differences that may exist.  
By combining information about genetic differences between normal and disease tissues along 
with information contained in your medical records, it may be possible to identify the genetic 
changes that are associated with your particular type of cancer.  This same process will be 
performed with normal and cancerous tissues obtained from a number of other people who have 
agreed to participate in this research project.  In this way, we expect to identify most of the 
genetic changes associated with many different kinds of cancer.  By comparing treatment 
responses of patients with various cancers (through recorded medical information), this project 
could also lead to more knowledge about why certain cancers respond differently to treatments.  
With such knowledge, future treatment options could potentially become customized to a 
patient’s unique genetic make-up.   
 
Description of the Research 
 
Collection of Samples and Medical Information  
• Your biopsy is optional. During your procedure, cancerous tissue will be removed.    This 
will be done at the time of sigmoidoscopy (at the same time as the other biopsy if you 
have consented to that) 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  12  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
• We will collect a sample of blood (approximately 4 tablespoons), drawn from a vein in 
your arm, as a second type of normal tissue.  
• We will also collect information from your medical records, including your age, ethnic 
background, diagnosis, disease history, medical treatments, and response to treatments.  
 
Coding of Tissue Samples and Medical Information  
• Your tissues and blood sample, and medical information will be labeled with a 
confidential project-assigned ID.  
• Only Drs. Citrin and Uldrick at The Center for Cancer Research, NCI will have the 
information that matches the code to traditionally-used identifying information, such as 
your name, address, phone number, or social security number.  Drs. Citrin and Uldrick 
will keep the information that matches the confidential code to this identifying 
information in a safeguarded database.  Only authorized personnel, who have specifically 
agreed to protect your identity, will have access to this database. All materials conveyed 
to the HPV-Related Cancer Genome Project will be labeled with a project-assigned ID, 
removing traditionally-used identifying information, such as your name, address, phone 
number, or social security number. All other researchers and personnel, including those 
who will be working with your samples and medical information, will not have access to 
any of the traditionally-used identifying information about you.   
 
Storage and Release of Samples and Medical Information  
• Your coded tissue samples will be sent to an NCI-sponsored storage facility.  The facility 
will process the samples and then send portions of your samples to different types of 
laboratories for analysis as part of this project.  One type of laboratory will analyze your 
DNA by a method called sequencing.  Other laboratories will study your samples by 
different methods.  The remaining tissue from your samples might be stored for an 
unlimited period of time for use in future research related to cancer, or perhaps in other 
research projects if you provide consent for these studies.  
• Information obtained from analyses performed on your coded samples and medical 
information will be entered into project databases along with information acquired from 
the other research participants in this project.   
o Anonymous information from the analyses, which cannot be traced to any 
individual patient, may be available to anyone on one of several completely 
public Internet databases of scientific information.   
o Information obtained from more detailed analyses, along with your confidential 
coded medical information, will be put into a controlled-access database.  The 
information in this database will be available only to researchers who have 
received approval from an NIH Data Access Committee. In gaining access to such 
information, researchers have to agree to use the data only for research projects 
and not to ever try to use it in order to identify the donor of the material. 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  13  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
However, despite all of the safety measures that we will use, we cannot guarantee 
that your identity will never become known. 
 
Please note that traditionally-used identifying information about you, such as your name, 
address, telephone number, or social security number, will NOT be put into either the public 
or controlled-access databases for this project.  
 
 
Potential Benefits of Participating in the Project 
You should not expect to personally benefit from this research, aside from the knowledge that 
your participation will help researchers and health professionals around the world to better 
understand the causes of cancer and other diseases. Research projects such as this lead to better 
ways to prevent, detect, treat, and cure such illnesses.  
 
Potential Risks of Participating in the Project 
 
Physical Risks   
• There are very few physical risks associated with this project.  Possible side effects from 
drawing the blood sample include mild pain, bleeding, bruising, and infection at the site 
of the needle insertion.  Fainting or light-headedness can sometimes occur, but usually 
lasts only a few minutes. Every precaution will be taken to minimize these effects.  
 
Psychological or Social Risks Associated with Loss of Privacy    
• Your privacy is very important to us, and we use many safety measures to protect your 
privacy.  However, despite all of the safety measures that we will use, we cannot 
guarantee that your identity will never become known.  Although your genetic 
information is unique to you, you do share some genetic information with your children, 
parents, brothers, sisters, and other relatives.  Consequently, it may be possible that 
genetic information from them could be used to help identify you.  Similarly, it may be 
possible that genetic information from you could be used to help identify them.    
• While neither the public nor the controlled-access databases developed for this project 
will contain information that is traditionally used to identify you (your name, address, 
telephone number, or social security number), technology may be developed in the future 
that would allow someone to link your genetic or medical information in our databases 
back to you.  For example, someone could compare information in our databases with 
information from you (or a relative) in another database and be able to identify you (or 
your relative).  It is also possible that there could be violations to the security of the 
computer systems used to store the codes linking your genetic and medical information 
back to you. Because some genetic variations can help to predict the current or future 
health problems of you and your relatives, this information may be of interest to 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  14  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
employers, health providers, insurance companies, and others.  Patterns of genetic 
variation also can be used by law enforcement agencies to identify a person or his/her 
relatives.  Therefore, your genetic information could potentially be used in ways that 
could cause you or your family distress, such as by revealing that you (or a relative) carry 
a genetic disease or by leading to the denial of employment or insurance for you (or a 
relative).  
• There also may be other privacy risks that we have not foreseen. 
  
While we believe that the risks to you and your family are very low, we are unable to tell you 
exactly what all of the risks are.  There are some state laws that protect against genetic 
discrimination by employers or insurance companies, but there is currently no federal law that 
prohibits such discrimination.  We believe that the benefits of learning more about cancer and 
other diseases outweigh these potential risks. 
 
Will your medical information be kept private? 
We will do our best to make sure that the personal information in your medical record will be 
kept private.  However, we cannot guarantee total privacy.  Organizations that may look at 
and/or copy your medical records for research, quality assurance, and data analysis include: 
 
• The National Cancer Institute (NCI) and other government agencies, like the Food 
and Drug Administration (FDA), which are involved in keeping research safe for 
people. 
• National Cancer Institute Institutional Review Board 
• The study sponsor Mitos Pharmaceuticals 
• Qualified representatives from Mitos Pharmaceuticals, the pharmaceutical company 
who produces Tempol MTS-01. 
 
A description of this clinical trial will be available on http://www.Clinicaltrials.gov, as required 
by U.S. Law.  This Web site will not include information that can identify you.  At most the Web 
site will include a summary of the results.  You can search this Web site at any time.


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  15  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
Project Results   
If research from this project is published in professional journals, there will be no traditionally-
used identifying information, such as your name, address, telephone number, or social security 
number, included in the publications.  Some publications from this project will be found at the 
HIV Tumor Molecular Characterization Project website.   
 
Your individual results will not be added to your medical record, and they generally will not be 
reported back to you. However, your doctors will periodically review results.  If a gene change is 
identified that is not related to this research study, but has a well-established relationship to a 
human disease, your doctors will notify you if you choose.  Such unexpected test results  are 
known as “incidental findings”.  
If we find a change in a gene that is important to you or your family’s health, the results will 
need to be confirmed in a clinical laboratory.  If you want this to be done, we will draw an 
additional blood sample and send it for confirmatory testing. Once the results are available, if 
you would like to receive your results we will offer to have you come to NIH (at our expense) 
to have genetic education and counseling to explain this result.  If you do not want to come to 
NIH, we will help you find a local genetic healthcare provider who can explain it to you (at 
your expense). 
 
If we find gene changes that are not known to be important at this time, we will not share that 
information with you. As this is a rapidly changing field, it is possible that genetic variants that 
are not known to be important at this time may be shown to be important at a later date. If you 
are receiving care from another physician who thinks that this testing may be of use in your care 
and treatment, you may contact us at any time and we will share the results with your physician.  
 
Please let us know your preference by initialing one of the following statements:  
 
_[ ]___ I DO NOT want to be recontacted if genetic variants with potential health implications 
are discovered.  
_[ ]___ I DO want to be recontacted if genetic variants with potential health implications are 
discovered. (You will be given a choice to learn or not learn about a genetic change that we 
find.)  
 
Financial Compensation/Costs 
You will not be paid to participate in this project.  Your tissue samples and your medical 
information will be used for research purposes only and will not be sold.  It is possible that some 
of the research conducted using your tissue samples or medical information will eventually lead 
to the development of new diagnostic tests, drugs or other commercial products.  Should this 
occur, you will not receive any part of the profits generated from such products. 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  16  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
 
Alternatives to Participating in the Project 
The alternative option is not to participate in this project.  
 
Voluntary Participation   
The choice to participate in this research by donating your tissues and medical information is 
completely up to you. No matter what you decide, your decision will not affect your medical 
care.  
  
Withdrawal from the Project 
Once your coded samples have been distributed to the participating research laboratories and 
centers, and your information transferred to the appropriate databases, you will not be able to 
withdraw your information from this research project. However, you may be able to request the 
return or destruction of the tissue samples if you so desire. 
 
My tissue and blood may be used in the Anal Cancer Genome Project  
 
Yes              No               Initials_________ 
 
Additional Optional Studies  
We would like to keep some of the tissue and blood that are collected for future research.  These 
specimens will be identified by a number and not your name.  The use of your specimens will be 
for research purposes only and will not benefit you.  It is also possible that the stored specimens 
may never be used.  Results of research done on your specimens will not be available to you or 
your doctor.  It might help people who have cancer and other diseases in the future.   
 
If you decide now that your tissue and blood can be kept for research, you can change your mind 
at any time. Just contact us and let us know that you do not want us to use your tissue, blood, and 
urine.  Then any tissue and blood that remain will be destroyed.  
 
Please read each sentence below and think about your choice. After reading each sentence, circle 
and initial the answer that is right for you.  No matter what you decide to do, it will not affect 
your care. 
 
 
 
 
 
 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  17  of  19  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
 
1. My tissue, blood, and urine specimens may be kept for use in research to learn about, prevent, 
or treat cancer.  
 
Yes              No               Initials_________ 
 
2. My specimens may be kept for use in research to learn about, prevent or treat other health 
problems (for example: diabetes, Alzheimer's disease, or heart disease).  
 
Yes              No               Initials_________ 
 
3. Someone may contact me in the future to ask permission to use my specimen(s) in new 
research not included in this consent.  
 
Yes              No               Initials_________ 
 
HIV Testing  
 
As part of this study, we will test you for infection with the human immunodeficiency virus 
(HIV), the virus that causes AIDS.  If you are infected with HIV you will be able to participate in 
this study.  We will tell you what the results mean, how to find care, how to avoid infecting 
others, how we report newly diagnosed HIV infection, and the importance of informing your 
partners at possible risk because of your HIV infection. 
 


MEDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• 
Adult Patient or              • Parent, for Minor Patient 
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  18  of  19  pages 
 
PATIENT IDENTIFICATION 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH 
STUDY (Continuation Sheet) 
• 
Adult Patient or 
• Parent, for Minor Patient 
NIH-2514-1 (07-09) 
P.A.:  09-25-0099 
 
File in Section 4:  Protocol Consent 
 
 
OTHER PERTINENT INFORMATION 
 
1. Confidentiality.  When results of an NIH research study are reported in medical journals or 
at scientific meetings, the people who take part are not named and identified.  In most cases, the 
NIH will not release any information about your research involvement without your written 
permission.  However, if you sign a release of information form, for example, for an insurance 
company, the NIH will give the insurance company information from your medical record.  This 
information might affect (either favorably or unfavorably) the willingness of the insurance 
company to sell you insurance. 
 
The Federal Privacy Act protects the confidentiality of your NIH medical records.  However, you 
should know that the Act allows release of some information from your medical record without 
your permission, for example, if it is required by the Food and Drug Administration (FDA), 
members of Congress, law enforcement officials, or authorized hospital accreditation 
organizations. 
 
2. Policy Regarding Research-Related Injuries.  The Clinical Center will provide short-term 
medical care for any injury resulting from your participation in research here.  In general, no 
long-term medical care or financial compensation for research-related injuries will be provided 
by the National Institutes of Health, the Clinical Center, or the Federal Government.  However, 
you have the right to pursue legal remedy if you believe that your injury justifies such action. 
 
3. Payments.  The amount of payment to research volunteers is guided by the National 
Institutes of Health policies.  In general, patients are not paid for taking part in research studies at 
the National Institutes of Health.  Reimbursement of travel and subsistence will be offered 
consistent with NIH guidelines. 
 
4. Problems or Questions.  If you have any problems or questions about this study, or about 
your rights as a research participant, or about any research-related injury, contact the Principal 
Investigator, Deborah Citrin, M.D.,  CRC, B2-3500, Telephone:  301-496-5457. You may also 
call the Clinical Center Patient Representative at (301) 496-2626. If you have any questions 
about the use of your tissue for future research studies, you may also contact the Office of the 
Clinical Director, Telephone:  301-496-4251.  
 
5. Consent Document.  Please keep a copy of this document in case you want to read it again. 
 
 
 
 
 
 
 
 


MEDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
         •    Adult Patient or             •      Parent, for Minor Patient              
STUDY NUMBER: 
11-C-0129 
CONTINUATION:  page  19  of  19  pages 
 
PATIENT IDENTIFICATION 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH 
STUDY (Continuation Sheet) 
• 
Adult Patient or 
• Parent, for Minor Patient 
NIH-2514-1 (07-09) 
P.A.:  09-25-0099 
 
File in Section 4:  Protocol Consent 
 
 
 
 
 
 
 
COMPLETE APPROPRIATE ITEM(S) BELOW: 
 
A. Adult Patient’s Consent 
B. Parent’s Permission for Minor 
Patient. 
I have read the explanation about this study and have 
been given the opportunity to discuss it and to ask 
questions.  I hereby consent to take part in this study. 
I have read the explanation about this 
study 
and 
have 
been 
given 
the 
opportunity to discuss it and to ask 
questions.  I hereby give permission for 
my child to take part in this study.   
(Attach NIH 2514-2, Minor’s Assent, if 
applicable.) 
 
  
 
 
 
Signature of Adult Patient/Legal Representative
 
Date 
 
 
 
Print Name 
Signature of Parent(s)/Guardian 
 
 
 
Print Name 
C. Child’s Verbal Assent (If Applicable) 
The information in the above consent was described to my child and my child agrees to 
participate in the study. 
 
 
 
  
 
 
 
 
Signature of Parent(s)/Guardian 
Date 
 
Print Name 
THIS CONSENT DOCUMENT HAS BEEN APPROVED FOR USE  
FROM JULY 22, 2013 THROUGH JULY 21, 2014.  
 
 
  
 
 
 
Signature of Investigator 
Date 
 
 
 
Print Name 
Signature of Witness 
 
 
 
Print Name