Clinical trial NCT02770014
Conditions: Epidermal Growth Factor Receptor Non-Small Cell Lung Cancer
Keywords: Non-Small Cell Lung Cancer Epidermal Growth Factor Receptor
Sponsor: Dana-Farber Cancer Institute
Start date: 2016-06-01; Completion date: 2019-06-19
Enrollment: 43 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
Patient with Non-Small Cell Lung Cancer (NSCLC) that might have a genetic change (mutation) in the Epidermal Growth Factor Receptor (EGFR) are invited to take part in this study.

This research study is evaluating a new blood test that is capable of detecting an EGFR mutation in cancer without a biopsy.

Detailed description:
This research study is a Phase II clinical trial. This research study will determine if a rapid blood test can be used to detect EGFR mutations in patients with newly diagnosed lung cancer and use that information to rapidly start patients on a pill-based therapy.

This blood test has not previously been used to select patients for treatment with Erlotinib without confirming this finding on a biopsy.

Arms: arm 1: Eligible EGFR mutations include exon 19 deletion or exon 21 L858R mutation. Erlotinib will be initially dosed at a pre-determine dosage daily, and it will be given on a 6-week cycle with treatment administered on an outpatient basis
Interventions: intervention 1: Erlotinib
Intervention descriptions: intervention 1: None

Protocol documents:
Prot_SAP_000.pdf: 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
  
 
 
 
 
 
 
 
 
TITLE: Rapid plasma genotyping for early initiation of erlotinib in EGFR 
mutant lung cancer 
 
PROTOCOL NUMBER:     16-093 
 
STUDY DRUG:         Erlotinib  
 
PRINCIPAL INVESTIGATOR:  Geoffrey R. Oxnard, M.D. 
 
CO-INVESTIGATORS:     Pasi A. Jänne, M.D. Ph.D. 
               Lynette Sholl, M.D. 
 
STATISTICIAN:        Suzanne Dahlberg, Ph.D. 
 
SPONSOR:           Dana-Farber Cancer Institute 
 
 
 
 
  


Protocol: 16-093: Rapid plasma genotyping for early initiation of erlotinib in EGFR mutant lung cancer  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
i 
SCHEMA – DIAGNOSTIC PHASE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SCHEMA –TREATMENT PHASE 
 
 
 
 
 
 
 
 
 
 
 
**Participants showing clinical benefit to erlotinib may continue to receive study treatment beyond disease 
progression with the approval of the treating investigator. 
 
 
 
 
 
 
 
 
 
 
 
Plasma 
genotyping  
(2-4 business 
day 
turnaround 
time) 
Advanced 
NSCLC, 
ungenotyped 
(~100 pts)* 
Treatment Phase: trial 
of initiating erlotinib 
based on plasma 
genotype (~30 
patients, see below) 
Plasma + 
for EGFR 
mutation 
* enriched for 
Asian or light 
smokers 
Plasma  - 
for EGFR 
mutation 
Off-Trial at  
Standard 
Treatment 
Plasma + for 
EGFR  
L858R or 
exon 19 
Immediate 
initiation of 
therapy with 
erlotinib 
Review 
eligibility for 
treatment on 
study 
6 week CT 
imaging to 
determine 
ORR
 
-Consent 
-Screening 
-Registration 
-Blood Draw 
-Plasma 
Genotyping 
Initiated  
PD – Discontinue Study** 
SD – Continue, unless 
intolerable toxicity or EGFR 
WT on tissue (discontinue 
at investigators discretion) 
PR/CR – Continue Study 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
ii 
SYNOPSIS 
 
Study Title: 
 
Rapid plasma genotyping for early initiation of erlotinib in EGFR 
mutant lung cancer 
Study Phase: 
II 
Study Rationale: 
Plasma genotyping using a ddPCR-based platform has been 
demonstrated to rapidly, accurately and noninvasively detect targetable 
genomic alterations such as EGFR sensitizing mutations (exon 19 del 
and L858R) in advanced lung adenocarcinoma. This study will evaluate 
a new diagnostic and treatment paradigm in which newly diagnosed or 
progressive advanced lung adenocarcinoma patients will undergo rapid 
plasma genotyping followed by immediate initiation of erlotinib therapy 
in patients with detected EGFR mutations.  
Primary Objective(s): 
 
Demonstrate a high objective response rate to erlotinib in patients with 
advanced NSCLC positive for an EGFR mutation by plasma genotyping. 
Secondary Objective(s): 
 
1. Determine the time from study registration to treatment 
initiation using a rapid plasma genotyping strategy versus 
standard tumor genotyping.  
2. Ascertain the positive predictive value of plasma genotyping for    
patients with recently diagnosed advanced NSCLC. 
Study Design: 
 
Open-label single-arm phase II study  
Study Population: 
 
Patients with newly diagnosed, progressive or recurrent advanced lung 
adenocarcinoma with clinical characteristics that increase the likelihood 
of possessing an EGFR mutation (never/light smokers or Asian race); all 
subjects must have tumor biopsy tissue available for analysis at 
enrollment or a plan to obtain this tissue. Re-biopsy at the development 
of treatment resistance is encouraged. 
Study Size: 
100 patients will be screened in the diagnostic portion of this study using 
a CLIA plasma genotyping assay. 30 patients positive for an EGFR 
mutation by this assay will continue in the treatment portion of this trial 
with immediate treatment with erlotinib. 
Drug, Dose, and Mode of 
Administration: 
Erlotinib 150 mg orally daily. 
Drug Manufacturer: 
Astellas  
Duration of Treatment: 
Until disease progression or intolerable toxicity 
Efficacy Assessments: 
 
CT assessment of response per RECIST v1.1 will be performed every 6 
weeks for a total of 24 weeks. 
Correlative Analysis: 
If technically feasible, baseline tumor biopsy material should  be 
available for standard EGFR genotyping. 
Statistical Methods: 
 
Treatment with erlotinib among those who test positive for an EGFR 
sensitizing mutation (exon 19 del/L858R) via plasma genotyping will be 
considered worthy of further study if the lower bound of the two-sided 
90% exact binomial confidence interval around the objective response 
rate exceeds 0.40; this is consistent with observing at least 17 responses 
(CR or PR) among the 30 patients enrolled on the study. 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
iii 
Date of Original Approved 
Protocol: 
April 26, 2016 
Date of Most Recent 
Protocol Amendment (if 
applicable): 
February 15, 2017 
 
 
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
iv 
 
TABLE OF CONTENTS 
Synopsis ....................................................................................................................................................................... ii 
1. 
OBJECTIVES .................................................................................................................................................... 1 
1.1 
Study Design .................................................................................................................................................... 1 
1.2 
Primary Objectives .......................................................................................................................................... 1 
1.3 
Secondary Objectives ...................................................................................................................................... 1 
2. 
BACKGROUND ................................................................................................................................................ 1 
2.1 
Study Disease .................................................................................................................................................. 1 
2.2 
Plasma Genotyping ......................................................................................................................................... 2 
2.3 
Study Assay ...................................................................................................................................................... 2 
2.4 
Study Agent ...................................................................................................................................................... 4 
2.5 
Rationale ......................................................................................................................................................... 4 
3. 
PARTICIPANT SELECTION .......................................................................................................................... 4 
3.1 
Eligibility Criteria ........................................................................................................................................... 4 
3.2 
Exclusion Criteria ........................................................................................................................................ 5 
3.3 
Inclusion of Women, Minorities and Other Underrepresented Populations ................................................... 6 
4. 
REGISTRATION PROCEDURES .................................................................................................................. 6 
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions ........................................................................... 6 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions ....................................................................... 6 
4.3 
General Guidelines for Other Participating Institutions .......................................................................... 6 
4.4 
Registration Process for Other Participating Institutions ............................................................................. 6 
5. 
STUDY PROCEDURES .................................................................................................................................... 6 
5.1 
Initial Plasma Genotyping ............................................................................................................................... 6 
5.2 
Serial Plasma Genotyping ............................................................................................................................... 7 
5.3 
Tissue Genotyping ........................................................................................................................................... 7 
6. 
TREATMENT PLAN ........................................................................................................................................ 7 
6.1 
Pre-treatment Criteria ................................................................................................................................... 8 
6.2  Agent Administration & Storage ................................................................................................................. 8 
6.3 
Definition of Dose-Limiting Toxicity ............................................................................................................ 9 
6.4 
General Concomitant Medication and Supportive Care Guidelines ............................................................... 9 
6.5 
Duration of Therapy ......................................................................................................................................... 9 
6.6 
Treatment Assessments .................................................................................................................................. 10 
6.7 
Duration of Follow Up .................................................................................................................................. 10 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
v 
6.8 
Criteria for Removal from Study ................................................................................................................... 10 
7. 
EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS .................................... 11 
7.1 
Anticipated Toxicities .................................................................................................................................... 11 
7.2 
Toxicity Management .................................................................................................................................... 11 
7.3 
Dose Modifications/Delays ........................................................................................................................... 12 
8. 
DRUG FORMULATION AND ADMINISTRATION ................................................................................. 12 
8.1 
Erlotinib ........................................................................................................................................................ 12 
9. 
CORRELATIVE/SPECIAL STUDIES .......................................................................................................... 13 
9.1 
Pharmacokinetic Studies ............................................................................................................................... 14 
9.2 
Pharmacodynamic Studies ............................................................................................................................ 14 
10. 
STUDY CALENDAR ...................................................................................................................................... 14 
11. 
MEASUREMENT OF EFFECT..................................................................................................................... 16 
11.1  Antitumor Effect– Solid Tumors .................................................................................................................... 16 
12. 
ADVERSE EVENT REPORTING REQUIREMENTS ............................................................................... 21 
12.1  Definitions ..................................................................................................................................................... 21 
12.2  Procedures for AE and SAE Recording and Reporting ................................................................................. 23 
12.3  Reporting Requirements ................................................................................................................................ 23 
12.4  Reporting to the Drug Manufacturer (Astellas) ............................................................................................ 23 
12.5  Reporting to the Institutional Review Board (IRB) ....................................................................................... 24 
12.6  Reporting to the Food and Drug Administration (FDA) ............................................................................... 24 
12.7  Reporting to the NIH Office of Biotechnology Activities (OBA) ................................................................... 24 
12.8  Reporting to the Institutional Biosafety Committee (IBC)............................................................................. 24 
12.9  Reporting to Hospital Risk Management....................................................................................................... 25 
12.10 Reporting to Astellas ..................................................................................................................................... 25 
12.11 Monitoring of Adverse Events and Period of Observation ............................................................................ 25 
13. 
DATA AND SAFETY MONITORING .......................................................................................................... 26 
13.1  Data Reporting .............................................................................................................................................. 26 
13.2  Safety Meetings ............................................................................................................................................. 26 
13.3  Monitoring ..................................................................................................................................................... 26 
14. 
REGULATORY CONSIDERATIONS .......................................................................................................... 27 
14.1  Protocol Review and Amendments ................................................................................................................ 27 
14.2  Informed Consent .......................................................................................................................................... 27 
14.3  Ethics and Good Clinical Practice (GCP) .................................................................................................... 27 
14.4  Study Documentation .................................................................................................................................... 28 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
vi 
14.5  Records Retention ......................................................................................................................................... 28 
14.6  Multi-center Guidelines ................................................................................................................................. 28 
14.7  Cooperative Research and Development Agreement (CRADA)/Clinical Trials Agreement (CTA) .............. 28 
15. 
STATISTICAL CONSIDERATIONS ............................................................................................................ 28 
15.1  Study Design/Endpoints ................................................................................................................................ 28 
15.2  Sample Size/Accrual Rate .............................................................................................................................. 29 
15.3  Stratification Factors .................................................................................................................................... 29 
15.4  Analysis of Secondary Endpoints .................................................................................................................. 29 
15.5  Reporting and Exclusions .............................................................................................................................. 29 
16. 
REFERENCES ................................................................................................................................................. 30 
17. 
APPENDICES .................................................................................................................................................. 31 


Protocol: 16-093: Rapid plasma genotyping for early initiation of erlotinib in EGFR mutant lung cancer  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
1 
1. OBJECTIVES 
 
1.1 
Study Design 
 
This single-arm phase II study will treat 30 patients with erlotinib based upon a positive plasma 
genotyping assay revealing an EGFR activating mutation (exon 19 del, L858R). To identify these 30 
patients, we will screen 100 patients with newly diagnosed, progressive or recurrent advanced NSCLC 
that have not yet undergone standard genotyping. This study will examine a novel treatment strategy 
utilizing rapid plasma genotyping and immediate erlotinib treatment in EGFR mutant patients. The study 
population will be enriched in never/light smokers and patients of Asian race. All patients will undergo 
rapid plasma genotyping followed by immediate treatment in EGFR mutant patients. Standard tissue 
genotyping will be performed in parallel if adequate tumor tissue is available; for those without tissue 
available for genotyping at study start, a biopsy to confirm tumor genotype and assess resistance is 
expected at the end of study.  Patients where biopsy fails and is not felt to be feasible or safe may still go 
on treatment if an EGFR mutation is detected by plasma genotyping. Given the high specificity & 
positive predictive value of this assay, false positive results are rare. Patients will undergo baseline CT 
imaging which will be repeated initially after 6 weeks and then at 12, 18 and 24 weeks. Patients will 
continue on erlotinib until they develop clinically significant progression as per current standard of care. 
Re-biopsy upon the development of treatment resistance will be encouraged but will not be covered by 
this study. The primary statistical analysis of response rate will be performed in 30 patients initiating 
erlotinib therapy based on plasma genotype.  
 
1.2 
Primary Objectives 
 
- 
Demonstrate a high objective response rate to erlotinib in patients with advanced NSCLC positive 
for an EGFR mutation (exon 19 del/L858R) by plasma genotyping. 
 
1.3 
Secondary Objectives 
 
- 
Determine the time from study registration to treatment initiation using a rapid plasma 
genotyping strategy versus standard tumor genotyping.  
 
- 
Ascertain the positive predictive value and false negative rate of plasma genotyping for patients 
with recently diagnosed advanced NSCLC among patients with tissue available for standard 
genotyping. 
 
2. BACKGROUND 
 
2.1 
Study Disease 
 
EGFR mutant NSCLC represents a genomically distinct subgroup of lung cancer. These patients have 
been demonstrated in multiple large randomized trials to exhibit high ORR and progression-free survival 
when treated with first-generation EGFR kinase inhibitors such as erlotinib.1-5 However, these agents are 
minimally active in EGFR wild-type patients. The use of these agents is thus largely restricted to patients 
possessing an EGFR sensitizing mutation. The timely initiation of these treatments hinges upon 
accurately and rapidly detecting these predictive EGFR mutations. The only means of detecting these 
mutations currently is through genotyping performed upon a tissue biopsy – an invasive and often time 
consuming process.  
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
2 
The development of newer genotype-directed therapies in resistant disease has also led to an increased 
need for post-treatment tissue biopsies in order to allow clinical trial enrollment.6,7 A patient with 
advanced NSCLC may thus undergo multiple tissue biopsies during the course of their disease with the 
availability of tumor tissue representing a key limitation. The need for tissue biopsies invariably leads to 
both a delay in the initiation of erlotinib therapy in EGFR mutant patients as well as standard 
chemotherapy or potential clinical trial enrolment in EGFR wild type patients – in extreme cases patients 
may be unable to access certain treatments or trials if a biopsy fails or is not technically feasible.    
 
2.2 
Plasma Genotyping 
 
Plasma genotyping is a promising and evolving analytic method which allows for noninvasive 
tumor genotyping to be performed on patient plasma samples. Cell-free DNA (cfDNA) can be 
readily isolated from these samples and contains a portion of tumor derived DNA. This cfDNA 
may then be evaluated using various genotyping assays in order to detect the presence of a 
potentially targetable genomic alteration. The potential of this technology has been demonstrated 
in various early studies across multiple tumor types. These have demonstrated that highly sensitive 
qualitative genotyping assays are able to detect mutations in cfDNA reflecting underlying mutations in a 
patient’s tumor.8-10 However, interpretation of these highly sensitive qualitative assays is marred by false 
positives caused by the detection of clinically insignificant levels of mutations in cfDNA.11 As such, no 
plasma genotyping assays have yet entered routine clinical use. Competing assays which analyze 
circulating tumor cells initially garnered similar enthusiasm, but have been slowed by significant 
technical challenges.12   
 
2.3 
Study Assay 
 
Our group has developed a novel assay utilizing droplet digital PCR (ddPCR) technology to perform 
noninvasive and quantitative genotyping on cfDNA collected from plasma samples. This assay utilizes 
ddPCR to emulsify collected cfDNA from patient plasma into approximately 20 000 droplets that 
undergo individualized PCR reactions and analysis allowing for the quantification of mutant versus 
wildtype copy number [Figure 1].13 Previously published work by our group has demonstrated the 
technical feasibility and accuracy of this plasma genotyping assay for detecting both activating and 
resistance mutations in EGFR (exon 19 del, L858R and T790M) as well as KRAS mutations in NSCLC 
patients.13 This assay is both highly sensitive and quantitative which creates unique advantages over 
previous plasma genotyping methods. We have demonstrated that the quantitative nature of this assay 
combined with quality control methods can minimize the false positive results that have plagued earlier 
assays. The quantitative nature of this assay may also be exploited to allow prediction of early treatment 
failure as well as the development of treatment resistance. 
Figure 1: Plasma genotyping using droplet digital PCR (ddPCR). Cell free DNA (cfDNA) is extracted 
from a plasma specimen and emulsified with oil into ~20,000 droplets, each containing approximately 
0-1 molecules of target DNA. PCR is performed to endpoint in each droplet. These droplets are run 
through a flow cytometer, where droplets containing mutant and wildtype DNA emit different colored 
signals. The count of these signals allows quantification of allelic prevalence.  


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
3 
Figure 2: change in EGFR mutation copy 
number in advanced NSCLC patients with (A) 
and without (B) a partial radiographic response 
after initiating a new line of therapy (PR – partial 
response, SD – stable disease, PD – progressive 
disease per RECIST 1.1). 
Figure 3: log-fold change in mutation copy 
number in advanced NSCLC patients correlates 
with radiographic response in patients treated 
with both standard chemotherapy and kinase 
inhibitors (per RECIST 1.1). 
Following initial validation of this assay in a small 
group of patients as described above, we 
retrospectively examined this assay in a larger group 
of metastatic NSCLC patients with EGFR sensitizing 
mutations (exon 19 del, L858R) and acquired 
resistance to EGFR kinase inhibitors. This study 
compared the test characteristics of our ddPCR-based 
plasma genotyping assay for the detection of both 
EGFR sensitizing and the T790M acquired resistance 
mutation in a cohort of 41 patients with advanced 
NSCLC who had undergone re-biopsy and standard 
tissue genotyping for comparison. This revealed 70% 
assay sensitivity for detection of EGFR T790M and a 
93% assay specificity to T790M. In addition, a subset 
of 15 of these patients underwent serial plasma 
genotyping after beginning a new line of 
systemic/targeted therapy. This subset of patients 
underwent baseline plasma genotyping followed by 
repeat testing with each treatment cycle. Patients with 
a partial response to treatment uniformly exhibited 
decreased levels of EGFR cfDNA over time whereas 
patients without response exhibited stable or increased 
levels [Figure 2].14 These data indicate that this assay 
may also predict treatment outcome as early as 4 weeks 
after initiating treatment – potentially allowing early 
treatment modification.  
 
We have subsequently initiated a prospective study of 
ddPCR-based plasma genotyping in a planned cohort 
of 340 NSCLC patients in order to assess its ability to 
accurately detect EGFR sensitizing (exon 19 del, 
L858R), T790M and KRAS G12X mutations. These 
patients include newly diagnosed patients, those with 
acquired resistance to kinase inhibitors and those 
undergoing a new line of subsequent treatment. The 
aims of this study include assessing both test 
characteristics compared to gold standard tissue 
genotyping performed on a biopsy specimen as well as 
correlating change in detectable levels of mutations 
during treatment with radiographic response through 
serial blood testing. This study has accrued 250 patients 
thus far. Median TAT for plasma ddPCR is 3 days 
(range 1-5). Specificity of plasma ddPCR is 99% for 19 
del/L858R (94/95) and 100% for KRAS (82/82), but 
lower for T790M at resistance (81%, 22/27). Sensitivity 
of plasma ddPCR is 75% for 19 del/L858R (73/97) and 73% for T790M (30/41) but lower for KRAS 
(62%, 16/26).  
 
Taken together, these previous studies indicate that ddPCR-based plasma genotyping using our validated 
assay is able to detect EGFR sensitizing mutations (exon 19 del, L858R) in metastatic NSCLC with a 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
4 
high degree of specificity and acceptable sensitivity. A positive result from this assay is thus highly 
specific for the presence of an EGFR mutation and clinically actionable given the very low likelihood of 
false positive results.  
 
2.4 
Study Agent 
 
Erlotinib is an oral tyrosine kinase inhibitor which specifically inhibits the epidermal growth factor receptor 
(EGFR) through non-covalent competitive binding to the ATP-binding site of the receptor. It preferentially 
inhibits the activity of EGFR possessing activating mutations in the kinase domain. This agent is FDA 
approved for the treatment of advanced NSCLC possessing an activating mutation in the EGFR kinase 
domain (e.g. EGFR exon 19 del, L858R).1,2  
 
Erlotinib is a well tolerated oral medication with a favorable side-effect profile. The most frequent adverse 
events noted in previous studies include diarrhea, acneiform rash and changes in skin/hair. Rare but serious 
adverse events including pneumonitis and hepatotoxicity have also been reported in previous studies.1,2 
 
Erlotinib has been previously demonstrated in multiple phase III trials to exhibit similar overall survival 
benefit to first-line platinum-doublet chemotherapy in advanced NSCLC possessing an EGFR sensitizing 
mutation (exon 19 del/L858R). The objective response rate (ORR) in these trials has been approximately 
70% with a disease control rate approaching 90% in most trials.1,2 Given this efficacy data and its 
favorable toxicity profile, erlotinib has been adopted as the standard initial treatment of advanced EGFR 
mutant NSCLC. The standard initial dosing of erlotinib is 150 mg po daily. 
 
2.5 
Rationale 
 
This rapid and accurate ddPCR-based plasma genotyping assay combined with immediate treatment with 
erlotinib in EGFR mutant (exon 19 del/L858R) patients has the potential to both expedite appropriate 
therapy as well as avoid missed treatment opportunities in patients where tissue biopsies are delayed or 
not feasible. We have designed a prospective single-arm phase II study to evaluate a novel treatment 
strategy employing rapid plasma genotyping followed by immediate erlotinib treatment in EGFR mutant 
patients (exon 19 del/L858R) compared with standard genotyping followed by treatment. This study 
would specifically evaluate this novel treatment strategy compared with standard treatment with respect 
to the speed with which erlotinib therapy is initiated, the appropriateness of the first-line treatment 
initiated and overall response rate. 
 
3. PARTICIPANT SELECTION 
 
3.1 
Eligibility Criteria 
 
Participants must meet the following screening criteria in order to enroll and undergo plasma 
genotyping on this study: 
 
3.1.1 
Histologically or cytologically confirmed metastatic NSCLC including recurrent disease  
3.1.2 
EGFR genotype must not be known. However, pending EGFR tumor genotyping is 
allowed. 
3.1.2.1 Participants with positive or pending EGFR mutation on plasma genotyping 
performed at the central lab are eligible for enrollment, and will not need to 
repeat initial plasma genotyping on study.  


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
5 
3.1.3 
Tissue must be available for genotyping or biopsy planned to obtain tissue for genotyping. 
Biopsy requirement may be waived if not technically feasible and plasma genotyping 
reveals an eligible EGFR mutation (exon 19 del/L858R). Determination of technical 
feasibility must be made independently of plasma genotyping results. 
3.1.4 
Participants must possess at least two of the following clinical characteristics which enrich 
for EGFR mutations: 
 
smoked less than 10 pack years  
 
Asian race 
 
Adenocarcinoma (including adenosquamous carcinoma) on histology or cytology. 
3.1.5 
Participants must have measurable disease with at least one lesion that can be accurately 
measured in longest dimension as >2 cm with conventional imaging techniques or >1 cm 
with a spiral CT scan per RECIST v1.1. 
3.1.6 
Participants must have progressive, advanced cancer as defined by one of the following: 
 
Newly diagnosed, untreated advanced disease 
 
Newly diagnosed, untreated metastatic recurrence of earlier stage disease (previous 
treatment of early stage disease allowed). 
 
Clinical determination of progressive disease on previous systemic therapy as 
evidenced by plan to change treatment. Any number of prior therapies are 
acceptable excluding previous EGFR kinase inhibitors. 
3.1.7 
Age 18 years or older. 
3.1.8 
ECOG performance status 0-2.  
3.1.9 
Participant must be able to understand and give consent to participate in the study.  
3.1.10 Patient must be a candidate for systemic therapy with erlotinib based on clinical 
assessment. Patients must meet the following criteria before beginning therapy (Note: these 
are not required for initial study enrollment and plasma genotyping):  
‐ 
ECOG performance status of 0-2 
‐ 
Platelets >75 
‐ 
AST & ALT < 3x the upper limit of normal 
‐ 
Creatinine clearance > 30 mL/min by Cockroft-Gault 
‐ 
No other contraindication to erlotinib 
‐ 
Female participants of child-bearing age must agree to use adequate contraception 
(hormonal, barrier or abstinence) for the duration of the study while receiving 
erlotinib and undergo a pregnancy test. Any evidence or suspicion of pregnancy 
should be reported to the treating physician immediately. 
‐ 
Male participants must agree to use adequate contraception for the duration of the 
study while receiving erlotinib 
 
3.2 
Exclusion Criteria 
 
The following attributes will render a participant ineligible for this study: 
3.2.1 
Participants must not have had chemotherapy within the past 10 days. 
3.2.2 
Participants must not have had prior treatment with an EGFR kinase inhibitor, EGFR 
directed therapy or investigational agent. 
3.2.3 
Participants must not have residual adverse events from previous therapy greater than 
CTCAE v4.0 grade 2 at the time of registration. 
3.2.4 
Participants must not have symptomatic brain metastases or brain metastases requiring 
steroids. Asymptomatic brain metastases not requiring steroids are acceptable. 
3.2.5 
Participant must not have a history of allergy to erlotinib. 
3.2.6 
Second primary cancer which is active and requiring treatment.  
3.2.7 
Participants must not be known to be pregnant or breastfeeding.  
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
6 
3.3 
Inclusion of Women, Minorities and Other Underrepresented Populations 
 
Participants who are enrolled on study will reflect the patient population seen at the Dana Farber/Harvard 
Cancer Center. This study is designed to be enriched for patients who are more likely to possess an EGFR 
mutation. As a result, participants of Asian race will be preferentially enrolled in this study. This study 
does not exclude participants of other ethnicities. 
 
4. REGISTRATION PROCEDURES 
 
4.1 
General Guidelines for DF/HCC Institutions 
 
Institutions will register eligible participants in the Clinical Trials Management System (CTMS) 
OnCore. Registrations must occur prior to the initiation of protocol therapy. Any participant not 
registered to the protocol before protocol therapy begins will be considered ineligible and 
registration will be denied. 
 
An investigator will confirm eligibility criteria and a member of the study team will complete the 
protocol-specific eligibility checklist. 
 
Registration on the Initial Registration arm (Step 1) occurs at the time of initial plasma 
genotyping. Registration to the erlotinib treatment arm (Step 2) takes place once positive EGFR 
mutation status is confirmed. Following registration for erlotinib treatment, participants may 
begin protocol therapy. Issues that would cause treatment delays should be discussed with the 
Overall Principal Investigator (PI). If a participant does not receive protocol therapy following 
registration, the participant’s registration on the study must be canceled. Registration 
cancellations must be made in OnCore as soon as possible.  
 
4.2 
Registration Process for DF/HCC Institutions 
 
DF/HCC Standard Operating Procedure for Human Subject Research Titled Subject Protocol 
Registration (SOP #: REGIST-101) must be followed.   
  
4.3 
General Guidelines for Other Participating Institutions 
 
N/A 
 
4.4 
Registration Process for Other Participating Institutions 
 
N/A 
 
5. STUDY PROCEDURES 
 
5.1 
Initial Plasma Genotyping 
 
All participants will undergo a paired blood draw on the same day that they are registered in the study. 
Blood may be drawn the following business day if same day draw is not feasible. Three 10 mL EDTA 
tubes of blood will be collected at the clinical blood lab. Plasma will be prepared immediately after the 
blood draw, frozen and one tube transported to the central laboratory at the Brigham & Women’s Hospital 
Center for Advanced Molecular Diagnostics (CAMD) and the two remaining tubes transported to the 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
7 
translational research lab (TRL) at DFCI for exploratory studies (Appendix A: Plasma Preparation SOP). 
Extraction of cfDNA and ddPCR-based plasma genotyping for EGFR exon 19 del, L858R and T790M 
mutations will then be performed at CAMD as previously described.12 The remaining plasma shipped to 
the TRL will be used for confirmatory EGFR plasma genotyping, KRAS G12X plasma genotyping and 
exploratory studies (9. Correlative/Special Studies).   Participants with positive or pending plasma 
genotyping performed at CAMD may enroll to the study without repeating initial plasma genotyping on 
study.  
 
5.2 
Serial Plasma Genotyping 
 
Participants which are found to have a detectable EGFR exon 19 del or L858R mutation on initial plasma 
genotyping will subsequently undergo serial plasma genotyping. A single 10 mL EDTA tube of blood 
will be drawn on Cycle 1 Day 1 and at set intervals of 2 weeks, 6 weeks, 12 weeks, 18 weeks, 24 weeks 
and approximately every 2-3 months on therapy. A final sample for plasma genotyping will be collected 
on study termination if not coinciding with one of the previous timepoints. Blood samples will be 
collected in the clinical blood lab and plasma prepared immediately after the blood draw, frozen and 
transported to the central laboratory at CAMD (Appendix A: Plasma Preparation SOP). Extraction of 
cfDNA and ddPCR-based plasma genotyping for EGFR exon 19 del, L858R, T790M and KRAS G12X 
mutations will be performed. Unused plasma and cfDNA will be stored and utilized for exploratory 
studies (9. Correlative/Special Studies). 
 
5.3 
Tissue Genotyping 
 
All participants should undergo initial tissue genotyping on available biopsy material as per institutional 
standard of care at the site at which they are enrolled in the study. If available, this genotyping must be 
pending or ordered at the time of enrollment and must include at least testing for EGFR mutations and 
ALK rearrangements. If not available, a plan to obtain this tissue through biopsy must exist. If biopsy fails 
or is not technically feasible, patients with detectable EGFR mutation by plasma genotyping may still 
receive erlotinib on the treatment phase of the study. Targeted next-generation gene sequencing (NGS) 
will be requested for each patient where sufficient tissue is available but will not be a requirement for 
enrollment in the study. Given that tissue genotyping for EGFR and ALK are considered standard of care, 
the cost of these tests will not be covered by the study. Should a patient have insufficient tissue for initial 
genotyping, the decision as to whether to pursue re-biopsy in order to obtain further tissue for genotyping 
as a part of standard of care will be left to the individual investigator based on their standard practice. 
 
For patients that are EGFR mutation positive and are treated with erlotinib, re-biopsy and repeat 
genotyping for resistance mutations will be encouraged at the time of disease progression. The results 
from this testing will be collected by the study where available in order to examine rates and mechanisms 
of acquired resistance to erlotinib. Any biopsy done to determine tumor genotype will be considered 
standard of care and will not be reimbursed by the study. 
 
6. TREATMENT PLAN  
 
Participants found to possess an EGFR exon 19 del or L858R mutation on rapid plasma genotyping will 
begin treatment with erlotinib. Erlotinib is an oral tyrosine kinase inhibitor which is approved for the 
treatment of advanced EGFR mutant NSCLC. Erlotinib will be initially dosed at 150 mg daily and will be 
given on a 6-week cycle with treatment administered on an outpatient basis. Dose reductions will be 
performed in response to expected toxicities of treatment (7. Expected Toxicities and Dosing 
Delays/Modifications). No other concurrent anti-neoplastic systemic therapies may be prescribed while 
the patient is participating in the study. 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
8 
 
Treatment Description 
Agent 
Pre-medications 
Dose 
Route 
Schedule 
Cycle Length 
Erlotinib 
None 
150 mg 
po 
Daily for 6 weeks 
(42 days) 
Every 6 weeks  
(42 days) 
 
6.1 
Pre-treatment Criteria 
 
6.1.1 
Cycle 1, Day 1 
 
All study participants must meet eligibility requirements in order to enroll in the study and undergo initial 
plasma genotyping. Those participants found to possess an EGFR exon 19 del or L858R mutation on 
plasma genotyping will be treated with erlotinib. EGFR negative patients by plasma ddPCR will not be 
treated on study but will be followed on the study until they begin standard of care therapy. All 
participants must have been assessed by an oncology provider within 4 weeks of registration with a 
history, physical examination, CBC, serum chemistry and liver function tests. Baseline staging 
investigations including a CT chest/abdomen with bone scan or PET/CT must be performed within 1 
month of starting treatment. Either an MRI brain or CT head with contrast is also required within 1 month 
of starting treatment. Subjects must meet the following criteria to begin treatment: 
‐ 
ECOG performance status of 0-2 
‐ 
Platelets >75 
‐ 
AST & ALT < 3x the upper limit of normal 
‐ 
Creatinine clearance > 30 mL/min by Cockroft-Gault 
‐ 
No other contraindication to erlotinib 
‐ 
Female participants of child-bearing age must agree to use adequate contraception 
(hormonal, barrier or abstinence) for the duration of the study while receiving 
erlotinib and undergo a pregnancy test. Any evidence or suspicion of pregnancy 
should be reported to the treating physician immediately. 
‐ 
Male participants must agree to use adequate contraception for the duration of the 
study while receiving erlotinib 
 
6.1.2 
Subsequent Cycles 
 
During subsequent cycles, treatment dosing should be performed according to the dose modifications 
details in Section 7.3. 
 
6.2 
Agent Administration & Storage 
 
6.2.1 
Erlotinib 
 
Erlotinib will be administered orally on a continuous schedule with a dose of 150 mg po daily on a 6 
week cycle of treatment. The beginning of any cycle of treatment may be delayed at the clinical 
provider’s discretion for the treatment of therapy-related toxicities. Dose modification at the beginning of 
any cycle may be performed due to toxicity as described (7. Expected Toxicities and Dosing 
Delays/Modifications). If participants neglect to take a dose, they will be instructed to take the dose if 
there is more than 12 hours until the next dose. If a dose is vomited within 30 minutes of taking it, the 
participant will be instructed to utilize an anti-emetic and repeat the dose. Tablets should not be crushed, 
split, or dissolved in water. 
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
9 
Erlotinib tablets will be provided by the study at the appropriate dosage in 6 week cycles with overage. 
The tablets should be stored at room temperature. No pre-medication is required for treatment. 
 
6.3 
Definition of Dose-Limiting Toxicity 
 
N/A  
 
6.4 
General Concomitant Medication and Supportive Care Guidelines 
 
Participants should receive all appropriate supportive care at the discretion of their primary oncologist 
(e.g. topical steroids, antibiotics, anti-emetics, g-csf, transfusions). Concomitant use of full-dose 
anticoagulation using low-molecular weight heparin or other indicated anticoagulation is permitted with 
the exception of warfarin (see below). Treatment of skin toxicities including topical corticosteroids and 
topical/oral antibiotics is encouraged. The use of oral corticosteroids is discouraged for skin toxicity < 
grade 2 but may be used at the discretion of the oncologist. Use of corticosteroids to treat brain metastases 
is prohibited at study entry. 
 
In addition, the following concomitant therapies are discouraged from the study due to known 
interactions: 
‐ 
Grapefruit juice (CYP3A4 inhibitor which may increase erlotinib levels and 
increased toxicity) 
‐ 
Ciprofloxacin (CYP3A4 and CYP1A2 inhibitor which may increase erlotinib levels 
and increased toxicity) 
‐ 
Cigarette smoking should be actively discouraged and all appropriate cessation 
methods employed. Smoking may induce CYP1A2 and result in lowered erlotinib 
levels and thus decreased effectiveness. 
‐ 
Other significant CYP3A4 inhibitors or inducers (Appendix D) 
‐ 
Other anti-neoplastic systemic therapies 
‐ 
Warfarin 
 
The absorption of erlotinib may also be dependent on gastric pH and thus the use of proton pump 
inhibitors (PPI) such as omeprazole should be limited as it may decrease the bioavailability of the drug. 
However, the use of PPIs is not explicitly excluded but if medically necessary should be maximally 
separated from the erlotinib dose although this may still result in reduced bioavailability. Additional 
potential drug-drug interactions should be reviewed by the enrolling sub-investigator as per standard of 
care and medications discontinued as appropriate (please refer to erlotinib FDA package insert for full list 
of potential drug-drug interactions). 
 
6.5 
Duration of Therapy 
 
Participants with an EGFR sensitizing mutation by plasma ddPCR will receive erlotinib 150 mg daily 
without interruption. No maximum number of cycles of treatment is prescribed in this study. However, 
treatment dose may be decreased or interrupted secondary to toxicity as described (7. Expected Toxicities 
and Dosing Delays/Modifications). Duration of therapy will depend on individual response, evidence of 
disease progression and tolerance. In the absence of treatment delays due to adverse events, treatment 
may continue until one of the following criteria applies: 
 
Disease progression warranting treatment change (investigator determined), 
 
Unacceptable adverse event(s) defined as > grade 3 toxicity that does not resolve 
with dose reduction or holding treatment. 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
10 
 
Participant demonstrates an inability or unwillingness to comply with the oral 
medication regimen and/or documentation requirements 
 
Participant decides to withdraw from the study, or 
 
General or specific changes in the participant's condition render the participant 
unacceptable for further treatment in the opinion of the treating investigator. 
 
Subjects who, at time of radiographic progression, are deemed to be gaining clinical benefit from erlotinib 
in the opinion of the treating investigator may continue treatment with erlotinib on study. Objective 
progression will not be a pre-defined endpoint of this study and will not be measured centrally in this 
study. As previously described, objective response rate will be the primary study endpoint and will be 
assessed by central radiologists per RECIST v1.1. 
 
Additionally, patients with progression in the brain only while on treatment and without evidence of 
systemic progression can, after completion of local therapy to the brain (e.g. radiation therapy) continue 
treatment with erlotinib on protocol. For these patients, criteria for objective progression will have been 
met for the purposes of calculation of progression free survival, but treatment with erlotinib can continue 
until systemic progression or intolerable toxicity at the judgment of the treating investigator. Study drug 
should be held on days when radiation therapy is given; additional washout before or after radiation is at 
the discretion of the investigator. 
 
6.6 
Treatment Assessments  
 
As described, all participants will undergo initial screening with plasma genotyping. They will undergo 
assessment of eligibility at the same clinic visit and appropriate examinations/testing/baseline staging will 
be performed as described (6.1. Pre-Treatment Criteria).  
 
On Treatment Assessments: Participants treated with erlotinib will be evaluated by an oncology provider 
every cycle (6 weeks) with a routine history and physical. Bloodwork including at least a CBC, chemistry 
and LFTs must be performed within a week of each assessment. CT scanning of all sites of disease will be 
performed every 6 weeks for the first 24 weeks and then at least every 3 months thereafter unless 
otherwise clinically indicated. Patients positive for an EGFR mutation by plasma genotyping but negative 
by tissue genotyping will undergo an interim CT scan at 4 weeks after initiating erlotinib to confirm 
response. Serial plasma genotyping will be performed at 2 weeks after starting treatment and then with 
every re-staging CT scan. After the fourth CT scan, clinical visits and blood work may be relaxed to every 
12 weeks coinciding with imaging investigations. 
 
End of Study Assessments: Participants will be treated with erlotinib until evidence of significant disease 
progression or unacceptable toxicity. A final blood draw for plasma genotyping will be performed at the 
time of study termination for each participant.  
 
6.7 
Duration of Follow Up  
 
Participants will be followed within 28 days (+/- 7 days) of their last dose of erlotinib for possible 
treatment-related adverse events. Participants removed from study for unacceptable treatment-related 
adverse events will be followed until resolution or stabilization of the adverse event. 
  
6.8 
Criteria for Removal from Study  
 
Participants positive for an EGFR sensitizing mutation by plasma ddPCR will be removed from study when 
any of the criteria listed in Section 6.5 applies. EGFR negative patients by plasma ddPCR will be removed 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
11 
from the study when they begin standard of care therapy. The reason for study removal and the date the 
participant was removed must be documented in the study-specific case report form (CRF). Alternative 
care options will be discussed with the participant. 
 
In the event of unusual or life-threatening complications, participating investigators must 
immediately notify the Principal Investigator (or Protocol Chair), Geoffrey Oxnard, MD at 617-632-
6049. 
 
7. EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS  
 
Dose delays and modifications will be made using the following recommendations. Toxicity assessments 
will be done using the CTEP Active Version of the NCI Common Terminology Criteria for Adverse 
Events (CTCAE version 4.0) which is identified and located on the CTEP website at: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 
If possible, symptoms should be managed symptomatically. In the case of toxicity, appropriate medical 
treatment should be used (including anti-emetics, anti-diarrheals, etc.). 
 
All serious adverse events (CTCAE v4.0 Grade >3) experienced by participants will be collected from the 
time of the first dose of study treatment, through the study and until the final study visit. Participants 
continuing to experience toxicity at the off study visit may be contacted for additional assessments until 
the toxicity has resolved or is deemed irreversible. 
  
7.1 
Anticipated Toxicities 
  
Erlotinib is an approved drug for the treatment of EGFR mutant advanced NSCLC. As such, appropriate 
measures will be taken to ensure the safety of participants in this study in accordance with current 
standards of care. Toxicity will be assessed by individual study investigators for each patient at their 
regular clinic visits or more frequently if clinically indicated. Investigators will manage all toxicity as per 
standard care but will only be required to report related grade 3 or greater toxicity. 
  
Common toxicities of erlotinib include: 
-diarrhea 
-acneiform rash 
-skin/hair/nail changes  
 
Rare but concerning toxicities include:  
-interstitial lung disease 
-transaminitis/hepatotoxicity 
-renal failure 
-gastrointestinal perforation 
-bullous and exfoliative skin disorders including Stevens-Johnson syndrome/toxic epidermal necrolysis 
-myocardial infarction/ischemia 
-cerebrovascular accident 
-microangiopathic hemolytic anemia with thrombocytopenia 
-ocular disorders including corneal ulceration/perforation 
-embryofetal lethality/severe fetal harm 
 
Please refer to erlotinib FDA package insert for additional details on frequency of these toxicities. 
  
7.2 
Toxicity Management 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
12 
 
 
There is no known antidote to treat an overdose of erlotinib and efforts should be directed at providing 
optimal supportive care. 
 
If a severe non-hematological adverse reaction develops with erlotinib use, treatment must be withheld 
until the event has resolved or improved. Thereafter, treatment can be resumed as appropriate at a reduced 
dose depending on the initial severity of the event.   
 
7.3 
Dose Modifications/Delays 
 
 
For subjects receiving erlotinib, dose interruptions or reductions may be required following potential 
drug-related toxicities. Rash, diarrhea, pneumonitis, hepatotoxicity and other adverse events have been 
reported in response to treatment with erlotinib. Toxicity-related dose reduction is permitted at the 
discretion of the treating investigator. Dose reduction is recommended if two toxicity-related dose 
interruptions are required. Dose interruption of more than 14 consecutive days will result in a patient 
coming off study. 
 
At each visit during the Treatment Period, subjects should first be evaluated for the occurrence of adverse 
events and laboratory abnormalities. Management of possible adverse events as well as dose 
delay/modification or discontinuation of study treatment should occur as per institutional standard of care 
for erlotinib. Specific treatment of these toxicities will be decided by the treating oncologist for each 
patient. Adverse events are graded according to NCI Common Terminology Criteria for Adverse Events 
v4.0. However, only grade 3 and greater toxicities will be reported in this study given the erlotinib is 
already an FDA approved drug for the treatment of NSCLC. 
 
If dose reduction is necessary, two possible dose reductions are suggested in a stepwise fashion (initially 
to 100 mg and subsequently to 50mg if necessary). Decisions regarding dose reduction will be made by 
the treating oncologist and dose reductions encouraged particularly in elderly patients or those with 
treatment-related toxicity. Dose escalation after dose reduction is not permitted.  
 
 
8. DRUG FORMULATION AND ADMINISTRATION  
  
8.1 
Erlotinib 
 
8.1.1 
Description 
 
Erlotinib is a small molecule tyrosine kinase inhibitor with activity against EGFR. The half-life of 
erlotinib is 36.2 hours. Approximately 83% of the erlotinib dose is eliminated in the feces and 
approximately 8% is excreted in the urine.  
 
Refer to the Product Information Sheet for information regarding the physical and chemical properties of 
erlotinib hydrochloride, tablets, and list of excipients. 
  
8.1.2 
Form 
 
Erlotinib hydrochloride tablets are manufactured by Astellas, inc, and consist of conventional immediate-
release tablets containing erlotinib hydrochloride salt equivalent to 150, 100 or 50 mg. In addition to the 
active ingredient, each tablet contains lactose (hydrous), microcrystalline cellulose, sodium starch 
glycolate, sodium lauryl sulfate, and magnesium stearate.  
  


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
13 
8.1.3 
Storage and Stability 
 
The erlotinib hydrochloride tablets are packaged in opaque plastic bottles, and should be stored at 
controlled room temperature (15 to 30C).  
  
8.1.4 
Compatibility 
 
N/a 
 
8.1.5 
Handling 
 
The Investigator (or assigned designee, i.e., study pharmacist) will dispense the proper number of each 
strength tablet to the subject to satisfy dosing requirements for the study. The containers provided to the 
subject should be labeled with proper instructions for use. The lot numbers, dosing start dates and the 
number of tablets for each dosage strength must be recorded on the drug accountability pages of record 
for the site. The subject must be instructed to return all unused erlotinib in the provided packaging at each 
subsequent visit. 
 
8.1.6 
Availability 
 
Erlotinib is commercially available but will be supplied free-of-charge from Astellas, Inc.. 
 
8.1.7 
Preparation 
 
N/a 
  
8.1.8 
Administration 
 
Erlotinib is an oral therapy that must be taken on an empty stomach (1 hour before or 2 hours after 
meal). 
 
8.1.9 
Ordering 
 
Erlotinib will be ordered from Astellas inc. using an order form that has been provided. Drug will be 
provided from the commercial supply.  
 
8.1.10 Accountability 
 
The investigator, or a responsible party designated by the investigator, must maintain a careful record 
of the inventory and disposition of the agent (investigational or free of charge) using the NCI Drug 
Accountability Record or another comparable drug accountability form. (See the CTEP website at 
http://ctep.cancer.gov/protocolDevelopment  for the “Policy and Guidelines for  Accountability and Storage 
of Investigational Agents” or to obtain a copy of the drug accountability form.) 
 
8.1.11 Destruction and Return 
 
At the end of the study, unused supplies of erlotinib should be destroyed according to institutional 
policies. Destruction will be documented in the Drug Accountability Record Form. 
  
9. CORRELATIVE/SPECIAL STUDIES  
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
14 
9.1 
Pharmacokinetic Studies 
 
N/a 
 
9.2 
Pharmacodynamic Studies 
 
9.2.1 
Laboratory Correlative Studies 
 
9.2.1.1 Collection of Plasma Specimens 
 
All patients will undergo plasma collection upon study enrollment and at regular intervals for the purpose 
of plasma genotyping as previously described. Excess plasma and cell-free DNA (cfDNA) not used in 
initial EGFR plasma genotyping testing will be retained for exploratory analyses. These may include 
testing novel mutations using various plasma genotyping platforms. This testing may be conducted at the 
Belfer Institute or at outside laboratories collaborating with the DFCI. No patient samples will be sold to 
outside entities and only de-identified samples will be released to outside laboratories for testing as part of 
established collaborations with DFCI investigators.  
 
9.2.1.2 Collection of excess baseline tumor tissue 
 
All study participants will be required to consent to genomic analysis of any remaining tumor tissue not 
needed for clinical purposes as a condition of enrollment on protocol.  Banked tumor specimens (including 
surgical biopsies, core needle biopsies, or large volume pleural effusions) will be evaluated by a 
pathologist to ensure adequacy for DNA extraction. These samples may be analyzed for genomic 
alterations using both next-generation gene sequencing, fluorescence in situ hybridization (FISH) and 
other methods. 
 
 
10. STUDY CALENDAR 
 
Baseline evaluations including a history, physical exam, vitals, relevant blood work, and baseline 
imaging are to be conducted within 4 weeks prior to start of protocol therapy. Laboratory studies must 
be drawn within 7 days of starting study drug.  
All assessments must be performed prior to administration of any study medication. All study 
assessments should be administered within + 7 calendar days of the protocol-specified date, 
unless otherwise noted.  
Re-imaging of sites of disease should be performed every 6 weeks for 24 weeks after the 
initiation of study drug, and then at least every 3 months thereafter as per standard of care. 
Follow-up tumor assessments may be made within + 7 calendar days of the protocol-specified 
date. 
 
 
 
 
 
 
 
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
15 
 
a: Albumin, alkaline phosphatase, total bilirubin, BUN, calcium, chloride, creatinine, glucose, 
phosphorus, potassium, total protein, SGOT  [AST], SGPT [ALT], sodium, magnesium 
bLaboratory studies must be drawn within 7 days of starting study drug. 
 
DIAGNOSTIC PHASE 
(pre-treatment) 
THERAPEUTIC PHASE 
(6 week treatment cycles) 
Test/Procedure 
Enrollment: 
(within 4 
weeks of 
start) 
Registratione 
Day 1 
Cycle 
1f 
Day 14 
Cycle 1 
Day 1  
Cycle 2, 
3, 4 
 
Every 2-3 
months (per 
institutional 
standard) 
after 
completing 
Cycle 4 
End of Study 
Within 30 days 
of off study 
 Observations 
Informed 
Consent 
X 
 
 
 
 
 
 
History and 
Physical 
Examination 
X 
 
X 
X 
X 
X 
X 
Vital signs, 
weight 
X 
 
X 
X 
X 
X 
X 
Height 
X 
 
 
 
 
 
 
ECOG PS 
X 
 
X 
X 
X 
X 
X 
Assessment of 
high-grade 
adverse events  
 
 
X 
X 
X 
X 
X 
Review of Drug 
Diary 
 
 
 
 
X 
X 
X 
Dispense 6-week 
supply of 
erlotinib 
 
 
X 
 
X 
X 
 
Tests & Labs 
Serum chemistrya 
 
 
Xb
X 
X 
X 
 
CBC with diff  
 
 
Xb
X 
X 
X 
 
Serum or urine 
pregnancy test 
 
 
Xg 
 
 
 
 
Recommend 
biopsy/re-biopsy 
& order 
genotyping if 
availablec  
X 
 
 
 
 
 
X 
Collect 3 10 cc 
EDTA tubes of 
blood for plasma 
genotypingd 
 
X 
 
 
 
 
 
Collect single 10 
cc EDTA tube of 
blood for plasma 
genotyping 
 
 
X 
X 
X 
X 
X 
Imaging 
Chest CT +/- 
abdomen 
X 
 
 
 
X* 
X 
X
Brain MRI or CT 
X 
 
 
 
 
 
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
16 
cIf biopsy for tumor genotyping is not performed prior to starting therapy, then biopsy to confirm 
tumor genotype is expected, if technically feasible, after progression on study. 
dRepeat plasma genotyping not required if positive or pending at the central lab at time of 
registration.  
eRegistration to the Initial Registration arm (Step 1) occurs at the time of initial plasma genotyping.  
fRegistration to the erlotinib treatment arm (Step 2) occurs once positive EGFR mutation status is 
confirmed. 
g Required for female participants of child-bearing age.  
 
*Baseline scan and initial 4 follow-up scans will undergo objective assessment for response; subsequent 
scans will be used for clinical assessment of progression but will not undergo objective measurement. 
Participants positive for an EGFR mutation by plasma genotyping but negative by tissue genotyping will 
undergo an interim CT scan at 4 weeks after initiating erlotinib to confirm response. 
 
All assessments must be performed prior to administration of any study medication. All study 
assessments and medications should be administered within + 7 calendar days of the protocol-
specified date, unless otherwise noted. Follow-up tumor assessments may be made within + 7 
calendar days of the protocol-specified date. 
 
11. MEASUREMENT OF EFFECT  
 
Response rate is the primary endpoint of this trial. Participants with measurable disease will be 
assessed by RECIST 1.1 criteria. For the purposes of this study, participants should be reevaluated 
after an initial 42 days of treatment, constituting 1 cycle. After an initial 6 week scan to document 
response, participants will undergo follow-up CT scans every 6 weeks for 24 weeks. After this 
period, restaging CT scans should be conducted per institutional standard of care. The standard scan 
for all patients should be at least a CT of the chest with IV contrast. Additional sites of disease 
(abdomen, pelvis, neck, head) should also be scanned if there is known disease in these areas. Non-
contrast scans are acceptable if IV contrast is contraindicated. Clinicians may perform additional 
scans if clinically indicated. Objective progression will not be measured in this study. 
 
11.1 
Antitumor Effect– Solid Tumors 
 
For the purposes of this study, participants should be re-evaluated for response every 6 weeks after 
their initial 6 week scan for a total of 4 scans and then should be followed as per institutional standard 
of care thereafter. Response and progression will be evaluated in this study using the new international 
criteria proposed by the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 guideline. 
Changes in the diameter (unidimensional measurement) of the tumor lesions are used in the 
RECIST 1.1 criteria. 
 
11.1.1 Definitions 
 
Evaluable for toxicity. All participants who receive at least one dose of study treatment will be 
evaluable for toxicity from the time of their first treatment. 
 
Evaluable for objective response. Only those participants who have measurable disease present at 
baseline, have received at least one cycle of therapy, and have had their disease re-evaluated will 
be considered evaluable for response. These participants will have their response classified 
according to the definitions stated below. (Note: Participants who exhibit objective disease 
progression or die prior to the end of cycle 1 will also be considered evaluable.} 
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
17 
11.1.2 Disease Parameters 
 
Measurable disease. Measurable disease is the presence of at least one (1) lesion that can be 
accurately measured in at least one dimension with longest diameter  >20 millimeters (mm) using 
conventional techniques (CT, MRI, x-ray) or  >10 mm with spiral CT scan. Measurable lesions must 
be at least 2 times the slice thickness in mm. All tumor measurements must be recorded in millimeters 
(or decimal fractions of centimeters). 
 
Malignant lymph nodes. To be considered pathologically enlarged and measurable, a lymph node 
must be > 15 mm in short axis when assessed by CT scan (CT scan slice thickness recommended to 
be no greater than 5 mm). At baseline and in follow-up, only the short axis will be measured and 
followed. 
 
Non-measurable disease. All other lesions (or sites of disease), including small lesions (longest diameter 
<10 mm or pathological lymph nodes with > 10 to < 15mm short axis) are considered non-measurable 
disease. Bone lesions, leptomeningeal disease, ascites, pleural/pericardial effusions, lymphangitis 
cutis/pulmonis, inflammatory breast disease, abdominal masses identified by physical exam that are not 
measurable by reproducible imaging techniques, and cystic lesions are all considered non-measurable. 
 
Target lesions. All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in total, 
representative of all involved organs, should be identified as target lesions and recorded and 
measured at baseline. Lesions must be accurately measured in 1 dimension with a minimum size of 
10 mm by CT or MRI (slice thickness no greater than 5 mm), 20 mm by chest x-ray. Nodes must 
have a short axis > 15 mm. The short axis should be included in the sum of the lesions in the 
calculation of response. Nodes that shrink to < 10 mm are considered normal. Target lesions should 
be selected on the basis of their size, be representative of all the involved organs, and should be 
lesions that can be followed with reproducible repeated measurements.  
 
Lytic bone lesions or mixed lytic-blastic lesions, with identifiable soft tissue components, that can be 
evaluated by cross sectional imaging techniques such as CT or MRI can be considered target lesions if 
the soft tissue component meets the definition of measurability as defined above. Cystic lesions thought 
to represent cystic metastases can be considered as target lesions. However, if non-cystic lesions are 
present, these are preferred for selection as target lesions. Lesions in previously irradiated areas or areas 
subject to other loco-regional therapy are usually not considered measurable unless there has been 
demonstrated progression of that lesion.  
 
Non-target lesions. All other lesions, including small lesions < 10 mm or pathological lymph nodes 
measuring > 10 mm to < 15 mm in short axis, as well as truly non-measurable lesions, which include 
leptomeningeal disease, ascites, pleural or pericardial effusion, inflammatory breast disease, 
lymphangitic involvement of skin or lung, abdominal masses identified by physical exam that are not 
measurable by reproducible imaging techniques.  
 
11.1.3 Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation, using a ruler, calipers, or digital 
measurement tool. All baseline evaluations should be performed as closely as possible to the beginning of 
treatment and never more than 4 weeks before the beginning of the treatment. 
The same method of assessment and the same technique should be used to characterize each identified 
and reported lesion at baseline and during follow-up. Imaging-based evaluation is preferred to evaluation 
by clinical examination when both methods have been used to assess the anti-tumor effect of a 
treatment. 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
18 
 
Clinical lesions. Clinical lesions will only be considered measurable when they are superficial (e.g., skin 
nodules and palpable lymph nodes). For the case of skin lesions, documentation by color 
photography, including a ruler to estimate the size of the lesion, is recommended. 
 
Chest x-ray. Lesions on chest x-ray are acceptable as measurable lesions when they are clearly defined 
and surrounded by aerated lung; however, CT is preferable. 
 
Conventional CT and MRI. These techniques should be performed with cuts of 10 mm or less in slice 
thickness contiguously. Spiral CT should be performed using a 5 mm contiguous reconstruction 
algorithm. This applies to tumors of the chest, abdomen, and pelvis. Head and neck tumors and those of 
extremities usually require specific protocols. 
 
Ultrasound (US). When the primary endpoint of the study is objective response evaluation, US 
should not be used to measure tumor lesions. It is, however, a possible alternative to clinical 
measurements of superficial palpable lymph nodes, subcutaneous lesions, and thyroid nodules. US might 
also be useful to confirm the complete disappearance of superficial lesions usually assessed by 
clinical examination. 
 
FDG PET and PET/CT. The acquisition of FDG PET and FDG PET/CT scans should follow the NCI 
Guidelines for using FDG PET as an indicator of therapeutic response (L.K. Shankar, J.M. Hoffman, S. 
Bacharach, M.M. Graham, J. Karp, A.A. Lammertsma, S. Larson, D.A. Mankoff, B.A. Siegel, A. Van 
den Abbeele, J. Yap, D. Sullivan. Consensus recommendations for the use of 18F-FDG PET as an 
indicator of therapeutic response in patients in National Cancer Institute Trials. J Nucl Med, 47(6):901-
903, 2006). Patients should avoid strenuous exercise and be on a low carbohydrate diet for 24 hours prior 
to the scan. Patients should fast for 4 hours or longer prior to the FDG injection and should have a serum 
glucose of less than 200 mg/dL at the time of FDG injection. A 10-20 mCi dose of FDG should be 
injected for typical adult patients. For longitudinal studies with multiple scans, particular attention should 
be paid to ensure consistent patient preparation and acquisition parameters between the follow-up scan 
and the baseline scan.  
 
Endoscopy, Laparoscopy. The utilization of these techniques for objective tumor evaluation has not 
yet been fully and widely validated. Their uses in this specific context require sophisticated equipment 
and a high level of expertise that may only be available in some centers. Therefore, the utilization of 
such techniques for objective tumor response should be restricted to validation purposes in reference 
centers. However, such techniques may be useful to confirm complete pathological response when 
biopsies are obtained. 
 
Tumor markers. Tumor markers alone cannot be used to assess response. If markers are initially 
above the upper normal limit, they must normalize for a subject to be considered in complete 
clinical response. Specific additional criteria for standardized usage of prostate-specific antigen (PSA) 
and CA-125 response in support of clinical trials are being developed. 
 
Cytology, Histology. These techniques can be used to differentiate between partial responses (PR) and 
complete responses (CR) in rare cases (e.g., residual lesions in tumor types, such as germ cell 
tumors, where known residual benign tumors can remain). 
 
The cytological confirmation of the neoplastic origin of any effusion that appears or worsens during 
treatment when the measurable tumor has met criteria for response or stable disease is mandatory to 
differentiate between response or stable disease (an effusion may be a side effect of the treatment) and 
progressive disease. 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
19 
 
11.1.4  Response Criteria  
 
11.1.4.1 Evaluation of Target Lesions 
 
Complete Response (CR): Disappearance of all target lesions. Any pathological lymph node must 
have reduction in short axis to < 10 mm. 
 
Partial Response (PR): At least a 30% decrease in the sum of the diameters of target lesions, taking as 
reference the baseline sum diameters. 
 
Progressive Disease (PD): At least a 20% increase in the sum of the diameters of target lesions, taking as 
reference the smallest sum on study with at least a 5 mm absolute increase in the sum of all lesions. The 
appearance of one or more new lesions* denotes disease progression.  
 
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for 
PD, taking as reference the smallest sum diameters while on study. 
 
Unknown (UN): Assessment of target lesions cannot be made due to insufficient or unevaluable data. In 
this case, a concise explanation must be given. 
 
Note: If tumor response data is missing for target lesions, the overall assessment must be UN unless 
there is new disease that would result in an overall assessment of PD. However, if there is missing or 
unevaluable data for non-target lesions, but data is available for all target lesions, the overall response 
for that time point will be assigned based on the sum LD of all target lesions. Additionally, the 
assessment of CR cannot be made if there is missing or unevaluable data for non-target lesions. In this 
case, the overall assessment would be PR. 
 
*Definition of New Lesion: The finding of a new lesion should be unequivocal (i.e. not due to 
difference in scanning technique, imaging modality) or findings thought to represent something other 
than tumor (ex: new bone lesions may be healing or flare of pre-existing lesions). However, a lesion 
identified on a follow-up scan in an anatomical location that was not scanned at baseline is considered 
new and will indicate PD. If a new lesion is equivocal (because of small size, etc.), follow-up evaluation 
will clarify if it truly represents new disease and if PD is confirmed, progression should be declared 
using the date of the initial scan on which the lesion was discovered.  
 
11.1.4.2 Evaluation of Non-Target Lesions 
 
Complete Response (CR): Disappearance of all non-target lesions and 
normalization of tumor marker level. All lymph nodes must be non-pathological in size ( < 10 mm 
short axis).  
 
Note: If tumor markers are initially above the upper normal limit, they must normalize for a 
subject to be considered in complete clinical response. 
 
Incomplete Response/Stable Disease (SD): Persistence of one or more non-target lesions and/or 
maintenance of tumor marker level above the normal limits. 
 
Progressive Disease (PD): Appearance of one or more new lesions* (new lesions must be > 
slice thickness) and/or unequivocal progression of existing non-target lesions. 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
20 
Overall level of substantial worsening that merits discontinuation of therapy. A useful test that 
can be applied when assessing non-targets for unequivocal progression is to consider if the 
increase in overall disease burden based on the change in non-measurable disease is 
comparable in magnitude to the increase that would be required to declare PD for measurable 
disease. 
 
Unknown (UN): Assessment of non-target lesions cannot be made due to insufficient or unevaluable 
data. In this case, a concise explanation must be given. 
 
11.1.4.3 Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the treatment until disease 
progression/recurrence (taking as reference for progressive disease the smallest measurements recorded 
since the treatment started). The participant's best response assignment will depend on the 
achievement of both measurement and confirmation criteria. 
 
For Patients with Measurable Disease (i.e., Target Disease) 
 
Target 
Lesions 
Non-Target 
Lesions 
New 
Lesions 
Overall 
Response 
Best Overall Response for 
when Confirmation is 
Required: 
CR 
CR 
No 
CR 
>4 wks confirmation 
CR 
Non-CR/Non-PD 
No 
PR 
>4 wks confirmation 
CR 
Not evaluated
No
PR
PR 
Non-CR/Non-
PD/Not 
evaluated 
No 
PR 
SD 
Non-CR/Non-
PD/Not 
evaluated 
No 
SD 
Documented at least once 
>4 wks from baseline 
PD 
Any 
Yes or No
PD
No prior SD, PR or CR 
Any 
PD* 
Yes or No
PD
Any 
Any 
Yes
PD
* 
In exceptional circumstances, unequivocal progression in non-target lesions may 
be accepted as disease progression. 
 
Note:   Participants with a global deterioration of health status requiring 
discontinuation of treatment without objective evidence of disease progression at 
that time should be reported as "symptomatic deterioration". Every effort should be 
made to document the objective progression even after discontinuation of treatment. 
 
 
For Patients with Non-Measurable Disease (i.e., Non-Target Disease) 
 
Non-Target Lesions 
New 
Lesions 
Overall Response 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
21 
CR 
No 
CR 
Non-CR/non-PD 
No 
NonCR/non-PD 
Not all evaluated 
No 
Not evaluated 
Unequivocal PD 
Yes or No 
PD 
Any 
Yes 
PD 
Non-CR/non-PD is preferred over stable disease for non-target disease since SD is 
increasingly used as endpoint for assessment of efficacy in some trials so to assign this 
category when no lesions can be measured is not advised.  
 
11.1.5 Duration of Response 
 
Duration of overall response: The duration of overall response is measured from the time measurement 
criteria are met for CR or PR (whichever is first recorded) until the first date that recurrence or PD is 
objectively documented, taking as reference for PD the smallest measurements recorded since the 
treatment started. 
 
Duration of overall complete response: The duration of overall CR is measured from the time 
measurement criteria are first met for CR until the first date that recurrent disease is objectively 
documented. 
 
Duration of stable disease: Stable disease is measured from the start of the treatment until the criteria 
for progression are met, taking as reference the smallest measurements recorded since the treatment 
started. 
 
11.1.6 Response Review 
 
An expert radiologist independent of the study will review all cases to objectively determine response 
classification. 
 
12. ADVERSE EVENT REPORTING REQUIREMENTS 
 
12.1 
Definitions 
 
12.1.1 Adverse Event (AE) 
 
An adverse event (AE) is any undesirable sign, symptom or medical condition or experience that develops 
or worsens in severity after starting the first dose of study treatment or any procedure specified in the 
protocol, even if the event is not considered to be related to the study.  
 
Abnormal laboratory values or diagnostic test results constitute adverse events only if they induce clinical 
signs or symptoms or require treatment or further diagnostic tests.  
 
12.1.2 Serious adverse event (SAE) 
 
A serious adverse event (SAE) is any adverse event, occurring at any dose and regardless of causality 
that:  
 
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
22 
 
Results in death 
 
Is life-threatening. Life-threatening means that the person was at immediate risk of death 
from the reaction as it occurred, i.e., it does not include a reaction which hypothetically might 
have caused death had it occurred in a more severe form. 
 
Requires or prolongs inpatient hospitalization (i.e., the event required at least a 24-hour 
hospitalization or prolonged a hospitalization beyond the expected length of stay). Hospitalization 
admissions and/or surgical operations scheduled to occur during the study period, but planned 
prior to study entry are not considered SAEs if the illness or disease existed before the person was 
enrolled in the trial, provided that it did not deteriorate in an unexpected manner during the trial 
(e.g., surgery performed earlier than planned). 
 
Results in persistent or significant disability/incapacity. Disability is defined as a 
substantial disruption of a person’s ability to conduct normal life functions. 
 
Is a congenital anomaly or birth defect; or 
 
Is an important medical event when, based upon appropriate medical judgment, it may 
jeopardize the participant and require medical or surgical intervention to prevent one of the 
outcomes listed above. Examples of such medical events include allergic bronchospasm requiring 
intensive treatment in an emergency room or at home; blood dyscrasias or convulsions that do not 
result in inpatient hospitalization, or the development of drug dependency or drug abuse. 
 
Events not considered to be serious adverse events are hospitalizations for: 
 
routine treatment or monitoring of the studied indication, not associated with any 
deterioration in condition, or for elective procedures 
 
elective or pre-planned treatment for a pre-existing condition that did not worsen 
 
emergency outpatient treatment for an event not fulfilling the serious criteria outlined 
above and not resulting in inpatient admission 
 
respite care 
 
12.1.3 Expectedness 
 
Adverse events can be 'Expected' or 'Unexpected.'  
 
12.1.3.1 Expected adverse event 
 
Expected adverse events are those that have been previously identified as resulting from administration of 
the agent. For the purposes of this study, an adverse event is considered expected when it appears in the 
current adverse event list, the package insert or is included in the informed consent document as a 
potential risk.   
 
Refer to Section 6.1 for a listing of expected adverse events associated with the study agent(s). 
 
12.1.3.2 Unexpected adverse event 
 
 
For the purposes of this study, an adverse event is considered unexpected when it varies in nature, 
intensity or frequency from information provided in the current adverse event list, the package insert or 
when it is not included in the informed consent document as a potential risk.   
 
12.1.4 Attribution 
 
Attribution is the relationship between an adverse event or serious adverse event and the study treatment. 
Attribution will be assigned as follows: 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
23 
 
Definite – The AE is clearly related to the study treatment. 
 
Probable – The AE is likely related to the study treatment. 
 
Possible – The AE may be related to the study treatment.  
 
Unlikely - The AE is doubtfully related to the study treatment. 
 
Unrelated - The AE is clearly NOT related to the study treatment. 
 
12.2 
Procedures for AE and SAE Recording and Reporting 
 
Participating investigators will assess the occurrence of CTCAE v4.0 grade >3 AEs and SAEs at all 
participant evaluation time points during the study.  
 
All CTCAE v4.0 grade >3 AEs and SAEs whether reported by the participant, discovered during 
questioning, directly observed, or detected by physical examination, laboratory test or other means, will 
be recorded in the participant’s medical record and on the appropriate study-specific case report forms.  
 
The descriptions and grading scales found in the revised NCI Common Terminology Criteria for Adverse 
Events (CTCAE) version 4.0 will be utilized for AE reporting. All appropriate treatment areas should 
have access to a copy of the CTCAE version 4.0. 
A copy of the CTCAE version 4.0 can be downloaded from the CTEP website at: 
 
 http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 
12.3 
Reporting Requirements 
 
For multi-site trials where a DF/HCC investigator is serving as the principal investigator, each 
participating investigator is required to abide by the reporting requirements set by the DF/HCC. The study 
must be conducted in compliance with FDA regulations, local safety reporting requirements, and 
reporting requirements of the principal investigator.  
 
Each investigative site will be responsible to report SAEs that occur at that institution to their respective 
IRB. It is the responsibility of each participating investigator to report serious adverse events to the study 
sponsor and/or others as described below.  
 
12.4 
Reporting to the DF/HCC Overall Principal Investigator 
 
12.4.1 Serious Adverse Event Reporting 
 
All serious adverse events that occur after the initial dose of study treatment, during treatment, or within 
30 days of the last dose of treatment must be reported to the DF/HCC Overall Principal Investigator on 
the local institutional SAE form. This includes events meeting the criteria outlined in Section 11.1.2, as 
well as the following: 
 
 
Grade 3 (severe) Events – Only events that are unexpected and possibly, probably or 
definitely related/associated with the intervention. 
 
 
All Grade 4 (life-threatening or disabling) Events – Unless expected AND specifically 
listed in the protocol as not requiring reporting. 
 
 
All Grade 5 (fatal) Events – When the participant is enrolled and actively participating in 
the trial OR when the event occurs within 30 days of the last study intervention.  


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
24 
 
Note: If the participant is in long term follow up, report the death at the time of continuing review.  
 
Serious adverse events that occur after initial plasma genotyping and before initial dose of study 
treatment do not need to be reported, unless they are related with the blood draw.  
 
Participating investigators must report each serious adverse event to the DF/HCC Overall Principal 
Investigator within 24 hours of learning of the occurrence. In the event that the participating investigator 
does not become aware of the serious adverse event immediately (e.g., participant sought treatment 
elsewhere), the participating investigator is to report the event within 24 hours after learning of it and 
document the time of his or her first awareness of the adverse event. Report serious adverse events by 
telephone, email or facsimile to: 
 
 
 
Geoffrey R. Oxnard 
 
 
 
Phone: 617-632-6049 
 
 
Email: goxnard@partners.org 
 
 
Fax: 617-632-5786 
 
Within the following 24-48 hours, the participating investigator must provide follow-up information on 
the serious adverse event. Follow-up information should describe whether the event has resolved or 
continues, if and how the event was treated, and whether the participant will continue or discontinue study 
participation. 
 
12.4.2 Non-Serious Adverse Event Reporting  
 
Non-serious grade 3 or greater adverse events will be reported to the DF/HCC Overall Principal 
Investigator on the toxicity Case Report Forms. Given that erlotinib is an FDA approved medication for 
the treatment of advanced NSCLC, adverse events of grade 2 or less should be recorded in the patient’s 
medical record as a part of standard of care but do not need to be reported centrally to the trial.  
 
12.5 
Reporting to the Institutional Review Board (IRB) 
 
Investigative sites within DF/HCC will report all serious adverse events directly to the DFCI Office for 
Human Research Studies (OHRS). 
 
12.6 
Reporting to the Food and Drug Administration (FDA) 
 
The DF/HCC Overall Principal Investigator, as holder of the Non-Significant Risk IDE, will be 
responsible for all communication with the FDA per 21 CFR Part 812.150.  
 
Unexpected fatal or life-threatening experiences associated with the use of the study treatment will be 
reported to FDA as soon as possible but in no event later than 10 working days after initial receipt of the 
information. 
 
  
12.7 
Reporting to the NIH Office of Biotechnology Activities (OBA) 
 
N/a 
 
12.8 
Reporting to the Institutional Biosafety Committee (IBC) 
 
N/a 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
25 
 
12.9 
Reporting to Hospital Risk Management 
 
Participating investigators will report to their local Risk Management office any subject safety reports or 
sentinel events that require reporting according to institutional policy. 
 
12.10 Reporting to Astellas 
 
Reportable SAEs include those occurring after the receipt of the first dose of erlotinib until 30 days after 
receipt of the last dose of erlotinib. These SAEs must be reported to Astellas immediately for a death or 
life-threatening event, or within 24 hours of notification of PI for other types of SAEs. These time frames 
also apply to additional information concerning previously submitted reports of an SAE. 
 
Within 24 hours of awareness of a serious adverse event, whether or not related to the study drug, the 
Investigator will complete and submit a Medwatch 3500A Form to FDA, containing all required 
information (reference 21 CFR 312.32).  The Investigator will submit a copy of this MedWatch 3500A 
form to Astellas by either e-mail or fax, within the same timeframe.  If submission of this SAE to FDA or 
Astellas or is not possible within 24 hours, the Investigator’s local drug safety contact (IRB, etc.) should 
be informed by phone. 
 
The SAE documentation, including the Medwatch 3500A Form and available source records should be 
emailed or faxed to:  
 
Astellas Pharma Global Pharmacovigilance – United States 
Email: Safety-us@us.astellas.com 
Fax number: (847) 317-1241 
 
The following minimum information is required:  
-Study number/IIT regulatory identifier 
-Subject number, sex and age 
-The date of report 
-A description of the SAE (event, seriousness of the event) 
-Causal relationship to the study drug 
-Follow-up information for the event should be sent promptly (within 7 days) as necessary. 
 
12.11 Monitoring of Adverse Events and Period of Observation 
 
All adverse events, both serious and non-serious, and deaths that are encountered from initiation of study 
intervention, throughout the study, and within 30 days of the last study intervention should be followed to 
their resolution, or until the participating investigator assesses them as stable, or the participating 
investigator determines the event to be irreversible, or the participant is lost to follow-up. The presence 
and resolution of AEs and SAEs (with dates) should be documented on the appropriate case report form 
and recorded in the participant’s medical record to facilitate source data verification.  
 
For some SAEs, the study sponsor or designee may follow-up by telephone, fax, and/or monitoring visit 
to obtain additional case details deemed necessary to appropriately evaluate the SAE report (e.g., hospital 
discharge summary, consultant report, or autopsy report).  
 
Participants should be instructed to report any serious post-study event(s) that might reasonably be related 
to participation in this study. Participating investigators should notify the DF/HCC Overall Principal 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
26 
Investigator and their respective IRB of any unanticipated death or adverse event occurring after a 
participant has discontinued or terminated study participation that may reasonably be related to the study.   
 
13. DATA AND SAFETY MONITORING 
 
13.1 
Data Reporting 
 
13.1.1 Method  
 
The ODQ will collect, manage, and monitor data for this study.  
 
13.1.2 Data Submission  
 
The schedule for completion and submission of case report forms (paper or electronic) to the ODQ is as 
follows: 
 
Form 
Submission Timeline 
Eligibility Checklist 
Complete prior to registration with ODQ 
On Study Form 
Within 14 days of registration 
Baseline Assessment Form 
Within 14 days of registration 
Treatment Form 
Within 10 days of the last day of the cycle 
Adverse Event Report Form 
Within 10 days of the last day of the cycle 
Response Assessment Form 
Within 10 days of the completion of the cycle 
required for response evaluation 
Off Treatment/Off Study Form 
Within 14 days of completing treatment or being 
taken off study for any reason 
Follow up/Survival Form 
Within 14 days of the protocol defined follow up 
visit date or call 
 
13.2 
Safety Meetings 
 
The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor toxicity and 
accrual data from this trial. The committee is composed of clinical specialists with experience in oncology 
and who have no direct relationship with the study. Information that raises any questions about participant 
safety will be addressed with the Principal Investigator and study team. 
 
The DSMC will meet quarterly and/or more often if required to review toxicity and accrual data.  
Information to be provided to the committee may include:  up-to-date participant accrual; current dose 
level information; DLT information; all grade 2 or higher unexpected adverse events that have been 
reported; summary of all deaths occurring within 30 days for Phase I or II protocols; for gene transfer 
protocols, summary of all deaths while being treated and during active follow-up; any response 
information; audit results, and a summary provided by the study team. Other information (e.g. scans, 
laboratory values) will be provided upon request.  
 
13.3 
Monitoring  
 
Involvement in this study as a participating investigator implies acceptance of potential audits or 
inspections, including source data verification, by representatives designated by the DF/HCC Overall 
Principal Investigator (or Protocol Chair) or DF/HCC. The purpose of these audits or inspections is to 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
27 
examine study-related activities and documents to determine whether these activities were conducted 
and data were recorded, analyzed, and accurately reported in accordance with the protocol, institutional 
policy, Good Clinical Practice (GCP), and any applicable regulatory requirements.  
 
All data will be monitored for timeliness of submission, completeness, and adherence to protocol 
requirements. Monitoring will begin at the time of participant registration and will continue during 
protocol performance and completion.  
 
The sponsor / IND holder will work with the DFCI Clinical Trials Office to secure an appropriate 
monitoring plan that will include, but not be limited to, the following activities to ensure protocol and 
regulatory compliance and data integrity. Monitoring will be conducted by independent and qualified 
monitors. Monitoring activities will include: ongoing reviews of regulatory files, verifying participant 
eligibility and the consent process on 100% of participants, verifying safety events and study endpoints 
for all enrolled participants, and an ongoing review of CRF completion and query resolution. During 
these activities, monitors will assess for trends and perform additional monitoring based on identified 
areas of need. 
 
14. REGULATORY CONSIDERATIONS 
 
14.1 
Protocol Review and Amendments 
 
This protocol, the proposed informed consent and all forms of participant information related to the 
study (e.g., advertisements used to recruit participants) and any other necessary documents must be 
submitted, reviewed and approved by a properly constituted IRB governing each study location.  
Any changes made to the protocol must be submitted as amendments and must be approved by the 
IRB prior to implementation. Any changes in study conduct must be reported to the IRB. The 
DF/HCC Overall Principal Investigator (or Protocol Chair) will disseminate protocol amendment 
information to all participating investigators.  
All decisions of the IRB concerning the conduct of the study must be made in writing. 
 
14.2 
Informed Consent 
 
All participants must be provided a consent form describing this study and providing sufficient 
information for participants to make an informed decision about their participation in this study. The 
formal consent of a participant, using the IRB approved consent form, must be obtained before the 
participant is involved in any study-related procedure. The consent form must be signed and dated by the 
participant or the participant’s legally authorized representative, and by the person obtaining the 
consent. The participant must be given a copy of the signed and dated consent document. The 
original signed copy of the consent document must be retained in the medical record or research file.  
 
14.3 
Ethics and Good Clinical Practice (GCP) 
 
This study is to be conducted according to the following considerations, which represent good and 
sound research practice: 
 
E6 Good Clinical Practice: Consolidated Guidance 
www.fda.gov/downloads/RegulatoryInformation/Guidances/UCM129515.pdf  
 
US Code of Federal Regulations (CFR) governing clinical study conduct and ethical 
principles that have their origin in the Declaration of Helsinki 
o Title 21 Part 11 – Electronic Records; Electronic Signatures 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr11_02.html 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
28 
o Title 21 Part 50 – Protection of Human Subjects 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr50_02.html  
o Title 21 Part 54 – Financial Disclosure by Clinical Investigators 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr54_02.html  
o Title 21 Part 56 – Institutional Review Boards 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr56_02.html  
o Title 21 Part 312 – Investigational New Drug Application 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr312_02.html  
 
State laws 
 
DF/HCC research policies and procedures http://www.dfhcc.harvard.edu/clinical-
research-support/clinical-research-unit-cru/policies-and-procedures/  
 
It is understood that deviations from the protocol should be avoided, except when necessary to 
eliminate an immediate hazard to a research participant. In such case, the deviation must be reported 
to the IRB according to the local reporting policy.  
 
14.4 
Study Documentation 
 
The investigator must prepare and maintain adequate and accurate case histories designed to record all 
observations and other data pertinent to the study for each research participant. This information enables 
the study to be fully documented and the study data to be subsequently verified. 
 
Original source documents supporting entries in the case report forms include but are not limited to 
hospital records, clinical charts, laboratory and pharmacy records, recorded data from automated 
instruments, microfiches, photographic negatives, microfilm or magnetic media, and/or x-rays.  
 
14.5 
Records Retention 
 
All study-related documents must be retained for the maximum period required by applicable federal 
regulations and guidelines or institutional policies.  
 
14.6 
Multi-center Guidelines 
 
N/A  
 
14.7 
Cooperative Research and Development Agreement (CRADA)/Clinical Trials Agreement 
(CTA)  
 
N/A  
 
15. STATISTICAL CONSIDERATIONS  
 
15.1 
Study Design/Endpoints 
 
This single-arm phase II study will treat 30 patients with erlotinib based upon a positive plasma 
genotyping assay revealing an EGFR sensitizing mutation (exon 19 del, L858R). To identify these 30 
patients, we will screen 100 patients with newly diagnosed, progressive or recurrent advanced NSCLC 
that have not yet undergone standard genotyping. This study will examine a novel treatment strategy 
utilizing rapid plasma genotyping and immediate erlotinib treatment in EGFR mutant patients. The study 
population will be enriched in never/light smokers and patients of Asian race. All patients will undergo 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
29 
rapid plasma genotyping followed by immediate treatment in EGFR mutant patients. Standard tissue 
genotyping will be performed in parallel. Patients will undergo baseline CT imaging which will be 
repeated every 6 weeks for a total of 24 weeks. Patients positive for an EGFR mutation by plasma 
genotyping but negative by tissue genotyping will undergo an interim CT scan at 4 weeks after initiating 
erlotinib to confirm response. The primary statistical analysis of response rate will be performed in 30 
patients initiating erlotinib therapy based on plasma genotype. 
 
Objective response rate (primary endpoint) among patients with advanced NSCLC harboring an EGFR 
mutation by plasma genotyping and treated with erlotinib, will be evaluated using RECIST 1.1 criteria, 
and no patients shall be replaced or omitted in the estimation of response rate. Treatment with erlotinib 
among those who test positive for an EGFR mutation via plasma genotyping will be considered worthy of 
further study if the lower bound of the two-sided 90% exact binomial confidence interval around the 
objective response rate exceeds 0.40; this is consistent with observing at least 17 responses (CR or PR) 
among the 30 patients enrolled on the study. If the true but unknown underlying response rate under this 
treatment paradigm is 0.45, there is a 0.14 chance of calling this study a success; if the response rate is 
higher (0.65), then the probability of declaring this approach successful is 0.88. 
 
The operating characteristics of this design will be recalibrated if the final number of patients harboring 
EGFR mutations in plasma is not exactly equal to 30; in this case, a revised decision rule will be fixed 
such that the lower bound of the two-sided 90% exact binomial confidence interval around the objective 
response rate will need to exceed 0.40 in order to declare study success. 
 
15.2 
Sample Size/Accrual Rate 
 
100 participants recruited over a 2 year period will undergo plasma genotyping for potential treatment 
with erlotinib on study. It is anticipated that approximately 30 patients will be positive for an EGFR (exon 
19 del/L858R)  sensitizing mutation by plasma. After recruitment of 50 patients is complete, the accrual 
rate and number of patients treated with erlotinib will undergo re-assessment for feasibility.  
 
15.3 
Stratification Factors 
 
N/a 
 
15.4 
Analysis of Secondary Endpoints 
 
From a total of 100 NSCLC patients studied, we estimate that 30 will have an EGFR sensitizing mutation 
(exon 19 del/L858R), respectively, based upon prior prevalence data at our institution. Concordance 
between tumor and plasma genotyping results will be calculated using a Cohen’s kappa. The potential 
clinical value of the ddPCR genotyping assay will be estimated using: 
• 
Positive predictive value (PPV): To be clinically useful, the PPV must exceed 90% for the plasma 
assays for EGFR and KRAS mutations. 
• 
Sensitivity: The sensitivity of each assay must exceed 70% to have clinical value. 
• 
Efficiency: The turnaround time (TAT) between ordering the plasma genotyping and obtaining 
the result will be compared to the TAT for tumor genotyping. We will compute the turnaround time for 
each, and compare them using the Wilcoxon-test. To have maximal clinical value, the median TAT for 
plasma genotyping must be less than 3 days. 
 
15.5 
Reporting and Exclusions 
 
15.5.1 Evaluation of toxicity: All participants will be evaluable for toxicity from the time of their first 
treatment. 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
30 
 
15.5.2 Evaluation of response: All participants included in the study must be assessed for response to 
treatment, even if there are major protocol treatment deviations or if they are ineligible. Each participant 
should be assigned one of the following categories: 1) complete response, 2) partial response, 3) stable 
disease, 4) progressive disease, 5) unevaluable. Patients meeting the eligibility criteria and receiving at least 
1 dose of study medication will be included in the main analysis of response rate. 
 
 
 
16. REFERENCES  
 
1. 
Rosell R, Carcereny E, Gervais R, et al. Erlotinib versus standard chemotherapy as first-line 
treatment for European patients with advanced EGFR mutation-positive non-small-cell lung 
cancer (EURTAC): a multicentre, open-label, randomised phase 3 trial. Lancet Oncol. 
2012;13(3):239-246. 
2. 
Zhou C, Wu YL, Chen G, et al. Erlotinib versus chemotherapy as first-line treatment for patients 
with advanced EGFR mutation-positive non-small-cell lung cancer (OPTIMAL, CTONG-0802): 
a multicentre, open-label, randomised, phase 3 study. Lancet Oncol. 2011;12(8):735-742. 
3. 
Mok TS, Wu YL, Thongprasert S, et al. Gefitinib or carboplatin-paclitaxel in pulmonary 
adenocarcinoma. N Engl J Med. 2009;361(10):947-957. 
4. 
Maemondo M, Inoue A, Kobayashi K, et al. Gefitinib or chemotherapy for non-small-cell lung 
cancer with mutated EGFR. N Engl J Med. 2010;362(25):2380-2388. 
5. 
Mitsudomi T, Morita S, Yatabe Y, et al. Gefitinib versus cisplatin plus docetaxel in patients with 
non-small-cell lung cancer harbouring mutations of the epidermal growth factor receptor 
(WJTOG3405): an open label, randomised phase 3 trial. Lancet Oncol. 2010;11(2):121-128. 
6. 
Janne PA, Ramalingam S, Yang J, al. e. Clinical activity of the mutant-selective EGFR inhibitor 
AZD9291 in patients (pts) with EGFR inhibitor–resistant non-small cell lung cancer (NSCLC). 
American Society of Clinical Oncology Annual Meeting; 2014; Chicago, United States. 
7. 
Sequist L, Soria J, Gadgeel S, al. e. First-in-human evaluation of CO-1686, an irreversible, highly 
selective tyrosine kinase inhibitor of mutations of EGFR (activating and T790M). American 
Society of Clinical Oncology Annual Meeting; 2014; Chicago, United States. 
8. 
Higgins MJ, Jelovac D, Barnathan E, et al. Detection of tumor PIK3CA status in metastatic breast 
cancer using peripheral blood. Clin Cancer Res. 2012;18(12):3462-3469. 
9. 
Diaz LA, Williams RT, Wu J, et al. The molecular evolution of acquired resistance to targeted 
EGFR blockade in colorectal cancers. Nature. 2012;486(7404):537-540. 
10. 
Dawson SJ, Tsui DW, Murtaza M, et al. Analysis of circulating tumor DNA to monitor metastatic 
breast cancer. N Engl J Med. 2013;368(13):1199-1209. 
11. 
Hindson BJ, Ness KD, Masquelier DA, et al. High-throughput droplet digital PCR system for 
absolute quantitation of DNA copy number. Anal Chem. 2011;83(22):8604-8610. 
12. 
Maheswaran S, Sequist LV, Nagrath S, et al. Detection of mutations in EGFR in circulating lung-
cancer cells. N Engl J Med. 2008;359(4):366-377. 
13. 
Oxnard GR, Paweletz CP, Kuang Y, et al. Noninvasive detection of response and resistance in 
EGFR-mutant lung cancer using quantitative next-generation genotyping of cell-free plasma 
DNA. Clin Cancer Res. 2014;20(6):1698-1705. 
14. 
Sacher A, Oxnard G, Mach S, et al. Prediction of lung cancer genotype noninvasively using 
droplet digital PCR (ddPCR) analysis of cell-free plasma DNA (cfDNA). American Society of 
Clinical Oncology Annual Meeting; 2014; Chicago, United States.  
 
 
 
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: February 15, 2017 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
31 
 
 
17. APPENDICES  
 
Appendix A: Plasma Preparation SOP 
Appendix B: Performance status criteria 
Appendix C: Cockcroft-Gault equation 
Appendix D: CYP3A4 inhibitors / inducers 
Appendix E: U.S. Physician Prescribing Information for Erlotinib 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date: July 14, 2016  
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
32 
Appendix A: Plasma Preparation SOP 
 
NOTE: Time period from draw to freezing of plasma must be less than 3 hours. 
 
Baseline plasma preparation (DFCI Longwood) 
1. Draw 10 mL of venous blood individually into three labelled EDTA tubes, 30 mL total.  
2. Send one tube of blood to the central laboratory at the Brigham & Women’s Hospital Center 
for Advanced Molecular Diagnostics (CAMD) via Lab Control. Lab Control will then 
prepare the plasma to be sent to CAMD using their plasma preparation protocol. 
3. Send the other two tubes of blood to the Clinical Research Laboratory (CRL) at DFCI.  
4. After receipt of EDTA tubes, the CRL should immediately centrifuge both tubes for 10 
minutes at 1500 (+/- 150) x g. NOTE: Break switch must be off so the cell/plasma interface 
is not disturbed. 
5. Individually pipette each plasma layer into a 15 mL tube labeled “plasma-1.” NOTE: Do not 
dip the tip of the pipette into the plasma/cell surface and leave a thin plasma layer intact over 
the interface. 
6. Centrifuge the two 15 mL tubes containing only plasma for 10 minutes at 3000 (+/-150) x g. 
7. Use a fresh pipette tip to transfer the supernatant of each of the two tubes into two other 15 
mL tubes labeled “plasma-2.” NOTE: Leave about 0.3 mL of plasma in each centrifuged 15 
mL tube. This leftover 0.3 mL contains cellular debris. 
8. Label 8 cryovials with study ID, draw date, clinical trial #, and draw ID (Screen-IA, Screen-
IB).  
9. Use a fresh pipette tip to transfer plasma from each “plasma-2” tube into a maximum of four 
3.6 mL cryovials per tube of blood (recommend 1 mL plasma per cryovial, total of 8 
cryovials).  
10. Freeze immediately upright at -70C or colder until pick-up by Translational Research 
Laboratory. 
 
  
 
 
 
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date:  February 15, 2017  
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
33 
 
 
 
Baseline plasma preparation (other sites) 
1. Draw 10 mL of venous blood individually into three labelled EDTA tubes, 30 mL total.  
2. Immediately centrifuge all three tubes for 10 minutes at 1500 (+/- 150) x g. NOTE: Break 
switch must be off so the cell/plasma interface is not disturbed. 
3. Individually pipette each plasma layer into a 15 mL tube labeled “plasma-1.” NOTE: Do not 
dip the tip of the pipette into the plasma/cell surface and leave a thin plasma layer intact over 
the interface. 
4. Centrifuge the three 15 mL tubes containing only plasma for 10 minutes at 3000 (+/-150) x g. 
5. Use a fresh pipette tip to transfer the supernatant of each of the three tubes into three other 15 
mL tubes labeled “plasma-2.” NOTE: Leave about 0.3 mL of plasma in each centrifuged 15 
mL tube. This leftover 0.3 mL contains cellular debris. 
6. Label 2 cryovials with patient MRN, study ID, draw date, and clinical trial #. Label four 
cryovials with study ID, draw date, clinical trial #, and draw ID (Screen-IA, Screen-IB). 
7. Use a fresh pipette tip to transfer plasma from each “plasma-2” tube into at least two 3.6 mL 
cryovials per tube of blood (recommend 2 mL plasma per cryovial, total of 6 cryovials). 
8. Freeze immediately upright at -70C or colder until shipping. 
9. Place the two cryovials labeled with patient MRN in a transport container with dry ice and 
ship via FedEx courier service to CAMD. Include an EPIC requisition form if shipping from 
a Partners hospital. Also, send an email to BWHgeneticsLabs@partners.org with patient 
name, MRN, and the time of shipment. 
10. Send the remaining four cryovials to the Translational Research Laboratory.  
 
 
 
 
 
 
 
 
 
 
 
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date:  February 15, 2017  
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
34 
 
 
 
 
Follow-up plasma preparation (DFCI + outside hospital) 
1. Draw 10 mL of venous blood individually into one labelled EDTA tube.  
2. For DFCI Longwood samples, send the tube of blood to the Clinical Research Laboratory for 
the next step. For other sites, skip this step and proceed to the next step. 
3. Immediately centrifuge the EDTA tube for 10 minutes at 1500 (+/- 150) x g. NOTE: Break 
switch must be off so the cell/plasma interface is not disturbed. 
4. Individually pipette the plasma layer into a 15 mL tube labeled “plasma-1.” NOTE: Do not 
dip the tip of the pipette into the plasma/cell surface and leave a thin plasma layer intact over 
the interface. 
5. Centrifuge the 15 mL sstube with only plasma for 10 minutes at 3000 (+/- 150) x g. 
6. Use a fresh pipette tip to transfer the supernatant into a second 15 mL tube labeled “plasma-
2.” NOTE: Leave about 0.3 mL of plasma in the centrifuged 15 mL tube. This leftover 0.3 
mL contains cellular debris. 
7. Label the cryovials with study ID, draw date, clinical trial #, and draw ID (usually cycle #). 
8. Use a fresh pipette tip to transfer plasma from the “plasma-2” tube into a maximum of two-
four 3.6 mL cryovials per tube of blood (recommend 1-2 mL of plasma per cryovial, total 2-4 
cryovials).  
9. Freeze immediately upright at -70C or colder until shipment to or pick-up by Translational 
Research Laboratory.  
 
 
 
Center for Advanced Molecular Diagnostics, Shapiro 5   
Brigham and Women’s Hospital  
75 Francis Street 
Boston, MA 02115 
Phone: 857-307-1500 
 
Translational Research Laboratory/Belfer Center of Applied Cancer Science 
Dana-Farber Cancer Institute 
Attn. Cloud Paweletz 
360 Longwood Avenue, LC-4202 
Boston, MA 02115 
 
 
 
 
 
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date:  February 15, 2017  
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
35 
 
 
Appendix B: 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. 
 
 
 
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date:  February 15, 2017  
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
36 
 
 
Appendix C: Cockcroft-Gault equation 
 
 
CrCl for males (mL/min) =   
 
 
 
[140 - age (years)] X [weight (kg)1] 
(72) X [Serum creatinine (mg/dL)] 
 
CrCl for females (mL/min) =  
 
 
 
(0.85) X [140 - age (years)] X [weight (kg)1] 
(72) X [Serum creatinine (mg/dL)] 
 
For SI units: 
CrCl for males (mL/min) =   
 
 
 
[140 - age(years)] X [weight(kg)1] X (1.23) 
[serum creatinine (μmol/L)] 
 
CrCl for females (mL/min) =  
 
 
 
[140 - age(years)] X [weight(kg)1] X (1.05) 
[serum creatinine (μmol/L)] 
 
1 If the subject is obese (> 30% over ideal body weight), use ideal body weight in calculation of estimate 
CrCl 
 
 
 
 
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date:  February 15, 2017  
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
37 
 
 
 
Appendix D: CYP3A4 inhibitors / inducers 
 
CYP3A4 inhibitors 
 
 
 
Acetominophen 
Acetazolamide 
Amioderone 
Amlodipine 
Amprenavir 
Anastrozole 
Aprepitant 
Atazanavir 
Atorvastatin 
Azelastine 
Azithromycin 
Betamethasone 
Bortezomib 
Bromocriptine 
Caffiene 
Cerivastatin 
Chloramphenicol 
Chlorzoxazone 
Cimetadine 
Ciprofloxacin 
Cisapride 
Clarithromycin 
Clemastine 
Clofazimine 
Clotrimazole 
Clozapine 
Cocaine 
Cyclophosphamide 
Cyclosporine 
Danazol 
Delavirdine 
Desipramine 
Dexmedetomidine 
Diazepam 
Diclofenac 
Dihydroergotamine 
Diltiazem 
Disulfiram 
Docetaxel 
Doxorubicin 
Doxycycline 
Drospirenone 
Efavirenz 
Enoxacin 
Entacapone 
Ergotamine 
Erythromycin 
Ethinyl estradiol 
Etoposide 
Felodipine 
Fentanyl 
Fluconazole 
Fluoxetine 
Fluvastatin 
Fluvoxamine 
Fosamprenavir 
Glyburide 
Grapefruit juice 
Haloperidol 
Hydralazine 
Ifosfamide 
Imatinib 
Indinavir 
Irbesartan 
Isoniazid 
Isradapine 
Itraconazole 
Ketoconazole 
Lansoprazole 
Lidocaine 
Lomustine 
Losartan 
Lovastatin 
Mefloquine 
Mestranol 
Methadone 
Methimazole 
Methoxsalen 
Methylprednisolone 
Metronidazole 
Miconazole 
Midazolam 
Mifepristone 
Mirtazapine 
Mitoxantrone 
Modafinil 
Nefazodone 
Nelfinavir 
Nevirapine 
Nicardipine 
Nifedipine 
Nisoldipine 
Nitrendipine 
Nizatidine 
Norfloxacin 
Olanzapine 
Omeprazole 
Orphenadrine 
Oxybutynin 
Paroxetine 
Pentamidine 
Pergolide 
Phencyclidine 
Pilocarpine 
Pimozide 
Pravastatin 
Prednisolone 
Primaquine
Progesterone 
Propofol 
Propoxyphene 
Quinidine 
Quinine 
Quinupristin 
Rabeprazole 
Risperidone 
Ritonavir 
Saquinavir 
Selegiline 
Sertraline 
Sildenafil 
Sirolimus 
Sulconazole 
Tacrolimus 
Tamoxifen 
Telithromycin 
Teniposide 
Testosterone 
Tetracycline 
Ticlopidine 
Tranylcypromine 
Trazodone 
Troleandomycin 
Valproic acid 
Venlafaxine 
Verapimil 
Vinblastine 
Vincristine 
Vinorelbine 
Zafirlukast 
Ziprasidone 
CYP3A4 inducers 
 
 
 
Aminoglutethimide 
Carbamazapine 
Fosphenytoin 
St. John’s wort 
Nevirapine 
Oxcarbazepine 
Pentobarbital 
Phenobarbital 
Phenytoin 
Primidone 
Rifabutin 
Rifampin
Rifapentine 
 
(Adapted from Cytochrome P-450 Enzymes and Drug metabolism. In: Lacy CF, Armstrong LL, Goldman MP, Lance 
LL eds. Drug Information Handbook 12TH ed. Hudson, OH; LexiComp Inc. 2004: 1619-1631.) 
 
 
 
 
 


Protocol: 16-093: Rapid Initiation of Erlotinib for Advanced NSCLC Using Genotyping of Cell-free Plasma 
DNA  
Version date:  February 15, 2017  
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
38 
 
 
Appendix E: U.S. Physician Prescribing Information for Erlotinib 
(Double-Click below image to access full prescribing information) 
 
 


DOSING LOG
Study Participant
Erlotinib
Self-Administration
Cycle: ___
For each  dose take: ________
Study Drug Diary
Dana-Farber/Harvard Cancer Center
Please indicate the date, time, amount taken and any comments. 
Participant Identifier: ____________________
Protocol # : 16-093
Your MD ____________________ Phone ________
Day 1
Your RN _____________________ Phone ____________________
Day 2
Day 3
STUDY DRUG INSTRUCTIONS:
Day 4
Day 5
Study Drug: Erlotinib
Day 6
How Much:  Your dose is ____. 
Day 7
How Often: You will take each dose once daily
Day 8
When: You should take your dose around the same time
Day 9
each day
Day 10
SPECIAL INSTRUCTIONS:
Day 11
Day 12
Day 13
Day 14
Day 15
Day 16
Day 17
Day 18
Day 19
Day 20
Day 21
Day 22
Day 23
Day 24
Day 25
Day 26
Day 27
Day 28
Day 29
Day 30
Day 31
Day 32
Day 33
Day 34
Day 35
Participant Signature: _____________________________
Day 36
Day 37
Date: _______________________
Day 38
Day 39
Day 40
Day 41
Day 42
Take erlotinib at least one hour before or at least two hours 
after the ingestion of a meal (on an empty stomach).
Take erlotinib with at least an eight ounce glass of water.
Do not eat grapefruit or drink grapefruit juice while you are 
being treated with erlotinib.
Take erlotinib about the same time of day.
Some over-the-counter (OTC) drugs should be avoided while 
taking erlotinib. Check with your research team before 
starting any new OTC drug.
If you forget to take a dose of erlotinib, take the drug as soon 
as you remember, as long as it is at least 12 hours before the 
next dose is due to be taken the following day.
Store the erlotinib tablets in the original container at room 
temperature, away from heat and moisture. Keep erlotinib 
tablets away from children and pets.
If you should vomit after taking erlotinib, you can re-take the 
dose within 30 minutes of vomiting. If more than 30 minutes 
has passed, the dose will be skipped. Please contact your 
study nurse or MD for additional instructions.
Date
Comments
Amount Taken