Clinical trial NCT00631852
Conditions: Breast Cancer
Keywords: Breast Cancer, Biomarkers, Ginseng Root
Sponsor: Southern Illinois University
Start date: 2008-02-01; Completion date: 2019-06-30
Enrollment: 16 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This study was designed to explore the changes brought about by gelatin encapsulated extract of American Ginseng Root (LEAG) in breast cancer tumors and surrounding normal breast epithelial cells. Various tumor biomarkers, as well as inflammatory mediators, will be examined in tissue following LEAG treatment.

Detailed description:
Asian ginseng (Panax ginseng) and its close relative American ginseng (Panax quinquefolium) are perennial aromatic herbs that are widely used in Asian medicine. Ginseng root is used as a tonic thought to increase the body's resistance to stress and fatigue, to increase endurance under heavy physical activity, and to improve well-being in age-related debilitation. Most of the ginseng consumed, even in Asian populations, is American ginseng, and the majority of American ginseng is grown and processed in Wisconsin, with quality and standardization overseen by the Ginseng Board of Wisconsin. Furthermore, in Asian medicine, Asian ginseng (Panax ginseng) and American ginseng (Panax quinquefolium) are common components in herbals used for cancer prevention and treatment. Indeed, retrospective studies have shown that patients who consumed ginseng on a regular basis experienced cancers at a reduced rate, however, breast cancer was not considered. Ginseng has been used medicinally for over 2000 years and there are no substantiated serious adverse effects, and few, if any, non-serious adverse effects. The World Health Organization lists ginseng as a traditional medicine with very low toxicity. Clinical trials have also demonstrated an anti-hyperglycemic action of American ginseng. These studies utilized capsules containing dried, ground Ontario-grown P. qinquefolius L. root. The ground AG root preparation had an onset of action of 40 minutes. They found no significant increase in anti-hyperglycemic action after 40 minutes and no significant increase in anti-hyperglycemic action using 1 gram versus 3 gram dosing.

LEAG is a standardized preparation of lyophilized water-extract of American ginseng root in 250-mg gelatin capsules. The ginseng was purchased through the Ginseng Board of Wisconsin and the lyophilized extract has been certified for percentage of each and total ginsenoside content and screened for safe levels of minerals, metals, and pesticides by ConsumerLab.com, a leading testing service company of dietary supplements.

Arms: arm 1: four, 250mg tablets daily 5-14 days prior to surgery
Interventions: intervention 1: American Ginseng root
Intervention descriptions: intervention 1: four, 250mg tablets daily 5-14 days prior to surgery

Protocol documents:
Prot_SAP_000.pdf: 
IND 79586 
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SCI Protocol #:  
 
SCI 07-001.7 
 
SCRIHS Protocol #:  
07-153 
 
 
TITLE:  A Phase II Biomarker Trial of Gelatin Encapsulated Extract of American Ginseng 
               Root in Breast Cancer  
 
 
 
Coordinating Center: 
 
Simmons Cancer Institute 
 
 
SIU School of Medicine 
 
 
 
*Principal Investigator: 
 
Elizabeth Peralta, M.D. 
SIU School of Medicine 
Department of Surgery 
315 West Carpenter Street 
Room 2013 
P.O. Box 19638 
Springfield, IL 62794-9638 
Telephone (217) 545-7230 
Fax (217) 545-6823 
eperalta@siumed.edu 
 
 
Sub-Investigators: 
 
 
Gary Dunnington, M.D.  
 
 
 
 
 
SIU School of Medicine 
Department of Surgery 
315 West Carpenter Street 
Room 2013 
P.O. Box 19638 
Springfield, IL 62794-9638 
Telephone (217) 545-8880 
Fax (217) 545-6823 
gdunnington@siumed.edu 
 
 
 
 
 
 
 


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2018 
 
Krishna Rao, M.D., Ph.D. 
 
 
 
 
 
 
John Godwin, M.D., M.S. 
Simmons Cancer Institute 
 
 
 
 
 
 
Simmons Cancer Institute 
SIU School of Medicine  
 
 
 
 
 
 
SIU School of Medicine 
Department of Internal Medicine 
 
 
 
 
Department of Internal Medicine 
Division of Hematology/Oncology  
 
 
 
Division of Hematology/Oncology 
315 West Carpenter Street 
 
 
 
 
 
 
315 West Carpenter Street 
P.O. Box 19678 
 
 
 
 
 
 
P.O. Box 19678 
Springfield, IL 62794-9678  
 
 
 
 
 
Springfield, IL 62794-9678 
Telephone (217) 545-7089  
 
 
 
 
 
Telephone (217) 545-1946 
Fax (217) 545-6823 
 
 
 
 
 
 
 
Fax (217) 545-6823 
krao@siumed.edu 
 
 
 
 
 
 
 
jgodwin@siumed.edu 
 
 
Statistician: 
Project Manager: 
 
 
Stephen J. Markwell 
Kathy Robinson, Ph.D. 
 
Statistics & Research Consulting  
Simmons Cancer Institute 
 
SIU School of Medicine 
SIU School of Medicine 
 
913 N. Rutledge 
315 West Carpenter Street 
 
P.O. Box 19623 
Room 2066 
 
Springfield, IL 62794-9623 
P.O. Box 19677 
 
Telephone (217) 545-0092 
Springfield, IL 62794-9677 
 
Fax (217) 545-5218 
Telephone (217) 545-1946 
 
smarkwell@siumed.edu  
Fax (217) 545-6823 
 
 
krobinson@siumed.edu 
 
 
 
 
 
 
 
 
Responsible Research Nurse/ 
Responsible Data Manager: 
Study Coordinator: 
 
 
 
Jennifer Bekker, BSN, RN, OCN 
Nora Klinger 
 
Simmons Cancer Institute 
Simmons Cancer Institute 
 
SIU School of Medicine 
SIU School of Medicine 
 
315 West Carpenter Street 
315 West Carpenter Street 
 
Room 3000 
Room 3000 
 
P.O. Box 19677 
P.O. Box 19677 
 
Springfield, IL 62794-9677 
Springfield, IL 62794-9677 
 
Telephone (217) 545-7929 
Telephone (217) 545-0031 
 
Fax (217) 545-6823 
Fax (217) 545-6823 
 
sklug@siumed.edu 
nklinger@siumed.edu 
 


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Investigational Agent: 
Gelatin Encapsulated Standardized Lyophilized Water-Extract  
 
 
of American Ginseng root derived from Panax quinquefolius,  
 
 
L. 
 
 
IND Number: 
79586 
 
 
Protocol History: 
 
 
Version #:  
1.8 
 
 
Version Date: 
06-05-2018 
 
 
 
Version Number 
Amendment Date 
Reason for Amendment 
1.1 
11-12-07 
Requests from FDA 
1.2 
11-13-07 
Alter definition of 
uncontrolled hypertension 
1.3 
02-15-2008 
Clarify method and time point 
for pregnancy testing. 
1.4 
03-03-2008 
Clarify Inclusion Criteria #10 
and Exclusion Criteria #10 
1.5 
12-16-2008 
DRT recommendations 
1.6 
10-26-2009 
Clarify size criteria for 
Inclusion Criteria #1 
1.7 
01-26-2011 
Addition of angiopoietin-2 
biomarker testing, formatting 
and administrative changes 
1.8 
06-05-2018 
Updated Objectives based on 
availability of data  
 
 
 
 
 


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SYNOPSIS 
 
PROTOCOL SYNOPSIS 
Study Number 
SCI 07-001.1 
 
 
Title 
A Phase II Biomarker Trial Of Gelatin Encapsulated Extract Of American Ginseng Root 
(LEAG) In Breast Cancer.    
 
 
Clinical Phase 
Phase II  
 
 
Objectives 
 
Primary To analyze the serum and in vivo tissue biomarker response of breast cancer tumor and 
surrounding normal breast epithelial cells to preoperative treatment with gelatin 
encapsulated lyophilized water-extract of American Ginseng root (LEAG). 
Secondary To compare  before and after administration of LEAG responses  on a proteinomic panel 
of inflammatory mediators. 
 
To establish a base of comparison of biomarkers between breast cancer patients and the 
database of women with increased breast cancer risk in the Surrogate Endpoints and 
Lifestyle Factors (SELF) study. 
 
 
Study Agent 
New chemical entity (NCE): A gelatin encapsulated standardized lyophilized water-
extract of American Ginseng root derived from Panax quinquefolius, L. (LEAG) (250 
mg per capsule). 
Treatment dosage is 1 gram per day (4 capsules per day). 
 
 
Study Population 
A total of 25 to 50 female patients age > 18. 
 
New diagnosis of breast cancer with biopsy showing invasive or non-invasive breast 
cancer (DCIS) at least 0.5cm greatest diameter on imaging.   
 
Surgical patients undergoing lumpectomy, subtotal, or total mastectomy are eligible. 
 
 
Design 
Single Center, Non-Randomized, Unblinded, Investigator Initiated Phase II biomarker 
Trial. 
 
 
Intervention 
A total of 1 gram of LEAG per day for a minimum of 5 days and a maximum of 14 
days. 
 
Four 250 mg capsules taken with food in the morning.  
 
 
Treatment Group 
Surgical resection alone.  For 5 to 14 days preceding their scheduled surgical 
procedure, the patient will be treated with a total of 1 gram of LEAG per day. Subjects 
must complete a minimum of 5 days of treatment with LEAG prior to day of surgery.    
 
 


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Study Evaluations 
The diagnostic core biopsy specimen will be compared to the operative specimen for the 
following: 
 
 
    Primary Objective 
               Evaluations 
Proliferation Markers: Immunohistochemistry for ER, PR, Ki67, cyclin D1, COX-2 
 
 
 
Angiogenesis Marker:  Angiopoetin 2 
 
 
Secondary Objective 
               Evaluations 
 
 
 
 
Evaluate changes in inflammatory mediator proteinomic panel ( adiponectin, CRP, 
HGF, IGF-1, IGF-1R, IL-10, IL-12p40, IL-1b, IL-1ra, IL-2, IL-23, IL-4, IL-6, IL-8MCP-
1, TGFb1, TNFa). 
 
 
 
Establish a comparison of biomarkers between breast cancer patients and the 
database of women with increased breast cancer risk in the SELF study. 
 
Collect anthropometric data (height, weight, body composition, waist-hip ratio), dietary 
history, exercise habits, insulin resistance blood panel (HOMA index, leptin, ghrelin, 
and adiponectin) and Gail Score. 
 
 
Hypothesis  
LEAG will have an anti-proliferative effect on human breast tumors and benign breast 
epithelia. LEAG may favorably alter biomarkers of inflammation and the metabolic 
syndrome.   
 
 
Safety 
Considerations 
All patients will be monitored for toxicity related to therapy.  Adverse events will be collected 
through the post-surgery visit and all related or possibly related adverse events for 30 days 
following discontinuation of LEAG therapy or until resolution or stabilization of the 
adverse event. Discontinuation of treatment will be considered in patients experiencing 
excessive toxicity. 
 
 
Statistical 
Considerations 
High variability among tumors in the patient population is anticipated.  Each patient will serve as 
her own control; pre-treatment biopsy tissue will be compared to post-treatment surgical tissue. 
Descriptive statistics including the mean, median, range, standard deviation, interquartile range, 
skewness, and kurtosis will be calculated for each measure.  Paired t-tests, or Wilcoxon signed-
rank tests, depending on the distributional characteristics of the variables, will be used to assess 
changes in biomarkers from biopsy to surgery.  In order to examine the inter-relationships 
between the anthropometric data, the cytological markers, serum ginsenoside concentrations, and 
a panel of inflammatory serum proteins, data visualization techniques will be employed. 
Correlation coefficients will be used to summarize linear relationships between continuous 
measures.  Regression techniques will be used to model nonlinear relationships. All statistical 
procedures will be performed in consultation with the Division of Statistics and Research 
Consulting at SIU School of Medicine.  
 
 


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Timeline 
Patient enrollment and data collection are expected to be complete within 72 months. 


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TABLE OF CONTENTS 
 
 
Page 
SYNOPSIS ...................................................................................................................................... i 
 
SCHEMA ..................................................................................................................................... vii 
 
1.0 OBJECTIVES ..........................................................................................................................1 
1.1 
Primary Objectives ........................................................................................................1 
1.2 
Secondary Objectives ....................................................................................................1 
 
2.0 BACKGROUND ......................................................................................................................2 
2.1 
Breast Cancer, Problem, and Relevant Cancer Biology ................................................2 
2.2 
Adiposity, Diet, Diabetes, Hyperinsulinemia and Breast Cancer Risk ..........................2 
2.3 
Exercise and Breast Cancer Risk ...................................................................................4 
2.4 
Ginseng Has Both Anti-Cancer and Anti-Diabetic Effects ...........................................4 
2.5 
Gelatin Encapsulated Lyophilized Water-Extract of American Ginseng root (LEAG) 7 
2.6 
Rationale ........................................................................................................................7 
 
 
3.0 PATIENT SELECTION .........................................................................................................8 
3.1 
Eligibility Criteria  .........................................................................................................8 
3.2 
Exclusion Criteria ..........................................................................................................9 
3.3 
Inclusion of Women and Minorities ............................................................................10 
 
4.0 REGISTRATION PROCEDURES ......................................................................................10 
4.1  
General Guidelines .......................................................................................................10 
4.2  
Registration Process .....................................................................................................10 
4.3  
Criteria for Enrollment .................................................................................................10 
 
5.0 TREATMENT PLAN ............................................................................................................11 
5.1 
Screening Procedures...................................................................................................11 
5.2 
Study Visit 1 ................................................................................................................11 
5.3 
Treatment Regimen ......................................................................................................13 
5.4 
Interim Telephone Call ................................................................................................13 
5.5 
Day of Surgery Visit ....................................................................................................14 
5.6 
Follow-up Post Surgery Visit.......................................................................................14 
5.7 
Study Role-Out: Additional Procedures for the First Five Patients .............................15 
 
6.0 GINSENG THERAPY ...........................................................................................................15 
 
6.1 
Summary ......................................................................................................................15 
 
6.2 
Study Agent ..................................................................................................................15 
 
6.3 
Preparation ...................................................................................................................16 
 
6.4 
Mechanism of Action ...................................................................................................16 


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6.5 
Administration Guidelines ...........................................................................................16 
 
6.6 
Duration of Therapy .....................................................................................................17 
 
6.7 
Dose Reductions ..........................................................................................................17 
 
6.8 
Storage and Accountability ..........................................................................................17 
 
6.9 
Availability...................................................................................................................18 
 
 
7.0 RISKS/ PRECAUTIONS ......................................................................................................18 
 
7.1  
Contraindications/ Precautions ....................................................................................18 
 
7.2  
Concomitant Medications ............................................................................................18 
 
7.3  
Prohibited concomitant Medications ...........................................................................19 
 
8.0  ASSESSMENT INSTRUMENTS ........................................................................................19 
 
8.1  
Gail Score ....................................................................................................................19 
 
8.2  
Tecumseh Occupational and Minnesota Leisure Time Activity Questionnaires .........20 
 
8.3  
National Cancer Institute Dietary History Questionnaire ............................................20 
 
9.0  LABORATORY TESTS AND METHODS .......................................................................20 
 
9.1  
Blood Collection ..........................................................................................................20 
 
9.2  
Pathology ....................................................................................................................23 
 
10.0  CRITERIA FOR REMOVAL FROM STUDY................................................................24 
 
11.0  ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS .........................24 
11.1 
Adverse Event Characteristics .....................................................................................24 
11.2 
Adverse Event Reporting .............................................................................................25 
11.3 
Safety Reporting Requirements for IND Holders ........................................................25 
11.4 
IND Annual Reports ....................................................................................................27 
 
 
12.0  STUDY CALENDAR .........................................................................................................28 
 
13.0  DEFINITIONS OF MEASUREMENT  ............................................................................29 
13.1 
Diagnostic Disease Parameters for Inclusion in Study ................................................29 
 
14.0  DATA REPORTING / REGULATORY CONSIDERATIONS .....................................29 
14.1 
Adverse Events ............................................................................................................29 
14.2 
Institutional Review Board Approval ..........................................................................30 
14.3 
Sponsor and Investigator Requirements ......................................................................30 
14.4 
Study Initiation .............................................................................................................30 
14.5 
Study Completion ........................................................................................................31 
14.6 
 Informed consent .........................................................................................................31 
14.7 
Data Collection ............................................................................................................31 
14.8 
Compensation ..............................................................................................................33 
 


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15.0 PARTICIPATING INSTITUTIONS .................................................................................33 
 
16.0  STATISTICAL CONSIDERATIONS ..............................................................................33 
 
16.1 
Sample size/ Accrual rate .............................................................................................34 
 
REFERENCES .............................................................................................................................35 
 
 


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APPENDICES 
 
APPENDIX A 
Tecumseh Occupational Physical Activity Questionnaire 
 
APPENDIX B 
 Minnesota Leisure-Time Physical Activity Questionnaire 
 
APPENDIX C 
Dietary History Questionnaire 
 
APPENDIX D 
 Gail Score Calculation 
 
APPENDIX E 
Certificate of Analysis 
 
APPENDIX F 
Performance Status Scale  
 
APPENDIX G 
Clinical Pharmacology Customized Monograph 
 
APPENDIX H 
 Drug Accountability Log 
 
APPENDIX I 
Patient Diaries 
            Blood Pressure Diary 
            Blood Sugar Diary 
            Medication Diary 
 
 
 


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STUDY SCHEMA 
 
 
 
 
 
Positive Biopsy for Breast Cancer 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical 
Treatment 
Scheduled 
Obtain Informed Consent and Dispense 
LEAG to Patient 
5 to 14 days of LEAG 
Surgery 
Screen for I/E criteria 
Collect Adverse Events 
Final Study Visit/Call 
Collect AE’s for 30 days following final 
dose of LEAG 


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1.0 OBJECTIVES 
 
1.1 Primary Objectives 
 
 
Analyze biomarker in vivo response of breast cancer tumors and surrounding normal breast 
 
epithelial cells to preoperative treatment with gelatin encapsulated lyophilized water-  
 
 
extract of American Ginseng root (LEAG). 
 
1.1.1 The diagnostic core biopsy will be compared to the operative specimen for effects  
 
 
on the following proliferative and tumor biomarkers: immunohistochemistry for  
 
 
ER, PR, Ki67, cyclin D1, COX-2. 
 
1.2 Secondary Objectives 
 
1.2.1   To compare  before and after administration of LEAG responses  on a proteinomic 
 panel of inflammatory mediators. 
•  Evaluate changes in inflammatory mediator proteinomic panel ( 
adiponectin,CRP,HGF,IGF-1,IGF-1R,IL-10, IL-12p40,IL-1b,IL-1ra,IL-2,IL-23,IL-
4,IL-6,IL-8, MCP-1, TGFb1,TNFa).insulin, ghrelin and leptin; measured at 
baseline and after 5-14 days of treatment.  
• Measure angiogensis marker, angiopoetin 2. 
 
     1.2.2     In a preliminary manner compare the Gail risk model, anthropomorphic                 
                        measurements, dietary history, exercise habits, and biomarkers of insulin               
                        resistance between breast cancer  patients in this study and our database of            
                       women with increased breast cancer risk participating in the ongoing Surrogate      
                       Endpoints and Lifestyle Factors (SELF) study.  
•     Collect anthropometric data (height, weight, body composition, waist-hip ratio,      
 BMI), dietary history and exercise habits using the same instruments, as our SELF 
 study (Appendices A, B, and C) at baseline.  
•     Calculate the homeostasis model assessment (HOMA) index [insulin resistance  
 (HOMA-IR) = fasting insulinemia (mU/mL) × fasting glycemia (mmol/L)/22.5)]  
 (collected fasting on the day of surgery).  
•     Measure serum leptin, ghrelin, and adiponectin levels (collected fasting on the day 
 of surgery).  
•  Evaluate Breast cancer risk assessment through calculation of a Gail Score  
                  
(Appendix D) 
 


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2.0 BACKGROUND 
 
2.1 Breast Cancer, Problem and Relevant Cancer Biology 
 
With the aging demographics of this country, breast cancer incidence is expected to double over 
the next 15 years, bringing prevention efforts to the forefront (1). Current prevention methods 
include chemoprevention with the selective estrogen receptor modulator, tamoxifen, versus 
oophorectomy or prophylactic mastectomy. While effective, these measures entail potential 
adverse effects. Greater than 90% of women with breast cancer risk profiles high enough to 
consider chemoprevention with tamoxifen decide against taking it. In contrast, there is strong 
public acceptance of dietary supplements such as soy and green tea which are perceived as safe 
and health-promoting. An ideal breast cancer prevention agent would be a safe nutritional 
intervention that could also have additional metabolic benefits.  Western women have the highest 
incidence of breast cancer in the world, and since less than ten percent of breast cancer is 
attributed to known genetic causes, nutrition and lifestyle are suspected to be significant factors 
contributing to this risk. The raised incidence of breast cancer in Western countries parallels the 
prevalence of the so-called metabolic syndrome, the major components of which are obesity, 
hyperinsulinemia, dyslipidemia, and atherosclerosis.  It is an open question whether these two 
trends are biologically linked (see discussion below). Our study aim is to evaluate whether the 
gelatin encapsulated lyophilized water-extract of American Ginseng root (LEAG) is a potential 
breast cancer prevention agent and is able to directly affect both breast cancer cell proliferation in 
newly diagnosed tumors, as well as positively influence the inflammatory mediators potentially 
involved in obesity associated pathways that may increase the risk of breast cancer. 
 
2.2 Adiposity, Diet, Diabetes, Hyperinsulinemia and Breast Cancer Risk 
 
There are several lines of epidemiological evidence that Western diet and lifestyle influence the 
increased rate of breast cancer.  Asian women, who have some of the lowest rates of breast 
cancer in the world, acquire a risk level approximating the national average over several 
generations after immigrating to the United States (2). The pattern of factors associated with 
breast cancer incidence in Western countries parallels the major components of the insulin 
resistance syndrome: hyperinsulinemia, dyslipidemia, hypertension and atherosclerosis.  High 
total energy intake and decreased physical exercise lead to excess adipose tissue, which increases 
free fatty acids and tumor necrosis factor alpha (TNFa) (3).  These two components may be 
involved in the pathogenesis of hyperinsulinemic glucose intolerance in genetically predisposed 
individuals as they grow older (4).   
 
It is generally agreed that obese women are at increased risk for postmenopausal, but not pre-
menopausal, breast cancer. A plausible mechanism that could link obesity to breast cancer may 
be that mammary carcinogenesis is promoted in obese post-menopausal women as a result of 
synergistic activity between the concomitants of hyperinsulinemia, such as insulin-like growth 
factor (IGF) increase, and increased estrogen concentrations derived from aromatization in 
adipose tissue. In addition to these facts, it is now proposed that a third mechanism is plausible. 


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Excess energy intake and resultant hyperglycemia can cause up-regulation of phosphoinositide  
3-kinase (PI3-K) signaling via its two downstream effector serine-threonine protein kinases, Akt 
and the mammalian target of rapamycin (mTOR).  Akt and mTOR are known to have oncogenic 
properties mediated in part by suppression of apoptotic signals and in addition by their effects on 
cell cycling. In obese humans increased PI3K signaling may lead to mitochondrial damage and be 
part of the pathway of mammary carcinogenesis inducing ductal hyperplasia and DNA damage 
through oxidative stress.   
 
 The observation that tumors utilize glucose more avidly than normal tissues dates back to 1964 
(5) and since then has prompted a number of epidemiologic studies comparing breast cancer rates 
among subjects with diabetes versus those with normoglycemia. Retrospective studies show a 
mild positive correlation (RR 1.2-2.0), but researchers admit that confounding variables such as 
the lower consumption of alcohol among diabetics versus non-diabetics tend to weaken the 
association (6). While studies to date seem to show a mild increased risk of breast cancer 
associated with type II diabetes, the potential impact from a prevention perspective is increased 
by a number of considerations.  The prevalence of obesity and type II diabetes in the United 
States has doubled in the decade since the Atherosclerosis Risk in Communities Study 
commenced, and even a mild correlation could account for more than 10% of the breast cancer 
diagnoses in this country per year (5). Persons who are not yet diabetic or obese but who have a 
predisposition as evidenced by overweight (BMI > 25 but < 30) account for as much as 35% of 
the U.S. population. The study we are proposing looks at the potential reversibility of the 
epithelial lesions associated with diet induced obesity and diabetes.  
 
Epidemiological reports are inconsistent on the association between breast cancer risk and the 
dietary intake of either individual fatty acids or of antioxidant vitamins. The inconsistencies may 
in part be due to interactions between the two classes of nutrients at the level of the cell 
membrane, affecting their potential role in mammary carcinogenesis. The effects of specific 
dietary fatty acids and antioxidant vitamins on experimental mammary cancer systems have been 
compared with reported epidemiological associations of the same agents with breast cancer risk 
in humans (7). An increased ratio of n-3 to n-6 polyunsaturated fatty acids (PUFAs) in the diet 
inhibits the growth of a rat mammary cancer model. There is also evidence that members of the 
n-3 PUFA series can inhibit the growth of human breast cancer cells both in vitro and in 
explants. Clinical trials of supplementary n-3 PUFAs in conjunction with a reduced fat intake 
have been proposed for breast cancer prevention. In particular, it is suggested that n-3 PUFAs 
have an inhibitory effect on COX-2 activity (8). 
 


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2.3 Exercise and Breast Cancer Risk 
 
Multiple epidemiologic studies have evaluated the association between exercise and breast 
cancer risk. A recent review of 18 cohort and 23 case-control studies found that observations 
from 26 of these studies including 108,031 breast cancer cases demonstrated that exercise (both 
occupational and leisure-time) is associated with a 30% reduction in breast cancer risk (9). 
Further supporting a reduced risk associated with exercise, a significant graded dose-response 
relationship was found in 16 of the studies (9). Moderate non-vigorous exercise can increase 
insulin sensitivity and improve dyslipidemia even without change in body weight (10, 11).   Thus 
exercise can serve to counter the negative influences associated with obesity and breast cancer 
pathogenesis. 
 
 
2.4 Ginseng has both anti-cancer and anti-diabetic effects 
 
Studies in Dr. Murphy’s laboratory have characterized an extract of the American ginseng root 
that inhibits proliferation of human breast cancer cells in culture and in animal models.  Studies 
from this and other laboratories have shown that American ginseng and ginsenosides may inhibit 
cancer cell proliferation by inducing gene and protein expression of the cell cycle regulatory 
protein p21, thus arresting tumor cell cycle progression (12), by inducing cancer cell apoptosis 
through activation of caspase-3 protease via a bcl-2-insensitive pathway and by sensitizing 
multidrug-resistant tumor cells to chemotherapy (13, 14). Together, these data indicate that the 
individual ginsenosides may inhibit cancer cell proliferation via different mechanisms of action 
and in a concentration-dependent manner.  
 
The treatment of human breast cancer cell lines MCF-7 or MDA-MB-231 with a water-extract of 
powdered North American ginseng root produced a significant decrease in cell proliferation in a 
dose-dependent and estrogen receptor-independent manner (15).  Moreover, in athymic nude 
mice inoculated with either MCF-7 or MDA-MB-231 cells, treatment with a 1% solution of 
American ginseng extract in lieu of drinking water produced a ≥ 50% reduction in tumor size 
when compared to water-only controls (16).  Recent laboratory studies have determined that 
ginseng also significantly enhances the efficacy of doxorubicin and tamoxifen on breast cancer 
cell proliferation in vitro, and on tumor growth in nude mice in vivo.  
 
Further studies from this laboratory and others, have elucidated the ginsenoside components in 
ginseng that exhibit the anti-tumor effects (17, 18). Ginsenosides are saponin glycosides unique 
to and the major biologically active components in ginseng.  Over 20 different ginsenosides have 
been identified and, based on their structural differences; the ginsenosides found in American 
and Asian ginseng have been categorized into two main classifications: 20(S)-protopanaxadiol 
and 20(S)-protopanaxatriol.  The 20(S)- protopanaxadiol group contains the ginsenosides (i.e., 
ginsenosides Rc, Rg3, Rh2) that have been shown to have the most potent anti-cancer activity 
(18) and do not exhibit the estrogenic activity of ginseng extract (19, 20) and other ginsenosides 
(21, 22). Figure 2 shows the effects of various ginsenosides on cell proliferation.  Results clearly 
show that these ginsenosides inhibit cancer cell proliferation (4), induce cancer cell death (13, 


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12), and prevent cancer metastasis (23).  Thus, it appears that ginsenosides Rc, Rg3, and Rh2 
may be responsible for the therapeutic effects of American and Asian ginseng in experimental 
studies.  Ginsenosides Rc and Rh2 have been shown to have the most potent anti-cancer activity 
(see Figure 1), and do not exhibit the estrogenic activity of ginseng ethanol extracts (21). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     Ginsenoside Rc           GInsensoside Rh2 
 
 
 
 
      
 
 
 
 
 
 
Figure.1 Chemical structure of ginsenosides 
 
  
 
     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
0
25
50
75
100
0.01
0.1
1
Concentration (mg/ml)
Rg3+Rh2
Rc+Rh2
Rh2
Rg3
Rc
GE
Inhibition of
Cell Proliferation
(% of vehicle
control)
 
Figure 2.  The effect of American ginseng root extract (GE) and 
ginsenosides, alone and in combination 
 


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Recently, ginseng extract (13) and the ginsenosides Rg3 and Rh2 (23) were shown to inhibit cell 
proliferation and disrupt MAP kinase signaling in a dose-dependent manner in human breast and 
prostate cancer cells, respectively. Ginseng and ginsenosides also have metabolic effects which 
may reduce carcinogenesis via the inflammatory and hyperinsulinemic states associated with the 
metabolic syndrome. American ginseng, in doses of 1 to 3 grams, taken 40 minutes before a 
glucose challenge test reduced postprandial glycemia in both diabetic and non-diabetic subjects 
(24, 25). Morever, 20(S)-protopanaxatriol inhibits inducible nitric oxide synthase and COX-2 
expression through inactivation of NFκB in RAW264.7 macrophages that were stimulated with 
endotoxin lipopolysaccharide (26). 
 
An advantage of ginseng therapy is that it remains potent following oral administration.  
Pharmacokinetic studies have revealed that following oral administration of ginseng, the 
ginsenosides are absorbed and pass through the system unmetabolized (i.e., Rg1, Rd, Re, Rb1, 
Rb2, Rc) (27); are hydrolyzed and conjugated with fatty acids into metabolites that become more 
metabolically stable and retain their activity, and/or are deglycosylated and degraded into 
metabolites that are either more potent anti-cancer compounds (i.e., protopanaxadiol, 
protopanaxatriol, IH-901, Compound K or M1) (28, 29), or have no reported anti-cancer activity 
(i.e., Rh1, Rf1).  Interestingly, ginsenosides Rb1 and Rc can be metabolized into the potent anti-
cancer ginsenosides Rg3 and Rh2 by acid environment and intestinal flora (30).  Ginsenoside 
Rg3 is rapidly metabolized by the gut into Rh2 and protopanaxadiol (26), both of which possess 
greater anti-tumor activity than Rg3.  
 
Our existing study, the Surrogate Endpoints and Lifestyle Factors (SELF) trial, has as its goal to 
analyze the prevalence in women seeking risk assessment for breast cancer, of insulin resistance, 
central obesity, and proliferative changes in mammary ductal cells, and determine whether these 
potential surrogate endpoint biomarkers (SEBs) have a positive correlation with breast cancer 
risk.  The findings will be used to refine the relevant biomarkers and perform a power analysis 
for a 5-year clinical trial with breast cancer as an endpoint. Once these biomarkers are validated, 
other candidate prevention agents for breast cancer could be incorporated into future trials.  
Significant correlations between SEB and breast cancer incidence will allow clinicians to identify 
women who can effectively lower their breast cancer risk, potentially with American ginseng. 
Therefore we will establish a base of comparison between breast cancer patients and participants 
in the SELF study by collecting anthropometric data (height, weight, body composition, waist-
hip ratio), dietary history, exercise habits, and insulin resistance blood panel (HOMA index, 
leptin, ghrelin, and adiponectin) and calculated 5 year risk of breast cancer (Gail score) in 
participating breast cancer patients. Contingent on an observed antiproliferative effect of ginseng 
on tumor or surrounding normal breast tissue in treated breast cancer patients or on the other 
surrogate markers of breast cancer risk, a breast cancer prevention trial involving exercise with or 
without ginseng supplementation will be designed. 
 


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2.5 Gelatin Encapsulated Standardized Lyophilized Water-Extract of American Ginseng 
root derived from Panax quinquefolius, L. (LEAG) 
 
Asian ginseng (Panax ginseng) and its close relative American ginseng (Panax quinquefolium) 
are perennial aromatic herbs that are widely used in Asian medicine.  Ginseng root is used as a 
tonic thought to increase the body’s resistance to stress and fatigue, to increase endurance under 
heavy physical activity, and to improve well-being in age-related debilitation. Most of the 
ginseng consumed, even in Asian populations, is American ginseng, and the majority of 
American ginseng is grown and processed in Wisconsin, with quality and standardization 
overseen by the Ginseng Board of Wisconsin. Furthermore, in Asian medicine, Asian ginseng 
(Panax ginseng) and American ginseng (Panax quinquefolium) are common components in 
herbals used for cancer prevention and treatment.  Indeed, retrospective studies have shown that 
patients who consumed ginseng on a regular basis experienced cancers at a reduced rate (31), 
however, breast cancer was not considered.  Ginseng has been used medicinally for over 2000 
years and there are no substantiated serious adverse effects, and few, if any, non-serious adverse 
effects. The World Health Organization lists ginseng as a traditional medicine with very low 
toxicity (32, 33).  Clinical trials have also demonstrated an anti-hyperglycemic action of 
American ginseng. These studies utilized capsules containing dried, ground Ontario-grown P. 
qinquefolius L. root. The ground AG root preparation had an onset of action of 40 minutes (24). 
They found no significant increase in anti-hyperglycemic action after 40 minutes (24) and no 
significant increase in anti-hyperglycemic action using 1 gram versus 3 gram dosing. 
 
LEAG is a standardized preparation of lyophilized water-extract of American ginseng root in 
250-mg gelatin capsules. The ginseng was purchased through the Ginseng Board of Wisconsin 
and the lyophilized extract has been certified for percentage of each and total ginsenoside content 
and screened for safe levels of minerals, metals, and pesticides by ConsumerLab.com, a leading 
testing service company of dietary supplements (Appendix E). 
 
2.6 Rationale 
 
Studies that target primary prevention are difficult due to the large number of subjects and many 
years of follow-up that are required.  Our strategy is to evaluate the effect of oral ginseng on 
several proliferative tumor associated biomarkers, as well as inflammatory and obesity related 
biomarkers.   
 
There is precedent for the use of biomarkers in short-term neoadjuvant therapy of breast cancer. 
The IMPACT trial compared the preoperative use of tamoxifen with anastrozole alone or in 
combination in postmenopausal women (n=330) with primary breast cancer (34). 
Immunohistochemical levels of the proliferation marker Ki-67, estrogen receptor (ER), 
progesterone receptor (PR), and HER-2 neu were assessed at diagnosis, 2 weeks, and 12 weeks. 
A reduction in Ki-67 was seen at 2 weeks in the majority of patients (93%, 85%, and 84% of 
those treated with anastrozole, tamoxifen, and combination, respectively). The percent reduction 
of Ki-67 by treatment group paralleled the tumor response rate and disease-free survivals of these 
different treatments, confirming the value of Ki-67 as a biomarker of tumor response to therapy 


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(35). Because the proliferation marker Ki-67 has been shown to be reduced by as little as two 
weeks of neoadjuvant therapy (35), we hypothesize that proteins that regulate the cell cycle, 
inflammation, and cell death can show alteration in expression within one cell cycle and can be 
detectable in tumor specimens after 5 or more days of treatment. 
Targets for cancer prevention are being sought among the numerous regulatory molecules 
involved in cellular proliferation, differentiation, and DNA repair. A morphological description 
of breast carcinogenesis is currently based on a model of progression from hyperplasia to DCIS 
to invasive carcinoma. This is based on both analogy to the colon cancer hyperplasia-dysplasia 
model (for which many of the genes involved in the progression have been identified) and on 
surgical and autopsy studies.  In a study comparing benign proliferative lesions occurring in the 
same breast with invasive cancer, 50% of the hyperplastic lesions and 80% of the ductal 
carcinoma in situ (DCIS) shared at least one LOH with the adjacent cancer (36). In the breast, the 
process of intraepithelial neoplasia can be shown to contain a spectrum of morphologic findings 
ranging from ductal hyperplasia to atypical ductal hyperplasia to DCIS. The earliest precursor 
lesions rarely show overt markers of malignancy such as p53 mutation, but they do differentially 
express cell cycle regulatory proteins. Immunohistological and RT-PCR studies of proliferative 
ductal epithelial lesions in breast tissue associated with resected carcinoma show increased cyclin 
D1 expression, which mediates cell cycle progression, in 72% of DCIS and 27% of atypical 
ductal hyperplasia (37, 38). In contrast, cyclin D2, which regulates cell cycle arrest, is abundant 
in finite-lifespan human mammary epithelial cells (HMEC) and benign breast tissue, but is 
decreased or undetectable in 87% of breast cancer cell lines and primary tumors (39).  Recently, 
cyclooxygenase-2 (COX-2) staining was found to be increased not only in DCIS but in the 
stroma and benign breast tissue surrounding the lesion (40). COX-2 modulates prostanoid 
production in the direction of stimulating epithelial proliferation and is upregulated in colon, 
breast, and other cancers (41). COX-2 upregulation may also be associated with diabetes. Human 
endothelial cells cultured in high glucose conditions show increased COX-2 mRNA and protein 
and increases in oxidative stress (42).  Though cell proliferation and regulation are obviously 
important, they are no longer the only targets of therapy. Mechanisms of tumor spread and 
angiogenesis are also highly studied,  
Angiopoietin plays a physiologic role in angiogenesis and lymphangiogenesis and is involved in 
the maintenance of vascular function and integrity52.  Four members (Ang 1, Ang 2, Ang 3, and 
Ang 4) make up this family with 2 receptors, Tie 1 and Tie 2.  An increasing number of studies 
show that angiopoietin-2 correlates with tumor angiogenesis, tumor stage, lymph node invasion 
and length of survival51,52,53,54,55,56. Many cancers, including lung, breast, neuroendocrine, 
colorectal, and melanomas have associations of high angiopoietin-2 and stage of disease; 
therefore, signifying high potential as a biomarker of stage and/ or metastasis. This potential is 
not only due to its broad association with cancer in general but also its ease of analysis in serum. 
Agents which inhibit angiopoietin’s actions would, therefore, also have high potential for use in 
cancer treatment.  
 
 
The present study was designed to explore the changes brought about by LEAG in breast cancer 
tumors and surrounding normal breast epithelial cells. Various tumor biomarkers, as well as 


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inflammatory mediators, will be examined in tissue following LEAG treatment.  Positive trends 
and/or results in this study will be the basis for future studies utilizing LEAG. 
 
 
3.0 PATIENT SELECTION 
 
3.1 Eligibility Criteria 
 
1. Patients with a cytologically confirmed diagnosis of breast cancer with a biopsy showing 
invasive or non-invasive breast cancer (DCIS) at least 1.0 cm greatest diameter on 
imaging (biopsy must have been performed within 6 months of screening visit). 
2. Surgical patients, undergoing lumpectomy, subtotal or total mastectomy. 
3. Age > 18 years of age. 
4. Female. 
5. Patients must have tissue blocks available from diagnostic biopsy. 
6. Negative pregnancy test, medical history of surgical sterilization, or 1 year post-
menopausal. The effects of LEAG on the developing human fetus at the recommended 
therapeutic dose are unknown.  For this reason women of child-bearing potential must 
agree to use adequate contraception (hormonal or barrier method of birth control; 
abstinence) prior to study entry and for the duration of study participation. 
7. Patient must be willing to forgo surgery for a minimum of 5 days. 
8. The ability and willingness to sign a written consent. 
9. Patients currently being treated for hypertension must be on a stable dose of medication 
for the past 30 days. 
10. Diabetic patients must be well controlled (HbA1c < 8.5 within past 60 days or 
documented fasting blood glucose < 140 mg/dl  for three consecutive days). Known 
diabetics who have experienced episodes of symptomatic hypoglycemia in the last 6 
months are also considered poorly controlled and will be excluded from study 
participation. 
11. ECOG status of < 2 or Karnofsky > 60% (Appendix F). 
 
3.2 Exclusion Criteria 
 
1. Patients with previous or concurrent malignancy, excluding non-melanotic skin cancer. 
Malignancies treated and without recurrence or symptoms of recurrence within the last 3 
years are acceptable. 
2. Patients with evidence of distant metastatic disease.  
3. Patients who have had chemotherapy, biologic or radiotherapy within 6 months of 
biopsy. 
4. Patient usage of herbal supplements or alternative medications not approved by the FDA 
within 1 week of starting study drug. LEAG or related ginseng products, and combination 
products containing ginseng should be discontinued within 6 weeks of starting study 
drug. 


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5. Patients with a history of allergic reactions attributed to compounds of similar chemical 
or biologic composition to LEAG, including other products claiming to contain ginseng 
in any form. 
6. Patients with a history of a chronic inflammatory process, including, but not limited to, 
rheumatoid arthritis and lupus.  This includes patients on concurrent chronic systemic 
steroids or anti-inflammatory medications. 
7. The subject has active bleeding (i.e. gastrointestinal ulcer with bleeding) or a 
pathological condition that carries a high risk of bleeding, in the investigator’s opinion. 
8. Patients with any swallowing dysfunction leading to difficulty taking the investigational 
therapy are ineligible for the study. 
9. Uncontrolled intercurrent illness including, but not limited to, ongoing or active 
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac 
arrhythmia, or psychiatric illness/social situations that would limit compliance with study 
requirements.  HIV-positive patients on combination antiretroviral therapy are ineligible 
because of the potential for pharmacokinetic interactions with LEAG.  Appropriate 
studies will be undertaken in patients receiving combination antiretroviral therapy when 
indicated. 
10. Patients with poorly controlled diabetes (control indicated with HbA1c < 8.5 within past 
60 days or documented fasting blood glucose < 140 mg/dl  for three consecutive days). 
Known diabetics who have experienced episodes of symptomatic hypoglycemia in the 
last 6 months are also considered poorly controlled and will be excluded from study 
participation. 
11. Patients with uncontrolled hypertension   (SBP > 140 mmHg or DBP > 90 mmHG).  
Should a subject’s blood pressure on initial presentation fall above defined parameters 
for hypertension two additional blood pressure measurements will be performed at least 
15 minutes apart. The initial blood pressure and two additional measurements will be 
averaged. If the average of the three measurements remains above the defined parameters 
for hypertension, the patient will be excluded.  If the average of the three measurements 
falls below the defined parameters for hypertension, the patient will be considered to 
meet eligibility. 
12. Pregnant or breast feeding women.  Women must be willing to use birth control 
throughout study duration. 
13. Patients on other investigational medications or having been treated with an 
investigational agent within 6 weeks prior to biopsy. 
14. Patients currently receiving coumadin therapy or who have been treated with coumadin 
within the 2 weeks prior to biopsy.  
15. Patients taking monoamine oxidase inhibitors. 
 
 
3.3 Inclusion of Women and Minorities 
 
Women and members of all races and ethnic groups are eligible for this trial.   
 
 


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4.0 REGISTRATION AND ENROLLMENT PROCEDURES 
 
4.1 General Guidelines 
 
To be eligible for registration to this study, the patient must meet each inclusion criteria listed on the 
eligibility checklist and none of the exclusion criteria should apply.  To be registered, the patient 
must have the ability to understand and the willingness to sign the written informed consent.  
 
 
4.2 Registration Process 
  
• Contact the Clinical Trials Office (CTO) at 217-545-7929 with patient information: 
name, physician, and diagnosis. 
• CTO staff will screen patients’ charts for eligibility.  The CTO must have the 
following information, at minimum, to determine eligibility: past medical history 
information, diagnostic biopsy report, radiologic exams, and staging information. 
• If the patient is eligible following chart review: CTO staff will meet with patient to 
review the Informed Consent Form and proceed in obtaining written consent.  
 
4.3 Criteria for Enrollment 
   
• Confirmation that patient has met all of the Inclusion Criteria and none of the 
Exclusion Criteria. 
• Patient has voluntarily signed informed consent document. 
 
 
5.0 TREATMENT PLAN 
 
5.1 Screening Procedures 
 
5.1.1    History and physical reviewed and recorded, including performance status.  
5.1.2    Concomitant medications reviewed and recorded. 
5.1.3    Vital signs reviewed and recorded. 
5.1.4    Inclusion and exclusion criteria will be reviewed. 
5.15 
Review and record available HbA1c status (within past 60 days) or fasting blood 
 
glucose values (three consecutive days below 140 mg/dl) 
5.1.6    Informed consent process 
5.1.7 Pregnancy test, if required 
 
5.2 Study Visit 1 
 
5.2.1   Obtain tissue blocks for immunohistochemisty from core biopsy 
 


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•   Proliferation Markers: immunohistochemistry for ER, PR, Ki67, 
 
  cyclin D1, Cox-2, and angiopoietin 2.  
 
•  Cytotoxicity Markers: cyclin D2 and TUNEL 
 
•  Angiogenesis Markers:  angiopoetin 2 
 
 
5.2.2   Fasting lab work will be obtained. 
 
Serum for levels of gRc and gRh2, inflammatory mediator proteinomic panel (IL1b,  
IL6, IL8, MCP-1, TNFa, HGF, NGFb, Insulin, and Leptin), pregnancy test (if not 
already done at screening visit) if woman is of child-bearing potential, HOMA index, 
leptin, ghrelin, and adiponectin. 
 
5.2.3   Questionnaires will be completed 
 
            Dietary, Tecumseh and Minnesota Activity Questionnaires 
 
A. Tecumseh and Minnesota Occupational and Leisure Time Activity 
Questionnaires:  Both occupational and leisure time exercise exposure for the 
prior 12 months will be measured by the Tecumseh and Minnesota occupational 
and leisure time activity questionnaires. The validity and reliability of the 
Tecumseh Occupational Physical Activity Questionnaire (43) has been 
documented by Ainsworth (44, 45) (Appendix A).  Leisure time physical activity 
will be measured by the Minnesota Leisure Time Physical Activity Questionnaire 
(Appendix B) which has also been previously tested for validity and reliability and 
is a well-accepted measurement tool (43).  Of note, the use of the Tecumseh and 
Minnesota Occupational and Leisure Time Surveys allow for calculation of 
energy expenditure.  Specifically, each activity recorded on the survey will be 
assigned a calculated metabolic equivalent (MET) value based on the published 
compendium of physical activity (46).  This MET value will be multiplied by the 
number of hours spent in each activity per week (i.e.  METs x hrs/wk). This 
variable (METs x hrs/wk) will then be analyzed for the study group as a 
continuous variable and in quartiles.   
 
B. National Cancer Institute Dietary History Questionnaire: The current 
proposal will utilize the Dietary History Questionnaire (DHQ) developed by the 
Risk Factor Monitoring and Methods Branch (RFMMB) of the National Cancer 
Institute. The Eating at America’s Table Study conducted by the RFMMB 
compared their new DHQ with the previous standard Block and Willet food 
frequency questionnaires (FFQs). The DHQ performed best of all in a randomized 
sample of 1,640 men and women (47). The DHQ is a self-administered 
questionnaire that represents a refinement over the RFMMB Block FFQ, with 


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improved comprehension across various economic and ethnic groups and 
increased attention to dietary constituents of interest in disease prevention: fiber, 
energy, carotenoids and vitamin A, E and C (Appendix C). The questionnaire will 
be entered into an ASCII text file and analyzed using Diet*Calc Version 1.2 free 
downloadable software. Energy intake (kcal/kg), refined carbohydrate, fat, and 
fruit and vegetable intake (% of total intake) will be analyzed as continuous 
variables and by quartiles.  
 
5.2.4   Anthropometric data will be collected 
 
           Body measurements including height and waist-hip ratio and body composition. 
 
A.  Waist-hip ratio:  Over light clothing with a measuring tape in inches:  waist 
girth (W) is measured at the minimum circumference between the costal margin 
and the iliac crest; hip girth (H) is measured at the greatest circumference at the 
level of the greater trochanters. The ratio of W/H is normal for females if less than 
0.85.  
 
B. Body composition:  Body composition will be estimated by bioelectric 
impedance analysis performed with a hand-held device (Omrons HBF-360 body 
Fat Analyzer).   
 
            5.2.5   Performance Status based on Karnofsky Scale (Appendix F). 
 
5.2.6   Gail score will be calculated (Appendix D). 
 
Gail score:  Age, race, age at menarche, age at first live birth, number of first degree 
relatives with breast cancer, number of breast biopsies and presence of atypical ductal 
hyperplasia will be entered into a Gail score calculation program.  The resulting score 
represents a patient’s 5-year cumulative risk of breast cancer.  A risk greater than 
1.66% is the threshold for chemoprevention trials. 
 
 5.2.7   Study drug dispensed 
 
Four 250 mg capsules of LEAG will be dispensed for every day of  treatment 
expected (5-14 days) based on the scheduled surgery date. 
 
 
5.3  Treatment Regimen 
 
5.3.1  Patients will be treated with ginseng for 5 to 14 days prior to surgery.  The final 
 
dose of LEAG will be administered the day prior to surgery as surgical patients 
 
are asked to abstain from food and drink (excluding water) over night prior to 
 
surgery. 


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5.3.2  Patients will take four, 250mg tablets daily. 
 
5.3.3  Patients will be given a drug diary to record dates of ginseng therapy in order to 
monitor compliance. 
 
5.3.4  Because ginseng has a rare risk of lowering the blood sugar level, patients with      
          diabetes (as defined by the American Diabetes Association) will be encouraged to 
 
use their home blood glucose machine to monitor  their blood sugar twice a day 
 
during treatment and report any readings less than 60.  Patients without a home 
 
monitoring device will be instructed to report any signs or symptoms of 
 
hypoglycemia  such as lightheadedness, sweating or confusion.  Patients will be 
 
provided a diary to track their twice daily glucose checks. 
 
5.3.5  Because ginseng has been reported to alter blood pressure and heart rate, patients 
 
being treated for hypertension will be encouraged to report any changes of blood 
 
pressure greater than 20 mmHg increase from baseline.  Patients should be  
 
encouraged to have blood pressure readings daily.  Patients will be provided with 
 
a diary (Appendix I) and a blood pressure monitoring system to record daily blood 
           pressure measurements.  If preferred, patients may use their own home                  
           monitoring device or use a monitor found at a local drug store.   
 
   
5.4  Interim Phone Call 
 
 
All patients will be contacted within 48-72 hours by telephone (or in-person if 
 
more convenient for patient) of starting medication to assess any adverse events.  
 
Any adverse events will be reported to the principle investigator for review and 
 
assessment. 
 
 
 
5.5  Day of Surgery Visit 
 
5.5.1  Repeat fasting lab work. 
 
5.5.2  Obtain tissue samples during scheduled surgery. 
 
5.5.3  Review and complete drug accountability and calculate compliance.  Collect Ginseng  
             medication diary and any unused study drug. 
 
5.5.4  Obtain vital signs. 
 
5.5.5  Complete performance status evaluation. 


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5.5.6  Review and complete adverse event log. 
 
5.5.7  Review and record concomitant medications. 
 
5.5.8  Collect, review and record blood pressure and/or blood sugar diaries (Appendix I), if  
                        indicated. 
 
 
5.6  Follow-up Post Surgery Visit 
 
5.6.1  Adverse events will be collected through the post-surgery follow-up visit and all 
related or possibly related adverse events for at least 30 days following the last dose 
of LEAG and continue to be followed until all adverse events have resolved or 
stabilized (Grade 2 or less by CTCAE vs. 3.0). 
 
5.6.2  Obtain vital signs and perform physical exam. 
 
5.6.3 Performance status will be completed. 
 
5.6.4    Duration of follow up   
 
    
 
 
Patients will be followed until the post-surgery follow-up visit (generally 10-20  
 
 
 
 
days) following surgical resection.  All related or possibly related adverse events  
 
 
 
 
will be followed for 30 days from the final dose of LEAG or until resolution or  
 
 
 
 
stabilization (Grade 2 or less) of adverse event. Patients removed from study   
 
 
 
 
for  unacceptable adverse events will be followed until resolution or stabilization  
 
 
 
 
of the adverse event. 
 
 
5.7 Study Role-Out: Additional Procedures for the First 5 Patients 
 
Additional procedures will be conducted to evaluate the effects of LEAG on platelet function. 
The first 5 patients enrolled will have platelet function assessed prior to surgery with an interim 
analysis of platelet function and bleeding complications prior to additional patient enrollment to 
determine if platelet function should be evaluated in all study patients. After 5 patients have 
completed the study protocol a safety meeting will convene to determine if pre-operative 
assessment of platelet function is needed in all study patients. The following procedures have 
been added for the first five patients.  
 
 
 
5.7.1 
Added Exclusion Criteria 
• Role-out patients taking aspirin, other anti-coagulants, or anti-platelet aggregate 
are excluded at this time.  Platelet Function Assay -100 may be affected by anti-
coagulant use.  


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5.7.2 Added Pre-LEAG Administration Laboratory Test 
• Platelet Function Assay-100 test ( 2 citrate tubes of blood prior to taking LEAG) 
 
5.7.3 Added post-LEAG but pre-surgical laboratory test 
• Repeat Platelet Function Assay-100 test prior to surgery (2 citrate tubes of blood 
drawn day of surgery) 
 
 5.7.4   Interim Analysis of Platelet Function Assay completed following completion of 5 
subjects.  All PFA-100 results were within normal limits.  Recommendations 
from Data Review Team state that further Platelet Function Assay testing is not 
necessary. 
 
6.0 GINSENG THERAPY 
 
6.1  Summary 
 
• LEAG, 1 gram (4 capsules) by mouth daily taken with food in the morning. 
• All patients will receive a minimum of 5 days and a maximum of 14 days of treatment 
with LEAG for treatment prior to surgical therapy.  
• The final dose of LEAG will be taken the day prior to surgery to satisfy the fasting 
recommendation prior to surgery. 
 
6.2  Study Agent 
  
The investigational agent is a clear gelatin capsule containing 250 mg of lyophilized water- 
extract of American Ginseng root. The lyophilized extract is a white powdery substance that can 
be seen through the clear gelatin capsule. The capsule is intended for oral use and does not 
contain any active or inactive substances other than the lyophilized water-extract of American 
Ginseng root. For additional information on general use of all types of ginseng, please see the 
Customized Monograph published by Clinical Pharmacology (Appendix G) and the 
Investigator’s Brochure. 
 
 
6.3 Preparation 
 
No preparation needed.  
 
6.4 Mechanism of Action 
 
The major active components of ginseng are the ginsenosides found within the compound.  
Ginsenosides, also called panaxosides, are triterpenoid saponin glycosides.  Asian ginseng 
contains up to 13 different ginsenosides which may have opposing actions on one another. Small 
animal tests have indicated that the active components of ginseng can prolong exercise time, 


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stimulate protein synthesis, inhibit platelet aggregation, stimulate the proliferation of hepatic 
ribosomes, prevent stress-induced ulcers, and increase the activity of interferons (clinical 
pharmacology).  The antiplatelet effect appears to be a result of the activity of panaxynol and 
ginsenosides Ro, Rg1, and Rg2.  Enhanced nitric oxide production in the lung, heart, and kidney, 
as well as the corpus cavernosum has been proposed as a mechanism of action. Various glycans 
have demonstrated a hypoglycemic effect in normal mice (clinical pharmacology).  The 
ginsenosides found within the gelatin encapsulated lyophilized water-extract of American 
Ginseng root used in this study are as follows:  
 
 
Ginsenosides per gram of Gelatin Encapsulated lyophylized water-extract of American Ginseng 
Root 
 
 
 
 
 
 
 
 
Ginsenoside 
mg 
Rg1 
2.38 
Re 
16.3 
Rf 
0 
Rb1 
25 
Rc 
4.60 
Rb2 
0.81 
Rd 
7.75 
Total  
40.04 
 
 
6.5  Administration Guidelines  
 
Patients will be instructed verbally on the administration of gelatin encapsulated lyophilized 
water-extract of American Ginseng root.   
 
The study agent will be self-administered in an open-label, unblinded manner to all patients 
enrolled in the study.  During the treatment period, patients will receive 1 gram (4 capsules) of 
LEAG each day.  Capsules should be taken at approximately the same time daily.  To reduce the 
insomnia and hypoglycemic effects, LEAG administration is recommended with breakfast.   
 
Patient must complete at least 5 days of treatment with LEAG prior to day of surgery. LEAG will 
be dispensed to the patient on the last clinic visit prior to the scheduled date of surgery.  
Treatment with study medication will be initiated 5 to 14 days prior to surgery and end the night 
before surgery. If the patient is not seen in clinic the day that study drug is to be initiated, a 
reminder telephone call will be made to the patient.  A capsule count will be taken the day of 
surgery.  
 


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Patients will be given a drug diary to record dates of ginseng therapy in order to monitor compliance. 
 
 
6.6  Duration of Therapy  
 
In the absence of treatment delays due to adverse event(s), treatment may continue for 14 days or 
until one of the following criteria applies: 
 
• Intercurrent illness that prevents further administration of treatment, 
 
• Unacceptable adverse event(s) or toxicity of grade 3 or higher, 
 
• Patient decides to withdraw from the study, or 
 
• General or specific changes in the patient’s condition that render the patient  
unacceptable for further treatment in the judgment of the investigator. 
 
6.7  Dose Reductions  
 
Reported adverse events and potential risks are described in Section 7.  If LEAG therapy is 
discontinued prior to surgery, blood levels of LEAG will not be drawn on the day of surgery but 
the breast tissue will be studied for immunohistochemistry, in situ TUNEL, and oxidative stress 
as described.  Dose reductions of LEAG are not permitted. 
 
6.8  Storage and Accountability 
 
 
All study material should be stored at room temperature and out of direct light.  LEAG will be 
supplied to the patients in white opaque bottles with child resistant closures. The study agent 
required for completion of this study has been provided by Dr. Murphy’s laboratory at Southern 
Illinois University.  The Clinical Research Office will document receipt and dispensation of 
study agent on the accountability log (Appendix H) in accordance with regulations.  
 
Agent Inventory Records – The investigator, or a responsible party designated by the 
investigator, must maintain a careful record of the inventory and disposition of the American 
Ginseng.  Dispensation of drug to each individual patient must be recorded on the accountability 
log (Appendix H). 
 
 
6.9  Availability 
  
The American Ginseng root has been obtained from the Ginseng Board of Wisconsin and 
analyzed for content by consumerlab.com.  The extraction process was performed by Dr. 
Murphy’s Laboratory at Southern Illinois University prior to analysis. American Ginseng will 
only be available through the Clinical Research Office of the Simmons Cancer Institute at SIU 


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School of Medicine.   The investigational agent will be stored at room temperature in a locked 
cabinet. 
 
7.0   Risks/ Precautions 
 
7.1  Contraindications/Precautions 
 
• 
Ginseng is generally well tolerated when taken orally.  Various sources indicate that long 
term use should be limited to 3 months. 
• 
The most common side effects reported include headache, nervousness/anxiety, sleep 
disturbances, and gastrointestinal disturbances. 
• 
Estrogenic effects, such as breast tenderness and vaginal bleeding have been reported 
though not well substantiated.  
• 
Reports of changes in blood pressure and blood sugar levels indicate that individuals 
being treated for hypertension and/or diabetes should use ginseng with caution. 
• Ginseng has been reported to interact with coumadin. Use with coumadin should be 
closely monitored.  
 
 
7.2  Concomitant Medications 
 
Because there is a potential for interaction of American Ginseng with other concomitantly 
administered drugs, the case report form must capture the concurrent use of all other drugs, over-
the-counter medications, and alternative therapies.   
 
 All medications currently being taken by the subject (including over the counter                           
 medications and herbal supplements) need to be entered into the Concomitant Medication           
 Log for each subject.  Concomitant medications will be monitored from enrollment into the 
study through the post-surgery visit.  The information collected will include dates of 
administration, dosage, and form. 
 
 
7.3  Prohibited Concomitant Medications 
 
  
7.3.1 Products Containing Ginseng 
 
• All products containing or claiming to contain any form of ginseng product 
including oral and external application products are prohibited from use during 
this study and for six weeks prior to initial biopsy.  
 
7.3.2 Coumadin 
 


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• Due to a report concerning the possible interaction between coumadin and 
ginseng, patients currently being treated with coumadin are ineligible for the 
study. 
 
All other medications, prescription, and over the counter, that affect platelets 
and/or clotting functions should be used with caution. 
 
7.3.3 Herbal Supplements and Alternative Medications not approved by the FDA. 
 
• All Herbal Supplements and Alternative Medications not approved by the FDA 
including oral and external application products are prohibited from use during 
this study and for six weeks prior to initial biopsy. 
 
 
7.3.4  Aspirin, other anti-coagulants, and anti-platelet aggregates 
 
• Aspirin and other anti-coagulants are only prohibited in the first 5 role-out 
patients until the effects of LEAG on platelet function can be assessed.  
 
 
8.0 ASSESSMENT INSTRUMENTS 
 
8.1 Gail score (Appendix D) 
 
Age, race, age at menarche, age at first live birth, number of first degree relatives with breast 
cancer, number of breast biopsies and presence of atypical ductal hyperplasia will be entered into 
a Gail score calculation program (Appendix D) (National Cancer Institute Breast Cancer Risk 
Assessment Tool online calculator at www.cancer.gov/bcrisktool/).  The resulting score 
represents a patient’s 5-year cumulative risk of breast cancer.  A risk greater than 1.66% is the 
threshold for chemoprevention trials. 
 
 
8.2 Tecumseh Occupational and Minnesota Leisure Time Activity Questionnaires 
(Appendices A and B) 
 
Both occupational and leisure time exercise exposure for the prior 12 months will be measured 
by the Tecumseh and Minnesota occupational and leisure time activity questionnaires. The 
validity and reliability of the Tecumseh Occupational Activity Questionnaire (43) has been 
documented by Ainsworth (44, 45).  Leisure time physical activity will be measured by the 
Minnesota Leisure Time Activity Questionnaire which has also been previously tested for 
validity and reliability and is a well-accepted measurement tool (43).  Of note, the use of the 
Tecumseh and Minnesota Occupational and Leisure Time Surveys allow for calculation of 
energy expenditure.  Specifically, each activity recorded on the survey will be assigned a 
calculated metabolic equivalent (MET) value based on the published compendium of physical 


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activity (46).  This MET value will be multiplied by the number of hours spent in each activity 
per week (i.e. METs x hrs/wk). This variable (METs x hrs/wk) will then be analyzed for the 
study group as a continuous variable and in quartiles.   
 
8.3 National Cancer Institute Dietary History Questionnaire (Appendix C) 
 
The current proposal will utilize the Dietary History Questionnaire (DHQ) developed by the Risk 
Factor Monitoring and Methods Branch (RFMMB) of the National Cancer Institute. The Eating 
at America’s Table Study conducted by the RFMMB compared their new DHQ with the previous 
standard Block and Willet food frequency questionnaires (FFQs). The DHQ performed best of all 
in a randomized sample of 1,640 men and women (47). The DHQ is a self-administered 
questionnaire that represents a refinement over the RFMMB Block FFQ, with improved 
comprehension across various economic and ethnic groups and increased attention to dietary 
constituents of interest in disease prevention: fiber, energy, carotenoids and vitamin A, E and C. 
The questionnaire will be entered into an ASCII text file and analyzed using Diet*Calc Version 
1.2 free downloadable software. Energy intake (kcal/kg), refined carbohydrate, fat, and fruit and 
vegetable intake (% of total intake) will be analyzed as continuous variables and by quartiles.  
 
 
9.0 LABORATORY TESTS  AND  METHODS 
 
9.1 Blood Collection 
 
Collection of blood for inflammatory mediators and HOMA index must occur within 2 weeks of 
treatment.  Participants will have blood drawn prior to starting ginseng and on the day of             
surgery. 
  
 
A. 
Fasting Blood Draw (NPO after midnight):  
 
1. Draw 40 cc blood from a vein into vacutainer tubes:  6mL in EDTA, 6mL in Na 
Heparin, 5mL in clot activator tube, and 24mL in serum tubes.   (Serum tubes to 
be refrigerated (4˚C) until centrifuged, and then serum will be aliquoted into 1ml 
cryotubes).   
 
2. An additional 2 tubes of blood with citrate will be drawn on the first five patients 
for the Platelet Function Assay-100. – See section 5.7.4 
 
3.  Serum for ginsenoside levels and inflammatory proteins stored in   -80˚C freezer in 
lab prior to shipping to Carbondale laboratory. 
 
4.  Analyze serum for HOMA index, leptin, ghrelin, adiponectin, and angiopoietin.  
 


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5.  Analyze serum for gRc and gRh2, IL1b, IL6, IL8, MCP-1, TNFa, HGF, NGFb, 
insulin, leptin.  
 
 
B. Inflammatory Serum Protein Panel (LINCOplex) and Serum Adipokine Panel 
 
Serum levels of TNFa and IL6 are elevated in patients who are obese or hyperinsulinemic 
and play an important role in the pathogenesis of type II diabetes. These serum markers 
also declined in insulin-resistant individuals who participated in an exercise program 
(48). In a study of adipokine expression in cancer patients, breast and colorectal cancer 
patients had blood plasma levels of insulin, TNF-alpha and breast epithelial expression of 
estrogen and progesterone receptors higher than controls. In the same study, breast cancer 
patients, but not colorectal cancer patients, had plasma levels and adipose tissue 
expression of leptin significantly higher than controls, associated with elevated values of 
estrogen and progesterone-receptors (49).  These serum markers can be assayed 
simultaneously in a multiplex immunoassay (human adipokine panel B, LINCO, St. 
Louis, MO) using Luminex technology. The assay will be performed by the SIU Cancer 
Institute Molecular Core Facility.  Serum adipokine levels of breast cancer patients before 
and after ginseng treatment will be compared. Serum will be collected and stored at -
80°C until the assay is performed. 
 
High serum angiopoietin-2 levels have been associated with tumor burden, stage of 
disease, and metastatic spread. Pre-LEAG serum levels will be compared with post-
LEAG serum levels of enroll patients. ELISA assays will be use to batch the samples and 
perform angiopoiten-2 analysis.  
 
 
C.  High performance Liquid Chromatography-Mass Spectrophotometry 
 
The concentrations of G2, grh in serum will be measured using liquid chromatography 
followed by tandem mass spectrometry. This combination is able to provide excellent 
sensitivity, speed and offers positive compound identification through the use of multiple 
reaction monitoring (MRM).  Prior to analysis, samples of gRc and gRh2 will be analyzed 
using tandem mass spectrometry to determine the characteristic fragmentation pattern of 
each compound.  During analysis, the mass spectrometer will be set up to monitor only 
signals corresponding to the molecular weights of the two compounds of interest.  The 
instrument will then fragment each compound and indicate whether the fragmentation 
pattern matches the previously recorded one.  This method is used often for monitoring 
specific compounds in complex samples, such as the detection of steroid use in athletes.  
It provides a positive identification through accurate mass measurement followed by a 
characteristic fragmentation pattern. Absolute quantification is calculated by either 
measuring a calibration curve with known samples or by using an internal standard. 
 
 


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         D.  Risks and side effects for Blood Tests 
 
Likely 
Unlikely 
• 
Slight discomfort and/or pain when drawing 
blood 
• 
Bruising at the site  
• 
Minor bleeding at the site (just after sample is 
drawn) 
• 
Infection at the site  
• 
Fainting 
 
 
 
           E. Immunocytochemistry 
 
Unstained paraffin-embedded sections from the diagnostic biopsy and the resected specimen 
including tumor and histologically normal breast epithelium will be subjected to 
immunostaining using a streptavidin-peroxidase technique. Briefly, permeabilized sections 
will have endogenous peroxidase activity blocked with 1X blocking solution (Kirkegaard & 
Perry Laboratories, Gaitersburg, MD) and the antigen unmasked by incubating in 10mM 
citrate buffer, pH 6.0 for 5 min at 95° C and rinsing with TBS.  Nonspecific binding of the 
secondary antibody will be blocked with normal goat serum for 15 min, then sections will be 
incubated with a 1:50 dilution of rabbit anti-human COX-2 polyclonal antibody (Santa Cruz 
Biotechnology, Inc., Santa Cruz, CA), or cyclin D1 (Labvision).  Immunoperoxidase staining 
will be performed using a biotin/strepavidin peroxidase complex (HistoMark Kirkegaard & 
Perry Laboratories, Gaitersburg, MD) and DAB substrate (Research Genetics, Huntsville, 
AL). Sections will be counterstained with hematoxylin.  Fetal kidney tissue will be used as a 
positive control, and the primary antibody will be replaced with normal rabbit serum as a 
negative control. The ER, PR, and Ki67 staining will be done in the pathology department of 
the hospital where the diagnostic biopsy was performed, in order to optimally compare 
baseline and treated tumor.  
 
 
F.  In situ TUNEL 
 
Unstained paraffin-embedded sections from the diagnostic biopsy and the resected 
specimen including tumor and histologically normal breast epithelium will be assayed for 
apoptosis by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-
labeling (TUNEL).  5 µm sections will be deparaffinized and rehydrated in ethanol 
followed by an antigen retrieval step consisting of boiling in 0.01 M sodium citrate buffer 
for 2 min.  Sections will be incubated with proteinase K (6.2 µg/ml; Boehringer 
Mannheim, Indianapolis, IL) followed by TdT (300 enzyme units/ml, Pharmacia Biotec, 
Piscataway, NJ) and Bio-14-dATP (0.94nM, GIBCO-BRL, Life Technologies). 
Biotinylated ATP will be detected using the ABC staining method (Vector Laboratories). 
As a positive control, slides will be pre-treated with DNase (20K units/ml; Sigma 
Biosciences, St. Louis, MO). Cells will be counted as TUNEL-positive if their nuclei 


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fluoresce and display typical apoptotic morphology with chromatin condensation. The 
number of apoptotic cells will be defined as the number of TUNEL-positive cells per 
field after counting 20 sequential fields at 250X. 
 
 
G.  Assessment of oxidative stress by MDA Assay 
 
This assay will be used to determine the amount of lipid peroxidation by the 
malondialdehyde (MDA) levels as described by Ohkawa (50). Approximately 1 gm of 
tumor and normal breast tissue will be harvested, weighed and homogenized with a glass 
homogenizer in 1:10 wt:wt PBS. BHT will be added to the homogenates to arrest further 
oxidation and the homogenates will be stored at -80°C. The homogenates will then be 
analyzed for thiobarbituric acid reactive substances (TBARS) using commercially 
available assay kit from Zeptometrix.  Briefly, mammary homogenate will be added to 
8.1% SDS and vortexed.  Thiobarbituric acid will then be added and placed in 95° C 
water bath for 60 minutes.  The samples will be cooled to room temperature and 
centrifuged at 3000 rpm for15 minutes. Supernatants from experimental samples and 
MDA standards will be measured by fluorescence excitation at 530 nm and emission at 
550 nm. 
 
 
 
9.2 Pathology Studies 
 
 
9.2.1. Tissue Needed 
 
• 10gm segment of grossly normal tissue processed for paraffin  
      embedded slides                           
 
• 10gm segment of tumorous tissue processed for paraffin embedded 
                        slides  
 
 
 
• Pathology slides stained for ER, PR, Ki67 and inked for margins 
 
• Unstained sections processed for SIU lab for cyclin D1 and cyclin D2,   
                        COX-2, and TUNEL 
 
9.2.2  Procedure 
 
On the day of surgery, the breast tissue will be submitted to the pathologist and 
inked for margins per routine. The tissue will be sectioned and margins studied per 
routine. From the grossly normal breast tissue that would be otherwise discarded, a 
20 gm segment will be frozen for oxidative stress MDA assay, and a 10 gm segment 
will be processed for paraffin-embedded slides. The tumor will be processed as 
paraffin-embedded slides per routine diagnostic stains.  Tumor and normal breast 


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slides will be stained for ER, PR, and Ki-67 in the pathology dept of the hospital 
where the surgery takes place. Unstained paraffin sections of tumor and normal 
breast will be allocated to Dr. Peralta’s lab for immunohistochemical staining for 
cyclin D-1, cyclin D-2, COX-2 and TUNEL. These sections will be cut from tissue 
remaining in paraffin blocks after adequate diagnostic studies have been completed. 
 
 
 
10.0 CRITERIA FOR REMOVAL FROM STUDY  
 
Patients will be removed from study when any of the criteria listed in Section 7.3 applies. The 
reason for study removal and the date the patient was removed must be documented in the Case 
Report Form. 
 
Noncompliance 
Patient noncompliance of study medication will be defined as the patient voluntarily taking fewer 
than 80% of their assigned study medication.  For example, out of 10 days of therapy the patient 
would need to miss at least 3 doses to be noncompliant.  Temporary discontinuation of the 
investigational product by a physician’s order due to adverse events or disease complication does 
not constitute non-compliance. 
 
 
 
11.0 ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS  
 
11.1 Adverse Event Characteristics  
 
• 
CTCAE term (AE description) and grade:  The descriptions and grading scales 
found in the revised NCI Common Terminology Criteria for Adverse Events 
(CTCAE) version 3.0 will be utilized for AE reporting.  All appropriate treatment 
areas should have access to a copy of the CTCAE version 3.0.  A copy of the 
CTCAE version 3.0 can be downloaded from the CTEP web site 
(http://ctep.cancer.gov). 
 
• 
“Expectedness”:  AEs can be ‘Unexpected’ or ‘Expected’  
 
• 
Attribution of the AE: 
- 
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. 
 
11.2 Adverse Event (AE) Reporting 
 
An adverse event is any untoward medical occurrence in a patient that does not necessarily have 


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a causal relationship with the study intervention.  An AE can, therefore, be any unfavorable and 
unintended sign (including an abnormal laboratory finding), symptom or disease temporarily 
associated with the use of a medical treatment or procedure (attribution of unrelated, unlikely, 
possible, probable, or definite). 
 
Adverse events will be reported once treatment with the study agent begins to the Chairperson of 
the Springfield Committee for Research Involving Human Subjects (SCRIHS) at Southern 
Illinois University School of Medicine, 801 N. Rutledge Street, Springfield, IL 62702, telephone 
number: 217/545-7936.   
 
Submission requirements of AE’s, as defined by the SCRIHS procedure manual, will be strictly 
adhered to. 
 
Adverse events that are expected and outlined in the pre-op discussion and/or listed in the  
surgical consent as related to surgery or anesthesia will not be reported. 
 
 
 
11.3 Safety Reporting Requirements for IND Holders 
 
In accordance with 21 CFR 212.32, sponsor-investigators of studies conducted under an IND 
must comply with following safety reporting requirements:  
 
1. Expedited IND Safety Reports: 
 
• Seven Calendar-Day Telephone or Fax Report 
   
The Sponsor-Investigator is required to notify the FDA of any fatal or life-
threatening adverse event that is unexpected and assessed by the investigator to 
be possibly related to the use of LEAG.  An unexpected adverse event is one 
that is not already described in the Investigator Brochure.  Such reports are to be 
telephoned or faxed to the FDA within seven calendar days of first learning of 
the event.  Each telephone call or fax transmission (see fax number below) 
should be directed to the FDA new drug review division in the Center for Drug 
Evaluation and Research or in the product review division for the Center for 
Biologics Evaluation and Research, whichever is responsible for the review of 
the IND. 
 
• 15 Calendar-Day Written Report 
   
The Sponsor-Investigator is also required to notify the FDA and all participating 
investigators, in a written IND Safety Report, of any serious, unexpected AE 
that is considered possibly related to the use of LEAG.  An unexpected adverse 
event is one that is not already described in the Investigator Brochure. 
 


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Written IND Safety Reports should include an Analysis of Similar Events in 
accordance with regulation 21 CFR § 312.32.  All safety reports previously filed 
with the IND concerning similar events should be analyzed.  The new report 
should contain comments on the significance of the new event in light of the 
previous, similar reports.   
 
Written IND safety reports with Analysis of Similar Events are to be submitted 
to the FDA and all participating investigators within 15 calendar days of first 
learning of the event.  The FDA prefers these reports on a MedWatch 3500A 
Form but alternative formats are acceptable (e.g. summary letter). 
 
FDA fax number for IND Safety Reports: 
 
1-800-FDA-0178  (1-800-332-0178) 
 
 
 
MedWatch 3500A Reporting Guidelines 
 
 
In addition to completing appropriate patient demographic and suspect medication 
information, the report should include the following information within the Event 
Description (Section 5) of the MedWatch 3500A form: 
 
•    Treatment regimen (dosing frequency, combination therapy, administration  
 
    dates); 
•    Protocol description (and number, if assigned); 
• Description of event, severity, treatment, and outcome, if known; 
•    Supportive laboratory results and diagnostics; and  
•    Investigator’s assessment of the relationship of the adverse event to each  
 
              investigational product and suspect medication.  
 
11.4 IND Annual Reports 
 
In accordance with the regulation 21 CFR § 312.32, the Sponsor-Investigator shall 
within 60 days of the anniversary date that the IND went into effect, submit a brief 
report of the progress of the investigation.  Please refer to the Code of Federal 
Regulations, 21 CFR § 312.32 for a list of the elements required for the annual report.   


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12.0  STUDY CALANDER 
 
  
Screening 
Study Visit 
One 
Follow-up Phone 
Call 
Study Visit Two 
Study Visit Three 
Informed Consent 
 
X 
 
 
 
 
LEAGA, 
 
X-----------------------------------------------------X 
 
Surgery 
 
 
 
X 
 
Demographics 
X 
 
 
 
 
 Medical History and Physical 
X 
 
 
 
X 
Vital Signs 
X 
X 
 
X 
X 
Concurrent Medications 
X 
X---------------------------------------------------------------------------------X 
Height 
X 
 
 
 
 
Weight 
X 
 
 
 
 
Body mass Index 
 
X 
 
 
 
Performance Status 
X 
X 
 
X 
X 
Waist Hip Ratio 
 
X 
 
 
 
Body Composition 
 
X 
 
 
 
Gail Model Risk Assessment 
 
X 
 
 
 
NCI Dietary Questionnaire 
 
X 
 
 
 
Tecumseh Questionnaire 
 
X 
 
 
 
Minnesota Questionnaire 
 
X 
 
 
 
Fasting Blood Draw for 
Laboratory StudiesB 
 
X 
 
X 
 
Platelet Function Assay-100G 
 
X 
 
X 
 
Adverse Event Evaluation 
 
X--------------------------------------------------------------------------------------X 
Radiologic EvaluationC 
X 
 
 
 
 
Tissue Collection 
X 
 
 
X 
 
Pregnancy testD 
X 
 
 
 
 
HbA1c/ Blood glucoseE 
X 
 
 
 
 
DiaryF 
 
 
 
 
 
Capsule CountH 
 
 
 
X 
 
A: LEAG must be taken for a minimum of 5 days and no more than 14 days.  Final dose to be taken day prior to surgery.  Patients 
are required to keep a Ginseng medication diary. 
B: Patients must be NPO after midnight. Draw 40 cc of blood from a vein into vacutainer tubes:  6mL in EDTA, 6mL in Na 
Heparin, 5mL in clot activator tube, and 24mL in serum tubes.. Refrigerate serum tubes at 4˚C until centrifugation for serum 
collection and storage. 
C: All radiologic evaluations must be completed within 6 weeks of treatment. (mammogram, ultrasound, and MRI are acceptable) 
D: Urine pregnancy test for patients of child bearing potential. 
E: Only required in diabetic patients. If an HbA1c has not been conducted within 60 days, a fasting blood glucose finger stick of < 
140 mg/dl for 3 consecutive days will be allowed as a substitute for verification of control. 
F: Patient must be given a diary for blood pressures and/ or blood glucose by finger stick if they are being treated for hypertension 
or have been diagnosed with diabetes, respectively. Diaries need only be kept while patient is actively on LEAG (5-14 days). 
Diaries to be returned to research nurse on day of surgery.  
G: The Platelet Function Assay-100 test is only conducted on the first 5 patients enrolled.  Draw 2 – 2.7mL citrate tubes.   
H:  Patients are required to keep a Ginseng medication diary.  The diary and pill bottle should be returned the day of surgery. 


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13.0 DEFINITIONS OF MEASUREMENT  
 
13.1  Diagnostic Disease Parameters for Inclusion in Study 
 
• Measurable disease 
 
Measurable lesions are defined as those that can be accurately measured in at least 
one dimension (longest diameter to be recorded) as >0.5 cm with conventional 
techniques (mammography, MRI, ultrasound).  All tumor measurements must be 
recorded decimal fractions of centimeters. 
 
•  Non-measurable disease  
 
                        All lesions <0.5 cm using mammography, MRI or ultrasound, are considered non- 
                        measurable disease.   
 
All measurements should be taken and recorded in metric notation using a ruler or 
calipers.  All baseline evaluations should be performed as closely as possible to 
the beginning of treatment and never more than 6 weeks before the day of surgery. 
 
• Mammogram   
 
 
Lesions on mammogram films are acceptable as measurable lesions when they are 
 
clearly defined and surrounded by fatty breast tissue. 
 
• Ultrasound (US) 
 
Ultrasound measurement of tumor is an adjunct to the clinical measurement of 
palpable breast tumors and lymph nodes and to the mammographic measurement 
of tumor.  When the clinically palpable lesion is larger than the US image, the 
clinical measurement is primary. 
 
• Magnetic Resonance Imaging (MRI) 
 
14.0 DATA REPORTING / REGULATORY CONSIDERATIONS 
 
 
14.1 Adverse Events 
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in  
Section 11.0 (Adverse Events: List and Reporting Requirements). 
 
 


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14.2 Institutional Review Board Approval 
This protocol, the informed consent document, and relevant supporting information must  be 
submitted to the IRB for review and must be approved before the study is initiated.  In addition, 
any advertising materials must be approved by the IRB.  The study will be  conducted in 
accordance with U.S. FDA, applicable national and local health authority, and IRB requirements. 
The Principal Investigator is responsible for keeping the IRB apprised of the progress of the 
study and of any changes made to the protocol as deemed appropriate, but in any case, the IRB 
approval must be updated at least once a year.  The Principal Investigator must also keep the IRB 
informed of any significant adverse events. 
Investigators are required to promptly notify their respective IRB of all adverse drug reactions 
that are both serious and unexpected.  This generally refers to serious adverse events that are not 
already identified in the Investigator Brochure and that are considered possibly or probably 
related to the study drug by the investigator.  Some IRBs may have  other specific adverse event 
requirements to which investigators are expected to adhere.  Submit IRB information to:  
Erin Campbell 
Southern Illinois University School of Medicine 
801 N. Rutledge 
Springfield, IL 62702 
Phone:  217/545-7602 
E-mail: ecampbell@siumed.edu  
 
14.3 Sponsor and Investigator Requirements  
Sponsors are responsible for selecting qualified investigators, providing them with the 
information they need to conduct an investigation properly, ensuring proper monitoring of the 
investigation(s), ensuring that the investigation(s) is conducted in accordance with the general 
investigational plan and protocols contained in the IND, maintaining an effective IND with 
respect to the investigations, and ensuring that the FDA and all participating investigators are 
promptly informed of significant new adverse effects or risks with respect to the drug. Please 
refer to the Code of Federal Regulations, Title 21, Subpart D, 312.50 through 312.69 at:    
 
 
 
 
 
 
 
 
 
 
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm. 
 
 
14.4 Study Initiation 
 
Before the start of this study the following documents must be on file at the Clinical Research 
Office: 
 


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• U.S. Food and Drug Administration (FDA) Form 1572, signed by the Principal 
Investigator. 
o The names of any sub-investigators must appear on this form.  Investigators must 
also complete all regulatory documentation as required by local regulations. 
• Current curricula vitae and license of the Principal Investigator. 
• Final Protocol and ICF 
• Written documentation of IRB approval of protocol and ICF (identified by title and date 
of approval) for each site. 
• Written documentation from the FDA assigning an IND number to the trial and the 
approval to begin the study. 
 
14.5 Study Completion 
The following data and materials are required to be on file at the Clinical Research Office before 
a study can be considered complete or terminated: 
• Copies of protocol amendments and IRB approval/notification, if appropriate. 
• Copies of the IRB final report/termination document, documentation of submission to 
the IRB and to the FDA. 
• A summary of the study prepared by the Principal Investigator (study report, manuscript 
and/or abstract). 
• All regulatory documents (e.g., updated curriculum vitae for each Principal Investigator, 
updated U.S. FDA Form 1572 for each site). 
14.6 Informed Consent 
The informed consent documents must be signed by the patient, or the patient’s legally 
authorized representative, before his or her participation in the study.  The case history for each 
patient shall document that informed consent was obtained prior to participation in the study.  A 
copy of the informed consent documents must be provided to the patient or the patient’s legally 
authorized representative.  If applicable, they will be provided in a certified translation of the 
local language. 
Original signed consent forms must be filed in the site study binder or in each patient’s study file. 
 
14.7 Data Collection  
 
Patient medical information obtained by this study is confidential, and disclosure to third parties 
other than those noted below is prohibited. Upon the patient’s permission, medical information 
may be given to his or her personal physician or other appropriate medical personnel responsible 


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for his or her welfare. 
 
Data generated by this study must be available for inspection upon request by representatives of 
the U.S. FDA, local health authorities, and their authorized representative(s), collaborators and 
licensees, and the site, if IRB. 
 
All study related data will be kept and locked in the Clinical Research Office at Southern Illinois 
University School of Medicine.  Submission of all study assessments, mammography, blood 
tests, and body composition results along with all case report forms should be submitted to the 
Clinical Research Office (CRO) to be placed in the patients study chart in a timely manner.  The 
case report form completion guidelines are as follows: 
 
 Retention of Records 
 
U.S. FDA regulations (21 CFR §312.62[c]) require that records and documents pertaining to the 
conduct of this study and the distribution of investigational drug, including CRFs, consent forms, 
laboratory test results, and medication inventory records, must be retained by the Principal 
Investigator for two years after marketing application approval.  If no application is filed, these 
records must be kept two years after the study is discontinued and the U.S. FDA and the 
applicable national and local health authorities are notified.   
 
Confidentiality/ Data Collection  
 
Patients will be assigned a unique patient identification number upon enrollment.  Study data and 
results will be kept confidential.  No personal identification will be used in any publications 
resulting from this study.  Results of the baseline and follow-up assessments will be shared with 
the subjects and they can request any data to be sent to their primary care physician. All of the 
data will be collated into a database that will be coded so that individual subjects identities will 
be known only to the investigators.  
 
 
 Analysis of Safety 
 
With respect to the safety goals of this study, toxicities specific to this therapy are not known at   
this time. Therefore, patients will be monitored for unexpected toxicities and if any serious side 
effects are observed, an independent monitoring committee will examine the data and evaluate 
the appropriate course of the study. At the conclusion of the study, all unexpected toxicities will 
be summarized and reported. 
 
To evaluate a potential effect of LEAG on platelet function, a Platelet Function Assay-100 test 
will be conducted on the first five patients enrolled. Platelet function will be assessed prior to 
LEAG administration and prior to surgery on the day of surgery.  All adverse events will be 


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monitored for 30 days beyond the last dose of LEAG, including bleeding complications. 
Following completion of the study protocol by 5 patients the Data Safety Monitoring Committee 
will review the adverse events associated with LEAG administration paying particular attention 
to platelet function. The committee will make a recommendation on continued monitoring of 
platelet function or its removal from required study procedures for the remainder of patients 
enrolled. – See section 5.7.4 
 
 
14.8 Compensation 
 
No benefits will be promised and no rewards for participation will be stated.  Subjects will not 
receive payment for participating in this study.  All medical care will be charged in the usual 
way. LEAG will be provided by the Simmons Cancer Institute at Southern Illinois University 
School of Medicine. Initial and follow-up specialized blood tests strictly required for the study 
and study medication will be provided free of cost.  
 
 
15.0 PARTICIPATING INSTITUTIONS  
 
SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF MEDICINE  
MEMORIAL MEDICAL CENTER  
ST. JOHN’S HOSPITAL 
 
 
 
16.0 STATISTICAL CONSIDERATIONS 
 
Statistical Methods 
 
High variability among tumors in the patient population is anticipated.  Each patient will serve as 
her own control; pre-treatment biopsy tissue will be compared to post-treatment surgical tissue. 
Descriptive statistics including the mean, median, range, standard deviation, interquartile range, 
skewness, and kurtosis will be calculated for each measure.  Paired t-tests, or Wilcoxon signed-
rank tests, depending on the distributional characteristics of the variables, will be used to assess 
changes in biomarkers from biopsy to surgery.  In order to examine the inter-relationships 
between the anthropometric data, the cytological markers, serum ginsenoside concentrations, and 
a panel of inflammatory serum proteins, data visualization techniques will be employed. 
Correlation coefficients will be used to summarize linear relationships between continuous 
measures.  Regression techniques will be used to model nonlinear relationships. All statistical 
procedures will be performed in consultation with the Division of Statistics and Research 
Consulting at SIU School of Medicine.  
 
 
 


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16.1 Sample Size/Accrual Rate 
 
This study is expected to accrue 25 to 50 patients based on the time frame of treatment (5-14 
days). Accrual will take approximately 3 years. 
 


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53. Park J, Park K, Kim Y, et. al. Serum Angiopoietin-2 as a clinical marker for lung cancer. 
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APPENDIX A 
 
 
 
Tecumseh Occupational Physical Activity Questionnaire 


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APPENDIX B 
 
 
 
Minnesota Leisure-Time Physical Activity Questionnaire 


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APPENDIX C 
 
 
 
Dietary History Questionnaire 


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 APPENDIX D 
 
 
 
Gail Score Calculation 


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APPENDIX E 
 
 
 
Certificate of Analysis 
 


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


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APPENDIX G 
 
 
 
Clinical Pharmacology Customized Monograph 


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APPENDIX H 
 
 
 
Drug Accountability Log 


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APPENDIX I 
 
 
 
Patient Diaries