Conditions: Breast Cancer Breast Carcinoma Cancer of Breast Malignant Tumor of Breast
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 55
Healthy volunteers: no

Brief summary:
The investigators propose to conduct a study to test an alternative dosing schedule of palbociclib. With the current three-week on and one week off schedule, a significant number of patients develop grade 3 or higher degree of neutropenia and require dose reduction and sometimes discontinuation. This potentially compromises the efficacy of the drug. In addition, as the half-life of palbociclib is 27 hours, 1 week break with the standard 3 weeks on and 1 week off dosing schedule could potentially lead to recovery of Rb phosphorylation during the off week. Hence, the investigators propose a 5 days on and 2 days off schedule each week without any weeks off drug. Although the cumulative doses each 28-day cycle is roughly the same with this schedule compared to conventional dosing, the bone marrow is not exposed to the drug continuously for 21 days and rather gets frequent breaks from therapy. The investigators hypothesize that the 5 days on and 2 days off schedule is more tolerable with less frequent high grade neutropenia and dose interruption/reduction. In addition, this schedule also provides for a more continuous drug delivery to the patient since there is not a week's break in therapy, which could ultimately prove to be more efficacious.

Detailed description:

Arms:
arm 1: * Palbociclib should be taken by mouth with food on a 5 days on/2 days off schedule (meaning: on Days 1-5, 8-12, 15-19, and 22-26 of each 28-day cycle).
* Patients who are receiving letrozole will take it daily by mouth, every day of each 28-day cycle.
* Patients who are receiving fulvestrant will receive it as two intramuscular injections (one into each buttock) on Days 1 and 15 of Cycle 1 and then on Day 1 of each cycle thereafter.
* Goserelin is given as a subcutaneous injection every 28 days. It is preferred to be given on Day 1 of each cycle, but it may be administered on any day of the treatment cycle to accommodate its specific Q28-day cycle. It will be given to pre- or peri-menopausal women only.
* Optional research biopsy at baseline and progression
* Blood for research at baseline, cycle 1 day 15, cycle 2 day 1, every 2-3 months (to coincide with imaging studies), and time of progression

Interventions: intervention 1: Palbociclib intervention 2: Letrozole intervention 3: Fulvestrant intervention 4: Optional research biopsy intervention 5: Goserelin intervention 6: Research blood draw intervention 7: Circulating tumor cell blood draw intervention 8: Tumor biopsy (optional)
Intervention descriptions: intervention 1: Palbociclib at a dose of 125 mg should be taken by mouth with food on a 5 days on/2 days off schedule intervention 2: Patients who are receiving letrozole will take it daily by mouth, every day of each 28-day cycle, at a dose of 2.5 mg. intervention 3: Patients who are receiving fulvestrant will receive it at a dose of 500 mg as two 5 mL intramuscular injections (one into each buttock) on Days 1 and 15 of Cycle 1 and then on Day 1 of each cycle thereafter. intervention 4: Patients may consent to paired tumor biopsies at baseline and time of progression. intervention 5: Goserelin is given as a subcutaneous injection every 28 days. It is preferred to be given on Day 1 of each cycle, but it may be administered on any day of the treatment cycle to accommodate its specific Q28-day cycle. It will be given to pre- and peri-menopausal women only. intervention 6: -Blood will be drawn at the following time points for serum, plasma, cfDNA, and germline DNA (only at baseline):

* Baseline
* C1D15
* C2D1
* Every 2-3 months thereafter (to coincide with imaging studies)
* Time of progression intervention 7: -Baseline, cycle 2 day 1, post 2 or 3 months of therapy (to coincide with first tumor imaging), and progression intervention 8: -Baseline and progression

Protocol document:
Prot_SAP_000.pdf: 
Protocol Version: 04/12/2019 Amendment #5 
Page 1 of 68 
 
 
A phase II clinical trial assessing the safety of an alternative dosing schedule of palbociclib 
in metastatic hormone receptor positive breast cancer 
 
Washington University School of Medicine 
Division of Oncology 
660 South Euclid Avenue, Campus Box 8056 
St. Louis, MO  63110 
 
Protocol #: 201612098 
Version Date: 04/12/2019 
 
Coordinating Center: 
Washington University School of Medicine 
 
Principal Investigator: 
Cynthia X. Ma, M.D., Ph.D. 
Phone: (314) 362-9383 
E-mail:  cynthiaxma@wustl.edu 
 
Co-Investigators: 
 
Jairam Krishnamurthy, M.D. 
 
 
 
 
University of Nebraska 
 
 
 
 
Phone:  (402) 559-1800 
 
 
 
 
E-mail:  jairam.krishnamurthy@unmc.edu 
 
Rebecca Aft, M.D., Ph.D. 
Washington University School of Medicine 
Department of Surgery 
Phone:  (314) 747-0063 
Email: aftr@wustl.edu 
 
Mark Watson, M.D., Ph.D. 
Washington University School of Medicine 
Siteman Cancer Center Tissue Procurement Core Facility 
 
 
 
Phone: (314) 454-7919 
E-mail: watsonm@wustl.edu 
 
Hsian-Rong Tseng, Ph.D.  
University of California Los Angeles (UCLA) 
Department of Molecular and Medical Pharmacology 
 
 
 
 
Phone: (310) 794 1977 
E-mail: hrtseng@mednet.ucla.edu 
 
 
 


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Sub-Investigators 
 
 
Institution 
 
 
Modality 
Foluso O. Ademuyiwa, M.D.  
Washington University 
Medical Oncology 
Ron Bose, M.D., Ph.D. 
 
Washington University 
Medical Oncology 
Mathew Cherian, M.D. 
 
Washington University 
Medical Oncology 
Ashley Frith, M.D. 
 
 
Washington University 
Medical Oncology 
Lindsay Peterson, M.D. 
 
Washington University  
Medical Oncology 
Leonel Hernandez Aya, M.D.  
Washington University 
Medical Oncology 
Jingqin (Rosy) Luo, Ph.D. 
 
Washington University 
Biostatistics 
Peter Oppelt, M.D. 
 
 
Washington University 
Medical Oncology 
Haeseong Park, M.D.  
 
Washington University 
Medical Oncology 
Carol Rigden, M.D.  
 
Washington University 
Medical Oncology 
Rama Suresh, M.D. 
 
 
Washington University 
Medical Oncology 
Katherine N. Weilbaecher, M.D. 
Washington University 
Medical Oncology 
 
Study Drug(s): 
 
Palbociclib (Ibrance) 
ClinicalTrials.gov #: 
NCT03007979 
 
CONFIDENTIAL 
The information contained in this document is regarded as confidential and, except to the extent necessary to 
obtain informed consent, may not be disclosed to another party unless law or regulations require such 
disclosure.  Persons to whom the information is disclosed must be informed that the information is 
confidential and may not be further disclosed by them 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Protocol Version: 04/12/2019 Amendment #5 
Page 3 of 68 
A phase II clinical trial assessing the safety of an alternative dosing schedule of palbociclib 
in metastatic hormone receptor positive breast cancer 
 
Protocol Revision History 
 
Initial Approval Version 
 
 
 
 
 
 
01/10/2017 
Amendment #1 Version 
 
 
 
 
 
 
03/01/2017 
Amendment #2 Version 
 
 
 
 
 
 
12/05/2017 
Amendment #3 Version  
 
 
 
 
 
 
05/08/2018 
Amendment #4 Version 
 
 
 
 
 
 
02/19/2019 
Amendment #5 Version  
 
 
 
 
 
 
04/12/2019 
 
 


Protocol Version: 04/12/2019 Amendment #5 
Page 4 of 68 
A phase II clinical trial assessing the safety of an alternative dosing schedule of palbociclib 
in metastatic hormone receptor positive breast cancer 
 
Principal Investigator Signature Page 
 
 
Principal Investigator 
(printed): 
      
Name of Institution:       
  
 PI Signature 
 
 
 
 
 
Date 
 
By my signature, I agree to personally supervise the conduct of this study 
and to ensure its conduct in compliance with the protocol, informed 
consent, IRB/HRPO procedures, the Declaration of Helsinki, ICH Good 
Clinical Practices guidelines, and the applicable parts of the United 
States Code of Federal Regulations or local regulations governing the 
conduct of clinical studies. 
 
 
 
 
 


Protocol Version: 04/12/2019 Amendment #5 
Page 5 of 68 
A phase II clinical trial assessing the safety of an alternative dosing schedule of palbociclib 
in metastatic hormone receptor positive breast cancer 
 
SCHEMA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Palbociclib at 125 mg 5 days on/2 days off with standard dose of letrozole or fulvestrant for 
indefinite number of 28-day cycles (until progression). 
 
CBC with differential on C1D15, then on Day 1 of each cycle**. 
 
Dose modification will follow the same guideline as for the conventional dosing, except for 
remaining on the 5 days on/2 days off schedule. 
 
Research serum TK activity at baseline, and prior to palbociclib administration on C1D15, 
C2D1, q2-3 months to coincide with tumor imaging studies, and at progression. 
 
Cell free DNA at baseline, C1D15, C2D1, q2-3 months to coincide with tumor imaging 
studies, and at progression; germline DNA at baseline. 
 
Circulating tumor cells at baseline, C2D1, post 2 or 3 months of therapy (to coincide with 
first tumor imaging), and at progression. 
 
Optional research biopsy at baseline and progression. 
 
**Labs and office visits could be reduced in frequency to q2-3 cycles to coincide with tumor 
imaging studies in patients on stable doses of palbociclib for at least 6 consecutive cycles.  
 
Registration (n=47*) 
*47 evaluable patients are needed for the primary endpoint. Any patient 
who receives a dose of study treatment is evaluable for toxicity. 
Assessment of rate of Grade 3 or higher neutropenia 
 
Assessment of rate of palbociclib dose reduction or discontinuation 
CT scans every 3 months or earlier if clinically indicated 
and to be assessed as per RECIST criteria
Eligible patients: Advanced clinical stage ER+ HER2- breast cancer 


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Table of Contents 
SCHEMA ...................................................................................................................................................................... 5 
1.0 
BACKGROUND AND RATIONALE ............................................................................................................. 8 
1.1 
Hormone Receptor Positive Breast Cancer ................................................................................. 8 
1.2 
Palbociclib (Ibrance) .............................................................................................................. 8 
1.3 
Study Rationale .................................................................................................................. 10 
1.4 
Correlative Studies Background ............................................................................................. 10 
2.0 
OBJECTIVES ................................................................................................................................................ 12 
2.1 
Primary Objective ............................................................................................................... 12 
2.2 
Secondary Objectives ........................................................................................................... 12 
2.3 
Exploratory Objectives ......................................................................................................... 13 
3.0 
PATIENT SELECTION ................................................................................................................................. 13 
3.1 
Inclusion Criteria ................................................................................................................ 13 
3.2 
Exclusion Criteria................................................................................................................ 14 
3.3 
Inclusion of Women and Minorities ........................................................................................ 15 
4.0 
REGISTRATION PROCEDURES ................................................................................................................ 15 
4.1 
Confirmation of Patient Eligibility .......................................................................................... 16 
4.2 
Patient Registration in the Siteman Cancer Center OnCore Database ............................................. 16 
4.3 
Assignment of UPN ............................................................................................................. 16 
5.0 
TREATMENT PLAN .................................................................................................................................... 17 
5.1 
Agent Administration ........................................................................................................... 17 
5.2 
Evaluability ........................................................................................................................ 18 
5.3 
General Concomitant Medication and Supportive Care Guidelines ................................................ 18 
5.4 
Women of Childbearing Potential ........................................................................................... 18 
5.5 
Duration of Therapy ............................................................................................................ 19 
5.6 
Duration of Follow-up .......................................................................................................... 19 
6.0 
DOSE DELAYS/DOSE MODIFICATIONS ................................................................................................. 19 
6.1 
Hormone Therapy Dose Modifications .................................................................................... 19 
6.2 
Ovarian Suppression Dose Modifications ................................................................................. 19 
6.3 
Dose Modifications for Palbociclib ......................................................................................... 20 
6.4 
Re-Treatment Criteria .......................................................................................................... 21 
7.0 
REGULATORY AND REPORTING REQUIREMENTS ............................................................................ 22 
7.1 
Definitions ......................................................................................................................... 22 
7.2 
Reporting to the Human Research Protection Office (HRPO) at Washington University .................... 24 
7.3 
Reporting to the Quality Assurance and Safety Monitoring Committee (QASMC) at Washington 
University ..................................................................................................................................... 24 
7.4 
Reporting Requirements for Secondary Sites ............................................................................ 24 
7.5 
Reporting to Secondary Sites ................................................................................................. 25 
7.6 
Reporting to Pfizer .............................................................................................................. 25 
7.7 
Timeframe for Reporting Required Events ............................................................................... 25 
8.0 
PHARMACEUTICAL INFORMATION ...................................................................................................... 25 
8.1 
Palbociclib (Ibrance) ............................................................................................................ 25 
8.2 
Letrozole (Femara) .............................................................................................................. 31 
8.3 
Fulvestrant (Faslodex) .......................................................................................................... 32 
8.4 
Goserelin ........................................................................................................................... 33 
9.0 
CORRELATIVE STUDIES ........................................................................................................................... 34 
9.1 
Archival Tumor Sample Submission (Mandatory) ..................................................................... 34 
9.2 
Tumor Biopsies (OPTIONAL) ............................................................................................... 35 


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9.3 
Blood for circulating biomarkers including Serum, Plasma, ctDNA and germline DNA .................... 36 
9.4 
Additional blood draw for CTC (circulating tumor cells): ............................................................ 38 
10.0      STUDY CALENDAR .................................................................................................................................... 42 
11.0 
DATA SUBMISSION SCHEDULE .............................................................................................................. 43 
12.0 
MEASUREMENT OF EFFECT .................................................................................................................... 43 
12.1 
Antitumor Effect – Solid Tumors ........................................................................................... 43 
12.2 
Disease Parameters .............................................................................................................. 43 
12.3 
Methods for Evaluation of Measurable Disease ......................................................................... 44 
12.4 
Response Criteria ................................................................................................................ 47 
13.0 
DATA AND SAFETY MONITORING ......................................................................................................... 49 
14.0 
AUDITING .................................................................................................................................................... 50 
15.0 
STATISTICAL CONSIDERATIONS ........................................................................................................... 51 
15.1 
Study Description ................................................................................................................ 51 
15.2 
Sample Size Calculations ...................................................................................................... 51 
15.3 
Data Analysis Plan .............................................................................................................. 52 
16.0 
MULTICENTER REGULATORY REQUIREMENTS ................................................................................ 52 
17.0 
REFERENCES ............................................................................................................................................... 54 
APPENDIX A: ECOG Performance Status Scale ....................................................................................................... 57 
APPENDIX B: PALBOCICLIB MEDICATION DIARY .......................................................................................... 58 
APPENDIX C: LETROZOLE MEDICATION DIARY ............................................................................................. 59 
APPENDIX D: List of CYP3A4 Strong Inhibitors and Inducers ................................................................................ 60 
APPENDIX E: OPERATING PROCEDURE FOR CTC COLLECTION ................................................................. 61 
APPENDIX F: OPERATING PROCEDURE FOR CTC HANDLING/SHIPMENT ................................................. 65 
APPENDIX G:  ARCHIVAL TUMOR SPECIMEN SUBMISSION FORM ............................................................. 68 
 
 


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1.0 
BACKGROUND AND RATIONALE 
 
1.1 
Hormone Receptor Positive Breast Cancer 
 
Hormone receptor positive (estrogen receptor (ER+) and/or progesterone receptor (PR+)) 
breast cancers account for nearly 80% of breast cancer diagnoses. Endocrine therapies are 
the cornerstone of treatment for these cancers. A meta-analysis by the Early Breast Cancer 
Trialists’ Collaborative Group showed that these agents substantially reduce the relapse 
rate and mortality in the adjuvant setting for early stage breast cancers that were ER+ or 
PR+ (1). 
 
In spite of advances in endocrine therapy, a considerable clinical challenge remains in the 
form of many women presenting with systemic relapse of breast cancer either during or 
after completion of adjuvant hormone therapy. In aromatase inhibitor (AI) resistant setting, 
hormonal therapy such as a different AI, tamoxifen or the selective estrogen-receptor down 
regulator fulvestrant, as single agents have shown limited clinical benefit (2-4). Although 
the mTOR inhibitor everolimus has shown to improve PFS in the AI resistant setting, its 
activity is modest and is associated with significant toxicity including mucositis and 
hyperglycemia (5).  
 
Cyclin D1–CDK4–CDK6 (CDK- Cyclin dependent kinase) complex is a key downstream 
effector in ER+ and PR+ breast cancer and retains its function even after development of 
resistance to endocrine therapy (6,7). Targeting CDK4 and CDK6 is an attractive strategy 
to overcome this resistance. 
 
1.2 
Palbociclib (Ibrance) 
 
Palbociclib (Ibrance, Pfizer) is a highly selective small-molecule inhibitor of CDK4 and 
CDK6, which can be administered orally. It results in loss of RB1 phosphorylation in vitro 
and leads to cell cycle arrest at the G1-S phase in ER+ breast cancer (8). While initial phase 
2 studies demonstrated single agent activity in hormone receptor positive breast cancer (9), 
subsequent studies have reported synergistic activity with endocrine therapies in ER+/PR+ 
breast cancer. In preclinical studies, palbociclib was effective in both tamoxifen sensitive 
and resistant ER+ breast cancer cell lines (7).   
 
An open-label randomized phase 2 study involving postmenopausal patients with newly 
diagnosed metastatic ER+ and human epidermal growth factor receptor (Her-2/neu) 
negative breast cancer (PALOMA1), showed that palbociclib in combination with letrozole 
was associated with significantly prolonged PFS when compared with letrozole alone (10). 
This resulted in an accelerated FDA approval of palbociclib for use in this specific patient 
population (11). In this trial, 27 patients in the palbociclib plus letrozole group (33%) had 
dose interruptions because of adverse events, compared with only three (4%) patients in 
the letrozole group. In the combination group, 37 (45%) patients required a delay in the 
start of a subsequent treatment cycle because of an adverse event and 33 (40%) patients 
had a dose reduction. In this study, 11 (13%) patients in the palbociclib plus letrozole group 


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and two (2%) patients in the letrozole group discontinued the study because of an adverse 
event. Of these discontinuations, six (7%) patients in palbociclib plus letrozole group and 
two (2%) patients in the letrozole group discontinued because of treatment-related adverse 
events. 
 
A randomized phase 3 study to confirm the efficacy of palbociclib in combination with 
letrozole in this setting (PALOMA2) was recently reported at ASCO 2016 annual meeting 
and again demonstrated a significant improvement in progression free survival (PFS): 24.8 
(22.1-NR) months in the palbociclib/letrozole arm vs 14.5 (12.9-17.1) months in the 
placebo/letrozole arm, HR 0.58; p<0.000001 (12). Among the 444 patients treated with 
palbociclib and letrozole, neutropenia (any grade) occurred in 80% of patients vs. 6% in 
the placebo/letrozole arm.  The incidence of grade 3 and 4 neutropenia in the 
palbociclib/letrozole arm was 56% and 10%, respectively.  Grade 3 or 4 non-hematological 
AEs were uncommon. 9.7% of patients in the palbociclib/letrozole arm vs 5.9% in the 
placebo/letrozole arm discontinued treatment due to AEs (12).  
 
Most recently, a randomized phase 3 study (PALOMA3) assessed the safety and efficacy 
of the combination of palbociclib and fulvestrant vs placebo and fulvestrant after disease 
progression after prior endocrine therapy in premenopausal and postmenopausal women 
with hormone receptor positive and Her-2/neu negative advanced breast cancer. In this 
study, premenopausal females also received goserelin for ovarian suppression. A 
significantly prolonged PFS was noted with the combination of palbociclib and fulvestrant 
compared with fulvestrant and placebo. The dosing schedule of palbociclib was 125 mg po 
daily for 3 weeks followed by one week off drug (13).   
 
Similar to PALOMA2, most common hematologic adverse events reported for the 
palbociclib–fulvestrant group in PALOMA3 were neutropenia and leukopenia. 
Neutropenia (any grade) occurred in 78.8% of the patients receiving palbociclib–
fulvestrant versus 3.5% in the placebo–fulvestrant group, leukopenia in 45.5% versus 
4.1%, anemia in 26.1% versus 9.9%, and thrombocytopenia in 19.4% versus 0%. Grade 3 
or 4 neutropenia occurred in 62.0% of the patients receiving palbociclib–fulvestrant versus 
0.6% of the patients receiving placebo–fulvestrant, leukopenia in 25.2% versus 0.6%, 
anemia in 2.6% versus 1.7%, and thrombocytopenia in 2.3% versus 0%.   The most 
common nonhematologic adverse events were fatigue, nausea (29.0% vs. 26.2%), and 
headache, all of which were more common in the palbociclib-fulvestrant group. A higher 
incidence of infections was also reported in the palbociclib–fulvestrant group (13).  
 
Palbociclib dose was reduced in 109 of 345 patients (31.6%), whereas the placebo dose 
was reduced in 3 of 172 patients (1.7%). Discontinuation of palbociclib or matching 
placebo owing to adverse events occurred in 9 patients (2.6%) receiving palbociclib and 3 
patients (1.7%) receiving placebo (13).  
 
 


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1.3 
Study Rationale 
 
The current dose modification guidelines for palbociclib are as follows: 
 
CTCAE*  grade 
Dose modifications 
Grade 1 or 2  
No adjustment required 
Grade 3 
No dose adjustment is required. Consider repeating complete 
blood count monitoring one week later. Withhold initiation of 
next cycle until recovery to Grade ≤2 
Grade 3 ANC 
(<1000 to 500/mm3) 
+ Fever > 38.5C 
and/or infection 
Withhold Palbociclib and initiation of next cycle until 
recovery to Grade ≤2 (≥1000/mm3). Resume at next lower 
dose 
Grade 4 
Withhold Palbociclib and initiation of next cycle until 
recovery to Grade ≤2. Resume at next lower dose 
*Common terminology criteria for adverse events 
 
We propose to conduct a study to test an alternative dosing schedule of palbociclib. With 
the current three-week on and one week off schedule, a significant number of patients 
develop grade 3 or higher degree of neutropenia and require dose reduction and sometimes 
discontinuation. This potentially compromises the efficacy of the drug. In addition, as the 
half-life of palbociclib is 27 hours, 1 week break with the standard 3 weeks on and 1 week 
off dosing schedule could potentially lead to recovery of Rb phosphorylation during the 
off week.  Hence, we propose a 5 days on and 2 days off schedule each week without any 
weeks off drug.  Although the cumulative doses each 28-day cycle is roughly the same 
with this schedule compared to conventional dosing, the bone marrow is not exposed to 
the drug continuously for 21 days and rather gets frequent breaks from therapy.  We 
hypothesize that the 5 days on and 2 days off schedule is more tolerable with less frequent 
high grade neutropenia and dose interruption/reduction.  In addition, this schedule also 
provides for a more continuous drug delivery to the patient since there is not a week’s break 
in therapy, which could ultimately prove to be more efficacious. 
 
1.4 
Correlative Studies Background 
 
Serum TK1 activity 
Thymidine kinase-1 (TK1) is an enzyme which plays a critical role in the synthesis of 
DNA.  All human cells express this enzyme during normal cell division through E2F-
dependent transcription with only small amounts of the enzyme released into the serum 
(14,15).  Due to higher rates of replication compared to normal tissues, tumors are capable 
of secreting pathologic levels of TK1 which can be detected via an ELISA assay.  In 
patients with metastatic breast cancer, TK1 expression and activity in human serum, was 
predictive for therapy response and correlated with PFS and OS (16). Given that TK1 
expression is E2F-dependent, we hypothesize that CDK4 inhibitors, if active in a particular 
tumor, would result in reduced serum TK1 activity and can be used as a potential biomarker 


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for the pharmacodynamics effect of CDK4/6 inhibition.  We will also evaluate changes in 
serum TK1 activity in relation to tumor response as an exploratory endpoint in this study. 
 
Cell-free circulating tumor DNA (ctDNA) sequencing 
Plasma samples from cancer patients often carry small amounts of fragmented cell-free 
DNA of 160-180 base pairs, which are originated from the necrosis or apoptotic process of 
cancer cells.  Advances in the next generation sequencing (NGS) technology and digital 
genomic techniques support the clinical validity of cell-free circulating DNA (ctDNA) 
sequencing analysis to non-invasively identify actionable genomic alterations, monitor 
treatment response, and investigate resistance mechanisms (17).  To investigate whether 
ctDNA sequencing could serve as an early predictor of response and provide clues of 
resistance mechanisms, blood for cell free tumor DNA sequencing will be collected before, 
during and at the time of progression to assess changes in the mutation profile including 
PIK3CA, RB1, ESR1, TP53 and others.  These genes are chosen as PIK3CA, TP53 and 
ESR1 are among the most common mutations in AI resistant ER+ breast cancer (18,19) 
and palbociclib has shown to be effective in ER pos breast cancers that carry these 
mutations (20,21).  However, there is limited data on whether these mutations could be 
used to monitor treatment response and whether mutations in these genes could be acquired 
or enriched during or at progression on palbociclib.  It is of particular importance whether 
ESR1 mutation could develop at the time of acquired treatment resistance. The results may 
have implications on the development of subsequent treatment strategies.  RB1 mutation 
has been implicated as a de novo and acquired treatment resistance mechanism to CDK4/6 
inhibition (21-23), however, the incidence of RB1 mutation after progression on 
palbociclib combination regimen is unknown.  This trial will provide this valuable data for 
future studies of targeted agents aimed to treat RB1 mutant tumors.  
 
Tumor analysis 
In addition to archival tumor specimens, in consented patients who have accessible tumors, 
tumor biopsies will be obtained before and/or after disease progression to examine 
mechanisms of intrinsic and acquired resistance mechanisms, by proteomic analysis 
including reverse phase protein array, immunohistochemistry of pRB, RNA expression 
profiling and targeted or whole exome sequencing studies depending on funding 
availabilities.    
 
Patient derived xenograft (PDX)  
PDX models allow the opportunity for in-depth molecular characterization of the tumor 
and investigation of mechanisms of response/resistance to treatments, therefore whenever 
possible, we will try to engraft biopsy samples to immunocompromised mice from 
consented patients as described in our previous publications (24).  
 
Circulating tumor cells (CTC) 
CTCs are rare events in the bloodstream, but may provide an accessible source of material 
for detection, characterization and monitoring of non-hematologic malignancies.  Current 
estimates suggest that these cells are present in numbers as low as 1 to 10 in 109 blood 
cells.  The majority of studies, including those in the setting of metastatic breast cancer, 
utilized the FDA-cleared CellSearch System for CTC enumeration, and showed the 


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prognostic value of CTC count in both progression free survival and overall survival (25).  
With the advances of technologies, we and others have developed new methods of CTC 
isolation that may allow for more accurate enumeration and even biochemical 
characterization of these cells (26,27). Recent studies have also demonstrated success in 
genomic, transcriptomic, and proteomic analyses in breast cancer CTCs (28,29). These 
data support the use of CTCs as valuable information source to non-invasively identify 
actionable genomic alterations, monitor treatment response, and investigate resistance 
mechanisms.  To investigate whether CTC-based gene expression profiling could serve as 
an early predictor of response and provide clues of resistance mechanisms, blood will be 
collected before, during and at the time of progression to assess changes in the gene 
expression profile, including PAM50 molecular classifiers (30-32) and cell cycle genes and 
regulators. Very limited data exist regarding the molecular markers for predicting or 
monitoring treatment response and resistance to palbociclib, it has been reported that 
CDK4/6 inhibitor treatment shifted ER+/HER2- models from a high risk (luminal B) to a 
low risk (luminal A) molecular-phenotype (33). We will associate the baseline and shift of 
CTC-based molecular subtype with patients’ clinical response.  This trial will provide this 
valuable data for the development of non-invasive companion diagnostics or monitoring 
tools for patients to receive palbociclib.  
 
 
2.0 
OBJECTIVES 
 
2.1 
Primary Objective 
 
To determine the rate of grade 3 or higher neutropenia in patients with hormone receptor 
positive breast cancer treated with palbociclib on a 5 days on/2 days off schedule within 
the first 29 days of treatment. 
 
2.2 
Secondary Objectives 
 
1. To determine the rate of grade 3 or higher neutropenia in patients with hormone 
receptor positive breast cancer treated with palbociclib on a 5 days on/2 days off 
schedule during all cycles. 
2. To determine the rate of palbociclib dose reduction, interruption, or discontinuation. 
3. To determine the adverse events profile of palbociclib given on a 5 days on/2 days off 
schedule. 
4. To determine the progression free survival in patients with hormone receptor positive 
breast cancer treated with palbociclib on a 5 days on/2 days off schedule. 
5. To determine the overall response rate (CR+PR) in patients with hormone receptor 
positive breast cancer treated with palbociclib on a 5 days on/2 days off schedule. 
6. To determine the clinical benefit rate (CR+PR+SD for at least 6 months) in patients 
with hormone receptor positive breast cancer treated with palbociclib on a 5 days on/2 
days off schedule. 
 
 


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2.3 
Exploratory Objectives 
 
1. To assess changes in cell free DNA mutation profile, including mutations in TP53, 
PIK3CA, ESR1, and RB1 and their correlation with treatment response. 
2. To correlate archival tumor mutation profile and RB protein status with treatment 
response. 
3. To assess intrinsic and acquired resistance mechanisms to palbociclib in tumor samples 
collected at baseline and at progression. 
4. To assess changes in serum thymidine kinase activity and correlate with treatment 
response and absolute neutrophil count. 
5. To establish patient derived xenograft (PDX) models from tumor biopsies before 
treatment and at progression for future studies. 
6. To assess baseline and changes in Circulating Tumor Cell (CTC) gene expression 
profiles and to correlate with treatment response.   
 
 
3.0 
PATIENT SELECTION 
 
3.1 
Inclusion Criteria 
 
1. Histologically confirmed metastatic ER+ and/or PR+ and HER2- breast cancer who are 
candidates for palbociclib in combination with either letrozole or fulvestrant per 
treating physician. 
  
2. Presence of measurable or non-measurable disease by RECIST 1.1 criteria.   
 
3. One prior systemic therapy in the metastatic setting is allowed, but patients who have 
not had any prior systemic therapies in the metastatic setting are also eligible. 
 Note: patients who were started on endocrine therapy monotherapy as their 1st line 
or 2nd line systemic therapy in the metastatic setting for no more than 28 days and 
without clinical progression prior to the initiation of the study drug therapy are 
allowed to enroll on the study as their 1st line or 2nd line therapy, respectively.  
 
4. At least 18 years of age. 
 
5. ECOG performance status ≤ 2 (see Appendix A) 
 
 
 
 
 
 
 
 
 
 


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6. Normal bone marrow and organ function as defined below: 
a. Absolute neutrophil count ≥ 1,500/mcl 
b. Platelets ≥ 100,000/mcl 
c. Total bilirubin ≤ IULN or total bilirubin ≤ 3.0 x IULN with direct bilirubin within 
normal range in patients with documented Gilbert’s syndrome 
d. AST(SGOT)/ALT(SGPT) ≤ 1.5 x IULN (up to 5 x IULN in patients with liver 
disease) 
e. Creatinine ≤ IULN OR creatinine clearance ≥ 60 mL/min/1.73 m2 for patients with 
serum creatinine levels above institutional normal (IULN) (calculated by 
Creatinine Clearance Estimate by Cockcroft-Gault Equation) 
 
7. Pre- or post-menopausal women are allowed.  If pre- or peri-menopausal, concurrent 
ovarian suppression for pre- or peri-menopausal women is required. 
 
8. Women of childbearing 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.  Should a woman become pregnant or suspect she is pregnant 
while participating in this study, she must inform her treating physician immediately. 
 
9. Able to swallow and retain oral medication.  
 
10. Washout of at least 3 weeks from prior chemotherapy or targeted therapy that induces 
myelosuppression and recovery of treatment related adverse events to grade 1 or less, 
with the exception of alopecia, is required prior to the start of palbociclib.  
 
11. Ability to understand and willingness to sign an IRB approved written informed 
consent document (or that of legally authorized representative, if applicable). 
 
3.2 
Exclusion Criteria 
 
1. Prior therapy with any CDK inhibitor. 
 
2. Currently receiving any other investigational agents. 
 
3. Currently receiving exogenous estrogen replacement therapy (topical vaginal estrogen 
therapy is allowed). 
 
4. Known brain metastases.  Patients with known brain metastases must be excluded from 
this clinical trial because of their poor prognosis which could affect the evaluation of 
all-cycle adverse events. 
 
5. A history of allergic reactions attributed to compounds of similar chemical or biologic 
composition to palbociclib or other agents used in the study. 
 
6. Receiving any medications or substances that are potent inhibitors or inducers of 
CYP3A isoenzymes within 7 days prior to registration. 


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7. Clinically significant history of liver disease. 
 
8. A condition that would interfere with enteric absorption. 
 
9. Uncontrolled intercurrent illness including, but not limited to, ongoing or active 
infection, symptomatic congestive heart failure, unstable angina pectoris, or cardiac 
arrhythmia. 
 
10. Pregnant and/or breastfeeding.  Women of childbearing potential must have a negative 
pregnancy test within 7 days of study entry. 
 
11. Known HIV-positivity on combination antiretroviral therapy because of the potential 
for pharmacokinetic interactions with palbociclib. In addition, these patients are at 
increased risk of lethal infections when treated with marrow-suppressive therapy.  
Appropriate studies will be undertaken in patients receiving combination antiretroviral 
therapy when indicated. 
 
3.3 
Inclusion of Women and Minorities 
 
Women and members of all races and ethnic groups are eligible for this trial.  Enrollment 
will be restricted to women as breast cancer occurs primarily in women. 
 
 
4.0 
REGISTRATION PROCEDURES 
 
Patients must not start any protocol intervention prior to registration through the Siteman 
Cancer Center. 
 
The following steps must be taken before registering patients to this study: 
 
1. Confirmation of patient eligibility by Washington University 
2. Registration of patient in the Siteman Cancer Center OnCore database 
3. Assignment of unique patient number (UPN) 
 
Once the patient has been entered in the Siteman Cancer Center OnCore database, the WUSM 
coordinator will forward verification of enrollment and the UPN via email. 
 
 
 


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4.1 
Confirmation of Patient Eligibility 
 
Confirm patient eligibility by collecting the information listed below and scanning and 
emailing it to the research coordinator listed in the Siteman Cancer Center Clinical Trials 
Core Protocol Procedures for Secondary Sites packet at least one business day prior to 
registering patient: 
 
1. Your name and contact information (telephone number, fax number, and email 
address) 
2. Your site PI’s name, the registering MD’s name, and your institution name 
3. Patient’s race, sex, and DOB 
4. Three letters (or two letters and a dash) for the patient’s initials 
5. Currently approved protocol version date 
6. Copy of signed consent form (patient name may be blacked out) 
7. Planned date of enrollment 
8. Completed eligibility checklist, signed and dated by a member of the study team 
9. Copy of appropriate source documentation confirming patient eligibility 
 
4.2 
Patient Registration in the Siteman Cancer Center OnCore Database 
 
Registrations may be submitted Monday through Friday between 8am and 5pm CT. Urgent 
late afternoon or early morning enrollments should be planned in advance and coordinated 
with the Washington University research coordinator.  Registration will be confirmed by 
the research coordinator or his/her delegate by email within one business day. Verification 
of eligibility and registration should be kept in the patient chart. 
 
All patients at all sites must be registered through the Siteman Cancer Center OnCore 
database at Washington University. 
 
4.3 
Assignment of UPN 
 
Each patient will be identified with a unique patient number (UPN) for this study.  Patients 
will also be identified by first, middle, and last initials.  If the patient has no middle initial, 
a dash will be used on the case report forms (CRFs).  All data will be recorded with this 
identification number on the appropriate CRFs. 
 
 
 
 


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5.0 
TREATMENT PLAN 
 
5.1 
Agent Administration 
 
Agent 
Dose 
Route 
Schedule 
Cycle Length 
Palbociclib 
125 mg 
PO 
5 days on and 2 days off, starting 
C1D1 
28 days 
(4 weeks) 
Letrozole* 
2.5 mg 
PO 
Daily 
Fulvestrant* 
500 mg 
IM 
Every 14 days for the first 3 doses 
followed by every 28 days 
Goserelin** 
3.6 mg 
SC 
Every 28 days 
(Day 1 of each cycle) 
* Letrozole OR fulvestrant will be administered with palbociclib per physician choice. 
** Only if pre- or peri-menopausal  
 
Patients will be instructed to make use of medication diaries (Appendices B and C) to act 
as records of administration for palbociclib and letrozole (if applicable). 
 
Palbociclib at a dose of 125 mg should be taken by mouth with food on a 5 days on/2 days 
off schedule (meaning: on Days 1-5, 8-12, 15-19, and 22-26 of each 28-day cycle).  If a 
patient misses a day’s dose entirely, she must be instructed not to make it up the next day 
but just take her regular dose at the next assigned time.  If a patient vomits any time after 
taking a dose, she must be instructed not to retake the dose but resume subsequent dosing 
at the next assigned time.  If a patient inadvertently takes an extra dose during a day, she 
must be instructed to not take the next day’s dose. 
 
Patients who have been on stable doses of palboclib for 6 consecutive cycles can be 
assessed for retreatment every 2 or 3 cycles to coincide with imaging.  These patients must 
meet retreatment criteria (as described in Section 6.4) and will have labs drawn for 
retreatment (CBC with differential and CMP) and correlative studies (serum, plasma, cell-
free DNA, and circulating tumor cells) to correspond with imaging studies that take place 
every 2-3 cycles.  This allows patients on stable doses of palbociclib to return to clinic for 
retreatment at greater intervals.    
 
Patients who are receiving letrozole will take it daily by mouth, every day of each 28-day 
cycle, at a dose of 2.5 mg.  If a patient misses a day’s dose entirely, she must be instructed 
not to make it up the next day but just take her regular dose on the next day.  If a patient 
vomits any time after taking a dose, she must be instructed not to retake the dose but resume 
subsequent dosing on the next day.  If a patient inadvertently takes an extra dose during a 
day, she must be instructed to not take the next day’s dose. 
 
Patients who are receiving fulvestrant will receive it at a dose of 500 mg as two 5 mL 
intramuscular injections (one into each buttock) on Days 1 and 15 of Cycle 1 and then on 
Day 1 of each cycle thereafter. 
 


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Goserelin is given as a subcutaneous injection every 28 days.  It is preferred to be given 
on Day 1 of each cycle, but it may be administered on any day of the treatment cycle to 
accommodate its specific Q28-day cycle.  It will be given to pre- and peri-menopausal 
women only. 
5.2 
Evaluability 
 
All patients who receive any study treatment are evaluable for toxicity.  Patients are 
evaluated from first receiving study treatment until a 30-day follow up after the conclusion 
of treatment or death. 
 
All patients are evaluable for disease response unless they discontinue treatment due to 
treatment related adverse events(s) prior to completion of a first disease assessment. 
 
5.3 
General Concomitant Medication and Supportive Care Guidelines 
 
While taking palbociclib, patients should be instructed to avoid food or drugs that are 
known strong CYP3A4 inhibitors or inducers, including grapefruit and grapefruit juice. 
Please refer to Appendix D for a list of prohibited medications.  
 
No specific antidotes exist for the treatment of palbociclib overdose. Since renal excretion 
of palbociclib is minimal, the benefit of hemodialysis in the treatment of a palbociclib 
overdose is probably negligible. The treatment of overdose of palbociclib should consist 
of general supportive measures. If indicated, elimination of unabsorbed drug should be 
achieved by emesis or gastric lavage. 
 
5.4 
Women of Childbearing Potential 
 
Women of childbearing potential (defined as women with regular menses, women with 
amenorrhea, women with irregular cycles, women using a contraceptive method that 
precludes withdrawal bleeding, and women who have had a tubal ligation) are required to 
have a negative pregnancy test within 7 days prior to the first dose of palbociclib.   
 
Women of childbearing potential are required to use two forms of acceptable contraception, 
including one barrier method, during participation in the study and for 90 days following 
the last dose of palbociclib.  
 
If a patient is suspected to be pregnant, all study drugs should be immediately discontinued.  
In addition, a positive urine test must be confirmed by a serum pregnancy test.  If it is 
confirmed that the patient is not pregnant, the patient may resume dosing. 
 
If a female patient or female partner of a male patient becomes pregnant during therapy or 
within 90 days after the last dose of palbociclib, the investigator must be notified in order 
to facilitate outcome follow-up. 
 
 
 


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5.5 
Duration of Therapy 
 
If at any time the constraints of this protocol are considered to be detrimental to the 
patient’s health and/or the patient no longer wishes to continue protocol therapy, the 
protocol therapy should be discontinued and the reason(s) for discontinuation documented 
in the case report forms. 
 
In the absence of treatment delays due to adverse events, treatment may continue 
indefinitely or until one of the following criteria applies: 
 
 Documented and confirmed disease progression 
 Death 
 Adverse event(s) that, in the judgment of the investigator, may cause severe or 
permanent harm or which rule out continuation of study drug 
 General or specific changes in the patient’s condition render the patient unable to 
receive further treatment in the judgment of the investigator 
 Suspected pregnancy 
 Serious non-compliance with the study protocol 
 Lost to follow-up 
 Patient withdraws consent 
 Investigator removes the patient from study 
 The Siteman Cancer Center decides to close the study 
 
Patients who prematurely discontinue treatment for any reason will be followed as 
indicated in the study calendar. 
 
5.6 
Duration of Follow-up 
 
After coming off treatment, patients will be followed for 30 days to collect adverse events.  
Patients removed from study for unacceptable adverse events will be followed until 
resolution or stabilization of the adverse event. 
 
6.0 
DOSE DELAYS/DOSE MODIFICATIONS 
 
6.1 
Hormone Therapy Dose Modifications 
 
No dose adjustments are permitted for fulvestrant or letrozole, but interruptions are allowed 
at the discretion of the treating physician.  Hormonal therapy should continue while holding 
palbociclib due to palbociclib related AEs.  
 
6.2 
Ovarian Suppression Dose Modifications 
 
No dose adjustments are permitted for goserelin. 
 
 
 


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6.3 
Dose Modifications for Palbociclib 
 
Patients will be monitored for toxicity and the dose of palbociclib may be adjusted as 
indicated in the dose modification table below. 
 
Dose Level 
Palbociclib 5 Days On / 2 Days Off 
1 (starting dose) 
125 mg/day 
-1 
100 mg/day 
-2 
75 mg/day 
Note that palbociclib dose reduction below 75 mg/day is not allowed 
 
Dose reduction by 1 and, if needed, 2 dose levels will be allowed depending on the type 
and severity of toxicity encountered.  Patients requiring more than 2 dose reductions will 
be discontinued from the study. 
 
Recommended dose reductions for palbociclib are detailed in the table below. Doses may 
be held as needed for toxicity resolution during a cycle. Doses omitted for toxicity are not 
replaced or restored within the same cycle (meaning that the cycle remains 28 days 
regardless of the number of doses of taken). 
 
Treatment with palbociclib should be permanently discontinued if toxicity has not 
recovered to grade ≤ 2 within two weeks. 
  
Palbociclib Dose Modifications Based on Worst Treatment-Related Toxicity in the 
Previous Cycle 
Worst Toxicity During Previous Cycle 
New Dose Level 
Grade 4 neutropenia 
Decrease by one dose level 
Grade 4 thrombocytopenia 
Decrease by one dose level 
Grade 3 neutropenia associated with a 
documented infection or fever ≥ 38.5 ºC 
Decrease by one dose level 
Grade ≥ 3 non-hematologic toxicity (includes 
nausea, vomiting, and diarrhea only if 
persisting despite maximal medical treatment) 
Decrease by one dose level 
Delay by > 1 week in receiving the next 
scheduled dose due to persisting treatment-
related toxicities 
If recovery occurs within 2 weeks, 
continue and decrease by one dose 
level 
Inability to deliver at least 80% of the planned 
dose of PD 0332991 due to adverse events 
possibly related to study treatment 
Decrease by one dose level 
 
 
 


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6.3.1 Dose Adjustments Due to QTc Prolongation 
 
Any patients who develops new grade 2 or greater ECG QT corrected interval 
prolonged at any time during the study will need to have the ECG repeated 
immediately for confirmation. 
 
Grade 2: no adjustments; continue at same dose level 
Grade 3 (reversible cause identified and corrected): withhold treatment until QTc 
≤ 470 msec, then resume treatment at the same dose level 
Grade 3 (no reversible cause identified): withhold treatment until QTc ≤ 470 msec, 
then decrease palbociclib by one dose level 
Grade 4: permanently discontinue palbociclib 
 
6.4 
Re-Treatment Criteria 
 
A new cycle of treatment with palbociclib may begin only if: 
 ANC ≥1,000/mcL. 
 Platelet count ≥50,000/mcL. 
 Non-hematologic toxicities have returned to baseline or Grade ≤1 severity (or, at 
the investigator’s discretion, Grade ≤2 if not considered a safety risk for the 
patient). 
 
Criteria for dose interruption within cycle: 
 ANC <500/mcL. 
 Platelet count <50,000/mcL. 
 
Re-treatment within the cycle may only be started when ANC ≥500/mcL and platelet count 
≥50,000/mcL. 
 
Doses omitted for toxicity within a cycle are not replaced or restored within the same cycle 
(meaning that the cycle remains 28 days regardless of the number of doses of taken). 
 
If these conditions are not met, hormone therapy may be continued but treatment with 
palbociclib must be delayed by one week. If, after a one-week delay, all toxicities have 
recovered within the limits described above, treatment with palbociclib can be resumed. 
 
If the patient has not recovered after 2 weeks despite dose reduction to the lowest dose 
level, treatment with palbociclib will be permanently discontinued.  
 
 
 
 


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7.0 
REGULATORY AND REPORTING REQUIREMENTS 
 
The entities providing oversight of safety and compliance with the protocol require reporting as 
outline below. 
 
The Washington University Human Research Protection Office (HRPO) requires that all events 
meeting the definition of unanticipated problem or serious noncompliance be reported as outlined 
in Section 7.2. 
 
Pfizer requires that all serious adverse drug experiences (defined as the events described in 
Sections 7.1.2, 7.1.3, and 7.1.4) be reported as outlined in Section 7.6. 
 
7.1 
Definitions 
 
7.1.1 Adverse Events (AEs) 
 
Definition: any unfavorable medical occurrence in a human subject including any 
abnormal sign, symptom, or disease. 
 
Grading: the descriptions and grading scales found in the revised NCI Common 
Terminology Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for 
all toxicity reporting.  A copy of the CTCAE version 4.0 can be downloaded from 
the CTEP website. 
 
Attribution (relatedness), Expectedness, and Seriousness: the definitions for the 
terms listed that should be used are those provided by the Department of Health 
and Human Services’ Office for Human Research Protections (OHRP).  A copy of 
this guidance can be found on OHRP’s website: 
http://www.hhs.gov/ohrp/policy/advevntguid.html 
 
7.1.2 Serious Adverse Event (SAE) 
 
Definition:  any adverse drug experience occurring at any dose that results in any 
of the following outcomes: 
o Death 
o A life-threatening adverse drug experience 
o Inpatient hospitalization or prolongation of existing hospitalization 
o A persistent or significant disability/incapacity (i.e., a substantial disruption 
of a person’s ability to conduct normal life functions) 
o A congenital anomaly/birth defect 
o Any other experience which, based upon appropriate medical judgment, 
may jeopardize the subject and may require medical or surgical intervention 
to prevent one of the outcomes listed above 
 
 
 


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7.1.3 Unexpected Adverse Experience 
 
Definition: any adverse drug experience, the specificity or severity of which is not 
consistent with the current investigator brochure (or risk information, if an IB is not 
required or available). 
 
7.1.4 Life-Threatening Adverse Experience  
 
Definition: any adverse drug experience that places the subject (in the view of the 
investigator) at immediate risk of death from the reaction as it occurred, i.e., it does 
not include a reaction that, had it occurred in a more severe form, might have caused 
death. 
 
7.1.5 Unanticipated Problems 
 
Definition: 
 
 unexpected (in terms of nature, severity, or frequency) given (a) the research 
procedures that are described in the protocol-related documents, such as the 
IRB-approved research protocol and informed consent document; and (b) 
the characteristics of the subject population being studied; 
 related or possibly related to participation in the research (“possibly related” 
means there is a reasonable possibility that the incident, experience, or 
outcome may have been caused by the procedures involved in the research); 
and 
 suggests that the research places subjects or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was 
previously known or recognized. 
 
7.1.6 Noncompliance 
 
Definition: failure to follow any applicable regulation or institutional policies that 
govern human subjects research or failure to follow the determinations of the 
IRB.  Noncompliance may occur due to lack of knowledge or due to deliberate 
choice to ignore regulations, institutional policies, or determinations of the IRB. 
 
7.1.7 Serious Noncompliance 
 
Definition: noncompliance that materially increases risks, that results in substantial 
harm to subjects or others, or that materially compromises the rights or welfare of 
participants. 
 
 
 


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7.1.8 Protocol Exceptions 
 
Definition: A planned deviation from the approved protocol that are under the 
research team’s control. Exceptions apply only to a single participant or a singular 
situation. 
 
Local IRB pre-approval of all protocol exceptions must be obtained prior to the 
event. For secondary sites, the Washington University PI will issue approval of the 
exception, but it must also be submitted to the local IRB with documentation of 
approval forwarded to Washington University.  Washington University IRB 
approval is not required for protocol exceptions occurring at secondary sites. 
 
7.2 
Reporting to the Human Research Protection Office (HRPO) at Washington 
University 
 
The PI is required to promptly notify the IRB of the following events: 
 
 Any unanticipated problems involving risks to participants or others which occur 
at WU, any BJH or SLCH institution, or that impacts participants or the conduct of 
the study. 
 Noncompliance with federal regulations or the requirements or determinations of 
the IRB. 
 Receipt of new information that may impact the willingness of participants to 
participate or continue participation in the research study. 
 
These events must be reported to the IRB within 10 working days of the occurrence of the 
event or notification to the PI of the event.  The death of a research participant that qualifies 
as a reportable event should be reported within 1 working day of the occurrence of the 
event or notification to the PI of the event. 
 
7.3 
Reporting to the Quality Assurance and Safety Monitoring Committee 
(QASMC) at Washington University 
 
The PI is required to notify the QASMC of any unanticipated problem occurring at WU or 
any BJH or SLCH institution that has been reported to and acknowledged by HRPO as 
reportable.  (Unanticipated problems reported to HRPO and withdrawn during the review 
process need not be reported to QASMC.) 
 
QASMC must be notified within 10 days of receipt of IRB acknowledgment via email to 
a QASMC auditor. 
 
7.4 
Reporting Requirements for Secondary Sites 
 
The research team at each secondary site is required to promptly notify the Washington 
University PI and research coordinator of all reportable events (as described in Section 7.6) 
within 1 working day of the occurrence of the event or notification of the secondary site’s 


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PI of the event.  This notification may take place via email if there is not yet enough 
information for a formal written report (using either an FDA MedWatch form if required 
or an institutional SAE reporting form if not).  A formal written report must be sent to the 
Washington University PI and research coordinator within 10 working days of the 
occurrence of the event or notification of the secondary site’s PI of the event.  The death 
of a research participant that qualifies as a reportable event should be reported within 1 
working day of the occurrence of the event or notification of the secondary site’s PI of the 
event. 
 
The research team at a secondary site is responsible for following its site’s guidelines for 
reporting applicable events to its site’s IRB according to its own institutional guidelines.  
 
7.5 
Reporting to Secondary Sites 
 
The Washington University PI (or designee) will notify the research team at each secondary 
site of all reportable events that have occurred at other sites within 10 working days of the 
occurrence of the event or notification of the PI of the event.  This includes events that take 
place both at Washington University and at other secondary sites, if applicable. 
 
7.6 
Reporting to Pfizer 
 
Within 24 hours of first awareness of the event (immediately if the event is fatal or life-
threatening), the PI or designee will report to Pfizer by facsimile any serious adverse drug 
experience (those events defined in Sections 7.1.2, 7.1.3, and 7.1.4) that occur during the 
SAE reporting period (as defined in Section 7.5) in a study subject assigned to receive 
palbociclib.  Such SAEs will be reported using the Serious Adverse Event Report form and 
Fax Cover Sheet provided by Pfizer.  SAEs should be reported as soon as they are 
determined to meet the definition, even if complete information is not yet available. 
 
Even though there may not be an associated SAE, exposure to palbociclib during 
pregnancy or lactation is reportable. 
 
7.7 
Timeframe for Reporting Required Events  
 
Adverse events will be tracked for 30 days following the last day of study treatment. 
 
8.0 
PHARMACEUTICAL INFORMATION 
 
8.1 
Palbociclib (Ibrance) 
 
8.1.1 Palbociclib Description 
 
Molecular Weight: 447.5 
Molecular Formula: C24H29H7O2 
 
 


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Formulation: Capsules that use common compendial excipients (corn starch, 
microcrystalline cellulose, sodium starch glycolate, magnesium stearate 
(nonbovine)) will be used in clinical programs.  The capsule shells are 
manufactured from gelatin NF. 
 
8.1.2 Clinical Pharmacology 
 
Palbociclib is a highly selective inhibitor of Cdk4/cyclinD1 kinase activity (IC50 = 
11 nM; Ki = 2 nM). Palbociclib has selectivity for Cdk4/6, with little or no activity 
against a large panel of 34 other protein kinases including other Cdks and a wide 
variety of tyrosine and serine/threonine kinases. Cdk6, another enzyme that also 
complexes with cyclin-D subunits, is also commonly expressed in mammalian cells 
and tumors. Cdk6 is highly homologous to Cdk4 and can perform the same function 
by phosphorylating Rb, thus potentially creating a redundant mechanism to 
promote cell cycle progression. Consequently, inhibition of both enzymes is 
necessary to ensure complete suppression of Rb phosphorylation and the greatest 
possible spectrum of antitumor activity. Results indicate that palbociclib inhibits 
Cdk6 with equivalent potency to Cdk4. 
 
8.1.3 Pharmacokinetics and Drug Metabolism 
 
To date pharmacokinetic data have been reported for four studies (A5481001, 
A5481002, A5481003 and A5481004). Final PK data are available from studies 
A5481001 and A5481002.  Pharmacokinetic parameters are available from all 74 
patients enrolled in Protocol A5481001 following a single-dose (Day 1 of Cycle 1), 
and from 51 patients following multiple-dose administration (Day 8 of Cycle 1) of 
daily doses ranging from 25 to 225 mg of palbociclib. On Day 1, all patients had 
detectable plasma concentrations of palbociclib at the first measured time point (1 
hour) following oral administration. The exposure (AUC(0-10) and Cmax) increased 
in a dose-proportional manner over the dose range of 25-225 mg QD following 
palbociclib administration on Days 1 and 8 of Cycle 1, although some variability 
(low to moderate) around these doses was observed particularly at the 150 mg QD 
dose level. 
 


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Steady-state PK parameters are available for nine patients on Day 14 of Cycle 1 
(receiving 200 mg SC 0332991 QD for 2 weeks) and four patients on Day 21 of 
Cycle 1 (receiving 125 mg QD for 3 weeks).  Palbociclib was absorbed with a 
median Tmax of ~4 hours. The mean palbociclib Vz/F was 3103 L, which is 
significantly greater than total body water (42 L), indicating that palbociclib 
extensively penetrates into peripheral tissues. Palbociclib was eliminated slowly; 
the mean elimination half-life (t½) was 26.5 hours and the mean CL/F was 86.1 
L/hour. Palbociclib accumulated following repeated dosing with a median Rac of 
2.4, which is consistent with the elimination half-life.  
 
 


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Renal excretion of palbociclib was a minor route of elimination with ~1.7% of the 
drug excreted unchanged in urine over the 10-hour collection period in the 125 mg 
and 200 mg dose group, combined. The mean renal clearance (CLR) was 6.59 
L/hour.  
 
An exploratory evaluation of the circulating metabolites for palbociclib was 
conducted in plasma samples obtained from patients treated with palbociclib 200 
mg QD. Preliminary assessment of the pooled plasma samples on Day 14 of Cycle 
1 indicated that the glucuronide conjugate of palbociclib and the lactam of 
palbociclib were the main metabolites present in plasma. Other metabolites 
observed were the glucuronide conjugates of hydroxylated palbociclib and the 
glucuronide conjugate of reduced palbociclib. 
  
The preliminary results from the recently performed food-effect study (“A5481021, 
a Phase 1, open-label 4 sequence 4 period crossover study of palbociclib (PD-
0332991) in healthy volunteers to estimate the effect of food on the bioavailability 
of palbociclib”) has provided evidence that when a single 125 mg dose of 
palbociclib was administered under fed conditions (including high fat or low fat 
meal given together with palbociclib, or moderate fat meal given 1 hour before and 
2 hours after palbociclib) as a freebase formulation the palbociclib exposure levels 
were more uniform across the population than when taken in the fasting condition.  
 
 
 
Drug-drug interaction between palbociclib and letrozole was evaluated during the 
Phase 1 portion of a breast cancer study (A5481003). The preliminary data indicate 
a lack of a potential for drug-drug interaction between palbociclib and letrozole 
when administered in combination. 
 
 


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8.1.4 Supplier(s) 
 
Pfizer will supply the study agent.  The study agent will be free of charge to the 
patient.  
 
8.1.5 Dosage Form and Preparation 
 
Medication will be provided in non-patient specific bottles containing either 125 
mg, 100 mg, or 75 mg capsules. The patient number and the protocol number should 
be recorded on the bottle label in the spaces provided. Site personnel must ensure 
that patients clearly understand the directions for self-medication. Patients should 
be given a sufficient supply to last until their next study visit. Unused drug and/or 
empty bottles should be returned to the site at the next study visit. Palbociclib is an 
agent that must be handled and administered with care. Patients should be instructed 
to keep their medication in the bottles provided and not transfer it to any other 
container. Due to possible unknown hazards associated with topical and 
environmental exposure to experimental agents, capsules must not be opened 
and/or emptied into any vehicle for oral ingestion; capsules must be swallowed 
intact. 
 
8.1.6 Storage and Stability 
 
Palbociclib capsules should be stored at controlled room temperature (15-25°C, 59-
77°F) in their original container. Medication should be kept in a secured locked 
area at the study site in accordance with applicable regulatory requirements. 
Returned medication should be stored separately from medication that needs to be 
dispensed.  
 
To ensure adequate records, palbociclib capsules will be accounted for as instructed 
by Pfizer. Unless otherwise authorized by Pfizer, at the end of the clinical trial all 
drug supplies unallocated or unused by the subjects must be returned to Pfizer or 
its designee. All containers of palbociclib that were sent to the investigator 
throughout the study must be returned to the sponsor or designee, whether they are 
used or unused, and whether they are empty or contain capsules. 
 
8.1.7 Administration 
 
Patients should be instructed to swallow capsules whole and not to chew them prior 
to swallowing. No capsule should be ingested if it is broken, cracked, or otherwise 
not intact. Patients should take palbociclib with food and should be encouraged to 
take their dose at approximately the same time each day. 
 
 
 


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8.1.8 Special Handling Instructions 
 
Females of childbearing potential should not handle or administer the study agent 
unless they are wearing gloves. 
 
8.1.9 Pregnancy 
 
Fertility and teratology studies with PD 0332991 have not been conducted; 
therefore, safety for pregnant women of childbearing capacity and for the fetus 
cannot be implied from the existing data. If the drug is used during pregnancy, or 
if the patient becomes pregnant while receiving this drug, the patient should be 
apprised of the potential hazard to the fetus.  
 
PD 0332991 caused testicular degeneration in rats and dogs. The incidence and 
severity was dose related and correlated with decreases in testicular weight in the 
rat. Testicular degeneration was not reversed after cessation of treatment and 
progressed in severity in both species. Testicular degeneration produced by PD 
0332991 is consistent with Cdk inhibition and alterations in cell cycle kinetics. 
 
Women of childbearing potential must have a negative pregnancy test prior to 
treatment with PD 0332991. Female patients must be surgically sterile or be 
postmenopausal, or must agree to use effective contraceptive during the period of 
the trial and for at least 90 days after completion of treatment. The decision of 
effective contraception will be based on the judgment of the principal investigator 
or a designated associate. 
 
8.1.10 QT Interval 
 
The patients enrolled in clinical studies should be closely monitored for potential 
cardiovascular symptoms. Appropriate monitoring should include clinical 
examinations, vital signs, routine ECGs, and AEs monitoring. In case of QTc 
prolongation, concomitant conditions such as electrolyte unbalances or use of 
medications affecting the QT interval should be ruled out or corrected. In case of 
clinically significant toxicities, PD 0332991 administration should be interrupted 
and the dose reduced as indicated in clinical protocols. 
 
In Study A5481001 using QTcF, 46 of 73 patients had a maximum increase from 
baseline of <30 msec and no patient had a maximum on treatment value of  ≥500 
msec. Notably, one female patient who had received PD 0332991 at 75 mg QD on 
Schedule 3/1, had a maximum QTcF increase of 67 msec from baseline to Cycle 1. 
Additionally, QTcF increases ranging from 39 to 51 msec compared to baseline 
persisted throughout her ECG collection period of 5 subsequent cycles. After 7 
cycles, the dose was increased to 100 mg QD. The patient remained on treatment 
for a total of 39 cycles with no cardiac related adverse events. QT data analysis for 
study A5481002 indicated no clinically significant mean changes with ECGs. 
Using Fridericia's correction in the A5481002 study, all 17 subjects in the analysis 


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had a maximum increase from baseline of <30 msec and a maximum post-baseline 
value for QTc of <500 msec. 
 
8.2 
Letrozole (Femara) 
 
8.2.1 Letrozole Description 
 
Letrozole is an aromatase inhibitor indicated for adjuvant treatment of 
postmenopausal women with hormone receptor positive early breast cancer; 
extended adjuvant treatment of postmenopausal women with early breast cancer 
who have received prior standard adjuvant tamoxifen therapy; and first- and 
second-line treatment of postmenopausal women with hormone receptor positive 
or unknown advanced breast cancer. 
 
Chemical Name: 4,4’-(1H-1,2,4-Triazol-1-ylmethylne)dibenzonitrile 
Molecular Formula: C17H11N5 
Molecular Weight:  285.31 
 
8.2.2 Mechanism of Action 
 
Letrozole is a nonsteroidal competitive inhibitor of the aromatase enzyme system; 
it inhibits the conversion of androgens to estrogens.  It inhibits the aromatase 
enzyme by competitively binding to the heme of the cytochrome P450 subunit of 
the enzyme, resulting in a reduction of estrogen biosynthesis in all tissues. 
 
8.2.3 How Supplied 
 
Letrozole tablets are supplied as 2.5 mg tablets.  Letrozole is commercially available 
and will be billed to the patient or her insurance. 
 
8.2.4 Dosage Form and Preparation 
 
Tablets are dark yellow, film-coated, round, slightly biconvex, with beveled edges. 
 
8.2.5 Storage 
 
Store at controlled room temperature (25°C; excursions permitted to 15-30°C). 
 
8.2.6 Method of Administration 
 
Patients should be instructed to take letrozole tablets by mouth with or without food. 
 
 
 


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8.2.7 Potential Drug Interactions 
 
Letrozole is generally safe to administer with other medicines. However, 
concomitant use of agents and herbal products that alter ER function are 
specifically not allowed. 
 
For further information, please refer to the FDA-approved package insert for   
letrozole. 
 
8.3 
Fulvestrant (Faslodex) 
 
8.3.1 Fulvestrant Description 
 
Fulvestrant is an estrogen receptor antagonist indicated for the treatment of 
hormone receptor positive metastatic breast cancer in postmenopausal women with 
disease progression following antiestrogen therapy and the treatment of hormone 
receptor positive, HER2-negative advanced or metastatic breast cancer in 
combination with palbociclib in women with disease progression after endocrine 
therapy. 
 
Chemical Name: 7-alpha-[9-(4,4,5,5,5-penta fluoropentylsulphinyl) nonyl]estra-
1,3,5-(10)-triene-3,17-beta-diol 
Molecular Formula: C32H47F5O3S 
Molecular Weight:  606.77 
 
8.3.2 Mode of Action 
 
Fulvestrant is an estrogen receptor antagonist that binds to the estrogen receptor in 
a competitive manner with affinity comparable to that of estradiol and 
downregulates ER protein in human breast cancer cells. 
 
8.3.3 How Supplied 
 
Fulvestrant is supplied as two 5 mL clear neutral glass (Type 1) barrels, each 
containing 250 mg/5 mL of fulvestrant for intramuscular injection and fitted with a 
tamper evident closure. 
 
Fulvestrant is commercially available and will be billed to the patient or her 
insurance. 
 
8.3.4 Dosage Form and Preparation 
 
Fulvestrant, an injection for intramuscular administration, is supplied as 5-mL 
prefilled syringes containing 250 mg/5mL fulvestrant. 
 
 
 


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8.3.5 Storage 
 
Refrigerate, 2-8°C.  To protect from light, store in the original carton until time of 
use. 
 
8.3.6 Method of Administration 
 
Fulvestrant will be given as two intramuscular injections (one in each buttock). 
 
8.3.7 Potential Drug Interactions 
 
There are no known drug-drug interactions. 
 
8.4 
Goserelin 
 
8.4.1 Goserelin Description 
 
Synthetic decapeptide analogue of GnRH. 
 
Chemical Name or Amino Acid Sequence: [D-Ser(But)6,Azgly10].  Its chemical 
structure 
is 
pyro-Glu-His-Trp-Ser-Tyr-D-Ser(But)-Leu-Arg-Pro-Azgly-NH2 
acetate. 
Other Names: Zoladex 
Classification: GnRH agonist 
Molecular Formula: [C59H84N18O14•(C2H4O2)x where x = 1 to 2.4] 
 
M.W.:  1269  
Approximate Solubility:  Goserelin is freely soluble in glacial acetic acid. It is 
soluble in water, 0.1M hydrochloric acid, 0.1M sodium hydroxide, 
dimethylformamide and dimethyl sulfoxide. Goserelin acetate is practically 
insoluble in acetone, chloroform and ether [AstraZeneca, Package Insert]. 
 
8.4.2 Mode of Action 
 
Goserelin has actions similar to those of naturally occurring GnRH (also known as 
LHRH). Normally, GnRH is released in a pulsatile manner to maintain levels of 
gonadotropins. Goserelin, in contrast, is continuously administered, which leads to 
down-regulation of the GnRH receptor on the pituitary gland and ultimately 
decreased production of FSH and LH. 
 
8.4.3 How Supplied 
 
Goserelin is supplied as a sterile, biodegradable product containing goserelin 
acetate equivalent to 3.6 mg of goserelin. Goserelin is designed for subcutaneous 
injection with continuous release over a 28-day period. Goserelin acetate is 
dispersed in a matrix of D,L-lactic and glycolic acids copolymer (13.3-14.3 
mg/dose) containing less than 2.5% acetic acid and up to 12% goserelin-related 


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substances and presented as a sterile, white to cream colored 1-mm diameter 
cylinder, preloaded in a special single use syringe with a 16-gauge x 36 +/- 0.5 mm 
siliconized needle with protective needle sleeve (SafeSystem™ Syringe) in a 
sealed, light and moisture proof, aluminum foil laminate pouch containing a 
desiccant capsule. Studies of the D,L-lactic and glycolic acids copolymer have 
indicated that it is completely biodegradable and has no demonstrable antigenic 
potential [AstraZeneca, Package Insert]. 
 
Goserelin is commercially available and will be billed to the patient or her insurance. 
 
8.4.4 Storage 
 
Store at controlled room temperature (do not exceed 25°C). 
 
8.4.5 Method of Administration 
 
Goserelin should be administered subcutaneously every 28 days into the anterior 
abdominal wall below the navel line using an aseptic technique under the 
supervision of a physician. 
 
8.4.6 Potential Drug Interactions 
 
Goserelin is generally safe to administer with other medicines.  
 
For further information, please refer to the FDA-approved package insert for 
goserelin. 
 
 
9.0 
CORRELATIVE STUDIES 
 
 
9.1 
Archival Tumor Sample Submission (Mandatory) 
 
All samples should be marked with the patients' study number, initials and date of the 
sample using an indelible marker.  Archival tumor specimens will be requested for research 
purposes for investigations of predictors of response from all patients pre-registered to the 
study.   
 
Please submit archival tumor specimens to Dr. Cynthia Ma’s laboratory (address below) 
within 60 days of registration. Patients enrolled at University of Nebraska could have 
samples batch shipped to Washington University School of Medicine.  If available, 
archived tumor tissue (from primary breast tumor as well as metastatic tumor, if available) 
is required for all patients. Tumor blocks will be sectioned and stained for assessment of 
tumor content. A tumor rich block (from both primary and metastatic tissue, if available) 
is preferred. Otherwise, 15 to 20 of 10 micron section unstained slides from the tumor rich 


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area are acceptable.  An H&E slide associated with the tumor block or unstained slides is 
needed as well. Additional tissue may be requested if it is not adequate.   
 
Please include pathology report associated with the archival tumor material. 
 
Archival tumor specimens along with the completed Archival Tumor Specimen 
Submission Form (Appendix G) are to be shipped to Dr. Cynthia Ma’s laboratory at the 
address below: 
 
Dr. Cynthia Ma Laboratory 
Attn: Jeremy Hoog 
 
Washington University School of Medicine 
 
4515 McKinley Research Building 
Campus Box 8076 
3rd Floor, Room 3111A 
St. Louis, MO 63110 
Phone: (314) 747-9309 
 
9.2 
Tumor Biopsies (OPTIONAL) 
 
9.2.1 Collection of Specimens 
 
Patients may consent to paired tumor biopsies at baseline and time of progression. 
 
Tissue should be collected as follows: 
 
 First Core (Washington University only) - in 10% formalin to tumor bank  
 First Core (Secondary site only) – to be processed into paraffin embedded 
blocks at local lab/tumor bank per institutional procedures* 
 Second Core - immediately frozen in OCT block at bedside  
 Third Core (Washington University only) - in DMEM (red medium) fresh 
to lab for engrafting (to Dr. Shunqiang Li’s laboratory) 
 Fourth Core - immediately frozen in OCT block at bedside 
 Fifth Core (Washington University only) - in DMEM (red medium) fresh to 
lab for engrafting (to Dr. Shunqiang Li’s laboratory) 
 
*Only 1 fixed core (to become 1 block) for each time point will be accepted 
 
 
 


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9.2.2 Handling of Specimens 
 
Tumor biopsies (with the exception of tumor biopsies collected for PDX models) 
should be sent to Dr. Watson same day (Washington University patients) or in batch 
shipments (Secondary site patients).   
 
Mark A. Watson, M.D., Ph.D. 
Siteman Cancer Center Tissue Procurement Facility 
425 S. Euclid Ave. 
Room 5120 
St. Louis, MO  63110 
Phone:  (314) 454-7615 
Fax:  (314) 454-5525 
E-mail:  tbank@wudosis.wustl.edu 
 
Tumor biopsies for Human in Mouse Modeling (PDX models) will be placed in 
cold DMEM High Glucose media, chilled on wet ice and immediately sent to Dr. 
Shunqiang Li’s laboratory for further preparation. The procedure of tissue 
collection will be handled in a sterile fashion because the tissues will be engrafted 
into highly immunodeficient NOD/SCID mice. The address is as below: 
 
Shunqiang Li, M.D. 
4515 McKinley Research Building 
St. Louis, MO 63110 
Phone:  (314) 747-9311(Lab) 
 (314) 362-3244 (Office) 
 (314) 596-8476 (Cell) 
Pager:  (314) 424-5911 or (314) 508-7804 
E-mail: shunqiangli@wustl.edu 
 
 
9.3 
Blood for circulating biomarkers including Serum, Plasma, ctDNA and 
germline DNA   
 
9.3.1 Collection of Specimens 
 
Blood will be drawn at the following time points for serum, plasma, ctDNA, and 
germline DNA (only at baseline): 
 Baseline 
 C1D15 
 C2D1 
 Every 2-3 months thereafter (to coincide with imaging studies) 
 Time of progression 
 
 
 


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At each time point, the following tubes will be collected: 
 4-5 mL in a serum tube (redtop) 
 8 mL in an EDTA tube (pink or purple top) for plasma 
 8 mL x 2 in a Streck Cell-Free DNA BCT for plasma circulating DNA 
 At baseline only, the EDTA tube collected for plasma will also be processed 
for germline DNA. 
 
9.3.2 Handling of Specimens 
 
Process the serum tube as follows: allow to clot for 30 minutes and then 
immediately centrifuge at 1200G for 10 minutes at 4°C.  The serum should then be 
stored as 1 mL aliquots at -60°C to -80°C at each site until arrangements are made 
for shipping to the central site for analysis at the end of the study. 
 
Process plasma tube as follows: mix several times to ensure adequate 
anticoagulation and place on ice. Deliver tubes to laboratory within 30 minutes of 
draw and spin at 1000G for 10 min at 4°C. The plasma is aspirated off in 1 mL 
aliquots and transferred to cryovials to be frozen and stored in LN2 vapor or at -
60°C to -80°C.   
 
Process baseline plasma/germline DNA tube as follows: mix several times to ensure 
adequate anticoagulation and place on ice. Deliver tubes to laboratory within 30 
minutes of draw and spin at 1000G for 10 min at 4°C. The plasma is aspirated off 
in 1 mL aliquots and transferred to cryovials to be frozen and stored in LN2 vapor 
or at -60°C to -80°C.  White blood cell pellets are created with the retaining white 
blood cells.  Germline DNA will be processed from the white blood cell pellets. 
 
Process the Streck Cell-free DNA BCT tubes as follows: mixing several times at 
room temperature.  Do not put on ice.  Deliver to tumor bank for further processing 
and freeze the cell free plasma at -60°C to -80°.  Procedures for local processing: 
Centrifuge the Cell-Free DNA BCT at 1600 x g for 20 minutes at room temperature. 
Transfer 4.5mL of plasma into three 1.72 mL or one 5.0 mL flip-top 
microcentrifuge tubes. Centrifuge the 1.7mL or 5.0 mL microcentrifuge tubes at 
13000 rpm ( ~ 16000 x g) for 10 mnutes at 4°C to pellet any remaining cells.  Use 
a P-1000 Rainin Pipette to transfer the supernatant into labeled 2.0 mL or 5.0 mL 
cryovials. (Avoid contaminating the plasma with any pelleted material, i/e/, buffy 
coat cells). Place the cryovials into the -60 to -80°C temporary storage location. 
 
 
 
 


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Note - that the above sample processing will occur at local laboratories or tumor 
bank for patients enrolled at University of Nebraska. Samples will be batch shipped 
to the Siteman Cancer Center Tissue Procurement Facility with address listed 
below. 
 
Mark A. Watson, M.D., Ph.D. 
Siteman Cancer Center Tissue Procurement Facility 
425 S. Euclid Ave. 
Room 5120 
St. Louis, MO  63110 
Phone:  (314) 454-7615 
Fax:  (314) 454-5525 
E-mail:  tbank@wudosis.wustl.edu 
 
9.4 
Additional blood draw for CTC (circulating tumor cells): 
 
9.4.1 Collection of Blood 
 
Blood will be drawn at the following time points for CTC: 
 Baseline 
 C2D1 
 Post 2 or 3 months after start of therapy (to coincide with ONLY the 1st 
imaging assessment of tumor response) 
 Time of progression 
At each time point, the following tubes will be collected: 
 8ml in a yellow-top ACD tube (provided in kit) to be shipped to UCLA  
 (1) additional 8 ml EDTA tube for Washington University patients 
Note: Patients who were started on study drug therapy prior to the activation 
of the protocol version 3 will have blood collected for CTC at the next required 
timepoints.  If all of the pre-progression samples (baseline, C2D1, and with the 
1st imaging) were missed, blood will be collected to coincide with the next 
available imaging timepoint, followed by the blood collection at the subsequent 
disease progression.    
9.4.2 Handling of Specimens 
 
Kit is available for the collection and shipment of blood being shipped to UCLA.  
Please refer to Appendices E and F for specific collection, handling, and shipping 
information.   Please label specimen with patients' study number, initials and date 
of the sample using an indelible marker.  After mixing, the tube should be placed 
on ice until shipping overnight via FedEx.  Please do not collect blood on Fridays 
or the day before a Holiday.    
 
 


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Please ship to the address below: 
 
Yazhen Zhu, M.D., Ph.D. 
Project Scientist 
Department of Molecular and Medical Pharmacology 
University of California, Los Angeles 
California NanoSystems Institute, Room 4310 
570 Westwood Plaza 
Los Angeles, CA 90095-1770 
Cell: (310) 254 4754 
Fax: (310) 206 8975  
 
Additional blood collected for CTC analysis for Washington University patients 
will need to be transported on ice (after mixing) using a microfluidic device, 
Parsortix for direct CTC isolation to Dr. Rebecca Aft’s laboratory listed below.   
 
Dr. Rebecca Aft Laboratory 
 
 
Rebecca Aft, M.D., Ph.D. 
 
 
Clinical Sciences Research Building (CSRB) 
 
 
Room 6634 
 
 
St. Louis, MO  63110 
 
 
Phone:  (314) 362-5688 
 
 
 


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9.4.3 Correlative Study Calendar 
 
Correlative 
Study 
Blood/Tumor 
Type of Collection 
Volume 
Time Point 
Process 
at Site 
Temperature 
conditions for 
storage/shipping 
Archival tumor 
for research 
Primary tumor 
Tumor rich block 
(preferred) or 15-20 
10 micron section 
unstained slides.  
H&E slide needed as 
well 
N/A 
Baseline 
N/A 
Ambient 
Archival tumor 
for research 
Metastatic 
tumor 
Tumor rich block 
(preferred) or 15-20 
10 micron section 
unstained slides.  
H&E slide needed as 
well 
N/A 
Baseline 
N/A 
Ambient 
Tumor for 
research 
(optional) 
Tumor 
1 core processed into 
paraffin embedded 
block, 2 cores frozen 
in OCT at bedside, 2 
cores in DMEM 
fresh (Wash U 
patients only) 
3 cores 
secondary 
sites, 5 
cores 
Wash U 
only 
Baseline and 
at Time of 
Disease 
Progression 
NO 
Core #1 should be 
processed into a 
paraffin embedded 
block and be 
stored/shipped at 
ambient temperature 
(batch shipments for 
secondary sites).  
Cores #2 and #4 
should be 
immediately snap 
frozen and stored at 
-60 °C to -80°C 
(batch shipments for 
secondary sites).  
Cores #3 and #5 
placed in cold 
DMEM Glucose 
media should be 
chilled on wet ice 
and immediately 
taken to Dr. Li’s lab 
(Wash U only) 
Serum for 
research 
Whole blood 
Clot tube (red) 
4-5 mL 
Baseline, 
C1D15, 
C2D1, every 
2-3 months 
thereafter (to 
coincide with 
imaging), 
time of 
progression 
YES 
Stored at -60°C to -
80°C (secondary 
sites will ship in 
batches) 


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Plasma for 
research 
Whole blood 
EDTA (pink or 
purple) – the 
baseline EDTA tube 
collected for plasma 
will also be 
processed for 
germline DNA 
8 mL 
Baseline, 
C1D15, 
C2D1, every 
2-3 months 
thereafter (to 
coincide with 
imaging), 
time of 
progression 
YES 
Stored at -60°C to -
80°C (secondary 
sites will ship in 
batches) 
Whole blood for 
plasma 
circulating DNA 
(ctDNA) 
Whole blood 
Cell-free DNA BCT 
(Streck) 
8 mL x 2 
Baseline, 
C1D15, 
C2D1, every 
2-3 months 
thereafter (to 
coincide with 
imaging), 
time of 
progression 
YES 
Stored at -60°C to -
80°C (secondary 
sites will ship in 
batches) 
Germline DNA 
for research 
Whole blood  
EDTA (pink or 
purple) – the 
baseline EDTA tube 
collected for plasma 
will also be 
processed for 
germline DNA 
8 mL 
Baseline 
YES 
Stored at -60°C to -
80°C (secondary 
sites will ship in 
batches) 
Blood for 
detection of 
circulating tumor 
cells 
Whole blood  
ACD (yellow) 
8 mL 
Baseline, 
C2D1, post 
2-3 months 
after start of 
therapy 
(coincide 
with ONLY 
1st imaging), 
time of 
progression 
YES 
Shipped overnight 
to UCLA on ice 
(avoid Fridays and 
day before holiday) 
Blood for 
detection of 
circulating tumor 
cells (Wash U 
ONLY) 
Whole blood  
EDTA (purple) 
8 mL 
Baseline, 
C2D1, post 
2-3 months 
after start of 
therapy 
(coincide 
with ONLY 
1st imaging), 
time of 
progression 
YES 
Transported on ice 
(after mixing) to Dr. 
Aft’s lab 


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10.0 
STUDY CALENDAR 
Screening/baseline evaluations are to be conducted within 2 weeks prior to start of protocol therapy.  Scans and x-rays must be done no 
more than 4 weeks prior to the start of the protocol therapy.  There is a +/-3 day window around each study visit. 
 
Screening 
Baseline 
Day 1 of 
each 
cycle8  
C1D15 
C2D1 
C2D15 
End of every 2nd 
or 3rd cycle8 
Time of 
progression 
30 
day 
f/u 
Informed consent 
X 
 
 
 
 
 
 
 
 
H&P, ECOG PS 
X 
 
X 
 
X 
 
 
X 
 
CBC w/diff 
X 
 
X 
X 
X 
X 
 
 
 
CMP 
X 
 
X 
 
X 
 
 
 
 
β-hCG1 
X 
 
 
 
 
 
 
 
 
Imaging 
X 
 
 
 
 
 
X 
X 
 
Palbociclib 
 
 
Given on a 5 days on / 2 days off schedule for each 28-day 
cycle 
 
 
Fulvestrant3 
 
 
X 
X 
X 
 
 
 
 
Letrozole3 
 
 
Daily 
 
 
Goserelin4 
 
 
X 
 
X 
 
 
 
 
Medication diary 
 
 
Daily, to be returned at the end of each cycle 
 
 
AE assessment 
 
 
X ----------------------------------------------------------------------------------X 
Archival Tissue 
 
X7
 
 
 
 
 
 
 
Research biopsy (optional) 
 
X 
 
 
 
 
 
X 
 
Blood for serum 
 
X 
 
X5 
X5 
 
X2,5 
X 
 
Blood for plasma 
 
X 
 
X5
X5 
 
X2,5 
X 
 
Blood for cfDNA 
 
X 
 
X5
X5 
 
X2,5 
X 
 
Blood for germline DNA 
 
X 
 
 
 
 
 
 
 
Blood for circulating tumor cells 
 
X 
 
 
X 
 
X6
X 
 
1. 
Women of childbearing potential only 
2. 
Beginning with the end of Cycle 2 but to coincide with imaging studies 
3. 
Either fulvestrant OR letrozole will be given (MD decision) 
4. 
Goserelin will be given to premenopausal women only 
5. 
Instruct patient take palbociclib/hormonal therapy after blood draw, meaning blood draw needs to happen prior to the day’s treatment.  
6. 
Post 2 or 3 months after start of therapy (to coincide with ONLY the 1st imaging assessment of tumor response) 
7. 
Archival tissue should include both primary and metastatic tissue 
8. 
Labs and office visits could be reduced in frequency to q2-3 cycles to coincide with tumor imaging studies in patients on stable doses of palbociclib for at least 6 consecutive 
cycle


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11.0 
DATA SUBMISSION SCHEDULE 
 
Case report forms with appropriate source documentation will be completed according to the 
schedule listed in this section. 
 
Case Report Form 
Submission Schedule 
Original Consent Form 
Prior to registration 
On-Study Form 
Prior to starting treatment 
Treatment Form 
Every cycle1 and end of treatment 
Toxicity Form 
Continuous 
Treatment Summary Form 
Completion of treatment 
Specimen Collection Form 
Per protocol 
Follow Up Form 
30 Day follow-up 
Tumor Measurement Form 
Baseline, end of every 2nd or 3rd cycle, and end 
of treatment 
1At physician discretion, patients that have been on a stable dose of Palbo for 6 consecutive cycles, may dose in q2-3 
cycle intervals to coincide with tumor imaging studies.  The treatment data forms will be completed accordingly. 
 
Any queries generated by Washington University must be responded to within 28 days of receipt 
by the participating site.  The Washington University research team will conduct a regular review 
of data status at all secondary sites, with appropriate corrective action to be requested as needed. 
 
 
12.0 
MEASUREMENT OF EFFECT 
 
12.1 
Antitumor Effect – Solid Tumors 
 
For the purposes of this study, patients should be re-evaluated for response every 12 weeks.  
In addition to a baseline scan, confirmatory scans should also be obtained not less than 4 
weeks following initial documentation of objective response. 
 
Response and progression will be evaluated in this study using the new international 
criteria proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) 
guideline (version 1.1) (34).  Changes in the largest diameter (unidimensional 
measurement) of the tumor lesions and the shortest diameter in the case of malignant lymph 
nodes are used in the RECIST criteria. 
 
12.2 
Disease Parameters 
 
Measurable disease:  Measurable lesions are defined as those that can be accurately 
measured in at least one dimension (longest diameter to be recorded) as >20 mm by chest 
x-ray, as >10 mm with CT scan, or >10 mm with calipers by clinical exam.  All tumor 
measurements must be recorded in millimeters (or decimal fractions of centimeters). 
 
 
 


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Malignant lymph nodes:  To be considered pathologically enlarged and measurable, a 
lymph node must be >15 mm in short axis when assessed by CT scan (CT scan slice 
thickness recommended to be no greater than 5 mm).  At baseline and in follow-up, only 
the short axis will be measured and followed. 
 
Non-measurable disease:  All other lesions (or sites of disease), including small lesions 
(longest diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), 
are considered non-measurable disease.  Bone lesions, leptomeningeal disease, ascites, 
pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, 
and abdominal masses (not followed by CT or MRI), are considered as non-measurable. 
 
Note:  Cystic lesions that meet the criteria for radiographically defined simple cysts should 
not be considered as malignant lesions (neither measurable nor non-measurable) since 
they are, by definition, simple cysts. 
 
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable 
lesions, if they meet the definition of measurability described above. However, if non-
cystic lesions are present in the same patient, these are preferred for selection as target 
lesions. 
 
Target lesions:  All measurable lesions up to a maximum of 2 lesions per organ and 5 
lesions in total, representative of all involved organs, should be identified as target lesions 
and recorded and measured at baseline.  Target lesions should be selected on the basis of 
their size (lesions with the longest diameter), be representative of all involved organs, but 
in addition should be those that lend themselves to reproducible repeated measurements.  
It may be the case that, on occasion, the largest lesion does not lend itself to reproducible 
measurement in which circumstance the next largest lesion which can be measured 
reproducibly should be selected.  A sum of the diameters (longest for non-nodal lesions, 
short axis for nodal lesions) for all target lesions will be calculated and reported as the 
baseline sum diameters.  If lymph nodes are to be included in the sum, then only the short 
axis is added into the sum.  The baseline sum diameters will be used as reference to further 
characterize any objective tumor regression in the measurable dimension of the disease. 
 
Non-target lesions:  All other lesions (or sites of disease) including any measurable lesions 
over and above the 5 target lesions should be identified as non-target lesions and should 
also be recorded at baseline.  Measurements of these lesions are not required, but the 
presence, absence, or in rare cases unequivocal progression of each should be noted 
throughout follow-up.  
 
12.3 
Methods for Evaluation of 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 4 weeks before the beginning of the treatment. 
 
 
 


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The same method of assessment and the same technique should be used to characterize 
each identified and reported lesion at baseline and during follow-up. Imaging-based 
evaluation is preferred to evaluation by clinical examination unless the lesion(s) being 
followed cannot be imaged but are assessable by clinical exam. 
 
Clinical lesions:  Clinical lesions will only be considered measurable when they are 
superficial (e.g., skin nodules and palpable lymph nodes) and 10 mm diameter as assessed 
using calipers (e.g., skin nodules).  In the case of skin lesions, documentation by color 
photography, including a ruler to estimate the size of the lesion, is recommended.  
 
Chest x-ray:  Lesions on chest x-ray are acceptable as measurable lesions when they are 
clearly defined and surrounded by aerated lung.  However, CT is preferable.  
 
Conventional CT and MRI:  This guideline has defined measurability of lesions on CT 
scan based on the assumption that CT slice thickness is 5 mm or less.  If CT scans have 
slice thickness greater than 5 mm, the minimum size for a measurable lesion should be 
twice the slice thickness.  MRI is also acceptable in certain situations (e.g. for body scans).   
 
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and temporal 
resolution; however, there are many image acquisition variables involved in MRI, which 
greatly impact image quality, lesion conspicuity, and measurement.  Furthermore, the 
availability of MRI is variable globally.  As with CT, if an MRI is performed, the technical 
specifications of the scanning sequences used should be optimized for the evaluation of the 
type and site of disease.  Furthermore, as with CT, the modality used at follow-up should 
be the same as was used at baseline and the lesions should be measured/assessed on the 
same pulse sequence.  It is beyond the scope of the RECIST guidelines to prescribe specific 
MRI pulse sequence parameters for all scanners, body parts, and diseases.  Ideally, the 
same type of scanner should be used and the image acquisition protocol should be followed 
as closely as possible to prior scans.  Body scans should be performed with breath-hold 
scanning techniques, if possible. 
 
PET-CT:  At present, the low dose or attenuation correction CT portion of a combined 
PET-CT is not always of optimal diagnostic CT quality for use with RECIST 
measurements.  However, if the site can document that the CT performed as part of a PET-
CT is of identical diagnostic quality to a diagnostic CT (with IV and oral contrast), then 
the CT portion of the PET-CT can be used for RECIST measurements and can be used 
interchangeably with conventional CT in accurately measuring cancer lesions over time.  
Note, however, that the PET portion of the CT introduces additional data which may bias 
an investigator if it is not routinely or serially performed.   
 
Ultrasound:  Ultrasound is not useful in assessment of lesion size and should not be used 
as a method of measurement.  Ultrasound examinations cannot be reproduced in their 
entirety for independent review at a later date and, because they are operator dependent, it 
cannot be guaranteed that the same technique and measurements will be taken from one 
assessment to the next.  If new lesions are identified by ultrasound in the course of the 


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study, confirmation by CT or MRI is advised.  If there is concern about radiation exposure 
at CT, MRI may be used instead of CT in selected instances. 
 
Endoscopy, Laparoscopy:  The utilization of these techniques for objective tumor 
evaluation is not advised.  However, such techniques may be useful to confirm complete 
pathological response when biopsies are obtained or to determine relapse in trials where 
recurrence following complete response (CR) or surgical resection is an endpoint. 
 
Tumor markers:  Tumor markers alone cannot be used to assess response.  If markers are 
initially above the upper normal limit, they must normalize for a patient to be considered 
in complete clinical response.   
 
Cytology, Histology:  These techniques can be used to differentiate between partial 
responses (PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor 
types, such as germ cell tumors, where known residual benign tumors can remain). 
 
The cytological confirmation of the neoplastic origin of any effusion that appears or 
worsens during treatment when the measurable tumor has met criteria for response or stable 
disease is mandatory to differentiate between response or stable disease (an effusion may 
be a side effect of the treatment) and progressive disease. 
 
FDG-PET:  While FDG-PET response assessments need additional study, it is sometimes 
reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in 
assessment of progression (particularly possible 'new' disease).  New lesions on the basis 
of FDG-PET imaging can be identified according to the following algorithm:  
 
 Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of 
PD based on a new lesion. 
 No FDG-PET at baseline and a positive FDG-PET at follow-up:  If the positive 
FDG-PET at follow-up corresponds to a new site of disease confirmed by CT, this 
is PD.  If the positive FDG-PET at follow-up is not confirmed as a new site of 
disease on CT, additional follow-up CT  scans are needed to determine if there is 
truly progression occurring at that site (if so, the date of PD will be the date of the 
initial abnormal FDG-PET scan).  If the positive FDG-PET at follow-up 
corresponds to a pre-existing site of disease on CT that is not progressing on the 
basis of the anatomic images, this is not PD. 
 FDG-PET may be used to upgrade a response to a CR in a manner similar to a 
biopsy in cases where a residual radiographic abnormality is thought to represent 
fibrosis or scarring.  The use of FDG-PET in this circumstance should be 
prospectively described in the protocol and supported by disease-specific medical 
literature for the indication.  However, it must be acknowledged that both 
approaches may lead to false positive CR due to limitations of FDG-PET and 
biopsy resolution/sensitivity. 
  
Note:  A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake 
greater than twice that of the surrounding tissue on the attenuation corrected image. 


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12.4 
Response Criteria 
 
12.4.1 Evaluation of Target Lesions 
 
Complete Response (CR):  Disappearance of all target lesions.  Any pathological 
lymph nodes (whether target or non-target) must have reduction in short axis to <10 
mm. 
 
Partial Response (PR):  At least a 30% decrease in the sum of the diameters of 
target lesions, taking as reference the baseline sum diameters. 
 
Progressive Disease (PD):  At least a 20% increase in the sum of the diameters of 
target lesions, taking as reference the smallest sum on study (this includes the 
baseline sum if that is the smallest on study).  In addition to the relative increase of 
20%, the sum must also demonstrate an absolute increase of at least 5 mm.  (Note:  
the appearance of one or more new lesions is also considered progressions). 
 
Stable Disease (SD):  Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum diameters while on 
study. 
 
12.4.2 Evaluation of Non-Target Lesions 
 
Complete Response (CR):  Disappearance of all non-target lesions and 
normalization of tumor marker level.  All lymph nodes must be non-pathological 
in size (<10 mm short axis). 
 
Note:  If tumor markers are initially above the upper normal limit, they must 
normalize for a patient to be considered in complete clinical response. 
 
Non-CR/Non-PD:  Persistence of one or more non-target lesion(s) and/or 
maintenance of tumor marker level above the normal limits. 
 
Progressive Disease (PD):  Appearance of one or more new lesions and/or 
unequivocal progression of existing non-target lesions.  Unequivocal progression 
should not normally trump target lesion status.  It must be representative of overall 
disease status change, not a single lesion increase.     
 
Although a clear progression of “non-target” lesions only is exceptional, the 
opinion of the treating physician should prevail in such circumstances, and the 
progression status should be confirmed at a later time by the review panel (or 
Principal Investigator). 
 
 


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12.4.3 Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the 
treatment until disease progression/recurrence (taking as reference for progressive 
disease the smallest measurements recorded since the treatment started).  The 
patient's best response assignment will depend on the achievement of both 
measurement and confirmation criteria. 
    
For Patients with Measurable Disease (i.e., Target Disease) 
Target 
Lesions 
Non-Target 
Lesions 
New 
Lesions 
Overall 
Response 
Best Overall Response 
when Confirmation is 
Required* 
CR 
CR 
No 
CR 
>4 wks. Confirmation** 
CR 
Non-CR/Non-
PD 
No 
PR 
>4 wks. Confirmation** 
CR 
Not evaluated 
No 
PR 
PR 
Non-CR/Non-
PD/not 
evaluated 
No 
PR 
SD 
Non-CR/Non-
PD/not 
evaluated 
No 
SD 
Documented at least once 
>4 wks. from baseline** 
PD 
Any 
Yes or 
No 
PD 
no prior SD, PR or CR 
Any 
PD*** 
Yes or 
No 
PD 
Any 
Any 
Yes 
PD 
* 
See RECIST 1.1 manuscript for further details on what is evidence of a new lesion. 
** 
Only for non-randomized trials with response as primary endpoint. 
*** 
In exceptional circumstances, unequivocal progression in non-target lesions may be 
accepted as disease progression. 
Note: 
Patients with a global deterioration of health status requiring discontinuation of 
treatment without objective evidence of disease progression at that time should be reported 
as “symptomatic deterioration.”  Every effort should be made to document the objective 
progression even after discontinuation of treatment.
 
                                      For Patients with Non-Measurable Disease (i.e., Non-Target Disease) 
Non-Target Lesions 
New Lesions 
Overall Response 
CR 
No 
CR 
Non-CR/non-PD 
No 
Non-CR/non-PD* 
Not all evaluated 
No 
not evaluated 
Unequivocal PD 
Yes or No 
PD 
Any 
Yes 
PD 
*  ‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since 
SD is increasingly used as an endpoint for assessment of efficacy in some trials so to 
assign this category when no lesions can be measured is not advised 


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12.4.4 Duration of Response 
 
Duration of overall response:  The duration of overall response is measured from 
the time measurement criteria are met for CR or PR (whichever is first recorded) 
until the first date that recurrent or progressive disease is objectively documented 
(taking as reference for progressive disease the smallest measurements recorded 
since the treatment started). 
 
The duration of overall CR is measured from the time measurement criteria are first 
met for CR until the first date that progressive disease is objectively documented.  
 
Duration of stable disease:  Stable disease is measured from the start of the 
treatment until the criteria for progression are met, taking as reference the smallest 
measurements recorded since the treatment started, including the baseline 
measurements.  
 
12.4.5 Progression-Free Survival 
 
PFS is defined as the duration of time from start of treatment to time of progression 
or death, whichever occurs first. 
 
12.4.6 Response Review 
 
It is strongly recommended that all responses be reviewed by an expert(s) 
independent of the study at the study’s completion.  
 
 
13.0 
DATA AND SAFETY MONITORING 
 
In compliance with the Washington University Institutional Data and Safety Monitoring Plan, an 
independent Data and Safety Monitoring Committee (DSMC) will be specifically convened for 
this trial to review toxicity data at least every 6 months following the activation of the first 
secondary site.  A DSMC will consist of no fewer than 3 members including 2 clinical investigators 
and a biostatistician.  Like investigators, DSMC members are subject to the Washington University 
School of Medicine policies regarding standards of conduct. Individuals invited to serve on the 
DSMC will disclose any potential conflicts of interest to the trial principal investigator and/or 
appropriate university officials, in accordance with institution policies. Potential conflicts that 
develop during a trial or a member’s tenure on a DSMC must also be disclosed. 
 
The Data and Safety Monitoring (DSM) report will be prepared by the study statistician with 
assistance from the study team, will be reviewed by the DSMC, and will be submitted to the 
Washington University Quality Assurance and Safety Monitoring Committee (QASMC). This 
report will include: 
 HRPO protocol number, protocol title, Principal Investigator name, data coordinator name, 
regulatory coordinator name, and statistician 


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 Date of initial HRPO approval, date of most recent consent HRPO approval/revision, date 
of HRPO expiration, date of most recent QA audit, study status, and phase of study 
 History of study including summary of substantive amendments; summary of accrual 
suspensions including start/stop dates and reason; and summary of protocol exceptions, 
error, or breach of confidentiality including start/stop dates and reason 
 Study-wide target accrual and study-wide actual accrual including numbers from 
participating sites 
 Protocol activation date at each participating site 
 Average rate of accrual observed in year 1, year 2, and subsequent years at each 
participating site 
 Expected accrual end date and accrual by site 
 Objectives of protocol with supporting data and list the number of participants who have 
met each objective 
 Measures of efficacy 
 Early stopping rules with supporting data and list the number of participants who have met 
the early stopping rules 
 Summary of toxicities at all participating sites 
 Abstract submissions/publications 
 Summary of any recent literature that may affect the safety or ethics of the study  
 
Further DSMC responsibilities are described in the DSMC charter. 
 
Until such a time as the first secondary site activates this protocol, a semi-annual DSM report to 
be prepared by the study team will be submitted to the QASM Committee beginning 6 months 
after study activation at Washington University. 
 
The study principal investigator and coordinator will monitor for serious toxicities on an ongoing 
basis. Once the principal investigator or coordinator becomes aware of an adverse event, the AE 
will be reported to the HRPO and QASMC according to institutional guidelines (please refer to 
Section 7.0). 
 
Refer to the Washington University Quality Assurance and Data Safety Monitoring Committee 
Policies and Procedures for full details on the responsibilities of the DSMC at 
https://siteman.wustl.edu/wp-content/uploads/2015/10/QASMC-Policies-and-Procedures-
03.31.2015.pdf 
 
 
14.0 
AUDITING 
 
As coordinating center of this trial, Washington University (via the Quality Assurance and Safety 
Monitoring Committee (QASMC) will monitor each participating site to ensure that all protocol 
requirements are being met; that applicable federal regulations are being followed; and that best 
practices for patient safety and data collection are being followed per protocol.  Participating sites 
will be asked to send copies of all audit materials, including source documentation.  The audit 
notification will be sent to the Washington University Research Patient Coordinator, who will 
obtain the audit materials from the participating institution. 


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Notification of an upcoming audit will be sent to the research team one month ahead of the audit. 
Once accrual numbers are confirmed, and approximately 30 days prior to the audit, a list of the 
cases selected for review (up to 10 for each site) will be sent to the research team. However, if 
during the audit the need arises to review cases not initially selected, the research team will be 
asked to provide the additional charts within two working days. 
 
Items to be evaluated include: 
 Subject screening and enrollment 
 Reporting of adverse events 
 Maintenance of HIPAA compliance 
 Completeness of regulatory documentation 
 Completeness of participant documentation 
 Acquisition of informed consent 
 IRB documentation 
 Issues of protocol adherence 
 
Additional details regarding the auditing policies and procedures can be found at 
https://siteman.wustl.edu/wp-content/uploads/2015/10/QASMC-Policies-and-Procedures-
03.31.2015.pdf 
 
 
15.0 
STATISTICAL CONSIDERATIONS 
 
15.1 
Study Description 
 
This is a single arm phase II clinical trial with metastatic HR+ HER2- breast cancer patients 
treated by palbociclib on a 5 days on/2 days off schedule.  
 
The primary endpoint of the trial is the rate of grade 3 or higher adverse events (AE rate) 
within the first 29 days (equivalently, 1-AE rate, i.e., the proportion of patients not 
suffering grade 3 or 4 AEs) The secondary endpoints include AE rate in all cycles, rate of 
palbociclib dose reduction or interruption or discontinuation, AE profiles, PFS, ORR, and 
clinical benefit rate.  
 
15.2 
Sample Size Calculations 
 
The rate of grade 3 or higher neutropenia in PALOMA -1 and PALOMA – 3 was 54% and 
62% respectively. We anticipate the new schedule to have less toxicity leading to around 
40%-50% AE rate. The sample size was calculated to test the one-sided null hypothesis 
that 1-AE (adverse event) rate ≤ 0.38 (i.e., AE rate>0.62) versus the alternative that 1-AE 
rate ≥ 0.6 (i.e., AE rate<0.4). Enrollment of 47 patients will be required to achieve 90% 
power (actual power=91.8%) based on one-sample binomial exact test at a 5% level (actual 
alpha=4.7%). If no grade 3 or higher adverse events were observed on 24 or more patients 
on the alternative dosing schedule, the alternative dosing will be deemed to show better 
toxicity profile than standard schedule.  


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The CBR was estimated as 84.3% (80%~88%) in 1st line and 67% from PALOMA-3 in 
2nd line patients. With an estimation that 70% of the enrolled patients are 2nd line, we 
expect approximately 33 2nd line patients and 14 1st line patients and thus ~22 2nd line 
patients with ~11 1st line patients with clinical benefit. With 33 2nd line patients, the CBR 
can be estimated with a 95% two-sided Clopper-Pearson exact CI of 48.5~82.3% given 
the true CBR is 67% as in PALOMA-3 while the CBR in the 14 1st line patients can be 
estimated with a 95% CI of 55.5%~97.7% given the true CBR is 84.3%. 
 
15.3 
Data Analysis Plan 
 
Patient characteristics and adverse events profiles will be summarized by descriptive 
statistics. AE rate, ORR, CBR will each be estimated accompanied with 95% confidence 
interval (CI).  PFS will be analyzed by Kaplan-Meier method and 1-year PFS rate will be 
estimated with 95% CI. All analyses will be conducted among all patients, as well as by 
subgroups of interest (e.g., line of therapy).  
 
TK1 serum marker will be correlated with absolute neutrophil count along measured time 
points and tumor response by Pearson or Spearman correlation coefficient as appropriate. 
 
 
16.0 
MULTICENTER REGULATORY REQUIREMENTS 
 
Washington University requires that each participating site sends its informed consent document 
to be reviewed and approved by the Washington University Regulatory Coordinator (or designee) 
prior to IRB/IEC submission.    
 
Site activation is defined as when the secondary site has received official written documentation 
from the coordinating center that the site has been approved to begin enrollment.  At a minimum, 
each participating institution must have the following documents on file at Washington University 
prior to study activation: 
 Documentation of IRB approval of the study in the form of a letter or other official 
document from the participating institution’s IRB.  This documentation must show 
which version of the protocol was approved by the IRB. 
 Documentation of IRB approval of an informed consent form. The consent must 
include a statement that data will be shared with Washington University, including the 
Quality Assurance and Safety Monitoring Committee (QASMC), the DSMC (if 
applicable), and the Washington University study team. 
 Documentation of FWA, signed FDA Form 1572 (if applicable), and the CVs of all 
participating investigators. 
 Protocol signature page signed and dated by the investigator at each participating site. 
 
The coordinating center Principal Investigator (or designee) is responsible for disseminating to the 
participating sites all study updates, amendments, reportable adverse events, etc.  Protocol/consent 
modifications and IB updates will be forwarded electronically to the secondary sites within 4 
weeks of obtaining Washington University IRB approval.  Activated secondary sites are expected 


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to submit protocol/consent/IB modifications to their local IRBs within 4 weeks of receipt unless 
otherwise noted.  Upon the secondary sites obtaining local IRB approval, documentation of such 
shall be sent to the Washington University study team within 2 weeks of receipt of approval. 
 
Documentation of participating sites’ IRB approval of annual continuing reviews, protocol 
amendments or revisions, all SAE reports, and all protocol violations/deviations/exceptions must 
be kept on file at Washington University. 
 
The investigator or a designee from each institution must participate in a regular conference call 
to update and inform regarding the progress of the trial. 
 
 
 


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17.0 
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5472.CAN-15-0728. 
24. 
Li S, Shen D, Shao J, Crowder R, Liu W, Prat A, et al. Endocrine-therapy-resistant ESR1 
variants revealed by genomic characterization of breast-cancer-derived xenografts. Cell 
Rep 2013;4(6):1116-30 doi 10.1016/j.celrep.2013.08.022. 
25. 
Hayes DF, Cristofanilli M, Budd GT, Ellis MJ, Stopeck A, Miller MC, et al. Circulating 
tumor cells at each follow-up time point during therapy of metastatic breast cancer 
patients predict progression-free and overall survival. Clinical cancer research : an 


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Page 56 of 68 
official journal of the American Association for Cancer Research 2006;12(14 Pt 1):4218-
24 doi 10.1158/1078-0432.ccr-05-2821. 
26. 
Lin M, Chen JF, Lu YT, Zhang Y, Song J, Hou S, et al. Nanostructure embedded 
microchips for detection, isolation, and characterization of circulating tumor cells. 
Accounts of chemical research 2014;47(10):2941-50 doi 10.1021/ar5001617. 
27. 
Chen JF, Zhu Y, Lu YT, Hodara E, Hou S, Agopian VG, et al. Clinical Applications of 
NanoVelcro Rare-Cell Assays for Detection and Characterization of Circulating Tumor 
Cells. Theranostics 2016;6(9):1425-39 doi 10.7150/thno.15359. 
28. 
Boral D, Vishnoi M, Liu HN, Yin W, Sprouse ML, Scamardo A, et al. Molecular 
characterization of breast cancer CTCs associated with brain metastasis. Nature 
communications 2017;8(1):196 doi 10.1038/s41467-017-00196-1. 
29. 
Gulbahce N, Magbanua MJM, Chin R, Agarwal MR, Luo X, Liu J, et al. Quantitative 
Whole Genome Sequencing of Circulating Tumor Cells Enables Personalized 
Combination Therapy of Metastatic Cancer. Cancer research 2017;77(16):4530-41 doi 
10.1158/0008-5472.CAN-17-0688. 
30. 
Cancer Genome Atlas N. Comprehensive molecular portraits of human breast tumours. 
Nature 2012;490(7418):61-70 doi 10.1038/nature11412. 
31. 
Perou CM, Sorlie T, Eisen MB, van de Rijn M, Jeffrey SS, Rees CA, et al. Molecular 
portraits of human breast tumours. Nature 2000;406(6797):747-52 doi 
10.1038/35021093. 
32. 
Parker JS, Mullins M, Cheang MC, Leung S, Voduc D, Vickery T, et al. Supervised risk 
predictor of breast cancer based on intrinsic subtypes. Journal of clinical oncology : 
official journal of the American Society of Clinical Oncology 2009;27(8):1160-7 doi 
10.1200/JCO.2008.18.1370. 
33. 
Knudsen ES, Witkiewicz AK. Defining the transcriptional and biological response to 
CDK4/6 inhibition in relation to ER+/HER2- breast cancer. Oncotarget 
2016;7(43):69111-23 doi 10.18632/oncotarget.11588. 
34. 
Eisenhauer EA, Therasse P, Bogaerts J, Schwartz LH, Sargent D, Ford R, et al. New 
response evaluation criteria in solid tumours: Revised RECIST guideline (version 1.1). 
European Journal of Cancer 2009;45(2):228-47. 
 
 
We would like to thank the Alvin J. Siteman Cancer Center at Washington University School of 
Medicine and Barnes-Jewish Hospital in St. Louis, Missouri, for the use of the Clinical Trials 
Core which provided protocol development services. The Siteman Cancer Center is supported in 
part by an NCI Cancer Center Support Grant #P30 CA91842. 
 
 


Protocol Version: 04/12/2019 Amendment #5 
 
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APPENDIX A: ECOG Performance Status Scale 
 
 
Grade 
 
 
Description 
0 
Normal activity.  Fully active, able to carry on all pre-disease 
performance without restriction. 
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). 
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. 
3 
 
In bed >50% of the time.  Capable of only limited self-care, confined 
to bed or chair more than 50% of waking hours. 
 
4 
100% bedridden.  Completely disabled.  Cannot carry on any self-care.  
Totally confined to bed or chair. 
5 
 
Dead. 
 
 
 
 


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APPENDIX B: PALBOCICLIB MEDICATION DIARY 
 
Today’s Date:    
 
 
 
 
 
 
Agent:   Palbociclib 
 
Cycle:    
 
 
 
 
 
 
 
Study ID#:   
 
 
 
 
INSTRUCTIONS TO THE PATIENT: 
1. Complete one form for each month.  Take _____mg ( ___capsules) of palbociclib with food on a 5 days on/2 
days off schedule.  Take the palbociclib with a glass of water and drink the glass of water in as little time as 
possible.  Swallow the capsules whole and do not chew the capsules.   
2. Record the date, the number of capsules taken, and when you took them. 
3. If you forget to take your palbociclib dose before 6:00PM, then do not take a dose that day.  Restart taking it the 
next day. 
4. If you have any questions or notice any side effects, please record them in the comments section.  Record the 
time if you should vomit. 
5. Please return the forms to your physician or your study coordinator when you go to your next appointment.  
Please bring your unused study medications and/or empty bottles with you to each clinic visit so that a pill count 
can be done. 
Day 
Date 
What time was dose taken? 
# of capsules taken
Comments 
1 
 
 
 
 
2 
 
 
 
 
3 
 
 
 
 
4 
 
 
 
 
5 
 
 
 
 
6 
 
 
 
 
7 
 
 
 
 
8 
 
 
 
 
9 
 
 
 
 
10 
 
 
 
 
11 
 
 
 
 
12 
 
 
 
 
13 
 
 
 
 
14 
 
 
 
 
15 
 
 
 
 
16 
 
 
 
 
17 
 
 
 
 
18 
 
 
 
 
19 
 
 
 
 
20 
 
 
 
 
21 
 
 
 
 
22 
 
 
 
 
23 
 
 
 
 
24 
 
 
 
 
25 
 
 
 
 
26 
 
 
 
 
27 
 
 
 
 
28 
 
 
 
 


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APPENDIX C: LETROZOLE MEDICATION DIARY 
 
Today’s Date:    
 
 
 
 
 
 
Agent:   letrozole 
 
Cycle:    
 
 
 
 
 
 
 
Study ID#:   
 
 
 
 
INSTRUCTIONS TO THE PATIENT: 
1. Complete one form for each month.  Take _____mg ( ___tablets) of letrozole daily with or without food, at 
approximately the same time each day.  Take the letrozole with a glass of water and drink the glass of water in 
as little time as possible.  Swallow the letrozole whole and do not chew them.  
2. Record the date, the number of tablets taken, and when you took them. 
3. If you forget to take your letrozole dose before 6:00PM, then do not take a dose that day.  Restart taking it the 
next day. 
4. If you have any questions or notice any side effects, please record them in the comments section.  Record the 
time if you should vomit. 
5. Please return the forms to your physician or your study coordinator when you go to your next appointment.  
Please bring your unused study medications and/or empty bottles with you to each clinic visit so that a pill count 
can be done. 
Day 
Date 
What time was dose taken? 
# of tablets taken 
Comments 
1 
 
 
 
 
2 
 
 
 
 
3 
 
 
 
 
4 
 
 
 
 
5 
 
 
 
 
6 
 
 
 
 
7 
 
 
 
 
8 
 
 
 
 
9 
 
 
 
 
10 
 
 
 
 
11 
 
 
 
 
12 
 
 
 
 
13 
 
 
 
 
14 
 
 
 
 
15 
 
 
 
 
16 
 
 
 
 
17 
 
 
 
 
18 
 
 
 
 
19 
 
 
 
 
20 
 
 
 
 
21 
 
 
 
 
22 
 
 
 
 
23 
 
 
 
 
24 
 
 
 
 
25 
 
 
 
 
26 
 
 
 
 
27 
 
 
 
 
28 
 
 
 
 


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APPENDIX D: List of CYP3A4 Strong Inhibitors and Inducers 
(http://medicine.iupui.edu/clinpharm/ddis/clinical-table/) 
 
Inhibitors 
Indinavir 
Nelfinavir 
Ritonavir 
Clarithromycin 
Itraconazole 
Ketoconazole 
Nefazodone 
Lopinavir 
Posaconazole 
Saquinavir 
Telaprevir 
Telithromycin 
Voriconazole 
Grapefruit and grapefruit juice 
 
Inducers 
Carbamazepine 
Efavirenz 
Nevirapine 
Phenobarbital 
Phenytoin 
Pioglitazone 
Rifabutin 
Rifampin 
St. John’s Wort 
Troglitazone 
 
 
 
 
 
 
 
 
 
 


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APPENDIX E: OPERATING PROCEDURE FOR CTC COLLECTION 
 
Standard Operating Procedure for Whole Blood Collection  
----Kit Instruction for Use (for samples shipped to UCLA) 
 
1 PURPOSE  
1.1 
Whole Blood Collection is intended for use to perform CTC testing from human 
blood samples.  
 
2 SCOPE 
2.1 
Whole Blood Collection Kit is intended for professional use only, by a licensed 
phlebotomy technician. 
 
3 DEFINITIONS AND ACRONYMS 
3.1 
N/A 
 
4 RELATED PROCEDURES / FORMS 
# 
Procedure 
SOP0013.2 
Instructions for Shipping Human Blood Samples 
 
5 SPECIMEN 
5.1 
N/A 
 
6 REAGENTS 
6.1 
N/A 
 
7 SUPPLIES 
7.1 
Supplies 
Quantity 
Description 
Location 
Storage upon 
arrival 
1 
One FedEx pouch contains one FedEx 
Express Package Airbill (pre-filled with 
addresses and priority Overnight 
checked) , see blood shipment SOP for 
detail 
On top, between 
the Styrofoam 
and cardboard  
shipping boxes 
Peel and stick the 
pouch on top of the 
cardboard box, 
retain the sender’s 
copy, affix all the 
copies of the airbill 
in the pouch  
3 
The same FedEx pouch also contains 
three shipping labels: 1)Biomedical 
Material, 2)Exempt Human 
Specimen and 3) Keep refrigerated 
upon arrival 
, see blood shipment SOP for detail 
On top, between 
the Styrofoam 
and cardboard  
shipping boxes 
Peel and stick these 
three labels on the 
side of the 
cardboard box  
2 
In 1 small specimen bag (primary 
container), containing one Yellow top 
(ACD) blood tube, absorbent pad and 
On top of ice 
gels, in 
Styrofoam box  
RT or 4oC 


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one 50 mL conical tube (secondary 
container). see Appendix Figure 1 and 2 
3 
Three (3) big specimen bags with 3-4 
ice gel packs in each specimen bag, see 
Appendix Figure 4 
In Styrofoam 
box 
4oC 
2 
The shipping boxes include one 
Styrofoam box (inside) and one 
cardboard box (outside), see blood 
shipment SOP for detail 
 
RT or preferably at 
4oC 
1 
Blood draw Instruction which is placed 
in the pouch of small specimen bag 
 
RT 
 
7.2 
Equipment and Reagents to be Supplied by User 
Quantity 
Description 
1 
BD Vacutainer Safety-Lok Blood Collection Set with Pre-attached holder 
1 
Elastic band   
2 
Alcohol antiseptic 
1 
Gauze sponge  
1 
Band-aid 
1 
Instruction for Use 
Do NOT use the kit if any damage of the package is observed.     
 
8 QUALITY CONTROL 
8.1 
Whole Blood Collection Kit components should be obtained in one Biohazard-labeled 
plastic bag. Do NOT use the kit if any damage of the package is observed.     
 
9 Blood Draw Instructions 
Step 
Action 
 
Upon kit arrival 
1 
Open the cardboard box and locate the FedEx pouch. See blood shipment SOP 
(instruction) for affixing the Airbill and shipping labels. 
2 
Open Styrofoam box, locate the small specimen bag which have blood collection 
tube and 50 mL conical tube. Place these items at room temperature, or keep them 
in the same Styrofoam box. 
3 
Store the gel ice packs in 4oC. Read blood draw instructions located in the pouch 
of the small specimen bag. 
 
Blood Draw Procedures 
4 
Collection and labeling:  Draw 1 full tube of blood into the yellow top collection 
tube. Label the tube with 1) human blood; 2) date (11/17/16) and 3) study number 
(i.e: W001). 
5 
Place one blood tube into one 50 mL tube, making sure that the absorbent pad 
protects the blood tube between blood tube and 50 mL tube. Close the conical 


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tube cap tightly. Place the 50 mL tube in the small specimen bag. Seal the 
specimen bag. 
6 
Take out all three big ice gel bags from 4oC. The first big ice gel bag is placed on 
the bottom of the Styrofoam shipping box. Place the two 50mL conical tubes in 
the second big ice gel bag which is put above the first ice gel bag. Seal the second 
bag completely. The third big ice gel bag will be placed on the top of the shipping 
box covering the two conical tubes. One can open the third big ice gel bag to 
evenly distribute the small ice gel in the shipping box. 
7 
Seal the shipping boxes tightly: Seal both inside (Styrofoam) and outside 
(cardboard) shipping boxes tightly with tape. See the SOP for blood shipment 
 
10 Contact Information 
Contact CytoLumina lab at 310-794-1977 or email smalleymatthewd@gmail.com with any 
questions. 
 
11 Appendix 
Figure 1. Picture of labeled tubes in sealed sterile. 
 
                                                  Blood Draw Instruction (for customers) 
A. 
Obtain blood draw items in the shipping box and in the hospital.  
a1. 
1 - BD Vacutainer Safety-Lok Blood Collection Set with Pre-attached holder (not 
supplied by the kit) 
a2. 
1 - Elastic band (not supplied by the kit) 
a3. 
2 - Alcohol antiseptic (not supplied by the kit) 
a4. 
1 - Band-aid (not supplied by the kit) 
a5. 
1 - Gauze sponge (not supplied by the kit) 
a6. 
1 - yellow top blood tube (supplied by the kit) 
a7. 
1 – 50 mL conical tube with the absorbent pads as the secondary containers for protecting 
blood tube (supplied by the kit) 
a8. 
1- small specimen bag. Each 50 mL conical tube is always placed in each small specimen 
bag 
a9. 
Ice gel packs in three big specimen bags must be stored in refrigerated (4oC) at least 12 
hours before blood draw.  
 
 


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B. 
Blood Draw Procedure:   
 
b1. 
Collection and label:  Draw 1 full tube of blood into the yellow top collection tube. Label 
the tube with 1) human blood; 2) date (11/17/16) and 3) study number (i.e: W001) 
b2: 
Place one blood tube into one 50 mL tube, making sure that the absorbent pad protects 
the blood tube in between blood tube and 50 mL tube. Close the conical tube cap tightly. 
Place the 50 mL tube in the small specimen bag. Seal the small specimen bag. 
b3.    Take out all three big ice gel bags from 4oC. The first big ice gel bag is placed on the 
bottom of the Styrofoam shipping box. Put the ice gel bag with blood tubes in the middle. 
Seal the middle big specimen bag tightly. The third big ice gel bag will be placed on the 
top of the shipping box covering the blood tube/50 mL conical tube. 
b4:   
Seal the shipping boxes tightly: Seal both inside (Styrofoam) and outside (cardboard) 
shipping boxes tightly with tape. See the SOP for blood shipment 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX F: OPERATING PROCEDURE FOR CTC HANDLING/SHIPMENT 
 
Standard Operating Procedure (SOP) for Blood Shipping and Handling 
 
1. Whole Blood Shipment kit 
Whole Blood shipment kit is intended for use to ship the blood for performing CTC testing from 
human blood samples.  
 
2. Shipment kit contents 
Quantity 
Description 
Location 
Storage upon 
arrival 
1 
One FedEx pouch contains one FedEx 
Express Package Airbill (pre-filled with 
addresses and priority Overnight 
checked), see Fig 1. 
On top, between 
the Styrofoam 
and cardboard  
shipping boxes 
Peel and stick the 
pouch on top of the 
cardboard box, 
retain the sender’s 
copy, affix all the 
copies of the airbill 
in the pouch  
3 
The same FedEx pouch also contains 
three shipping labels: 1)Biomedical 
Material, 2)Exempt Human 
Specimen and 3) Keep refrigerated 
upon arrival, see Fig 1 
 
On top, between 
the Styrofoam 
and cardboard  
shipping boxes 
Peel and stick these 
three labels on the 
side of the 
cardboard box  
1 
Blood shipping Instruction which is 
placed in the same FedEx pouch 
On top, between 
the Styrofoam 
and cardboard  
shipping boxes 
RT 
2 
The shipping boxes include one 
Styrofoam box (inside) and one 
cardboard box (outside) 
 
RT or preferably at 
4oC 
 
 
 
Equipment and Reagents to Be Supplied by User 
Quantity 
Description 
1 
Packing tape 
 
Do NOT use the kit if any damage of the package is observed.     
 
 
 


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3. Shipping Instructions 
Biological materials must be packaged according to the triple packaging principle depicted in 
Figure 1. The three elements of triple packaging include: primary receptacle, leak-proof 
secondary container, and durable outer container (Fig 2)                                                                     
 
3-1:               Shipping kit:: The items in one shipping kit are: 
 In one big specimen bag, contains 
1 - yellow top blood collection tube  
 
 
1 – 50 mL conical tube with the absorbent pads for protecting blood tube  
 
 
1- small specimen bag. One 50 mL conical tube is always placed in one    
                          small bag before or after the blood draw 
 Three big specimen bags containing Ice gel packs 
 Two shipping boxes include one Styrofoam box (inside) and one cardboard box 
(outside) 
 
3-2                 Open the cardboard box and locate the FedEx pouch. Read the shipping     
instruction carefully. Peel and stick the pouch on top of the cardboard box. Peel 
and affix the three labels on the side of the cardboard box: 1)Biomedical 
Material, 2)Exempt Human Specimen and 3) Keep refrigerated upon arrival, 
see Appendix Figure 1 
3-3                  Use the prefilled FedEx airbill or fill out a new airbillforms as followings:  
Item #1  Sender’s name and address 
Item #3  Recipient’s name and address 
Item #4  Service: FedEx Priority Overnight 
Item #5  Packaging: Other 
Item #6: Special Handling, Direct Signature, check “No” for dangerous goods 
Item #7: Payment, Bill to _______________ 
3-4                Seal the shipping boxes: Seal both inside (Styrofoam) and outside (cardboard)   
                     shipping boxes tightly with tape 
 
4. Contact Information 
Contact CytoLumina lab at 310-794-1977 or email smalleymatthewd@gmail.com to ask any 
questions. 
 
 


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5. Appendix 
Figure 1.  
 
 
 
Figure 2.  
 
   
 
 
  
                                      
                                   
 
                                          
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX G:  ARCHIVAL TUMOR SPECIMEN SUBMISSION FORM 
 
Laboratory of Dr. Cynthia X. Ma 
Archival Tumor Specimen Submission Form 
 
HRPO ID#:   
201612098 
 
 
 
 
 
 
 
Submitter Last 
Name:    
 
 
 
 
 
Participant Study #:   
 
 
 
 
 
 
 
 
Submitter First 
Name:    
 
 
 
 
 
Participant Name (Initials):  Last:   
  First:    
  Middle:   
 
 
Submitter’s 
Phone #:   
 
 
 
 
 
 
Collection Site (select one):   
☐Washington University School of Medicine 
 
☐University of 
Nebraska Medical Center 
 
Study Time Point:   
ARCHIVE 
 
 
 
 
 
 
Specimen(s) Submitted:  Clinical Research Coordinator to provide date & time collected and # of specimens.  
Include completed form with specimen shipment. 
Parent Label 
Parent Type 
Date & Time 
Collected 
Number of 
Specimens 
Primary or 
Metastatic 
 
☐Fixed tissue 
block 
☐Fixed tissue slide 
 
 
☐Primary 
☐Metastatic 
 
☐Fixed tissue 
block 
☐Fixed tissue slide 
 
 
☐Primary 
☐Metastatic 
 
☐Fixed tissue 
block 
☐Fixed tissue slide 
 
 
☐Primary 
☐Metastatic 
 
☐Fixed tissue 
block 
☐Fixed tissue slide 
 
 
☐Primary 
☐Metastatic 
 
☐Fixed tissue 
block 
☐Fixed tissue slide 
 
 
☐Primary 
☐Metastatic 
   
Processing Notes: 
A tumor rich block (from both primary and metastatic tissue, if available) is preferred. Otherwise, 15 to 20 of 10 
micron section unstained slides from the tumor rich area are acceptable.  An H&E slide associated with the tumor 
block or unstained slides is needed as well. Additional tissue may be requested if it is not adequate.  Please include 
pathology report. 
 
Shipment Address: 
 
 
 
 
 
Dr. Cynthia Ma Laboratory 
Attn: Jeremy Hoog 
Washington University School of Medicine 
4515 McKinley Research Building 
Campus Box 8076 
3rd Floor, Room 3111A 
St. Louis, MO 63110 
Phone: (314) 747-9309