Conditions: Breast Cancer Breast Cancer Female
Keywords: senior adult postmenopausal
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 9
Healthy volunteers: no

Brief summary:
The purpose of this study is to adjust the amount of docetaxel participants receive based on the level of docetaxel measured in their blood. This method of dose adjustment is called pharmacokinetic (PK)-adjusted docetaxel. The researchers believe that adjusting the dose of docetaxel using this method will lessen the side effects associated with docetaxel in cancer treatment.

Detailed description:

Arms:
arm 1: Standard of Care Docetaxel and Cyclophosphamide (TC) Chemotherapy + Surveys. TC Regimen with Function Assessment of Cancer Therapy (FACT) Surveys. All participants will receive TC for cycle 1 with subsequent cycles repeated every 3 weeks for a total of 4 cycles. All initial dosing will be based on actual body weight and height. Participants will receive up to 4 doses of chemotherapy. Following their 4th dose of chemotherapy, or the last dose of chemotherapy in which blood level monitoring was performed, participants will be assessed for side effects from the chemotherapy and complete their final written 53 question survey about their quality of life.

Interventions: intervention 1: Standard of Care: Docetaxel intervention 2: Standard of Care: Cyclophosphamide intervention 3: Function Assessment of Cancer Therapy (FACT) Surveys
Intervention descriptions: intervention 1: Pharmacokinetic(PK)-guided docetaxel. Cycle 1: 75 mg/m\^2, intravenously (IV) on Day 1 for 60 minutes. Beginning with cycle 2, the docetaxel dose will be individually adjusted before each cycle. intervention 2: Cycle 1: 600 mg/m\^2, via IV on Day 1 for 30 minutes. The cyclophosphamide dose will not be changed unless dictated by toxicity. intervention 3: Participants will complete the FACT-Taxane and FACT-Breast quality of life assessment written surveys at baseline, during each chemotherapy cycle, and 3-5 weeks following the last cycle in which PK monitoring was performed.

Protocol document:
Prot_SAP_000.pdf: 
 
 
 
 Multicenter study investigating utilization of pharmacokinetic (PK)-guided 
docetaxel in senior adult breast cancer patients receiving docetaxel and 
cyclophosphamide (TC) chemotherapy  
NCT02502864 
 
Amendment Version 1.0 
October 2, 2015 






MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
TABLE OF CONTENTS 
 
 
Page 
SCHEMA .......................................................................................................................................iv 
 
1. OBJECTIVES 
 ..................................................................................................................... 5 
 
2. BACKGROUND  ..................................................................................................................... 6 
2.1  
Study Synopsis 
2.2  
Rationale 
 
3. PATIENT SELECTION ....................................................................................................... 16 
3.1  
Inclusion Criteria  ............................................................................................................ 16 
3.2  
Exclusion Criteria ............................................................................................................ 17 
3.3  
Inclusion of Women and Minorities .............................................................................. 17 
3.4  
Patient Registration……………………………………..………….………………….18 
3.5  
Removal of Patients from Study…………………………...……….…………………18 
 
4. TREATMENT PLAN ............................................................................................................ 19 
4.1  
Chemotherapy Administration ...................................................................................... 19 
4.2  
Docetaxel PK Dose Adjustment ...................................................................................... 19 
4.3  
Supportive Care Guidelines ............................................................................................ 20 
4.4  
Duration of Therapy ........................................................................................................ 20 
 
5. DOSING DELAYS/DOSE MODIFICATIONS .................................................................. 21 
 
6. PHARMACEUTICAL INFORMATION ........................................................................... 21 
 
7. PHARMACOKINETIC ANALYSIS ................................................................................... 22 
 
8. STUDY CALENDAR ............................................................................................................ 23 
 
9. REGULATORY AND REPORTING REQUIREMENTS ................................................ 25 
 
10.1 
Reporting  
10.1.1 Unexpected and Serious Adverse Experiences…………………………………..29 
10.2 
Data Reporting ................................................................................................................. 29 
10.2.1 Institutional Review Board………………………………………………………29 
10.2.2 Data Management and Monitoring/Auditing ......................................................... 29 
10.2.3 Informed Consent………………….…………………………………………….30 
10.2.4 Hospital/Clinical Records………………………………………………………..30 
10.2.5 Investigator Study Files………………………………………………………….30 
3 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
 
10.3 
Affiliate Site Required Documentation ......................................................................... 30 
 
11. STATISTICAL CONSIDERATIONS ................................................................................. 31 
 
REFERENCES ............................................................................................................................ 34 
 
INFORMED CONSENT TEMPLATE ......................................................................................... 
 
 
APPENDICES 
 
APPENDIX A 
ECOG Performance Status Criteria ............................................................................................ A-1 
 
APPENDIX B 
Docetaxel Pharmacokinetic Sampling Instructions......................................................................B-1 
 
APPENDIX C………………………………………………………………………...………..C-1 
FACT-Breast version 4 
 
APPENDIX D………………………………………………………………………...………..D-1 
FACT-Taxane version 4 
 
APPENDIX E………………………………………………………………………...………..E-1 
Instrumental Activities of Daily Living (IADL) Scale 
 
APPENDIX F……………………………………………………………………………………F-1 
Mini-Mental State Examination (MMSE) 
 
APPENDIX G…………………………………………………………………………………G-1 
Mini Nutritional Assessment (MNA) 
 
 
 
 
 
 
 
 
 
4 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
 
 
 
 
 
 
 
1. OBJECTIVES 
 
1.1. 
Primary Objective:  
To demonstrate that PK guided dosing of docetaxel chemotherapy improves the ability 
to achieve a targeted AUC ( 2.5-3.7 mg*hr/L) within 4 cycles of therapy in patients > 
65 years of age with breast cancer receiving TC (docetaxel and cyclophosphamide) as 
compared with historical non-PK guided therapy from patients receiving a similar 
regimen 
 
1.2. 
Secondary Objectives: 
 To demonstrate that PK guided dosing of docetaxel chemotherapy decreases the 
incidence of grade 3 and 4 neutropenia and febrile neutropenia in cycles following PK 
adjustment (cycles 2-4) when compared with cycle 1 and historical non-PK guided 
therapy in patients > 65 years of age with breast cancer receiving TC chemotherapy. 
 
To assess whether a higher Chemotherapy Risk Assessment Scale for High-Age 
Patients (CRASH) score at baseline is associated with a higher docetaxel AUC after 
cycle 1 and greater need for dose reductions based on the PK-guided dosing algorithm 
in patients > 65 years of age with breast cancer receiving TC chemotherapy. 
 
To assess whether a lower Instrumental Activities of Daily Living (IADL) total score 
at baseline is associated with a higher docetaxel AUC after cycle 1 and greater need for 
dose reductions based on the PK-guided dosing algorithm in patients > 65 years of age 
with breast cancer receiving TC chemotherapy. 
 
To assess whether a higher level of comorbidity, as defined by the Cumulative Illness 
Rating Scale for Geriatrics (CIRS-G) total score, is associated with a higher docetaxel 
AUC after cycle 1 and greater need for dose reductions based on the PK-guided dosing 
algorithm in patients > 65 years of age with breast cancer receiving TC chemotherapy. 
 
To assess whether drug interactions, as measured by the total number of potential drug 
interactions (PDI) with docetaxel and the level of significance of each interaction, is 
associated with a higher docetaxel AUC after cycle 1 and greater need for dose 
reductions based on the PK-guided dosing algorithm in patients > 65 years of age with 
breast cancer receiving TC chemotherapy. 
5 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
 
To assess  the relationship between the Function Assessment of Cancer Therapy 
(FACT) Taxane and Breast Cancer scores and docetaxel AUC results in patients > 65 
years of age with breast cancer receiving TC chemotherapy. 
   
 
 
 
2. BACKGROUND 
 
2.1  
 Study Synopsis  
 
Docetaxel is a semisynthetic taxane that inhibits the microtubule network and is used in 
the treatment of many types of cancers.  Standardized dosing of docetaxel, based on body-
surface-area (BSA), is associated with significant variability in drug exposure (up to 10-
fold variation in area under the concentration-time curve [AUC]).[1, 2]  The clinical 
relevance of this is underscored given the correlation between AUC and both grade 4 
neutropenia and febrile neutropenia.[1]  Docetaxel AUC has also been correlated with 
efficacy endpoints.  The AUC of docetaxel has been the parameter most associated with 
biologic effects.[1, 3]  Validated limited sampling strategies have been developed that 
allow the AUC for docetaxel therapy to be estimated from two samples, one taken towards 
the end of the infusion and a second taken one hour after the end of infusion.[3-5]  This 
provides practical support for the further evaluation of docetaxel AUC measurements to 
guide dosing in cancer patients.   
 
The docetaxel and cyclophosphamide (TC) regimen has shown superior overall and 
disease free survival compared with doxorubicin and cyclophosphamide (AC) in early 
stage breast cancer patients receiving adjuvant chemotherapy.[6]    The docetaxel and 
cyclophosphamide (TC) regimen is the preferred adjuvant treatment at Moffitt Cancer 
Center for early stage breast cancer patients > 65 years of age and thus will be the regimen 
utilized in this trial.  The risk of docetaxel toxicity is higher in patients > 65 years of age. 
The rate of grade 4 neutropenia was 63% in patients > 65 years of age compared with 30% 
in younger patients.  Though docetaxel PK parameters were similar across ages, 
variability was higher in older patients (9.6-fold compared with 5-fold).[7]   
 
Although it has been suggested that PK-guided drug dose adjustment may be necessary to 
optimize anticancer efficacy and minimize associated toxicities, the lack of a routinely 
available testing method has impeded its clinical adoption.  Saladax Biomedical, Inc. 
(Saladax) develops novel diagnostic assays for the practical delivery of personalized medicine 
and companion diagnostics, delivering actionable diagnostic data to physicians to optimize 
the use of current and new pharmaceutical products.  Saladax has developed a highly 
sensitive, accurate, reproducible and reliable homogeneous immunoassay for the 
6 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
measurement of docetaxel levels in plasma samples, the MyDocetaxelTM assay [8]. 
The PK model used by Saladax to calculate AUC results for docetaxel was initially developed 
and validated by Bruno and colleagues [1], with data from 547 patients [5, 9] comprising 
multiple tumor types.  The majority of patients received 75 mg/m2 as 1-hour infusions.  Using 
their population PK parameters and model, an optimal limited sampling strategy (LSS) was 
reported by Baille et al. [4] which allows calculation of the docetaxel AUC from only two 
plasma samples. 
 
 
The purpose of this study is to demonstrate the value of PK-directed docetaxel therapy to 
decrease interpatient variability of the docetaxel AUC in breast cancer patients > 65 years 
of age receiving TC.  We will also compare the toxicity associated with PK-directed 
docetaxel dosing with historical data from patients > 65 years of age receiving TC and 
assess the relationship between several geriatric focused functional assessments and the 
need for docetaxel dosing adjustments.[6]  This will be a multicenter study, with Moffitt 
Cancer Center being the lead institution in collaboration with a select number of 
community oncology offices. Breast cancer patients > 65 years of age who are scheduled 
to receive 4 cycles of adjuvant TC as their chemotherapy regimen will be enrolled on the 
study.  Patients will initially receive TC dosed in the usual manner for the practice.   
 
During cycle 1, a blood sample will be taken 5 + 5 minutes prior the end of the docetaxel 
infusion and a second blood sample will be taken 45 + 15 minutes after the end of the 
docetaxel infusion for assessment of docetaxel plasma concentrations.  The 
MyDocetaxelTM assay results obtained from these blood samples will be used to calculate 
an AUC, which will then be used to determine what adjustments need to be made to the 
docetaxel dose for the second TC cycle to achieve a docetaxel AUC of 2.5 to 3.7 mg*hr/L. 
During cycle 2, a blood sample will again be taken 5 + 5 minutes prior the end of the 
docetaxel infusion and a second blood sample will be taken 45 + 15 minutes after the end 
of the docetaxel infusion to see if the patient achieved the target AUC range.  If the patient 
is within range, the same docetaxel dose will be utilized for cycle 3 and blood samples 
will again be taken as previously described to ensure the patient remained in range.  If the 
patient was not within range on cycle 2, the docetaxel dose for cycle 3 will again be 
appropriately adjusted using the docetaxel AUC value from cycle 2 to achieve an 
docetaxel AUC of 2.5 to 3.7 mg*hr/L as was done previously.  These patients will also 
have blood samples drawn as previously described on cycle 3.  This process will be 
repeated for cycle 4. Patients will be assessed for toxicity prior to each cycle of TC. 
 
2.2  
Rationale 
 
Docetaxel is a semisynthetic taxane that inhibits the microtubule network and is used in 
many types of cancers including both locally advanced and metastatic breast cancer, lung 
7 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
cancer, prostate cancer and gastric cancer.  In clinical practice, the docetaxel dose is 
calculated according to a patient’s estimated body surface area (BSA). Although 
convenient, significant interpatient variability in drug disposition makes this method 
inadequate for standardizing the optimal therapeutic outcome for a large proportion of 
patients.  Variability in drug clearance and AUC of 10-fold and 7-fold, respectively means 
that some patients will be undertreated while others may be at higher risk for toxicity 
(Figure 1).[10]  Docetaxel is metabolized to its primary metabolite, hydroxydocetaxel, via 
cytochrome P-450 (CYP) 3A4.  This enzyme has demonstrated greater than 20-fold 
variability across populations and some data suggests that approximately 60-70% of the 
interpatient variability of docetaxel PK may be explained by differences in CYP3A4.[11]  
 Other external factors may explain the remaining variability.[12]   
 
Figure 1: Clearance as a function of drug administration regimens for docetaxel. Solid line 
represents the mean and dotted line represents the median. 
 
 
Though Docetaxel clearance exhibits high interpatient variability when dosed by BSA 
(Figure 1), the intrapatient variability between cycles remains low.[13]  Over the past 
decade, it has been increasingly recognized that the traditional concept of therapeutic drug 
monitoring (TDM) can be effectively applied to enhance the optimal use of anticancer 
agents. Successful examples in oncology practice include methotrexate, busulfan and 
fluorouracil.[14-16]  The PK properties of docetaxel along with efficacy of TDM 
strategies support the idea that individualization of docetaxel therapy may be a worthy and 
feasible pursuit to optimize its use.     
 
 
2.2.1   
Docetaxel Systemic Exposure-Toxicity Relationship   
 
Correlation of plasma levels of docetaxel with hematologic toxicity, the major dose-
limiting toxicity, has been well-established while associations of plasma levels and 
clinical efficacy have been reported less frequently.  The docetaxel PK parameter that is 
most associated with biologic effects is total exposure, or AUC.  Docetaxel AUC has been 
8 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
correlated with both grade 4 neutropenia and febrile neutropenia.   
 
This relationship was evaluated in 640 patients receiving docetaxel monotherapy as part 
of 24 different Phase II trials.[1]  Docetaxel plasma levels were assessed using 4 different 
limited sampling strategies (each with 3 time points) and PK parameters were calculated 
using population PK and Bayesian estimation.  The majority of patients (95%) received 
docetaxel 100 mg/m2. Approximately 30% of patients had non-small cell lung cancer 
(NSCLC) and 36% had breast cancer.  The median AUC was 4.81 mg*hr/L (95% range of 
2.93-9.52).  Docetaxel clearance was found to be a strong, independent predictor of both 
grade 4 neutropenia and febrile neutropenia (p<0.0001).  The first course docetaxel AUC 
was found to be a predictor of time to tumor progression (TTP) in patients with NSCLC 
(p=0.0232), however there was not a clear association between any docetaxel PK 
parameter and response rate or TTP in the breast cancer patients.  In a subset including the 
NSCLC patients, a change in AUC from 4.2 to 6.5 mg*hr/L was predictive of an 
approximate 2-fold increase in the odds of developing a severe adverse effect.[17]   
 
The relationship between docetaxel PK and toxicity was also assessed in the older cancer 
patient population.[7]  Single agent docetaxel 75 mg/m2 every three weeks was 
administered to 20 patients > 65 years of age or older (median was 71, range of 65-80) and 
20 patients younger than 65 years of age (median was 53, range of 26-64).  All patients 
had solid tumors with breast, lung, prostate and angiosarcoma being most common.  The 
median AUC was 6.01 (1.54-13.7) mg*hr/L in the older patient population compared with 
5.69 (2.47-10.2) mg*hr/L in the younger population.  There were no significant 
differences in measures of docetaxel exposure parameters between the younger and older 
populations.  However, the rates of grade 4 neutropenia and febrile neutropenia were 
higher in the patients > 65 years of age (63% and 16%, respectively) compared with 
younger patients (30% and 0%, respectively).  Though not statistically significant, there 
was a strong trend (p=0.056).  The odds ratio for a patient > 65 developing grade 4 
neutropenia compared with a 50 year old patient was 1.98  (p=0.091).  Overall, patients 
with grade 4 neutropenia did not have a significantly higher AUC value compared with 
patients who developed grade 3 or less neutropenia.  However, the greatest percent 
decrease in ANC was in patients who had AUC values in the upper quartile compared 
with patients in the inter or lower quartiles (p=0.0390 for trend). (Figure 2)  The frequency 
of non-hematologic toxicities including grade 1 or 2 alopecia, asthenia, nausea, oral 
mucositis, cutaneous toxicity, and neuropathy were not different between age groups.  
This suggests that use of PK-guided therapy in patients > 65 years of age receiving 
docetaxel may be especially beneficial since this population has shown a higher risk of 
developing grade 4 neutropenia and febrile neutropenia.  Additionally, the apparent lack 
of correlation between docetaxel PK parameters and outcomes in the breast cancer 
population suggests that dose adjustments may decrease toxicity without having a 
negative effect on drug efficacy.   
 
9 
 
 




MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
docetaxel 
Minami et al., 
2006[20] 
Histologically 
confirmed solid 
tumor indicated 
for docetaxel 
69 
60 mg/m2 1 hour 
infusion every 3 
weeks 
Median=2.68 
Severe neutropenia, 34.8% 
Median AUC with neutrophils < 
500 = 2.73 
Median AUC with neutrophils ≥ 
500 = 2.49 
ten Tije et al., 
2005[7] 
Histologically 
confirmed solid 
tumor indicated 
for docetaxel 
51 
75 mg/m2 1 hour 
infusion every 3 
weeks 
Age< 65 = 5.69 
Age≥65=6.01 
Grade 4 neutropenia 
Age< 65 = 30% 
Age≥65=63% 
Febrile neutropenia 
Age< 65 = 0% 
Age≥65=16% 
Bruno et al., 
1998[1] 
Histologically 
confirmed solid 
tumor indicated 
for docetaxel 
640 
75 mg/m2 1 hour 
infusion every 3 
weeks 
Median = 4.8 
Logistic regression AUC of 
p=0.0232 
Bruno et al., 
2003[17] 
NSCLC 
 
180 
100 mg/m2 1 
hour infusion 
every 3 weeks 
Median = 4.98 
Range 3.24 – 9.76 
Change ins AUC from 4.2 to 7.2 
increase odds of severe AE by ~2-
fold 
Goh et al., 
2002[21] 
Solid tumor 
indicated for 
docetaxel 
 
31 
Either 75 or 100 
mg/m2 1 hour 
infusion every 3 
weeks 
75 group = 5.1 
100 group = 5.5 
AUC significant correlated with 
ANC nadir (p = 0.001) 
Extra et al., 
1993[22] 
Histologically 
confirmed 
malignancies not 
amenable to 
current therapy 
65 
23 for 
PK 
 
Dose ranging 
from 5 – 115 mg 
/m2 1 hour 
infusion every 2 
- 3 weeks 
70 m/m2 dose 2.79 
Emax model fit of AUC with 
percent change in neutropenia (r = 
0.672, p=0.001) AUC50 = 0.967 
 
 
2.2.2  Outcomes From Studies Incorporating PK Guided Docetaxel   
 
The implementation of PK-directed docetaxel dosing has used several different strategies.  
One method took advantage of the fact that docetaxel is primarily metabolized through 
CYP3A4 and used an assay assessing levels of exogenous cortisol metabolite in the 
urine.[23]  The total amount of 24-hour urinary 6-beta-hydroxycortisol is significantly 
correlated with the clearance of docetaxel.  The investigators aimed to demonstrate that 
application of this cortisol method to individualize docetaxel dosing could decrease PK and 
pharmacodynamics variability of docetaxel compared with BSA-based dosing.  The target 
AUC was 2.66 mg*hr/L in the individualized arm and was based on the mean value from a 
previous study in which 29 patients were treated with 60 mg/m2 of docetaxel.  Fifty-nine 
patients with advanced NSCLC were randomized to standard BSA-based dosing arm and 
received docetaxel 60 mg/m2 every 3 weeks or the individualized arm where dosing was 
based on estimated clearance.  In individualized arm, the dose required to target the AUC 
11 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
ranged from 37.4 to 76.4 mg/m2 demonstrating the interpatient variability previously 
discussed.  The mean AUC and standard deviation (SD) was 2.71 mg*hr/L (range 2.02 to 
3.40 mg*hr/L) and 0.40 mg*hr/L in the BSA-based arm and 2.64 mg*hr/L (range 2.15 to 
3.07 mg*hr/L) and 0.22 mg*hr/L in the individualized arm.  The difference in SD was 
significantly less in the individualized arm (p<0.01).  The percentage decrease in ANC was 
similar in both groups, though the SD was again smaller in the individualized arm.  This 
trial supports the notion that individualized dosing of docetaxel can decrease interpatient 
variability. 
 
A second trial used a limited sampling strategy in combination with a validated PK model 
and Bayesian analysis to compare BSA-dosing with PK-guided docetaxel.[3]  A total of 30 
patients were enrolled, 15 of whom receiving standard BSA-dosing (either 100 mg/m2 or 75 
mg/m2) and 15 who received PK-guided docetaxel.  The investigators aimed to evaluate the 
effect of PK-guided, AUC targeted, individualized docetaxel dosing on interindividual 
variability in exposure.  The target AUC was 4.90 mg*hr/L for patients receiving 100 
mg/m2 and 3.68 mg*hr/L for those receiving 75 mg/m2, based on the linearity of docetaxel 
PK. Approximately 40% of patients had breast cancer and 20% had prostate cancer, with 
other solid tumors making up the rest of the population. All 15 patients in the individualized 
group completed at least two PK-guided cycles of docetaxel and this group demonstrated a 
lower interpatient variability by 39% (p=0.055) compared with the standard BSA-dosed 
patients (Figure 3).  Additionally, PK-guided patients had decreased interpatient variability 
in the percentage decrease in ANC by approximately 50%.   
 
 
These two trials support the feasibility of using AUC to guide docetaxel therapy in the 
clinical setting and the ability of this technique to decrease interpatient variability.   
 
 
Figure 3.  AUC values (mg*h/L) for all evaluated courses in the PK guided dosing group (course 1 and 
subsequent courses; N=51), specified per course number and extrapolated to a dose of 100 mg/m2 for reasons 
of comparison[3] 
 
 
 
 
 
 
 
 
 
 
 
 
12 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
 
 
 
2.2.3  Practical Implementation of PK-Guided Docetaxel  
 
Given the high interpatient variability of docetaxel and correlation between AUC and the 
primary toxicity of grade 4 neutropenia, the use of PK to guide docetaxel dosing is an 
attractive option. To translate this into clinical practice, a reliable assay as well as a 
defined therapeutic range to target is required along with an appropriate dose-adjustment 
strategy.  This trial will use the MyDocetaxel™ assay (Saladax Biomedical, Inc., 
Bethlehem, PA).[8]  Blood collection kits will be provided to the clinical sites and the 
plasma samples will be shipped to the 
 
 for analysis.  The assay requires 2 blood samples to be drawn during 
each docetaxel infusion; the first drawn within 10  minutes before the end of infusion and 
the second between 30-60 minutes after the end of infusion.  The freshly drawn blood 
samples will be processed and shipped to the laboratory by the Personalized Medicine 
Fellow.  Based on established limited sampling and population PK modeling, the AUC 
will be calculated from these two points [1, 4, 13] and the AUC results reported back to 
the Personalized Medicine Fellow.    
 
Given the lack of prospective data to validate an optimal therapeutic range for the 
docetaxel AUC, investigators have used retrospective data assessing the relationship 
between AUC and toxicity.  The different thresholds for docetaxel dose adjustments based 
upon the AUC are illustrated below in the context of the relationship with toxicity (Figure 
4).  The relationship between AUC and the primary hematologic toxicity of neutropenia 
across a variety of tumor types and dose ranges is shown.  The targeted AUC range of 3.1 
+/- 20% (or 2.5-3.7 mg*hr/L) for patients receiving docetaxel 75 mg/m2 was empirically 
derived from the apparent “cutpoints” for these trials, specifically from the published 
work of Minami, Alexandre and Ozawa, along with ongoing trials with the same assay in 
China and internal review by Saladax of the results from their CLIA lab.[18-20].   
 
Figure 4: Schematic representation of relationship with AUC and pharmacodynamic endpoints from the 
literature[7, 17-20]  
 
 
 
 
 
 
 
 
 
Ozawa, 2008 
1.78 for no FN – 3.30 for FN  
Alexandre, 2007 
4.1 for FN  
Odds ratio = 2.51 
Minami, 2006 
2.49 for neut. ≥ 500 
2.73 for neut. < 500  
ten Tije, 2005 
6.01 & age   ≥ 65 
16% FN 
Bruno, 2003 
Increase from 4.8 to7.2 
Increase odds of severe AEs ~2X 
13 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
 
 
 
 
 
    
AUC mg*h/L  FN = febrile neutropenia;  AEs = adverse events 
 
A dose adjustment algorithm for docetaxel has been constructed and is based on toxicity and on 
the results of plasma concentrations from the preceding applications (Figure 5).  This algorithm 
was developed using the information pulled from the literature (i.e. the range of AUCs observed, 
the relationship with toxicities, etc.). [1-5, 7, 9-11, 13, 17-24]  
 
 
 
 
Figure 5: Proposed literature derived dose adjustment algorithm in the context of reported PK/PD 
relationships. 
AUC (mg.h/L) from 
Previous Cycle 
Suggested % Dose Adjustment Algorithm 
(Assumes initial dosing of 75 mg/m2) * 
Toxicity 
Grade 0 - 2 
Toxicity 
Grade 3 - 4 
> 4.8 
- 30% 
- 30% 
3.8 - 4.8 
- 15% 
Follow package insert instructions:  Do not 
administer drug with neutrophil counts 
<1500 cells/mm2.  With grade 4 toxicity, 
reduce next dose by 25%. 
2.5 - 3.7 
No Change 
1.5 - 2.4 
+ 10% 
< 1.5 
+ 20% 
* The information presented provides an algorithm adapted from dose adjustment recommendations 
published in: 
Engels FK, et al.  Clin Cancer Res  17(2): 353-362, 2011 [3] 
Extra JM, et al.  Cancer Res  53(5): 235-252, 1993 [18] 
Bruno R, et al. J Clin Oncol  16(1):187-196, 1998 [1] 
Baker SD, et al.  Clin Cancer Res  10(6):1976-1983, 2004 [2] 
Baker SD, et al.  Clin Pharmacokinet  45(3): 235-252, 2006 [25] 
 
The suggested dosing algorithm for docetaxel presented above will be incorporated into 
the present trial for the AUC concentrations below the recommended range.  Given the 
adjuvant nature of the trial and the treatment goal of cure for these patients, dose 
AUC < 1.4,  
↑ 20% 
1.5<AUC< 2.4 
↑ 10% 
2.5< AUC < 3.7 
none 
3.8<AUC< 4.8 
↓ 15% 
AUC > 4.9 
↓30% 
14 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
reductions for concentrations above the recommended range will only be performed in the 
event of toxicity as described in section 4.2 below.   
 
2.2.4  Use of the TC Regimen in Older Breast Cancer Patients 
 
The combination of doxorubicin and cyclophosphamide (AC) is one of the most common 
adjuvant chemotherapy regimens for breast cancer patients with operable disease.  Based 
on the efficacy of docetaxel in the metastatic breast cancer setting and the potential for 
toxicities from AC, including cardiac toxicity, the combination of docetaxel and 
cyclophosphamide (TC) was attractive.  The two regimens were compared in 1016 
operable breast cancer patients with stage I, II, or III disease.  Patients received either AC 
or TC every 3 weeks for 4 cycles.  Dexamethasone 8 mg orally twice daily x 5 doses, 
starting the day before chemotherapy, was given as a premedication for patients receiving 
docetaxel.  Prophylactic growth factors were not permitted.  After 7 years of follow up, 
the disease free survival (DFS) was 75% in the AC arm compared to 81% in the TC arm 
(HR 0.74, 0.56-0.98, p=0.033).  The OS was 82% in the AC arm compared to 87% in the 
TC arm (HR 0.69, 0.50-0.97, p=0.032). Patients who received AC had higher rates of 
nausea and vomiting while those who received TC had higher rates of myalgia, arthralgia, 
edema and febrile neutropenia.[6, 25]   
 
Of the total 1016 patients, approximately 17% were 65 years of age or older.  The median 
age in the older population was 69 with range of 65-77 compared with a median age of 50 
(range 27-64) for the younger patients.   The benefit of TC over AC was similar in the 
older population in terms of both DFS and OS.  Older patients had higher rates of febrile 
neutropenia compared with younger patients (8% compared with 4%).  Other common 
grade 3 or 4 toxicities of TC are listed in the table below.[6] 
 
 
< 65 years old (%) 
> 65 years old (%) 
Neutropenia 
60 
52 
Thrombocytopenia 
<1 
0 
Febrile neutropenia 
4 
8 
Asthenia 
3 
6 
Edema 
1 
0 
Myalgia 
2 
0 
Arthralgia 
1 
<1 
Nausea 
2 
3 
Vomiting 
1 
0 
 
Patients > 65 years of age and older with operable breast cancer are commonly given the 
TC regimen at Moffitt Cancer Center and many other sites.  The higher rate of febrile 
neutropenia in the older population and the 52% rate of grade 3 or 4 neutropenia suggest 
15 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
that PK-guided therapy may be helpful to optimize dosing of this regimen in patients > 65 
years of age.  Given that the PK profile of docetaxel did not differ between older and 
younger patients and the fact that older patients may be more susceptible to the 
neutropenic effects of docetaxel, the commercially available MyDocetaxel™ assay may be 
helpful in individualizing the drug for this older population.  The present study will 
evaluate the use of PK-guided docetaxel chemotherapy to achieve a target AUC of 2.5-3.7 
mg*hr/L within 4 cycles of therapy in patients > 65 years of age with breast cancer 
receiving adjuvant TC in both academic and community practice oncology settings.   
 
2.2.5  Geriatric Assessments 
 
The relationship between docetaxel exposure and several validated methods of predicting 
toxicity outcomes in the older cancer population will also be assessed as part of this trial.  
These will include the Chemotherapy Risk Assessment Scale for High-Age Patients 
(CRASH), Instrumental Activities of Daily Living (IADL) and the Cumulative Illness 
Rating for Geriatrics (CIRS-G). 
 
The CRASH score has been shown to distinguish several toxicity risk levels into the 
following categories: low, intermediate-low, intermediate-high, or high.   It includes 
chemotherapy risk, hematologic risk factors (diastolic BP, IADL, and LDH) and non-
hematologic risk factors (ECOG PS, Mini-mental status score and mini-nutritional 
assessment score.  In a prospective, multicenter study in 518 patients > 70 years of age 
who were starting a new chemotherapy regimen, twenty-four different parameters were 
assessed with the purpose analyzing a large number of likely variable to create and then 
validate a clinically relevant tool to predict risk of chemotherapy toxicity.  The final 
CRASH score consists of two subscores, one to predict for hematologic and the other for 
nonhematologic toxicity.  The best model for hematologic toxicity included IADL, lactate 
dehydrogenase level, diastolic blood pressure and toxicity of the chemotherapy regimen 
(Chemotox).  The best model for nonhematologic toxicity included ECOG performance 
status, Mini-Mental Status score, Mini-Nutritional Assessment score, and Chemotox.  
Bootstrap internal validation and independent sample validation supported stable risk 
categorization and P trend < 0.001.[26]  The CRASH scoring tool is available through the 
Moffitt Cancer Center website at: http://moffitt.org/cancer-types--treatment/cancers-we-
treat/senior-adult-oncology-program-tools.  The IADL scale assesses the patient’s ability 
to perform on 9 different functional domains and is incorporated into the CRASH score 
discussed above.[27]   
 
The CIRS-G measures chronic illness burden in the elderly.   This is a 14 category scale 
measuring the cardiovascular, respiratory, gastrointestinal, genitourinary, musculo-
skeletal-integumentary, neuropsychiatric, and general systems.  For each of the 14 
systems, the illness burden is rated on a 5 point scale (none, mild, moderate, severe, 
extremely severe). The total score (out of 65) is then calculated with higher numbers being 
16 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
more indicative of higher disease burden.  The feasibility and reliability of the CIRS-G 
rating scale was assessed in 141 elderly outpatients who received comprehensive physical 
examinations, reviews of symptoms and laboratory testing.  This data was then used by 
nurse practitioners, physician’s assistants and geriatric psychiatrists to determine the 
CIRS-G ratings of chronic illness burden.  The interrater reliability was 0.78-0.88 
(intraclass correlations) for the scores.[28]  This scale is also available as an online tool at 
the above Moffitt Senior Adult Website. 
 
 
 
 
 
3. PATIENT SELECTION 
 
3.1  
Inclusion Criteria  
Patients meeting all of the following criteria will be considered for enrollment in the study: 
 
o Patients must have histologically confirmed localized or locally advanced breast cancer for 
which the treatment plan includes chemotherapy with 4 cycles of standard TC (docetaxel 
75 mg/m2 and cyclophosphamide 600mg/m2) 
 
o Age > 65 years (Senior adult focused study given increased risk for toxicity) 
o Patients must be female 
o ECOG performance status <2. (Appendix A) 
o Patients must have normal organ and marrow function as defined below: 
 
 
- 
leukocytes >3,000/µL 
 
 
 
- 
absolute neutrophil count >1,500/µL 
 
 
 
- 
platelets >100,000/µL 
- 
total bilirubin within normal institutional limits 
- 
AST(SGOT)/ALT(SGPT) <1.5 x institutional upper limit of normal 
-     
alkaline phosphatase < 2.5 x institutional upper limit of normal 
 
o No pre-existing neuropathy grade > 1 per the NCI CTCAE version 4.0 
 
o Be postmenopausal (defined as amenorrheic for at least 12 months) 
 
o All patients must be informed of the investigational nature of this study and be willing to 
provide written informed consent in accordance with Institutional guidelines and GCP 
indicating that they understand the purpose of and procedures required for the study and 
are willing to participate prior to the beginning of any specific study procedures. 
 
3.2  
Exclusion Criteria 
Any patient meeting any of the following criteria will be excluded from participating: 
17 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
 
o Have uncontrolled illness (including, but not limited to, ongoing or active infection, 
congestive heart failure, angina pectoris, or cardiac arrhythmia) that would limit 
compliance with study requirements. 
o Have psychiatric illness that would limit compliance with study requirements 
o Have history of allergic reactions attributed to compounds of similar chemical or biologic 
composition to taxanes (docetaxel or paclitaxel) or cyclophosphamide. 
o Have known seropositivity for human immunodeficiency virus, hepatitis C virus, hepatitis 
B surface antigen, or syphilis.  Does not require serologic confirmation as a study 
procedure. 
o Not willing to follow protocol requirements or to give informed consent 
 
 
3.3 Inclusion of Women and Minorities 
 
Women of all races and ethnic groups are eligible for this trial.  Inclusion criteria is restricted 
to women in an effort to decrease overall patient variability.   
 
 
 
3.4  
Patient Registration 
Once clinical eligibility is confirmed, patients must sign an informed consent prior to 
registration indicating awareness of the investigation nature of the study and its 
inherent risks in keeping with the policies of the hospital and Federal regulations 
(Code of Federal Regulations Part 1X, Subpart B, Sections 50.20-50.27).  Once the 
informed consent is signed and patient eligibility is confirmed, the patient will be 
assigned a unique Patient ID number consisting of the site identification number (for 
example 01, 02, etc.) and an ascending sequential number assigned by the site (001, 
002, 003, etc.).  For example, site 01’s first subject will be 001, so the Patient ID 
number for that subject will be 01-001.   
 
All subjects must be registered with the MCRN Coordinating Center to be able to 
participate in a trial. The participating site must fax or email the completed 
study specific eligibility checklist and registration forms, supporting documents 
and signed informed consent to the Coordinating Center. Unsigned or incomplete 
forms will be returned to the site. Once documents are received, the MCRN 
Research Coordinator will review them to confirm eligibility and to complete the 
registration process. If eligibility cannot be confirmed, the research coordinator 
will query the site for clarification or additional documents as needed. Subjects 
18 
 
 




MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
Chemotherapeutic Agent 
Dose 
Route 
Day 
Infusion 
Duration 
Docetaxel (Taxotere®) 
75 mg/m2 
IV 
1 
60 minutes 
Cyclophosphamide (Cytoxan®) 
600 mg/m2 
IV 
1 
30 minutes 
 
 
4.2  
Docetaxel PK-Guided Dose Adjustment 
 
Beginning with cycle 2, the docetaxel dose will be individually adjusted before each cycle. 
The cyclophosphamide dose will not be changed unless dictated by toxicity.  The 
docetaxel dose will be adjusted, if necessary, and the dose adjustment will be determined 
using the AUC results from the preceding cycle and the dose adjustment algorithm 
detailed below.  The dose may also be adjusted downward for clinical toxicity as 
described in section 5 below.  In the event that a patient experiences a docetaxel related 
toxicity ≥ grade 2, but has an AUC value that is below the target, the toxicity and 
subsequent dose reduction would take precedence over the PK-guided dose escalation 
recommendation.  For patients with toxicity grade < 1 on the day of treatment, the dose 
adjustment for cycle 2 will be made according to the following docetaxel dose-adjustment 
algorithm in consultation with the treating oncologist. 
 
Docetaxel Dose Adjustment Algorithm 
Toxicity Grade = 0/1 
Docetaxel Toxicity Grade ≥2a 
AUC 
(mg*hour/L) 
Dose Adjustment 
(± % of previous dose) 
Toxicity Considerations 
     AUC < 1.4 
+ 20% 
Grade 2: Physician discretion 
 
Grade 3a: Delay until recovery to 
< grade 2, and resume with 15% 
dose reduction unless patient’s 
AUC is > 4.9. 
 
Grade 4 hematologic: Delay until 
recovery to < grade 2, and 
resume with 30% dose reduction 
 
Grade 4 non-hematologic:  
Discontinue Treatment  
1.5 – 2.4 
+ 10% 
2.5 – 3.7 
Unchanged 
3.8 – 4.8 
-15% only in the event of 
grade 3 or higher toxicity 
AUC > 4.9 
-30% only in the event of 
grade 3 or higher toxicity 
 
 
 
 
 
 
a Asthenia, edema, myalgia/arthralgia, mucositis, neuropathy 
20 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
For patients who achieve the target AUC in any given cycle, the docetaxel dose will remain 
the same for the next cycle, with continued PK samples drawn per protocol to assure the 
target AUC was maintained.  In the event the AUC falls below the target range, the docetaxel 
dose for the subsequent cycle will be readjusted based on the out-of-range AUC and the dose 
adjustment algorithm above.  Given the adjuvant nature of the trial and the treatment goal of 
cure for these patients, dose reductions for concentrations above the recommended range will 
only be performed in the event of grade 3 or higher toxicity as indicated above. 
The patient’s required participation on the trial is completed after the post-cycle 4 
assessment for toxicity.  All dosing decisions will be made in consultation with and at the 
discretion of the primary treating medical oncologist.   
The dose of cyclophosphamide will remain the same unless dose reductions for toxicity 
are required (see Section 5). 
 
4.3  
Supportive Care Guidelines 
 
Supportive care therapy, including antiemetic prophylaxis, should follow institution 
specific guidelines for a moderately emetogenic chemotherapy regimen.  Hydration should 
also follow institution standards.  Dexamethasone 8 mg twice daily is recommended by 
the manufacturer the day before, day of, and day after the docetaxel infusion to prevent 
edema and infusion reactions, though may be adjusted by the primary treating physician 
based on patient specific factors.  All patients should receive either pegfilgrastim 6 mg SC 
x 1 or equivalent therapy (i.e. filgrastim, sargramostim, or tbo-filgrastim) 24 to 72 hours 
following the end of the docetaxel infusion as primary prophylaxis for febrile neutropenia. 
  
 
4.4  
Duration of Therapy 
 
 
 
In the absence of treatment delays due to adverse events, treatment should continue for 
 
 
four cycles or until one of the following criteria applies: 
 
• Disease recurrence 
• Intercurrent illness that prevents further administration of treatment, 
• Unacceptable adverse event(s), 
• Patient decides to withdraw from the study, or  
• General or specific changes in the patient's condition render the patient 
unacceptable for further treatment in the judgment of the investigator. 
 
 
5.   DOSING DELAYS/DOSE MODIFICATIONS 
 
21 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
All toxicities experienced during the course of each cycle will be assessed on the day of 
treatment, and graded using the Common Terminology Criteria for Adverse Events 
(CTCAE) version 4.0.  In the event of grade 2 non-hematologic toxicity associated with 
docetaxel (asthenia, edema, myalgia/arthralgia, neuropathy or mucositis), the dose of 
docetaxel will be decreased at the primary treating oncologist’s discretion.  In the event of 
grade 3 non-hematologic toxicity or grade 4 hematologic toxicity attributed by treating 
medical oncologist to docetaxel, docetaxel treatment will be withheld until recovery of the 
toxicity to grade < 2 and then restarted with a 15-20% dose reduction of docetaxel as 
described in section 4.2.  Treatment will be discontinued in cases of grade 4 non-
hematologic toxicity.  In the event that a patient experiences a docetaxel related toxicity, 
but has an AUC value that is below the target, the toxicity and subsequent dose reduction 
would take precedence over the PK-guided dose escalation recommendation.  
 
Any cyclophosphamide dose modifications secondary to toxicity will be at the discretion 
of the primary treating medical oncologist. 
 
 
6. PHARMACEUTICAL INFORMATION 
 
Commercially available supplies of the agents that comprise TC will be used for this 
study.  Please see the prescribing information for each agent for complete details on 
safety, formulation, preparation, administration, storage and stability and handling and 
disposal: Docetaxel (http://products.sanofi.us/Taxotere/taxotere.html) and 
cyclophosphamide (http://packageinserts.bms.com/pi/pi_cytoxan.pdf) 
 
Reported Adverse Events and Potential Risks 
The most common toxicities seen with docetaxel therapy include infections, neutropenia, 
anemia, febrile neutropenia, hypersensitivity reactions, thrombocytopenia, neuropathy, 
dyspnea, constipation, anorexia, nail disorders, fluid retention, asthenia, pain, nausea, 
diarrhea, vomiting, mucositis, alopecia, skin reactions and myalgia.  The toxicity severity 
and frequencies differ depending on the dose and schedule of the docetaxel.  When given 
with cyclophosphamide as part of the TC regimen, as is being used in this trial, the 
frequencies of these common side effects for patients > 65 are listed in the table below: 
 
 
Frequency of Grade 3-4 Toxicity in Patients > 65yo Receiving TC 
 
% 
Anemia 
<1 
Neutropenia 
52 
Thrombocytopenia 
0 
Febrile neutropenia 
8 
Asthenia 
6 
22 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
Edema 
0 
Fever 
6 
Myalgia 
0 
Arthralgia 
<1 
Stomatitis 
0 
Diarrhea 
5 
Nausea 
3 
Vomiting 
0 
 
 
Availability 
Docetaxel is commercially available as a sterile, nonpyrogenic injectable solution for 
intravenous administration. Each 10 mL contains 200 mg of docetaxel (20 mg/mL) in 
50/50 ratio with polysorbate 80/dehydrated alcohol.  The product should be further diluted 
for intravenous administration in 5% Dextrose for Injection USP or in 0.9% Sodium 
Chloride, USP to produce a final concentration of 0.3 mg/mL to 0.74 mg/mL. 
 
Storage and Stability 
Intact vials should be stored at room temperature between 2° and 25°C (36° and 77°F) and 
should be protected from light.  Docetaxel final dilution for infusion is stable at room 
temperature for 6 hours (including the 1 hour infusion time) and stable up to 48 hours if in 
a non-PVC bag and stored between 2° and 8°C. 
 
 
7. PHARMACOKINETIC ANALYSIS  
 
 
Saladax Biomedical’s MyDocetaxel™ Assay will be used to measure and report the AUC of 
docetaxel 
(see 
http://www.mycaretests.com/health-care-professionals/mycare-product-
information/mydocetaxel/ for complete details) based on the blood samples drawn for docetaxel 
plasma testing.   The MyDocetaxel™ proprietary assay is a homogenous two-reagent nanoparticle 
agglutination immunoassay used for detection of docetaxel in human plasma.  During each cycle 
(i.e. each administration of docetaxel), two blood samples, each consisting of 2 – 3mL of whole 
blood, must be collected from a peripheral port or venous draw for determination of the docetaxel 
plasma levels. The first blood sample will be collected 5 + 5 minutes before the end of the 
docetaxel infusion and a second sample will be collected 45 + 15 minutes after the end of the 
docetaxel infusion.  The AUC is calculated from the measured concentrations of docetaxel using a 
Bayesian population PK model.  This AUC result assumes the sample was drawn peripherally (i.e. 
not drawn from a portacath) and that the sample was handled according to the laboratory 
instructions provided in the collection kit.  The plasma samples collected for docetaxel PK testing 
will be tested for docetaxel levels in the CLIA licensed Johns Hopkins University Chemistry 
Reference Laboratory using IUO labeled MyDocetaxelTM assay kits provided by Saladax.  Each 
23 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
report will provide the calculated AUC in comparison to the target range of 2.5-3.7 mg.hr/L.  It is 
expected that results will be provided to the study team within 10 days following sample draw. 
 
 
 
8. STUDY CALENDAR 
 
Baseline evaluations are to be conducted within 1-week prior to start of protocol therapy.  In 
the event that the patient's condition is deteriorating, laboratory evaluations should be 
repeated within 48 hours prior to initiation of the next cycle of therapy. The assessments listed 
for each Cycle should be completed on +/-3 days from the first day of that cycle. 
 
Evaluations and Procedures 
Pre-study 
Cycle 1-4 
Off Study8 
 
 
D1 
D8-10 
 
Informed Consent 
X 
 
 
 
History and physical exam 
X 
X 
X 
X 
Medication history 
X 
 
 
 
Concurrent medications 
 
X 
 
 
ECOG Performance Status 
X 
X 
 
X 
Height and weight 
X 
 
 
 
CBC with diff1 
X 
X2 
X2 
X2 
AST/ALT/Alkaline phosphatase/Total 
Bilirubin/LDH 
X 
 
 
 
CRASH Score3 and IADL Assessment, 
MMSE and MNA 4 
X 
 
 
 
CIRS-G5 
X 
 
 
 
FACT-Taxane and Breast Assessment 
X 
X 
 
X 
Adverse Events and Toxicity Assessment 
(CTCAE v 4) 
X 
X 
 
X 
Docetaxel PK sample #1 and #26,7 
 
X 
 
 
Pegfilgrastim or equivalent9 
 
X 
 
 
1WBC, RBC, hemoglobin, hematocrit %, platelets count, neutrophils %, lymphocytes %, ANC and ALC to be 
recorded  
2CBC with differential at baseline, prior to each cycle of chemotherapy and then once between days 8-10 following 
chemotherapy administration during each cycle. 
3Chemotherapy Risk Assessment Scale for High-Aged Patients  
4Instrumental Activites of Daily Living 9 functional domain scale in addition to Folstein Mini-Mental State 
Assessment (MMSE) and Mini-Nutritional Assessment (MNA), which are all part of the CRASH score  
5Cumulative Illness Rating Scale for Geriatrics  
6First blood sample (2-3mL) to be taken 5 + 5 minutes prior to the end of the docetaxel infusion and second blood 
sample (2-3mL) to be taken 45 + 15 minutes following the end of the docetaxel infusion.  
7See Appendix C for detailed instructions on collecting, storing and shipping blood samples 
8Assessment and physical exam to be done 3-5 weeks following cycle 4 of TC or following the last cycle in which PK 
monitoring was be performed. 
9All patients should receive either pegfilgrastim 6 mg SC x 1 or equivalent therapy (i.e. filgrastim, sargramostim, or 
tbo-filgrastim) 24 to 72 hours following the end of the docetaxel infusion as primary prophylaxis for febrile 
neutropenia 
 
24 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
Pre-study Assessments 
A complete medical history, medication history, , demographics, physical examination 
(including height and weight for determination of body surface area [BSA, m2]) and 
performance status (ECOG) will be documented when patients are identified as being 
candidates for this study.  The following laboratory values will be recorded: WBC, RBC, 
hemoglobin, hematocrit %, platelets count, neutrophils %, lymphocytes %, ANC, ALC, 
AST, ALT, total bilirubin, and alkaline phosphatase.  The Chemotherapy Risk 
Assessment Scale for High-Age Patients (CRASH), Instrumental Activities of Daily 
Living (IADL), and Cumulative Illness Rating Scale for Geriatrics (CIRS-G) assessments 
will be performed at baseline for each patient.  Additionally, the LDH will be assessed and 
the Folstein Mini Mental Status (MMS) Assessment and Mini-Nutritional Assessment 
(MNA) will also be performed at baseline since they are required to complete the CRASH 
score, Patients will also complete the FACT-Taxane and FACT-Breast quality of life 
assessment written surveys at baseline.  Prior to starting their TC treatment, patients will 
also be assessed for any pre-existing toxicity using the Common Terminology Criteria for 
Adverse Events (CTCAE) version 4. 
 
Treatment Assessments 
Prior to the start of each cycle, the patient performance status will be assessed and their 
weight recorded for the determination of their BSA (in m2).  During cycle 1, a blood 
sample (2-3mL drawn into a 4mL lavender top K2EDTA Vacutainer® tube) will be taken 5 
+ 5 minutes prior the end of docetaxel infusion and a second blood sample will be taken 
45 + 15 minutes following the end of the docetaxel infusion for assessment of docetaxel 
plasma levels.  Please see Appendix B for detailed instructions on collecting, handling, 
storing and shipping the blood samples. The docetaxel plasma concentrations determined 
in these blood samples will be used to calculate the docetaxel dose for the second TC 
cycle to achieve a docetaxel area-under-the-concentration-time curve (AUC) of 2.5 to 3.7 
mg*hr/L or higher without the presence of toxicity.  During cycles 2-4, blood samples will 
again be taken 5 + 5 minutes prior the end of docetaxel infusion and 45 + 15 minutes 
following the end of the docetaxel infusion for assessment of docetaxel plasma levels and 
calculation of a docetaxel AUC.  Prior to each cycle of chemotherapy while the patient is 
on study, the following laboratory values will be assessed and recorded: WBC, RBC, 
hemoglobin, hematocrit %, platelets count, neutrophils %, lymphocytes %, ANC, ALC, 
AST, ALT, total bilirubin, and alkaline phosphatase.  Any changes to the patient’s current 
medications will also be recorded (concurrent medications).  Additionally, prior to each 
cycle of chemotherapy while the patient is on study, patients will be assessed for toxicity 
using the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0.  
Patients will also complete the FACT-Taxane and FACT-Breast quality of life assessment 
written surveys during each chemotherapy cycle .  Pegfilgrastim 6 mg SC x 1 or 
equivalent therapy (i.e. filgrastim, sargramostim, or tbo-filgrastim) will be given 24 to 72 
hours following the end of the docetaxel infusion as primary prophylaxis for febrile 
neutropenia to all patients.  
25 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
An additional CBC with differential will be drawn once between days 8-10 following each 
cycle of chemotherapy.  The WBC, RBC, hemoglobin, hematocrit %, platelets count, 
neutrophils %, lymphocytes %, ANC and ALC will be recorded.  The purpose of this 
additional CBC is to closely monitor patients given their age and risk of neutropenia with 
docetaxel based regimens. 
 
Post-treatment/Follow-up Assessments 
3-5 weeks following the 4th and last cycle of TC (or last cycle in which PK monitoring 
was performed), the patient will be assessed for toxicity and performance status and will 
have their WBC, RBC, hemoglobin, hematocrit %, platelets count, neutrophils %, 
lymphocytes %, ANC and ALC assessed.  A final FACT-Taxane and FACT-Breast 
quality of life assessment will also be completed by the patient.  The patient will officially 
be off study following this assessment. 
 
 
9. ADVERSE EVENTS AND REPORTING REQUIREMENTS 
 
An adverse event (AE) is any untoward medical occurrence in a patient or clinical 
investigation subject administered a pharmaceutical product and which does not necessarily 
have a causal relationship with this treatment.  An AE can therefore be any unfavorable and 
unintended sign (including an abnormal laboratory finding), symptom, or disease temporally 
associated with the use of a medicinal (investigational) product, whether or not related to the 
medicinal (investigational) product.   
Hospitalization for elective surgery or routine clinical procedures that are not the result of an 
AE (e.g., surgical insertion of central line) need not be considered AEs and should not be 
recorded as an AE.  Disease progression should not be recorded as an AE, unless it is 
attributable by the investigator to the study therapy.  During the collection of blood samples, 
patients may experience pain and/or bruising at the needle site, lightheadedness and/or fainting 
during or shortly after the blood draw, and in rare cases, localized clot formation and infections 
at the collection site.  These events are expected and should not be recorded as an AE. 
. 
9.1 Adverse Events (AE) Procedures 
 
The descriptions and grading scales found in the revised NCI Common Terminology Criteria 
for Adverse Events (CTCAE) version 4.0 will be utilized for adverse event reporting.  All 
appropriate treatment areas should have access to a copy of the CTCAE version 4.0.  A list of 
adverse events that have occurred or might occur (Reported Adverse Events and Potential 
Risks) can be found in Section 6 (Pharmaceutical Information).  A copy of the CTCAE 
version 4.0 can be downloaded from the CTEP web site 
(http://ctep.cancer.gov/reporting/ctc.html).  
 
26 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
Beginning at the time of subject consent, at each subject’s visit, the investigator will assess 
and document the occurrence of any adverse events.  The information on all adverse events 
CTCAE grade ≥2, whether reported by the subject or discovered by the investigator as a 
result of general questioning, during a physical examination, or in laboratory or other tests, 
will be recorded on the appropriate AE CRF in Oncore.  All AE, regardless of CTCAE 
grade, will be reported on the case report AE log which will be reviewed by the Primary 
Investigator for verification of CTCAE grading.  Any AE CTCAE grade ≥2 will then be 
reported appropriately in Oncore. Those illnesses/medical conditions present prior to starting 
the study treatment will only be considered AEs if they worsen after initiating the study 
treatment.  Abnormal laboratory or other test results will only be considered AEs if they 
cause clinical symptoms or signs or if they require treatment. 
As far as possible, each adverse event should be described in terms of: 
• Its duration (date of onset and resolution) 
• Severity - worst grade experienced during the interval (evaluated according to NCI-
CTCAE criteria, version 4) 
• Relationship to the study treatment  
• Action(s) taken 
• Outcome 
 
Causality Assessment 
The investigator will assess the causal relationship between the investigational product 
and all AEs.  The investigator will use his/her clinical expertise and judgment to select the 
category below that best fits the circumstances of the AE:  
Definite 
- 
Temporal relationship to the administration of the study drug and, 
- 
Course following a known reaction pattern and, 
- 
Improvement of the symptoms after dose reduction or discontinuation of the drug 
and, 
- 
Recurrence of the symptoms after re-administration of the drug; 
 
Probable 
- 
Temporal relationship to the administration of the drug and; 
- 
At least one of the following criteria is met: 
• Course following a known reaction pattern, 
• Improvement of the symptoms after dose reduction, 
• The subject’s current health status provides no other explanation for the event; 
 
Possible 
- 
Temporal relationship to the administration of the drug and 
- 
At least one of the following criteria is met: 
27 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
• Course following a known reaction pattern, 
• The event may also have been caused by other factors; 
 
Unlikely 
- 
No temporal relationship to the administration of the drug or, 
- 
Other factors are more likely to have caused the event; 
 
Not Related 
- 
No temporal relationship to the administration of the drug or 
- 
Other factors have caused the event; 
 
 
 
9.2 Suspected Adverse Events 
For reporting purposes, the categories of “Definite”, “Probable” and “Possible” will be 
summarized as “suspected” adverse events.  A suspected adverse event is an adverse event 
for which there is a reasonable possibility that docetaxel caused the adverse event.   
Information about all suspected adverse events should be recorded on the Adverse Event 
CRF in Oncore and will be appropriately followed up. 
 
9.3 Serious and Unanticipated Adverse Events 
A serious adverse event (SAE) is an undesirable sign, symptom or medical condition which: 
• is fatal or life-threatening, 
• results in required or prolonged hospitalization,  
• results in persistent or significant disability/incapacity,  
• constitutes a congenital anomaly or a birth defect (not applicable for this study), or 
• is medically significant (i.e. may jeopardize the patient and may require medical or 
surgical intervention to prevent one of the outcomes listed above). 
Events not considered to be serious adverse events are hospitalizations for the:  
• routine treatment or monitoring of the studied indication, not associated with any 
deterioration in condition,  
• treatment, which was elective or pre-planned, for a pre-existing condition that did not 
worsen, and 
• treatment on an emergency, outpatient basis for an event not fulfilling any of the 
definitions of serious given above and not resulting in hospital admission.  
An AE observed during the conduct of the study should be considered an unanticipated 
problem involving risk to human subjects only if it were unexpected, serious, and would 
have implications for the conduct of the study (e.g., requiring a significant, and usually 
28 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
safety-related, change in the protocol such as revising inclusion/exclusion criteria or 
including a new monitoring requirement, or informed consent).   
SAEs must be followed until resolution or deemed irreversible.  All relevant follow-up 
information must be promptly reported and recorded on the appropriate eCRF for that 
patient. 
 
9.4 Adverse Event Reporting Responsibility and Procedures 
All adverse events must be recorded on the appropriate CRF.  Non-serious Adverse Events 
will be recorded using the Adverse Event CRF in Oncore and will be monitored by the 
Primary Investigator on an on-going basis during the study.   
Information about all serious adverse events (SAE) will be collected and recorded. To ensure 
patient safety, each serious adverse event must be reported to the PI expeditiously. Moffitt 
Cancer Center and all participating sites will report SAEs by completing an SAE report in 
Oncore, the electronic data capture system. The SAE must be reported by email 
 to the MCRN within 2 working days. If applicable, the site 
should also follow protocol guidelines for additional reporting to government agencies.  
These toxicities will also be reviewed by the investigator and appropriate measures taken in 
terms of delaying or reducing or omitting the next cycle of therapy.   
The Primary Investigator will notify the IRB within 7 days after receipt of an Unanticipated 
SAE report in compliance with GCP and local requirements.  The Primary Investigator will 
also be in charge to inform all other concerned investigators of findings that could affect 
adversely the safety of the subjects, impact on the conduct of the trial or affect the favourable 
opinion to continue the trial.  All information on Suspected, Serious and Unanticipated 
Adverse Events will be reported by the investigators on the appropriate CRFs during the 
treatment phase up to 30 days after the end of the study treatment. 
Follow-up information about a previously reported Serious or Unanticipated Adverse Event 
must also be reported to the Primary Investigator within 24 hours of the investigator 
receiving this new information.  A new Serious Adverse Event CRF should be used, stating 
that this is a follow-up to the previously reported Serious or Unanticipated Adverse Event 
and giving the date of the original report.  Each re-occurrence, complication or progression 
of the original event should be reported as a follow-up to that event.  The follow-up 
information should describe whether the event has resolved or continues, if and how it was 
treated, and whether the subject continued or discontinued study participation. 
Serious unexpected adverse events related to the use of docetaxel or other study medication 
occurring from the time of administration of the first dose of study drug until 30 days after 
the final dose of study drug must be promptly reported to the FDA on a MedWatch form 
following Commercial Drug Reporting Guidelines.  Any serious unexpected adverse event 
must be reported to the Primary Investigator within 24 hours of the investigator receiving this 
new information so the appropriate reporting can be done in the 48 hour time frame. Any 
SAE occurring after this time that is thought to be possibly related to prior treatment with 
29 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
study drug should also be reported and recorded on the appropriate Electronic Case Report 
Forms (eCRF) for that patient. 
An Unanticipated Adverse Event that has not been previously documented (new occurrence) 
and is thought to be related to the study drugs (or therapy) may require further information 
from the investigator for FDA reporting. 
 
 
UNEXPECTED EVENT 
 
EXPECTED EVENT 
 
GRADES  3 
Attribution of Possible, 
Probable or Definite 
 
GRADES 4 and 5 
Regardless of Attribution 
 
GRADES 1 - 3 
 
GRADES 4 and 5 
Regardless of Attribution 
 
Grade 3 - Report by 
phone to PI within 24 hrs. 
Expedited report to follow 
within 10 working days. 
(Grade 1 and 2 – Adverse 
Event Expedited 
Reporting NOT required.) 
 
Inform PI within 24 hrs. 
Expedited report to follow 
within 10 working days. 
 
This includes all deaths 
within 30 days of the last 
dose of treatment with an 
investigational agent 
regardless of attribution. 
Any late death attributed to 
the agent (possible, 
probable, or definite) should 
be reported within 10 
working days. 
 
Adverse Event Expedited 
Reporting NOT required. 
 
Inform PI within 24 hrs.  
Expedited report to follow 
within 10 working days. 
 
This includes all deaths 
within 30 days of the last 
dose of treatment with an 
investigational agent 
regardless of attribution. 
Any late death attributed to 
the agent (possible, 
probable, or definite) 
should be reported within 
10 working days. 
 
 
For reasonable cause the Investigator and/or sponsor may terminate this study prematurely. 
Conditions that may warrant termination include, but are not limited to: the discovery of an 
unexpected, significant, or unacceptable risk to the patients enrolled in the study or if the accrual 
goals are met. A written notification of termination will be issued  
 
 
10.1 
Data Reporting 
 
10.2.1 Institutional Review Board 
 
 
No subject is to be enrolled on this protocol until the Center’s Institution Review   
 
 
Board has approved it. 
 
 
10.2.2  Data Management and Monitoring/Auditing 
Data will be captured in Oncore, Moffitt’s Clinical Trials Database. Regulatory 
documents and case report forms will be monitored internally according to Moffitt 
Cancer Center Monitoring Policies.  Monitoring will be performed regularly to verify data 
30 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
is accurate, complete, and verifiable from source documents; and the conduct of the trial 
is in compliance with the currently approved protocol/ amendments, Good Clinical 
Practice (GCP), and applicable regulatory requirements.  The Primary Investigator and 
study team will regularly assess the accuracy, management, and quality control of the 
data.  
 
To obtain access to Oncore, the site research staff must complete an Oncore Access 
Request Form and a Moffitt Information Systems Confidentiality Agreement (provided 
in the MCRN Handbook at the site initiation visit) and submit both to the Coordinating 
Center. Once the completed forms are received, the site coordinator will receive VPN 
access, logon/password, and information on how to access Oncore using the VPN. The 
MCRN Coordinating Center will provide Oncore training to the site once initial access 
is granted and on an ongoing basis, as needed.  
 
10.2.3  
Informed Consent 
The investigator is responsible for patient care and for obtaining consent by the 
patient.  Written informed consent must be obtained prior to entry of any patient. 
 
10.2.4  
Hospital/Clinic Records 
Hospital records for patients on this study are the responsibility of the investigator.  
They will be available for review by the sponsors of the trial, health care personnel 
involved in this study, the IRB, DHHS, and the FDA. 
 
10.2.5  
Investigator Study Files 
The Principal Investigator is responsible for maintaining study files for a period of 2 
years following the date a marketing application is approved for the drug for the 
indication for which it is being investigated; or if no application is to be filed or if the 
application is not approved for such indication, until 2 years after the investigation is 
discontinued and FDA is notified.  The following documents should be kept in the 
study files: 
A completed, signed FDA Form 1572 (Statement of Investigator) and copies of all 
current curricula vitae of all sub investigators listed on the Statement of the 
Investigator. 
 The original protocol and all amendments 
 Final IRB approval, annual renewals and all IRB correspondence 
 Blank Case Report Forms 
 Copy of all IRB approved Informed Consent forms with applicable version 
date 
 Updated laboratory certification and laboratory values (covering entire time of 
study) 
 Copy of all patient’s signed informed consent forms 
 The final completed case report form for all patients 
31 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
 
10.3 
Affiliate Site Required Documentation 
 
Before the study can be initiated at any site, the site will be required to provide regulatory 
documentation to the Moffitt Clinical Research Network (MCRN) at  Moffitt Cancer Center. 
Sites must provide a copy of their informed consent to the MCRN coordinating center for 
review and approval prior to submission of any documents to the site’s IRB. Any changes 
requested by the site’s IRB must be provided to the MCRN staff for review and approval prior 
to resubmission to the IRB. 
 
The MCRN Coordinating Center must receive the following trial specific documents either by 
hardcopy, fax, or email before a site can be activated for any trial: 
 
1. IRB Approval Letter that includes the protocol version and date 
2. FDA Related Forms 1572/1571/310 as appropriate 
3. Signed Protocol Title Page 
4. IRB Approved Consent Form 
5. Site Delegation of Authority Log 
6. Signed Financial Interest Disclosure Forms (principal and sub investigators) 
7. Updated Investigator/Personnel documents (CVs, licenses, Conflict of Interest 
statements, etc.) as needed 
8. Updated Laboratory Documents (certifications, normal ranges, etc.) as needed  
9. Signed protocol specific Task Order 
 
A study initiation teleconference will be held prior to the start of any study related activity at the 
site. Attendance is required for:  
• The site PI and appropriate research staff 
• Moffitt PI and MCRN research coordinator 
 
The requirements of the protocol and all associated procedures and processes will be reviewed 
and agreed upon prior to the activation of the study. The MCRN utilizes the EDC system, 
Oncore. Oncore training will be scheduled, if indicated, with the appropriate staff from the site.  
 
10.4 Protocol Monitoring Committee (PMC) 
The PMC meets once a month. The PMC reviews and evaluates safety and/or efficacy data for all 
physician authored clinical intervention trials. The PMC ensures the safety of patients and the 
validity and integrity of data. PMC reviews SAEs, deviations, Interim analysis, interim and final 
reports from the external Data Monitoring Committee (DMC) as well as audits both internally 
and externally. The PMC can make the following determinations, Accepted, Acceptable with 
Corrective Action and Tabled.  
 
Investigators of studies, which are designated to be reviewed by the PMC for data and safety 
monitoring, shall provide an interim analysis report of the study’s progress and summary of 
32 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
adverse events and deviations based on the phase of the study and the associated risk of the study 
or more often if applicable. The external DSMB (if applicable) shall forward its report for high-
risk studies designated for external review at least annually or more often if applicable.  
 
The PMC and/or the IRB may vote to suspend or terminate approval of a research study not being 
conducted in accordance with the IRB, the Cancer Center and/or regulatory requirements or that 
has been associated with unexpected problems or serious harm to subjects. The PMC/IRB will 
notify the PI in writing of such suspension or terminations. It is the responsibility of the 
PMC/IRB Chairperson to ensure prompt written notification of any suspensions or terminations 
of PMC/IRB approval to the relevant Federal Agencies, including OHRP, FDA, the study 
sponsor/funding source and if applicable, the Affiliate Program.  
 
 
11. STATISTICAL CONSIDERATIONS 
 
11.1 
Study Design/Endpoints 
 
This is a non-randomized trial assessing the impact of PK-guided docetaxel therapy in 
breast cancer patients > 65 years of age receiving TC.  All comparisons will be made 
using historical data.  The primary objective in this study is to demonstrate that PK guided 
docetaxel chemotherapy improves the ability to achieve a targeted AUC within 4 cycles of 
therapy in patients > 65 years of age with breast cancer receiving docetaxel as part of the 
standard TC regimen. 
 
11.2 
Sample Size/Accrual Rate 
 
Historical data suggest that 23% of patients receiving non-PK guided docetaxel achieve 
the targeted AUC within 4 cycles. We wish to detect an improvement with suitable power 
in those patients receiving docetaxel as part of TC. We estimate 50% of patients in the 
targeted AUC range after cycle 4 using the PK-guided dose adjustment of docetaxel. The 
level of significance is 0.05. A sample size of 52 evaluable patients achieves 97% power 
to detect a difference of 27% using the two-sided binomial test.  A sample size of 26 
evaluable patients achieves 84% power to detect a difference of 27% using the two-sided 
binomial test.  We will enroll 52  patients so at least 26 patients will be fully evaluable for 
all 4 cycles of therapy (based on drop out and sample mishandling from previous 
multicenter PK-directed therapy trials conducted by the investigators). 
 
11.3 
Analysis of Secondary Endpoints  
 
The incidence of grade 3 and 4 neutropenia and febrile neutropenia in cycles following 
PK adjustment (cycles 2-4) will be compared with cycle 1 and historical non-PK 
guided therapy using the Wilcoxon-Rank sum assessment. 
33 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
 
 
The association between the CRASH score, IADL total score, and CIRS-G score at 
baseline and the docetaxel AUC after cycle 1 will be assessed as a secondary endpoint 
along with the greater need for dose reductions based on the PK-guided dosing 
algorithm. The CRASH score will be reported as ordinal data (low, intermediate-low, 
intermediate-high, or high risk).  The IADL will be reported as binomial data. (greater 
or less than 26 based on how it is incorporated into the CRASH score). The CIRS-G 
will be reported as discrete data out of a possible score of 65.  The Wilcoxon-Rank 
sum and Chi-squared tests will be used as appropriate.  
 
 
Additionally, the relationship between PK-guided docetaxel patient profiles and the 
Function Assessment of Cancer Therapy (FACT) Taxane and Breast Cancer scores 
will be described.  
 
 
12.0 
 
Publications 
 
 
 
 
The study of these patients and results of all laboratory studies are considered private  
 
 
 
and confidential.  The progress and results of this study will not be presented without  
 
 
 
approval by the principal investigator.  The principal investigator prior to submission  
 
 
 
will review all abstracts and publications. 
 
 
 
 
REFERENCES 
 
1. 
Bruno, R., et al., Population pharmacokinetics/pharmacodynamics of docetaxel in phase II 
studies in patients with cancer. J Clin Oncol, 1998. 16(1): p. 187-96. 
2. 
Baker, S.D., et al., Comparative pharmacokinetics of weekly and every-three-weeks 
docetaxel. Clin Cancer Res, 2004. 10(6): p. 1976-83. 
3. 
Engels, F.K., et al., Therapeutic drug monitoring for the individualization of docetaxel 
dosing: a randomized pharmacokinetic study. Clin Cancer Res, 2011. 17(2): p. 353-62. 
4. 
Baille, P., et al., Optimal sampling strategies for bayesian estimation of docetaxel (Taxotere) 
clearance. Clin Cancer Res, 1997. 3(9): p. 1535-8. 
5. 
Launay-Iliadis, M.C., et al., Population pharmacokinetics of docetaxel during phase I studies 
studies using nonlinear mixed-effect modeling and nonparametric maximum-likelihood 
estimation. Cancer Chemother Pharmacol, 1995. 37(1-2): p. 47-54. 
6. 
Jones, S., et al., Docetaxel With Cyclophosphamide Is Associated With an Overall Survival 
Benefit Compared With Doxorubicin and Cyclophosphamide: 7-Year Follow-Up of US 
Oncology Research Trial 9735. J Clin Oncol, 2009. 27(8): p. 1177-83. 
34 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
7. 
ten Tije, A.J., et al., Prospective evaluation of the pharmacokinetics and toxicity profile of 
docetaxel in the elderly. J Clin Oncol, 2005. 23(6): p. 1070-7. 
8. 
Cline, D.J., et al., An automated nanoparticle-based homogeneous immunoassay for 
determining docetaxel concentrations in plasma. Ther Drug Monit, 2013. 35(6): p. 803-8. 
9. 
Bruno, R., et al., A population pharmacokinetic model for docetaxel (Taxotere): model 
building and validation. J Pharmacokinet Biopharm, 1996. 24(2): p. 153-72. 
10. 
Rudek, M.A., et al., Factors affecting pharmacokinetic variability following doxorubicin and 
docetaxel-based therapy. Eur J Cancer, 2004. 40(8): p. 1170-8. 
11. 
Hirth, J., et al., The effect of an individual's cytochrome CYP3A4 activity on docetaxel 
clearance. Clin Cancer Res, 2000. 6(4): p. 1255-8. 
12. 
Undevia, S.D., G. Gomez-Abuin, and M.J. Ratain, Pharmacokinetic variability of anticancer 
agents. Nat Rev Cancer, 2005. 5(6): p. 447-58. 
13. 
Sandstrom, M., et al., Model describing the relationship between pharmacokinetics and 
hematologic toxicity of the epirubicin-docetaxel regimen in breast cancer patients. J Clin 
Oncol, 2005. 23(3): p. 413-21. 
14. 
Ciurea, S.O. and B.S. Andersson, Busulfan in hematopoietic stem cell transplantation. Biol 
Blood Marrow Transplant, 2009. 15(5): p. 523-36. 
15. 
Saif, M.W., et al., Pharmacokinetically guided dose adjustment of 5-fluorouracil: a rational 
approach to improving therapeutic outcomes. J Natl Cancer Inst, 2009. 101(22): p. 1543-52. 
52. 
16. 
Galpin, A.J. and W.E. Evans, Therapeutic drug monitoring in cancer management. Clin 
Chem, 1993. 39(11 Pt 2): p. 2419-30. 
17. 
Bruno, R., et al., Alpha-1-acid glycoprotein as an independent predictor for treatment effects 
and a prognostic factor of survival in patients with non-small cell lung cancer treated with 
docetaxel. Clin Cancer Res, 2003. 9(3): p. 1077-82. 
18. 
Ozawa, K., H. Minami, and H. Sato, Logistic regression analysis for febrile neutropenia (FN) 
(FN) induced by docetaxel in Japanese cancer patients. Cancer Chemother Pharmacol, 2008. 
2008. 62(3): p. 551-7. 
19. 
Alexandre, J., et al., Relationship between cytochrome 3A activity, inflammatory status and 
the risk of docetaxel-induced febrile neutropenia: a prospective study. Ann Oncol, 2007. 
18(1): p. 168-72. 
20. 
Minami, H., et al., Pharmacokinetics and pharmacodynamics of protein-unbound docetaxel 
in cancer patients. Cancer Sci, 2006. 97(3): p. 235-41. 
21. 
Goh, B.C., et al., Explaining interindividual variability of docetaxel pharmacokinetics and 
pharmacodynamics in Asians through phenotyping and genotyping strategies. J Clin Oncol, 
2002. 20(17): p. 3683-90. 
22. 
Extra, J.M., et al., Phase I and pharmacokinetic study of Taxotere (RP 56976; NSC 628503) 
given as a short intravenous infusion. Cancer Res, 1993. 53(5): p. 1037-42. 
23. 
Yamamoto, N., et al., Randomized pharmacokinetic and pharmacodynamic study of 
docetaxel: dosing based on body-surface area compared with individualized dosing based on 
on cytochrome P450 activity estimated using a urinary metabolite of exogenous cortisol. J 
Clin Oncol, 2005. 23(6): p. 1061-9. 
35 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
24. 
Baker, S.D., A. Sparreboom, and J. Verweij, Clinical pharmacokinetics of docetaxel : recent 
developments. Clin Pharmacokinet, 2006. 45(3): p. 235-52. 
25. 
Jones, S.E., et al., Phase III trial comparing doxorubicin plus cyclophosphamide with 
docetaxel plus cyclophosphamide as adjuvant therapy for operable breast cancer. J Clin 
Oncol, 2006. 24(34): p. 5381-7. 
26. 
Extermann, M., et al., Predicting the risk of chemotherapy toxicity in older patients: the 
Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score. Cancer, 2012. 
118(13): p. 3377-86. 
27. 
Lawton, M.P., Scales to measure competence in everyday activities. Psychopharmacol Bull, 
1988. 24(4): p. 609-14. 
28. 
Miller, M.D., et al., Rating chronic medical illness burden in geropsychiatric practice and 
research: application of the Cumulative Illness Rating Scale. Psychiatry Res, 1992. 41(3): p. 
237-48. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Appendix A 
Eastern Cooperative Oncology Group Performance Status 
 
Grade 
ECOG 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out work 
of a light or sedentary nature, e.g., light house work, office work 
36 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
2 
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 
Capable of only limited self-care, confined to bed or chair more than 50% of waking 
hours 
4 
Completely disabled.  Cannot carry on any self-care.  Totally confined to bed or 
chair 
5 
Dead 
 
Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., Carbone, P.P.: Toxicity And 
Response Criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649-655, 1982.   
This scale was developed by the ECOG, Robert Comis, MD, Group Chair
37 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
Appendix B 
Docetaxel Pharmacokinetic Sampling Instructions 
Using Saladax Biomedical’s MyDocetaxel™ Test 
 
Samples for Pharmacokinetic (PK) Measurements:  For each chemotherapy application, two blood samples will be 
collected, with the first blood sample for PK assessment being collected 5 minutes before the end of docetaxel 
infusion and the second blood sample being collected ~30 to 60 minutes after the end of the docetaxel infusion. 
- 
DO NOT collect blood samples from the infusional IV line.  Rather, collect blood samples by 
venipuncture or through a peripheral IV line to avoid contamination by the infusing drug. 
- 
Freeze gel packs a minimum of 24 hours prior to use for shipment of plasma samples. 
- 
Samples collected on a Friday must be stored at 2 – 8oC immediately after processing and shipped to the 
laboratory on the following Monday.   
- 
Samples collected the day before a holiday must be must be stored at 2 – 8oC immediately after processing 
and shipped to the laboratory on the day following the end of the holiday, unless that is a Friday, in which case 
the sample should be shipped on the following Monday. 
 
The following procedure shall be followed for the collection, processing and shipment of PK blood specimens to The 
Johns Hopkins University Chemistry Reference Laboratory for evaluation with the MyDocetaxelTM assay: 
1. 
One patient blood sample of 2 – 3mL will be collected ~5 minutes before the end of docetaxel infusion 
and a second sample will be collected ~30 to 60 minutes after the end of the docetaxel infusion from a 
peripheral port or venous draw.  Standard phlebotomy techniques to collect venous blood specimens in 4.0mL 
lavender top K2EDTA tubes will be used.  Venous blood specimens will be collected by qualified medical 
personnel.  Universal Precautions when collecting blood specimens will be observed. 
2. 
The following patient-specific information must be recorded on the Laboratory Requisition Form which 
includes information such as: 
a. Patient ID 
b. Sample collection date and time 
c. The treatment regimen, drug dose and unit of concentration 
d. Cycle number 
e. Infusion start date and time 
f. Infusion end date and time 
3. 
The whole blood samples must be centrifuged within 10 minutes of the blood draw or immediately be placed 
on ice or refrigerated at 2-8°C and then centrifuged within 1 hour of the draw.  Centrifuge samples for 10 
minutes (preferred speed of 4,000g).  Samples not centrifuged per these instructions will not be tested.  
4. 
After centrifugation, carefully draw off the plasma from the top of the K2EDTA tube, avoiding the cell layer, 
and transfer to a secondary cryotube.  The plasma must be free of cells.  Squeeze the bulb of the disposable 
pipette before inserting the tip into the plasma.  Insert the pipette tip just beneath the top of the clear plasma 
layer and slowly release the bulb.  Track down as plasma is being drawn.  Aspirate only once to avoid 
disturbing the buffy coat/cellular layer between the plasma and red blood cells. 
5. 
Transfer the plasma sample into one of the supplied, 4mL graduated sample tubes.  Mark the provided label 
with the patient’s study identification number.  Attach the label lengthwise on the plasma tube.  Store the 
plasma sample at 2 – 8oC until shipment (must send sample to laboratory within 24-48Hr after collection). 
38 
 
 




MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
 
40 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
APPENDIX C: FACT-B version 4 
Below is a list of statements that other people with your illness have said are important. Please circle or mark one 
number per line to indicate your response as it applies to the past 7 days. 
 
PHYSICAL WELL-BEING 
 
Not 
at all 
A little 
bit 
Some-
what 
Quite
a bit 
Very 
much 
GP1 
I have a lack of energy ........................................................
0 
1 
2 
3 
4 
GP2 
I have nausea .......................................................................
0 
1 
2 
3 
4 
GP3 
Because of my physical condition, I have trouble 
meeting the needs of my family ..........................................
 
0 
 
1 
 
2 
 
3 
 
4 
GP4 
I have pain ...........................................................................
0 
1 
2 
3 
4 
GP5 
I am bothered by side effects of treatment ..........................
0 
1 
2 
3 
4 
GP6 
I feel ill ................................................................................
0 
1 
2 
3 
4 
GP7 
I am forced to spend time in bed .........................................
0 
1 
2 
3 
4 
 
 
SOCIAL/FAMILY WELL-BEING 
 
Not 
at all 
A little 
bit 
Some-
what 
Quite
a bit 
Very 
much 
GS1 
I feel close to my friends .....................................................
0 
1 
2 
3 
4 
GS2 
I get emotional support from my family .............................
0 
1 
2 
3 
4 
GS3 
I get support from my friends ..............................................
0 
1 
2 
3 
4 
GS4 
My family has accepted my illness .....................................
0 
1 
2 
3 
4 
GS5 
I am satisfied with family communication about my 
illness ..................................................................................
 
0 
 
1 
 
2 
 
3 
 
4 
GS6 
I feel close to my partner (or the person who is my main 
support) ...............................................................................
 
0 
 
1 
 
2 
 
3 
 
4 
Q1 
Regardless of your current level of sexual activity, please 
answer the following question. If you prefer not to answer it, 
please mark this box           and go to the next section. 
 
 
 
 
 
GS7 
I am satisfied with my sex life ............................................
0 
1 
2 
3 
4 
41 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
 
Please circle or mark one number per line to indicate your response as it applies to 
the past 7 days. 
 
 
 
EMOTIONAL WELL-BEING 
Not 
at all 
A little 
bit 
Some-
what 
Quite
a bit 
Very 
much 
GE1 
I feel sad ..............................................................................
0 
1 
2 
3 
4 
GE2 
I am satisfied with how I am coping with my illness ..........
0 
1 
2 
3 
4 
GE3 
I am losing hope in the fight against my illness ..................
0 
1 
2 
3 
4 
GE4 
I feel nervous .......................................................................
0 
1 
2 
3 
4 
GE5 
I worry about dying .............................................................
0 
1 
2 
3 
4 
GE6 
I worry that my condition will get worse .............................
0 
1 
2 
3 
4 
 
 
 
 
FUNCTIONAL WELL-BEING 
 
Not 
at all 
A little 
bit 
Some-
what 
Quite
a bit 
Very 
much 
 
GF1 
I am able to work (include work at home)...........................
0 
1 
2 
3 
4 
GF2 
My work (include work at home) is fulfilling .....................
0 
1 
2 
3 
4 
GF3 
I am able to enjoy life ..........................................................
0 
1 
2 
3 
4 
GF4 
I have accepted my illness ...................................................
0 
1 
2 
3 
4 
GF5 
I am sleeping well ................................................................
0 
1 
2 
3 
4 
GF6 
I am enjoying the things I usually do for fun .......................
0 
1 
2 
3 
4 
GF7 
I am content with the quality of my life right now ..............
0 
1 
2 
3 
4 
 
42 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
 
 
Please circle or mark one number per line to indicate your response as it applies to 
the past 7 days. 
 
 
 
ADDITIONAL CONCERNS 
 
Not at 
all 
A little 
bit 
Some-
what 
Quite
a bit 
Very 
much 
B1 
I have been short of breath ..................................................
0 
1 
2 
3 
4 
B2 
I am self-conscious about the way I dress ...........................
0 
1 
2 
3 
4 
B3 
One or both of my arms are swollen or tender ....................
0 
1 
2 
3 
4 
B4 
I feel sexually attractive .......................................................
0 
1 
2 
3 
4 
B5 
I am bothered by hair loss ...................................................
0 
1 
2 
3 
4 
B6 
I worry that other members of my family might someday 
get the same illness I have ...................................................
 
0 
 
1 
 
2 
 
3 
 
4 
B7 
I worry about the effect of stress on my illness ...................
0 
1 
2 
3 
4 
B8 
I am bothered by a change in weight ...................................
0 
1 
2 
3 
4 
B9 
I am able to feel like a woman.............................................
0 
1 
2 
3 
4 
P2 
I have certain parts of my body where I experience pain ....
0 
1 
2 
3 
4 
 
 
 
43 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
APPENDIX D: FACT-Taxane version 4 additional questions to be added to the FACT-B  
Below is a list of statements that other people with your illness have said are important.  
 
Please circle or mark one number per line to indicate your response as it applies to 
the past 7 days. 
 
 
 
ADDITIONAL CONCERNS 
 
Not at 
all 
A little 
bit 
Some-
what 
Quite 
a bit 
Very 
much 
NTX
1 
I have numbness or tingling in my hands ............................
0 
1 
2 
3 
4 
NTX
2 
I have numbness or tingling in my feet ...............................
0 
1 
2 
3 
4 
NTX
3 
I feel discomfort in my hands ..............................................
0 
1 
2 
3 
4 
NTX
4 
I feel discomfort in my feet .................................................
0 
1 
2 
3 
4 
NTX
5 
I have joint pain or muscle cramps ......................................
0 
1 
2 
3 
4 
HI12 
I feel weak all over ..............................................................
0 
1 
2 
3 
4 
NTX
6 
I have trouble hearing ..........................................................
0 
1 
2 
3 
4 
NTX
7 
I get a ringing or buzzing in my ears ...................................
0 
1 
2 
3 
4 
NTX
8 
I have trouble buttoning buttons ..........................................
0 
1 
2 
3 
4 
NTX
9 
I have trouble feeling the shape of small objects when 
they are in my hand .............................................................
 
0 
 
1 
 
2 
 
3 
 
4 
An6 
I have trouble walking .........................................................
0 
1 
2 
3 
4 
Tax1 
I feel bloated ........................................................................
0 
1 
2 
3 
4 
Tax2 
My hands are swollen ..........................................................
0 
1 
2 
3 
4 
Tax3 
My legs or feet are swollen .................................................
0 
1 
2 
3 
4 
Tax4 
I have pain in my fingertips .................................................
0 
1 
2 
3 
4 
44 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
Tax5 
I am bothered by the way my hands or nails look ...............
0 
1 
2 
3 
4 
45 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
APPENDIX E: Instrumental Activities of Daily Living (IADL) Scale (Lawton 1988) 
 
Name____________________________Rated__________________Date_____________ 
 
 
 
 
 
 
 
 
1. Can you use the telephone? 
 
1. 
Without help 
2. 
With some help, or 
3. 
Are you completely unable to use the telephone? 
3 
2 
1 
2. Can you get to places beyond walking distance? 
 
1. 
Without help 
2. 
With some help, or 
3. 
Are you completely unable to travel unless special arrangements 
are made 
3 
2 
1 
3. Can you go shopping for groceries? 
 
1. 
Without help 
2. 
With some help, or 
3. 
Are you completely unable to do any shoppping 
3 
2 
1 
4. Can you prepare your own meals? 
 
1. 
Without help 
2. 
With some help, or 
3. 
Are you completely unable to prepare any meals? 
3 
2 
1 
5. Can you do your own house work? 
 
1. 
Without help 
2. 
With some help, or 
3. 
Are you completely unable to do any housework? 
3 
2 
1 
6. Can you do your own handyman work? 
 
1. 
Without help 
2. 
With some help, or 
3. 
Are you completely unable to do any handyman work? 
3 
2 
1 
7. Can you do your own laundry? 
 
1. 
Without help 
2. 
With some help, or 
3. 
Are you completely unable to do laundry at all? 
3 
2 
1 
8a. Do you take medicines or use any medications? 
 
Yes (if yes, answer question 8b) 
No (if no, answer question 8c) 
 
8b. Do you take your own medicine? 
 
1. 
Without help (in the right doses at the right times) 
2. 
With some help (if someone prepares it for you and/or reminds 
you to take it) 
3. 
You are completely unable to take your own medicine? 
3 
2 
 
1 
8c. If you had to take medicine, could you do it? 
 
1. 
Without help (in the right doses at the right times) 
2. 
With some help (if someone prepares it for you and/or reminds 
you to take it) 
3. 
You would be completely unable to take your own medicine? 
3 
2 
1 
9. Can you manage your own money? 
 
1. 
Without help 
2. 
With some help, or 
3. 
Are you completely unable to manage money? 
3 
2 
1 
46 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
Appendix 2 - INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL) SCALE (Lawton 1988)  
The IADL Scale evaluates more sophisticated functions than the ADL Index. Patients or 
caregivers can complete the form in a few minutes. The first answer in each case except for 8a 
indicates independence; the second, capability with assistance; and the third, dependence. In 
this version, the maximum score is 29, although scores have meaning only for a particular 
patient, as when declining scores over time reveal deterioration. Questions 4-7 tend to be 
gender-specific. Modify them as you see fit.  
Ref: Lawton MP. Scales to measure competence in everyday 
 
47 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
APPENDIX F: Mini-Mental State Examination (MMSE) 
 
 
48 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
 
  
Mini-Mental State Examination (continued from previous page) 
 
 
 
MINI-MENTAL STATE EXAMINATION 
Patient Maximum 
Score  
Score 
ORIENTATION 
_____  
 5 
 
What is the (year) (date) (day) (month)? 
_____                 5 
 
Where are we (country) (state) (county) (city) (clinic)? 
 
REGISTRATION 
_____                 3 
Name three objects, allotting one second to say each one. Then ask the patient to name all 
three objects after you have said them.  Give one point for each correct answer. 
Repeat them until he hears all three. Count trials and record number. 
 
APPLE....BOOK.....COAT 
 
Number of trials________ 
 
    
 
ATTENTION AND CALCULATION 
_____                 5 
Begin with 100 and count backwards by 7 (stop after five answers): 93, 86, 79, 72, 65.  
Score one point for each correct answer. If the patient will not perform this task, 
ask the patient to spell “World” backwards (DLROW).  Record the patient’s 
spelling:_______ Score one point for each correctly placed letter. 
 
RECALL 
_____                 3 
Ask the patient to repeat the objects above (see Registration). Give one point for each 
correct answer. 
 
LANGUAGE 
_____                 2 
Naming: Show a pencil and a watch, and ask the patient to name them. 
 
_____  
 1 
 
Repetition: Repeat the following:  “No ifs, ands, or buts.” 
 
_____                 3 
Three-Stage Command: Follow the three-stage command, “Take a paper in your right 
hand; fold it in half, and put it on the table. 
 
_____                 1 
Reading: Read and obey the following: “Close your eyes”  (show the patient the item 
written on page 2). 
 
_____  
 1 
 
Writing: Write a sentence (on page 2). 
 
_____  
   1 
 
Copying: Copy the design of the intersecting pentagons (on page 2). 
 
_____  
30 
 
Total Score Possible 
 
Page 1 of 2 
49 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
 
 
 
C L O S E   Y O U R   E Y E S 
 
  
 
W R I T E   A   S E N T E N C E 
 
 
 
 
 
 
  
 
C O P Y   D E S I G N 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 2 of 2 
50 
 
 


MCC #: 18118 
PI:  Christine M. Walko, PharmD 
March 5, 2015 
 
APPENDIX G: Mini Nutritional Assessment (MNA) 
 
51