Conditions: Estrogen Receptor Positive Breast Cancer
Keywords: mTOR Tamoxifen Breast Cancer
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 28
Healthy volunteers: no

Brief summary:
This is an open label phase II clinical trial to determine the efficacy, toxicity, and safety of TAK-228 plus tamoxifen in patients with newly diagnosed ER-positive, HER2-negative breast cancer.

Detailed description:
The mTOR pathway is commonly dysregulated in ER-positive breast cancers and represents a key resistance mechanism to endocrine therapy such as tamoxifen. We plan to target the mTOR pathway with mTORC1/2 inhibitor TAK-228 to overcome tamoxifen resistance in early-stage ER-positive breast cancer. An open label phase II clinical trial will be conducted to determine the efficacy, toxicity, and safety of TAK-228 plus tamoxifen in patients with newly diagnosed ER-positive, HER2-negative breast cancer. TAK-228 (30 mg weekly) plus tamoxifen (20 mg daily) will be administered for 16 weeks. Patients will undergo tumor biopsy before starting the study treatment and after 6 weeks of study treatment. Blood samples for pharmacokinetics analysis will be obtained 1 hour before and after TAK-228 dosing on days 1 and 15 of the study.

Arms:
arm 1: TAK-228 will be orally administered at 30 mg weekly for 16 weeks.

Tamoxifen will be orally administered at 20 mg daily for 16 weeks.

Interventions: intervention 1: TAK-228 intervention 2: Tamoxifen
Intervention descriptions: intervention 1: MTORC1/2 inhibitor intervention 2: Non-steroidal anti-estrogen

Protocol document:
Prot_SAP_002.pdf: 
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OPEN LABEL, PHASE II TRIAL OF NEOADJUVANT TAK-228 PLUS TAMOXIFEN IN PATIENTS 
WITH ESTROGEN RECEPTOR (ER)-POSITIVE, HUMAN EPIDERMAL GROWTH FACTOR RECEPTOR 
TYPE 2 (HER2)-NEGATIVE BREAST CANCER. 
ANETT. 
 
 
 
 
Indication: 
Patients with newly diagnosed ER-positive, HER2-negative breast 
cancer 
Phase: 
II 
 
  Version:                                       11  
 
Protocol History 
  Original 
25 June 2018 
 
 
 
Investigator/Authors and Study Center: 
Jenny Chang, M.D. 
Houston Methodist Cancer Center 
6445 Main Street  
Houston, Texas 
77030 
713-441-0681  
 
 
 
 
IND Number: 132898 
 
IRB Number: Pro00016065 
 
 
This is an investigator-initiated study. The principal investigator Jenny Chang (who may also be referred to as 
the sponsor-investigator), is conducting the study and acting as the sponsor.  Therefore, the legal/ethical 
obligations of the principal investigator include both those of a sponsor and those of an investigator. 


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PROTOCOL SUMMARY  
Study Title:  Open Label, Phase II Trial Of Neoadjuvant TAK-228 Plus Tamoxifen In Patients With 
Estrogen Receptor (ER)-Positive, Human Epidermal Growth Factor Receptor Type 2 (HER2)-Negative 
Breast Cancer 
Phase:  II  
Number of Patients:  35  
Study Objectives:  
Primary 
• 
To evaluate Ki67 before and after treatment with the mammalian target of rapamycin complex 
(mTORC) 1 and 2 inhibitor TAK-228 plus the non-steroidal agent tamoxifen in patients with 
newly diagnosed ER-positive, HER2-negative breast cancer. 
Secondary 
• 
To evaluate the pathological complete response (pCR) rate after treatment with TAK-228 plus 
tamoxifen in patients with newly diagnosed ER-positive, HER2-negative breast cancer.  pCR 
will be defined as the absence of residual invasive and in situ cancer on hematoxylin and 
eosin evaluation of the complete resected breast specimen and all sampled regional lymph 
nodes following completion of neoadjuvant systemic therapy (i.e., ypT0 ypN0 in the current 
American Joint Committee on Cancer staging system). 
• 
To evaluate the preoperative endocrine prognostic index score after treatment with TAK-228 
plus tamoxifen in patients with newly diagnosed ER-positive, HER2-negative breast cancer. 
• 
To assess the toxicity and safety of TAK-228 plus tamoxifen in patients with newly diagnosed 
ER-positive, HER2-negative breast cancer.   
Exploratory  
• 
To determine the plasma pharmacokinetics of the TAK-228 plus tamoxifen combination. 
• 
To assess the correlation between pCR to TAK-228 plus tamoxifen and changes in Ki67, 
p53/p63/p73, phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT)/mTOR, and NFkB 
pathways in ER-positive, HER2-negative breast tumors. 
• 
To assess tumor mutational status to identify predictors of response to the TAK-228 plus 
tamoxifen combination. 
• 
To evaluate Oncotype DX recurrence score before and after treatment with TAK-228 plus 
tamoxifen. 
Overview of Study Design:   
This open label phase II trial is designed to determine the efficacy and safety of TAK-228 plus tamoxifen in 
patients with newly diagnosed ER-positive, HER2-negative breast cancer. TAK-228 (30 mg weekly [QW]) plus 
tamoxifen (20 mg daily [QD]) will be orally (p.o.) administered for 16 weeks. The treatment scheme is shown 
below. Dose adjustments for TAK-228-associated toxicities will be made based on previous literature. Baseline 
assessment, prespecified visits, and follow-up visit will be conducted as described below.  
To evaluate the efficacy of the study treatment, Ki67 will be measured pre- and post-treatment, with the 
expectation of a post-treatment reduction. Based on prior data for Ki67 changes in the tamoxifen only arm of 
the IMPACT trial, we will assume null and alternative hypotheses of 60% and 80% reduction in Ki67, 
respectively. Transformations of the geometric mean and 95% confidence interval will be employed to obtain 
mean and standard deviation estimates.  
Study Population:   
Patients with newly diagnosed ER-positive, HER2-negative breast cancer. Patients ineligible for inclusion are 
those with metastatic disease; those previously treated with hormonal therapy (tamoxifen, aromatase inhibitor) 
or PI3K, AKT, dual PI3K/mTOR, TORC1/2, or TORC1 inhibitors; and those with known hypersensitivity to 


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tamoxifen or mTOR inhibitors. 
Duration of Study:  16 weeks. 


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TABLE 1 SCHEDULE OF EVENTS 
Visit 
Screeninga 
Baselineb 
V1 
V2 
V3 
V4 
V5 
V6 
V7* 
EOT 
Week 
-4 to -3 
-2 to -1 
1 
3 
4 
6 
8 
12 
16* 
 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion 
X 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
Physical Examc 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Height 
X 
 
 
 
 
 
 
 
 
 
Weight 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
ECOG PS 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vital Signsd 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
12-Lead ECGe 
 
X 
 
 
 
 
 
 
 
X 
Hematologyf 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Clinical Chemistryg 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
FSH/LH/Estradiolh 
 
X 
 
 
 
 
 
 
 
 
Serum Pregnancy (β-hCG )i 
 
X 
 
 
 
 
 
 
 
 
Urinalysisj 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Fasting Lipid Panelk 
 
X 
 
 
X 
 
X 
X 
X 
X 
Bilateral Mammogram and USl 
 
X 
 
 
 
 
 
 
 
X 
Breast MRIm 
 
X 
 
 
 
 
 
 
 
X 
Clinical Breast Exam 
 
X 
 
 
X 
 
X 
X 
X 
X 
Concomitant Therapies 
 
Continuous from screening period 
Tumor Assessments (RECIST 1:1)  
 
X 
 
 
 
 
 
 
 
X 
Biopsyn 
 
X 
 
 
 
X 
 
 
 
 
Tumor Tissueo 
 
X 
 
 
 
X 
 
 
 
 
TAK-228   Administrationp 
 
 
 
Weekly from day 1, week 1 through day 1, week 16 
 
Tamoxifen   Administrationp 
 
 
 
Continuous daily from day 1, week 1 through day 7, week 16 
 
AEs  and  SAEs 
 
 
 
From ICF signing up to and including 30 days after local treatmentq 
Pharmacokineticsr 
 
 
 
Days 1 and 15 
 


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Abbreviations:  AE = adverse event; ALT = alanine transaminase;  ANC = absolute neutrophil count; aPTT = activated partial thromboplastin time;  ASP = 
aspartate transaminase; β-hCG = beta-human chorionic gonadotropin; CBC = complete blood count; ECG = electrocardiogram; ECOG PS = Eastern 
Cooperative Oncology Group performance status (see Appendix A); EOT = end of treatment; FBG = fasting blood glucose; FSH = follicle stimulating hormone; 
HbA1c = hemoglobin A1c; HDL-C = high-density lipoprotein cholesterol; ICF = informed consent form; INR = international normalized ratio; LDL-C = low-
density lipoprotein cholesterol; LH = luteinizing hormone; MRI = magnetic resonance imaging; p.o. = orally; PT = prothrombin time; QD = daily; QW = weekly; 
RECIST = Response Evaluation Criteria in Solid Tumors; SAE = serious adverse event; SOC = standard of care; US = ultrasound; V = visit; WBC = white 
blood cell. Tests and procedures should be done on schedule, but V windows of ± 4 days are allowed (except as otherwise specified) occasionally for 
holidays, vacations, and other administrative reasons or if extenuating circumstances prevent a patient from beginning treatment or completing a scheduled 
assessment within this time frame. Patients will receive surgery within 30 days of the final dose of study treatment. EOT is defined as 7 to 10 days after the 
final dose of study treatment. 
a. Within 28 days prior to  the week 1, day 1 dose of TAK-228 plus tamoxifen.    
b. Within 7 days prior to the week 1, day 1 dose of TAK-228 plus tamoxifen. Only screening procedures not performed within 7 days of dosing are required at 
baseline.  
c. The baseline symptom-directed medical history and physical examination are not required if the screening medical history and physical examination were 
conducted within 3 to 7 days prior to week 1, day 1. 
d. Vital sign (blood pressure, heart rate, and oral or temporal temperature) measurements will be obtained during screening, at baseline, and before every V. 
e. A 12-lead ECG will be performed at baseline, at EOT, and when clinically indicated.  
f. A blood sample for CBC with platelet count and differential WBC count will be obtained at baseline; every V [±1 day]; at EOT; and when clinically indicated. 
If a patient is found to have an ANC <500/mm3, platelet count < 25,000/mm3, or both, the CBC with differential should be repeated at least every other day 
until the ANC and platelet count have exceeded these values.   
g. A blood sample for the clinical chemistry panel (albumin, sodium, potassium, carbon dioxide, chloride, blood urea nitrogen, creatinine, total bilirubin, alkaline 
phosphatase, AST, and ALT) and evaluation of magnesium, uric acid, and lactate dehydrogenase will be obtained at baseline; every V [±1 day]; at EOT; and 
when clinically indicated. Fasting serum glucose is to be repeated every week for the length of the study and during follow-up. In-home daily glucose monitoring 
will be performed by the patients. All patients will be given a glucometer to monitor their daily FBG levels at home. FBG level should be measured after at least 
8 hours of fasting. On scheduled TAK-228 dosing days, FBG will be measured before TAK-228 dose. Patients with any abnormal readings (i.e., ≥ 150 mg/dL) 
will be instructed to notify the study staff immediately for further instructions on the management of their hyperglycemia. Hyperglycemia observed during home 
glucose monitoring should be confirmed in the clinic.  Investigators will be responsible for reviewing the home glucose monitoring logs for hyperglycemia. If no 
irregularities in the FBG level are observed during a minimum of 2 consecutive months, then the frequency of home fasting glucose testing can be reduced to a 
minimum frequency of once weekly, depending on the investigator’s judgment and approval. Patients will continue to notify the investigator of FBG levels that 
exceed 150 mg/dL and, if blood glucose levels are not well-controlled or the patient requires either oral hypoglycemic agents or insulin to control blood glucose 
levels, then the frequency of home testing of FBG levels will be reinstated to daily. HbA1c level will be measured at screening, week 8, and EOT. Coagulation 
parameters (PT/INR and aPTT) will be measured  at baseline, every V, and EOT. 
h. FSH/LH/Estradiol will be measured in all patients at baseline. 
i. For women of childbearing potential, the results of a serum β-hCG pregnancy test must be negative within 7 days before the first treatment dose is 
administered. If the screening serum β-hCG pregnancy test is performed more than 7 days before dosing, it must be repeated at baseline, with results 
known to be negative prior to administration of the first dose of the study drugs. β-hCG pregnancy testing is to be repeated as clinically indicated. 
j. Urinalysis will be performed at baseline, every V, and EOT. 
k. A fasting lipid panel will be obtained at baseline; week 4, 8, 12, and 16 of treatment; and EOT. This panel includes total cholesterol, HDL-C, LDL-C, and 
triglycerides. 
l. Bilateral mammogram and US will be performed at baseline and EOT. NOTE: Bilateral mammogram and US performed as SOC can be used for 
screening/baseline if performed within 90 days prior to the week1, day 1 dose of TAK-228 plus tamoxifen. 
m. Breast MRI will be performed at baseline and EOT. NOTE: Breast MRI performed as SOC can be used for screening/baseline if performed within 60 days 
prior to the week 1, day 1 dose of TAK-228 plus tamoxifen.  
n. In patients with accessible tumor, biopsies will be conducted at baseline and week 6 of treatment, and if the patient progresses while on treatment, before 
the patient starts the new treatment. 
o. Banked tumor tissue obtained as part of the patient’s standard care and additional biopsies will be evaluated at a later time to determine the correlation of 
specific molecular markers (ER; Ki67; mitotic index; apoptosis; levels of S6K, 4EBP-1, EIF4E, EIF4G, and EIF4A; levels of phosphorylated S6K, p53, p63, and 
p73; and p73 and p63 gene signatures) with clinical parameters such as tumor response. These correlative studies will help define a biomarker signature 
associated with p63/p73 and/or PI3K/AKT dependence and NFkB in ER-positive breast cancers as well as identify new therapeutic options for this group of 
patients. Tumor mutational analysis will also be performed to identify predictors of treatment response. Oncotype DX testing will also be performed on biopsy 
and surgical tissue samples. 
p. TAK-228 30 mg p.o. QW for 16 weeks plus tamoxifen 20 mg p.o. QD for 16 weeks. Adjust dose accordingly with Dose Level (see TAK-228 dose 
modifications). 
q. AEs and SAEs will be captured from the time of ICF signing up to and including 30 days after local treatment. Study treatment-related SAEs that occur 
beyond 30 days after local treatment and any study patient death should also be reported.  
r.  Blood samples for PK analysis will be obtained 1 hour (± 15 minutes) before TAK-228 dosing and 1 hour (± 5 minutes) after TAK-228 dosing on days 1 and 
15. Collect blood samples (10 ml per sampling timepoint) and batch the plasma for future analyses. 
*Patients will be treated until completion of 16 weeks. 


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TABLE OF CONTENTS 
PROTOCOL SUMMARY ........................................................................................................................ 2 
STUDY OVERVIEW DIAGRAM ............................................................................................................. 4 
SCHEDULE OF EVENTS ....................................................................................................................... 5 
LIST OF FIGURES ................................................................................................................................. 9 
LIST OF TABLES ................................................................................................................................... 9 
LIST OF ABBREVIATIONS  ................................................................................................................. 10 
1. BACKGROUND AND STUDY RATIONALE ..................................................................................... 13 
1.1. 
Scientific Background ............................................................................................................. 13 
1.1.1. Disease Under Treatment ................................................................................................ 15 
1.1.2. TAK-228 ........................................................................................................................... 15 
2. NON-CLINICAL SUMMARY ............................................................................................................. 16 
2.1 Pharmacology ................................................................................................................................ 16 
2.2 Safety Pharmacology ..................................................................................................................... 16 
2.3 Drug Metabolism and Pharmacokinetics ........................................................................................ 16 
2.4 Toxicology ...................................................................................................................................... 16 
3. SUMMARY OF EFFECTS IN HUMANS ........................................................................................... 17 
3.1 Pharmacokinetics ........................................................................................................................... 18 
3.2 Safety ........................................................................................... 21Error! Bookmark not defined. 
       4. Clinical Summary of Safety .............................................................................................................. 23 
4.1 Special Warnings and Precautions for Use .................................................................................... 23 
4.1.1 Insulin and Glucose Levels ................................................................................................... 23 
4.1.2 Cardiac Effects ..................................................................................................................... 23 
4.1.3 Renal Function ..................................................................................................................... 20 
4.1.4 Rash ..................................................................................................................................... 20 
4.1.5 Pneumonitis .......................................................................................................................... 20 
4.2 Interactions With Other Medicaments and Other Forms of Interaction ........................................... 20 
5. TAMOXIFEN.  .................................................................................................................................. 20 
6. STUDY RATIONALE ........................................................................................................................ 25 
7. STUDY OBJECTIVES ...................................................................................................................... 28 
7.1 Primary Objectives ......................................................................................................................... 28 
7.2 Secondary Objectives..................................................................................................................... 28 
7.3 Tertiary/Exploratory Objectives ...................................................................................................... 28 
8. STUDY ENDPOINTS ....................................................................................................................... 29 
8.1 Primary Endpoints .......................................................................................................................... 29 
8.2 Secondary Endpoints ..................................................................................................................... 29 
8.3 Tertiary/Exploratory Endpoints ....................................................................................................... 29 
9. STUDY DESIGN .............................................................................................................................. 29 
9.1 Overview of Study Design .............................................................................................................. 29 
9.2 Number of Patients ......................................................................................................................... 30 
9.3 Duration of Study ............................................................................................................................ 30 
10. STUDY POPULATION ................................................................................................................... 30 
10.1 Inclusion Criteria ........................................................................................................................... 30 
10.2 Exclusion Criteria.......................................................................................................................... 31 
11. STUDY DRUG ................................................................................................................................ 33 
11.1 Study Drug Administration ............................................................................................................ 33 


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11.1.1 Dose modification Guidelines ............................................................................................. 33 
11.1.2 Criteria for Dose Reduction ................................................................................................ 33 
11.2 Recommended Dose Modifications for Tamoxifen Treatment-Associated Toxicity ...................... 34 
11.3 Excluded Concomitant Medications and Procedures and potential Drug-Drug interactions ......... 34 
11.4 Permitted Concomitant Medications and Procedures ................................................................... 35 
11.5 Precautions and Restrictions ........................................................................................................ 35 
11.6 Management of Clinical Events .................................................................................................... 36 
11.6.1 Management of Hyperglycemia .......................................................................................... 36 
11.6.2 Management of Hyperlipidemia .......................................................................................... 37 
11.6.3 Management of Oral Mucositis ........................................................................................... 38 
11.6.4 Management of Rash ......................................................................................................... 38 
11.6.5 Management of Nausea/Vomiting ...................................................................................... 39 
11.6.6 Management of Cardiac Abnormalities ............................................................................... 39 
11.6.7 Management of Other Nonhematologic Toxicities (Including Asthenia, Weakness and 
Fatigue) ................................................................................................................................ 40 
11.6.8 Management of Aspartate Aminotransferase/Alanine Aminotransferase Elevations .......... 41 
11.6.9 Management of Non-infectious Pneumonitis ...................................................................... 41 
11.7 Description of Investigational Agents ........................................................................................... 42 
11.8 Dispensation ................................................................................................................................. 42 
11.9 Packaging and Labeling ............................................................................................................... 42 
11.10. Storage, Handling, and Accountability…………………………………………...……………….42 
11.11. Study Compliance…………..…………………………………………………………...…...…….43 
11.12. Termination of Treatment and/or Study Participation…………………..……..………………..43 
12. CRITERIA FOR RESPONSE ......................................................................................................... 43 
12.1 RECIST 1.1 .................................................................................................................................. 43 
13. STATISTICAL AND QUANTITATIVE ANALYSES ......................................................................... 44 
13.1 Statistical Methods ....................................................................................................................... 44 
13.1.1 Determination of Sample Size ............................................................................................ 44 
13.1.2 Randomization and Stratification ........................................................................................ 44 
13.1.3 Populations for Analysis ..................................................................................................... 44 
13.1.4 Procedures for Handling Missing, Unused, and Spurious Data .......................................... 45 
13.1.5 Demographic and Baseline Characteristics ........................................................................ 45 
13.1.6 Efficacy Analysis ................................................................................................................. 45 
13.1.7 PKs/Biomarkers .................................................................................................................. 45 
13.1.8 Safety Analysis ................................................................................................................... 46 
14. ADVERSE EVENTS ....................................................................................................................... 48 
14.1 Definitions ..................................................................................................................................... 46 
14.1.1 Adverse Event Definition .................................................................................................... 46 
14.1.2 Serious Adverse Event Definition ....................................................................................... 46 
14.2 Procedures for Reporting Serious Adverse Events ...................................................................... 47 
14.3 Procedures for Reporting Drug Exposure During Pregnancy and Birth Events ............................ 48 
15. ADMINISTRATIVE REQUIREMENTS............................................................................................ 48 
15.1 Product Complaints ...................................................................................................................... 48 
16. REFERENCES ............................................................................................................................... 50 
APPENDICES ...................................................................................................................................... 52 
Appendix A: CTCAE Version 4.03 (dated June-14-2010) ............................................................ 52 
Appendix B: List of Antidepressants and Association with CYP2D6 and Tamoxifen  ................... 53 
Appendix C: Eastern Cooperative Oncology Group Performance Status Scale ........................... 54 


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Appendix D: New York Heart Association Functional Classifications ........................................... 55 
Appendix E: List of Relevant Cytochrome P450 Inhibitors and Inducers .................................... .56 
 
 
LIST OF FIGURES 
Figure 1 Study Overview Diagram ……………………………………………………………………………….....4 
Figure 2 MCF-7 cells………………………………………………………………………………………………...27 
Figure 3 ZR-75-30 Tam resistant cells…………………………………………………………………………….27  
Figure 4 Study Overview Diagram…………………………………………………………………………………29 
 
LIST OF TABLES 
Table 1 Schedule of Event: Phase II Clinical trial TAM+TAK-228……………………………………………… 5 
Table 2 Summary of TAK-228 Clinical Studies……………………………………………………………….… 18 
Table 3 Tamoxifen Pharmacokinetics……………………………………………………………………………. 21 
Table 4 Tamoxifen Side Effect……………………………………………………………………………………..22 
Table 5 Tamoxifen Drug Interactions……………………………………………………………………………...23 
Table 6 Dose-limiting Toxicity of TAK-228 ……………………………………………………………………….34  
Table 7 TAK-228 Dose Modifications……………………………………………………………………………...34 
Table 8  Management of Hyperglycemia…………………………….…………………………………………....37 
Table 9  Management of Hyperlipidemia…………………………….…………………………………………....37 
Table10 Management of Oral Mucositis…………………………….…………………………….………...…….38 
Table 11 Management of Rash…………………………….…………………………….………………………...38 
Table 12 Management of Nausea/Vomiting…………………………….………………………………………...39  
Table 13  Management of Left Ventricular Dysfunction…………………….……………………………….…..39 
Table 14  Management of QTc Prolongation…………………….…………………………………………….....39 
Table 15 Management of Other Non-hematologic Toxicities (Including Asthenia, Weakness, and Fatigue) 
.…….…………………………………………………………………………………………………………………..40 
Table 16 Management of Aspartate Aminotransferase/Alanine Aminotransferase Elevations……………..40 
Table 17 Management of Non-infectious Pneumonitis…………………………………………………………..41 
 
 
 
 
 
 
 


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LIST OF ABBREVIATIONS  
 
Abbreviation 
Term 
AE 
adverse event 
AI 
aromatase inhibitor 
AKT 
protein kinase B 
ALT 
alanine aminotransferase 
ANC 
absolute neutrophil count 
API 
active pharmaceutical ingredient 
AST 
aspartate aminotransferase 
AUC 
area under the curve 
Cmax 
maximum plasma concentration 
CBR 
clinical benefit rate 
CI 
confidence interval 
CR 
     complete response 
CRF 
     case report form 
CTCAE   
     Common Terminology Criteria for Adverse Events 
CYP 
cytochrome P450 
DDI 
drug-drug interaction 
DLT 
  dose-limiting toxicity 
ECG 
electrocardiogram 
4EBP-1 
eukaryotic translation initiation factor 4E binding protein-1 
EIF 
eukaryotic translation initation factor 
ER 
estrogen receptor 
EOT  
end of treatment 
FBG 
fasting blood glucose 
FDA 
Food and Drug Administration 
FSG 
fasting serum glucose 
GI 
gastrointestinal  
GLP 
Good Laboratory Practice 
HbA1c 
glycosylated hemoglobin 
HER2 
human epidermal growth factor receptor 2 
HR 
hazard ratio 
IB 
investigator brochure 


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Abbreviation 
Term 
ICF 
informed consent form 
IC50 
IHC 
half-maximal inhibitory concentration 
immunohistochemical 
IV 
intravenous 
mBC 
metastatic breast cancer 
MM 
multiple myeloma 
MTD 
maximum tolerated dose 
mTOR 
mammalian target of rapamycin 
mTORC 
mammalian target of rapamycin complex  
NCI 
National Cancer Institute 
NHL 
non-Hodgkin Lymphoma 
OCT 
 organic cation transporter  
PAX2 
 paired box 2 
pCR 
 pathological complete response 
PD 
PEPI 
 progressive disease 
preoperative endocrine prognostic index 
PFS 
progression-free survival 
PI3K 
phosphatidylinositol 3-kinase 
PK 
pharmacokinetics 
p.o. 
per os; by mouth (orally) 
PPI 
 protein pump inhibitor 
PR 
 partial response 
QD 
 once daily 
QD×3 days per week 
 once daily for 3 consecutive days followed by a 4-day dosing holiday every week 
QD×5 days per week 
 once daily for 5 consecutive days followed by a 2-day dosing holiday every week 
QTc 
 heart rate-corrected QT interval  
QW 
once weekly 
RECIST 
Response Evaluation Criteria in Solid Tumors 
RP2D 
recommended phase II dose 
S6K1 
ribosomal protein S6 kinase 1 
SAE 
serious adverse event 
SD 
stable disease 
SSRI 
selective serotonin reuptake inhibitor 
tmax 
time to reach Cmax 


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Abbreviation 
Term 
TEAE 
treatment-emergent adverse event 
TTP 
time to progression 
ULN  
upper limit of normal 
US 
ultrasound 
WM 
Waldenström’s macroglobulinemia 
 
 
 
 


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1.    BACKGROUND AND STUDY RATIONALE 
 
1.1    Scientific Background 
STUDY RATIONALE 
The two distinct mammalian targets of rapamycin (mTOR) complexes, mTORC1 and mTORC2, play 
crucial roles in regulating tumor cell growth, metabolism, and motility.1 Clinical trials with mTOR inhibitors 
have shown promising results. The open label, phase II TAMRAD (Tamoxifen plus Everolimus) study 
evaluated the efficacy of the mTOR inhibitor everolimus combined with tamoxifen in endocrine therapy 
(aromatase inhibitor [AI])-resistant patients. AI-pretreated patients were selected to enrich for 
phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT)/mTOR-driven tumors, which would be more 
likely to be sensitive to mTOR inhibition. Postmenopausal women with AI-resistant hormone receptor–
positive, human epidermal growth factor receptor 2 (HER2)-negative, metastatic breast cancer (mBC) were 
randomly assigned to receive tamoxifen 20 mg daily (QD) plus everolimus 10 mg QD (n=54) or tamoxifen 
alone (n=57). Randomization was stratified by primary and secondary hormone resistance. The primary 
endpoint was clinical benefit rate (CBR), defined as the percentage of all patients with complete response, 
partial response, or stable disease at 6 months. The CBR was 61% (95% confidence interval [CI], 47–74) 
with tamoxifen plus everolimus and 42% (95% CI, 29–56) with tamoxifen alone. Time to progression (TTP) 
increased from 4.5 months with tamoxifen alone to 8.6 months with tamoxifen plus everolimus, 
corresponding to a 46% reduction in risk of progression with the combination (hazard ratio [HR], 0.54; 95% 
CI, 0.36–0.81). Risk of death was reduced by 55% with tamoxifen plus everolimus versus tamoxifen alone 
(HR, 0.45; 95% CI, 0.24–0.81). The main toxicities associated with tamoxifen plus everolimus were fatigue 
(72% vs. 53% with tamoxifen alone), stomatitis (56% vs. 7%), rash (44% vs. 7%), anorexia (43% vs. 18%), 
and diarrhea (39% vs. 11%). This study suggests that tamoxifen plus an mTOR inhibitor increase CBR, 
TTP, and overall survival compared with tamoxifen alone in postmenopausal women with AI-resistant 
mBC.2  
 
Results from the BOLERO 2 trial demonstrated that an mTOR inhibitor (everolimus) combined with an AI 
(exemestane) improves progression-free survival (PFS) in patients with hormone receptor-positive 
advanced breast cancer previously treated with nonsteroidal AIs. The PFS rate for patients treated with 
exemestane and everolimus was 7.8 months compared with 3.2 months for those treated with exemestane 
alone (HR, 0.45, 95% CI, 0.38–0.54, P < 0.0001). This treatment combination also proved to be safe. The 
most common grade 3/4 adverse event (AE) was stomatitis (8% in the everolimus plus exemestane group 
vs. 1% in the placebo plus exemestane group). Here, we propose to determine the efficacy of the 
mTORC1/2 inhibitor TAK-228 in combination with tamoxifen in patients with newly diagnosed hormone 
receptor-positive breast cancer by evaluating the change in Ki67 and pathological complete response 
(pCR) rate. 
 
BACKGROUND  
mTOR activity is frequently dysregulated in human cancers. mTORC1 and mTORC2 regulate cell growth, 
metabolism, angiogenesis, and cell survival and are currently being investigated as potential cancer 
therapeutic targets. TAK-228 (Millennium Pharmaceuticals) alone and in combination with conventional 
agents has demonstrated cytotoxic and antiproliferative activity in cells lines with mTORC1 and/or 
mTORC2 activity.3 TAK-228 is a potent and selective ATP-dependent mTORC1/2 inhibitor and is 
structurally and mechanistically distinct from rapamycin and the rapalogs, which only partially inhibit 
mTORC1.4 Phase I and II studies of TAK-228 monotherapy and combination therapies are being 
conducted in patients with solid and liquid malignancies.  The purpose of these studies is to determine the 
highest dose of TAK-228 that can be given safely to patients. Millennium Pharmaceuticals-sponsored 
clinical trials of TAK-228 in combination with exemestane or fulvestrant in postmenopausal women with 


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estrogen receptor (ER)/progesterone receptor-positive mBC (NCT02049957) and in combination with the 
oral PI3Kα inhibitor TAK-117 (previously MLN1117; NCT01899053) are currently ongoing and the results 
are awaited.5,6 In a phase I study, Infante et al. determined the maximum tolerated dose (MTD) of TAK-228 
to be 6 mg orally (p.o.) QD. Common TAK-228-related toxicities included hyperglycemia and rash, which 
were manageable and reversible.1 
 
Tamoxifen is a non-steroidal agent with potent antiestrogenic properties. Tamoxifen competitively binds to 
ERs on tumor cells and other tissue targets, producing a nuclear complex that decreases DNA synthesis 
and inhibits estrogen effects. Tamoxifen causes G0 and G1 cell cycle arrest. Tamoxifen is cytostatic rather 
than cytocidal, as it prevents (pre)cancerous cells from dividing but does not cause cell death. Tamoxifen 
itself is a prodrug, having relatively little affinity for its target protein, the ER. It is metabolized in the liver by 
cytochrome P450  (CYP)2D6 and CYP3A4 into active metabolites such as 4-hydroxytamoxifen 
(afimoxifene) and N-desmethyl-4-hydroxytamoxifen (endoxifen),7,8 which have a 30–100 times greater 
affinity for the ER than tamoxifen itself. These active metabolites compete with endogenous estrogen for 
ER binding. In breast tissue, 4-hydroxytamoxifen acts as an ER antagonist to inhibit the transcription of 
estrogen-responsive genes.9 Tamoxifen binds to the ER, which in turn interacts with DNA. The 
ER/tamoxifen complex recruits other proteins known as corepressors, including NCoR and SMRT, to 
inhibit estrogen-responsive genes.10 Tamoxifen function can be regulated by a number of different 
variables including growth factors.11 High HER2 expression levels have been shown to induce tamoxifen 
resistance.12 Tamoxifen seems to require the protein paired box protein 2 (PAX2) for its full anticancer 
effect.10,13,14 In the presence of high PAX2 expression, the tamoxifen/ER complex is able to suppress the 
expression of the proproliferative HER2 protein. In contrast, when amplified in breast cancer-1 expression 
is higher than PAX2, the tamoxifen/ER complex upregulates HER2 expression, resulting in the stimulation 
of breast cancer growth.10,14  
 
Tamoxifen is currently used for the treatment of both early and advanced ER-positive breast cancer in 
premenopausal and postmenopausal women15 and is the most common hormone treatment for male 
breast cancer.16 The Food and Drug Administration (FDA) has approved tamoxifen for the prevention of 
breast cancer in high-risk women17 and contralateral breast cancer. In 2006, the large STAR clinical study 
concluded that the ER antagonist raloxifene is equally effective as tamoxifen in reducing the incidence of 
breast cancer. Furthermore, after a mean 4-year follow-up, the incidence of uterine cancers and blood 
clots was 36% and 29% lower in women taking raloxifene than in women taking tamoxifen, respectively, 
although these differences were not statistically significant.18-20 
 
Studies have aimed to identify new therapeutic strategies to overcome endocrine therapy resistance in 
hormone receptor-positive breast cancers.21 An emerging mechanism of endocrine resistance is aberrant 
PI3K/AKT/mTOR signaling.21-23 Growing evidence supports a close interaction between mTOR and ER 
signaling pathways. The mTORC1 substrate ribosomal protein S6 kinase 1 (S6K1) phosphorylates 
activation function domain 1 of the ER, which is responsible for ligand-independent receptor activation.24,25 
Non-steroidal endocrine therapy is the cornerstone of treatment for patients with newly diagnosed and 
advanced hormone receptor-positive breast cancer. Tamoxifen has become the treatment of choice in 
premenopausal and postmenopausal patients with newly diagnosed ER-positive breast cancer.26-30 
Unfortunately, not all patients respond to neoadjuvant nonsteroidal endocrine therapy (primary or de novo 
resistance), and even patients who initially respond eventually relapse (acquired resistance). For disease 
progression, first-line treatment options include AIs (steroidal or nonsteroidal) and the ER antagonists 
fulvestrant and raloxifene.31-33 
 
A minimum percentage of women with ER-positive, HER2-negative breast cancer will respond to 


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neoadjuvant tamoxifen therapy. Based on clinical findings and other data, ER-targeted therapy combined 
with a mTORC1/2 inhibitor may achieve high blockade of proliferation pathways and better pCR rates 
than ER-targeted therapy alone in newly diagnosed ER-positive breast cancer patients. Here, we propose 
an open label phase II clinical trial to determine the efficacy (change in Ki67, pCR rate, and preoperative 
endocrine prognostic index score [PEPI] score) and safety of TAK-228 plus tamoxifen in patients with 
newly diagnosed ER-positive breast cancer. Serial cancer tissue samples will be obtained for molecular 
studies of tumor response. Toxicity will be graded according to the National Cancer Institute (NCI) 
Common Terminology Criteria for Adverse Events (CTCAE) version 4.03 (see Appendix A). Tumor 
assessment will include mammogram, breast ultrasound (US), and breast magnetic resonance imaging at 
baseline and end of treatment (EOT). Hematologic function, biochemical measures, vital signs, renal 
function (urinalysis), and coagulation parameters (prothrombin time/international normalized ratio, 
activated partial thromboplastin time) will be assessed at baseline, every visit, and EOT. Hemoglobin A1c 
(glycosylated hemoglobin; HbA1c) will be assessed at baseline, week 8, and EOT. Lipid profile will be 
assessed at baseline; week 4, 8, 12, and 16 of treatment; and EOT. Tissue will be collected at baseline 
and week 6 of treatment and from the surgical specimen. Blood samples for pharmacokinetics (PK) 
analysis will be obtained 1 hour (± 15 minutes) before TAK-228 dosing and 1 hour (± 5 minutes) after 
TAK-228 dosing on days 1 and 15. Blood samples (10 ml per sampling timepoint) will be collected and 
plasma batched for future analyses. 
 
1.1.1    Disease Under Treatment 
Newly diagnosed ER-positive, HER2-negative breast cancer 
 
1.1.2     TAK-228  
Millennium has developed TAK-228, a novel, highly selective, orally bioavailable ATP-competitive inhibitor 
of the serine/threonine kinase mTOR. TAK-228 (formerly INK128) selectively and potently inhibits mTOR 
(half-maximal inhibitory concentration [IC50] = 1.1 nM), inhibits mTORC1/2 signaling, and blocks cell 
proliferation. mTOR regulates cell growth, translation, angiogenesis, and cell survival by integrating 
nutrient and hormonal signals.34 mTOR plays a key role in several pathways that are frequently 
dysregulated in human cancer. mTORC1 is best known as a key regulator of protein translation through 
phosphorylation of eukaryotic translation initiation factor 4E binding protein-1 (4EBP-1) and S6K1. 
mTORC2 is best known for its ability to fully activate (S473 phosphorylation) AKT, which regulates 
proliferation and survival pathways.35 
 
mTORC is an important therapeutic target as it is a key intracellular point of convergence for a number of 
cellular signaling pathways. mTOR inhibition may suppress abnormal cell proliferation, tumor 
angiogenesis, and abnormal cellular metabolism, thus providing the rationale for the use of mTOR 
inhibitors alone or in combination with chemotherapeutic agents in the treatment of solid and hematological 
malignancies. Rapamycin and newly approved rapalogs (temsirolimus and everolimus) are specific and 
allosteric inhibitors of mTORC1. These agents only partially inhibit mTORC1 signaling pathways and do 
not inhibit mTORC2, which has shown to be an emerging therapeutic target in cancer research. TAK-228, 
which targets both mTORC1 and mTORC2, was developed to address the incomplete inhibition of the 
mTOR pathway by rapalogs. 
TAK-228 is being developed for both oncology and non-oncology indications. TAK-228 monotherapy and 
combination therapies with chemotherapy, other molecularly targeted therapies, and antihormonal agents 
are being investigated for the treatment of advanced solid and hematologic malignancies.  


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2.    NONCLINICAL SUMMARY 
2.1 
Pharmacology 
TAK-228 selectively and potently inhibits mTOR (IC50 = 1.1 nM), inhibits mTORC1/2 signaling, and blocks 
cell proliferation.  TAK-228, administered p.o. in multiple human tumor xenograft mouse models, inhibited 
angiogenesis and tumor growth by inhibiting mTOR signaling at plasma concentrations associated with in 
vitro inhibition of mTOR in a dose- and time-dependent manner. These effects display a clear PK-to-
pharmacodynamic relationship.3 TAK-228 inhibits both the phosphorylation of S6 and 4EBP1, the 
downstream substrates of TORC1, and selectively inhibits AKT phosphorylation at Serine 473, as 
evidenced by decreased phosphorylated AKT, the downstream substrate of TORC2.3-5 TAK-228 inhibits 
mTOR signaling and has demonstrated anticancer activity against a number of human solid tumor cell-line 
xenograft mouse models, including phosphatase and tensin homolog mutant endometrial, breast, and 
renal cell carcinomas. Findings from these nonclinical pharmacology studies suggest that TAK-228 has 
therapeutic potential as a p.o. administered mTORC1/2 inhibitor for the treatment of cancers associated 
with dysregulated activation of the PI3K/AKT/mTOR pathway. 
2.2  Safety Pharmacology 
TAK-228 has a low potential to affect the human ether-à-go-go related gene potassium ion channel and 
does not affect cardiovascular parameters in telemeterized monkeys. 
 
2.3 
Drug Metabolism and Pharmacokinetics 
TAK-228 displayed dose-proportional plasma exposures, a moderate propensity to cross the blood-brain 
barrier, and modest (70.5%) human plasma protein binding. TAK-228 distributed mainly to the plasma 
fraction of human blood. There was no obvious concentration-dependent red blood cell distribution of TAK-
228 in human blood. 
 
TAK-228 did not inhibit P-glycoprotein but did inhibit breast cancer resistance protein, organic cation 
transporter (OCT)1 and OCT2. 
 
Recently completed in vitro metabolism experiments in human hepatocytes using 
14C-labeled TAK-228 
suggest that TAK-228 is metabolized primarily via CYP1A2 (approximately 31%-40%), with a minor 
contribution from CYP3A4 (approximately 11%-22%). These data suggest that TAK-228 is also 
metabolized by direct glucuronidation (approximately 22%) and an unidentified non-uridine diphosphate 
glucuronosyl transferase pathway (approximately 18%). The new data differ from the previous in vitro CYP 
phenotyping data obtained using recombinant CYP enzymes, which suggested the involvement of 
CYP2C9 (approximately 35%), CYP2C19 (approximately 28%), and CYP3A4 (approximately 28%) in TAK-
228 metabolism. In addition, physiologically based PK modeling and simulation using the new metabolism 
data for TAK-228 suggest that the risk for a metabolism-based drug-drug interaction with TAK-228 appears 
to be low. Therefore, strong CYP1A2 inhibitors and CYP inducers should be administered with caution and 
at the discretion of the investigator during the study.  
 
2.4 
Toxicology 
The toxicologic profiles obtained in the Good Laboratory Practice (GLP)-compliant and non-GLP-compliant 
studies in rats and monkeys were generally consistent with pharmacologic inhibition of mTORC1/2 activity.  
 
The findings in rat and monkey repeat-dose toxicology studies with TAK-228, including bone marrow and 
lymphoid depletion; gastrointestinal (GI), liver, pancreas, and skin effects; and effects on glucose and 
insulin levels, can be monitored in clinical trials. The toxicities seen in the repeat-dose toxicology studies, 
such as GI effects and glucose and insulin increases, are consistent with the treatment-emergent adverse 


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events (TEAEs), including mucositis and hyperglycemia, observed to date in patients receiving TAK-228. 
Rat and rabbit range-finding embryo-fetal studies demonstrated teratogenic, fetotoxic, and abortive effects 
with TAK-228. TAK-228 does not present a genotoxic risk and was negative for phototoxicity in the 3T3 
fibroblast assay. 
 
 
3.    
SUMMARY OF EFFECTS IN HUMANS  
TAK-228 is in clinical development as a single agent in 3 phase 1 studies including Study INK128-001 in 
patients with advanced solid malignancies; Study INK128-002 in patients with multiple myeloma (MM), 
non-Hodgkin lymphoma, and Waldenström’s macroglobulinemia (WM); and Study C31002 to measure the 
effect of TAK-228 on heart rate-corrected QT interval (QTc) in patients with advanced solid malignancies. It 
has also been investigated in combination with paclitaxel (with or without trastuzumab) in patients with 
advanced solid tumors (phase 1 Study INK128-003). TAK-228 is also being tested in combination with 
exemestane or fulvestrant in women with ER-positive, HER2-negative advanced or mBC (phase 1b/2 
Study C31001) and in combination with the oral PI3Kα inhibitor TAK-117 (previously MLN1117; Study 
C32001). 
 
TAK-228 dosing regimens tested thus far include QD, weekly (QW), QD×3 days per week (once daily for 
3 consecutive days followed by a 4-day dosing holiday every week), and QD×5 days per week (once daily 
for 5 consecutive days followed by a 2-day dosing holiday every week). 
As of 2015, a new TAK-228 capsule containing milled active pharmaceutical ingredient (API) was 
developed to allow scaled-up production. The milled API could result in a faster absorption profile with 
possibly higher maximum concentration (Cmax), which could present a different safety profile compared to 
the previous unmilled API capsules. Therefore, an additional study, a Phase I open label study to evaluate 
the safety, tolerability, and PK of TAK-228 as a single agent and in combination with paclitaxel in adult 
patients with advanced non-hematological malignancies (study TAK-228-1004), was designed to 
determine the recommended phase 2 dose (RP2D) for single-agent milled TAK-228 (QD and QW) and 
QD×3days per week in combination with paclitaxel, as well as the effect of high-fat meal on the PK of 
milled API. 
Table 2 below summarizes TAK-228 doses, schedules, and API studied as well as evaluable PK 
population studies in all these studies. Details on PK and safety information for each study are available in 
the current IB edition. 


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TABLE 2  Summary of TAK-228 Clinical Studies 
 
3.1 Pharmacokinetics 
PK data from Studies INK128-001, INK128-002, and INK128-003 indicate that TAK-228 exhibits fast oral 
absorption (time to Cmax [tmax] generally between 1-4 hours after dosing) and dose-linear PK with a 
mean plasma half-life of approximately 8 hours. TAK-228 does not accumulate meaningfully in plasma 
when dosed as frequently as once daily under any of 4 tested dosing regimens. The PK data of TAK-228 
were generally consistent across 3 phase 1 studies, suggesting no appreciable difference in the PK of 
TAK-228 among patients with advanced solid tumors or patients with MM or WM. 
There were no meaningful differences in the PK of TAK-228 when administered 24 hours after a 30-minute 
intravenous (IV) infusion of 80 mg/m2 paclitaxel (Study INK128-003) compared with single-agent TAK-228 
(Studies INK128-001 and INK128-002). The PK of paclitaxel also remained generally unaffected by TAK-
228 co-administration, indicating the lack of a PK interaction between TAK-228 and paclitaxel. 


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There were no readily apparent differences in either the Cmax or area under the curve (AUC) of 4 mg 
TAK-228 unmilled or milled capsules when administered under fasted conditions. 
Compared to the fasted state, when 4 mg of milled TAK-228 API was administered following a standard 
high-fat breakfast, there was an approximately 38% reduction in Cmax and a delay in tmax (median tmax 6 
hours [fed] vs. 2 hours [fasted]), but there was no meaningful change in AUC. The differences observed 
when TAK-228 was dosed under fed versus fasted conditions may help explain the different MTDs 
determined for TAK-228 QD dosing in Study INK128-001 compared with study MLN0128-1004. 
There were no readily apparent differences in the PK of TAK-228 when administered in conjunction with 
either 25 mg exemestane or with 500 mg fulvestrant. 
3.2 Safety 
Among the 438 patients who had received ≥1dose of study drug as of the clinical data cutoff date (09 
December 2015), 20 deaths had occurred within 30 days of the last dose. Of these fatal events, 1 death 
(ventricular fibrillation and cardiac arrest in Study INK128-001) was considered related to TAK-228 
treatment.  
Across the studies and regardless of causality or dosing regimen, the most common TEAEs included 
nausea, fatigue, hyperglycemia, vomiting, diarrhea, stomatitis, and decreased appetite.  
 
4.    
CLINICAL SUMMARY OF SAFETY 
4.1 Special Warnings and Precautions for Use 
4.1.1  Insulin and Glucose Levels 
Hyperglycemia and hyperinsulinemia are known toxicities associated with inhibition of mTOR and related 
pathways based on nonclinical studies. A rise in fasting plasma glucose has been observed as early as 1 
to 2 days following oral administration of TAK-228. However, most episodes of hyperglycemia occurred 
within the first 60 days after initiation of treatment with TAK-228, have been either grade 1 or grade 2, and 
have responded quickly to oral metformin. Daily in-home glucose monitoring and early initiation of 
hyperglycemia treatment are essential. For patient self-monitoring of blood glucose, a finding of fasting 
blood glucose (FBG) ≥ 150 mg/dL measured by glucometer would initiate closer monitoring of serum 
glucose and possible intervention. Patients with grade 1 hyperglycemia (fasting serum glucose [FSG] > the 
upper limit of normal [ULN] ≤ 160 mg/dL) are treated with oral hypoglycemic agents (e.g., metformin), and 
patients with ≥ grade 2 hyperglycemia (FSG > 160 mg/dL) are treated aggressively with oral hypoglycemic 
agents and/or insulin as clinically indicated. Daily home monitoring and early treatment have resulted in 
good control of glucose levels for the majority of TAK-228-treated patients who developed hyperglycemia.  
 
4.1.2  Cardiac Effects 
Cardiac events (including QTc prolongation and arrhythmias) have been infrequently observed in clinical 
studies of TAK-228. As of December 2015, there has been 1 report of ventricular fibrillation and cardiac 
arrest post-dose that had a fatal outcome and was assessed as related to TAK-228. Recent results of the 
C31002 phase 1 study indicate that treatment with TAK-228 is not associated with clinically meaningful 
effects on the overall electrocardiographic safety profile. Routine cardiac monitoring with baseline and EOT 
electrocardiograms (ECGs) and physical examination constitute the core cardiac safety monitoring in all 
TAK-228 studies.  
Preliminary results from a dedicated study of the effects of TAK-228 on the QTc interval (study C31002) 
show lack of clinically relevant effects on QTc interval, PR and QRS intervals, minimal effects on heart 
rate, and absence of treatment-emergent ECG morphology findings and therefore treatment with TAK-228 


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is not associated with clinically meaningful effects on the overall electrocardiographic safety profile (further 
details available in the current IB version). 
For subjects showing any signs of cardiac instability after TAK-228 dosing, additional monitoring onsite 
before clinic discharge should be considered. 
 
4.1.3  Renal Function 
Elevations in creatinine (regardless of causality) have been observed in subjects receiving TAK-228, all of 
which have been reversible with drug interruption and/or supportive care with IV hydration. Further 
evaluation of the renal insufficiency with urine electrolytes suggested a pre-renal etiology with a low 
fractional excretion of sodium < 1%. However, the AE cases were confounded by multiple factors such as 
nausea, vomiting, hyperglycemia, concomitant medications with GI side effects such as metformin, and 
hydronephrosis, any of which may have also contributed to dehydration and elevated creatinine. Patients 
should drink at least 20 ounces of fluids a day, especially on days requiring fasting (per protocol), with 
administration of IV fluids in the clinic as indicated to avoid dehydration. Each dose of TAK-228 should be 
taken orally with 8 ounces (240 ml) of water. 
 
Baseline macroscopic urinalysis and routine serum chemistries along with other safety laboratory 
assessments are performed in all TAK-228 studies. Additionally, microscopic urinalysis, 12-hour urine 
collection, and evaluation of spot urine electrolytes, protein and creatinine, and serum chemistry should be 
performed when the serum creatinine is ≥ grade 1, according to NCI CTCAE version 4.03, to further 
evaluate possible etiologies for the renal dysfunction. 
 
4.1.4  Rash 
Rash observed in clinical studies of TAK-228 tends to be maculopapular and pruritic and has ranged from 
grade 1 to 3. For the most part, rash and pruritus improve with antihistamines, topical steroid creams, 
and/or dose interruption. Some patients have required pulse systemic steroids, dose reduction, and/or 
study treatment discontinuation. 
 
4.1.5  Pneumonitis 
Pneumonitis is a known potential risk of mTOR inhibitors. Early recognition, prompt intervention, and a 
conservative risk management approach are recommended for pneumonitis management in patients 
receiving rapalog therapy and TAK-228. Symptoms of pneumonitis will be closely monitored in all study 
patients. 
 
4.2  Interactions With Other Medicaments and Other Forms of Interaction 
Clinical DDI studies have not been conducted with TAK-228. At this time, there are no known drug 
interactions. In vitro data, including CYP induction/inhibition and transporter inhibition studies conducted for 
TAK-228, suggest a low risk for TAK-228 to precipitate a DDI. Although potential DDIs with TAK-228 
cannot be ruled out based on the known metabolism characteristics of TAK-228, the potential risk is 
considered low. 
Potential risks of combination TAK-228 and tamoxifen include fatigue, stomatitis, rash, anorexia, and 
diarrhea. This data is based on the combination of tamoxifen with everolimus, an mTORC1 inhibitor.2 
5. TAMOXIFEN38 
Drug Name: Tamoxifen 
Synonym(S): Tam, Tamoxifene 
Common Trade Name(S): APO-TAMOX®, GEN-TAMOXIFEN®, NOLVADEX-D®, NOVO-TAMOXIFEN®, 
TAMOFEN® 


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Classification: endocrine antihormone 
Mechanism of Action: Tamoxifen and several of its metabolites are thought to act as estrogen 
antagonists. Tamoxifen competitively binds to ERs on tumor cells and other tissue targets, producing a 
nuclear complex that decreases DNA synthesis. This mechanism appears to have cytostatic effects, 
causing G0 and G1 cell cycle arrest. Tamoxifen may also have cytotoxic activity; tamoxifen may induce 
apoptosis independent of ER expression. Tamoxifen acts as an estrogen agonist on endometrium, bone, 
and lipids. 
TABLE 3 TAMOXIFEN PHARMACOKINETICS 
Interpatient 
Variability 
Considerable variation in serum concentrations after single doses and at steady state; genetic polymorphism may 
influence the efficacy and toxicity of tamoxifen and its metabolites 
Oral Absorption 
Well absorbed 
 
time to peak plasma concentration 
3-7 hours 
Distribution 
high concentrations found in uterus and breast tissue 
 
Cross blood brain barrier?  
yes 
 
Volume of distribution 
20 L/kg 
 
Plasma protein binding 
99% 
Metabolism 
Metabolized by hepatic cytochrome1 P450; major CYP3A4, 2C8/9, 2D6; minor 2A6, 2B6, 2E1 
 
Active metabolite(s)  
 
N-desmethyltamoxifen, 
4-hydroxytamoxifen, 
and 
4-hydroxy-N-
desmethyltamoxifen (endoxifen) 
 
Inactive metabolite(s) 
Yes 
Excretion 
Extensive enterohepatic circulation 
 
 
Urine 
9-13% 
 
Feces 
26-65%, excreted into bile 
 
Terminal half-life 
5-7 days, range 3-21 days; major metabolite 9-14 days 
 
Clearance 
No information found 
Uses:  
Primary uses: Brain tumors, Breast cancer, Melanoma, Soft tissue sarcoma 
Other uses: Carcinoid tumor, Endometrial cancer, Pancreatic cancer  
Special Precautions:  
Carcinogenicity: Tamoxifen is carcinogenic. 
Mutagenicity: Tamoxifen is not mutagenic in the Ames test or mammalian in vivo mutation test. The 
clastogenicity of tamoxifen is not known. 
Fertility: Tamoxifen may cause menstrual cycle disturbances, including infrequent or light menstruation and 
amenorrhea. Tamoxifen does not induce menopause. Premenopausal women should be advised not to 
become pregnant while taking tamoxifen. Tamoxifen has been used to treat infertility.  
Pregnancy: Tamoxifen has been assigned to FDA Pregnancy Category D. There is positive evidence of 
human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (e.g., if 
the drug is needed for a life-threatening situation or a serious disease for which safer drugs cannot be 
used or are ineffective).  
Breastfeeding: Breastfeeding is not recommended while using tamoxifen because of its potential secretion 
into breast milk. Tamoxifen may inhibit lactation. 
Special populations: The risk of tamoxifen-associated serious AEs (SAEs) is higher in patients older than 
50 years of age. Women of childbearing potential should initiate tamoxifen during menstruation; barrier or 
non-hormonal contraceptives should be used and pregnancy avoided for 2 months after tamoxifen is 
discontinued. Porphyric patients must avoid tamoxifen, as tamoxifen has been associated with acute 
attacks of porphyria.  
Side Effects:  
Table 4 below includes AEs that presented during drug treatment but may not necessarily have a causal 
relationship with the drug. Because clinical trials are conducted under very specific conditions, the AE rates 
observed may not reflect the rates observed in clinical practice. AEs are generally included if they were 
reported in more than 1% of patients in the product monograph or pivotal trials and/or determined to be 


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clinically important. When placebo-controlled trials are available, AEs are included if the incidence is > 5% 
higher in the treatment group. 
TABLE 4 TAMOXIFEN SIDE EFFECTS 
Organ site 
Side effect 
Allergy/immunology 
hypersensitivity reactions (<3%), vasculitis 
Bone 
marrow/febrile 
neutropenia 
Myelosuppression; anemia, leukopenia, neutropenia, thrombocytopenia, transient (<10%) 
Cardiovascular 
QT prolongation, cardiovascular event (4%, severe 1%), hypertension (7-11%), ischemic heart disease (1-3%, severe 
0.6%), thromboembolic events (2-5%, severe 1-2%) 
Constitutional symptoms 
Fatigue (4-24%, severe 2%), sweating (6-18%, severe 3%), weight gain (8-9%), weight loss (23%) 
Dermatology/skin 
Alopecia (<5%), cutaneous lupus erythematosus, nail changes (3%), porphyria cutanea tarda, radiation recall, rash 
(<13%), skin changes (6-19%), Stevens-Johnson syndrome, erythema multiforme, bullous pemphigoid (<1%) 
Endocrine 
Hot flashes (25-81%, severe 4%) 
Gastrointestinal 
Anorexia (1-3%) constipation (1-8%), diarrhea (2-7%, severe 0.04%), dyspepsia (6%) dry mouth (2%) nausea (5-26%, 
severe 0.7%), vomiting (2%) 
Hemorrhage 
Hemorrhage, vaginal bleeding (2-23%, severe 0.1-0.3%) 
Hepatobiliary/ 
pancreas 
Cholestasis (<1%), gallstones; generally occurs after 2-3 years of treatment, pancreatitis (<1%), liver dysfunction, 
hepatitis (<1%) 
Infection 
Urinary tract infection (10%), vulvovaginal candidiasis (4%) 
Lymphatics 
Peripheral edema (8-11%) 
Metabolic/laboratory 
Elevated creatinine, hypercalcemia (< 1%), altered lipid profile; decreased total and LDL cholesterol, decreased HDL 
cholesterol, hypercholestremia (3%), increased triglycerides (≤ 1%) 
Musculoskeletal 
Arthritis (14%), arthrosis (4%) favorable effect on bone mass, fractures (4-8%), osteoporosis (6-7%) 
Neurology 
Anxiety (6%), depression (4-12%, severe 0.2%), dizziness (8-12%, severe 0.6%), ischemic cerebrovascular events (1-
3%, severe 1%), insomnia (6-17%, severe 1%), paresthesia (5%) 
Ocular/visual 
Cataracts (<7%), corneal changes (≤ 0.1%), retinopathy (≤1%), vision changes (6%, severe 0.4%) 
Pain 
abdominal pain (7-9%), arthralgia/myalgia (4-29%, severe 0.4-0.9%), back pain (10%), bone pain (6%), breast pain 
(6%), chest pain (5%), cramps (4%, severe 0.2%), headache (2-16, severe 0.8%), pain not specified (16%), tumor pain 
Pulmonary 
Cough (4-10%), pharyngitis (<1%), pneumonitis (<1%)  
Renal/genitourinary 
Endometrial polyps, hyperplasia, endometriosis (≤1%), ovarian cysts (<3%), pruritus vulvae (<1%), vulvovaginitis 
(5%), urinary incontinence (4%), uterine fibroids (≤1%), non-infectious vaginal discharge, leukorrhea (9-13%), vaginal 
dryness (<3%) 
Secondary malignancy 
Endometrial cancer (0.8%), uterine sarcoma 
Sexual/reproductive 
function 
Impotence (<1%), menstrual dysfunction, priapism  
Syndromes 
Flu syndrome (6%), tumor flare (<10%)  
 
Hot flashes are one of the most common AEs reported in women taking tamoxifen, but are rarely severe. 
If severe, they may be controlled in some patients by a decreased or divided dose. Patients who have their 
sleep interrupted by drenching night sweats may benefit by taking their tamoxifen in the morning. Several 
medications have been shown to decrease the frequency and severity of hot flashes. Occasionally 
tamoxifen must be discontinued due to severe hot flashes that significantly decrease quality of life.  
Tamoxifen flare response: A transient increase in bone pain, local disease flare (increase in size of 
preexisting lesions, swelling, and redness), and/or hypercalcemia may occur at the initiation of therapy in 
patients with metastatic disease. Serum calcium should be evaluated in any patient with extensive bony 
metastases who has symptoms suggestive of hypercalcemia. The so-called tamoxifen flare response may 
be a favorable sign, although hypercalcemia may require treatment.  
Endometrial changes: Tamoxifen has a stimulant effect on the endometrium, possibly by acting as a 
partial estrogen agonist. Tamoxifen use has been associated with an increased incidence of endometrial 
changes, including hyperplasia, polyps, uterine fibroids, and endometriosis.  
Uterine malignancies associated with tamoxifen are typically adenocarcinomas of the endometrium; 
uterine sarcomas, an endometrial cancer with poor prognosis, have also been rarely reported. The relative 
risk of endometrial cancer increases with the duration of tamoxifen therapy; this relative risk is small and 
must be weighed against the potential benefits of tamoxifen. Patients receiving or who have received 
tamoxifen should have routine gynecological care and should be advised to immediately report any 
abnormal gynecologic symptoms, such as menstrual irregularities, abnormal vaginal bleeding or discharge, 
and pelvic pain and pressure. Imaging, including endovaginal US and/or endometrial biopsy, may be 
necessary to rule out malignancy.  


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Ocular changes (retinopathy, corneal opacities, and decreased visual acuity) have been reported in 
patients receiving tamoxifen. A modest increase in the risk of developing cataracts has been associated 
with tamoxifen treatment. The relationship between tamoxifen dose and cataract formation is not known. 
Cataract formation may be due to tamoxifen-mediated inhibition of chloride channels in the lens. Macular 
degeneration does not appear to predispose subjects to tamoxifen-related ocular toxicity nor does 
tamoxifen accelerate progression of macular degeneration. Patients receiving or who have received 
tamoxifen should be questioned about symptoms of ocular toxicity during follow-up and should seek 
prompt medical attention for changes in vision.  
Thromboembolic events, including deep vein thrombosis, stroke, and pulmonary embolism, are 
increased with tamoxifen use. Use tamoxifen with caution in individuals with a history of thromboembolic 
events, particularly those not receiving systemic anticoagulation therapy.  
Hepatotoxicity usually consists of transient asymptomatic elevation of hepatic enzymes. However, more 
serious liver abnormalities, including fatty liver, cholestasis, and hepatitis, have occurred infrequently; 
rarely fatalities have been reported. 
Lipid profile: Tamoxifen favorably affects lipid profiles by decreasing total and low-density lipoprotein 
cholesterol concentrations; this effect does not translate to a reduced risk of ischemic heart disease. Less 
favorably, tamoxifen appears to moderately decrease high-density lipoprotein cholesterol concentrations 
and increase triglyceride levels. Rarely, cases of pancreatitis have occurred. Periodic monitoring of plasma 
cholesterol and triglyceride concentrations is advised for patients taking tamoxifen who have preexisting 
hyperlipidemias or other clinical indications. 
Myelosuppression has been reported with tamoxifen. Temporary decreases in platelet and leukocyte 
counts may occur. Hemorrhagic tendencies are uncommon, and platelet counts have returned to normal 
without treatment interruption. If myelosuppression is suspected, monitor complete blood counts. Use 
tamoxifen with caution in patients with thrombocytopenia or leukopenia.  
Bone mass: Tamoxifen generally has a favorable effect on bone mass. Tamoxifen reduces bone 
resorption and decreases bone turnover as manifested by reductions in bone turnover markers and 
increases in bone density. Tamoxifen acts mainly on trabecular bone, such as the lumbar spine, and has 
little effect on cortical bone. The effect of tamoxifen on bone density may depend on menopausal status, 
as premenopausal women have demonstrated a loss of bone mineral density of the lumbar spine and hip. 
Further information is needed to evaluate the long-term effects of tamoxifen on the risk of osteoporosis and 
fracture. 
TABLE 5 TAMOXIFEN DRUG INTERACTIONS 
Agent 
Effect 
Mechanism 
Management 
Aldeskleukin 
Increased risk of hypersensitivity 
Unknown 
Monitor for signs and symptoms of 
hypersensitivity reactions  
Aminoglutethimide 
Decreased tamoxifen and its active 
metabolites concentration 
Increased metabolism 
Avoid concurrent use 
Anastrozole 
Tamoxifen decreases plasma anastrozole 
level by 27%, but has no significant effect 
on estrogen suppression by anastrozole; 
anastrozole has no significant effects on 
the pharmacokinetics of tamoxifen. 
 
 
Bexarotene 
35% decrease in tamoxifen plasma 
concentrations 
Unknown; likely be due to 
induction of CYP3A4 by 
bexarotene 
Clinical 
significance 
unclear; 
consider 
alternate agent (s) 
Bromocriptine 
Increased tamoxifen concentrations 
Decreased metabolism of 
tamoxifen 
Caution 
Cyclophosphamide 
Decreased 
cytotoxic 
effects 
of 
cyclophosphamide 
Unknown 
Avoid 
concurrent 
use; 
start 
adjuvant 
tamoxifen after chemotherapy is complete 
Cytotoxic agents 
Increased risk of thromboembolic events 
Unknown 
Caution 
Doxorubicin 
Decreased cytotoxic effects of doxorubicin 
Unknown 
Avoid 
concurrent 
use; 
start 
adjuvant 
tamoxifen after chemotherapy is complete 
Estrogens 
May interfere with therapeutic effect of 
tamoxifen 
May counter the estrogen 
suppression 
effect 
of 
tamoxifen  
*See below 


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Exemestane 
No significant effects on tamoxifen or 
exemestane pharmacokinetics 
 
 
Fluorouracil 
Decreased cytotoxic effects of fluorouracil 
Unknown 
Avoid 
concurrent 
use; 
start 
adjuvant 
tamoxifen after chemotherapy is complete 
Grapefruit juice 
May affect bioavailability of tamoxifen and 
its active metabolite 
May 
inhibit 
CYP3A4 
metabolism of tamoxifen in 
intestinal wall 
†See below 
Letrozole 
Tamoxifen decreases 
plasma letrozole level by 
38%, but has no significant effect on 
estrogen suppression by letrozole; letrozole 
has no effects on the pharmacokinetics of 
tamoxifen and its major metabolites 
 
 
Mitomycin 
Increased 
risk 
of 
hemolytic 
uremic 
syndrome 
Unknown 
Avoid concurrent use 
Paroxetine and other 
selective 
serotonin 
inhibitors that inhibit 
CYP2D6 
Reduced 
tamoxifen active metabolite 
concentrations 
Inhibits 
CYP2D6 
metabolism of tamoxifen 
‡See below 
Rifamycins 
(e.g. 
rifabutin, 
rifampin, 
rifapentine) 
Reduced 
tamoxifen 
concentrations; 
potentially 
increased 
levels 
of 
N-
desmethyltamoxifen 
metabolite, 
and 
subsequently endoxifen (active metabolite) 
Induced 
CYP3A4 
metabolism of tamoxifen 
No alteration of efficacy expected; clinical 
impart is unknown 
Thyroid 
function 
tests 
Elevated thyroid hormone levels (T4 and 
T3) 
Increased 
thyroxine-
binding globulin 
None, thyroid function does not appear to be 
affected 
Warfarin 
Delayed, 
major, 
possible; 
increased 
anticoagulant effect 
Unknown 
Monitor prothrombin time, adjust warfarin 
dose accordingly 
*Estrogen use with tamoxifen: Hormone replacement therapy is not recommended following  ER-positive 
breast cancer or while on tamoxifen. Postmenopausal symptoms can cause considerable distress to patients; 
replacement therapy may be considered if other treatment options fail. If estrogen is used, prescribe the lowest 
dose to relieve symptoms, monitor patient carefully, and consider short term use. For vaginal complaints such 
as dyspareunia, dryness, and sexual dysfunction, REPLENS®, a long-lasting vaginal moisturizer, can be tried. 
If ineffective, low dose topical estrogen may then be considered. ESTRING® produces a local effect with 
systemic levels measurable only for the first 24 hours of the three-month ring. PREMARIN® cream can be used 
but may have variable systemic levels related to the absorption through the vaginal tissues. The potential risks 
and benefits should be discussed, the lowest dose to relieve symptoms should be used, and treatment should 
be assessed regularly. 
†Grapefruit juice and tamoxifen: Grapefruit juice inhibits CYP3A4-mediated metabolism of tamoxifen in the 
intestine and may increase tamoxifen plasma levels. The clinical significance of a low rate of intestinal 
metabolism to active metabolites is unknown. Patients should be monitored for signs of tamoxifen toxicity. 
‡Antidepressant use with tamoxifen: The metabolism of tamoxifen to active 4-hydroxy-N-desmethyl-
tamoxifen (endoxifen) is inhibited by the selective serotonin reuptake inhibitor (SSRI) paroxetine, a potent 
CYP2D6 inhibitor. Other SSRIs that inhibit CYP2D6 also inhibit tamoxifen metabolism. The magnitude of 
reduction in endoxifen plasma concentration associated with CYP2D6 inhibitors also depends on variations in 
CYP2D6 genotypes. The minimally active levels of tamoxifen and its metabolites are not known. The clinical 
significance of a low rate of endoxifen hydroxylation is not known; the potential benefit of antidepressant use 
must be weighed against the potential risk. Antidepressants that weakly inhibit or do not inhibit CYP2D6 may be 
considered. 
List of Antidepressant and Tamoxifen Interactions:  
Tamoxifen is converted to 4-hydroxytamoxifen, endoxifen, and other active metabolites by the liver enzyme 
CYP2D6. The efficacy of tamoxifen may vary among individuals due to genetic variation in CYP2D6 
activity and coadministration of drugs that may modulate CYP2D6 activity.  
SSRIs are a commonly used class of antidepressants, which inhibit CYP2D6 to varying degrees. 
Concurrent administration of some SSRIs and tamoxifen has been shown to lower levels of endoxifen, but 
not 4-hydroxytamoxifen. The clinical implications of this decline in endoxifen levels are unclear, because 
tamoxifen concentrations do not appear to change substantially. However, retrospective evidence 
presented at the 2009 American Society of Clinical Oncology meeting indicate that concomitant use of 


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tamoxifen and moderate/potent CYP2D6 inhibitors significantly increase the risk of breast cancer 
recurrence. In the SSRI subanalysis, tamoxifen in combination with moderate or potent CYP2D6 inhibitors 
was associated with a 25–92% greater relative risk of breast cancer recurrence (depending on duration of 
coexposure) compared with tamoxifen alone. Weak CYP2D6 inhibitors were not associated with increased 
risk of breast cancer recurrence. A recent retrospective study from Ontario also suggests that the greater 
risk of breast cancer recurrence with paroxetine may be associated with increased cancer death.  
Drugs that could potentially reduce efficacy and thus, should be used with caution include any strong 
CYP2D6 inhibitor such as fluoxetine, paroxetine, chlorpromazine, miconazole, quinine, and bupropion and 
any moderate CYP2D6 inhibitor such as ketoconazole, trazodone, and amiodarone. The safest course of 
action is to avoid coadministration of tamoxifen and any of these medications. However, each patient’s 
particular needs and circumstances should be evaluated to determine what is best for them.  
Serotonin norepinephrine reuptake inhibitors such as venlaflaxine and desvenlafaxine are weak CYP2D6 
inhibitors and do not lower the concentration of endoxifen. These are better choices for women taking 
tamoxifen who also require medication for depression or relief of hot flashes.  
Appendix B lists examples of commonly used antidepressants and their association with CYP2D6 and 
tamoxifen.  
Supply and Storage: 
Tablets: Apotex, Genpharm, and Novopharm supply tamoxifen as 10 or 20 mg tablets. 
AstraZeneca supplies tamoxifen as a 20 mg tablet. Selected non-medicinal ingredients: lactose. 
Aventis Pharma supplies tamoxifen as 10 or 20 mg tablets. Selected non-medicinal ingredients: lactose. 
Store tamoxifen at room temperature and protect from light. 
Dosage Guidelines: 
This protocol will use 20 mg p.o. QD. Guidelines for dosing also include consideration of absolute 
neutrophil count (ANC). Dosage may be reduced, delayed, or discontinued in patients with bone marrow 
depression due to cytotoxic/radiation therapy or other toxicities. 
 
Adults: 
Oral:  
 
 
 
20 mg p.o. QD 
Dosage in renal failure: 
 
No adjustment required 
Dosage in hepatic failure: 
Adjustment required, no details found; dosing may be based on serum levels of tamoxifen 
and its active metabolites 
Dosage in dialysis: 
 
    
No adjustment required  
 
 
6. STUDY RATIONALE 
The recently completed phase II TAMRAD trial evaluated the benefit of adding an mTOR inhibitor 
(everolimus) to tamoxifen in the advanced disease setting. The trial included 211 postmenopausal women 
with hormone receptor-positive, HER2-negative advanced breast cancer previously treated with a non-
steroidal AI in the adjuvant or metastatic setting. Patients were randomized to receive tamoxifen alone  (20 
mg p.o. QD) or tamoxifen plus everolimus (10 mg p.o. QD). The primary study endpoint was CBR at 6 
months. Tamoxifen plus everolimus was superior to tamoxifen alone in terms of CBR (61% vs. 42%; P = 
0.045) and TTP (8.6 vs. 4.5 months). Furthermore, the addition of everolimus increased overall survival by 
55% (HR, 0.45; 95% CI, 0.28–0.81; exploratory log-rank P = 0.007).2  
In the phase III randomized BOLERO 2 trial, 724 postmenopausal women with hormone receptor-positive 
mBC who had progressed on a non-steroidal AI (anastrozole or letrozole) were enrolled. Eligible women 
were randomized (2:1) to receive exemestane (25 mg QD) plus  everolimus (10 mg QD) or exemestane 
plus placebo.  Baseline characteristics were well balanced between the two study groups. The median age 
was 62 years, and 56% and 84% of patients had visceral involvement and hormone-sensitive disease, 
respectively. Previous therapy included letrozole or anastrozole (100%), tamoxifen (48%), fulvestrant 
(16%), and chemotherapy (68%). The primary endpoint was PFS, and the secondary endpoints included 


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survival, response rate, and safety. Also a preplanned interim analysis was performed by an independent 
data and safety monitoring committee after 359 PFS events were observed. A significant PFS benefit was 
observed for everolimus plus exemestane over exemestane alone. At the interim analysis, median PFS by 
local assessment was 6.9 months with everolimus plus exemestane and 2.8 months with placebo plus 
exemestane (HR for progression or death, 0.43; 95% CI, 0.35–0.54; P < 0.001). Median PFS by central 
assessment was 10.6 months and 4.1 months in the everolimus plus exemestane and placebo plus 
exemestane groups, respectively (HR, 0.36; 95% CI, 0.27–0.47; P < 0.001). The most common grade 3 or 
4 AEs were stomatitis (8% in the everolimus plus exemestane group vs. 1% in the placebo plus 
exemestane group), anemia (6% vs. < 1%), dyspnea (4% vs. 1%), hyperglycemia (4% vs. <1%), fatigue 
(4% vs. 1%), and pneumonitis (3% vs. 0%). Based on these results, the FDA approved the use of 
everolimus in combination with exemestane in July 2012. 
 
As the majority of breast cancers are ER positive, it is important to understand the underlying mechanisms 
leading to endocrine therapy resistance. HER2, PI3K, and mTOR have been postulated to be major 
pathways of treatment resistance.39,40 Less than 10% of ER-positive breast cancers overexpress HER2 
and therefore, it is not a major mechanism of escape from endocrine therapy. On the other hand, the 
PI3K/mTOR pathway is commonly dysregulated in ER-positive breast cancers and represents a key 
escape/resistance mechanism to endocrine therapy. The use of mTOR inhibitors has been explored as a 
front-line treatment for advanced breast cancers, but not for newly diagnosed ER-positive breast cancers. 
The TAMRAD and BOLERO 2 trials showed that blocking endocrine resistance mediated by PI3K and 
other prosurvival pathways with an mTOR inhibitor provided a significant PFS benefit compared with 
endocrine therapy alone or placebo.39  
 
The development of new therapies has led to an overall decline in breast cancer mortality. Importantly, 
evidence indicates that treatment resistance and relapse are the primary causes of mortality in breast 
cancer. Furthermore, the number of patients who are resistant to standard hormonal/endocrine therapies 
far exceeds the number of patients with triple negative breast cancer. Despite this, little focus has been 
placed on identifying new therapeutic targets to overcome treatment resistance in the various breast 
cancer types.  Our group has identified autophagy as a mechanism of endocrine resistance and survival in 
ER-positive breast cancer (unpublished data). Targeting prosurvival and endocrine resistance pathways 
such as mTOR and autophagy with FDA-approved inhibitors would increase the response to endocrine 
therapy in endocrine-resistant, ER-positive breast cancer. This proposal uses a novel approach to 
overcome endocrine resistance and improve endocrine therapy efficacy in newly diagnosed ER-positive 
breast cancer —  combining endocrine therapy with blockade of prosurvival and resistance pathways in 
ER-positive breast cancer cells. The main scientific goal of this proposal is to target mTORC1/mTORC2 
signaling pathways with TAK-228 to overcome tamoxifen resistance in ER-positive breast cancer. 
 
 
Preclinical Data 


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Figure 2 
As shown in Figure 2, the mTOR inhibitor INK128 (TAK-228) synergistically enhances the antiproliferative 
effect of tamoxifen in ER-positive MCF-7 breast cancer cells. Proliferation by WST-1 assay was assessed 
in cells treated with INK128, tamoxifen, or both for 96 h. 
 
 
 
Figure 3 
As shown in Figure 3, the  tamoxifen-resistant ER-positive ZR75-30 cell line does not respond to tamoxifen 
treatment. INK128 alone at a concentration of 10 µM significantly reduced proliferation. Proliferation by 
WST-1 assay was assessed in cells treated with INK128, tamoxifen, or both for 96 h. 
 
 
 


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Rationale for Selected Dose and Schedules of TAK-228 
RP2D for milled TAK-228 Weekly Schedule: 30 mg p.o. QW 
The selected RP2D of 30 mg TAK-228 QW is based on the findings from 2 studies: Study INK128-001 and 
Study MLN0128-1004.  
Study INK128-001 was the first-in-human study of TAK-228. This was an open label study designed to 
determine the MTD and to identify dose-limiting toxicities (DLTs) for p.o. administration of single-agent 
unmilled TAK-228, and to characterize the safety and tolerability of escalating doses of TAK-228 in 
patients with advanced solid tumors. In this study, 116 patients with advanced solid tumors received TAK-
228 (2 – 40 mg via 4 dosing schedules: QD (31 patients), QDx3 days per week (33 patients), QDx5 days 
per week (22 patients), and QW (30 patients) in the dose escalation phase. Doses of 40 mg QW, 30 mg 
QW, and 5 mg QD were further evaluated in an additional 82 patients in the expansion phase.  
Improved tolerability, including a reduced frequency of TEAEs leading to dose interruptions and 
modifications, respectively (30 mg QW: 24% and 41%, vs 40 mg QW: 19% and 77% as of data cut off 9 
December, 2015) and longer duration of clinical benefit favored 30 mg QW dosing as a RP2D and 
schedule for further development.  
Scale-up manufacturing of TAK-228 capsules required the introduction of a physical milling step during the 
granulation process to control for particle size distribution of TAK-228 drug substance. In order to observe 
whether this milling step altered the safety and PK profile of TAK-228, the recommended dose of 30 mg 
milled TAK-228 QW was further evaluated and confirmed in Study MLN0128-1004 in which a total of 14 
patients were enrolled and assigned, sequentially, to 2 QW dosing cohorts: 20 mg QW and 30 mg QW 
milled TAK-228 (see Table 6 below). 
TABLE 6 Dose-Limiting Toxicity Observed with Milled TAK-228 QW in Study MLN0128-1004   
Dose of Milled TAK-228 
Number 
of 
Evaluable 
Patients 
Patients with DLTs observed 
in Cycle 1 
20 mg QW 
6 
None 
30 mg QW 
6 
None 
DLT = dose-limiting toxicity; QW = once weekly. 
As none of the patients in either dose cohort experienced DLT in Cycle 1, a dose of 30 mg milled TAK-228 
QW, dosed in empty-stomach conditions was selected as RP2D for further development. No clinically 
meaningful differences in PK of TAK-228 were noted between the unmilled TAK-228 (Study INK128-001) 
and milled TAK-228 (Study MLN0128-1004) when given QW (further details available in the current IB 
version). 
 
Innovation 
This proposal is innovative in various aspects. Firstly, it targets the ER with an FDA-approved compound 
(tamoxifen). Tamoxifen competitively binds to ERs on tumor cells and other tissue targets, producing a 
nuclear complex that decreases DNA synthesis and inhibits estrogen effects. Secondly, our proposal is 
highly relevant given that mTOR inhibitors are currently being investigated for the treatment of ER-positive 
endocrine-resistant breast cancer. Here, we propose an open label phase II study of TAK-228 in 


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combination with tamoxifen in patients with newly diagnosed ER–positive breast cancer. Use of TAK-228 
plus tamoxifen is supported by strong data showing that this combination decreases ER-positive breast 
cancer cell proliferation and increases pCR in patients with newly diagnosed ER–positive breast cancer. 
Thirdly, the correlation of specific molecular markers (ER; Ki67; mitotic index; apoptosis; levels of S6K1, 
4EBP-1, eukaryotic translation initiation factor (EIF)4E, EIF4G, and EIF4A; levels of phosphorylated S6K1, 
p53, p63, and p73; and p73 and p63 gene signatures) with clinical parameters such as tumor response will 
help define a biomarker signature associated with p63/p73 and/or PI3K/AKT dependence and NFkB in ER-
positive breast cancers and identify new therapeutic options for patients with ER-positive breast cancers. 
All tissues collected during the study will be stored for future analyses including genomic analyses. Tumor 
biopsy specimens obtained at the time of first diagnosis and week 6 of treatment will be correlated with the 
surgical specimen. An additional biopsy will be obtained from patients whose disease progresses while on 
treatment. 
 
7.    STUDY OBJECTIVES 
 
7.1    Primary Objective 
 
• 
To evaluate Ki67 before and after treatment with the mTORC1/2 inhibitor TAK-228 plus the 
non-steroidal agent tamoxifen in patients with newly diagnosed ER-positive, HER2-negative 
breast cancer. 
 
7.2    Secondary Objectives 
 
• 
To evaluate the pCR rate after treatment with TAK-228 plus tamoxifen in patients with newly 
diagnosed ER-positive, HER2-negative breast cancer.  pCR is defined as the absence of 
residual invasive and in situ cancer on hematoxylin and eosin evaluation of the complete 
resected breast specimen and all sampled regional lymph nodes following completion of 
neoadjuvant systemic therapy (i.e., ypT0 ypN0 in the current American Committee on Cancer 
staging system). 
• 
To evaluate the PEPI score after treatment with TAK-228 plus tamoxifen in patients with 
newly diagnosed ER-positive, HER2-negative breast cancer. 
• 
To assess the toxicity and safety of TAK-228 plus tamoxifen in patients with newly diagnosed 
ER-positive, HER2-negative breast cancer.   
 
7.3    Tertiary/Exploratory Objectives  
 
• 
To determine the plasma PK of the TAK-228 plus tamoxifen combination. 
• 
To assess the correlation between pCR to TAK-228 plus tamoxifen and changes in  tissue-
based markers including Ki67, p53/p63/p73, PI3K/AKT/mTOR, and NFkB pathways in ER-
positive, HER2-negative breast tumors. 
• 
To assess tumor mutational status to identify predictors of response to the TAK-228 plus 
tamoxifen combination. 
• 
To evaluate Oncotype DX recurrence score before and after treatment with TAK-228 plus 
tamoxifen. 
 
 


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9.2    Number of Patients 
The calculated sample size is 35 patients, with enrollment considered the day the informed consent form 
(ICF) is signed.  
 
9.3    Duration of Study 
Patients will receive TAK-228 QW and tamoxifen QD for 16 weeks. Screening for inclusion in the study will 
be done within 28 days prior to the day 1 dose of TAK-228 and tamoxifen. Baseline vital signs, labs, 
physical exam, and biopsy and tumor tissue collection will be done within 7 days prior to the day 1 dose of 
TAK-228 and tamoxifen. Visits will occur at weeks 1, 3, 4, 6, 8, 12, and 16 and at end of treatment (7 to 10 
days after the final dose of study treatment). 
 
10.    
STUDY POPULATION 
The study is designed for patients with newly diagnosed ER-positive, HER2-negative breast cancer. 
Written informed consent is required before performing any study-specific tests or procedures. Signing of 
the Informed Consent Form can occur outside the 28-day screening period. All screening evaluations must 
be completed and reviewed to confirm that patients meet all eligibility criteria before study entry. Results of 
standard-of-care tests or examinations performed prior to obtaining informed consent and within 28 days 
prior to study entry (except where otherwise specified) may be used for screening assessments rather than 
repeating such tests. The investigator will maintain a screening log to record details of all patients 
screened and to confirm eligibility or record reasons for screening failure, as applicable. 
 
10.1    Inclusion Criteria 
Each patient must meet all of the following inclusion criteria to be enrolled in the study: 
1. Female or male ≥ 18 years of age. 
2. Newly diagnosed ER-positive, HER2-negative breast cancer. ER-positive is defined as ≥ 1% 
immunohistochemical (IHC) staining of any intensity. HER2 test result is negative if a single test 
(or both tests) performed show: 
- 
IHC 1+ or 0  
- 
In situ hybridization negative based on: 
o Single-probe average HER2 copy number < 4.0 signals/cell 
o Dual-probe HER2/CEP17 ratio < 2 with an average HER2 copy number < 4.0 
signals/cell. 
3. Patients with stage II-III breast cancer are eligible if they are deemed appropriate for neoadjuvant 
endocrine therapy by the referring or treating medical oncologist. Patients with stage I disease are 
eligible if they are deemed borderline candidates for breast conservation and the treating surgeon 
recommends preoperative therapy to increase the chances of breast conservation. 
4. Eastern Cooperative Oncology Group performance status of ≤ 1 (see Appendix C). 
5. Female patients who: 
• 
Are postmenopausal for at least 1 year before the screening visit, OR 
• 
Are surgically sterile, OR 
• 
If they are of childbearing potential, agree to practice 1 effective method of contraception 
and 1 additional effective (barrier) method, at the same time, from the time of signing the 
ICF through 90 days (or longer, as mandated by local labeling [e.g., United Surgical 
Partners International, summary of product characteristics, etc.] after the last dose of the 
study drugs, OR  
• 
Agree to practice true abstinence, when this is in line with the preferred and usual lifestyle 
of the patient (periodic abstinence [e.g., calendar, ovulation, symptothermal, 
postovulation methods] and withdrawal, spermicides only, and lactational amenorrhea are 


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not acceptable methods of contraception. Female and male condom should not be used 
together). 
6. Male patients, even if surgically sterilized (i.e., status post-vasectomy), who: 
• Agree to practice highly effective barrier contraception during the entire study treatment 
period and through 120 days after the last dose of the study drugs, OR  
• 
Agree to practice true abstinence, when this is in line with the preferred and usual lifestyle 
of the patient. (periodic abstinence [e.g., calendar, ovulation, symptothermal, 
postovulation methods] and withdrawal, spermicides only, and lactational amenorrhea are 
not acceptable methods of contraception. Female and male condom should not be used 
together). 
• Agree not to donate sperm during the course of this study or within 120 days after 
receiving their last dose of the study drugs; 
7. Screening clinical laboratory values as specified below:  
a) Bone marrow reserve consistent with: ANC ≥ 1.5 x 109/L, platelet count ≥ 100 x 109/L, 
and hemoglobin ≥ 9 g/dL (without transfusion) within 1 week preceding the administration 
of the study drugs; 
b) Hepatic status: Serum total bilirubin ≤ 1 x ULN (in the case of known Gilbert's syndrome, 
a higher serum total bilirubin [> 1.5 x ULN] is allowed), aspartate aminotransferase (AST) 
and alanine aminotransferase (ALT) ≤ 1.5 x ULN, and alkaline phosphatase ≤ 1.5 x ULN; 
c) Renal status: Creatinine clearance ≥50 mL/min based on Cockcroft-Gault estimate or 
based on urine collection (12 or 24 hour); 
d) Metabolic status: HbA1c < 7.0%, FSG ≤ 130 mg/dL, and fasting triglycerides ≤ 300 
mg/dL.  
8. Ability to swallow oral medications.  
9. Voluntary written consent must be given before performance of any study-related procedure not 
part of standard medical care, with the understanding that consent may be withdrawn by the 
patient at any time without prejudice to future medical care. 
10. Negative serum pregnancy test within 7 days prior to the administration of the study drugs for 
women of childbearing potential. 
11. Patient must be accessible for treatment and follow-up. 
12. Patient must be willing to undergo breast biopsies as required by the study protocol. 
 
10.2    Exclusion Criteria 
Patients meeting any of the following exclusion criteria are not to be enrolled in the study: 
1. Any patient with metastatic disease.  
2. Other clinically significant comorbidities, such as uncontrolled pulmonary disease, active central 
nervous system disease, active infection, or any other condition that could compromise the 
patient’s participation in the study. 
3. Known human immunodeficiency virus infection. 
4. Known hepatitis B surface antigen-positive or known or suspected active hepatitis C infection. 
5. Any serious medical or psychiatric illness that could, in the investigator’s opinion, potentially 
interfere with the completion of the protocol-specified treatment. 
6. Diagnosed or treated for another malignancy within 2 years before administration of the first dose 
of the study drugs or previously diagnosed with another malignancy and have any evidence of 
residual disease. Patients with non-melanoma skin cancer or carcinoma in situ of any type are 
not excluded if they have undergone complete resection. 
7. Breastfeeding or pregnant. 


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8. Manifestations of malabsorption due to prior GI surgery, GI disease, or an unknown reason that 
may alter the absorption of TAK-228. Patients with enteric stomata are also excluded. 
9. Treatment with any investigational products within 2 weeks before administration of the first dose 
of the study drugs. 
10. Poorly controlled diabetes mellitus (defined as HbA1c > 7%). Patients with a history of transient 
glucose intolerance due to corticosteroid administration may be enrolled in the study if all other 
inclusion criteria and none of the other exclusion criteria are met. 
11. History of any of the following within the last 6 months before administration of the first dose of 
the study drugs: 
• Ischemic myocardial event, including  angina requiring therapy  and artery 
revascularization procedures   
• Ischemic cerebrovascular event, including transient ischemic attack and artery 
revascularization procedures 
• Requirement for inotropic support (excluding digoxin) or serious (uncontrolled) cardiac 
arrhythmia (including atrial flutter/fibrillation, ventricular fibrillation, and ventricular 
tachycardia)  
• Placement of a pacemaker for control of rhythm 
• New York Heart Association Class III or IV heart failure (see Appendix D)   
• Pulmonary embolism  
12. Significant active cardiovascular or pulmonary disease including: 
• Uncontrolled hypertension (i.e., systolic blood pressure > 180 mm Hg, diastolic blood 
pressure > 95 mm Hg). Use of antihypertensive agents to control hypertension before 
week 1, day 1 is allowed. 
• Pulmonary hypertension   
• Uncontrolled asthma or O2 saturation < 90% by arterial blood gas analysis or pulse 
oximetry on room air    
• Significant valvular disease, severe regurgitation, or stenosis by imaging independent of 
symptom control with medical intervention or history of valve replacement   
• Medically significant (symptomatic) bradycardia    
• History of arrhythmia requiring an implantable cardiac defibrillator   
• Baseline QTc prolongation (e.g., repeated demonstration of QTc interval > 480 
milliseconds or history of congenital long QT syndrome or torsades de pointes)  
13. Patients receiving systemic corticosteroids (either IV or oral steroids, excluding inhalers or low-
dose hormone replacement therapy) within 1 week before administration of the first dose of the 
study drugs. 
14. Daily or chronic use of a proton pump inhibitor (PPI) and/or having taken a PPI within 7 days 
before receiving the first dose of the study drugs. 
15. Patients unwilling or unable to comply with the study protocol.  
16. Patients previously treated with hormonal therapy (tamoxifen, AI) or PI3K, AKT, dual 
PI3K/mTOR, TORC1/2, or TORC1 inhibitors.  
17. Patients who are currently being treated with cancer therapy (chemotherapy, radiation therapy, 
immunotherapy, or biologic therapy) other than the trial therapy. 
18. Patients with hypersensitivity to mTOR inhibitors or tamoxifen.  
 


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11.    
STUDY DRUG 
11.1    Study Drug Administration 
Current protocol-specific criteria for administration of TAK-228 must be met and documented before drug 
administration. Study drug will be administered only to eligible patients under the supervision of the 
investigator. 
 
TAK-228 will be administered on an empty stomach. Patients should be instructed to refrain from eating 
and drinking (except for water and prescribed medications) for 2 hours before and 1 hour after each dose. 
Patients should drink at least 8 ounces (240 mL) of water with their TAK-228 dose. Patients should be 
instructed to take their study medication in the morning on each scheduled dosing day (day 1 of each week 
± 1 day) and not to take more than the prescribed dose at any time. Patients should swallow the study 
medication whole and not chew it, open it, or manipulate it in any way before swallowing. If a patient does 
not take their TAK-228 dose on the scheduled dosing day (day 1 of each week ± 1 day), then this will be 
considered a missed dose. Patients should record any missed doses in their diary and resume drug 
administration at the next scheduled time with the prescribed dosage. Under no circumstance should a 
patient repeat a dose or double-up doses. 
 
If severe emesis or mucositis prevents the patient from taking scheduled doses, that dose will be skipped. 
If emesis occurs after study medication ingestion, the dose will not be readministered, and patients should 
resume dosing at the next scheduled time with the prescribed dosage. Patients should record the 
occurrence of the emesis in their dosing diaries. Under no circumstance should a patient repeat a dose or 
double-up doses. 
 
Tamoxifen will be administered by the patient pursuant of a prescription obtained from the patient’s 
pharmacy. It is to be administered with or without food QD. Patients should be instructed to take their 
tamoxifen at approximately the same time each day and not to take more than the prescribed dose at any 
time. On TAK-228 scheduled dosing days, tamoxifen should be taken in the evening (before bed). Patients 
should swallow the tamoxifen whole and not chew it, crush it, or manipulate it in any way before 
swallowing. 
 
 
11.1.1  Dose Modification Guidelines 
TAK-228 should be administered, unless the patient has a grade 3 or greater TAK-228-related event. 
Guidelines for dose interruption and dose reduction are described below. 
 
       11.1.2  Criteria for Dose Interruption During a Cycle/Visit  
TAK-228 should be withheld for treatment-related toxicities that are grade 3 or higher despite supportive 
treatment per standard clinical practice. If the event resolves to grade 1 (or grade 2 for hyperglycemia or 
rash) or to baseline values within 3 weeks of interrupting treatment, then the patient may resume study 
treatment at a dose level reduced by 1 level.  
The following non-hematologic toxicities attributed to TAK-228 would not require dose interruption: 
• 
Grade 3 or higher nausea and/or emesis in the absence of optimal antiemetic prophylaxis (optimal 
antiemetic prophylaxis is defined as an antiemetic regimen that employs both a serotonin type 3 
receptor antagonist and a corticosteroid given in standard doses and according to standard schedules) 
• 
Grade 3 or higher diarrhea that occurs in the absence of optimal supportive therapy 
• 
Grade 3 fatigue 
 


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TABLE 7 TAK-228 DOSE MODIFICATIONS 
Dose Level 
TAK-228 Dose 
TAK-228 Number of Capsules and Strength 
0  
30 mg p.o. QW 
Six 5 mg capsules 
-1 
20 mg p.o. QW 
Four 5 mg capsules 
-2 
15 mg p.o. QW 
Three 5 mg capsules 
-3 
10 mg p.o. QW 
Two 5 mg capsules 
 
 
For patients who are unable to tolerate the protocol-specified dosing schedule, dose reductions or 
interruptions are permitted to manage drug-related toxicities. Patients whose treatment is interrupted or 
permanently discontinued due to an AE including abnormal laboratory value must be followed at least once 
a week for 4 weeks and subsequently at 4-week intervals until resolution or stabilization of the event, 
whichever comes first. Dose interruptions should be reported on the appropriate Dosage Administration 
case report form (CRF).  The maximum time allowed for toxicity-related treatment interruption is 21 days (3 
weeks) from the intended dosing day. If treatment interruption is >3 weeks or more than 3 dose reductions 
are required, the patient must be discontinued from the study treatment. However, they will need to 
complete the EOT visit within 30 to 40 days after the last dose of TAK-228, and the patient will continue to 
be followed for toxicity.  
 
 
11.2 Recommended Dose Modifications for Tamoxifen Treatment-Associated Toxicity 
 
There are no recommendations for tamoxifen dose modifications.  
 
11.3 Excluded Concomitant Medications and Procedures and Potential DDIs 
The following medications and procedures are prohibited during the study: 
• 
Other investigational agents including mTOR, PI3K, and AKT inhibitors 
• 
Other anticancer therapies including chemotherapy, immunotherapy, radioimmunotherapy, targeted 
agents, radiation, and surgery (palliative radiation and surgery for preexisting lesions is allowed during 
the study) 
• 
Systemic corticosteroids (either IV or oral steroids, excluding inhalers), unless necessary for the 
treatment of TAK-228-related rash.  
• 
Antiepileptic drugs for patients with treated brain metastasis 
• 
Concomitant administration of any PPI (e.g., omeprazole, esomeprazole, pantoprazole, lansoprazole, 
and rabeprazole) is not permitted during the study. Patients receiving PPI therapy before enrollment 
must stop using the PPI for 7 days before their first dose of study drugs.  
 
 
11.4 Permitted Concomitant Medications and Procedures  
• 
Histamine H2 receptor antagonists (e.g., ranitidine, famotidine, and nizatidine) may be allowed, if 
needed, provided they are not taken within 12 hours before and within 6 hours after administration 
of the study drugs. Patients receiving histamine H2 receptor antagonists before enrollment must 
stop using these medications for at least 24 hours before their first dose of the study drugs. 
Cimetidine, a moderate CYP1A2 inhibitor, is not recommended as a first choice H2 receptor 
antagonist. 


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• 
Neutralizing antacid preparations (acid neutralizers) and calcium supplements are permitted except 
from 2 hours before until 2 hours after TAK-228 administration. Some anti-gas preparations may 
also have antacid properties and should also not be permitted from 4 hours before until 2 hours 
after study drug administration. 
• 
Strong CYP1A2 inhibitors and CYP inducers should be administered with caution, at the discretion 
of the investigator (see Appendix E). Alternative treatments, if available, should be considered.. 
11.5 Precautions and Restrictions  
No dietary restrictions will be imposed on study patients other than the daily fasting glucose test. Patients 
are required to fast for glucose monitoring and refrain from eating or drinking for 2 hours before and 1 hour 
after each dose. 
Patients who show evidence of hyperglycemia during the study should be encouraged to follow a low 
carbohydrate diet. 
Patients should be encouraged to drink at least 20 ounces of fluids a day, especially on days requiring 
fasting. 
 
Pregnancy 
The effects of TAK-228 on human pregnancy and the development of the embryo or fetus are not known. 
Therefore, female and male patients participating in this study should avoid becoming pregnant or 
impregnating a partner, respectively.  
Women of childbearing potential and men should use effective methods of contraception during and 
through 90 and 120 days after the last dose of study drug, respectively, as specified below. 
Women must meet 1 of the following: 
• 
Postmenopausal for at least 1 year before the screening visit, OR 
• 
Surgically sterile, OR 
• 
If they are of childbearing potential, agree to practice 1 highly effective method of contraception and 1 
additional (barrier) method, at the same time from the time of ICF signing up to and including 90 days 
(or longer, as mandated by local labeling [e.g., United Surgical Partners International, summary of 
product characteristics, etc.]) after the last dose of the study drugs, OR 
• 
Agree to practice true abstinence, when this is in line with the preferred and usual lifestyle of the 
patient. (Periodic abstinence [e.g., calendar, ovulation, symptothermal, and postovulation methods] and 
withdrawal, spermicides only, and lactational amenorrhea are not acceptable methods of contraception. 
Female and male condoms should not be used together.) 
Males, even if surgically sterilized (i.e., status postvasectomy), must: 
• 
Agree to practice highly effective barrier contraception during the entire study treatment  period and 
through 120 days after the last dose of study drug, OR  
• 
Agree to practice true abstinence, when this is in line with the preferred and usual lifestyle of the 
patient. (Periodic abstinence [eg, calendar, ovulation, symptothermal, postovulation methods for the 
female partner], withdrawal, spermicides only, and lactational amenorrhea are not acceptable methods 
of contraception. Female and male condoms should not be used together.) 
• 
Agree not to donate sperm during the course of this study or 120 days after receiving their last dose of 
study drug. 
 


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11.6 Management of Clinical Events  
11.6.1 Management of Hyperglycemia 
Based on the TAK-228 clinical trials, most hyperglycemia episodes occurred within the first 60 days after 
initiation of treatment with TAK-228 and have been grade 1 or 2 and have responded quickly to oral 
metformin. Hyperglycemia has not been dose-limiting since instituting a standard regimen for early 
treatment of hyperglycemia.  
All patients who develop hyperglycemia during the study should have their glucose closely monitored by 
study staff. The investigator may choose either to continue close monitoring of patients who develop grade 
1 hyperglycemia (FSG > ULN ≤ 160 mg/dL) or, alternatively, consider initiating treatment with an oral 
hypoglycemic agent, such as metformin. All patients with grade ≥ 2 hyperglycemia (FSG > 160 mg/dL) 
must be treated aggressively with oral hypoglycemic agents and/or insulin as clinically indicated while 
continuing on TAK-228. The investigator should consult an endocrinologist, if needed, to aid in optimizing 
the patient’s hyperglycemia treatment plan. 
It is recommended that patients be treated initially with a fast-acting insulin sensitizer, such as metformin, 
at 500 mg p.o. QD and titrate up to a maximum of 1000 mg p.o. twice daily as needed. Concurrent 
administration of dipeptidyl peptidase-4 inhibitors (e.g., sitagliptin or vildagliptin) and/or insulin should also 
be considered.  Oral sulfonylureas (e.g., glipizide or glyburide) should be used with caution due to the 
higher hypoglycemia risk. The dose of oral hypoglycemic agents should be adjusted in patients with renal 
insufficiency. Hyperglycemic patients should also be encouraged to follow a low carbohydrate diet. 
 
If any fasting serum glucose reading performed at the site indicates hyperglycemia (> ULN or ≥ 110 
mg/dL), the study staff should first ascertain that the patient was fasting at the time of the blood draw (i.e., 
nothing by mouth for at least 8 hours prior to blood being obtained). 
 
In-Home Daily Fasting Glucose Monitoring 
In addition to obtaining fasting glucose levels at the clinic visits as outlined in the Schedule of Events, all 
patients will be given a glucometer to monitor their daily FBG levels at home. The level should be collected 
daily, predose on dosing days, and at approximately the same time each day. 
On Cycle 1 Day 1, the patient will be provided an in-home glucometer. Patients will be trained on proper 
use of the glucometer and instructed to collect a daily FBG level every morning (predose on dosing days), 
starting on Cycle 1 Day 2. Patients will be instructed to bring the glucometer with them to each study visit 
so that the data collected can be reviewed and recorded in the source documents. Investigators will be 
responsible for reviewing the home glucose monitoring logs for hyperglycemia. 
The patient will be instructed to contact the site immediately if the value is abnormal (i.e., ≥150 mg/dL) for 
further instructions on the management of their hyperglycemia. Hyperglycemia observed during home 
glucose monitoring should be confirmed in the clinic. 
If no irregularities in the fasting blood glucose level are observed during a minimum of 2 consecutive 
months, then the frequency of in-home fasting blood glucose testing can be reduced to a minimum 
frequency of once weekly, depending on the investigator’s judgment and approval. Patients will continue to 
notify the investigator of fasting blood glucose levels that exceed 150 mg/dL and, if blood glucose levels 
are not well controlled, or if the patient requires either oral hypoglycemic agents or insulin to control blood 
glucose levels, then the frequency of in-home testing of FBG levels will be reinstated to daily. 
Guidance on TAK-228 dose modification for patients with hyperglycemia is provided in Table 8 below. 


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TABLE 8  MANAGEMENT OF HYPERGLYCEMIA 
Grade 
Description 
Treatment 
Dose Modification 
1 
Fasting blood sugar >ULN 
to 160 mg/dL 
• 
Continue close monitoring of blood sugar. 
• 
Initiate oral hypoglycemic agent. 
None 
2 
>160 to 250 mg/dL 
• 
Initiate oral hypoglycemic agent and/or 
insulin if not well controlled on oral agent. 
None 
≥3 
>250 mg/dL 
• 
Initiate oral hypoglycemic agent and/or 
insulin. 
Hold TAK-228 until ≤grade 2.  
Resume TAK-228 based on timing of 
recovery after maximal treatment: 
• ≤1 week: resume TAK-228 at 
same dose and schedule. 
• >1 but ≤2 weeks: reduce TAK-
228 by 1 dose level 
• >2 weeks: discontinue patient 
from the study. 
Prevention/Prophylaxis: 
• 
Follow fasting glucose levels during clinic visits. 
• 
Monitor home glucometer test results. 
• 
Check HbA1c levels every 3 months during therapy. 
• 
Recommend life-style modifications, as appropriate (balanced diet, limited alcohol consumption, increased physical activity). 
• 
Most episodes of grade 1 or 2 hyperglycemia respond quickly to oral metformin. Early initiation of therapy at the lowest 
therapeutic dose is recommended to prevent higher grade hyperglycemia. 
• 
Fasting blood glucose levels ≥150 mg/dL by glucometer should be followed by closer monitoring of serum glucose and possible 
intervention.  
HbA1c=glycosylated hemoglobin; ULN=upper limit of normal. 
 
11.6.2 Management of Hyperlipidemia 
Guidance on TAK-228 dose modification for patients with hyperlipidemia is provided in Table 9. 
 
TABLE 9  MANAGEMENT OF HYPERLIPIDEMIA 
Grade 
Description 
Treatment 
Dose Modification 
1 
Cholesterol >ULN to 300 mg/dL 
Triglycerides >150 to 300 mg/dL 
None 
None 
2 
Cholesterol >300 to 400 mg/dL 
 
 
Triglycerides >300 to 500 mg/dL 
• 
Treat hyperlipidemia 
according to standard 
guidelines. 
• 
Triglycerides ≥500 mg/dL 
should be treated urgently, 
due to risk of pancreatitis. 
• 
Maintain dose, if tolerable. 
• 
If toxicity becomes intolerable, 
interrupt TAK-228 until 
recovery to ≤grade 1. Re-
initiate TAK-228 at the same 
dose level. 
3 
Cholesterol >400 to 500 mg/dL 
 
Triglycerides >500 to 1000 mg/dL 
Same as for grade 2. 
Hold TAK-228 until recovery to 
≤grade 1, then reinitiate TAK-228 at 
a dose reduced by 1 level.  
4 
Cholesterol >500 mg/dL 
Triglycerides >1000 mg/dL 
Same as for grade 2. 
Same as for grade 3. 
Prevention/Prophylaxis: 
Life-style modifications, as appropriate (balanced diet, limit alcohol consumption, increase physical activity) 
ULN=upper limit of normal. 
 
11.6.3 Management of Oral Mucositis 
Guidance on TAK-228 dose modification for patients with oral mucositis is provided in Table 10. 


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TABLE 10 MANAGEMENT OF ORAL MUCOSITIS 
Grade 
Description 
Treatment 
Dose Modification 
1 
Asymptomatic or mild 
symptoms. 
• 
Nonalcoholic mouth wash or 0.9% 
salt water rinse. 
• 
Consider topical corticosteroids at 
earliest signs of mucositis. 
None 
2 
Moderate pain, not interfering 
with oral intake. 
Modified diet indicated. 
• 
Topical analgesic mouth treatments. 
• 
Topical corticosteroids. 
• 
Initiate antiviral or antifungal therapy, 
if indicated. 
• 
Maintain TAK-228 dose if 
tolerable. 
• 
Hold only TAK-228 if intolerable 
until recovery to ≤grade 1, then 
restart at same dose. 
3 
Severe pain, interfering with oral 
intake. 
• 
Same as for grade 2. 
• 
Consider intralesional corticosteroids. 
• 
Hold TAK-228 until recovery to 
≤grade 1, then restart TAK-228 
at a dose reduced by 1 level. 
4 
Life-threatening consequences. 
• 
Same as for grade 2. 
• 
Consider intralesional corticosteroids. 
• 
Stop TAK-228 and discontinue 
patient from the study. 
Prevention/Prophylaxis: 
• 
Initiation of a nonalcoholic mouth wash or 0.9% salt water rinses 4 to 6 times daily is strongly recommended at the start of 
therapy before signs of mucositis develop. 
• 
Avoid using agents containing hydrogen peroxide, iodine, and thyme derivatives in management of stomatitis, as they may 
worsen mouth ulcers. 
 
11.6.4 Management of Rash 
Guidance on TAK-228 dose modification for patients with rash is provided in Table 11. 
TABLE 11  MANAGEMENT OF RASH 
Grade 
Description 
Treatment 
Dose Modification 
≤2 
Macules/papules covering ≤30% 
body surface area with or 
without symptoms. 
Consider treatment with topical steroid 
cream/ointment and/or oral anti-
histamines or antibiotics. 
None 
≥3 
Macules/papules covering >30% 
body surface area with or 
without symptoms. 
Consider treatment with topical steroid 
cream/ointment, oral anti-histamines, 
oral antibiotics, and/or pulsed steroids. 
Hold TAK-228 until ≤grade 2. 
 
Resume TAK-228 based on timing of 
recovery: 
• 
≤3 weeks: reduce TAK-228 by 1 
dose level.  
• 
>3 weeks: stop TAK-228 and 
discontinue patient from the study. 
Patients who develop grade 4 rash should permanently discontinue study treatment, unless they derive clinical benefit, in which case 
they may be retreated at a reduced dose level after recover to ≤grade 1 severity. Grade 4 rash is defined as rash 
acneifom/papulopustular with papules and/or pustules covering any % body surface area, which may or may not be associated with 
symptoms of pruritus or tenderness, and are associated with extensive superinfection with IV antibiotics indicated; life threatening 
consequences (NCI CTCAE Version 4.03, effective date 14 June 2010). 
 
Prevention/Prophylaxis: 
• 
Rash should be managed aggressively. The investigator should consider consulting a dermatologist or other specialist, if 
needed. 
• 
A skin biopsy at the site of rash should be considered as soon as possible after the initial episode. 
 
11.6.5 Management of Nausea/Vomiting 
Guidance on TAK-228 dose modification for patients with nausea and/or vomiting is provided in Table 12. 
 


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TABLE 12 MANAGEMENT OF NAUSEA/VOMITING 
Grade 
Description 
Treatment 
Dose Modification 
≤2 
Loss of appetite with or without 
decreased oral intake.  
1 to 5 episodes of vomiting within 
24 hours. 
• 
Maximize anti-emetic therapy. 
• 
Consider IV fluid hydration. 
None 
≥3 
Inadequate oral intake.  
≥6 episodes of vomiting within 
24 hours. 
• 
Maximize anti-emetic therapy. 
• 
Initiate tube feeding, IVF or 
TPN. 
If experienced for ≤72 hours, hold 
TAK-228 until ≤grade 1, then resume 
TAK-228 without dose modification. If 
experienced for >72 hours despite 
optimal therapy, hold TAK-228 until 
≤grade 1, then resume treatment with 
the dose of TAK-228 reduced by 1 
level. 
Prevention/Prophylaxis: 
Prophylactic use of antiemetic, antinausea, and antidiarrheal medications are encouraged and may be used before each TAK-228 
dosing as needed throughout the study. 
IV=intravenous; IVF=intravenous fluids; TPN=total parental nutrition. 
 
11.6.6 Management of Cardiac Abnormalities 
Management of Patients With Possible Cardiac Instability 
For patients showing signs of cardiac instability after TAK-228 administration, additional onsite monitoring 
before clinic discharge should be considered. 
 
Management of Patients With Left Ventricular Dysfunction 
Guidance on TAK-228 dose modification for patients with left ventricular dysfunction is provided in Table 
13. 
 
TABLE 13   MANAGEMENT OF LEFT VENTRICULAR DYSFUNCTION 
Grade 
Description 
Dose Modification 
1 
Asymptomatic decline in: 
LVEF >15% from baseline values, OR 
LVEF >10% to 15% from baseline values and is below 
institution’s LLN. 
No change; continue TAK-228 at the same dose and 
schedule. 
≥2 
Symptomatic cardiac dysfunction/congestive heart failure. 
Discontinue treatment. 
LLN=lower limit of normal; LVEF=left ventricular ejection fraction. 
Management of Patients with QTc Prolongation 
Guidance on TAK-228 dose modification for patients with prolonged QTc interval is provided in Table 14. 
 
TABLE 14  MANAGEMENT OF QTc PROLONGATION 
Grade 
Description 
Treatment 
Dose Modification 
2 
480 msec <QTc 
<501 msec 
Evaluate for other possible causes (e.g., 
electrolyte disturbance, concomitant 
medication, etc.). 
None; continue TAK-228 at the same dose and 
schedule. 


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TABLE 14  MANAGEMENT OF QTc PROLONGATION 
Grade 
Description 
Treatment 
Dose Modification 
≥3 
QTc ≥501 msec 
Evaluate for other possible causes (e.g., 
electrolyte 
disturbance, 
concomitant 
medicationa). 
Consider a formal consult by a cardiologist. 
Notify the study doctor. 
Additional ECGs may be performed at intervals 
that the treating physician deems clinically 
appropriate until repeated QTc measurements 
fall or are below the threshold interval that 
triggered the repeat measurement. 
Hold TAK-228. 
The decision whether to reinitiate TAK-228 with 
or without dose reduction and additional 
monitoring 
in 
those 
patients 
who 
had 
asymptomatic prolonged QTc ≥501 msec 
(grade 3) that has reverted to an acceptable 
interval, have previously tolerated TAK-228, 
and appear to have benefitted from treatment 
with either disease control or response, will be 
agreed to by the investigator on a case-by-case 
basis 
Patients 
who 
experience 
persistent 
symptomatic grade 3 or grade 4 QTc 
prolongation without another cause should 
permanently discontinue study treatment. 
ECG=electrocardiogram; IV=intravenous; msec=milliseconds; QTc=QT interval corrected for heart rate. 
aA list of medications known to prolong QTc can be found at https://www.crediblemeds.org/new-drug-list/  
 
11.6.7 Management of Other Non-hematologic Toxicities (Including Asthenia, Weakness, and 
Fatigue) 
Guidance on TAK-228 dose modification for patients with other non-hematologic toxicities is provided in 
Table 15. 
 
TABLE 15  MANAGEMENT OF OTHER NON-HEMATOLOGIC TOXICITIES (INCLUDING ASTHENIA, WEAKNESS, AND 
FATIGUE) 
Grade 
Description 
Treatment 
Dose Modification 
1 
Mild; asymptomatic or mild 
symptoms; clinical or diagnostic 
observations only; intervention not 
indicated. 
Initiate appropriate medical 
therapy and monitor. 
If tolerable, then no adjustment is 
required. 
2 
Moderate; minimal, local or 
noninvasive intervention indicated. 
Initiate appropriate medical 
therapy and monitor. 
• 
If tolerable, then no adjustment 
required. 
• 
If toxicity becomes intolerable, hold 
TAK-228 until recovery to ≤grade 1, 
then reinitiate at the same dose.  
≥ 3 
Severe or medically significant but 
not 
immediately 
life-threatening; 
hospitalization or prolongation of 
hospitalization indicated. 
 
Hold  TAK-228  until recovery to ≤grade 1. 
Reinitiate TAK-228 at dose reduced by 1 
level.  
Patients who develop grade 4 non-
hematological toxicities (with the exception 
of 
isolated 
non-clinically 
significant 
laboratory values) should permanently 
discontinue study treatment, unless they 
derive clinical benefit, in which case they 
may be retreated at a reduced dose level 
after recovery to ≤grade 1 severity. 
 
11.6.8 Management of AST/ALT Elevations 
Guidance on TAK-228 dose modification for patients with AST/ALT elevations is provided in Table 16. 
 


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TABLE 16         MANAGEMENT OF AST/ALT ELEVATIONS 
Grade 
Description 
Treatment 
Dose Modification 
1 
>ULN to 3×ULN 
None 
None 
2 
Asymptomatic with levels 3 to 
5×ULN; >3×ULN with the 
appearance of worsening fatigue, 
nausea, vomiting, right upper 
quadrant pain or tenderness, fever, 
rash, or eosinophilia. 
• 
Closely monitor LFTs at least 
weekly or more frequently as 
indicated. 
• 
Assess patient for other causes of 
transaminitis (e.g., past medical 
history, concomitant 
medications). 
None 
3 
>5 to 20×ULN; >5×ULN for >2 
weeks 
Same as for grade 2. 
Hold TAK-228 until ≤grade 1; Restart 
TAK-228 
at 
the 
same 
dose. 
Permanently 
discontinue 
study 
treatment if in combination with grade 2 
total bilirubin elevation when alternative 
causes cannot be identified (i.e., Hy’s 
Law). 
4 
>20×ULN 
Same as for grade 2. 
Stop TAK-228 and discontinue patient 
from 
the 
study. 
Permanently 
discontinue study treatment if in 
combination with grade 2 total bilirubin 
elevation when alternative causes 
cannot be identified (i.e., Hy’s Law). 
Prevention/Prophylaxis: 
Ensure proper screening of patients for study participation. 
LFTs=liver function tests; ULN=upper limit of normal. 
 
11.6.9 Management of Non-infectious Pneumonitis 
Guidance on TAK-228 dose modification for patients with pneumonitis is provided in Table 17. 
 
TABLE 17    MANAGEMENT OF NON-INFECTIOUS PNEUMONITIS 
Grade 
Description  
Treatment 
TAK-228 Dose Modification 
1 
Asymptomatic: Radiographic findings only. 
Rule out infection and closely 
monitor. 
None 
2 
Symptomatic: 
Not interfering with activities of daily living. 
Rule out infection and consider 
treatment with corticosteroids 
until symptoms improve to 
≤grade 1. 
Interrupt TAK-228 
• When symptoms ≤grade 
1, reinitiate TAK-228 at a 
dose reduced by 1 level. If 
no 
recovery 
within 
3 weeks (21 days), then 
discontinue TAK-228.  
3 
Symptomatic: 
Interfering with activities of daily living; 
Requires administration of oxygen. 
Rule out infection and consider 
treatment with corticosteroids 
until symptoms improve to 
≤grade 1. 
Interrupt 
TAK-228 
until 
symptoms resolve to ≤grade 1.  
• Consider reinitiating TAK-
228 at a dose reduced by 
1 level . 
• If toxicity recurs at grade 
3, discontinue TAK-228. 
4 
Life-threatening: 
Ventilatory support indicated. 
Rule out infection and consider 
treatment with corticosteroids. 
Discontinue TAK-228. 
 
11.7 Description of Investigational Agents 
TAK-228 will be supplied as capsules for oral administration. The study drug is available in 3 dose 
strengths, 1 mg, 3 mg, and 5 mg, each containing 1 mg, 3 mg, and 5 mg of TAK-228, respectively, in 


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addition to the following inactive ingredients: microcrystalline cellulose (solid filler/diluents), magnesium 
stearate (lubricant), and hard gelatin capsule. All 3 dose strengths are formulated into size 2 capsules, and 
each dose strength is differentiated by color, as listed below: 
• 
TAK-228 capsules, 1 mg - white opaque color 
• 
TAK-228 capsules, 3 mg – orange opaque color 
• 
TAK-228 capsules, 5 mg – grey opaque color  
Tamoxifen citrate USP is a non-steroidal antiestrogen commercially available in tablet formulation for oral 
administration. Each tablet contains 10 or 20 mg tamoxifen (equivalent to 15.2 or 30.4 mg tamoxifen 
citrate, respectively). Tamoxifen is available in generic formulations that may contain the following inactive 
ingredients depending on the specific generic formulation: croscarmellose sodium, hypromellose, lactose 
(monohydrate), magnesium stearate, polyethylene glycol 400, povidone, corn starch, and titanium dioxide.  
 
11.8 Preparation, Reconstitution, and Dispensation 
TAK-228 study drug will be provided in labeled bottles in accordance with all applicable regulations. 
Materials provided by the sponsor should be dispensed to patients with clear administration instructions 
from the investigator. TAK-228 is an anticancer drug and, as with other potentially toxic compounds, 
caution should be exercised when handling TAK-228 capsules. Tamoxifen is commercially available and 
will be provided through the patient’s pharmacy in accordance with all applicable laws and regulations 
regarding dispensing of a prescription medication.   
 
11.9 Packaging and Labeling 
TAK-228 will be provided by Millennium and will be handled at the investigative site as open label material. 
Sites must store TAK-228 according to the labeled conditions.  
TAK-228 capsules are packaged in 60-cc high-density polyethylene bottles with polypropylene, child-
resistant caps and induction seal. For all dose strengths, each bottle contains 30 capsules. 
Tamoxifen will be provided through the patient’s pharmacy and labeled according to both state and federal 
laws and regulations. 
 
11.10 Storage, Handling, and Accountability 
Upon receipt at the investigative site, the drug should be stored in the original bottles until use and stored 
at a room temperature of 15°C to 30°C (59°F to 86°F). All temperature excursions will be reported for 
assessment and authorization for continued use. All investigational supplies will be stored in the original 
packaging in a secure area with controlled access. All drug supplies should be used before the retest 
expiry date.  Because TAK-228 is an investigational agent, it should be handled with due care. In case of 
contact with broken capsules, raising dust should be avoided during the cleanup operation. The product 
may be harmful if inhaled, ingested, or absorbed through the skin. Gloves and protective clothing should 
be worn during the cleanup operation. The area should be ventilated and the spill site washed after 
material pickup is complete. The spilled material should be disposed of as hazardous medical waste in 
compliance with federal, state, and local regulations. In case of contact with the powder (e.g., from a 
broken capsule), the skin should be washed immediately with soap and copious amounts of water for at 
least 15 minutes. In case of contact with the eyes, copious amounts of water should be used to flush the 
eyes for at least 15 minutes. Medical personnel should be notified. Patients will receive instructions for 
home storage and administration of TAK-228. Accountability for TAK-228 at all study sites is the 
responsibility of the sponsor-investigator.  Tamoxifen should be stored at a controlled room temperature of 
20°C to 25°C (68°F to 77°F).  
 


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11.11 Study Compliance 
Study drug will be administered or dispensed only to eligible patients under the supervision of the 
investigator or identified sub-investigator(s). The appropriate study personnel will maintain records of study 
drug receipt and dispensing. 
 
11.12 Termination of Treatment and/or Study Participation 
Patients will be informed that they have the right to withdraw from the study at any time for any reason 
without prejudice to their medical care. The investigator also has the right to withdraw patients from the 
study for any of the following reasons: 
• AE 
• Protocol violation 
• Lost to follow-up 
• Progressive disease 
• Study termination  
• Other 
At the time of withdrawal, all study procedures outlined for the End of Study visit should be completed. The 
primary reason for the patient’s withdrawal from the study should be recorded in the source documents 
and CRF. 
 
12.    
CRITERIA FOR RESPONSE 
This study is designed to determine the change in Ki67 and pCR rate after TAK-228 in combination with 
tamoxifen in patients with ER-positive, HER2-negative breast cancer. 
 
12.1  Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 
The clinical tumor response will be assessed at baseline and before surgery using RECIST 1.1. RECIST  
1.1 offers a simplified, conservative, extraction of imaging data for wide application in clinical trials. They 
presume that linear measures are an adequate substitute for 2-dimensional methods and register four 
response categories.41 
  
 
Target Lesions (Main Tumor) 
• 
Complete Response (CR): Disappearance of all target lesions.  Any pathological lymph nodes 
(whether target or non-target) must have reduction in short axis to < 10 mm. 
• 
Partial Response (PR): At least a 30% decrease in the sum of the diameters of target lesions, using 
the baseline sum diameters as the reference. 
• 
Progressive Disease (PD): At least a 20% increase in the sum of the diameters of target lesions using 
the smallest sum while on study (includes the baseline sum) as the reference. In addition to the 
relative  20% increase, the sum must also demonstrate an absolute increase of at least 5 
mm. (Note: the appearance of one or more new lesions is also considered progression) 
• 
Stable Disease (SD):  Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for  
 
PD, using the smallest sum diameters while on study as the reference. 
 
Non-Target Lesions (Lymph Nodes) 
 
CR: Disappearance of all non-target lesions and normalization of tumor marker levels. All lymph nodes 
must be non-pathological in size (< 10 mm short axis). (Note:  If tumor markers are initially above the 
upper normal limit, they must normalize for a patient to be considered in complete clinical response.) 
• 
Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or maintenance of tumor marker  
 
levels above the normal limits. 


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• 
PD: Appearance of one or more new lesions and/or unequivocal progression of existing non-target 
lesions.  Unequivocal progression should not normally trump target lesion status.  It must be 
representative of overall disease status change, not a single lesion increase.     
Although a clear progression of “non-target” lesions only is exceptional, the opinion of the treating 
physician should prevail in such circumstances, and the progression status should be confirmed at a later 
time by the principal investigator. 
 
13.  STATISTICAL AND QUANTITATIVE ANALYSES 
 
13.1    Statistical Methods 
Based on prior data for Ki67 changes in the tamoxifen only arm of the IMPACT trial, we will assume null 
and alternative hypotheses of 60% and 80% reduction in Ki67, respectively.42 Transformations of the 
geometric mean and 95% CI were employed to obtain mean and standard deviation estimates.   
 
As a measure of safety, toxicity will be monitored during the trial based on a beta-binomial model, 
assuming a priori that the probability of toxicity p is distributed beta(0.2, 0.8). Study accrual will be 
suspended and the safety profile of the TAK-228 and tamoxifen combination will be reviewed by the safety 
monitoring committee if Pr(p > .20 | data) > 0.85. This stopping rule yields the following stopping bounds 
where the numerator represents the number of events needed to suspend accrual and the denominator 
represents the number treated at that point in the study: 3/6, 4/8, 5/12, 6/16, 7/20, 8/24. An event is defined 
as progression within 16 weeks.  Scenario 1 of the operating characteristics table (see below) indicates 
that the probability of stopping the study early for progression is very low when progression is uncommon; 
that is, the study has only a 4.2% chance of stopping early when the true progression rate is only 10%. The 
study has a 94.3% chance of stopping if the true progression rate is 40% and on average would take only 
7 patients to arrive at that conclusion.  The stopping rule assumes monitoring begins after 6 patients have 
been enrolled on study. 
 
Scenario 
True Pr(toxicity) 
Pr(stop early) 
Median # Pts (25%, 75%) 
1 
0.10 
0.042 
28 (28, 28) 
2 
0.20 
0.317 
28 (15, 28) 
3 
0.30 
0.723 
14 (6, 28) 
4 
0.40 
0.943 
7 (6, 13) 
5 
0.50 
0.995 
6 (6, 7) 
 
 
13.1.1     Determination of Sample Size 
A sample of 25 patients will provide 86% power to detect the hypothesized reduction in Ki67 with 5% alpha 
based on a two-sided, one sample t-test of mean percent change in Ki67 level, based on prior data for 
Ki67 changes in the tamoxifen only arm of the IMPACT trial.42 To account for attrition (estimated 20% 
screen failure/withdrawal rate) and 10% rate of unmatched pre- versus post-treatment biopsy samples, a 
sample of 35 patients is proposed for this study. 
 
13.1.2    Randomization and Stratification   
Randomization is not employed for this phase II study.  
 
13.1.3    Populations for Analysis 
All patients who received at least 1 dose of the study drugs will be included in a descriptive safety analysis.  
The safety profiles will be assessed through summaries of AEs, SAEs, AEs leading to treatment 


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discontinuation, and treatment-related death. The safety analysis will report the frequency of all AEs and 
laboratory abnormalities, as well as the frequency of dose interruptions, dose reductions, and toxicity-
related treatment discontinuation. Toxicity rates will be presented using the worst NCI CTCAE version 4.03 
grade per patient. 
 
13.1.4    Procedures for Handling Missing, Unused, and Spurious Data 
Data quality control will be performed on a regular basis by the research coordinator/research nurse to 
ensure timely, accurate, and complete patient data collection. Queries will be generated and resolved prior 
to the generation of interim and final summary reports. 
 
13.1.5    Demographic and Baseline Characteristics 
Demographic and baseline characteristics will be summarized for all patients participating in the study 
using descriptive analysis. Classification of patients as responders versus non-responders will be based on 
treatment response and changes in associated proliferation markers. 
 
13.1.6   Efficacy Analysis 
The single-arm, single-stage, phase II IMPACT clinical trial will be utilized to assess changes in Ki67 
levels. Ki67 levels will be log transformed (natural logarithm) to achieve approximately normally distributed 
data.42 The difference between the log-transformed values in pre- and post-treatment biopsy samples will 
be calculated. Based on prior data for Ki67 changes in the tamoxifen arm alone, we will assume null 
hypothesis and alternative hypotheses of 60% and 80% reduction in Ki67, respectively. Transformations of 
the geometric mean and 95% CI presented in Dowsett et al.42 were employed to obtain mean and standard 
deviation estimates. A sample of 25 patients will provide 86% power to detect the hypothesized reduction 
in Ki67 with 5% alpha based on a two-sided, one sample t-test of mean percent change in Ki67 level. To 
account for attrition (estimated 20% screen failure/withdrawal rate) and 10% rate of unmatched pre- versus 
post-treatment biopsy samples, a sample of 35 patients is proposed in the study.  
 
We assume that the combination will double the pCR rate compared to tamoxifen alone.  Assuming a pCR 
rate of 10% for tamoxifen alone, a one-tailed one sample test for population proportions based on the 
lower confidence limit of a Wilson’s Score interval will achieve 68.6% power at the 0.10 significance level 
to detect a pCR rate increase due to the addition of TAK-228 to tamoxifen assuming the true pCR rate of 
the combination is 20%.  Assuming a true pCR rate of 20% for the combination, we expect a lower bound 
for the Wilson Score 90% one-sided confidence interval of 12.4%. The power calculation is based on a 
simulation of 20,000 replications using the BINOMIAL option of the FREQ procedure of SAS. All statistical 
analyses will be conducted using SAS 9.4 (SAS Institute Inc., Cary, NC, USA). 
 
 
13.1.7    PK/Biomarkers 
Plasma PK of the TAK-228 plus tamoxifen combination will be determined on days 1 and 15. Blood 
samples for PK analysis will be obtained 1 hour (± 15 minutes) before TAK-228 dosing and 1 hour (± 5 
minutes) after TAK-228 dosing. Blood samples (10 mL per sampling timepoint) will be collected and 
plasma batched for future analyses. Banked tumor tissue obtained as part of the patient’s standard care 
and collected biopsy tissues will be evaluated for tissue-based biomarkers including ER; Ki67; mitotic 
index; apoptosis; levels of S6K1, 4EBP-1, EIF4E, EIF4G, and EIF4A; levels of phosphorylated S6K, p53, 
p63, and p73 levels; and p73 and p63 gene signatures. These biomarkers will be compared to clinical 
parameters such as tumor response to help define a biomarker signature associated with p63/p73 and/or 
PI3K/AKT dependence and NFkB in ER-positive breast cancers and to identify new therapeutic options for 
ER-positive breast cancer patients. Oncotype DX testing will also be performed on biopsy and surgical 


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tissue samples. 
 
 
13.1.8    Safety Analysis 
All patients who received at least 1 dose of the study drugs will be included in a descriptive safety analysis.  
The safety profiles will be assessed through summaries of AEs, SAEs, AEs leading to treatment 
discontinuation, and treatment-related death. The safety analysis will report the frequency of all AEs and 
laboratory abnormalities, as well as the frequency of dose interruptions, dose reductions, and treatment 
discontinuation for toxicity. Toxicity rates will be presented using the worst NCI CTCAE version 4.03 grade 
per patient. 
 
14.    
AES   
14.1    Definitions 
14.1.1    AE Definition 
AE is defined as any untoward medical occurrence in a patient or subject administered a pharmaceutical 
product; the untoward medical occurrence 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 it is related to the medicinal product. This includes any newly occurring event or a 
previous condition that has increased in severity or frequency since the administration of the study drug. 
An abnormal laboratory value will not be assessed as an AE unless that value leads to discontinuation or 
delay in treatment, dose modification, therapeutic intervention, or is considered by the investigator to be a 
clinically significant change from baseline.   
 
14.1.2    SAE Definition 
SAE is defined as any untoward medical occurrence that at any dose: 
• Results in death 
• Is life-threatening (refers to an AE in which the patient was at risk of death at the time of the 
event.  It does not refer to an event which hypothetically might have caused death if it were more 
severe) 
• Requires inpatient hospitalization or prolongation of an existing hospitalization  
• Results in persistent or significant disability or incapacity (disability is defined as a substantial 
disruption of a person’s ability to conduct normal life functions) 
• Results in a congenital anomaly/birth defect 
• Is a medically important event. This refers to an AE that may not result in death, be immediately 
life-threatening, or require hospitalization, but may be considered serious when, based on 
appropriate medical judgment, may jeopardize the patient, require medical or surgical intervention 
to prevent 1 of the outcomes listed above, or involves suspected transmission via a medicinal 
product of an infectious agent. Examples of such medical events include allergic bronchospasm 
requiring intensive treatment in an emergency room or at home, blood dyscrasias or convulsions 
that do not result in inpatient hospitalization, and development of drug dependency or drug abuse. 
Any organism, virus, or infectious particle (e.g., prion protein transmitting transmissible spongiform 
encephalopathy), pathogenic or non-pathogenic, is considered an infectious agent.   
Clarification should be made between a SAE and an AE that is considered severe in intensity (grade 3 or 
4), because the terms serious and severe are NOT synonymous. The general term severe is often used to 
describe the intensity (severity) of a specific event; the event itself, however, may be of relatively minor 
medical significance (such as a grade 3 headache). This is NOT the same as serious, which is based on 
patient/event outcome or action criteria described above and usually associated with events that pose a 


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threat to a patient’s life or ability to function. A severe AE (grade 3 or 4) does not necessarily need to be 
considered serious.  For example, a white blood cell count of 1000/mm3 to less than 2000 is considered 
grade 3 (severe) but may not be considered serious. Seriousness (not intensity) serves as a guide for 
defining regulatory reporting obligations. 
 
14.2    Procedures for Reporting SAEs 
AEs may be spontaneously identified by the patient and/or in response to an open question from study 
personnel or revealed by observation, physical examination, or other diagnostic procedures. Any clinically 
relevant deterioration in laboratory assessments or other clinical finding is considered an AE.  When 
possible, signs and symptoms indicating a common underlying pathology should be noted as one 
comprehensive event.   
SAEs must be reported to Takeda Pharmacovigilance (or designee) from the time of consent up to and 
including 30 days after administration of the last dose of TAK-228. Any SAE that occurs at any time after 
completion of TAK-228 treatment or after the designated follow-up period that the sponsor-investigator 
and/or sub-investigator considers to be related to any study drug must be reported to Takeda 
Pharmacovigilance (or designee). Planned hospital admissions or surgical procedures for an illness or 
disease that existed before the patient was enrolled in the trial are not to be considered AEs unless the 
condition deteriorated in an unexpected manner during the trial (e.g., surgery was performed earlier or later 
than planned). All SAEs should be monitored until they are resolved or are clearly determined to be due to 
a patient’s stable or chronic condition or intercurrent illness(es). 
Since this is an investigator-initiated study, the sponsor-investigator Dr. Jenny Chang is responsible for 
reporting SAEs to any regulatory agency and to the sponsor-investigator’s ethics committee or institutional 
review board. Regardless of expectedness or causality, all SAEs must also be reported in English to 
Takeda Pharmacovigilance or designee: 
• Fatal and Life-threatening SAEs: within 24 hours of the sponsor-investigator’s observation or 
awareness of the event 
• All other serious (non-fatal/non-life-threatening) events: within 4 calendar days of the 
sponsor-investigator’s observation or awareness of the event  
The Sponsor will send all SAE reports to Takeda Pharmacovigilance (or designee) within 24 hours but 
no later than 4 calendar days as per any agreements.  
The SAE report must include at minimum: 
• 
Event term(s) 
• 
Serious criteria 
• 
Intensity of the event(s): Sponsor-investigator’s or sub-investigator’s determination.  
Intensity for each SAE, including any lab abnormalities, will be determined using the NCI 
CTCAE version specified in the protocol, as a guideline, whenever possible.  The criteria 
are available online at http://ctep.cancer.gov/reporting/ctc.html. 
• 
Causality of the event(s): Sponsor-investigator’s or sub-investigator’s determination of 
the relationship of the event(s) to study drug administration.  
Follow-up information on the SAE may be requested by Millennium Pharmacovigilance (or designee).   
In the event that this is a multisite study, the sponsor-investigator is responsible to ensure that the SAE 
reports are sent to Takeda Pharmacovigilance (or designee) from all sites participating in the study.  Sub-
investigators must report all SAEs to the sponsor-investigator so that the sponsor-investigator can meet 
her foregoing reporting obligations to the required regulatory agencies and to Takeda Pharmacovigilance, 
unless otherwise agreed between the sponsor-investigator and sub-investigator(s).   
Relationship to all study drugs for each SAE will be determined by the investigator or sub-investigator by 
responding yes or no to the question: Is there a reasonable possibility that the AE is associated with the 
study drug(s). 


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Houston Methodist Cancer Center at: 
hmccsaereports@houstonmethodist.org 
Fax #: 713-790-5106 
US and Canada 
Toll-Free Fax #: 1-800-963-6290 
E-mail: takedaoncocases@cognizant.com 
All other countries (Rest of World) 
Fax #: 1 202 315 3560 
E-mail: takedaoncocases@cognizant.com 
Suggested Reporting Form:   
• 
SAE Report Form (a sample will be provided) 
• 
US 
FDA 
MedWatch 
3500A: 
http://www.fda.gov/Safety/MedWatch/HowToReport/DownloadForms/default.htm 
• 
Any other form deemed appropriate by the sponsor-investigator 
 
14.3   Procedures for Reporting Drug Exposure During Pregnancy and Birth Events 
If a patient becomes pregnant or suspects that she is pregnant while participating in this study, she must 
inform the investigator immediately and permanently discontinue the study drugs. The sponsor-investigator 
must immediately fax a completed Pregnancy Form to Takeda Pharmacovigilance or designee.  The 
pregnancy must be followed for the final pregnancy outcome (i.e., delivery, still birth, miscarriage) and 
Takeda Pharmacovigilance or designee will request this information from the sponsor-investigator. 
If a female partner of a male patient becomes pregnant during the male patient’s participation in this study, 
the sponsor-investigator must also immediately fax a completed Pregnancy Form to the Takeda 
Pharmacovigilance or designee. Every effort should be made to follow the pregnancy for the final 
pregnancy outcome. 
 
Suggested Pregnancy Reporting Form: 
Pregnancy Report Form (a sample will be provided by Takeda Pharmaceuticals)   
 
    
15. ADMINISTRATIVE REQUIREMENTS 
15.1   
Product Complaints   
A product complaint is a verbal, written, or electronic expression that implies dissatisfaction regarding the 
identity, strength, purity, quality, or stability of a drug product. Individuals who identify a potential product 
complaint situation should immediately contact Takeda (see below) and report the event. Whenever 
possible, the associated product should be maintained in accordance with the label instructions pending 
further guidance from a Takeda Quality representative. 
 
A medication error is a preventable event that involves an identifiable patient and that leads to 
inappropriate medication use, which may result in patient harm. While overdoses and underdoses 
constitute medication errors, doses missed inadvertently by a patient do not.  Individuals who identify a 
potential medication error situation should immediately contact Takeda (see below) and report the event.  
For Product Complaints or Medication Errors, call 
 
For ADCETRIS or PIPELINE Products: 
Phone: 1-844-ONC-TKDA (1-844-662-8532) 
Email: GlobalOncologyMedInfo@takeda.com 


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Fax: 1-800-881-6092, Hours Mon – Fri, 9 a.m. – 7 p.m. ET 
 
Product complaints in and of themselves are not AEs.  If a product complaint results in an SAE, an SAE 
form should be completed and sent to Takeda Pharmacovigilance.  


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16. REFERENCES    
 
1. Infante JR, et al, A phase 1, open label, dose escalation study of an investigational oral mammalian target 
of rapamycin inhibitor TAK-228 (INK128) administered once daily in patients with advanced malignancies.  
ASCO Abstract 5588. 
2. Bachelot T, et al, Randomized Phase II trial of everolimus in combination with tamoxifen in patients with 
hormone receptor–positive, human epidermal growth factor receptor 2–negative metastatic breast cancer 
with prior exposure to aromatase inhibitors: a GINECO study  J Clin Oncol 2012;30:2718-24. 
3. Maiso P, et al. Defining the role of TORC1/2 in multiple myeloma. Blood 2011;118: 6860-70. 
4. Ghobrial IM, et al. TAK-228 (INK128), an investigational oral gual TORC1/2 inhibitor, in patients (pts) with 
relapsed or refractory multiple myeloma (MM), non-Hodgkin’s lymphoma (NHL), or Waldenstrom 
macroglobulinemia (WM): preliminary results from a phase 1 dose-escalation study. ASH 2012, Abstract 
4038. 
5. ClinicalTrials.gov. Safety and Efficacy Study of TAK-228 in Combination with Exemestane or Fulvestrant 
in Postmenopausal Women with ER/PR+ Metastatic Breast Cancer. NCT02049957. 
6. ClinicalTrials.gov. Phase Ib Study of MLN0128 in Combination with MLN1117 in Adult Patients With 
Advanced Nonhematologic Malignancies. NCT01899053. 
7. Desta Z, et al. Comprehensive evaluation of tamoxifen sequential biotransformation by the human 
cytochrome P450 system in vitro: prominent roles for CYP3A and CYP2D6. J Pharmacol Exp Ther 
2004;310:1062-75.  
8. Wang DY, et al. Identification of estrogen-responsive genes by complementary deoxyribonucleic acid 
microarray and characterization of a novel early estrogen-induced gene: EEIG1. Mol Endocrinol 
2004;18:402-11. 
9. Shang Y, et al. "Cofactor dynamics and sufficiency in estrogen receptor-regulated transcription". Cell 
2000;103:843-52. 
10. Massarweh S, et al.. Tamoxifen resistance in breast tumors is driven by growth factor receptor signaling 
with repression of classic estrogen receptor genomic function. Cancer Res 2008;68:826-33. 
11. Hurtado A, et al. Regulation of ERBB2 by oestrogen receptor-PAX2 determines response to tamoxifen. 
Nature 2008;456:663-6. 
12. "New mechanism predicts tamoxifen response: PAX2 gene implicated in tamoxifen-induced inhibition of 
ERBB2/HER2-mediated tumor growth". www.modernmedicine.com. 2008-11-13. Retrieved 2008-11-14. 
13. Osborne CK, et al. Role of the estrogen receptor coactivator AIB1 (SRC-3) and HER-2/neu in tamoxifen 
resistance in breast cancer". J. Natl. Cancer Inst 2003;95:353-61.  
14. "Study sheds new light on tamoxifen resistance". News. CORDIS News. Retrieved 2008-11-14. 
15. Jordan VC. Fourteenth Gaddum Memorial Lecture. A current view of tamoxifen for the treatment and 
prevention of breast cancer. Br J Pharmacol 1993;110:507-17.  
16. "Breast cancer in men". CancerHelp UK. Cancer Research UK. 2007-09-28. Retrieved 2009-03-22. 
17. Center for Drug Evaluation and Research (03/08/2005). "Tamoxifen Information: reducing the incidence of 
breast cancer in women at high risk". U.S. Food and Drug Administration. Archived from the original on 
June 19, 2007. Retrieved July 3, 2007.  
18. National Cancer Institute (2006-04-26). "Study of Tamoxifen and Raloxifene (STAR) Trial". U.S. National 
Institutes of Health. Retrieved July 3, 2007. 
19. University of Pittsburgh. "STAR Study of Tamoxifen and Raloxifen". Archived from the original on June 11, 
2007. Retrieved July 3, 2007. 
20. Dr. Susan Love (April 22, 2006). "Study Finds New Use for Raloxifene: Reducing Breast Cancer in High-
Risk Postmenopausal Women". Retrieved March 19, 2009. 
21. "Tamoxifen vs Arimidex as Adjuvant Therapy | Health and Life. 
22. Howell A, et al. Results of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial after completion 
of 5 years' adjuvant treatment for breast cancer. Lancet 2005;365:60-2. 
23. "Arimidex After Two Years of Tamoxifen Reduces Recurrence in Post-Menopausal Women". 
BreastCancer.org. Archived from the original on February 18, 2008. Retrieved 2008-11-14. 


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24. Jakesz R, et al.. witching of postmenopausal women with endocrine-responsive early breast cancer to 
anastrozole after 2 years' adjuvant tamoxifen: combined results of ABCSG trial 8 and ARNO 95 trial". 
Lancet 2005;366:455-62.  
25. USA (2012-10-19). "Tamoxifen treatment of pr... [J Pediatr Endocrinol Metab. 1999 Sep-Oct] - PubMed - 
NCBI". Ncbi.nlm.nih.gov. Retrieved 2013-01-06. 
26. USA (2012-10-19). "Tamoxifen treatment for precocious puberty in McCu... [J Pediatr. 2003] - PubMed - 
NCBI". Ncbi.nlm.nih.gov. Retrieved 2013-01-06. 
27. USA (2012-10-19). "Tamoxifen improved final height p... [J Pediatr Endocrinol Metab. 2006] - PubMed - 
NCBI". Ncbi.nlm.nih.gov. Retrieved 2013-01-06. 
28. USA (2012-12-12). "The use of tamoxifen to improve height potential ... [Pediatrics. 2005] - PubMed - 
NCBI". Ncbi.nlm.nih.gov. Retrieved 2013-01-06. 
29. USA (2012-10-19). "Tamoxifen induces permanent growth arrest through selec... [Bone. 2007] - PubMed - 
NCBI". Ncbi.nlm.nih.gov. Retrieved 2013-01-06. 
30. USA (2012-10-19). "Tamoxifen impairs both longitudinal and cor... [J Bone Miner Res. 2008] - PubMed - 
NCBI". Ncbi.nlm.nih.gov. Retrieved 2013-01-06. 
31. Steiner AZ, et al. Comparison of tamoxifen and clomiphene citrate for ovulation induction: a meta-
analysis. Hum. Reprod 2005;20:1511-5.  
32. van Bommel EF, et al. Brief communication: tamoxifen therapy for nonmalignant retroperitoneal fibrosis. 
Ann Intern Med 2006;144:101-6.  
33. Sample, Ian (2007-06-13). "Q&A: Chemical castration". Guardian Unlimited. Retrieved 2007-09-10. 
34. Chiang GG, et al. Targeting the mTOR signaling network in cancer. Trends Mol Med 2007;13:433-42. 
35. Sabatini DM. mTOR and cancer: insights into a complex relationship. Nature Rev Cancer 2006;6:729-34. 
36. Genpharm Inc. Tamoxifen full prescribing information. 18 August 2003.  
37. Voss M, et al. Phase I study of investigational oral mTORC1/2 inhibitor TAK-228 (formerly MLN0128): 
expansion phase in patients with renal, endometrial, or bladder cancer. ESMO 2015, Abstract 364. 
38. Ghobrial IM, et al. TAK-228 (formerly MLN0128), an investigational oral dual TORC1/2 inhibitor: a phase I 
dose escalation study in patients with relapsed or refractory multiple myeloma, non-Hodgkin lymphoma, or 
Waldenstrom’s macroglobulinemia. Am J Hematol 2016;91:400-5 
39. Beaver JA, et al. The BOLERO-2 trial: the addition of everolimus to exemestane in the treatment of 
postmenopausal hormone receptor-positive advanced breast cancer. Future Oncol 2012;8:651-7. 
40. De Laurentiis M, et al. A meta-analysis on the interaction between HER-2 expression and response to 
endocrine treatment in advanced breast cancer. Clin Cancer Res 2005;11:4741-8. 
41. National Cancer Institute RECIST Guidelines and criteria. 
42. Dowsett M, et al. Short-term changes in Ki-67 during neoadjuvant treatment of primary breast cancer with 
anastrozole or tamoxifen alone or combined correlate with recurrence-free survival. Clin Cancer Res 
2005;11(2 Pt 2):951s-8s. 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDICES 
 
Appendix A: CTCAE Version 4.03 (dated June-14-2010) 
 
NCI Common Terminology Criteria for Adverse Events (CTCAE) v.4.03 data files and related 
documents are published here. The most current release files appear in this directory:  
Files: Booklet 
 
Content 
CTCAE_4.03_2010-06-
14_QuickReference_5x7.pdf 
Most recent release of core terminology: PDF document, 
traditional small booklet format. 
 
 
http://evs.nci.nih.gov/ftp1/CTCAE/About.html 
 
 
 


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Appendix B: List of Antidepressants and Association with CYP2D6 and Tamoxifen 
Class of drugs 
Drug 
CYP2D6 activity 
Tamoxifen Interaction 
Selective Serotonin 
Reuptake Inhibitors 
Fluoxetine  
Strong inhibitor 
Probable 
Paroxetine 
Strong Inhibitor 
Probable 
Sertraline 
Moderate inhibitor 
Possible 
Fluvoxamine 
Weak inhibitor 
Not likely 
Citalopram 
Weak inhibitor 
Not likely 
Escitalopram 
Weak inhibitor 
Not likely 
Selective 
Norepinephrine 
Reuptake Inhibitors 
Duloxetine 
Moderate inhibitor 
Possible 
Venlafaxine 
Weak inhibitor 
Not likely 
Desvenlafaxine 
Weak inhibitor 
Note likely 
Monoamine Oxidase 
Inhibitors 
Tranylcypromine 
Moderate inhibitor 
Possible 
Selegiline 
Weak inhibitor 
Not likely 
Tricyclics 
Clomipramine 
Moderate inhibitor 
Possible 
Amitriptyline 
Weak inhibitor 
Not likely 
Desipramine 
Moderate inhibitor 
Possible 
Nortryptyline 
Weak inhibitor 
Not likely 
Imipramine 
Moderate inhibitor 
Possible 
Doxepin 
Major substrate  
Not likely 
Trimipramine 
Major substrate 
Not likely 
Buspirone 
Major substrate 
Not likely 
Trazodone 
Major substrate 
Not likely 
Mirtazapine 
Weak inhibitor 
Not likely 
Bupropion 
Strong inhibitor 
Probable 
 
Drug interactions assigned documentation levels as outlined by Facts & Comparisons 4.0: 
• 
Certain: proven to occur in studies or recommended by reputable guidelines 
• 
Probable: very likely, but not proven in controlled studies 
• 
Possible: could occur, but data are very limited 
• 
Not likely: no good evidence of an altered clinical effect 


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Appendix C: Eastern Cooperative Oncology Group Performance Status Scale 
Grade 
Description 
0 
Normal activity.  Fully active, able to carry on all pre-disease performance without 
restriction 
1 
Symptoms but ambulatory.  Restricted in physically strenuous activity, but ambulatory 
and able to carry out work of a light or sedentary nature (e.g., light housework, office 
work) 
2 
In bed < 50% of the time.  Ambulatory and capable of all self-care, but unable to carry out 
any work activities.  Up and about more than 50% of waking hours. 
3 
In bed > 50% of the time.  Capable of only limited self-care, confined to bed or chair more 
than 50% of waking hours. 
4 
100% bedridden.  Completely disabled.  Cannot carry on any self-care.  Totally confined 
to bed or chair 
5 
Dead 
Source:  Oken MM, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am 
J Clin Oncol 1982;5:649-55.  
 
 
 
 
 
 
 
 
 
 
 
 


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Appendix D: New York Heart Association Functional Classifications 
Class Functional Capacity 
Objective Assessment 
I 
Patients with cardiac disease but without resulting limitations 
of physical activity. Ordinary physical activity does not cause 
undue fatigue, palpitation, dyspnea, or anginal pain. 
No objective evidence of 
cardiovascular disease. 
II 
Patients with cardiac disease resulting in slight limitation of 
physical activity. They are comfortable at rest. Ordinary 
physical activity results in fatigue, palpitation, dyspnea, or 
anginal pain. 
Objective evidence of minimal 
cardiovascular disease. 
III 
Patients with cardiac disease resulting in marked limitation of 
physical activity. They are comfortable at rest. Less than 
ordinary activity causes fatigue, palpitation, dyspnea, or 
anginal pain. 
Objective evidence of moderately 
severe cardiovascular disease. 
IV 
Patients with cardiac disease resulting in inability to carry on 
any physical activity without discomfort. Symptoms of heart 
failure or the anginal syndrome may be present even at rest. If 
any physical activity is undertaken, discomfort is increased. 
Objective evidence of severe 
cardiovascular disease. 
• 
Source: The Criteria Committee of New York Heart Association. Nomenclature and Criteria for 
Diagnosis of Diseases of the Heart and Great Vessels. Ninth Ed. Boston, MA: Little, Brown & 
Co; 1994:253-256.  
 
 
 
 
 
 
 
 
 
 
 


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Appendix E: List of Relevant Cytochrome P450 Inhibitors and Inducers 
Strong CYPA12 Inhibitors 
fluvoxamine 
ciprofloxacin 
 
Moderate CYPA12 Inhibitors 
cimetidine  
methoxsalen 
 
Clinically Significant Enzyme Inducers 
carbamazepine 
rifabutin 
St. Johns Wort 
phenobarbital 
rifampin 
 
phenytoin 
rifapentine 
 
 
 
 
Source:  fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteractionsLabeling/ 
ucm093664.htm.   
Note that these lists are not exhaustive.