Conditions: Breast Cancer Ductal Carcinoma in Situ
Keywords: Breast cancer Ductal carcinoma in situ (DCIS) Oxytocin
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 8
Healthy volunteers: no

Brief summary:
The purpose of this study is to examine the genetic material called microRNA of three types of specimens from women with breast cancer. The study also seeks to examine the effectiveness of using a new agent called oxytocin to increase the amount of nipple fluid that can be collected during surgery.

Detailed description:
Vast majority of breast cancers arise from ductal epithelium. Ductal cells can be collected through the nipple orifice very early in breast cancer development. The nipple aspirate ﬂuid (NAF) can be used to identify biomarkers that predict risk of breast cancer. To date, the biomarkers identified in nipple aspirate ﬂuid (NAF) have limited utility due to the large volume of NAF required for data analysis. Recent studies show intranasal oxytocin's utility in enhancing the yield of nipple aspirate ﬂuid (NAF) among healthy, non-lactating female patients as well as those at high risk for breast cancer. This capability is crucial for the analysis of various markers associated with breast disease and cancer such as microRNAs. The primary aim of the study is to determine whether the microRNA profile characterization is feasible with the collection of tissue, serum and NAF in patients with in situ and invasive breast cancer. Intranasal oxytocin will be used to enhance ﬂuid yielding of the NAF.

Arms:
arm 1: Subjects would receive 4 IU of intranasal oxytocin; one spray in each nostril, single-use.

Interventions: intervention 1: Intranasal Oxytocin
Intervention descriptions: intervention 1: Intranasal spray, one spray or 4 IU of oxytocin will be administered into each nostril of each patient about 15-30 minutes before NAF collection

Protocol document:
Prot_SAP_000.pdf: 
 
 
 
 
 
 
 
 
 
IDENTIFYING THE MIR FINGERPRINT IN NAF, SERUM, AND TISSUE IN 
PATIENTS WITH DCIS OR INVASIVE BREAST CANCER 
 
 
Regulatory Sponsor: 
Sheldon Feldman, MD 
Department of Surgery 
Herbert Irving Pavilion 
10th Floor, Suite 1005 
161 Fort Washington Ave. 
New York, NY 10032 
212-305-9676 
Funding Sponsor: 
New York Presbyterian Hospital 
177 Fort Washington Ave. 
New York, NY 10032 
212-305-9676 
Study Product: 
Intranasal Oxytocin 
Protocol Number: 
IRB-AAAL5203 
IND Number: 
117074 
 
 
 
 
 
Date: October 29, 2012 
 
Amended: September 27, 2016 
 
 
 
CONFIDENTIAL 
 
This document is confidential and the property of Sheldon Feldman, MD.  No part of it 
may be transmitted, reproduced, published, or used by other persons without prior written 
authorization from the study sponsor. 
 
 


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This material is the property of Sheldon Feldman, MD.  Do not disclose or use except as authorized in writing by the study sponsor 
 
Table of Contents 
STUDY SUMMARY ................................................................................................................................................... 1 
1 
INTRODUCTION .............................................................................................................................................. 2 
1.1 
BACKGROUND .................................................................................................................................................. 2 
1.2 
INVESTIGATIONAL AGENT ................................................................................................................................ 3 
1.3 
PRECLINICAL DATA ......................................................................................................................................... 4 
1.4 
CLINICAL DATA TO DATE ................................................................................................................................ 4 
1.5 
DOSE RATIONALE AND RISK/BENEFITS ............................................................................................................ 6 
2 
STUDY OBJECTIVES ...................................................................................................................................... 6 
3 
STUDY DESIGN ................................................................................................................................................ 7 
3.1 
GENERAL DESIGN ............................................................................................................................................ 7 
3.2 
PRIMARY STUDY ENDPOINTS ........................................................................................................................... 7 
3.3 
SECONDARY STUDY ENDPOINTS ...................................................................................................................... 7 
3.4 
PRIMARY SAFETY ENDPOINTS .......................................................................................................................... 8 
4 
SUBJECT SELECTION AND WITHDRAWAL ........................................................................................... 8 
4.1 
INCLUSION CRITERIA ....................................................................................................................................... 8 
4.2 
EXCLUSION CRITERIA ...................................................................................................................................... 8 
4.3 
SUBJECT RECRUITMENT AND SCREENING ........................................................................................................ 8 
4.4 
EARLY WITHDRAWAL OF SUBJECTS ................................................................................................................. 8 
4.4.1 
When and How to Withdraw Subjects .................................................................................................... 8 
4.4.2 
Data Collection and Follow-up for Withdrawn Subjects ....................................................................... 8 
5 
STUDY DRUG ................................................................................................................................................... 9 
5.1 
DESCRIPTION ................................................................................................................................................... 9 
5.2 
TREATMENT REGIMEN ..................................................................................................................................... 9 
5.3 
METHOD FOR ASSIGNING SUBJECTS TO TREATMENT GROUPS ......................................................................... 9 
5.4 
PREPARATION AND ADMINISTRATION OF STUDY DRUG ................................................................................... 9 
5.5 
SUBJECT COMPLIANCE MONITORING ............................................................................................................... 9 
5.6 
PRIOR AND CONCOMITANT THERAPY............................................................................................................... 9 
5.7 
PACKAGING.................................................................................................................................................... 10 
5.8 
BLINDING OF STUDY DRUG ............................................................................................................................ 10 
5.9 
RECEIVING, STORAGE, DISPENSING AND RETURN .......................................................................................... 10 
5.9.1 
Receipt of Drug Supplies ..................................................................................................................... 10 
5.9.2 
Storage ................................................................................................................................................. 10 
5.9.3 
Dispensing of Study Drug .................................................................................................................... 10 
5.9.4 
Return or Destruction of Study Drug ................................................................................................... 10 
6 
STUDY PROCEDURES .................................................................................................................................. 10 
6.1 
VISIT 1 ........................................................................................................................................................... 10 
6.2 
VISIT 2/END OF STUDY VISIT ......................................................................................................................... 11 
6.3 
STUDY CALENDAR ......................................................................................................................................... 11 
7 
STATISTICAL PLAN ..................................................................................................................................... 12 
7.1 
SAMPLE SIZE CONSIDERATION ....................................................................................................................... 12 
7.2 
STATISTICAL METHODS ................................................................................................................................. 12 
7.3 
SUBJECT POPULATION(S) FOR ANALYSIS ....................................................................................................... 13 
8 
SAFETY AND ADVERSE EVENTS ............................................................................................................. 13 
8.1 
DEFINITIONS .................................................................................................................................................. 13 
8.2 
RECORDING OF ADVERSE EVENTS ................................................................................................................. 15 
8.3 
REPORTING OF SERIOUS ADVERSE EVENTS .................................................................................................... 15 


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8.3.1 
Study Sponsor Notification by Investigator ......................................................................................... 15 
8.3.2 
EC/IRB Notification by Investigator .................................................................................................... 15 
8.3.3 
FDA Notification by Sponsor ............................................................................................................... 16 
SERIOUS ADVERSE EVENTS NOT CONSTITUTING UNANTICIPATED PROBLEMS ARE TO BE REPORTED TO THE HICCC 
DSMC. REPORTING SHOULD OCCUR WITHIN 24 HOURS OF KNOWLEDGE OF THE SAE OCCURRING AT OUR 
INSTITUTION OR AFFILIATE SITES. ............................................................................................................................ 17 
8.4 
UNBLINDING PROCEDURES ............................................................................................................................ 17 
8.5 
STOPPING RULES ............................................................................................................................................ 17 
8.6 
MEDICAL MONITORING .................................................................................................................................. 17 
8.6.1 
Internal Data and Safety Monitoring Board ........................................................................................ 17 
 
8.6.2  
Independent Data and Safety Monitoring Committee……………………………………………………… 18 
9 
DATA HANDLING AND RECORD KEEPING .......................................................................................... 17 
9.1 
CONFIDENTIALITY .......................................................................................................................................... 17 
9.2 
SOURCE DOCUMENTS ..................................................................................................................................... 18 
9.3 
CASE REPORT FORMS..................................................................................................................................... 18 
9.4 
RECORDS RETENTION .................................................................................................................................... 18 
10 
STUDY MONITORING, AUDITING, AND INSPECTING ....................................................................... 18 
10.1 
STUDY MONITORING PLAN ....................................................................................................................... 18 
10.2 
AUDITING AND INSPECTING ....................................................................................................................... 19 
11 
ETHICAL CONSIDERATIONS .................................................................................................................... 19 
12 
STUDY FINANCES ......................................................................................................................................... 19 
12.1 
FUNDING SOURCE ..................................................................................................................................... 19 
12.2 
CONFLICT OF INTEREST ............................................................................................................................. 19 
12.3 
SUBJECT STIPENDS OR PAYMENTS ............................................................................................................ 20 
13 
PUBLICATION PLAN .................................................................................................................................... 20 
 
 
 


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List of Abbreviations 
 
 
 
 
DCIS: ductal carcinoma in situ 
IM: intramuscular 
IV: intravenous 
miR: microRNA 
NAF: nipple aspirate fluid 
PK: pharmacokinetic 
SQ: subcutaneous


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Study Summary 
Title 
INTRANASAL OXYTOCIN USE IN IDENTIFYING THE MICRO-RNA 
FINGERPRINT IN NAF, SERUM, AND TISSUE IN PATIENTS WITH DCIS 
OR INVASIVE BREAST CANCER 
Short Title 
Oxytocin, microRNA and breast cancer 
Protocol Number 
IRB-AAAL5203 
Phase 
Pilot 
Methodology 
Pilot proof of principle study 
Study Duration 
1 year 
Study Center(s) 
Columbia University Medical Center 
Objectives 
To determine the feasibility of assessing miR profiles in NAF, serum 
and tissue of women diagnosed with DCIS or invasive breast cancer 
Number of Subjects 
40 
Diagnosis and Main 
Inclusion Criteria 
Patients with DCIS or invasive breast cancer scheduled for breast 
surgery at Columbia Medical Center 
Study Product, Dose, 
Route, Regimen 
Oxytocin (Syntocinon Spray), 4 IU (1 spray) per nostril, intranasal 
route, prior to nipple aspirate fluid collection 
Duration of 
administration 
Once before NAF is collected 
Reference therapy 
None 
Statistical 
Methodology 
Calculation of presence of miRs compared to normative reference 
population, binomial test to determine significant differences, 
Benjamin Hochberg procedure to rule out false positives, and ranking 
of miRs by p-value to determine most favorable biomarkers. 
 


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1 Introduction 
This document is a protocol for a human research study. This study is to be conducted according 
to US and international standards of Good Clinical Practice (FDA Title 21 part 312 and 
International Conference on Harmonization guidelines), applicable government regulations and 
Institutional research policies and procedures.  
1.1 Background 
Breast cancer is the leading cause of cancer death among women.  In 2008 alone, 458,400 deaths 
worldwide were due to breast cancer and more than 1.3 million women were newly diagnosed 
with breast cancer.1  Presently, the best and most widely accepted tool that we have to screen for 
breast cancer is the mammogram.  However, this modality remains radiation-based, is 
uncomfortable for patients, and has a maximum sensitivity of 70-90%.  The other main methods 
of detection include physical exam, ultrasound and MRI, each of which has its own set of 
limitations.  Physical exam requires a palpable lesion, which may hinder early diagnoses.  
Ultrasound is time-consuming and highly operator-dependent.  MRI is costly, lacks specificity and 
is not covered by insurance for non-high risk patients. 
 
As an alternative, we propose the use of NAF from breast cancer patients as a way to identify 
microRNA profiles.  Considering 90% of breast cancers originate from ductal epithelium, it is 
possible that cells and secretions collected from such ducts would allow for earlier detection of 
breast cancer.  The collection of NAF is furthermore appealing because it is a non-invasive method 
of obtaining specimens.  Ideally, NAF would be used to identify biomarkers that predict the risk 
of breast cancer and/or detect breast cancer in its early stages. 2,3,4 To date, cellular atypia, DNA 
methylation and proteins have all been studied in aspirate fluid.5,6 Our pilot appears to be the first 
to successfully extract and analyze miR from NAF.  
 
MiRs are small, 20-nucleotide non-coding RNAs that modulate messenger RNA transcription, 
leading to changes in tumor suppression and oncogenic expression.7  They tend to be more stable 
than protein markers, detectable in small quantities both inside and outside of cells.8  
                                                 
1 Jemal, Ahmedin, Freddie Bray, Melissa M. Center, Jacques Ferlay, Elizabeth Ward, and David Forman. "Global 
Cancer Statistics." CA: A Cancer Journal for Clinicians61.2 (2011): 69-90. 
2 Calin, G. A. "MicroRNA Profiling Reveals Distinct Signatures in B Cell Chronic Lymphocytic 
Leukemias." Proceedings of the National Academy of Sciences101.32 (2004): 11755-11760. 
3 Calin, G. A. "Human MicroRNA Genes Are Frequently Located at Fragile Sites and Genomic Regions Involved in 
Cancers." Proceedings of the National Academy of Sciences 101.9 (2004): 2999-3004. 
4 Lu, Jun, Gad Getz, Eric A. Miska, Ezequiel Alvarez-Saavedra, Justin Lamb, David Peck, Alejandro Sweet-
Cordero, Benjamin L. Ebert, Raymond H. Mak, Adolfo A. Ferrando, James R. Downing, Tyler Jacks, H. Robert 
Horvitz, and Todd R. Golub. "MicroRNA Expression Profiles Classify Human Cancers." Nature435.7043 (2005): 
834-38. 
5 Suijkerbuijk, Karijn P.M., Elsken Van Der Wall, Marc Vooijs, and Paul J. Van Diest. "Molecular Analysis of 
Nipple Fluid for Breast Cancer Screening." Pathobiology75.2 (2008): 149-152. 
6 Pavlou, M. P., V. Kulasingam, E. R. Sauter, B. Kliethermes, and E. P. Diamandis. "Nipple Aspirate Fluid 
Proteome of Healthy Females and Patients with Breast Cancer." Clinical Chemistry 56.5 (2010): 848-855. 
7 Croce, Carlo M., and George A. Calin. "MiRNAs, Cancer, and Stem Cell Division." Cell122.1 (2005): 6-7. 
8 Mitchell, P. S., R. K. Parkin, E. M. Kroh, B. R. Fritz, S. K. Wyman, E. L. Pogosova-Agadjanyan, A. Peterson, J. 
Noteboom, K. C. O'Briant, A. Allen, D. W. Lin, N. Urban, C. W. Drescher, B. S. Knudsen, D. L. Stirewalt, R. 
Gentleman, R. L. Vessella, P. S. Nelson, D. B. Martin, and M. Tewari. "Circulating MicroRNAs as Stable Blood-


CUMC IRB# AAAL5203 
 
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Protocol v. September 27, 2016 
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This material is the property of Sheldon Feldman, MD.  Do not disclose or use except as authorized in writing by the study sponsor 
Approximately 30 miRs have been found to play important roles in the progression of breast 
cancer.  These functions include differentiation of breast tissue from normal to cancerous cells9, 
tumor invasion, metastasis10,11 and metastatic suppression.12  
 
Our plan is to study the differences of miR profiles between cancerous breasts and healthy 
contralateral controls.  In addition to the benefits listed above, unique miR profiles would allow 
clinicians to evaluate treatment response, and provide more individualized, targeted disease 
management.  Thus far, a significant barrier to this strategy has been insufficient NAF yield.  
Specifically, we were able to collect NAF from 13/40 patients, of which 8 were successfully 
analyzed for miR.  One solution to this problem is the use of intranasal oxytocin, which has been 
shown to successfully increase milk letdown in both postpartum and non-lactational women.7,8 
Furthermore, both healthy and high-risk groups of non-lactating women were found to express 
significantly greater levels of NAF following intranasal oxytocin.  Compared to a 39-66% success 
rate of obtaining NAF from healthy female patients, intranasal oxytocin demonstrated success rates 
as high as 94%.2,4,9 
1.2 Investigational Agent 
Oxytocin is a natural neuropeptide that is synthesized in the hypothalamus and released by the 
posterior pituitary.  It is most commonly known in the United States for its role in promoting 
uterine contractions during labor.  In addition, the oxytocin pathway can also be triggered by 
suckling, which causes contraction of mammary myoepithelial cells and subsequent milk 
ejection.13 Recent studies demonstrate intranasal oxytocin’s utility in enhancing the yield of nipple 
aspirate fluid (NAF) among healthy, non-lactating female patients as well as those at high risk for 
breast cancer.  This capability is crucial for the analysis of various markers associated with breast 
disease and cancer such as proteins, methylated DNA and miRs.14,15,16  
 
                                                 
based Markers for Cancer Detection." Proceedings of the National Academy of Sciences 105.30 (2008): 10513-
10518. 
9 Iorio, M. V. "MicroRNA Gene Expression Deregulation in Human Breast Cancer."Cancer Research 65.16 (2005): 
7065-7070. 
10 Ma, Li, Julie Teruya-Feldstein, and Robert A. Weinberg. "Tumour Invasion and Metastasis Initiated by 
MicroRNA-10b in Breast Cancer." Nature 449.7163 (2007): 682-688.  
11 Huang, Qihong, Kiranmai Gumireddy, Mariette Schrier, Carlos Le Sage, Remco Nagel, Suresh Nair, David A. 
Egan, Anping Li, Guanghua Huang, Andres J. Klein-Szanto, Phyllis A. Gimotty, Dionyssios Katsaros, George 
Coukos, Lin Zhang, Ellen Puré, and Reuven Agami. "The MicroRNAs MiR-373 and MiR-520c Promote Tumour 
Invasion and Metastasis." Nature Cell Biology 10.2 (2008): 202-210. 
12 Tavazoie, Sohail F., Claudio Alarcón, Thordur Oskarsson, David Padua, Qiongqing Wang, Paula D. Bos, William 
L. Gerald, and Joan Massagué. "Endogenous Human MicroRNAs That Suppress Breast Cancer 
Metastasis." Nature 451.7175 (2008): 147-152. 
13 Molina, Patricia E. "The Hypothalamus & Posterior Pituitary Gland." Endocrine Physiology. 3rd ed. New York: 
Lange Medical /McGraw-Hill Medical Pub. Division, 2006. 
14 Zhang, Liping, Zhi-Ming Shao, Perrin Beatty, Maryam Sartippour, He-Jing Wang, Robert Elashoff, Helena 
Chang, and Mai N. Brooks. "The Use of Oxytocin in Nipple Fluid Aspiration." The Breast Journal 9.4 (2003): 266-
268. 
15 Shao, Zhi-Ming, and Mai Nguyen. "Nipple Aspiration in Diagnosis of Breast Cancer."Seminars in Surgical 
Oncology 20.3 (2001): 175-180. 
16 Suijkerbuijk, Karijn PM, Elsken Van Der Wall, Helen Meijrink, Xiaojuan Pan, Inne HM Borel Rinkes, Margreet 
GEM Ausems, and Paul J. Van Diest. "Successful Oxytocin-assisted Nipple Aspiration in Women at Increased Risk 
for Breast Cancer." Familial Cancer 9 (2010): 321-325.  


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Intranasal oxytocin (“Syntocinon Spray”) had been approved by the United States Food and Drug 
Administration (FDA) prior to 1982 for initial milk letdown, but was withdrawn from the market 
in 1995 by its manufacturer, Novartis, for financial reasons.17 Oxytocin now exists solely as the 
intravenous (IV) and intramuscular (IM) forms in the US.  It is marketed under the brand name 
“Pitocin” for induction, stimulation or reinforcement of labor; adjunctive therapy in abortion; 
promotion of uterine contractions during the third stage of labor; and control of postpartum 
bleeding.18  The nasal spray remains available outside of the US. 
1.3 Preclinical Data 
Oxytocin has long been studied in animals, and continues to be prescribed today by veterinarians.  
The IV, IM and subcutaneous (SQ) forms are indicated for obstetrical use and milk letdown in 
cows and sows.19 Many studies over the past several decades support the drug’s use in promoting 
animal lactation.  Exogenous oxytocin has been shown to increase milk letdown in animals as well 
as enhance milk production.19,20,21 Animal toxicity effects based on a few isolated experiments 
include fetal growth stimulation and leftward shift of the fetal oxygen dissociation curve.22 To 
date, there do not appear to be other significant side effects studied in animals exposed to 
exogenous oxytocin. 
1.4 Clinical Data to Date 
Oxytocin is a natural neuropeptide that is synthesized in the hypothalamus and released by the 
posterior pituitary.  It is most commonly known in the United States for its role in promoting 
uterine contractions during labor.  In addition, the oxytocin pathway can also be triggered by 
suckling, which causes contraction of mammary myoepithelial cells and subsequent milk 
ejection.13 
 
Intranasal oxytocin (“Syntocinon Spray”) was approved by the FDA prior to 1982 for initial milk 
letdown, but was withdrawn from the market in 1995 by its manufacturer, Novartis, for financial 
reasons.17 Oxytocin now exists solely in the intravenous (IV) and intramuscular (IM) forms in the 
US.  It is marketed under the brand name “Pitocin” for induction, stimulation or reinforcement of 
labor; adjunctive therapy in abortion; promotion of uterine contractions during the third stage of 
labor; and control of postpartum bleeding.18 
 
Recently, there has been a resurgence of the research involving intranasal oxytocin.  Increased 
NAF yield in the setting of intranasal oxytocin has been recorded among women with premature 
infants as well as among adoptive mothers.19,20 In the field of breast oncology, this drug has been 
safely used to improve NAF collection with the ultimate goal of enhancing biomarker analysis.   
                                                 
17 Lietzan, Erika K. "Citizen Petition." Letter to Division of Dockets Management. 8 Feb. 2006. MS. 
http://www.fda.gov/ohrms/dockets/dockets/06p0068/06p-0068-cp00001-01-vol1.pdf. 
18 "Oxytocin." Lexicomp Online. Lexicomp, n.d. Web. 05 Sept. 2012. <http://online.lexi.com/>. 
19 Gorewit, R.C., and R. Sagi. "Effects of Exogenous Oxytocin on Production and Milking Variables of 
Cows." Journal of Dairy Science 67.9 (1984): 2050-2054. 
20 Nostrand, S.D., D.M. Galton, H.N. Erb, and D.E. Bauman. "Effects of Daily Exogenous Oxytocin on Lactation 
Milk Yield and Composition." Journal of Dairy Science74.7 (1991): 2119-2127. 
21 Knight, C. H. "Short-term Oxytocin Treatment Increases Bovine Milk Yield by Enhancing Milk Removal without 
Any Direct Action on Mammary Metabolism." Journal of Endocrinology 142.3 (1994): 471-473. 
22 "Oxytocin - Animal Toxicity Studies." Oxytocin. National Library of Medicine HSDB Database, n.d. Web. 05 
Sept. 2012. <http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~qYnAi5:1:animal>. 


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This material is the property of Sheldon Feldman, MD.  Do not disclose or use except as authorized in writing by the study sponsor 
 
One group at UCLA (Zhang et al., 2003) studied nasal oxytocin in 9 healthy, non-lactating female 
volunteers between the ages of 19-41.  NAF collection before and after 25U oxytocin per nostril 
showed a significant increase in volume of 1.39 ± 2.2μL (p = 0.0116).  Six breasts that did not 
release NAF initially did so following oxytocin administration.  Pregnant women were excluded 
from the study because of the potential for abnormal uterine contractions; however, no adverse 
events were noted.14 
 
Several important oxytocin experiments were recently completed in Europe by van Diest et al.  In 
the first of a series (Suijkerbuijk, 2007), oxytocin-supported nipple aspiration was successful in 63 
of 67 healthy female volunteers.  This rate (94%) was overwhelmingly greater than those reported 
in previous studies not using oxytocin, which ranged from 39-66%.23,24 A subgroup analysis 
determined that there was sufficient material for genetic, epigenetic and proteomic 
characterizations.  Again, there were no side effects reported, with 66/67 women who would be 
willing to repeat the procedure and an average discomfort rating of 1.3 on a scale of 0-10.25 
 
A follow-up study was published in 2010 by the same group (Suijkerbuijk, 2010).  It demonstrated 
a similar effect of intranasal oxytocin on 90 patients at high risk for breast cancer.  NAF was 
successfully collected from 90% of the subjects, with a mean discomfort rating of 0.6 
(mammography averages 4.9, MRI 2.6).  A subgroup analysis among 50 patients showed that 
quantitative multiplex methylation-specific PCR was able to be performed on 100% of the 
samples, suggesting the utility of NAF in biomarker identification.16 
 
Studies using intranasal oxytocin have also become increasingly common in the field of 
psychiatry.  Intranasal oxytocin has been shown to increase sociability and decrease anxiety in 
both animals and human subjects.26,27 Several IND exemptions for Syntocinon Spray have been 
                                                 
23 Fabian, C. J. "Breast-tissue Sampling for Risk Assessment and Prevention." Endocrine Related Cancer 12.2 
(2005): 185-213. 
24 Wrensch, Margaret R., Nicholas L. Petrakis, Larry D. Gruenke, Virginia L. Ernster, Rei Miike, Eileen B. King, 
and Walter W. Hauck. "Factors Associated with Obtaining Nipple Aspirate Fluid: Analysis of 1428 Women and 
Literature Review." Breast Cancer Research and Treatment 15.1 (1990): 39-51. 
25 MacDonald, Elayne, Mark R. Dadds, John L. Brennan, Katrina Williams, Florence Levy, and Avril J. Cauchi. "A 
Review of Safety, Side-effects and Subjective Reactions to Intranasal Oxytocin in Human 
Research." Psychoneuroendocrinology 36.8 (2011): 1114-1126. 
26 Ross, Heather E., and Larry J. Young. "Oxytocin and the Neural Mechanisms Regulating Social Cognition and 
Affiliative Behavior." Frontiers in Neuroendocrinology 30.4 (2009): 534-547. 
27 Bartz, J. A., J. Zaki, N. Bolger, E. Hollander, N. N. Ludwig, A. Kolevzon, and K. N. Ochsner. "Oxytocin 
Selectively Improves Empathic Accuracy." Psychological Science 21.10 (2010): 1426-1428. 


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approved in these settings.  Other psychiatric diseases with which intranasal oxytocin are being 
studied include schizophrenia, autism and borderline personality disorder. 28,29,30 
 
Finally, among all trials found for the purposes of this IND proposal, oxytocin nasal spray side 
effects were minor and rare.  A meta-analysis of 38 randomized controlled trials between 1990-
2010 evaluating the safety of intranasal oxytocin found the most common side effects to be 
increased calmness, euphoria or energy; lightheadedness, drowsiness or headache; and nasal 
irritation, dry mouth or throat.  Other rare adverse reactions included abnormal uterine 
contractions, allergic dermatitis, anaphylaxis and water intoxication.25  
 
This drug is currently marketed outside the United States as Syntocinon Spray.  To our knowledge, 
it has not been withdrawn from marketing for any reasons related to safety or effectiveness. 
1.5 Dose Rationale and Risk/Benefits 
Based on prior studies in non-lactating women, we plan to administer one spray (4 IU) per nostril 
15-30 minutes before NAF collection. The benefits will be greater NAF yield for miR analysis.  
The risks include rare anaphylactic reactions, common headache, tachycardia or bradycardia, 
uncommon arrhythmia, very rare hypertension, common nausea and vomiting, rare rash and 
allergic dermatitis, and uncommon abnormal uterine contractions. Because of the possibility of 
abnormal uterine contractions, pregnant women will be excluded in the study.  [Frequency: Very 
common (> 1/10); common (> 1/100 to < 1/10); uncommon (> 1/1000 to < 1/100); rare 
(> 1/10 000 to < 1/1000); very rare (< 1/10 000), including isolated cases.] 
2 Study Objectives 
The main objective of this study is to demonstrate the feasibility of characterizing miR profiles in 
the NAF, serum and tissue of patients with DCIS or invasive breast cancer. Each set of miRs will 
be assessed for correlation with tumor presence. Tissue and serum are expected to be acquired 
from all patients. With the addition of intranasal oxytocin, bilateral NAF collection of adequate 
volume for analysis is expected from 77% of participants at increased risk for breast cancer.16 
 
Analysis of the miR profiles will include comparisons among the different biological samples 
(tissue, serum, NAF) in order to understand their relationships with one another. We hypothesize 
that cancer subtypes will be identifiable by unique miR fingerprints, with the goal of creating a 
breast cancer screening tool.  
 
                                                 
28 Pedersen, Cort A., and David L. Penn. "Oxytocin Treatment of Social Cognitive and Functional Deficits in 
Schizophrenia - Full Text View - ClinicalTrials.gov."Oxytocin Treatment of Social Cognitive and Functional 
Deficits in Schizophrenia - Full Text View - ClinicalTrials.gov. National Institute of Mental Health, n.d. Web. 
<http://clinicaltrials.gov/ct2/show/NCT01394471>. 
29 Guastella, Adam J., Stewart L. Einfeld, Kylie M. Gray, Nicole J. Rinehart, Bruce J. Tonge, Timothy J. Lambert, 
and Ian B. Hickie. "Intranasal Oxytocin Improves Emotion Recognition for Youth with Autism Spectrum 
Disorders." Biological Psychiatry 67.7 (2010): 692-694. 
30 Simeon, D., J. Bartz, H. Hamilton, S. Crystal, A. Braun, S. Ketay, and E. Hollander. "Oxytocin Administration 
Attenuates Stress Reactivity in Borderline Personality Disorder: A Pilot Study." Psychoneuroendocrinology 36.9 
(2011): 1418-421.  


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Our aim is to first demonstrate proof of principle. We would like to extend our initial trial by 1 
year since the NAF volumes were inadequate without pharmacologic enhancement. Specifically, 
we were able to collect NAF from 13/40 patients, of which 8 were successfully analyzed for miR. 
To remedy this problem, we propose collecting additional specimens in the setting of intranasal 
oxytocin. This project will establish a foundation from which future miR analysis may be 
completed. 
3 Study Design 
3.1 General Design 
We propose a pilot proof of principle study to assess and compare the miR fingerprint (or profile) 
in NAF, serum, and tissue from patients undergoing a lumpectomy or mastectomy for in situ or 
invasive breast cancer. As this study is a proof of concept there is no power presented. Other than 
the collection of NAF, treatment will not vary from the standard of care. The collection of all 
specimen types will be completed within the regularly scheduled operative time period. The 
surgery will not be prolonged in any way for specimen collection. Forty patients (20 with DCIS, 
20 with invasive breast cancer) will be entered into the study. A total of 5 patients will also undergo 
pharmacokinetic (PK) draws during the time of surgery to assess the baseline oxytocin level.  All 
other subjects enrolled will be enrolled into the “non-PK” cohort. Patients receiving care at the 
Breast Surgery Department at Columbia who meet criteria will be offered participation in the 
study. Patients will answer a brief questionnaire preoperatively. At the time of surgery  patients 
will undergo a blood draw as well as collection of NAF (via prior administration of intranasal 
oxytocin, gentle massage, aspirator, and breast pump from both breasts). The NAF and blood 
samples will be sent to the pathology lab for analysis of miR profile. At the completion of the case, 
the breast tissue will be sent to pathology per routine. Once in pathology, 5 paraffin-embedded 
slices will be created to evaluate for miR profile. Serum, NAF, and tissue will be analyzed for their 
miR profile. 
 
Once total RNA is extracted from the biological samples it will be processed to fluorescently label 
the microRNAs species according to the V2-Human microRNA array (Agilent). MicroRNA 
profiling will be obtained and analyzed using the gene-spring software analysis package. First, 
expression and cluster analysis will be performed to identify the microRNA that are expressed in 
our samples and to classify them accordingly to their expression. Then, the predicted targets of the 
over/down-regulated microRNAs will be identified using target prediction bioinformatics tools 
(TargetScan, Miranda and Pictarvert). Finally, statistical studies between over/under-represented 
microRNAs will be performed.  
3.2 Primary Study Endpoints 
The primary endpoint is feasible miR analysis of NAF as well as serum and tissue collected from 
study participants. 
3.3 Secondary Study Endpoints 
The secondary endpoint is sufficient NAF volumes following the administration of oxytocin. 


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3.4 Primary Safety Endpoints 
The primary safety endpoints are anaphylactic reactions or water intoxication secondary to 
intranasal oxytocin.  Refer to 1.5 for complete list of side effects. 
4 Subject Selection and Withdrawal 
4.1 Inclusion Criteria 
Patients meeting the following criteria may be included in the study: 
 All female patients with DCIS or invasive breast cancer who are scheduled for a 
lumpectomy or mastectomy and are receiving surgical care from the Breast Surgery 
Department at Columbia Medical Center.  
 Patients diagnosed with unilateral DCIS or invasive breast cancer 
4.2 Exclusion Criteria 
Patients meeting the following criteria will be excluded from the study: 
 Patients not receiving breast surgery care from the Department of Breast Surgery at 
Columbia Medical Center.  
 Pregnant patients are to be excluded given the risk associated with oxytocin.  
 Male patients  
 Patients with a prior breast cancer diagnosis 
 Patients who have had an adverse reaction to oxytocin 
4.3 Subject Recruitment and Screening 
Patients with unilateral DCIS or invasive breast cancer who are scheduled for a lumpectomy or 
mastectomy will be offered participation in this study. A negative pregnancy test is required for 
all women with child-bearing potential. Post-menopausal women (i.e., women who have not 
menstruated for at least 1 year) and women who have undergone hysterectomy or bilateral 
oophorectomy will not need to undergo a pregnancy test. All women of childbearing potential will 
be tested for pregnancy prior to enrollment. All participants will receive their care at Columbia 
Presbyterian in the Breast Surgery Department. 
4.4 Early Withdrawal of Subjects 
Subjects may withdraw at any time during the study. 
4.4.1 When and How to Withdraw Subjects 
Subjects may withdraw from the study at any time for any reason, and can do so by contacting the 
study coordinator by phone or e-mail. 
4.4.2 Data Collection and Follow-up for Withdrawn Subjects 
Withdrawn subjects may continue to follow-up at Columbia Presbyterian, but are not obligated to 
donate NAF, serum or tissue samples. 


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5 Study Drug  
5.1 Description 
Oxytocin is a natural neuropeptide that is synthesized in the hypothalamus and released by the 
posterior pituitary. It is most commonly known in the United States for its role in promoting uterine 
contractions during labor. In addition, the oxytocin pathway can also be triggered by suckling, 
which causes contraction of mammary myoepithelial cells and subsequent milk ejection.13 Recent 
studies demonstrate intranasal oxytocin’s utility in enhancing the yield of nipple aspirate fluid 
(NAF) among healthy, non-lactating female patients as well as those at high risk for breast cancer.  
This capability is crucial for the analysis of various markers associated with breast disease and 
cancer such as proteins, methylated DNA and miRs.14,15,16 
 
Intranasal oxytocin (“Syntocinon Spray”) had been approved by the United States Food and Drug 
Administration (FDA) prior to 1982 for initial milk letdown, but was withdrawn from the market 
in 1995 by its manufacturer, Novartis, for financial reasons.17 Oxytocin now exists solely as the 
intravenous (IV) and intramuscular (IM) forms in the US.  It is marketed under the brand name 
“Pitocin” for induction, stimulation or reinforcement of labor; adjunctive therapy in abortion; 
promotion of uterine contractions during the third stage of labor; and control of postpartum 
bleeding.18 The nasal spray remains available outside of the US. 
5.2 Treatment Regimen 
The Principal Investigator will administer one spray of intranasal oxytocin, or 4 IU, into each 
nostril approximately 15-30 minutes before NAF collection. Prior to collection, the nipples will be 
scrubbed with alcohol swabs to eliminate keratin plugs, breasts will be massaged by the MD 
investigator for approximately 2 minutes, but no more than approximately 7 minutes. An aspirator 
will be applied to each breast, and fluid will be collected into capillary tubes. NAF samples will 
be acquired from study subjects by the MD investigator in the operating room while under 
anesthesia before the opening incision.  The duration of time required to obtain NAF samples will 
be documented. 
5.3 Method for Assigning Subjects to Treatment Groups 
All subjects will receive the same treatment. 
5.4 Preparation and Administration of Study Drug 
Intranasal spray.  One spray or 4 IU of oxytocin will be administered into each nostril of each 
patient approximately 15-30 minutes before NAF collection. Study drug will be administered by 
the Principal Investigator. 
5.5 Subject Compliance Monitoring 
The principal investigator will administer the intranasal oxytocin, therefore assuring compliance. 
Proper documentation will be obtained. 
5.6 Prior and Concomitant Therapy 
N/A 


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5.7 Packaging 
Intranasal oxytocin is packaged into spray containers by the manufacturer (Novartis). 
5.8 Blinding of Study Drug 
N/A.  All patients enrolled in the study will receive intranasal oxytocin. 
5.9 Receiving, Storage, Dispensing and Return 
5.9.1 Receipt of Drug Supplies 
Upon receipt of the of the study treatment supplies, an inventory must be performed and a drug 
receipt documented by the appropriate research pharmacy personnel accepting the shipment. It is 
important that the designated study staff counts and verifies that the shipment contains all the items 
noted in the shipment inventory. Any damaged or unusable study drug in a given shipment (active 
drug or comparator) will be documented in the study files.  
5.9.2 Storage 
The drug must be refrigerated at 35.6 – 46.4 degrees Fahrenheit, and may be used up to 1 month 
after opening. 
5.9.3 Dispensing of Study Drug 
The drug will be stored at and dispensed by at the research pharmacy.  
5.9.4 Return or Destruction of Study Drug 
Empty/used oxytocin spray containers will be returned to the research pharmacy. At the 
completion of the study, there will be a final reconciliation of drug shipped, drug consumed, and 
drug remaining. This reconciliation will be logged on the drug reconciliation form, signed and 
dated. Any discrepancies noted will be investigated, resolved, and documented prior to return or 
destruction of unused study drug. Drug destroyed on site will be documented in the study files. 
6 Study Procedures 
6.1 Visit 1 
The collection of all specimen types will be completed within the regularly scheduled operative 
time period. The surgery will not be prolonged in any way for specimen collection. Patients will 
answer a brief questionnaire preoperatively, after the subject has consented to the trial and prior to 
administration of oxytocin. Blood pressure will be recorded prior to oxytocin administration and 
5 minutes post-administration of oxytocin.  
 
 
All patients will undergo a blood draw as well as collection of NAF (via prior administration of 
intranasal oxytocin, gentle massage, aspirator, and breast pump from both breasts). All biological 
samples will be collected by a qualified clinician. The NAF and blood samples will be sent to the 
pathology lab for analysis of miR profile. At the completion of the case, the breast tissue will be 
sent to pathology per routine. Once in pathology, 5 paraffin-embedded slices will be created to 
evaluate for miR profile. Serum, NAF, and tissue will be analyzed for their miR profile. 


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Five patients who are participating in the PK cohort of the trial will also undergo a PK blood draw 
at the time of surgery prior to oxytocin administration. This will be used to assess the baseline 
oxytocin level and will be done in conjunction with the pre-oxytocin blood draw to assess miR.  
These patients will have a second blood draw approximately 30 minutes after the administration 
of oxytocin to assess oxytocin levels in comparison to the baseline.  All blood draws will be done 
by a qualified clinician. 
 
Once total RNA is extracted from the biological samples it will be processed to fluorescently label 
the microRNAs species according to the V2-Human microRNA array (Agilent). MicroRNA 
profiling will be obtained and analyzed using the gene-spring software analysis package. First, 
expression and cluster analysis will be performed to identify the microRNA that are expressed in 
our samples and to classify them accordingly to their expression. Then, the predicted targets of the 
over/down-regulated microRNAs will be identified using target prediction bioinformatics tools 
(TargetScan, Miranda and Pictarvert). Finally, statistical studies between over/under-represented 
microRNAs will be performed. 
6.2 Visit 2/End of Study Visit 
One blood draw will be performed at the first standard of care, post-surgical outpatient follow-up 
visit. A final adverse event assessment will also be performed at this visit and documented.  Any 
unresolved, oxytocin related adverse events will be followed until resolution.  Any adverse events 
deemed unrelated to oxytocin administration will be considered resolved at this time. Any 
applicable standard of care interventions to address non-oxytocin related adverse events will be 
handled as per standard clinical practice. No further contributions to the study will be required 
after this visit. 
 
6.3 Study Calendar 
 
 
Pre-Study 
Visit 1 
Visit 2/End of Study Visit 
Informed consent 
X 
 
 
Demographics 
X 
 
 
Medical history 
X 
 
 
Oxytocin Administration 
 
X 
 
NAF collection 
 
X 
 
Adverse event evaluation 
X 
X 
Xe 
Blood Pressure 
X 
Xb 
 
B-HCGa 
Xa 
 
 
Patient Questionnaire 
 
Xd 
 
Serum Blood Draw 
 
X 
X 
Pharmacokinetic Blood Draw 
 
Xc 
 
Tissue from On-Study Surgery 
 
X 
 
a: Only for subjects who are of childbearing potential 
b: Blood pressure recordings will be taken prior to oxytocin administration, and approximately 5 minutes post-administration of oxytocin. 


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c: PKs will be drawn prior to the administration of oxytocin, and then a post-administration PK will be drawn approximately 30 minutes 
post oxytocin administration. 
d: Questionnaire can be administered any time after the subject signs the informed consent, so long as it is captured prior to the 
administration of oxytocin.e. Adverse events will be recorded at visit 2/End of Study visit, if there are any adverse events that are 
attributed to oxytocin, they will and must be followed until resolution.  All other adverse events that are not attributable to oxytocin will 
be considered closed out at this visit, and will be followed/addressed via standard of care clinical/medical interventional procedures. 
 
 
7 Statistical Plan 
7.1 Sample Size Consideration 
Contralateral breast without disease will serve as the control. In a sample of 40 patients with 
unilateral disease, we expect 60% of the patients to show significantly altered expression of 
miRNAs in the diseased breast as compared to the breast without disease for the test to be of 
clinical relevance. Ideally a detectable difference would be the difference between a null 
hypothesis of 0% and an alternative of 60% or a second alternative of 35%. Since this study is the 
first of its kind, we will consider the test to be not clinically relevant if less than 35% of patients 
show significantly altered expression miRNA in the diseased breast as compared to the breast 
without disease. 
 
Using a two sample z-test, type I error of 0.05, and a two-sided significance level, a sample size 
of 40 will have greater than 80% power to detect a difference between a null hypothesis of 35% 
and an alternative hypothesis of 60%. 
7.2 Statistical Methods 
The primary analysis will be conducted to determine the presence and expression levels of 800 
miRNA's among DCIS and invasive breast cancer patients. Based on the resulting profiles, we will 
determine whether or not its expression for each miRNA from the tumor side differs from that of 
the normal side. 
 
We will interrogate 800 miRNAs. The vast majority will not be expressed in any sample. A 
minority will be measurable/detectable in some samples and a smaller minority will be detectable 
in all samples. 
 
The presence of miRNA can be as follows:  
a. Present in tumor and absent in normal  
b. Present in normal and absent in tumor 
c. Present at high level in tumor and low level in normal  
d. Present at high level in normal side and low level in tumor.  
 
Of these a and c are most important and relevant for our analysis. If even a single miRNA is absent 
in tumor and present in 30% of cancers or if there is at least one miRNA out of these 800 that is 
present at low levels in all “normals” and high levels in 30% of tumors that would be a "success". 
We will dichotomize to low and high levels of miRNA to calculate frequencies and the associated 
risk estimates and 95% confidence intervals. The comparison of proportions will be performed 
using two-sample z-tests. 


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7.3 Subject Population(s) for Analysis 
Patients diagnosed with DCIS or invasive breast cancer. 
8 Safety and Adverse Events 
8.1 Definitions 
Adverse Event 
An adverse event (AE) is any symptom, sign, illness or experience that develops or worsens in 
severity during the course of the study. Intercurrent illnesses or injuries should be regarded as 
adverse events.  Abnormal results of diagnostic procedures are considered to be adverse events if 
the abnormality: 
 results in study withdrawal 
 is associated with a serious adverse event 
 is associated with clinical signs or symptoms 
 leads to additional treatment or to further diagnostic tests 
 is considered by the investigator to be of clinical significance 
Serious Adverse Event 
Adverse events are classified as serious or non-serious. A serious adverse event is any AE that is:  
 fatal 
 life-threatening 
 requires or prolongs hospital stay 
 results in persistent or significant disability or incapacity 
 a congenital anomaly or birth defect 
 an important medical event 
 
Important medical events are those that may not be immediately life threatening, but are clearly of 
major clinical significance. They may jeopardize the subject, and may require intervention to 
prevent one of the other serious outcomes noted above. For example, drug overdose or abuse, a 
seizure that did not result in in-patient hospitalization, or intensive treatment of bronchospasm in 
an emergency department would typically be considered serious.  
 
All adverse events that do not meet any of the criteria for serious should be regarded as non-
serious adverse events.  
Adverse Event Reporting Period 
The study period during which adverse events must be reported is normally defined as the period 
from the initiation of any study procedures to the end of the study treatment follow-up.  For this 
study, due to the short half life of oxytocin, the study treatment follow-up period for adverse event 
reporting will be considered completed at the Visit 2/End of Study visit as outlined in Protocol 
Section 6.2.  
Preexisting Condition 
A preexisting condition is one that is present at the start of the study. A preexisting condition 
should be recorded as an adverse event if the frequency, intensity, or the character of the condition 
worsens during the study period. 


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General Physical Examination Findings 
At screening, any clinically significant abnormality should be recorded as a preexisting condition. 
At the end of the study, any new clinically significant findings/abnormalities that meet the 
definition of an adverse event must also be recorded and documented as an adverse event.  
Post-study Adverse Event 
All unresolved, oxytocin related adverse events should be followed by the investigator until the 
events are resolved, the subject is lost to follow-up, or the adverse event is otherwise explained. 
At the last scheduled visit, the investigator should instruct each subject to report any subsequent 
event(s) that the subject, or the subject’s personal physician, believes might reasonably be related 
to participation in this study. The investigator should notify the study sponsor of any death or 
adverse event occurring at any time after a subject has discontinued or terminated study 
participation that may reasonably be related to this study. The sponsor should also be notified if 
the investigator should become aware of the development of cancer or of a congenital anomaly in 
a subsequently conceived offspring of a subject that has participated in this study.  
Abnormal Laboratory Values 
A clinical laboratory abnormality should be documented as an adverse event if any one of the 
following conditions is met:  
 The laboratory abnormality is not otherwise refuted by a repeat test to confirm the 
abnormality 
 The abnormality suggests a disease and/or organ toxicity 
 The abnormality is of a degree that requires active management; e.g. change of dose, 
discontinuation of the drug, more frequent follow-up assessments, further diagnostic 
investigation, etc. 
Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization should be 
documented and reported as a serious adverse event unless specifically instructed otherwise in this 
protocol. Any condition responsible for surgery should be documented as an adverse event if the 
condition meets the criteria for and adverse event.  
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported as an 
adverse event in the following circumstances: 
 Hospitalization or prolonged hospitalization for diagnostic or elective surgical 
procedures for a preexisting condition. Surgery should not be reported as an outcome 
of an adverse event if the purpose of the surgery was elective or diagnostic and the 
outcome was uneventful. 
 Hospitalization or prolonged hospitalization required to allow efficacy measurement 
for the study. 
 Hospitalization or prolonged hospitalization for therapy of the target disease of the 
study, unless it is a worsening or increase in frequency of hospital admissions as 
judged by the clinical investigator. 


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8.2 Recording of Adverse Events 
At each contact with the subject, the investigator must seek information on adverse events by 
specific questioning and, as appropriate, by examination. Information on all adverse events should 
be recorded immediately in the source document, and also in the appropriate adverse event module 
of the case report form (CRF). All clearly related signs, symptoms, and abnormal diagnostic 
procedures results should recorded in the source document, though should be grouped under one 
diagnosis. 
 
All adverse events occurring during the study period must be recorded. The clinical course of each 
event should be followed until resolution, stabilization, or until it has been determined that the 
study treatment or participation is not the cause. Serious adverse events that are still ongoing at 
the end of the study period must be followed up to determine the final outcome. Any serious 
adverse event that occurs after the study period and is considered to be possibly related to the study 
treatment or study participation should be recorded and reported immediately. 
8.3 Reporting of Serious Adverse Events 
8.3.1 Study Sponsor Notification by Investigator 
A serious adverse event must be reported to the study sponsor by telephone within 24 hours of the 
event. A Serious Adverse Event (SAE) form must be completed by the investigator and faxed to 
the study sponsor within 24 hours. The investigator will keep a copy of this SAE form on file at 
the study site. Report serious adverse events by phone and facsimile to: 
 
Sheldon Feldman, MD 
Phone 212-305-9676 
Fax 212-305-1522 
 
At the time of the initial report, the following information should be provided: 
 Study identifier 
 Study Center 
 Subject number 
 A description of the event 
 Date of onset 
 Current status 
 Whether study treatment was 
discontinued 
 The reason why the event is 
classified as serious 
 Investigator assessment of the 
association between the event and 
study treatment 
 
Within the following 48 hours, the investigator must provide further information on the serious 
adverse event in the form of a written narrative. This should include a copy of the completed 
Serious Adverse Event form, and any other diagnostic information that will assist the 
understanding of the event. Significant new information on ongoing serious adverse events should 
be provided promptly to the study sponsor 
8.3.2 EC/IRB Notification by Investigator 
Reports of all events (including follow-up information) that meet the definition of an 
unanticipated problem posing risk to subjects or others must be submitted to the IRB within one 
week (5 business days) following the occurrence of the unanticipated problem or the principal 


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investigator’s acquiring knowledge of the unanticipated problem in accordance with IRB policy. 
Additionally, the sponsor-investigator will submit a summary of all unanticipated problems that 
occurred since the beginning of the study at the time of continuing review. Copies of each report 
and documentation of IRB notification and receipt will be kept in the Regulatory binder.  
8.3.3 FDA Notification by Sponsor  
The Columbia University Medical Center Sponsor-Investigator, as holder of the IND, will be 
responsible for all communication with the FDA. Columbia University Medical Center Principal 
Investigator will report to the FDA, regardless of the site of occurrence, any adverse event that is 
serious, unexpected and there is evidence to suggest a causal relationship between the drug and 
the adverse event. These must be reported to the FDA and any affiliate sites as soon as possible, 
but in no case later than 15 calendar days after the sponsor determines that the information qualifies 
for reporting.  The Sponsor-Investigator will also submit an IND annual report to the FDA in 
accordance with 21.CFR 312.33. 
 
The Columbia University Medical Center Sponsor Investigator must report to the FDA and any 
affiliate site investigators as follows:  
• 
Any unexpected fatal or life-threatening event must be reported as soon as possible, 
but no later than 7 calendar days after the sponsor investigator initial receipt of the 
information 
• 
Any findings from epidemiological studies, pooled analysis of multiple studies, or 
clinical studies, whether or not conducted under an IND, and whether or not conducted by 
the sponsor-investigator, that suggest a significant risk in humans exposed to the drug  must 
be reported as soon as possible but no later than 15 calendar days after the sponsor-
investigator determines that the information qualifies for reporting 
• 
Any findings from animal or in vitro testing whether or not conducted under an 
IND, and whether or not conducted by the sponsor-investigator, that suggest a significant 
risk in humans exposed to the drug  must be reported as soon as possible but no later than 
15 calendar days after the sponsor-investigator determines that the information qualifies 
for reporting 
• 
Any clinically important increase in the rate of a serious suspected adverse 
reactions  over that listed in the protocol or Investigator Brochure 
• 
Expected SAEs and AEs will be included in the IND Annual Reports. 
Follow-up information to a safety report should be submitted as soon as the relevant 
information is available.  However, if the results of a sponsor’s investigation show that an 
adverse drug experience not initially determined to be reportable are so reportable, the 
sponsor investigator must report such experience as soon as possible, but no later than 15 
calendar days after the determination is made. 
 
All other serious unexpected experiences associated with the use of the study treatment will be 
reported to FDA as soon as possible but in no event later than 15 calendar days after initial receipt 
of the information. 
 
 


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8.3.4 DSMC Reporting by the Sponsor-Investigator 
Serious adverse events not constituting unanticipated problems are to be reported to the 
HICCC DSMC. Reporting should occur within 24 hours of knowledge of the SAE occurring 
at our institution or affiliate sites. 
8.4 Unblinding Procedures 
N/A.  Subjects are not blinded. 
8.5 Stopping Rules  
The study will be stopped immediately if the drug intervention causes more harm than benefit to 
the patients enrolled. 
8.6 Medical Monitoring 
It is the responsibility of the Principal Investigator to oversee the safety of the study at his/her site. 
This safety monitoring will include careful assessment and appropriate reporting of adverse events 
as noted above, as well as the construction and implementation of a site data and safety-monitoring 
plan (see section 9 Auditing, Monitoring and Inspecting). Medical monitoring will include a 
regular assessment of the number and type of serious adverse events. 
8.6.1 Internal Data and Safety Monitoring Board 
The principal investigator, Dr. Sheldon Feldman, is responsible for monitoring the data and safety 
related to this study. All adverse events (AE), including serious adverse events (SAE), and 
unanticipated problems (UP) will be reviewed in an ongoing manner by the principal investigator. 
 
8.6.2 Independent Data and Safety Monitoring Committee 
As per the Study Monitoring Plan (see Section 10.1), all monitoring reports generated by the 
Quality Monitor will be sent for review to the HICCC DSMC upon completion.  
In addition, semi-annual Safety Reports will be submitted to the HICCC DSMC for review. The 
Safety Reports will include, but is not limited to, the following information: enrollment status, 
toxicity information, unanticipated problems, and serious adverse events. 
9 Data Handling and Record Keeping 
9.1 Confidentiality 
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act (HIPAA).  Those 
regulations require a signed subject authorization informing the subject of the following:  
 What protected health information (PHI) will be collected from subjects in this study 
 Who will have access to that information and why 
 Who will use or disclose that information 
 The rights of a research subject to revoke their authorization for use of their PHI.  
In the event that a subject revokes authorization to collect or use PHI, the investigator, by 
regulation, retains the ability to use all information collected prior to the revocation of subject 


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authorization.  For subjects that have revoked authorization to collect or use PHI, attempts should 
be made to obtain permission to collect at least vital status (i.e. that the subject is alive) at the end 
of their scheduled study period. 
9.2 Source Documents 
Source data is all information, original records of clinical findings, observations, or other activities 
in a clinical trial necessary for the reconstruction and evaluation of the trial.  Source data are 
contained in source documents   Examples of these original documents, and data records include: 
hospital records, clinical and office charts, laboratory notes, memoranda, subjects’ diaries or 
evaluation checklists, pharmacy dispensing records, recorded data from automated instruments, 
copies or transcriptions certified after verification as being accurate and complete, microfiches, 
photographic negatives, microfilm or magnetic media, x-rays, subject files, and records kept at the 
pharmacy, at the laboratories, and at medico-technical departments involved in the clinical trial. 
9.3 Case Report Forms 
Case Report Forms will be completed for each subject enrolled into the clinical study through the 
CTMS. It is the investigator’s responsibility for ensuring that all clinical and laboratory data 
entered on the corresponding CRFs are complete, accurate and authentic. 
9.4 Records Retention 
Study records that identify participants will be kept confidential as required by law. Federal 
Privacy Regulations provide safeguards for privacy, security and authorized access. Except when 
required by law or otherwise authorized, name, address and telephone number will not identify 
participants or any other direct personal identifier in study records disclosed outside of Columbia 
University Medical Center. The file that links names and other personal information and code 
numbers will be kept secure at our site. Apart from the health care personnel involved in this study, 
study data will be available only to representatives of the Institutional Review Board (IRB) at the 
Columbia University Medical Center. 
 
10 Study Monitoring, Auditing, and Inspecting 
10.1 Study Monitoring Plan 
This study will be monitored at least twice a year by the departmental Quality Monitor who is 
under the supervision of the department’s Director of clinical trials. The monitor will review the 
regulatory binder, and regulatory submission to the IRB and the FDA to endure compliance. She 
will review study files to assess protocol compliance. The monitor will verify data accuracy 
through reconciliation of case report forms with source documents. A copy of the monitoring 
report will be filed in the regulatory documents. All monitoring reports will be forwarded to the 
DSMC for review. The investigator will allocate adequate time for such monitoring activities. The 
Investigator will also ensure that the monitor or other compliance or quality assurance reviewer is 
given access to all the above noted study-related documents and study related facilities (e.g. 
pharmacy, diagnostic laboratory, etc.), and has adequate space to conduct the monitoring visit. The 
HICCC-DSMC may conduct additional monitoring visits if deemed necessary. 


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10.2 Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the EC/IRB, the 
sponsor, government regulatory bodies, and University compliance and quality assurance groups 
of all study related documents (e.g. source documents, regulatory documents, data collection 
instruments, study data etc.). The investigator will ensure the capability for inspections of 
applicable study-related facilities (e.g. pharmacy, diagnostic laboratory, etc.). 
 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable University compliance and quality assurance 
offices. 
11 Ethical Considerations 
This study is to be conducted according to US and international standards of Good Clinical Practice 
(FDA Title 21 part 312 and International Conference on Harmonization guidelines), applicable 
government regulations and Institutional research policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted independent Ethics 
Committee (EC) or Institutional Review Board (IRB), in agreement with local legal prescriptions, 
for formal approval of the study conduct.  The decision of the EC/IRB concerning the conduct of 
the study will be made in writing to the investigator and a copy of this decision will be provided 
to the sponsor before commencement of this study. The investigator should provide a list of 
EC/IRB members and their affiliate to the sponsor. 
 
All subjects for this study will be provided a consent form describing this study and providing 
sufficient information for subjects to make an informed decision about their participation in this 
study. See Attachment B for a copy of the Subject Informed Consent Form. This consent form will 
be submitted with the protocol for review and approval by the EC/IRB for the study. The formal 
consent of a subject, using the EC/IRB-approved consent form, must be obtained before that 
subject is submitted to any study procedure. This consent form must be signed by the subject or 
legally acceptable surrogate, and the investigator-designated research professional obtaining the 
consent.  
 
12 Study Finances 
12.1 Funding Source 
Funded by private donors. 
12.2 Conflict of Interest 
Any investigator who has a conflict of interest with this study (patent ownership, royalties, or 
financial gain greater than the minimum allowable by their institution, etc.) must have the conflict 
reviewed by the Columbia University Conflict of Interest Committee with a Committee-sanctioned 
conflict management plan that has been reviewed and approved prior to participation in this study. 
All Columbia University investigators will follow the University conflict of interest policy. 


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12.3 Subject Stipends or Payments 
There will be no stipend or payments for study subjects. 
13 Publication Plan 
Neither the complete nor any part of the results of the study carried out under this protocol, nor 
any of the information provided by the sponsor for the purposes of performing the study, will be 
published or passed on to any third party without the consent of the study sponsor. Any investigator 
involved with this study is obligated to provide the sponsor with complete test results and all data 
derived from the study.