Conditions: Thromboembolism of Vein VTE in Colorectal Cancer Thromboembolism of Vein in Pancreatic Cancer Thromboembolism of Vein in Non-small Cell Lung Cancer
Keywords: Venous Thromboembolic Events in Cancer Patients Thromboembolism of Vein in Colorectal Cancer Thromboembolism of Vein in Pancreatic Cancer Thromboembolism of Vein in Non-small Cell Lung Cancer
Allocation: NON_RANDOMIZED | Intervention model: SEQUENTIAL
Enrollment: 64
Healthy volunteers: no

Brief summary:
This research study is evaluating a drug called isoquercetin to prevent venous thrombosis (blood clots), in participants who have pancreas, non small cell lung cancer or colorectal cancer.

Detailed description:
* This research study is a Phase II/III clinical trial.

  --The goal of this trial is to evaluate if isoquercetin can prevent blood clots in patients with pancreas, non small cell lung cancer or colorectal cancer. In the Phase II part of this study, the investigators are looking for the dose of isoquercetin to reduce D-dimer and demonstrate safety.
* Phase III Endpoint and Treatment Plan

  * Primary Endpoint for Phase III portion of protocol: Cumulative incidence of VTE.
  * Following the completion of the phase II portion, enrolled patients will be randomized 1:1 to Arm C (isoquercetin) or Arm D (placebo). The dose for Arm C will be determined after evaluation of the Phase II portion of the trial. The protocol will be amended when the decision is made whether to proceed to Phase III and what dose to use for Arm C. The study will be double-blinded to treatment arm. Lower extremity ultrasound will be performed at 56 days. Baseline D-dimer and correlative labs will be drawn at Day 1 and at 56 days. Patients will be followed for survival after completion of 56 days.
  * At BIDMC, optional blood draw will be performed at time 0 and 4 hours following the first dose of study drug.

Arms:
arm 1: \-- Cohort A: 500 mg, Once daily, 28 days

\- For both cohorts A and B, lower extremity ultrasound will be performed at 56 days. Baseline D-dimer and correlative labs will be drawn at Day 1 and at 56 days. Patients will be followed for survival after completion of 56 days. arm 2: --Cohort B: 1000 mg, Once daily, 28 days

\- For both cohorts A and B, lower extremity ultrasound will be performed at 56 days. Baseline D-dimer and correlative labs will be drawn at Day 1 and at 56 days. Patients will be followed for survival after completion of 56 days.

Interventions: intervention 1: Isoquercetin
Intervention descriptions: intervention 1: None

Protocol document:
Prot_SAP_000.pdf: 
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Protocol Version Date: October 27, 2016 
 
 
Local Protocol #:14-114 
 
 
Title: Randomized, placebo-controlled, double-blind phase II/III trial of oral 
isoquercetin to prevent venous thromboembolic events in cancer patients.  
 
Short Title: Cancer associated thrombosis and isoquercetin (CAT IQ) 
 
Principal Investigator: Jeffrey Zwicker, M.D.  
Beth Israel Deaconess Medical Center 
 
Coordinating Center: Beth Israel Deaconess Medical Center  
  
 
Statistician: Donna Neuberg, PhD  
Dana Farber Cancer Institute 
 
 
Agent(s): Isoquercetin (IND# 121404) – Quercegen Pharma   
 
Support Given By: NHLBI and Quercegen Pharma 
 
 
 
 


Phase II/III trial of antithrombotic activity of isoquercetin  
October 27, 2016 
 
 
 
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Figure 1. Protocol Schema


Phase II/III trial of antithrombotic activity of isoquercetin  
October 27, 2016 
 
 
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TABLE OF CONTENTS 
 
 
1. 
OBJECTIVES ................................................................................................................................................... 1 
1.1 
Study Design .................................................................................................................................................... 1 
1.2 
Primary Objectives .......................................................................................................................................... 1 
1.3 
Secondary Objectives ...................................................................................................................................... 1 
2 
BACKGROUND ............................................................................................................................................... 2 
2.1 
Study Agent(s) - Isoquercetin .......................................................................................................................... 2 
2.2 
Study Disease and correlative studies background ......................................................................................... 4 
2.3 
Rationale ......................................................................................................................................................... 5 
3 
PARTICIPANT SELECTION......................................................................................................................... 6 
3.1 
Eligibility Criteria ........................................................................................................................................... 6 
3.2 
Exclusion Criteria ........................................................................................................................................ 7 
3.3 
Inclusion of Women, Minorities and Other Underrepresented Populations ................................................... 8 
4 
REGISTRATION PROCEDURES ................................................................................................................. 9 
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions ........................................................................... 9 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions ....................................................................... 9 
4.3 
General Guidelines for Other Participating Institutions .......................................................................... 9 
4.4 
Registration Process for Other Participating Institutions ............................................................................. 9 
5 
TREATMENT PLAN ..................................................................................................................................... 10 
5.1 
Pre-treatment Criteria ................................................................................................................................. 11 
5.2 
Agent Administration ................................................................................................................................... 11 
5.3 
Duration of Therapy ....................................................................................................................................... 12 
5.4 
Duration of Follow Up .................................................................................................................................. 12 
5.5 
Criteria for Removal from Study ................................................................................................................... 13 
6 
EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS................................... 13 
6.1 
Anticipated Toxicities .................................................................................................................................... 13 
6.2 
Toxicity Management .................................................................................................................................... 14 
6.3 
Dose Modifications/Delays ........................................................................................................................... 15 
7 
DRUG FORMULATION AND ADMINISTRATION ................................................................................ 15 
7.1 
Isoquercetin ................................................................................................................................................... 15 
8 
CORRELATIVE/SPECIAL STUDIES ........................................................................................................ 17 


Phase II/III trial of antithrombotic activity of isoquercetin  
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8.1 
Pharmacodynamic and Correlative Studies .................................................................................................. 17 
9 
STUDY CALENDAR ..................................................................................................................................... 19 
10 
MEASUREMENT OF EFFECT ................................................................................................................... 22 
10.1 
Venous Thromboembolism (VTE) ............................................................................................................. 22 
10.2 
Major Hemorrhage ................................................................................................................................... 23 
10.3 
D-dimer .................................................................................................................................................... 23 
10.4 
TFMP levels and thrombotic risk ............................................................................................................. 23 
10.5 
Quality of Life ........................................................................................................................................... 23 
10.6 
Overall Survival ........................................................................................................................................ 23 
10.7 
Definitions ................................................................................................................................................ 23 
11 
ADVERSE EVENT REPORTING REQUIREMENTS .............................................................................. 24 
11.1 
Definitions ................................................................................................................................................ 24 
11.2 
Procedures for AE and SAE Recording and Reporting ............................................................................ 25 
11.3 
Adverse Events: List and Reporting Requirements ................................................................................... 26 
11.4 
Reporting to the Study Sponsor ................................................................................................................ 27 
11.5 
Reporting to the Institutional Review Board (IRB)................................................................................... 28 
11.6 
Reporting to the Food and Drug Administration (FDA) .......................................................................... 29 
11.7 
Reporting to National Heart Lung and Blood Institute ............................................................................ 29 
11.8 
Reporting to Hospital Risk Management .................................................................................................. 29 
11.9 
Monitoring of Adverse Events and Period of Observation ....................................................................... 29 
12 
DATA AND SAFETY MONITORING ........................................................................................................ 30 
12.1 
Data Reporting ......................................................................................................................................... 30 
12.2 
Safety Meetings ......................................................................................................................................... 31 
12.3 
Monitoring ................................................................................................................................................ 31 
13 
REGULATORY CONSIDERATIONS ......................................................................................................... 32 
13.1 
Protocol Review and Amendments ........................................................................................................... 32 
13.2 
Informed Consent ..................................................................................................................................... 32 
13.3 
Study Documentation ................................................................................................................................ 32 
13.4 
Records Retention ..................................................................................................................................... 33 
13.5 
Multi-center Guidelines ............................................................................................................................ 34 
14 
STATISTICAL CONSIDERATIONS .......................................................................................................... 34 
14.1 
Study Design/Endpoints ............................................................................................................................ 34 
14.2 
Secondary endpoint analysis .................................................................................................................... 38 
15 
PUBLICATION PLAN .................................................................................................................................. 39 


Phase II/III trial of antithrombotic activity of isoquercetin  
October 27, 2016 
 
 
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16 
REFERENCES ................................................................................................................................................ 40 
17 
APPENDICES ................................................................................................................................................. 44 
Appendix A:  Multicenter Data and Safety Monitoring Plan  
Appendix B: Performance Status Criteria  
Appendix C: Study Visit Templates  
Appendix D: Quality of Life Questionnaire  
Appendix E: Special studies specimen collection and shipping report  
 
 


Phase II/III trial of antithrombotic activity of isoquercetin  
October 27, 2016 
 
 
 
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1 
1. OBJECTIVES 
 
 
1.1 Study Design 
 
The goal of this randomized, placebo controlled, phase II/III trial is to evaluate 
isoquercetin as a novel anticoagulant in patients with advanced cancer (pancreatic, non-
small cell lung cancer, and colorectal cancer). The primary goal of the phase II study is 
to assess the relative reduction in D-dimer levels following isoquercetin administration 
and evaluate safety. Based on efficacy and safety data, a dose of isoquercetin will be 
selected for continued enrollment into a phase III trial in order to evaluate the 
effectiveness of isoquercetin in preventing VTE in cancer patients.  
 
1.2 Primary Objectives 
 
•     The phase II primary objective is to evaluate the efficacy of isoquercetin to reduce D-
dimer values  
•     The phase III primary objective is to assess the effectiveness of oral isoquercetin to 
prevent venous thromboembolic events in cancer patients   
 
1.3 Secondary Objectives 
 
•     To investigate the cumulative incidence of VTE according to tissue factor bearing 
microparticle status (and isoquercetin randomization).To evaluate the cumulative 
incidence of major hemorrhage between the groups of patients treated with isoquercetin 
versus placebo.  
•    To assess overall survival according to randomization and tissue factor bearing 
microparticle status  
•    To investigate the cumulative incidence of total or symptomatic VTE in all treatment 
arms (and according to tissue factor bearing microparticle status) 
•    To study the influence of isoquercetin on TFMP levels and change in TFMP levels over 
time.  
•    To evaluate the cumulative incidence of VTE in patients with elevated TFMP as well as 
very elevated d-dimer (>1500 mcg/L) overall and according to randomization.  
•    To assess for correlation between complete blood count, ECOG, histology, stage, D-
dimer, and levels of tissue factor bearing microparticles  
•  To investigate the influence of chemotherapy, blood counts, growth factors, ECOG 
performance status on tissue factor bearing microparticle levels as well as VTE risk. 
•    Influence of VTE and isoquercetin on Quality of Life (QOL) 
•    To investigate the association between isoquercetin plasma concentrations, inhibition of 
protein disulfide isomerase activity, and reduction in D-dimer. 
•    To evaluate the efficacy of isoquercetin to reduce D-dimer or VTE in cancer patients 
based on levels of circulating tissue factor bearing microparticles or Khorana risk model 
•   To compare VTE rates at completion of phase II with historical rates of VTE in similar 
population 
 


Phase II/III trial of antithrombotic activity of isoquercetin  
October 27, 2016 
 
 
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2 
2 BACKGROUND 
 
2.1 
Study Agent(s) - Isoquercetin 
 
Isoquercetin is naturally occurring flavonol present in a number of fruits and vegetables such 
as berries, apples, and onions. Isoquercetin is the 3-0 glucoside form of the flavonol quercetin 
which is designated as GRAS (generally recognized as safe) by the Food and Drug 
Administration.1 Recent studies have demonstrated potent antithrombotic activities of 
quercetin and related flavonoids in vitro and in animal models through inhibition of 
extracellular protein disulfide isomerase (PDI).2 The goal of this trial is to evaluate the 
anticoagulant and antithrombotic activity of isoquercetin in patients with advanced 
malignancy.  
 
Mechanism of action: 
Extracellular disulfide isomerization has been explored as a regulatory pathway in platelet 
activation and fibrin generation. Protein disulfide isomerase is a thiol isomerase that is secreted 
by platelets and endothelial cells following activation and localizes to the membrane surface.3-5 
The hemostatic targets of extracellular PDI continue to be elucidated and may include tissue 
factor and platelet integrins such as αIIβIIIa. The Furie laboratory recently demonstrated the 
critical role of extracellular PDI in regulating platelet thrombus formation and fibrin deposition 
in vivo.6 Employing intravital fluorescence microscopy to monitor a laser-induced vascular 
injury in mice, it was observed that inhibition of PDI with either bacitracin, a non-specific thiol 
isomerase inhibitor, or a specific and inhibitory monoclonal anti-PDI antibody completely 
blocked both platelet thrombus formation and fibrin generation in vivo.  
 
Following the observation that inhibitory antibodies against PDI block platelet thrombus and 
fibrin generation in vivo, a high throughput screen identified several related flavonoids 
(quercetin-3-rutinoside and isoquercetin) as potent inhibitors of PDI.2 The Kd of quercetin-3-
rutinoside for PDI in vitro is 2.8 µM as determined by surface plasmon resonance (SPR). PDI 
inhibition appears to be specific without evidence of significant inhibition of other thiol 
isomerases such as ERp57, ERp5, ERp72, or thioredoxin.  
 
We recently conducted a pharmacokinetic/pharmacodynamic study to assess the PDI-
inhibitory activity of isoquercetin in humans. Following an oral dose of isoquercetin (1000 mg 
capsules), the median peak concentration was 4.45 µM with a half-life of 8.2 hours. PDI 
inhibitory activity of plasma was measured using the fluorescent substrate dieosin glutathione 
disulfide (di-E-GSSG) to liberate a self-quenching N-terminal GSSG residue following 
cleavage of a disulfide bond. 7-9  In all study subjects, we detected significant PDI-inhibitory 
activity in plasma following the oral administration of isoquercetin 1000 mg capsule.10  


Phase II/III trial of antithrombotic activity of isoquercetin  
October 27, 2016 
 
 
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3 
 
Quercetin as an antithrombotic agent 
The antithrombotic potential of flavonoids first garnered attention in the 1990's following the 
publication of several large epidemiologic studies. In the Zupthen Elderly Study, the group of 
individuals who consumed over 30 mg of flavonoids daily experienced a nearly 70% reduction 
in mortality from myocardial infarction (adjusted RR 0.32, 95% CI 0.15-0.71) compared with 
those individuals who consumed less than 20 mg daily.11 A prospective study of nearly 35,000 
postmenopausal women demonstrated that flavonoid consumption reduced both cardiovascular 
and overall mortality12 which was also confirmed in a meta-analysis of 7 cohort studies.13 
Flavonoid consumption has also been linked with a decreased incidence of nonfatal and fatal 
stroke.14,15 Attempts have been made to identify which thrombotic risk factors are modulated 
with dietary flavonoid consumption but endpoints such as blood pressure, high and low-
density lipoprotein concentrations, and flow-mediated dilatation have yielded inconsistent 
results. Flavonoids such as isoquercetin are known to inhibit platelet function in vitro.16-19 The 
ingestion of either onion soup or quercetin -4’-O-β-D-glucoside (the predominant quercetin 
found in onions) inhibited ex vivo platelet aggregation.20,21 However there has never been a 
late stage clinical study on the use of isoquercetin to specifically prevent thrombotic events in 
humans. 
 
 
 
 
 
 
 
 
 
 
 
 
  


Phase II/III trial of antithrombotic activity of isoquercetin  
October 27, 2016 
 
 
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4 
 
  
 
Selection of dose: 
The inhibitory IC50 of PDI activity in vitro for isoquercetin metabolites ranges between 3-
10uM.2 Following the oral administration of isoquercetin (1000 mg) in healthy volunteers, the 
peak concentration of isoquercetin metabolites in healthy volunteers was 4.45µM and was 
associated with 67% inhibition of PDI activity in plasma at 4 hours.10  Isoquercetin is widely 
available as a health food supplement and small clinical studies have not demonstrated 
toxicity. In a pilot trial conducted in 16 patients with mild cognitive impairment, isoquercetin 
350 mg and ascorbic acid 400 mg taken for 6 months demonstrated a positive trend in 
cognitive function without any reported side effects (Investigators Brochure). In another study 
designed to evaluate the effect of isoquercetin and quercetin, thirteen individuals took 
isoquercetin 400 mg isoquercetin in conjunction with quercetin 1000 mg daily for two weeks 
without toxicity.22  Based on in vitro, animal, and human data as well as safety profile of 
isoquercetin (and parent compound quercetin), the planned sequential dosing cohorts for the 
clinical phase II trial are 500mg and1000 mg once daily.   
 
Absorption, Metabolism, and Bioavailability 
A number of clinical studies have investigated the metabolic fate of quercetin and its 
glucosides. Isoquercetin is better absorbed than quercetin aglycone, possibly due to increased 
stability at low pH.23 The pharmacokinetic study we conducted in healthy adults (isoquercetin 
1000 mg capsules) AUC was 1714 and T ½ of 8.23 hours. Isoquercetin undergoes 
deglycosylation by an extracellular β-glycosidase on the brush border of enterocytes yielding 
the aglycone.24,25 Although the absorption of quercetin and quercetin glucosides differ, all 
forms of quercetin are metabolized both in the enterocyte and liver and circulate as similar 
glucuronated, sulfated, and methylated conjugates.26-28 These conjugates have demonstrated 
biologic activity 2,29,30.  
 
Distribution 
 
Isoquercetin and its metabolites possess high affinity for serum albumin.31 Quercetin 
metabolites did not accumulate in tissue following four weeks of daily administration to pigs. 
Only the organs involved in metabolism and excretion such as the small intestine, liver, and 
kidney, contained higher concentrations than plasma32. The elimination of absorbed quercetin 
follows a biphasic profile, likely due to enterohepatic recirculation following elimination of 
quercetin metabolites in bile.31,33  
 
Excretion 
 
Following metabolism in the liver and/or degradation in the intestine, quercetin is 
excreted as exhaled CO2 with smaller amounts found in feces and urine.25,34  
 
2.2    Study Disease and correlative studies background 
 
 


Phase II/III trial of antithrombotic activity of isoquercetin  
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The prothrombotic state associated with malignant disease has been a recognized entity since 
the 1800’s. Almost 1 in 5 cases of venous thromboembolism (VTE) are thought to be related to 
cancer, and thrombosis is the second leading cause of mortality in cancer populations.35 The 
risk of thrombosis attributed to the malignant state is not uniform across all histological 
diagnoses. There is a 10-fold greater rate of VTE among patients suffering from ovarian, brain, 
and pancreatic cancers compared to those with other histologies.36 Randomized clinical trials 
have demonstrated a small absolute risk reduction in VTE with primary thromboprophylaxis of 
low molecular weight heparins. The absolute risk of VTE in these unselected cohorts is low (3-
5%) and thus the benefit of daily injection and potential risk for bleeding has tempered 
enthusiasm for non-targeted thromboprophylaxis approaches.  Different models and 
biomarkers are under investigation to identify those patients who are highest risk of developing 
thrombosis and thus would benefit the most from primary thromboprophylaxis. Khorana and 
colleagues developed and validated a scoring model that identified higher risk patients based 
on elevated platelet count, white blood cell count, body-mass index, and anemia.37  
Pathologic changes in microparticle populations contribute to the hypercoagulability 
associated with various disease states, including malignancy. Microparticles are  vesicular 
structures measuring less than 1 µm in size and are derived from a number of cells within the 
vascular compartment including leukocytes, platelets, red blood cells, and endothelial cells.38 
Some microparticles are considered procoagulant due to the exposure of negatively charged 
phospholipids on the external membrane leaflet for the support of thrombin generation.39,40 
Subpopulations of microparticles also express tissue factor, the in vivo initiator of blood 
coagulation.41,42 Circulating tissue factor-bearing microparticles augment thrombus formation 
in animal models43 and tumor-derived microparticles accumulate at the site of vascular 
injury.44 Our group previously demonstrated that tissue factor bearing microparticles are 
elevated in cancer patients diagnosed with VTE and appear to be derived from the underlying 
tumor.45 The association between tissue factor bearing microparticles and VTE has been 
described by several groups as well, including in a mouse model of vascular injury.44,46 
Notably, in our study the 1 year cumulative incidence of thrombosis in cancer patients with 
increased tissue factor bearing microparticles was 34.8% versus 0% in those without detectable 
tissue factor bearing microparticles.45 We recently completed a randomized phase II trial of 
low molecular weight heparin to prevent thrombosis in cancer patients with elevated tissue 
factor bearing microparticles.47 The primary endpoint was the cumulative incidence of VTE at 
60 days, as defined by symptomatic VTE or asymptomatic proximal DVT diagnosed by 
protocol-mandated bilateral lower extremity ultrasound. The overall cumulative incidence of 
thrombosis across the study was 11.3% at 60 days. The cumulative incidence of thrombosis in 
the high tissue factor bearing microparticle patients was 27% (N=11) compared with 5% 
(N=23) in those treated with low molecular weight heparin (P=0.06). 
 
2.3   Rationale 
 
Despite the high incidence and morbidity associated with VTE in cancer patients, primary 
thromboprophylaxis is not routinely recommended by oncologists largely due to a modest 
absolute benefit in unselected cancer cohorts and the need for patients to self-administer a 
daily injection. We previously observed a cumulative incidence of VTE of 11.3% at 60 days in 
patients with advanced non-small lung cancer, pancreatic cancer, and colorectal cancer.47 


Phase II/III trial of antithrombotic activity of isoquercetin  
October 27, 2016 
 
 
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Protein disulfide isomerase released by platelets and endothelial cells regulates both platelet 
accumulation and fibrin generation in animal models. Quercetin and related glucosides were 
recently discovered to be potent inhibitors of extracellular PDI activity in vitro and in vivo.2 
Antithrombotic properties of quercetin have been described in humans and we observed that 
the oral administration of isoquercetin results in PDI-inhibitory activity in human plasma. 
Fortuitously, isoquercetin is widely available flavonoid nutritional supplement.  Based on the 
safety profile and evident antithrombotic properties of isoquercetin, we aim to evaluate 
isoquercetin as an anticoagulant in cancer patients in a combined phase II/III clinical trial.  
 
3 PARTICIPANT SELECTION 
 
Laboratory tests required for eligibility must be completed within 15 days prior to study 
entry 
 
3.1   Eligibility Criteria 
 
Participants must meet the following criteria on screening examination to be eligible to participate 
in phase 2 and 3 of the study: 
 
3.1.1   Participants must have histologically confirmed malignancy that is metastatic or 
currently unresectable. 
        Eligible malignancies include:  
• Adenocarcinoma of the pancreas (currently unresectable or metastatic) 
• Colorectal (stage IV) 
• Non-small cell lung cancer (currently unresectable stage III or stage IV) 
3.1.2   Receiving or scheduled to receive first or second line chemotherapy (within 30 days of 
registration) 
 
3.1.3   Minimum age 18 years. Because limited dosing or adverse event data are currently 
available on the use of isoquercetin in participants <18 years of age, children are 
excluded from this study but will be eligible for future pediatric isoquercetin trials. 
 
3.1.4   Life expectancy of greater than 4 months. 
 
3.1.5   ECOG performance status <2 (see Appendix B ). 
 
3.1.6   Patient must be able to swallow capsules (phase III only) 
  
3.1.7   Participants must have preserved organ and marrow function as defined below: 
 
 
Absolute neutrophil count > 1,000/mcL 


Phase II/III trial of antithrombotic activity of isoquercetin  
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Platelets > 90,000/mcL 
 
PT and PTT < 1.5 x institutional upper limit of normal 
 
Total bilirubin < 2.0 mg/dl 
 
AST (SGOT)/ALT (SGPT) < 2.5 X institutional upper limit of normal 
    Creatinine < 2.0 mg/dl 
 
3.1.8   The effects of isoquercetin on the developing human fetus are unknown. For this 
reason, women of child-bearing potential and men must agree to use adequate 
contraception (hormonal or barrier method of birth control; abstinence) prior to study 
entry and for the duration of study participation. Should a woman become pregnant or 
suspect she is pregnant while participating in this study, she should inform her 
treating physician immediately. 
 
 
 
 
3.1.9   Ability to understand and the willingness to sign a written informed consent 
document. 
 
3.2 
Exclusion Criteria 
 
Participants who exhibit any of the following conditions at screening will not be eligible for 
admission into phase 2 or 3 of the study. 
 
3.2.1  Participants may not be concurrently receiving any other study agents. 
 
3.2.2  Participants with known brain metastases should be excluded from this clinical trial 
because of their poor prognosis and because they often develop progressive 
neurologic dysfunction that would confound the evaluation of neurologic and other 
adverse events. 
 
3.2.3   Prior history of documented venous thromboembolic event within the last 2 years 
(excluding central line associated events whereby patients completed anticoagulation).  
 
3.2.4   Active bleeding or high risk for bleeding (e.g. known acute gastrointestinal ulcer) 
 
3.2.5   History of significant hemorrhage (requiring hospitalization or transfusion) outside of 
a surgical setting within the last 24 months 
 
3.2.6   Familial bleeding diathesis 
 
3.2.7   Known diagnosis of disseminated intravascular coagulation (DIC) 
3.2.8   Currently receiving anticoagulant therapy  


Phase II/III trial of antithrombotic activity of isoquercetin  
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3.2.9   Current daily use of aspirin (>81mg daily), Clopidogrel (Plavix), cilostazol (Pletal), 
aspirin-dipyridamole (Aggrenox) (within 10 days) or considered to use regular use of 
higher doses of non-steroidal anti-inflammatory agents as determined by the treating 
physician (e.g ibuprofen > 800 mg daily or equivalent). 
 
3.2.10 Uncontrolled intercurrent illness including, but not limited to ongoing or active 
infection, symptomatic congestive heart failure, unstable angina pectoris, 
cardiac arrhythmia, or psychiatric illness/social situations that would limit 
compliance with study requirements. 
 
3.2.11 Known intolerance of niacin or ascorbic acid (including known G6PD 
deficiency) 
 
3.2.12 Pregnant women are excluded from this study because isoquercetin is a PDI 
inhibitor with the potential for teratogenic or abortifacient effects. Because there is 
an unknown but potential risk of adverse events in nursing infants secondary to 
treatment of the mother with isoquercetin, breastfeeding should be discontinued if 
the mother is treated with isoquercetin. These potential risks may also apply to other 
agents used in this study. 
 
3.3 
    Inclusion of Women, Minorities and Other Underrepresented Populations 
 
The study is open to any individual who has an advanced malignancy without 
discrimination based on race or gender. We do not anticipate that inclusion or exclusion 
criteria will negatively affect recruitment or retention of underrepresented minorities.  


Phase II/III trial of antithrombotic activity of isoquercetin  
October 27, 2016 
 
 
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4 REGISTRATION PROCEDURES 
 
   
4.1  General Guidelines for DF/HCC and DF/PCC Institutions 
 
Institutions will register eligible participants with the DF/HCC Quality Assurance 
Office for Clinical Trials (QACT) central registration system. Registration must occur 
prior to the initiation of therapy. Any participant not registered to the protocol before 
treatment begins will be considered ineligible and registration will be denied.  
 
An investigator will confirm eligibility criteria and a member of the study team will 
complete the QACT protocol specific eligibility checklist. . 
  
Following registration, participants may begin protocol treatment. Issues that would 
cause treatment delays should be discussed with the Overall Principal Investigator (PI). 
If a participant does not receive protocol therapy following registration, the participant’s 
registration on the study may be cancelled. . Notify the QACT Registrar of registration 
cancellations as soon as possible. 
 
4.2  Registration Process for DF/HCC and DF/PCC Institutions 
 
DF/HCC Standard Operating Procedure for Human Subject Research Titled Subject 
Protocol Registration (SOP #: REGIST-101) must be followed.   
 
 
 
  
4.3     General Guidelines for Other Participating Institutions 
 
Eligible participants will be entered on study centrally at BIDMC by the Study 
Coordinator. All sites should call the Study Coordinator at 617-667-1939 to verify 
treatment availability and eligibility.  
 
Following registration, participants should begin protocol treatment within 72 hours 
or as soon as possible. Issues that would cause treatment delays should be discussed 
with the Principal Investigator. If a participant does not receive protocol therapy 
following registration, the participant’s protocol status must be changed. The Study 
Coordinator should be notified of participant status changes as soon as possible. 
 
4.4     Registration Process for Other Participating Institutions 
 
To register a participant, the following documents should be completed by the research 
nurse or data manager and faxed
 to 
the Study Team: 
• Copy of all eligibility and screening documents 
• Signed participant consent form 


Phase II/III trial of antithrombotic activity of isoquercetin  
October 27, 2016 
 
 
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• HIPAA authorization form (if applicable) 
• Eligibility Checklist 
 
The research nurse or data manager at the participating site will then call 
or 
e-mail 
 the Study Coordinator to verify eligibility.  To 
complete the registration process, the Coordinator will follow DF/HCC Standard Operating 
Procedure for Human Subject Research Titled Subject Protocol Registration (SOP #: 
REGIST-101) and register the participant on the protocol.  The coordinator will fax or e-
mail the participant study number, and if applicable the dose treatment level, to the 
participating site.  The coordinator will also call the research nurse or data manager at the 
participating site and verbally confirm registration 
 
 
 
 
5 TREATMENT PLAN  
 
Treatment will be administered on an outpatient basis. Expected toxicities and potential risks 
as well as dose modifications for isoquercetin are described in Section 6 (Expected Toxicities 
and Dosing Delays/Dose Modification).  
 
Phase 
Agent* 
Isoquercetin Dose 
Route 
Schedule 
Cycle 
Phase II 
Isoquercetin 
(IQC-
950AN) 
250mg  
Cohort A: 500 mg  
or  
Cohort B: 1000 mg 
Oral 
capsules 
Cohort A: 2 
capsules once 
daily 
Cohort B: 4 
capsules once 
daily 
28 
days 
Phase III 
Isoquercetin 
(IQC-
950AN) or 
Placebo 
Cohort C: TBD 
or 
Cohort D: Placebo 
Oral 
capsules 
Once daily 
(TBD) 
28 
days 
*All capsules (placebo and isoquercetin) include ascorbic acid 62 mg and niacin 5 mg. 
 
Phase II 
Cohort A: Patients will receive isoquercetin 500 mg once daily (2 capsules). Continued 
enrollment into the dosing cohort will be based on the safety evaluation of the initial 5 patients. 
If there are >1 grade 3 or 4 toxicity (possibly, probably or definitely related to isoquercetin), 
then decision to enroll an additional cohort of 25 patients will be based on DSMC 
recommendations. If there are >3 grade 3 or 4 adverse events (possibly, probably or definitely 
related to isoquercetin), decision to proceed with enrollment into cohort B will be based on 
recommendations of the DSMC.  
 
Cohort B: Patients will receive isoquercetin 1000 mg once daily (4 capsules). Similar to cohort 
A, continued enrollment will be based on the absence of attributable significant toxicities. 
 


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For both cohorts A and B, lower extremity ultrasound will be performed at end of treatment 
visit. Baseline D-dimer and correlative labs will be drawn at Day 1 and at end of treatment visit. 
Patients will be followed for survival after completion of end of treatment visit. 
 
Phase III 
Following the completion of the phase II portion, enrolled patients will be randomized 1:1 to 
Arm C (isoquercetin) or Arm D (placebo). The dose for Arm C will be determined after 
evaluation of the Phase II portion of the trial.  The protocol will be amended when the decision 
is made whether to proceed to Phase III and what dose to use for Arm C.  The study will be 
double-blinded to treatment arm. Lower extremity ultrasound will be performed at end of 
treatment. Baseline D-dimer and correlative labs will be drawn at Day 1 and at end of treatment. 
Patients will be followed for survival after completion of end of treatment assessment. 
 
At BIDMC, optional blood draw will be performed at time 0 and 4 hours following the first 
dose of study drug. Non-collection of the optional blood draw will be permitted if patients 
ultimately decide not to stay for the 4 hour collection.   
 
NOTE: all capsules also have ascorbic acid and niacin to improve stability and bioavailability 
of isoquercetin.  
 
5.1     Pre-treatment Criteria 
   
5.1.1  Cycle 1, Day 1 (see Appendix C for C1D1 checklist) 
• Laboratory assessments recorded within 15 days of signing consent may be 
used to determine eligibility and does not have to be repeated (except 
complete blood count) 
• Absolute neutrophil count > 1,000/mcL 
• Platelet count > 90, 000 /µl 
• Patients must be able to tolerate PO capsules (phase III only) 
5.1.2   Cycle 2, Day 1 (Day 29) (see Appendix C for C2 D1 checklist) 
• Adequate platelet count (see section 6.3)   
• Non-heme toxicities possibly related to isoquercetin must return to grade 
2 or less 
 
5.2 
Agent Administration  
 
5.2.1   Isoquercetin or placebo 
 
Depending on assigned Cohort during Phase II or randomization in Phase III 
each capsules will contain 250 mg isoquercetin versus placebo. Isoquercetin will 
be supplied as oral capsules. Capsules will be consumed once daily (2 or 4 
capsules depending on cohort designation). Dose modifications will not be 


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made. Capsules will be dispensed from the research pharmacy on C1D1 and 
again on C2D1.  The capsules will be packaged as a 30 day supply (to allow for 
unexpected occurrences such as dropped capsule).   
 
Capsules may be swallowed with or without food. The capsules can be opened 
and the contents mixed with a small portion of soft acidic food such as apple 
sauce, puree of carrots, or pumpkin puree (Phase II only).  Missed doses must be 
taken within four hours of scheduled dose.  If longer than four hours, or if dose 
vomited, skip dose.  Subjects will keep a drug diary that will be provided to 
them by the study team.  Subjects will be instructed to return any unused drug.  
The unused returns will be counted by pharmacy and destroyed on-site per 
policy.     
 
 
 
 
5.3    Duration of Therapy 
 
Duration of therapy will be 56 days (+/- 7 days inclusion of windows) or until one of 
the following criteria applies: 
 
• Intercurrent illness that prevents further administration of treatment, 
• Unacceptable adverse event(s), 
• Participant demonstrates an inability or unwillingness to comply with the oral 
medication regimen and/or documentation requirements 
• Participant decides to withdraw from the study, or general or specific changes 
in the participant's condition render the participant unacceptable for further 
treatment in the opinion of the treating investigator. 
• Grade 3 or 4 hemorrhage and/or 
Symptomatic bleeding in a critical area or organ such as intracranial, 
intraspinal, intraocular, retroperitoneal, intra-articular or pericardial, or 
intramuscular with compartment syndrome, and/or bleeding causing a fall in 
hemoglobin level >2 g/L or bleeding leading to a transfusion of > 2 units of 
packed red blood cells. 
• Proximal deep vein thrombosis or pulmonary embolism 
• Condition requiring therapeutic anticoagulation 
• Prophylactic heparin or low molecular weight heparin for greater than 7 
consecutive days 
 
 
5.4     Duration of Follow Up  
 
Following completion of treatment, only the cause and date of death will be 
recorded. Participants removed from study for unacceptable adverse events will be 
followed until resolution or stabilization of the adverse event. Participants removed from 
active treatment will be followed for survival.  


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5.5     Criteria for Removal from Study  
 
Participants will be removed from study when any of the criteria listed in Section 
5.3 applies. The reason for study removal and the date the participant was removed 
must be documented in the study-specific case report form (CRF). Alternative care 
options will be discussed with the participant. 
 
In the event of unusual or life-threatening complications, participating investigators 
must immediately notify the Principal Investigator, 
 at 
.  
 
6 EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS  
 
Dose delays and modifications will be made using the following recommendations. Toxicity 
assessments will be done using the CTEP latest Version of the NCI Common Terminology 
Criteria for Adverse Events (CTCAE) which is identified and located on the CTEP website at: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 
If possible, symptoms should be managed symptomatically. In the case of toxicity, 
appropriate medical treatment should be used (including anti-emetics, anti-diarrheals, etc.). 
 
All adverse events experienced by participants will be collected from the time of the first dose 
of study treatment, through the study and until the final study visit. Participants continuing to 
experience toxicity at the off study visit may be contacted for additional assessments until the 
toxicity has resolved or is deemed irreversible. 
  
 
6.1 
Anticipated Toxicities 
  
 
A list of the adverse events and potential risks associated with the agents administered in this 
study appear below and will determine whether dose delays and modifications will be made 
or whether the event requires expedited reporting in addition to routine reporting. 
 
A number of clinical trials have shown minimal to no adverse effects from oral quercetin (the 
parent compound of isoquercetin). In several studies conducted to investigate various 
potential effects of quercetin on immune function, risk factors for heart disease, or exercise-
induced oxidative stress among others, the ingestion of quercetin by healthy subjects (males 
and females, group sizes ranging from 11 to 63; mean ages for treatment and control groups 
ranged from 20 to 46 years) at a daily dose of 600 to 1000 mg/day for periods of 1 to 6 weeks 
was not associated with any reports of adverse effects48-52 A randomized, double-blind, 
placebo-controlled 12-week study was conducted in which subjects (male and female, ages 18 
to 85 years) were randomized to consume a placebo (n = 335) or 500 (n=334) or 1,000 
(n=333) mg of quercetin daily. There were no significant toxicities or metabolic changes 
between the groups.53 
 


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Intravenous administration of quercetin can be associated with nephrotoxicity.  Doses up to 
11.4 mg/kg body weight (equivalent of 694 mg in a 60 kg patient) were associated with 
transient flushing and mild pain at the injection site54. At the higher dose levels of up to 54.1 
mg/kg body weight (equivalent to 10,000 mg orally), grade 1-4 nephrotoxicity was described, 
as well as dyspnea and emesis.   
 
Despite the potential antithrombotic activity of quercetin and flavonoids, hemorrhage has not 
been described as a toxicity in clinical studies. 
 
The supplied capsules contain ascorbic acid (62 mg) and niacin (5 mg) to prevent oxidation 
and improve absorption of isoquercetin. The recommended daily allowance of niacin is 
between 14 and 16 mg. Higher doses of niacin (between 300 mg and 6000 mg daily) are 
prescribed for hyperlipidemia and can be associated with flushing as well as other side effects 
such as hepatotoxicity. At physiologic dosing, side effects attributable to niacin would be 
unexpected. Similarly, ascorbic acid supplementation is not associated with significant 
toxicity. There are case reports of hemolytic anemia in patients with G6PD deficiency 
receiving extreme doses (several grams) of ascorbic acid. 
 
6.1.1 Adverse Event Lists(s) for Isoquercetin (with ascorbic acid and niacin) 
 
Mild hypotension (decrease in systolic blood pressure of less than 10mmHg) 
Mild nausea or diarrhea 
Hemolysis (rare)  
Hemorrhage 
Headache 
 
 
6.2 
Toxicity Management 
 
 
Hemorrhage  
• No modification: CTCAE grade 1 
• HOLD: CTCAE grade 2 hemorrhage 
Hold isoquercetin until resolution of grade 2 hemorrhage. The maximum number 
of consecutive days that isoquercetin can be held is 10 days before the participant 
must be taken off study.  A participant may only hold isoquercetin for one ten day 
period.  If a second grade 2 hemorrhage develops the participant must be taken off 
study.   
 
• Discontinue: CTCAE grade 3-4 hemorrhage or otherwise meets criteria for 
major hemorrhage  such as requiring transfusion 2 units PRBC, postoperative 
interventional radiology, endoscopic or operative intervention or life 


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15 
threatening consequences including spontaneous bleeding at critical site 
(intracranial, pericardial, retroperitoneal, intraocular, intraspinal)  
 
In cases of suspected isoquercetin toxicity (non-hematologic only): 
•Grade 2: if toxicity is tolerable to patient, maintain at same dose. If toxicity is intolerable 
to the patient, then interrupt quercetin until recovery to grade <1 
•Grade 3 : interrupt until grade <1 
•Grade 4 : discontinue isoquercetin 
 
6.3 
Dose Modifications/Delays 
  
For non-hematologic toxicity, see section 6.2 for dose delays.  
 
For thrombocytopenia: Grade 3 (platelet count <50,000 /mcl). Hold study drug until grade 2. 
The maximum amount of time that the study drug can be held without withdrawing the 
participant from the study is 10 days.  
 
7 DRUG FORMULATION AND ADMINISTRATION  
 
7.1 
Isoquercetin 
 
7.1.1  Description 
 
Isoquercetin, a glucoside form of quercetin, is a naturally occurring flavonol 
belonging to a broad group of pigmented substances of plant origin known as 
flavonoids. Flavonoids are a group of polyphenols characterized by a phenyl 
benzo(γ)pyrone-derived structure, consisting of 2 benzene rings, linked by a 
heterocyclic pyran or pyrone ring. The chemical name is: 2-(3,4-
dihydroxyphenyl)-3,5,7-trihydroxy-4H-1-benzopyran-4-one. The molecular 
formula is C21H20O12 and a molar mass of 464.38 g/mol. It is also known as 
quercetin-3-O-glucoside CAS Number is 482-35-9. 
 
Isoquercetin undergoes deglycosylation by an extracellular β-glycosidase on the 
brush border of enterocytes yielding the aglycone.24,25 Although the absorption of 
the related quercetin compounds may differ, all forms of quercetin are metabolized 
in the enterocyte and liver and circulate as similar glucuronated, sulfated, and 
methylated conjugates.26-28 These conjugates have demonstrated biologic 
activity2,29,30. The pharmacokinetic study we conducted in healthy adults 
(isoquercetin 500mg chews), resulted in a median peak concentration of 3.5 µM 
and T ½ of 9 hours. Following metabolism in the liver and/or degradation in the 
intestine, quercetin is principally excreted as exhaled CO2 with much smaller 
amounts found in feces and urine.25,34  
 


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There is limited data regarding cytochrome interactions and isoquercetin (see 
Investigators Brochure for additional details). The data is inconsistent data 
regarding the interaction of quercetin and metabolism of drugs by cytochrome 
CYP3A4. The AUC of nifedipine was not altered when co-administered with 
quercetin nor was the bioavailability of the saquinavir affected (both metabolized 
by CYP3A4). However, there is some evidence that cyclosporin levels can 
increase following quercetin administration.1 Pharmacokinetic profiles of drugs 
metabolized by other cytochromes (e.g. CYP2C9, CYP2C8) such as warfarin and 
rosiglitazone do not appear to be influenced by quercetin co-administration.  
Quercetin does not affect P-gp-mediated efflux as reflected by lack of effect on 
digoxin pharmacokinetics.1 
 
7.1.2  Form 
 
Isoquercetin occurs as a greenish-yellow, crystalline solid that is purified from 
plant sources (>99.5% purity) formulated into immediate release HPMC dark green 
capsules (size 0). 
 
Both placebo and isoquercetin capsules contain the following: ascorbic acid 
(62mg), niacin (5mg), magnesium stearate (5mg), colloidal silicon dioxide.  The 
capsules are manufactured and supplied by Pharmavize N.V. Isoquercetin capsules 
will contain 250 mg isoquercetin.  
 
 
7.1.3  Storage and Stability 
 
The isoquercetin and placebo capsules are packaged into high density 
polyethelene bottles and should be kept at room temperature. Stability studies 
have demonstrated that isoquercetin capsules are stable for at least 2 months and 
longer term stability studies are ongoing (packaging will be updated 
accordingly).  
 
7.1.4  Compatibility 
 
No specific compatibility issues 
7.1.5  Handling 
 
No specific measures necessary 
 
7.1.6  Availability 
 
Isoquercetin is commercially available but will be supplied free-of-charge from 
Pharmavize (as will placebo) as a 30 day supply distributed on C1D1 and C2D1 
by the local research pharmacy. 
 


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7.1.7  Preparation 
No specific preparation required.  
  
7.1.8  Administration 
 
Subjects will consume either 2 or 4 capsules daily (depending on cohort 
allocation). Capsules should be separated by approximately 24 hours.  
 
7.1.9  Ordering 
For shipment of isoquercetin, participating sites will contact: 
 
 
 
 
 
 
Isoquercetin will be sent directly to the participating hospital pharmacy for 
disbursement.  
 
7.1.10 Accountability 
 
The investigator, or a responsible party designated by the investigator, must 
maintain a careful record of the inventory and disposition of the agent 
(investigational or free of charge) using the NCI Drug Accountability Record or 
another comparable drug accountability form. (See the CTEP website at 
http://ctep.cancer.gov/protocolDevelopment  for the “Policy and Guidelines for  
Accountability and Storage of Investigational Agents” or to obtain a copy of the 
drug accountability form.)  Participants will record compliance with study 
treatment in a drug diary that will be provided to them.  The drug diary will be 
collected and re-dispensed at each study visit. 
 
7.1.11 Destruction and Return 
 
At the end of the study, unused supplies of isoquercetin should be destroyed 
according to institutional policies. Destruction will be documented in the Drug 
Accountability Record Form. 
 
8 CORRELATIVE/SPECIAL STUDIES  
8.1 Pharmacodynamic and Correlative Studies 
A total of 10 ml of blood will be drawn into blue top tubes (3.2% citrate) in either two 
5ml tubes or one 15ml tube.  


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Plasma will be separated at 2100 x G for 20 minutes. First centrifugation should be 
performed within 1 hour of specimen collection. The plasma layer will be centrifuged 
a second time at 2100 x G x 20 minutes in a single tube. The plasma supernatant will be 
transferred to a clean tube leaving the 1ml at the bottom of the tube undisturbed (to be 
discarded). The transferred plasma sample will be aliquoted (500µl) into 1.5ml 
eppendorf tubes.  
Tubes may be stored locally at -80oC and batch shipped on dry ice to CAT IQ 
Study Team
 
  
(BIDMC only) Optional blood draws include an additional 10ml drawn into citrated 
tubes for platelet aggregometry at time 0 and 4 hours. Tubes will be kept at room 
temperature for analysis in the Flaumenhaft laboratory. (see below) 
Correlative Studies: 
• Tissue factor bearing microparticles (TFMP) will be measured by impedance 
based flow cytometry in triplicate using internal positive controls. A 
determination of “high” TFMP is based on concentration greater than two-thirds 
of samples previously collected from patients with advanced cancer (highest 
tercile of cancer standards). Plasma samples will be stored at -80oC for up to 5 
years following the completion of the study. Additional testing for thrombosis risk 
factors or laboratory markers of coagulation activation may be performed on these 
stored samples.  (See Appendix E for specimen collection and shipping report) 
• Plasma PDI-inhibitory activity: The plasma PDI-inhibitory activity will be 
measured using a modified DiEGSSG assay.55 The exposure of the 
DiEGSSG probe to exogenous PDI and plasma results in increased 
fluorescence measured spectrophotometrically and can be used to detect 
the presence of PDI inhibitor activity. 
• D-dimer will be performed in a research laboratory using a commercially 
available ELISA (Roche Diagnostics). 
• Coagulation substrates of PDI. The physiological basis for anticoagulant 
activity of PDI inhibition continues to be investigated. Proposed 
mechanisms include altered activity of coagulation factors or inhibitors 
such as tissue factor or antithrombin. The functional activity of proposed 
coagulation substrates will be assessed on stored plasma (pending 
additional funding).  
• Platelet aggregometry (BIDMC only) will be performed by standard 
methodology to assess effect of PDI inhibition on platelet activity at 
baseline and 4 hours after study drug administration.  
 


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9 STUDY CALENDAR 
 
Baseline evaluations are to be conducted within 15 days prior to start of protocol therapy.  
All assessments must be performed prior to administration of any study medication. 
All study assessments and medications should be administered within + 7 days of the 
protocol-specified date, unless otherwise noted.


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Event/Procedure 
Screening/ 
Pre-
treatment 
visit 
Day 1 
(C1D1) 
Day 29  
(C2D1) 
Day 56 or 
End of 
Study 
Treatment 
Survival 
Assessment 
Day Range 
-15 to 0 
 
+ 2 days 
+ 5 days 
Q6 months 
History Assessments 
X 
 
 
 
 
Informed Consent 
X 
 
 
 
 
Inclusion/Exclusion 
Criteria 
X 
 
 
 
 
Medical History 
X 
 
X 
X 
 
ECOG Performance 
Status Score 
X 
 
X 
X 
 
Concomitant 
medication review 
X 
 
X 
X 
 
Treatment allocation6 
X 
 
 
 
 
Dispense study drug 
 
X 
X 
 
 
Drug Diary Collection3 
 
 
X 
X 
 
Safety Assessments 
 
 
 
 
 
Physical examination 
including vital signs  
X 
 
X 
X 
 
Height and Weight 
X 
 
 
 
 
AE/SAE assessment 
X 
 
X 
X 
 
Assessment of signs 
and symptoms of VTE 
and bleeding 
X 
 
X 
X 
 
Laboratory Tests 
 
 
 
 
 
Complete blood count 
with diff 
X 
X 
X 
X 
 
PT/PTT 
X 
 
 
 
 
Creatinine 
X 
 
X 
 
 
AST/ALT 
X 
 
X 
 
 
Total bilirubin 
X 
 
 
 
 
Urine HCG4 
X 
 
 
 
 
Correlative plasma 
samples (all sites)1 
 
X 
 
X 
 
Correlative plasma 
samples (BIDMC only) 
 
X5 
 
X 
 
Imaging 
 
 
 
 
 
Bilateral lower 
extremity ultrasound 
 
 
 
X 
 
Quality of Life Survey2 
 
X 
 
X 
 


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1Correlative lab instructions (TFMP) provided in Appendix E 
2QOL survey provided in Appendix D 
3Drug Diary  
4If applicable 
5Optional correlative labs to be drawn at time 0 and 4 hours (see section 7.1) 
6Phase II treatment allocation is by sequential dosing cohort, Phase III allocation is by randomization


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10 MEASUREMENT OF EFFECT  
 
10.1    Venous Thromboembolism (VTE) 
 
Cumulative incidence of venous thromboembolic events at 56 days (+/- 7 day windows) is 
the primary endpoint. The composite endpoint includes any symptomatic proximal or 
distal lower extremity DVT, symptomatic pulmonary embolism or fatal PE diagnosed by 
autopsy, asymptomatic proximal DVT diagnosed by screening compression ultrasound. 
All other venous or arterial events will be recorded and analyzed as secondary endpoints. 
 
Patients presenting with symptoms compatible with DVT and/or PE will undergo 
radiographic imaging with either compression ultrasound, VQ lung scan, or spiral CT. 
Confirmed episodes of VTE will be managed by the treating physician per standard of 
practice.  
 
Presence of any of the following will be considered diagnostic for a VTE: 
• New non-compressibility of lower extremity deep venous segments by compression 
ultrasound. Distal lower extremity thrombus (lower than popliteal vein) qualifies for 
primary VTE endpoint only if symptomatic. All proximal thrombi qualify as primary 
study endpoint if identified by screening ultrasound or are symptomatic.  
• Intraluminal defects in two or more views on pulmonary angiography 
• Sudden contrast cut-off of one or more vessels greater than 2.5 mm in diameter on a 
pulmonary angiogram 
• A high probability VQ lung scan showing one or more segmental perfusion defects 
with corresponding normal ventilation (mismatch defect) 
• Abnormal spiral CT showing thrombus in pulmonary vessels (subsegmental or larger)  
Note: intrabdominal thrombus related to tumor compression is not considered a VTE 
endpoint 
 
Other VTE 
Those VTE that do not qualify for the primary endpoint such as asymptomatic 
distal extremity deep vein thrombosis, asymptomatic pulmonary emboli diagnosed 
by CT, central line-associated thrombus will be recorded and analysed as 
secondary endpoints.  
Response Review 
An independent adjudication of VTE qualifying for the primary outcome will be 
performed. The review committee will be comprised of two independent hematologists 
and a radiologist. The committee will review the medical records and radiology report for 
all VTE that qualify for the primary VTE endpoint. In cases where committee feels that 
the radiology reports or medical records are equivocal then the primary radiology images 
will be reviewed by an independent radiologist for adjudication. 
 


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10.2    Major Hemorrhage 
 
Adhering to published guidelines, the criteria of major hemorrhage in non-surgical patients 
is:56 
• Fatal bleeding, and/or 
• Symptomatic bleeding in a critical area or organ such as intracranial, intraspinal, 
intraocular, retroperitoneal, intra-articular or pericardial, or intramuscular with 
compartment syndrome, and/or 
• Bleeding causing a fall in hemoglobin level >2 g/L or 
• Bleeding leading to a transfusion of > 2 units of packed red blood cells.   
10.3    D-dimer 
 
D-dimer will be measured at Beth Israel Deaconess Medical Center at baseline and end of 
treatment . Relative change in D-dimer will be assessed for each arm. 
10.4    TFMP levels and thrombotic risk 
Absolute TFMP levels will be measured at baseline and 56 days. A correlation between 
TFMP and thrombotic risk will be investigated according to randomization arm (see Section 
13.2). 
 
10.5    Quality of Life 
 
Quality of Life (QOL) will be assesses using EORTC QLQ-30 which is an internationally 
validated and widely utilized questionnaire (Appendix D).57 Scoring is based on responses 
to 30 questions dealing with functional quality (such as cognitive, physical, and emotional) 
as well as symptom burden (such as fatigue, nausea, and sleep).  The questionnaire will be 
completed at baseline visit and at the end of study assessment.  For non-English speaking 
participants, the questionnaire will be completed with a translator.  
 
10.6    Overall Survival  
 Will be recorded every 6 months.  
10.7    Definitions 
Evaluable for toxicity. All participants who receive at least one dose of study treatment 
will be evaluable for toxicity from the time of their first treatment. 
Evaluable for VTE and D-dimer endpoints. Only those participants who undergo an 
evaluation for VTE after day 1 (either diagnosed with VTE) or completed at least 1 
cycle of treatment (along with requisite off treatment evaluation) will be considered 
evaluable for VTE and D-dimer endpoints.  


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11   ADVERSE EVENT REPORTING REQUIREMENTS 
11.1 Definitions 
11.1.1 Adverse Event (AE) 
 
An adverse event (AE) is any undesirable sign, symptom or medical condition 
or experience that develops or worsens in severity after starting the first dose of 
study treatment or any procedure specified in the protocol, even if the event is 
not considered to be related to the study.  
 
Abnormal laboratory values or diagnostic test results constitute adverse events 
only if they induce clinical signs or symptoms or require treatment or further 
diagnostic tests.  
11.1.2 Serious adverse event (SAE) 
 
A serious adverse event (SAE) is any adverse event, occurring at any dose and 
regardless of causality that:  
• Results in death 
• Is life-threatening. Life-threatening means that the person was at immediate 
risk of death from the reaction as it occurred, i.e., it does not include a 
reaction which hypothetically might have caused death had it occurred in a 
more severe form. 
• Requires or prolongs inpatient hospitalization (i.e., the event required at 
least a 24-hour hospitalization or prolonged a hospitalization beyond the 
expected length of stay). Hospitalizations will not be considered SAEs 
unless they meet the criteria specified in the table in Section 11.3.2: 
DF/HCC Reportable AEs. Hospitalization admissions and/or surgical 
operations scheduled to occur during the study period, but planned prior to 
study entry are not considered SAEs if the illness or disease existed before 
the person was enrolled in the trial, provided that it did not deteriorate in an 
unexpected manner during the trial (e.g., surgery performed earlier than 
planned). 
• Results in persistent or significant disability/incapacity. Disability is 
defined as a substantial disruption of a person’s ability to conduct normal 
life functions. 
• Is a congenital anomaly or birth defect; or 
• Is an important medical event when, based upon appropriate medical 
judgment, it may jeopardize the participant and require medical or surgical 
intervention to prevent one of the outcomes listed above. Examples of such 
medical events include allergic bronchospasm requiring intensive treatment 
in an emergency room or at home; blood dyscrasias or convulsions that do 


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not result in inpatient hospitalization, or the development of drug 
dependency or drug abuse. 
 
Events not considered to be serious adverse events are hospitalizations for: 
routine treatment or monitoring of the studied indication, not associated with any 
deterioration in condition, or for elective procedures elective or pre-planned 
treatment for a pre-existing condition that did not worsen. Emergency outpatient 
treatment for an event not fulfilling the serious criteria outlined above and not 
resulting in inpatient admission respite care. 
 
11.1.3 Expectedness 
 
Adverse events can be 'Expected' or 'Unexpected.'  
11.1.4 Expected adverse event 
 
Expected adverse events are those that have been previously identified as resulting 
from administration of the agent. For the purposes of this study, an adverse event 
is considered expected when it appears in the current adverse event list or is 
included in the informed consent document as a potential risk.   
 
Refer to Section 6.1 for a listing of expected adverse events associated with the 
study agent(s). 
11.1.5 Unexpected adverse event 
 
 
For the purposes of this study, an adverse event is considered unexpected when it 
varies in nature, intensity or frequency from information provided in the current 
adverse event list or when it is not included in the informed consent document as a 
potential risk.   
11.1.6 Attribution 
 
Attribution is the relationship between an adverse event or serious adverse event 
and the study treatment. Attribution will be assigned as follows: 
 
• Definite – The AE is clearly related to the study treatment. 
• Probable – The AE is likely related to the study treatment. 
• Possible – The AE may be related to the study treatment.  
• Unlikely - The AE is doubtfully related to the study treatment. 
• Unrelated - The AE is clearly NOT related to the study treatment. 
11.2 Procedures for AE and SAE Recording and Reporting 
 


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26 
Participating investigators will assess the occurrence of AEs and SAEs at all participant 
evaluation time points during the study.  
 
All AEs and SAEs whether reported by the participant, discovered during questioning, 
directly observed, or detected by physical examination, laboratory test or other means, 
will be recorded in the participant’s medical record and on the appropriate study-specific 
case report forms.  
 
The descriptions and grading scales found in the revised NCI Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.03 will be utilized for AE reporting. All 
appropriate treatment areas should have access to a copy of the CTCAE version 4.03. 
A copy of the CTCAE version 4.03 can be downloaded from the CTEP website at: 
 
 http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 
11.3 Adverse Events: List and Reporting Requirements 
 
11.3.1 Expedited Adverse Event Reporting  
 
 
Investigators must report to the Overall PI any serious adverse event (SAE) that 
occurs after the initial dose of study treatment, during treatment, or within 30 days 
of the last dose of treatment on the local institutional SAE form.  
 
For multi-institution studies where a DF/HCC investigator is serving as the Overall 
Principal Investigator, each participating institution must abide by the reporting 
requirements set by the DF/HCC. This applies to any medical event equivalent to 
an unexpected grade 2 or 3 with a possible, probable or definite attribution, 
unexpected grade 4 toxicities, and grade 5 (death) regardless of study phase or 
attribution. 
 
11.3.2 DF/HCC Expedited Reporting Guidelines 
 
Investigative sites within DF/HCC and DF/PCC will report SAEs directly to the         
DFCI Office for Human Research Studies (OHRS) per the DFCI IRB reporting 
policy.  
 
 
Other investigative sites will report SAEs to their respective IRB according to the 
local IRB’s policies and procedures in reporting adverse events. A copy of the 
submitted institutional SAE form should be forwarded to the Overall PI within the 
timeframes detailed in the table below.   


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27 
 
 
 
 
 
 
 
 
 
 
 
Attribution 
DF/HCC Reportable AEs 
Gr. 2 & 3 AE 
Expected 
Gr. 2 & 3 AE 
Unexpected 
Gr. 4 AE Expected 
Gr. 4 AE 
Unexpected 
Gr. 5 AE 
Expected or 
Unexpected 
Unrelated 
Unlikely 
Not required 
Not required 
5 calendar days# 
5 calendar days 
24 business 
hours* 
Possible 
Probable 
Definite 
 
Not required 
 
5 calendar days 
 
5 calendar days# 
 
5 calendar days 
 
24 business 
hours* 
# If listed in protocol as expected and not requiring expedited reporting, event does not need to be reported. 
 
* For participants enrolled and actively participating in the study or for AEs occurring within 30 days of the last 
intervention, the AE should be reported within 24 business hours of learning of the event. 
 
 
The Overall PI will submit SAE reports from outside institutions to the DFCI OHRS 
according to DFCI IRB policies and procedures in reporting adverse events.  
 
 
.  
11.4 Reporting to the Study Sponsor 
11.4.1 Serious Adverse Event Reporting 
 
All serious adverse events that occur after the initial dose of study treatment, 
during treatment, or within 30 days of the last dose of treatment must be reported 
to the DF/HCC Overall Principal Investigator on the local institutional SAE form. 
This includes events meeting the criteria outlined in Section 10.1.2, as well as the 
following: 
 
• Grade 2 (moderate) and Grade 3 (severe) Events – Only events that are 
unexpected and possibly, probably or definitely related/associated with the 
intervention. 
 
• All Grade 4 (life-threatening or disabling) Events – Unless expected AND 
specifically listed in the protocol as not requiring reporting. 
 


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28 
• All Grade 5 (fatal) Events – When the participant is enrolled and actively 
participating in the trial OR when the event occurs within 30 days of the 
last study intervention.  
 
Note: If the participant is in long term follow up, report the death at the time of 
continuing review.  
 
Participating investigators must report each serious adverse event to the DF/HCC 
Overall Principal Investigator within 1 business day of learning of the occurrence. 
In the event that the participating investigator does not become aware of the 
serious adverse event immediately (e.g., participant sought treatment elsewhere), 
the participating investigator is to report the event within 24 hours after learning of 
it and document the time of his or her first awareness of the adverse event.  In the 
case of a medical emergency which may require unblinding, contact the Overall 
Principal Investigator.  Report serious adverse events by telephone, email or 
facsimile to: 
 
 
 
 
 
 
 
 
Within the following 24-48 hours, the participating investigator must provide 
follow-up information on the serious adverse event. Follow-up information should 
describe whether the event has resolved or continues, if and how the event was 
treated, and whether the participant will continue or discontinue study 
participation. 
11.4.2 Non-Serious Adverse Event Reporting  
 
Non-serious adverse events will be reported to the DF/HCC Overall Principal 
Investigator on the toxicity Case Report Forms.   
11.5 Reporting to the Institutional Review Board (IRB) 
 
Investigative sites within DF/HCC will report all serious adverse events directly to the 
DFCI Office for Human Research Studies (OHRS). 
 
Other investigative sites should report serious adverse events to their respective IRB 
according to the local IRB’s policies and procedures in reporting adverse events. A copy 
of the submitted institutional SAE form should be forwarded to: 
 
 
 
 
 


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The DF/HCC Principal Investigator will submit SAE reports from outside institutions to 
the DFCI Office for Human Research Studies (OHRS) according to DFCI IRB policies 
and procedures in reporting adverse events.  
11.6 Reporting to the Food and Drug Administration (FDA) 
 
 
The DF/HCC Overall Principal Investigator, as holder of the IND, will be responsible 
for all communication with the FDA. The DF/HCC Overall Principal Investigator will 
report to the FDA, regardless of the site of occurrence, any adverse event that is serious, 
unexpected and reasonably related (i.e., possible, probable, definite) to the study 
treatment. 
 
Unexpected fatal or life-threatening experiences associated with the use of the study 
treatment will be reported to FDA as soon as possible but in no event later than 7 
calendar days after initial receipt of the information. 
 
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. 
 
  
Events will be reported to the FDA by telephone (1-800-FDA-1088) or by fax (1-800-
FDA-0178) using Form FDA 3500A (Mandatory Reporting Form for investigational 
agents) or FDA Form 3500 (Voluntary Reporting Form for commercial agents). Forms 
are available at http://www.fda.gov/medwatch/getforms.htm.  
11.7 Reporting to National Heart Lung and Blood Institute 
The DF/HCC Overall Principal Investigator will report unanticipated problems or 
unexpected serious adverse events (fatal, life threatening or serious) that may be related 
to the study protocol to the NHLBI Program Officer within 7 days. If the event or 
problem is unexpected, and possibly/probably/or definitely related to the study drug and 
suggests greater risk of harm to the study participant(s) than was previously known or 
recognized will be reported within 30 calendar days.  
 
11.8 Reporting to Hospital Risk Management 
 
Participating investigators will report to their local Risk Management office any subject 
safety reports or sentinel events that require reporting according to institutional policy. 
11.9 Monitoring of Adverse Events and Period of Observation 
 
All adverse events, both serious and non-serious, and deaths that are encountered from 
initiation of study intervention, throughout the study, and within 30 days of the last 
study intervention should be followed to their resolution, or until the participating 


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30 
investigator assesses them as stable, or the participating investigator determines the 
event to be irreversible, or the participant is lost to follow-up. The presence and 
resolution of AEs and SAEs (with dates) should be documented on the appropriate case 
report form and recorded in the participant’s medical record to facilitate source data 
verification.  
 
For some SAEs, the study sponsor or designee may follow-up by telephone, fax, and/or 
monitoring visit to obtain additional case details deemed necessary to appropriately 
evaluate the SAE report (e.g., hospital discharge summary, consultant report, or autopsy 
report).  
 
Participants should be instructed to report any serious post-study event(s) that might 
reasonably be related to participation in this study. Participating investigators should 
notify the DF/HCC Overall Principal Investigator and their respective IRB of any 
unanticipated death or adverse event occurring after a participant has discontinued or 
terminated study participation that may reasonably be related to the study.   
 
12    DATA AND SAFETY MONITORING 
 
12.1 Data Reporting 
12.1.1 Method  
The QACT will collect, manage, and monitor data for this study.  
12.1.2 Data Submission  
The schedule for completion and submission of case report forms (paper or 
electronic) to the QACT is as follows: 
 
Form 
Submission Timeline 
Eligibility Checklist 
Complete prior to registration with QACT 
On Study Form 
Within 14 days of registration 
Baseline Assessment Form 
Within 14 days of registration 
Treatment Form 
Within 10 days of the last day of the cycle 
Adverse Event Report Form 
Within 10 days of the last day of the cycle 
Response Assessment Form 
Within 10 days of the completion of the cycle 
required for response evaluation 


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Off Treatment/Off Study Form Within 14 days of completing treatment or 
being taken off study for any reason 
Follow up/Survival Form 
Within 14 days of the protocol defined follow 
up visit date or call 
 
12.2 Safety Meetings 
 
During the phase II portion of the study, the DF/HCC Data and Safety Monitoring 
Committee (DSMC) will review and monitor toxicity and accrual data from this study. The 
committee is composed of clinical specialists with experience in oncology and who have 
no direct relationship with the study. Information that raises any questions about 
participant safety will be addressed with the Overall PI and study team. 
 
The DSMC will review each protocol up to four times a year or more often if required to 
review toxicity and accrual data. Information to be provided to the committee may include: 
up-to-date participant accrual; current dose level information; DLT information; all grade 
2 or higher unexpected adverse events that have been reported; summary of all deaths 
occurring with 30 days of intervention for Phase I or II protocols; for gene therapy 
protocols, summary of all deaths while being treated and during active follow-up; any 
response information; audit results, and a summary provided by the study team. Other 
information (e.g. scans, laboratory values) will be provided upon request. 
 
The DF/HCC Data and Safety Monitoring Board (DSMB) will review and monitor study 
progress, toxicity, safety and other data from this trial during the Phase III portion of the 
study. The board is chaired by a medical oncologist from outside of DF/HCC and has 
external and internal representation. Information that raises any questions about 
participant safety or protocol performance will be addressed with the Principal 
Investigator, statistician and study team members.  Should any major concerns arise, the 
DSMB will offer recommendations regarding whether or not to suspend the trial. 
 
The DSMB will meet twice a year to review accrual, toxicity, response and reporting 
information. A DSMB review will also be triggered if the number of toxicity events 
(possible or definite grade 3 or 4 toxicity or major hemorrhage) prompts an automatic 
enrollment hold within either cohort or prior the next dosing cohort. Information to be 
provided to the DSMB may include: participant accrual, treatment regimen information, 
adverse events and serious adverse events reported by category, summary of any deaths 
on study, audit results, and a summary provided by the study team. Other information 
(e.g. scans, laboratory values) will be provided upon request.  
12.3 Monitoring  
 
Involvement in this study as a participating investigator implies acceptance of potential 
audits or inspections, including source data verification, by representatives designated 
by the DF/HCC Overall Principal Investigator (or Protocol Chair) or DF/HCC. The 


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32 
purpose of these audits or inspections is to examine study-related activities and 
documents to determine whether these activities were conducted and data were 
recorded, analyzed, and accurately reported in accordance with the protocol, 
institutional policy, and any applicable regulatory requirements.  
 
All data will be monitored for timeliness of submission, completeness, and adherence 
to protocol requirements. Monitoring will begin at the time of participant registration 
and will continue during protocol performance and completion.  Refer to section 5 of 
Data Safety and Monitoring Plan for additional information regarding monitoring plan.  
 
13 REGULATORY CONSIDERATIONS 
 
13.1 Protocol Review and Amendments 
This protocol, the proposed informed consent and all forms of participant information 
related to the study (e.g., advertisements used to recruit participants) and any other 
necessary documents must be submitted, reviewed and approved by a properly 
constituted IRB governing each study location.  
Any changes made to the protocol must be submitted as amendments and must be 
approved by the IRB prior to implementation. Any changes in study conduct must be 
reported to the IRB. The DF/HCC Overall Principal Investigator (or Protocol Chair) 
will disseminate protocol amendment information to all participating investigators.  
All decisions of the IRB concerning the conduct of the study must be made in 
writing. 
13.2 Informed Consent 
 
All participants must be provided a consent form describing this study and 
providing sufficient information for participants to make an informed decision 
about their participation in this study. The formal consent of a participant, using 
the IRB approved consent form, must be obtained before the participant is 
involved in any study-related procedure. The consent form must be signed and 
dated by the participant or the participant’s legally authorized representative, and 
by the person obtaining the consent. The participant must be given a copy of the 
signed and dated consent document. The original signed copy of the consent 
document must be retained in the medical record or research file.  
  
13.3 Study Documentation 
 
The investigator must prepare and maintain adequate and accurate case histories 
designed to record all observations and other data pertinent to the study for each 


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research participant. This information enables the study to be fully documented and the 
study data to be subsequently verified. 
 
Original source documents supporting entries in the case report forms include but are 
not limited to hospital records, clinical charts, laboratory and pharmacy records, 
recorded data from automated instruments, microfiches, photographic negatives, 
microfilm or magnetic media, and/or x-rays.  
13.4 Records Retention 
 
All study-related documents must be retained for the maximum period required by 
applicable federal regulations and guidelines or institutional policies.  


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13.5 Multi-center Guidelines 
This protocol will adhere to the policies and requirements of the Dana-
Farber/Harvard Cancer Center. The specific responsibilities of the DF/HCC 
Overall Principal Investigator (or Protocol Chair), Coordinating Center, and 
Participating Institutions are presented in the Dana-Farber/Harvard Cancer Center 
Multi-Center Data and Safety Monitoring Plan (see Appendix A). 
• The DF/HCC Overall Principal Investigator/Coordinating Center is responsible 
for distributing all IND Action Letters or Safety Reports to all participating 
institutions for submission to their individual IRBs for action as required. 
• Mechanisms will be in place to ensure quality assurance, protocol compliance, 
and adverse event reporting at each site.  
• Except in very unusual circumstances, each participating institution will order the 
agent(s) directly from the supplier. A participating site may order the agent(s) 
only after the initial IRB approval for the site has been forwarded to the 
Coordinating Center.  
 
14   STATISTICAL CONSIDERATIONS 
The aim of this combined phase II/phase III trial is to evaluate isoquercetin as an effective 
anticoagulant in cancer patients.  
14.1 Study Design/Endpoints 
14.1.1 The primary endpoint of the Phase II trial is to investigate whether isoquercetin 
significantly reduces d-dimer values in cancer patients. D-dimer is a readily 
available biomarker used clinically in the prediction and diagnosis of VTE. In cancer 
cohorts, the D-dimer has modest specificity for predicting symptomatic 
thrombosis.58 However, D-dimer remains the most validated surrogate marker of 
thrombin generation in vivo and symptomatic VTE.   
14.1.1.1 Study Design: The trial is a sequential cohort study of isoquercetin 500 
mg and 1000 mg daily.       
 
 
14.1.1.2 Randomization: Patients will not be randomized. 
14.1.1.3 Accrual: Anticipated accrual is 10 patients per month across all study 
sites. 


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14.1.1.4 Sample Size Justification:  Plasma D-dimer levels typically decrease at 
least 20% following the initiation of anticoagulation.59 The sample size is 
based on a paired t-test of D-dimer concentrations measured on day 1 and 
end of treatment, to be performed separately for each arm. In the recently 
completed MicroTEC study, the median baseline D-dimer concentration 
for all cancer patients enrolled was 815 ug/L.47  Based on an estimated 
standard deviation of 0.3 for the ratio of the D-dimer levels at day 56 
over the D-dimer levels at day 1, a total of 26 subjects are needed per arm 
for a 90% power to declare the reduction significant if the true 
concentration at end of treatment is reduced by 20% in each isoquercetin 
arm (one-sided alpha 0.05). Estimated death or dropout of 5% prior to 56 
days, the sample size will be increased to a total of total 30 per arm (one-
sided alpha 0.05). With 30 eligible patients per dose level, there is greater 
than 60% power to detect an unacceptable attributable grade 3 or 4 rate of 
15% at 56 days using a one-sided 10% level exact binomial test in each 
dose level. (see table below) 
14.1.1.5  Decision to proceed with enrollment into Cohort B 
A sequential two-stage design will be employed in the Phase II portion of 
this trial, within each dose level, to evaluate the adverse events of major 
toxicity (probable or possibly related grade 3 or 4 adverse events 
including hemorrhage) at end of treatment for potential early termination 
of the dose in the case of excessive toxicity. After 5 patients have finished 
56 days of therapy, the study will be placed on hold and toxicities 
evaluated. If more than one major toxicity is observed within the first 5 
patients enrolled in Cohort A, the cohort will be suspended and detailed 
toxicity data reviewed for possible closure of the study to further accrual 
based on DSMC review. The probability of stopping accrual after the first 
5 patients based on the true but unknown toxicity event for major 
hemorrhages is shown in the table below. If the study criteria are met to 
reopen the second stage, accrual will begin after the first 5 patients have 
finished study  treatment and all toxicity data have been reviewed. With 5 
eligible patients in the first stage, the probabilities of observing at least 
one toxicity with corresponding true rate of 1% and 5% are, respectively, 
5% and 23%. With 30 eligible patients the respective probabilities of one 
or more events are 26% and 79%. The maximum width of a 95% 
confidence interval on any given toxicity, unadjusted for the two-stage 
design is 36%. Adjusting for the two-stage design, the maximum 95% 
confidence interval width would be 50%. If there are greater than 3 major 
toxicities in the 30 patients in Cohort A, then the cohort will be suspended 
and detailed toxicity data reviewed for possible closure of the study to 
further accrual based on DSMC recommendations. If the true but 
unknown toxicity event for major hemorrhages is 5% and 15%, the 
probability of proceeding to Cohort B after the evaluation of the 30 
patients in Cohort A is 92.5% and 30.8%, respectively. A similar two-
stage design will be employed for patients enrolled in Cohort B. If there 
are more than 1 major toxicities in the first 5 patients or three or more 


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major toxicities in the 30 patients in Cohort B, then we will only consider 
proceeding to the phase III portion of the study with isoquercetin 500 mg 
daily. 
True 
attributable 
toxicity 
0.05 
0.1 
0.15 
0.2 
0.25 
0.3 
0.35 
0.4 
0.45 
Probability 
of stopping 
early after 5 
patients 
0.023 
0.081 
0.165 
0.263 
0.367 
0.472 
0.572 
0.663 
0.744 
Probability 
of stopping 
at the end of 
the cohort A 
0.075 
0.373 
0.692 
0.883 
0.964 
0.991 
0.998 
0.999 
0.999 
 
 
14.1.1.6 Primary endpoint analysis: D-dimer concentrations will be compared 
for each patient at day 0 and end of treatment by a paired-t test analysis. 
Analysis will be performed on an intention to treat basis for patients who 
undergo randomization and completed the baseline and end of treatment  
D-dimer assessments.  
14.1.1.7 Determination of continuation with phase III trial and selection of 
dose. Following completion of the phase II study, decision will be made 
by principal investigators whether to proceed with enrollment into the 
phase III trial. The decision to continue will be principally guided by 
whether either isoquercetin arm reached the primary endpoint definition. 
If both isoquercetin arms meet the primary endpoint then selection of 
dose will be based on degree of reduction in D-dimer levels in each arm 
relative to baseline and toxicity profile with special attention to major 
hemorrhage episodes. If neither isoquercetin arm results in significant 
reduction in d-dimer values relative to baseline, then consideration to 
advance to phase III will be made based on overall VTE rate in the 
combined isoquercetin arms. D-dimer is a recognized biomarker of the 
prothrombotic state but is known to lack specificity in cancer cohorts58. 
Because it is possible that isoquercetin is an effective antithrombotic 
without altering plasma D-dimer values especially considering potential 
antiplatelet activity, we will also analyze the cumulative incidence of 
VTE collectively for the isoquercetin treated patients. A true cumulative 
incidence VTE rate of less than 10% would be considered promising in 
the combined isoquercetin arms, whereas a true cumulative incidence rate 
of 25% would not be worthy of further study. Treatment is considered 
promising among the 60 patients treated with isoquercetin when nine or 
fewer VTE are observed. This design has at least a 92% chance of 
concluding the treatment is effective when the true cumulative incidence 


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37 
rate is 10%, and less than a 5% chance of concluding the treatment is 
effective when the true cumulative incidence rate is 25% or more (Fisher 
exact test). If determination to proceed to phase III is based on promising 
VTE rates, then the higher dose level of isoquercetin will be utilized. 
14.1.2 The primary aim of the phase III trial is determine whether isoquercetin reduces the 
cumulative incidence of symptomatic or proximal VTE in cancer patients at 56 days.   
14.1.2.1 Study design: The trial is a randomized, placebo-controlled, double-
blinded phase III trial.  Study subjects are randomized to placebo or 
isoquercetin. The structure of the study matches the phase II study, the 
central differences being that VTE is the primary endpoint and a single 
isoquercetin arm is compared to placebo.    
14.1.2.2 Randomization: Central randomization (1:1) will be performed by 
QACT Office at DF/HCC and stratified by cancer diagnosis and 
institutions.  
14.1.2.3 Accrual: Anticipated accrual is 20 patients per month across all sites.    
14.1.2.4 Sample size justification: 
The overall incidence of thrombosis in cancer populations varies between 
2-40% based on histology, stage, chemotherapeutics, additional risk 
factors and mode of surveillance (imaging or symptomatic events). The 
overall cumulative incidence of VTE in recently conducted MicroTEC 
study with similar eligibility criteria and study design was 11.3%.The 
estimate of isoquercetin benefit is based on data from primary 
thromboprophylaxis trials that typically achieve VTE rates of 4% or 
less.60,61 Based on the estimated VTE rates of 11% in the placebo and 4% 
isoquercetin arms, a total of 281 isoquercetin-treated subjects and 281 
placebo-treated subjects would be required to reject the null hypothesis 
that the failure rates for experimental and control subjects are equal with 
probability (power) 0.85.  The 1-sided type I error probability associated 
with this test of this null hypothesis is 0.025.  In order to adjust for death 
or dropout of 5% prior to 56 days, the sample size is increased by an 
additional 28 patients. We plan an interim analysis for efficacy or futility 
after 50% of patients have been randomized that will be guided by 
O’Brien-Fleming boundaries. This will require an additional increase in 
sample size of 5% or 28 patients. Therefore, we plan to enroll a total of 
618 patients. A total of 30 patients enrolled in the phase II trial  will be 
included in the total accrual target and final VTE endpoint analysis.  
 
14.1.3 Primary endpoint analysis will be performed on an intention to treat basis following 
randomization for all patients who undergo baseline assessment for the presence of 
VTE and at least one dose of study medication. The cumulative incidence of VTE 


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will be assessed by competing risk analysis and differences between arms will be 
evaluated by the Gray test.62,63  
14.2 Secondary endpoint analysis 
 
•    Cumulative incidence of VTE in cancer patients with or without tissue factor bearing 
microparticles will be assessed for isoquercetin or placebo arms by a competing risk 
analysis and differences evaluated by the Gray test. We previously identified elevated 
tissue factor bearing microparticles as a significant risk factor for developing 
thrombosis with a cumulative incidence of 27-38%.45 We also will evaluate whether 
isoquercetin reduces the cumulative incidence of symptomatic or proximal VTE in 
cancer patients with elevated tissue factor bearing microparticles. Based on our 
previous data, we anticipate that approximately 45% of patients enrolled will have 
elevated tissue factor bearing microparticles (N=278) and half will be randomized to 
placebo or isoquercetin. Based on estimated VTE rates of 20% in the placebo and 7% 
in the isoquercetin arms for individuals with high tissue factor bearing microparticles, 
the probability (power) to reject the null hypothesis is 0.84. The 1-sided type I error 
probability associated with this test of the null hypothesis is 0.025 (Fisher exact test).   
•    The cumulative incidence of major hemorrhage between the groups of patients treated 
with isoquercetin versus those without. Analysis will include time to first major bleed, 
overall incidence of bleeding and analysis of bleeding events over time.  
•    Overall survival according to randomization and tissue factor bearing microparticle 
status will be analyzed by Kaplan Meier and significance testing by log-rank analysis 
•    Cumulative incidence of total or symptomatic VTE at 2 months in all treatment arms 
(and according to tissue factor bearing microparticle status) 
•    Influence of isoquercetin on TFMP levels and change in TFMP levels over time. This 
will be analyzed by continuous measurement of difference using ANOVA approach. 
•    Cumulative incidence of VTE in patients with elevated TFMP and very elevated d-
dimer (>1500 mcg/L) overall and according to randomization.  
•    Correlation between complete blood count, d-dimer, ECOG, histology, stage, and 
TFMP levels will be determined by assessing the correlation coefficient by standard 
methods (Pearson or Spearman’s coefficients).  
• Linear regression modelling will be performed to assess the influence of 
chemotherapy, blood counts, growth factors, ECOG performance status on TFMP 
levels.  
• Fine and Graey regression modelling will be performed to assess the influence of 
chemotherapy, blood counts, growth factors, ECOG performance status on VTE risk.  
• Quality of Life (QOL) will be assesses using EORTC QLQ-30 version 3 which is an 
internationally validated and widely utilized questionnaire.57 Scoring is based on 
responses to 30 questions dealing with functional quality and symptom burden.  The 
questionnaire will be completed at baseline visit and end of treatment assessments. All 
are reported on a range 0-100; a high score represents a high level of functioning and 
QOL. We will analyze the data using analysis of variance techniques if the QoL has 
constant variance across groups (based on VTE rates and treatment groups). If not, we 
will use the Kruskal-Wallis test based on ranked QoL scores. If the questionnaire 
developers provide guidelines for scoring in the presence of missing data, we will 


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follow those guidelines. Alternatively, we will tally the number of questionnaires for 
which a particular data item is missing. 
 
• Correlation between isoquercetin dose, plasma PDI inhibitory activity, and reduction 
in D-dimer or VTE incidence 
• Cumulative incidence of VTE according to Khorana score37  
• At completion of phase II portion, we will compare the cumulative incidence of VTE 
of all 60 patients enrolled with similar historical population. As described above the 
overall cumulative incidence of VTE with similar inclusion criteria and design was 
11%. We hypothesize the cumulative incidence of VTE in the phase II cohort will be 
4%. Based on these assumptions, the power for this comparison is 80% (N=60 with a 
1-sided alpha of 0.1 comparing 4% to historical 11% cumulative incidence rate using a 
Fisher exact test.) 
 
14.3 Reporting and Exclusions 
 
14.3.1 Evaluation of toxicity. All participants who received a dose of study drug will 
be assessed for toxicity. 
14.3.2 Evaluation of response.  All participants included in the study must be 
assessed for response to treatment, even if there are major protocol treatment 
deviations or if they are ineligible. For the phase II study, primary endpoint 
analysis will be performed on an intention to treat basis for patients who 
undergo randomization and completed both the baseline and day 56 blood draw. 
For the phase III study, primary endpoint analysis will be performed on an 
intention to treat basis following randomization for all patients who undergo 
baseline assessment for the presence of VTE.  
              
 
15    PUBLICATION PLAN 
 
The primary investigators hold primary responsibility for publication of study results 
without third party approval. Phase II and Phase III results may be presented and/or 
published separately. The results will be made public within 24 months of the end of data 
collection. Planned report will be in a peer-reviewed journal and an initial release may be an 
abstract that meets the requirements of the International Committee of Medical Journal 
Editors. A full report of the outcomes will be made no later than three (3) years after the end 
of data collection.  


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thrombus formation. Arterioscler Thromb Vasc Biol 2011;31:728-33. 
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Giesen PL, Rauch U, Bohrmann B, et al. Blood-borne tissue factor: another view of 
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Falati S, Liu Q, Gross P, et al. Accumulation of tissue factor into developing thrombi in 
vivo is dependent upon microparticle P-selectin glycoprotein ligand 1 and platelet P-selectin. J 
Exp Med 2003;197:1585-98. 
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cell-derived microparticle tissue factor contributes to fibrin formation during thrombus 
propagation. Blood 2004;104:3190-7. 
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Thomas GM, Panicot-Dubois L, Lacroix R, Dignat-George F, Lombardo D, Dubois C. 
Cancer cell-derived microparticles bearing P-selectin glycoprotein ligand 1 accelerate thrombus 
formation in vivo. J Exp Med 2009;206:1913-27. 
45. 
Zwicker JI, Liebman HA, Neuberg D, et al. Tumor-derived tissue factor-bearing 
microparticles are associated with venous thromboembolic events in malignancy. Clin Cancer Res 
2009;15:6830-40. 
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Manly DA, Wang J, Glover SL, et al. Increased microparticle tissue factor activity in cancer 
patients with Venous Thromboembolism. Thromb Res 2010;125:511-2. 
47. 
Zwicker JI, Liebman HA, Bauer KA, et al. Prediction and prevention of thromboembolic 
events with enoxaparin in cancer patients with elevated tissue factor-bearing microparticles: a 
randomized-controlled phase II trial (the Microtec study). British journal of haematology 2012. 
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Conquer JA, Maiani G, Azzini E, Raguzzini A, Holub BJ. Supplementation with quercetin 
markedly increases plasma quercetin concentration without effect on selected risk factors for heart 
disease in healthy subjects. The Journal of nutrition 1998;128:593-7. 
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Cureton KJ, Tomporowski PD, Singhal A, et al. Dietary quercetin supplementation is not 
ergogenic in untrained men. J Appl Physiol 2009;107:1095-104. 
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Nieman DC, Henson DA, Davis JM, et al. Quercetin ingestion does not alter cytokine 
changes in athletes competing in the Western States Endurance Run. J Interferon Cytokine Res 
2007;27:1003-11. 
51. 
Nieman DC, Henson DA, Gross SJ, et al. Quercetin reduces illness but not immune 
perturbations after intensive exercise. Med Sci Sports Exerc 2007;39:1561-9. 
52. 
Edwards RL, Lyon T, Litwin SE, Rabovsky A, Symons JD, Jalili T. Quercetin reduces 
blood pressure in hypertensive subjects. The Journal of nutrition 2007;137:2405-11. 


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53. 
Shanely RA, Knab AM, Nieman DC, Jin F, McAnulty SR, Landram MJ. Quercetin 
supplementation does not alter antioxidant status in humans. Free radical research 2010;44:224-
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Ferry DR, Smith A, Malkhandi J, et al. Phase I clinical trial of the flavonoid quercetin: 
pharmacokinetics and evidence for in vivo tyrosine kinase inhibition. Clinical cancer research : an 
official journal of the American Association for Cancer Research 1996;2:659-68. 
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Aaronson NK, Ahmedzai S, Bergman B, et al. The European Organization for Research and 
Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials 
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Ay C, Vormittag R, Dunkler D, et al. D-dimer and prothrombin fragment 1 + 2 predict 
venous thromboembolism in patients with cancer: results from the Vienna Cancer and 
Thrombosis Study. J Clin Oncol 2009;27:4124-9. 
59. 
Kuruvilla J, Wells PS, Morrow B, MacKinnon K, Keeney M, Kovacs MJ. Prospective 
assessment of the natural history of positive D-dimer results in persons with acute venous 
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Agnelli G, Gussoni G, Bianchini C, et al. Nadroparin for the prevention of thromboembolic 
events in ambulatory patients with metastatic or locally advanced solid cancer receiving 
chemotherapy: a randomised, placebo-controlled, double-blind study. Lancet Oncol 2009;10:943-
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Agnelli G, George DJ, Kakkar AK, et al. Semuloparin for thromboprophylaxis in patients 
receiving chemotherapy for cancer. N Engl J Med 2012;366:601-9. 
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Gray RJ. A class of K-sample tests for comparing the cumulative incidence of a competing 
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Campigotto F, Neuberg D, Zwicker JI. Biased estimation of thrombosis rates in cancer 
studies using the method of Kaplan and Meier. Journal of thrombosis and haemostasis : JTH 
2012;10:1449-51. 
 


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17 APPENDICES  
 


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APPENDIX A 
 
Dana-Farber/Harvard Cancer Center 
Multi-Center Data and Safety Monitoring Plan 
 
 
TABLE OF CONTENTS 
1.0 
INTRODUCTION   45 
 
1.1 Purpose 45 
1.2 Multi-Center Data and Safety Monitoring Plan Definitions 45 
2.0 
GENERAL ROLES AND RESPONSIBILITIES   46 
 
2.1 DF/HCC Sponsor   46 
2.2 Coordinating Center   46 
2.3 DF/HCC Quality Assurance Office for Clinical Trials (QACT)  47  
2.4 Participating Institution   47 
3.0 
DF/HCC REQUIREMENTS FOR MULTI-CENTER PROTOCOLS   48 
 
3.1 Protocol Distribution  50 
3.2 Protocol Revisions and Closures 
50 
3.3 Informed Consent Requirements 48 
3.4 IRB Documentation 49 
3.5 IRB Re-Approval 49 
3.6 Participant Confidentiality and Authorization Statement 49 
 
     3.6.1 
DF/HCC Multi-Center Protocol Confidentiality 50 
3.7 DF/HCC Multi-Center Protocol Registration Policy 50 
3.7.1 Participant Registration and Randomization 50 
3.7.2 Initiation of Therapy  50 
3.7.3 Eligibility Exceptions   50 
3.7.4 Verification of Registration, Dose Levels, and Arm Designation  50 
3.8 DF/HCC Protocol Case Number 
51 
3.9 Protocol Deviations, Exceptions and Violations 
51 
3.9.1 Definitions 
51 
3.9.2 Reporting Procedures 
51 
3.10 
Safety Assessments and Toxicity Monitoring 52 
3.10.1 
Guidelines for Reporting Serious Adverse Events  52 
3.10.2 
Guidelines for Processing IND Safety Reports   53 
3.11 
Data Management 
53 


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3.11.1 
Data Forms Review 55 
4.0 
REQUISITIONING INVESTIGATIONAL DRUG   53 
 
5.0 
MONITORING: QUALITY CONTROL   54 
 
5.1 Ongoing Monitoring of Protocol Compliance 56 
5.2 Evaluation of Participating Institution Performance 57 
5.2.1 Monitoring Reports 57 
6.0 
AUDITING: QUALITY ASSURANCE   55 
 
6.1 DF/HCC Sponsored Trials 57 
6.2 Participating Institution   58 
6.3 DF/HCC Sponsor and Coordinating Center 
58 
6.4  Sub-Standard Performance 58 
6.4.1 Corrective Actions 
58 
 
 
 
 
 
 
 
 
 
 
 
 


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1.0 INTRODUCTION 
 
The Dana-Farber/Harvard Cancer Center Multi-Center Data and Safety Monitoring Plan 
(DF/HCC DSMP) outlines the procedures for conducting a DF/HCC Multi-Center research 
protocol. The DF/HCC DSMP should serve as a reference for any sites external to DF/HCC 
that will be participating in the research protocol. 
 
 
1.1  Purpose 
 
To establish standards that will ensure that a Dana-Farber/Harvard Cancer Center Multi-
Center protocol will comply with Federal Regulations, Health Insurance Portability and 
Accountability Act (HIPAA) requirements and applicable DF/HCC Standard Operating 
Procedures. 
 
       1.2  Multi-Center Data and Safety Monitoring Plan Definitions 
 
DF/HCC Multi-center Protocol:  A research protocol in which one  or more outside 
institutions are collaborating with Dana-Farber/Harvard Cancer Center where  a DF/HCC 
investigator is the sponsor. DF/HCC includes Dana-Farber/Partners Cancer Care (DF/PCC) 
Network Clinical Trial Affiliates.  
 
Lead Institution:  One of the Dana-Farber/Harvard Cancer Center consortium members 
(Dana-Farber Cancer Institute (DFCI), Massachusetts General Hospital (MGH), Beth Israel 
Deaconess Medical Center (BIDMC), Children’s Hospital Boston (CHB), Brigham and 
Women’s Hospital (BWH)) responsible for the coordination, development, submission, and 
approval of a protocol as well as its subsequent amendments per the DFCI IRB and 
applicable regulatory guidelines (Food and Drug Administration (FDA), Office of 
Biotechnology Activities (OBA) etc.).  The Lead Institution is typically the home of the 
DF/HCC Sponsor. The Lead Institution also typically serves as the Coordinating Center for 
the DF/HCC Multi-Center Protocol.   
 
DF/HCC Sponsor:  The person sponsoring the submitted Multi-Center protocol.  Within 
DF/HCC, this person is the Overall Principal Investigator who takes responsibility for 
initiation, management and conduct of the protocol at all research locations. In applicable 
protocols, the DF/HCC Sponsor will serve as the single liaison with any regulatory 
agencies (i.e. FDA, OBA etc.). The DF/HCC Sponsor has ultimate authority over the 
protocol and is responsible for the conduct of the study at DF/HCC and all Participating 
Institutions. In most cases the DF/HCC Sponsor is the same person as the DF/HCC 
Principal Investigator; however, both roles can be filled by two different people.  
 
Participating Institution:  An institution that is outside the DF/HCC and DF/PCC 
consortium that is collaborating with DF/HCC on a protocol where the sponsor is a 
DF/HCC Investigator.  The Participating Institution acknowledges the DF/HCC Sponsor as 
having the ultimate authority and responsibility for the overall conduct of the study.    
 
 


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48 
Coordinating Center: The entity (i.e. Lead Institution) that provides administrative 
support to the DF/HCC Sponsor in order that he/she may fulfill the responsibilities outlined 
in the protocol document and DSMP, and as specified in applicable regulatory guidelines 
In general, the Lead Institution is the Coordinating Center for the DF/HCC Multi-Center 
Protocol. 
  
DF/HCC Quality Assurance Office for Clinical Trials: A unit within DF/HCC 
developed to computerize and manage data, and to provide a Quality Control and Quality 
Assurance function for DF/HCC trials.   
 
 2.0     GENERAL ROLES AND RESPONSIBILITIES 
  
 
For DF/HCC Multi-Center Protocols, the DF/HCC Sponsor, the Coordinating Center, and 
the Participating Institutions are expected to adhere to the following general responsibilities:  
 
 
2.1  DF/HCC Sponsor 
 
The DF/HCC Sponsor, Dr. Zwicker will accept responsibility for all aspects of conducting 
a DF/HCC Multi-Center protocol which includes but is not limited to:  
• Oversee the coordination, development, submission, and approval of the protocol as well as subsequent 
amendments.  
• Ensure that the investigators, study team members, and Participating Institutions are qualified and 
appropriately resourced to conduct the protocol.   
• Submit the Multi-Center Data and Safety Monitoring Plan as an appendix to the protocol. 
• Assure all Participating Institutions are using the correct version of the protocol. 
• Ensure that each participating investigator and study team receives adequate protocol training and/or a 
Site Initiation Visit prior to enrolling participants and throughout trial’s conduct as needed. 
• Ensure the protocol will be provided to each participating site in a language understandable to all site 
personnel when English is not the primary language.  
• Monitor progress and overall conduct of the study at all Participating Institutions.  
• Ensure all DFCI Institutional Review Board (IRB), DF/HCC and other applicable (i.e. FDA, OBA) 
reporting requirements are met.  
• Review data and maintain timely submission of data for study analysis.  
• Act as the single liaison with FDA (investigator-held IND trials) or OBA (gene therapy trials), as 
applicable. 
• Ensure compliance with all requirements as set forth in the Code of Federal Regulations, applicable 
DF/HCC requirements, HIPAA requirements, and the approved protocol. 
• Commit to the provision that the protocol will not be rewritten or modified by anyone other than the 
DF/HCC Sponsor. 
• Identify and qualify Participating Institutions and obtain accrual commitments prior to extending the 
protocol to that site.  
• Monitor accrual and address Participating Institutions that are not meeting their accrual requirements. 
 
 
 
2.2  Coordinating Center  
 
The Coordinating Center will assume the following general responsibilities: 
• 
Assist in protocol development  
• 
Maintain copies of Federal Wide Assurance and Institutional Review Board (IRB) approvals from 
all Participating Institutions. 


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49 
• 
Maintain FDA or OBA correspondence, as applicable. 
• 
Maintain updated roster of participants.  
• 
Verify eligibility. 
• 
Verify response. 
• 
Oversee the data collection process from Participating Institutions. 
• 
Maintain documentation of Serious Adverse Event (SAE) reports submitted by Participating 
Institutions and submit to DF/HCC Sponsor for timely review.   
• 
Distribute adverse events reported to the DF/HCC Sponsor that fall under the DFCI IRB Adverse 
Event Reporting Policy to all participating investigators. 
• 
Provide Participating Institutions with information regarding DF/HCC requirements that they will be 
expected to comply with. 
 
 
• 
Monitor Participating Institutions either by on-site or virtual monitoring.  
• 
Maintain Regulatory documents of all Participating Institutions.  
• 
Conduct regular communications with all Participating Institutions (conference calls, emails, etc).  
• 
Maintain documentation of all communications. 
• 
Ensure that each Participating Institution has the appropriate assurance on file with the Office of 
Human Research Protection (OHRP).     
 
 
2.3  DF/HCC Quality Assurance Office for Clinical Trials (QACT) 
 
In addition to the Coordinating Center, the DF/HCC QACT provides the following support 
services to assist the DF/HCC Sponsor: 
• 
Develop protocol specific case report forms (CRF/eCRFS). 
• 
QA/QC data of protocol specific CRFs.  
• 
Provide a central participant registration, which includes review of consent and eligibility. 
• 
Provide auditing services (funding and QACT approval required) 
. 
 
2.4  Participating Institution 
 
Each Participating Institution is expected to comply with all applicable Federal Regulations 
and DF/HCC requirements, the protocol and HIPAA requirements. All Participating 
Institutions will provide a list of personnel assigned to the role for oversight of data 
management at their site to the Coordinating Center.  
 
The general responsibilities for each Participating Institution are as follows: 
• 
Commit to the accrual of participants to the protocol. 
• 
Submit protocol and/or amendments to their local IRB. 
• 
Maintain a regulatory binder in accordance with DF/HCC requirements. 
• 
Provide the Coordinating Center with regulatory documents as requested. 
• 
Participate in protocol training prior to enrolling participants and throughout the trial as needed (i.e. 
teleconferences). 
• 
Update Coordinating Center with research staff changes on a timely basis. 
• 
Register participants through the Coordinating Center.  
• 
Submit source documents, research records, and CRFs per protocol specific submission guidelines to 
the Coordinating Center. 
• 
Submit Serious Adverse Event (SAE) reports to local IRB and directly to the Coordinating Center, in 
accordance with DF/HCC requirements.  
• 
Submit protocol deviations and violations to local IRB per local requirements and to the DF/HCC 
Sponsor in accordance with DF/HCC requirements. 
• 
Secure and store investigational agents and/or other protocol mandated drugs per federal guidelines 
and protocol requirements. 
• 
Have office space, office equipment, and internet access that meet HIPAA standards. 


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50 
• 
For protocols using investigational agents, the Participating Institution will order their own 
investigational agents regardless of the supplier (i.e. National Cancer Institute (NCI), pharmaceutical 
company). [This is the preferred method of ordering investigational agent. Some pharmaceutical 
companies may require the Coordinating Center to order study drug for external sites. Contact 
pharmacy to confirm this is feasible. Revise as necessary.] 
 
 3.0  DF/HCC REQUIREMENTS FOR MULTI-CENTER PROTOCOLS 
  
The following section will clarify DF/HCC Requirements and further detail the expectations 
for participating in a DF/HCC Multi-Center protocol.  
 
 
3.1  Protocol Distribution 
 
The Coordinating Center will distribute the final DFCI IRB approved protocol and any 
subsequent amended protocols to all Participating Institutions.    
 
 
3.2  Protocol Revisions and Closures 
 
The Participating Institutions will receive notification of protocol revisions and closures 
from the Coordinating Center.  It is the individual Participating Institution’s responsibility 
to notify its IRB of these revisions. 
 
• Non life-threatening revisions: Participating Institutions will receive written 
notification of protocol revisions regarding non life-threatening events from the 
Coordinating Center. Non-life-threatening protocol revisions must be IRB approved 
and implemented within 90 days from receipt of the notification. 
 
• Revisions for life-threatening causes: Participating Institutions will receive 
immediate notification from the Coordinating Center concerning protocol revisions 
required to protect lives with follow-up by fax, mail, e-mail, etc.  Life-threatening 
protocol revisions will be implemented immediately followed by IRB request for 
approval. 
 
• Protocol closures and temporary holds: Participating Institutions will receive 
notification of protocol closures and temporary holds from the Coordinating Center. 
Closures and holds will be effective immediately.  In addition, the Coordinating 
Center, will update the Participating Institutions on an ongoing basis about protocol 
accrual data so that they will be aware of imminent protocol closures. 
 
 
3.3  Informed Consent Requirements 
 
The DF/HCC approved informed consent document will serve as a template for the 
informed consent for Participating Institutions. The Participating Site consent form must 
follow the consent template as closely as possible and should adhere to specifications 
outlined in the DF/HCC Guidance Document on Model Consent Language for PI-Initiated 
Multi-Center Protocols.  This document will be provided separately to each Participating 
Site. 
 


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51 
Participating sites are to send their version of the informed consent document and HIPAA 
authorization, if a separate document, to the Coordinating Center for review and approval 
prior to submission to their local IRB. The approved consent form must also be submitted 
to the Coordinating Center after approval by the local IRB. 
 
The Principal Investigator (PI) at each Participating Institution will identify the physician 
members of the study team who will be obtaining consent and signing the consent form for 
therapeutic protocols. Participating institutions must follow the DF/HCC requirement that 
only attending physicians obtain informed consent and re-consent to international trials (i.e. 
drug and/or device trials).   
 
 
3.4  IRB Documentation 
 
The following must be on file with the Coordinating Center: 
• 
Approval letter of the Participating Institution's IRB  
• 
Copy of the Informed Consent Form approved by the Participating Institution’s IRB  
• 
Participating IRB’s approval for all amendments 
 
It is the Participating Institution's responsibility to notify its IRB of protocol amendments.  
Participating Institutions will have 90 days from receipt to provide the Coordinating Center 
their IRB approval for amendments to a protocol.    
 
 
3.5  IRB Re-Approval 
 
Verification of IRB re-approval from the Participating Institutions is required in order to 
continue research activities.  There is no grace period for continuing approvals. 
 
The Coordinating Center will not register participants if a re-approval letter is not received 
from the Participating Institution on or before the anniversary of the previous approval 
date.   
 
 
 
3.6  Participant Confidentiality and Authorization Statement 
 
In 1996, congress passed the first federal law covering the privacy of health information 
known as the Health Insurance Portability and Accountability Act (HIPPA). Any 
information, related to the physical or mental health of an individual is called Protected 
Health Information (PHI). HIPAA outlines how and under what circumstances PHI can be 
used or disclosed.  
 
In order for covered entities to use or disclose protected health information during the 
course of a study, the study participant must sign an Authorization.  This Authorization 
may or may not be separate from the informed consent document.  The Coordinating 
Center, with the approval from the DFCI IRB and if applicable NCI/CTEP, will provide a 
consent template, which covered entities (Participating Institutions) must use.  
 
The DF/HCC Sponsor will use all efforts to limit its use of protected health information in 
its trials.  However, because of the nature of these trials, certain protected health 


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52 
information must be collected per NCI requirements. These are the primary reasons why 
DF/HCC has chosen to use Authorizations, signed by the participant in the trial, rather than 
limited data sets with data use agreements. 
 
 3.6.1 DF/HCC Multi-Center Protocol Confidentiality 
 
All documents, investigative reports, or information relating to the participant are strictly 
confidential. Whenever reasonably feasible, any participant specific reports (i.e. Pathology 
Reports, MRI Reports, Operative Reports, etc.) submitted to the Coordinating Center must 
have the participant’s full name & social security number “blacked out” and the assigned 
DF/HCC QACT case number (as described below) and DF/HCC protocol number written 
in (with the exception of the signed informed consent document). Participant initials may 
only be included or retained for cross verification of identification 
 
 
3.7  DF/HCC Multi-Center Protocol Registration Policy 
 
3.7.1 Participant Registration and Randomization  
Refer to Section 4.3 and 4.4 of the protocol for instructions on patient registrations. 
 
Treatment may not begin without confirmation from the Coordinating Center 
that the participant has been registered.  
 
Randomization can only occur during QACT’s normal business hours, Monday through 
Friday from 8:00 AM to 5:00 PM Eastern Time. 
Individual research pharmacies will not be blinded to randomization allocation. The 
participant, investigator, and research team will be blinded to randomization allocation.  
 
3.7.2 Initiation of Therapy 
 
Participants must be registered with the DF/HCC QACT before receiving treatment.  
Treatment may not be initiated until the Participating Institution receives a faxed or e-
mailed copy of the participant’s registration confirmation memo from the Coordinating 
Center. Therapy must be initiated per protocol guidelines.  The DF/HCC Sponsor and 
DFCI IRB must be notified of any exceptions to this policy. 
 
3.7.3  Eligibility Exceptions 
 
The DF/HCC QACT will make no exceptions to the eligibility requirements for a protocol 
without DFCI IRB approval. The DF/HCC QACT requires each institution to fully comply 
with this requirement. 
 
3.7.4  Verification of Registration, Dose Levels, and Arm Designation 
 
A registration confirmation memo for participants registered to DF/HCC Multi-Center 
Protocol will be faxed or emailed to the registering institution within one business day of 


Phase II/III trial of antithrombotic activity of isoquercetin  
October 27, 2016 
 
 
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53 
the registration. Treatment may not be initiated until the site receives a faxed or e-mailed 
copy of the registration confirmation memo. 
 
 
3.8  DF/HCC Protocol Case Number 
 
Once eligibility has been established and the participant successfully registered, the 
participant is assigned a five digit protocol case number.  This number is unique to the 
participant on this trial and must be used for QACT CRF/eCRF completion and 
correspondence, and correspondence with the Coordinating Center.   
 
3.9  Protocol Deviations, Exceptions and Violations 
 
Federal Regulations require an IRB to review proposed changes in a research activity to 
ensure that researchers do not initiate changes in approved research without IRB review 
and approval, except when necessary to eliminate apparent immediate hazards to the 
participant. DF/HCC requires all departures from the defined procedures set forth in the 
IRB approved protocol to be reported to the DF/HCC Sponsor, who in turn is responsible 
for reporting to the DFCI IRB. 
  
For reporting purposes, DF/HCC uses the terms “violation”, “deviation” and “exception” 
to describe derivations from a protocol. All Participating Institutions must adhere to these 
requirements for reporting to the DF/HCC Sponsor and will follow their institutional 
policy for reporting to their local IRB. 
 
3.9.1  Definitions 
 
Protocol Deviation: Any departure from the defined procedures set forth in the IRB-
approved protocol which is prospectively approved prior to its implementation. 
 
Protocol Exception:  Any protocol deviation that relates to the eligibility criteria, e.g. 
enrollment of a participant who does not meet all inclusion/exclusion criteria. 
  
 
Protocol Violation: Any protocol deviation that was not prospectively approved by the IRB 
prior to its initiation or implementation.   
 
 3.9.2  Reporting Procedures 
 
DF/HCC Sponsor: is responsible for ensuring that clear documentation is available in the 
medical record and/or regulatory documents to describe all protocol exceptions, deviations 
and violations. The DF/HCC Sponsor will also be responsible for ensuring that all protocol 
violations/deviations are promptly reported per DFCI IRB guidelines.  
 
Participating Institutions: Protocol deviations require prospective approval from the DFCI 
IRB. The Participating Institution must submit the deviation request to the Coordinating 
Center who will then submit the deviation request to the DFCI IRB. Upon DFCI IRB 


Phase II/III trial of antithrombotic activity of isoquercetin  
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54 
approval the deviation is submitted to the Participating Institution IRB, per institutional 
policy. A copy of the Participating Institution’s IRB report and determination will be 
forwarded to the Coordinating Center within 10 business days after the original submission.  
 
All protocol violations must be sent to the Coordinating Center in a timely manner.  
 
Coordinating Center:  Upon receipt of the violation/deviation report from the Participating 
Institution, the Coordinating Center will submit the report to the DF/HCC Sponsor for 
review. Subsequently, the Participating Institution’s IRB violation/deviation report will be 
submitted to the DFCI IRB for review per DFCI IRB reporting guidelines.  
 
 
3.10  Safety Assessments and Toxicity Monitoring 
 
The study teams at all participating institutions are responsible for protecting the safety, 
rights and well-being of study participants. Recording and reporting of adverse events that 
occur during the course of a study help ensure the continuing safety of study participants.  
 
All participants receiving investigational agents and/or other protocol mandated treatment 
will be evaluated for safety.   The safety parameters include all laboratory tests and 
hematological abnormalities, physical examination findings, and spontaneous reports of 
adverse events reported by participants.  All toxicities encountered during the study will be 
evaluated according to the NCI criteria specified in the protocol. Life-threatening toxicities 
must be reported immediately to the DF/HCC Sponsor via the Coordinating Center.  
 
The participating Institutions will review and submit to their IRB according to their 
institutional policies and procedures. . 
 
3.10.1  Guidelines for Reporting Serious Adverse Events  
 
Guidelines for reporting Adverse Events (AEs) and Serious Adverse Events (SAEs) are 
detailed in protocol section 10.2. 
 
 
 
 
 
 
Participating Institutions must report the AEs to the DF/HCC Sponsor and the Coordinating 
Center following the DFCI IRB SAE Reporting Requirements.  
 
The Coordinating Center will maintain documentation of all Participating Institution 
Adverse Event reports and be responsible for communicating to all participating 
investigators, any observations reportable under the DFCI IRB Reporting Requirements.  
Participating Investigators will review any distributed AE reports, send a copy to their IRB 
according to their local IRB’s policies and procedures, and file a copy with their regulatory 
documents. 
 
 
 
 


Phase II/III trial of antithrombotic activity of isoquercetin  
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3.10.2  Guidelines for Processing IND Safety Reports  
 
FDA regulations require sponsors of clinical studies to notify the FDA and all participating 
investigators of any adverse experience associated with the use of the investigational agent 
that is both serious and unexpected. The DF/HCC Sponsor will review all IND Safety 
Reports and ensure that all IND Safety Reports are distributed to the Participating 
Institutions.  The Participating Institutions will review and submit to their IRB according to 
their institutional policies and procedures.   
  
 
3.11  Data Management 
 
The DF/HCC QACT develops a set of either paper or electronic case report forms 
(CRF/eCRFs), for use with the protocol.  These forms are designed to collect data for each 
study. The DF/HCC QACT provides a web based training for eCRF users. 
   
3.11.1  Data Forms Review 
 
When data forms arrive at the DF/HCC QACT, they are reviewed for completeness, 
protocol treatment compliance, adverse events (toxicities) and response. Data submissions 
are monitored for timeliness and completeness of submission. Participating Institutions are 
notified of their data submission delinquencies in accordance with the following: 
 
 
Incomplete or Questionable Data 
If study forms are received with missing or questionable data, the submitting institution 
will receive a written or electronic query from the DF/HCC QACT Data Analyst or study 
monitor.  Responses to all queries should be completed and submitted within 14 calendar 
days.  Responses may be returned on the written query or on an amended paper case report 
form, or in the case of electronic queries, within the electronic data capture (eDC) system. 
In the case of a written query for data submitted on a paper case report form, the query 
must be attached to the specific data being re-submitted in response.   
 
Missing Forms 
If study forms are not submitted on schedule, the Participating Institution will receive a 
Missing Form Report from the Coordinating Center noting the missing forms.  These 
reports are compiled by the DF/HCC QACT and distributed a minimum of four times a 
year.  
 
4.0  REQUISITIONING INVESTIGATIONAL DRUG 
  
The ordering of investigational agent is specified in the protocol.  Refer to section 6.4.9 for 
ordering information. 
 
Participating Institutions should order their own agent regardless of the supplier (i.e., NCI or 
a pharmaceutical company.)   
 


Phase II/III trial of antithrombotic activity of isoquercetin  
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If the agent is investigational, ensure that the pharmacy will be able to receive and store the 
agent according to state and federal requirements. The local IRB should be kept informed of 
who will supply the agent (i.e., NCI or a pharmaceutical company) so that any regulatory 
responsibilities can be met in a timely fashion.  
 
 
5.0  MONITORING: QUALITY CONTROL 
 
The quality control process for a clinical trial requires verification of protocol compliance 
and data accuracy. The Coordinating Center, with the aid of the QACT provides quality 
control oversight for the protocol. 
 
 
5.1  Ongoing Monitoring of Protocol Compliance 
 
At each Participating Institution, the first patient enrolled and then every tenth patient 
enrolled will be monitored for protocol compliance by the Coordinating Center.  The 
Participating Institutions will be required to submit participant source documents to the 
Coordinating Center for monitoring. Participating Institution may also be subject to on-site 
monitoring conducted by the Coordinating Center.  
 
The Coordinating Center will implement ongoing monitoring activities to ensure that 
Participating Institutions are complying with regulatory and protocol requirements, data 
quality, and participant safety. Monitoring will occur before the clinical phase of the 
protocol begins, continue during protocol performance and through study completion. 
Additional monitoring practices may include but are not limited to; source verification, 
review and analysis of the following: eligibility requirements of all participants , informed 
consent procedures, adverse events and all associated documentation, study drug 
administration/treatment, regulatory files, protocol deviations, pharmacy records, response 
assessments, and data management.  
 
Participating institutions will be required to participate in monthly Coordinating Center 
initiated teleconferences. “Newsletters” highlighting overall protocol progress and 
important announcements will be distributed regularly. 
 
Virtual Monitoring will be an ongoing process. Prior to enrolling patients, participating 
sites will be given templates for suggested binder organization as well as treatment 
checklists (See Appendix C) in order to ensure all required data is captured.   Source 
documentation will be reviewed prior to enrollment of participants. All required correlative 
plasma samples will be tracked using template provided (see Appendix E).  All sites will 
use a data entry system which provides a missing data report monthly for Coordinating 
Centers review. Participating Institutions will provide Coordinating Center with Delegation 
of Authority logs within 60 days of opening at a participating site and then annually prior 
to the continuing review report.  Participating Institutions will also provide Coordinating 
Center with Drug accountability logs every six months. Participating Institutions will be 
required to forward de-identified copies of participants’ medical record and source 
documents to the Coordinating Center to aid in source document verification. 


Phase II/III trial of antithrombotic activity of isoquercetin  
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57 
 
All data submitted to the DF/HCC QACT will be monitored for timeliness of submission, 
completeness, and adherence to protocol requirements. The Coordinating Center and if 
applicable, QACT Data Analysts assigned to the protocol, will perform the ongoing 
protocol data compliance monitoring. 
 
Additional monitoring activities may occur at the discretion of the DF/HCC Sponsor if 
incidents on non-compliance are discovered. 
 
 
5.2  Evaluation of Participating Institution Performance 
 
 5.2.1  Monitoring Reports 
 
The DF/HCC Sponsor will review all monitoring reports for on-site and virtual monitoring 
of Participating Institutions to ensure protocol compliance and ability to fulfill 
responsibilities of participating in the study. The DF/HCC Sponsor may increase the 
monitoring activities at Participating Institutions that are unable to comply with the 
protocol, DF/HCC Sponsor requirements or federal and local regulations. Participating 
Institutions may also be subject to an audit as determined by the DF/HCC Sponsor. 
 
 
5.3 Accrual Monitoring 
 
Prior to extending a protocol to an external site, the DF/HCC Sponsor will establish accrual 
requirements for each participating institution. Accrual will be monitored for each 
participating institution by the DF/HCC Sponsor or designee. Sites that are not meeting 
their accrual expectations may be subject to termination. As per the protocol feasibility 
questionnaires, all external sites are expected to enroll at least 2-5 patients a year. 
 
 6.0  AUDITING: QUALITY ASSURANCE 
 
Auditing is a method of Quality Assurance. Its main focus is to measure whether standards 
and procedures were followed. Auditing is the systematic and independent examination of 
all trial related activities and documents.  Audits determine if evaluated activities were 
appropriately conducted and whether data was generated, recorded and analyzed, and 
accurately reported per the protocol, Standard Operating Procedures (SOPs), and the Code 
of Federal Regulations (CFR). 
 
 
6.1  DF/HCC Sponsored Trials 
 
At a minimum, two on-site audits at each participating institution will be scheduled by the 
QACT assuming the enrollment threshold for an audit has been met.  A site will be eligible 
to be audited assuming at least three participants have received protocol treatment at that 
site.  The site would be eligible for a second on-site audit once an additional 5-10 subjects 
have been treated at the site.  Approximately 3-4 participants would be audited at the site 
over a 2 day period.  If violations which impact participant safety or the integrity of the 
study are found, more participant records may be audited.  Participating Institutions may be 
subject to additional audits if incidents of non-compliance are found. 


Phase II/III trial of antithrombotic activity of isoquercetin  
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58 
 
 
6.2  Participating Institution 
 
It is the Participating Institution’s responsibility to notify the Coordinating Center of all 
scheduled audit dates (internal) and re-audit dates (if applicable), which involve this 
protocol. All institutions will forward a copy of final audit and/or re-audit reports and 
corrective action plans (if applicable) to the Coordinating Center, within 12 weeks after the 
audit date.  
 
 
6.3  DF/HCC Sponsor and Coordinating Center  
 
The DF/HCC Sponsor will review all final audit reports and corrective action plans if 
applicable. The Coordinating Center, must forward these reports to the DF/HCC QACT per 
DF/HCC policy for review by the DF/HCC Audit Committee. Based upon the audit 
assessments the DF/HCC Audit Committee could accept or conditionally accept the audit 
rating and final report. Conditional approval could require the DF/HCC Sponsor to 
implement recommendations or require further follow-up.  For unacceptable audits, the 
DF/HCC Audit Committee would forward the final audit report and corrective action plan 
to the DFCI IRB as applicable. 
 
 
6.4  Sub-Standard Performance 
 
The DF/HCC Sponsor, DFCI IRB, is charged with considering the totality of an 
institution’s performance in considering institutional participation in the protocol. 
 
6.4.1  Corrective Actions 
 
Participating Institutions that fail to meet the performance goals of accrual, submission of 
timely accurate data, adherence to protocol requirements, and compliance with state and 
federal regulations, will be recommended for a six-month probation period. Such 
institutions must respond with a corrective action plan and must demonstrate during the 
probation period that deficiencies have been corrected, as evidenced by the improved 
performance measures. Participating Institutions that fail to demonstrate significant 
improvement will be considered by the DF/HCC Sponsor for revocation of participation. 
 
  


Phase II/III trial of antithrombotic activity of isoquercetin 
 
 
October 27, 2016 
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59 
Appendix B: Performance Status Criteria 
 
 
ECOG Performance Status Scale 
 
 
Karnofsky Performance Scale 
Grade 
Description 
Percent 
Description 
0 
Normal activity. Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no 
evidence of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of 
disease. 
1 
Symptoms, but ambulatory. 
Restricted in physically strenuous 
activity, but ambulatory and able to 
carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; 
some signs or symptoms of 
disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active 
work. 
2 
In bed < 50% of the time. 
Ambulatory and capable of all self-
care, but unable to carry out any 
work activities. Up and about more 
than 50% of waking hours. 
60 
Requires occasional assistance, 
but is able to care for most of 
his/her needs. 
50 
Requires considerable assistance 
and frequent medical care. 
3 
In bed >50% of the time. Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care 
and assistance. 
30 
Severely disabled, 
hospitalization indicated. Death 
not imminent. 
4 
100% bedridden. Completely 
disabled. Cannot carry on any self-
care. Totally confined to bed or 
chair. 
20 
Very sick, hospitalization 
indicated. Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly.  
5 
Dead. 
0 
Dead. 
 
 
 


 
 
 
60
Appendix C: 
 
Cycle 1, Day 1 (Day 1) 
 
 
Patient ID and Initials: ____________________ Hospital:_______________________ 
 
 
 
 Complete blood count with diff 
 
 Platelet count > 90,000/µl 
 
 Absolute neutrophil count >1,000/mcL 
 
 Correlative plasma sample 
 
 Correlative plasma sample at 0 and 4 hours (BIDMC only, optional) 
 
 Quality of life survey 
 
 Dispense study drug 
 
 Dispense drug diary 
 
 
Investigator signature: ________________________ 
Date:  ________________________ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
61
 
 
 
 
 
 
 
 
Cycle 2, Day 1 (Day 29) 
 
Patient ID and Initials: ____________________ Hospital:_______________________ 
 
 
 
 Medical history, ECOG and concomitant medication review    
 
 Physical exam including vital signs  
 
 AE/SAE assessment  
 
 Assessment of signs and symptoms of VTE and bleeding 
 
 Complete blood count with differential, Creatinine, AST/ALT 
 
 Absence of grade 3 thrombocytopenia (platelet count > 50,000/µl) 
 
 Non-heme toxicities possibly related to isoquercetin must return to grade 2 or less 
 
 Collect signed drug diary and provide a new one 
 
 
 
Investigator signature: ________________________ 
Date:  ________________________ 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
62
 
 
Day 56 or End of Study treatment 
 
         Patient ID and Initials: ___________________ Hospital: _______________________ 
 
          
 
          Medical history, ECOG and concomitant medication review    
 
 Physical exam including vital signs 
 
 AE/SAE assessment  
 
 Assessment of signs and symptoms of VTE and bleeding 
 
 Complete blood count with differential 
 
 Correlative plasma sample   
 
 Bilateral lower extremity ultrasound 
 
 Quality of Life Survey completed 
 
 Collect signed drug diary 
 
 
 
 
 
Investigator signature: ________________________ 
Date:  _______________________ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
63
APPENDIX D: QUALITY OF LIFE QUESTIONAIRE (EORTC QLQ-C30 v3) 
 
We are interested in some things about you and your health. Please answer all of the questions yourself by circling 
the number that best applies to you. There are no "right" or "wrong" answers. The information that you provide will 
remain strictly confidential. 
 
Please fill in your initials:  
Your birthdate (Day, Month, Year):  
Today's date (Day, Month, Year):  
 
                                                                                            Not at      A      Quite      Very 
                                                                                              All      Little    a Bit      Much 
1. Do you have any trouble doing strenuous activities, 
like carrying a heavy shopping bag or a suitcase?                                                 1               2               3               4 
 
2. Do you have any trouble taking a long walk?                                                    1               2               3               4 
 
3. Do you have any trouble taking a short walk outside of the house?                  1               2               3               4 
 
4. Do you need to stay in bed or a chair during the day?                                       1               2               3               4 
 
5. Do you need help with eating, dressing, washing 
yourself or using the toilet?                                                                                    1               2               3               4 
 
During the past week:                                                Not at      A      Quite      Very 
                                                                                              All      Little    a Bit      Much 
 
6. Were you limited in doing either your work or other daily activities?              1               2               3               4 
 
7. Were you limited in pursuing your hobbies or other 
leisure time activities?                                                                                            1               2               3               4 
 
8. Were you short of breath?                                                                                  1               2               3               4 
 
9. Have you had pain?                                                                                            1               2               3               4 
 
10. Did you need to rest?                                                                                        1               2               3               4 
 
11. Have you had trouble sleeping?                                                                        1               2               3               4 
 
12. Have you felt weak?                                                                                         1               2               3               4 
 
13. Have you lacked appetite?                                                                                1               2               3               4 
 
14. Have you felt nauseated?                                                                                  1               2               3               4 
 
15. Have you vomited?                                                                                           1               2               3               4 
 
16. Have you been constipated?                                                                             1               2               3               4 
 
 
 
 
 
 
 
Please go on to the next page 


 
 
 
64
During the past week:                                                Not at      A      Quite      Very 
                                                                                              All      Little    a Bit      Much 
 
17. Have you had diarrhea?                                                                                   1               2               3               4 
 
18. Were you tired?                                                                                               1               2               3               4 
 
19. Did pain interfere with your daily activities?                                                  1               2               3               4 
 
20. Have you had difficulty in concentrating on things, 
like reading a newspaper or watching television?                                                 1               2               3               4 
 
21. Did you feel tense?                                                                                          1               2               3               4 
 
22. Did you worry?                                                                                               1               2               3               4 
 
23. Did you feel irritable?                                                                                      1               2               3               4 
 
24. Did you feel depressed?                                                                                  1               2               3               4 
 
25. Have you had difficulty remembering things?                                                1               2               3               4 
 
26. Has your physical condition or medical treatment 
interfered with your family life?                                                                           1               2               3               4 
 
27. Has your physical condition or medical treatment 
interfered with your social activities?                                                                    1               2               3               4 
 
28. Has your physical condition or medical treatment 
caused you financial difficulties?                                                                          1               2               3               4 
 
 
For the following questions please circle the number between 1 and 7 that 
best applies to you 
 
29. How would you rate your overall health during the past week? 
 
1               2               3               4               5               6               7 
 
Very poor                                                                               Excellent 
 
30. How would you rate your overall quality of life during the past week? 
 
1               2               3               4               5               6               7 
 
Very poor                                                                               Excellent 
 
 
 
 
 
 
 
 
 
 


 
 
 
65
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
  
  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
66
Sample (Plasma) Shipment Report 
14-114: Randomized, placebo-controlled, double-blind phase II/III trial of 
oral isoquercetin to prevent venous thromboembolic events in cancer patients. 
 
Medical Center: ______________________________ 
 
Patient ID and Initials: ____________ 
 
Collection Date: ____/___     / _____                                                                              
 
Time of draw:    :     AM/PM        Number Samples drawn: _____________ 
Time of spin:      :     AM/PM        Number Samples sent: _____________ 
                                                                         Number Samples stored: _____________ 
 
Select the Appropriate Visit:  
 
Screening/Pre-treatment visit 
 
Day 56 (± 5 days) or End of Study treatment 
 
Completed By: 
 
 
 
Comments:  
 
 
 
NOTE: Please see attached study calendar and a detailed instruction about each sample 
day (visit).  
 
Contact Study Coordinator at Medical Center: _____________________ 
Phone:  _____________________       Email:   _____________________ 
 
This complete form and samples should be mailed to the above address.  Samples should be 
shipped Monday-Thursday only to ensure samples will still be viable upon receipt.  
Please email the study team at BIDMC the day the shipment is sent out.  Thank you! 
 
       
 
  
 
 
  
 


Mixing IQC-950AN capsule contents with food  
Quercegen Pharma.  2015-10-29 rev 1 
 
The contents of IQC-950AN capsules can be mixed with a small amount of food to aid in patient 
compliance.  Based on the dissolution profile of the capsules we can expect that capsule contents are 
released in the stomach, and the stability of IQC-950AN is expected to be good in the stomach.  The 
capsule contents are light yellow colored and the powder is lightly acidic with an otherwise neutral to 
slightly bitter taste. The capsules can be opened and the contents mixed with a small portion of soft 
food. The capsules are “locking”, but not sealed, so they can be opened with some twisting and pulling 
over the food however it is recommended that the opening and emptying be performed for the subject  
as the capsules are tightly filled and assuring full emptying is important.  
The contents are not strong-tasting so it is not necessary to make extra efforts to mask the taste.  It is 
recommended to mix the capsule contents with an already acidic soft-food as this will blend well with 
the taste. It is not recommended to disperse in a liquid because of low solubility and possibility of 
powder sticking to container walls.  
Since the capsule contents are yellow colored, it is recommended to use a yellowish soft-food which is 
readily available such as puree of carrots or pumpkin puree, or a darker soft food such as prune puree. 
However, for dosing consistency a single option or fewer options are recommended.  
Suggested instructions; 
A. 
Carefully twist off the top portion of the capsule over the soft-food you plan to use. Rolling the 
capsules helps with emptying. 
 
B. 
Sprinkle the contents of the capsule on a small amount of room temperature acidic food,  we 
recommend  puree of  carrots or pumpkin puree. It is important to verify complete transfer.   
C. 
Swallow the capsule contents in the soft food mixture right away, and follow with enough water 
to make sure the contents of the capsules are swallowed completely. Do not store the capsule content 
mixed with food for later use. 


Related Information on Stability in Aqueous Suspensions 
It is recommended to use the IQC-950AN capsule content with a lightly acidic soft-food and cool or cold 
temperatures soon after preparation.   
Standard Dissolution Testing of the IQC-950AN capsules shows that the contents are released in the 
stomach (see GMP release documents).   It is also known that isoquercetin (the active component of  
IQC-950AN) is stable during incubation with gastric content preparations (Chang et al., 2005; Zuo et al., 
2006). 
The stability of the parent quercetin molecule is both pH and temperature dependent, with acidic 
conditions and lower temperatures assuring the stability of quercetin suspensions.  In an acidic aqueous 
suspension (pH 2.7) and refrigerator temperature ( 4 °C)  quercetin remained stable for the duration of 
the storage period (96 hours) while greater than 80% of quercetin was recovered in the pH 7 system.  At 
room temperature, the stability of quercetin was reduced, such that 50% and 20% of quercetin 
degraded in the first 25 hours at pH 7 and 2.7, respectively ( Moon et al., 2008) . 
With the proposed conditions there should not be a significant difference between the use of filled 
capsules or the use of capsule contents consumed within a soft-food.   
References 
Chang, Q., Zuo, Z., Chow, M.S.S., Ho, W.K.K., (2005) Difference in absorption of the two structurally 
similar flavonoid glycosides, hyperoside and isoquercitrin, in rats. Eur. J. Pharm. Biopharm. 59, 549–555. 
Moon YJ, Wang L, DiCenzo R, Morris ME. (2008) Quercetin pharmacokinetics in humans. Biopharm Drug 
Dispos. May;29(4):205-17. 
Zuo, Z., Zhang, L., Zhou, L.M., Chang, Q., Chow, M., (2006) Intestinal absorption of hawthorn flavonoids – 
in vitro, in situ and in vivo correlations. Life Sci. 79, 2455–2462. 
 
 
 
 
 


 
Version: 1.14.2016  
 
Page 1 of 4 
 
Study Participant Self‐Administration Instructions 
The study staff will explain how to take the study drug(s) Isoquercetin capsules, but these are 
points to remember: 
 
1)  Each capsule will be consumed once daily 
 
2) Capsules may be swallowed with or without food. The capsules can be opened and the 
contents mixed with a small portion of soft acidic food such as apple sauce, puree of carrots, 
or pumpkin puree (Phase II only). 
 
3)   Missed doses must be taken within four hours of scheduled dose. If longer than four hours, 
or if dose vomited, skip dose. 
 
Please call your doctor or research nurse before taking any new prescription or over‐the‐
counter medications/supplements other than the study drugs. 
 
For any problems, issues, or questions you may have, please contact: Kari Nicolazzo, RRN 617‐
667‐8350 
 
 
Study Participant Self‐Administration Study Drug Diary 
 
Please record how many capsules you take of study drug Isoquercetin, the time you take them 
and any comments here below and bring the completed Diary as well as your study drug 
supply, including empty bottles, to every study visit. This will help us keep track of your study 
drug and how well you are tolerating it. 
 
 
Participant Identifier:    
 
 
 
Cycle Number: 
Protocol #: 14‐114 
 
 
 
 
Assigned Dose:   
Doctor:   
 
 
 
Nurse: 
 
 
 
 
 
 
 
You will take the following number of capsules each time (per dose) as listed in the table below: 
 
Isoquercetin 
__ Capsules  
Once a day 
  
Within 4 hours of scheduled dose 
 
 
 
 
 


 
Version: 1.14.2016  
 
Page 2 of 4 
 
 
Date 
Number of 
Isoquercetin Capsules 
Time of Dose 
Explanation for missed dose 
1 
 
 
______:______  □ a.m. / □ p.m. 
 
□ Dose Not Taken   
 
2 
 
 
______:______  □ a.m. / □ p.m. 
  
□ Dose Not Taken   
 
3 
 
 
______:______  □ a.m. / □ p.m. 
  
□ Dose Not Taken   
 
4 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
5 
 
 
______:______  □ a.m. / □ p.m. 
  
□ Dose Not Taken   
 
6 
 
 
______:______  □ a.m. / □ p.m. 
  
□ Dose Not Taken   
 
7 
 
 
______:______  □ a.m. / □ p.m. 
  
□ Dose Not Taken   
 
8 
 
 
______:______  □ a.m. / □ p.m. 
  
□ Dose Not Taken   
 
9 
 
 
______:______  □ a.m. / □ p.m. 
  
□ Dose Not Taken   
 
10 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
11 
 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
12 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
13 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
14 
 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
15 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 


 
Version: 1.14.2016  
 
Page 3 of 4 
 
16 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
17 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
18 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
19 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
20 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
21 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
22 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
23 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
24 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
25 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
26 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
27 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
28 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
29 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
30 
 
 
______:______  □ a.m. / □ p.m. 
 
 □ Dose Not Taken   
 
 
Participant/Caregiver Signature: _______________________________Date:_______________ 


 
Version: 1.14.2016  
 
Page 4 of 4 
 
 
 
 
 
 
 
 
FOR STUDY TEAM USE ONLY
Staff Initials:
Date Dispensed:
Date Returned:
# pills/caps/tabs dispensed:
# pills/caps/tabs returned:
# pills/caps/tabs that should have been taken:
Discrepancy Notes:


SPANISH (US) 
 
EORTC QLQ-C30 (versión 3)  
 
Estamos interesados en algunas cosas sobre usted y su salud. Por favor, conteste todas las preguntas usted mismo/a 
marcando con un círculo el número que mejor se aplique a su caso. No hay respuestas “correctas” ni “incorrectas”. La 
información que nos proporcione se mantendrá estrictamente confidencial. 
 
Por favor, escriba sus iniciales: 
 
Su fecha de nacimiento (día, mes, año): 
 
La fecha de hoy (día, mes, año): 
31 
 
 
 
Para 
Un 
Bastante Extremada- 
 
 
nada 
poco 
 
mente 
1. ¿Tiene alguna dificultad para realizar actividades que requieran un 
 
gran esfuerzo como llevar una bolsa de compras pesada o una maleta?  1 
2 
3 
4 
2. ¿Tiene alguna dificultad para salir a caminar por largo tiempo? 
1 
2 
3 
4 
3. ¿Tiene alguna dificultad para salir a caminar por  
 
corto tiempo fuera de la casa? 
1 
2 
3 
4 
4. ¿Necesita quedarse en cama o en una silla durante el día? 
1 
2 
3 
4 
5. ¿Necesita ayuda para comer, vestirse, bañarse o ir al baño? 
1 
2 
3 
4 
 
Durante la última semana:  
Para 
Un 
Bastante Extremada- 
 
 
nada 
poco 
 
mente 
6.  ¿Estuvo limitado/a al hacer su trabajo u otras actividades diarias? 
1 
2 
3 
4 
7. ¿Estuvo limitado/a al hacer sus pasatiempos u otras  
 
actividades de tiempo libre?  
1 
2 
3 
4 
8.  ¿Le faltó el aire? 
1 
2 
3 
4 
9.  ¿Ha tenido dolor? 
1 
2 
3 
4 
10.  ¿Necesitó descansar? 
1 
2 
3 
4 
11.  ¿Ha tenido problemas para dormir? 
1 
2 
3 
4 
12.  ¿Se ha sentido débil? 
1 
2 
3 
4 
13.  ¿Le ha faltado el apetito? 
1 
2 
3 
4 
14. ¿Ha sentido náuseas? 
1 
2 
3 
4 
15.  ¿Ha vomitado? 
1 
2 
3 
4 
16.  ¿Ha estado estreñido/a? 
1 
2 
3 
4 
 
Por favor, continúe en la página siguiente


SPANISH (US) 
© QLQ-C30 Copyright 1995 EORTC Quality of Life Group. Todos los derechos reservados. Versión 3.0 
 
 
Durante la última semana:  
Para 
Un 
Bastante Extremada- 
 
 
nada 
poco 
 
mente 
17.  ¿Ha tenido diarrea? 
1 
2 
3 
4 
 
18.  ¿Estuvo cansado/a? 
1 
2 
3 
4 
 
19.  ¿Interfirió el dolor con sus actividades diarias? 
1 
2 
3 
4 
 
20.  ¿Ha tenido dificultad para concentrarse en cosas 
 
como leer el periódico o ver televisión?  
1 
2 
3 
4 
 
21.  ¿Se sintió tenso/a? 
1 
2 
3 
4 
 
22.  ¿Se preocupó? 
1 
2 
3 
4 
 
23.  ¿Se sintió irritable (enojado/a)? 
1 
2 
3 
4 
 
24.  ¿Se sintió deprimido/a? 
1 
2 
3 
4 
 
25.  ¿Ha tenido dificultad para recordar cosas? 
1 
2 
3 
4 
 
26.  ¿Ha interferido su condición física o su 
 
tratamiento médico con su vida familiar? 
1 
2 
3 
4 
 
27.  ¿Ha interferido su condición física o su 
 
tratamiento médico con sus actividades sociales? 
1 
2 
3 
4 
 
28.  ¿Le ha causado su condición física o su 
 
tratamiento médico dificultades económicas? 
1 
2 
3 
4 
 
Para las siguientes preguntas, por favor, marque con un círculo el número del 1 al 7 
que mejor se aplique a su caso 
 
29.  ¿Cómo calificaría su salud en general durante la última semana? 
 
 
1 
2 
3 
4 
5 
6 
7 
 
 
Muy mala  
 
 
 
 
Excelente 
 
30.  ¿Cómo calificaría su calidad de vida en general durante la última semana? 
 
 
1 
2 
3 
4 
5 
6 
7 
 
 
Muy mala  
 
 
 
 
Excelente 
 
 
 
 
Firma del participante:_______________________________