Conditions: Lung Neoplasms Carcinoma, Non-Small-Cell Lung
Keywords: Bronchoscopy Metformin
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 6
Healthy volunteers: no

Brief summary:
The purpose of this study is to learn whether it is better to receive the drug Metformin with standard of care for lung cancer or just standard of care.

Detailed description:
Participants will need to be scheduled to undergo a surgical resection of their lung cancer at the Mayo Clinic in Rochester, Minnesota. They will be asked to provide a blood sample prior to their surgery. Samples of tumor tissue and normal lung tissue will be taken from the samples removed during your lung surgery. The tissue will be used to evaluate DNA. A skin biopsy at the edge of the incision that has already been made will be done during your surgery. We will take the skin and grow skin fibroblasts. Then we will reprogram the skin fibroblasts into induced pluripotent cells. You will be "randomized" into one of the study groups to either take Metformin for 6 months with your standard of care follow up or to receive standard of care follow up.

Arms:
arm 1: Metformin 850mg twice a day arm 2: Standard of Care Observation

Interventions: intervention 1: Metformin intervention 2: Placebo Comparator
Intervention descriptions: intervention 1: None intervention 2: Standard of Care Observation

Protocol document:
Prot_SAP_000.pdf: 
 
 
A pilot study of metformin as a 
chemoprevention agent in non-
small cell lung cancer 
 
 NCT01717482 
 
November 10, 2014 


A pilot study of metformin as a chemoprevention agent in non-small cell lung cancer 
           
 
 
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CONFIDENTIAL 
A pilot study of metformin as a chemoprevention agent in non-small cell lung cancer 
 
 
Regulatory Sponsor: 
Dennis A. Wigle, MD PhD 
Mayo Clinic Rochester 
201 First SW 
Rochester MN 55095 
507-284-8462 
 
Funding Sponsor: 
 
Alliance CCOP Cancer Prevention/Symptom Intervention 
Pilot Grant 
Study Product: 
Metformin (Glucophage) 
Protocol Number: (IRBe) 
12-006865  
 
Version:                             
 Version 5-November 10, 2014 


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Table of Contents 
 
STUDY SUMMARY ...................................................................................................................................... 5 
INTRODUCTION ......................................................................................................................................... 6 
1.1 
BACKGROUND ................................................................................................................................ 6 
1.2 
DOSE RATIONALE AND RISK/BENEFITS ........................................................................................... 10 
2 
STUDY OBJECTIVES ........................................................................................................................ 10 
3 
STUDY DESIGN ................................................................................................................................. 10 
3.1 
GENERAL DESIGN ......................................................................................................................... 10 
3.2 
EMBEDDED CORRELATIVE STUDIES ................................................................................................ 11 
4 
SUBJECT SELECTION ENROLLMENT AND WITHDRAWAL ...................................................... 12 
4.1 
INCLUSION CRITERIA ..................................................................................................................... 12 
4.2 
EXCLUSION CRITERIA .................................................................................................................... 12 
4.3 
SUBJECT RECRUITMENT, ENROLLMENT AND SCREENING .................................................................. 12 
4.4 
EARLY WITHDRAWAL OF SUBJECTS ................................................................................................ 12 
4.4.1 
When and How to Withdraw Subjects ........................................................................................ 12 
4.4.2 
Data Collection and Follow-up for Withdrawn Subjects .............................................................. 12 
5 
STUDY DRUG .................................................................................................................................... 13 
5.1 
DESCRIPTION ................................................................................................................................ 13 
5.2 
TREATMENT REGIMEN ................................................................................................................... 13 
5.3 
METHOD FOR ASSIGNING SUBJECTS TO TREATMENT GROUPS ............................................................ 13 
5.4 
PREPARATION AND ADMINISTRATION OF STUDY DRUG ..................................................................... 13 
5.5 
SUBJECT COMPLIANCE MONITORING .............................................................................................. 13 
5.6 
PRIOR AND CONCOMITANT THERAPY .............................................................................................. 13 
5.7 
PACKAGING .................................................................................................................................. 13 
5.8 
RECEIVING, STORAGE, DISPENSING AND RETURN ............................................................................. 14 
5.8.1 
Storage ................................................................................................................................... 14 
5.8.2 
Dispensing of Study Drug ......................................................................................................... 14 
5.8.3 
Return or Destruction of Study Drug ......................................................................................... 14 
6 
STUDY PROCEDURES ...................................................................................................................... 14 
6.1 
VISIT 1 ......................................................................................................................................... 14 
6.2 
VISIT 2 ......................................................................................................................................... 14 
6.3 
VISIT 3 ......................................................................................................................................... 14 
6.4 
MONTHLY TELEPHONE CALLS ........................................................................................................ 14 
6.5 
HALF YEARLY FOLLOW UP ............................................................ ERROR! BOOKMARK NOT DEFINED. 
7 
STATISTICAL PLAN ......................................................................................................................... 15 
7.1 
STATISTICAL METHODS ................................................................................................................. 15 
8 
SAFETY AND ADVERSE EVENTS ................................................................................................... 15 
8.1 
DEFINITIONS ................................................................................................................................ 15 
8.2 
RECORDING OF ADVERSE EVENTS .................................................................................................. 17 
8.3 
REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS ...................................... 17 
8.3.1 
Sponsor-Investigator reporting: notifying the Mayo IRB ............................................................. 17 
8.4 
MEDICAL MONITORING ................................................................................................................. 17 
9 
DATA HANDLING AND RECORD KEEPING .................................................................................. 18 
9.1 
CONFIDENTIALITY ........................................................................................................................ 18 


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9.2 
SOURCE DOCUMENTS .................................................................................................................... 18 
9.3 
CASE REPORT FORMS .................................................................................................................... 18 
9.4 
RECORDS RETENTION .................................................................................................................... 18 
10 
STUDY MONITORING, AUDITING, AND INSPECTING ................................................................ 19 
10.1 
STUDY MONITORING PLAN ............................................................................................................ 19 
10.2 
AUDITING AND INSPECTING ........................................................................................................... 19 
11 
ETHICAL CONSIDERATIONS ......................................................................................................... 19 
12 
STUDY FINANCES ............................................................................................................................ 19 
12.1 
FUNDING SOURCE ......................................................................................................................... 19 
12.2 
CONFLICT OF INTEREST ................................................................................................................. 19 
13 
REFERENCES ................................................................................................................................... 20 
 
 
 
 
 
 


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List of Abbreviations 
 
 
AE 
Adverse Event/Adverse Experience 
CFR 
Code of Federal Regulations 
CRF 
Case Report Form 
CTCAE 
Common Terminology Criteria for Adverse Events 
DSMB 
Data and Safety Monitoring Board 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s Brochure 
IND 
Investigational New Drug Application 
iPSC 
Induced Pluripotent Stem Cells  
IRB 
Institutional Review Board 
NSCLC 
Non-Small Cell Lung Cancer 
PHI 
PI 
Protected Health Information 
Principal Investigator 
RFS 
Recurrence Free Survival 
SAE 
Serious Adverse Event/Serious Adverse Experience 
SCC 
Squamous Cell Carcinoma 
SOP 
Standard Operating Procedure 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Study Summary 
Title 
A pilot study of metformin as a chemoprevention agent in non-small 
cell lung cancer 
Running Title 
A pilot study of metformin as a chemoprevention agent in non-small 
cell lung cancer 
Protocol Number 
12-006865  
Phase 
Phase II-Pilot study 
Methodology 
Patients will be identified and enrolled from Thoracic Surgical Clinics. 
Patients will undergo surgical resection with the collection of tumor 
tissue, normal lung, blood, and skin biopsies.  For patients enrolled in 
the study that were found to have stage IA-IIIA SCC, starting less than 
90 days  from the time of surgery, patients will be randomized to 
receive either 850 mg po BID of metformin or observation. Metformin 
dosing will include a 4 week ramp up of 850 mg po daily prior to 
starting the BID dose, for a total of 6 months of Metformin. Patients will 
be followed for 2 years from the time of surgery to evaluate 2-year 
Recurrence Free Survival.  
Overall Study 
Duration 
08/01/2012 to 07/30/2017 
Subject Participation 
Duration 
2 Years 
Single or Multi-Site  
Single Site 
Objectives 
1. To evaluate the feasibility of patient randomization, accrual, and 
tissue collection in a pilot study of metformin versus observation 
following resection of stage IA-IIIA lung squamous cell cancer for 
patients. 
2. To compare the 2-year recurrence free survival rate between 
metformin and observation. 
Number of Subjects 
100 
Diagnosis and Main 
Inclusion Criteria 
Suspected or biopsy proven Stage IA-IIIA NSCLC (must be proven 
squamous cell carcinoma at the time of surgery)medically fit for 
surgical resection (based on surgeon assessment), current or prior 
smoker, age >18, no existing untreated or prior cancer <5 years from 
diagnosis, willing and able to consent to study, undergo study 
interventions, and take study drug; not diabetic or currently taking 
metformin or other diabetic drug, ECOG performance status 0,1, or 2. 
 
Study Product, Dose, 
Route, Regimen 
Metformin dosing will include a 4 week ramp up of 850 mg po daily prior to 
starting the BID dose. 
Duration of 
Administration 
Six Months  


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Reference therapy 
Observation 
 
Introduction 
Insufficient data for the feasibility of enrolling lung cancer patients to a trial protocol of 
metformin versus placebo with concurrent collection of biospecimens raises questions regarding 
the potential of performing a large, randomized, phase III study. The proposed pilot study will 
collect data to demonstrate the potential for enrolling patients to such a protocol, assess the 
feasibility of performing the study using the CCOP mechanism, collecting biospecimens from 
patients on study, and generate preliminary data to assess if a large, randomized, phase III study 
is indeed feasible and justified. 
Metformin is a widely prescribed oral medication used as front-line therapy for type 2 diabetes. 
It has been shown to inhibit the growth of cancer cell lines, including breast cancer, in vitro and 
in vivo tumor models. Population and retrospective studies showed that metformin decreases the 
incidence of cancer and cancer-related mortality, and increases the response to neoadjuvant 
chemotherapy in diabetic patients. As a result, metformin is being investigated as a therapeutic 
agent in different clinical settings for many cancer subtypes. Evidence for an anti-cancer effect in 
NSCLC would justify its use as a preventative agent in the patient with treated disease. 
Successful execution of the correlative studies described will increase understanding of genomic 
changes in the precursor lesion bronchial dysplasia, and reveal potential therapeutic targets to 
prevent disease progression. 
Phase I/II studies directed toward effects on existing tumors or pre-invasive lesions with 
surrogate endpoints have shown promise, but may not translate to real effects on the 
histologically normal tissue and cell types that are the true targets of chemoprevention. Our 
recent in vitro data indicating heterogeneity in metformin response suggest that all patients may 
not respond equally to its potential chemoprevention effects. The preliminary data to be gathered 
in the proposed pilot study will be critical to evaluate the feasibility of performing a randomized, 
phase III trial addressing this question as an Alliance study through the cooperative group 
infrastructure.  The pilot data will also serve as important preliminary data for a correlative 
studies R01 grant in conjunction with a larger trial, with aims of evaluating the effects of 
metformin on patients with resected Stage IB-IIIA NSCLC, creating cohorts of metformin 
responders and non-responders based on disease recurrence, and finally generating iPS cells for 
in vitro studies and development of a metformin response index. This pilot trial will also address 
an under-represented area (lung cancer) in the Alliance Prevention Committee portfolio. 
1.1 
Background 
Non-small cell lung cancer (NSCLC) 
Worldwide, lung cancer remains the leading cause of cancer-related death in men and the second 
leading cause of cancer-related deaths in women (Jemal et al., 2011). The American Cancer 
Society estimates an incidence of 221,130 new cases of lung cancer for 2011 with 156,940 
deaths (Siegel et al., 2011). Non-small cell lung cancer (NSCLC) accounts for more than 80% of 
all pulmonary neoplasms with greater than 60% of patients presenting with advanced or 
metastatic disease at the time of diagnosis [SEER; Little 2007]. Despite having a better chance 
for cure following surgical resection, even patients with early stage disease have a relatively high 


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risk of recurrence, with reported local recurrence rates ranging from 13% to 45% for Stage I 
disease and 17% to 55% for Stage II disease [Kelsey 2009, Lardinois 2005, Goodgame 2009]. 
Despite advances in screening, targeted therapies, adjuvant chemotherapy, minimally invasive 
surgery, and stereotactic radiation, the overall approach to lung cancer care has changed little in 
over 25 years, with relatively minimal improvements in survival. 
 
Metformin as a chemoprevention agent 
Metformin is an insulin sensitizer commonly used to treat diabetes. It lowers serum insulin levels 
and also directly inhibits cell growth. In addition to inhibiting gluconeogenesis, it also activates 
AMP kinase in epithelial cells by an LKB dependent mechanism. AMP kinase activation 
suppresses cell proliferation in malignant and nonmalignant cells by two different pathways -- 
inhibition of mTOR as well as through upregulation of p53/p21. Metformin may exert anti-
tumour effects through both insulin dependent and insulin-independent mechanisms. Metformin 
also has indirect anti-proliferative effects related to lower systemic levels of insulin. The drug is 
well tolerated even by individuals without diabetes and does not cause hypoglycemia. Its main 
limited side effects are transient nausea and diarrhea. Lactic acidosis, a major adverse effect, is 
rare and seen only in those with concomitant renal failure or liver disease. Recent studies have 
shown its potential as a cancer prevention drug in cancers such as breast, prostate, pancreas, and 
colon.  
 
In observational epidemiologic work, Evans et al. reported the risk of subsequent cancer 
diagnosis (all cancer types) was reduced in type 2 diabetics who received metformin (OR 0.85 
for any vs. no metformin exposure). The protective effect increased with greater metformin 
exposure (measured as total dose prescribed or total duration of use). Additionally, Bowker et al. 
reported cancer mortality was lower in diabetics receiving metformin (vs. sulfonylureas or 
insulin, HR 0.50-0.77), but they did not study diabetics not receiving any drug therapy. 
Furthermore, while confirming lower cancer risk in diabetics receiving metformin (versus those 
not receiving metformin).  Finally, Libby et al. have reported a significantly reduced risk of 
incident cancers (HR 0.63, 95% CI 0.53-0.75) in diabetics receiving metformin (versus those not 
receiving metformin); they recommended a randomized trial be conducted to “assess whether 
metformin is protective in a population at high risk for cancer”. Although many preventative 
agents have been or are being explored in NSCLC, such as sulindac, celecoxib, selenium, and 
others, none to date have shown proven benefit. 
 
Metformin for non-small cell lung cancer 
Large, phase III randomized studies for evaluating the effects of metformin as a 
chemoprevention agent are already underway in breast cancer. Although preliminary data 
suggests a potential effect in non-small cell lung cancer (Memmott RM et al., 2010), no trials 
addressing the question are yet open and enrolling. The recurrence rate for treated NSCLC 
ranges from 30-70% based on clinical and pathologic stage.  For patients in the Stage IB-IIIA 
stage categories, adjuvant platinum-based chemotherapy has shown proven benefit with an 
increase in 5 year survival of 5-13%. Despite this improvement, recurrence rates remain high. 
Preliminary data has suggested activity of metformin in reducing cancer risk. Because metformin 
is a generic, inexpensive, well known and generally well tolerated oral agent that is commonly 
used to treat diabetes (including lung cancer patients who have diabetes), its evaluation as a 
potential adjuvant treatment for NSCLC can take place in an accelerated fashion. As lung 


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squamous cell carcinoma commonly affects the proximal airways, in contrast to lung 
adenocarcinoma, which typically affects more distal airway-alveolar units, the potential to 
bronchoscopically survey for precursor lesions such as bronchial dysplasia or carcinoma in-situ 
is feasible. Given this, we will institute the described pilot study protocol to evaluate the 
feasibility of metformin administration and tissue collection and to characterize the genomic 
alterations associated with these disease phenotypes under the influence of metformin 
administration.  Interestingly, metformin has been linked to a number of the newly-identified 
genes identified with significant mutations in lung squamous cell carcinoma, including PTEN, 
PIK3CA, TP53, TSC1, BRAF, Notch1 and CREBBP. Whether metformin modifies the 
functional outcome for any of the novel mutations identified in invasive lung squamous cell 
carcinoma will be addressed in this pilot study. 
 
Genomic alterations in the development and progression of NSCLC 
A convergence of the ongoing rapid decrease in cost combined with increases in throughput for 
massively parallel sequencing technologies have set the stage for an exponential increase in the 
amount of detailed tumor sequencing data available. Pending results from the NCI sponsored 
TCGA projects in addition to other large-scale sequencing efforts for NSCLC will no doubt shed 
further light on recurring mutations in NSCLC and relevant molecular subtypes.  DNA 
sequencing of NSCLC has been incredibly productive to date. The potential for EGFR-directed 
therapy in lung adenocarcinoma was originally described by Paez et al. (2004), in a project 
sequencing the activation domain from numerous tyrosine kinase receptors in the human genome 
from NSCLC tumor specimens. Through this work and other studies (Lynch et al., 2004), 
mutations in EGFR were discovered that correlated with response to gefitinib, and the era of 
targeted therapy for lung adenocarcinoma was born. EGFR-directed tyrosine kinase inhibitors 
such as erlotinib and gefitinib have now been studied extensively in a number of large 
international clinical trials, demonstrating equivalence with platinum-based chemotherapy for 
patients harboring sensitizing EGFR mutations (Mok et al., 2009). In a similar manner, 
EML4/ALK translocations were discovered by sequencing an expression library from a 
surgically resected lung adenocarcinoma specimen. Soda and colleagues (2007) found an 
inversion within chromosome 2p that leads to the formation of a fusion gene comprising portions 
of the echinoderm microtubule-associated protein-like 4 (EML4) gene and the anaplastic 
lymphoma kinase (ALK) gene. Functional studies in mouse NIH3T3 cells demonstrated that 
forced expression of this human fusion tyrosine kinase generated transformed foci in culture and 
subcutaneous tumours in nude mice. Data suggest that patients who harbor this mutation do not 
benefit from treatment with EGFR-kinase inhibitors, but do show sensitivity to ALK inhibition. 
Recent clinical studies have shown that patients with EML4-ALK fusion NSCLC have a better 
overall survival with crizotinib treatment, a novel ALK inhibitor, than with standard platinum-
based chemotherapy (Shaw et al., 2011).  
 
Despite these dramatic advances, little is known about precursor lesions for NSCLC. 
Adenocarcinoma in situ (AIS) remains a poorly understood entity from the standpoint of 
genomic alterations. The availability of well-characterized biospecimens for genome sequencing 
studies has hampered efforts in understanding this presumed precursor lesion for lung 
adenocarcinoma. Lung squamous cell carcinoma, in contrast, has a readily accessible precursor 
lesion termed bronchial dysplasia. Bronchoscopic studies of patients with NSCLC show a high 
frequency of bronchial dysplasia and carcinoma in situ. No detailed genomic characterization of 


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such lesions has yet been performed.  Targeted agents which have been developed for the 
treatment of lung adenocarcinoma are largely ineffective for lung squamous cell carcinoma.  The 
underlying genomic alterations in lung SCC are poorly described, and no targeted agents are 
currently approved for the treatment of lung SCC. 
 
Metformin pharmacogenomics using patient-derived iPS cells 
A number of recent pilot chemoprevention trials in multiple tumor types have attempted to show 
signals for specific agents by applying them first against established, invasive tumors. The 
validity of this strategy in identifying chemoprevention agents remains to be determined. A 
contrarian view holds that such a strategy will never accurately identify true chemoprevention 
agents. Histologically normal bronchial airway epithelia represent the field within which pre-
invasive and then invasive malignancy develops in lung SqCC, and these cells represent the true 
target tissue for chemoprevention strategies in this disease. Assessing “response” however in the 
absence of a target lesion remains elusive. A further potential flaw in standard chemoprevention 
approaches is the unlikely possibility that all patients will show equivalent responsiveness to a 
specific strategy. Correctly identifying “responders” and “non-responders” to most 
chemoprevention agents has not been feasible, but may represent a crucial link to finding 
successful approaches. For example, recent data have suggested that LKB1 (STK11) mutations 
may influence responsiveness to either metformin or phenformin in vitro ( Shackelford et al., 
2013). Such genotypes in developing tumors might account for some of the heterogeneity in 
metformin responsiveness that has been observed in epidemiological studies across multiple 
tumor types.  
 
Since the discovery of induced pluripotent stem cells (iPSCs) in 2007, this technology has been 
used to model diseases, interrogate drug response and toxicity, and create multiple differentiated 
cell types in unlimited quantity to evaluate potential for therapeutic transplantation (Yamanaka, 
2012). Through ectopic expression of a series of pluripotency transgenes in somatic cells, 
specifically Oct4, Sox2, Nanog, and c-Myc, these cells develop properties similar to embryonic 
stem cells, with the ability to self-renew and differentiate into any cell population from all 3 
primary germ layers (Takahashi et al., 2007). Because this technology does not involve embryo 
destruction, it bypasses the ethical controversies associated with derivation of traditional 
embryonic stem cells. In addition to the compelling possibility of using iPSCs for therapeutic 
transplantation, there is a growing realization that in vitro pharmacogenomic studies may be an 
important application. Patient-derived iPS cells have been utilized to evaluate the 
pharmacogenomics of drug response in a growing number of disease and organ models. This 
principle has been applied to study cardiotoxicity, hepatotoxicity, and other pharmacogenomic 
paradigms in a patient, cell type and disease-specific context not feasible using other systems 
(Liang et al., 2013 and Medine et al,. 2013). Patient-specific iPS cells and their differentiated 
progeny may represent a new model for personalized medicine, with the ability to exhibit 
“patient in a dish” disease phenotypes or drug responses (Mordwinkin, et al., 2013). This model 
system represents unexplored potential to evaluate patient-specific responsiveness in 
chemoprevention. 
 


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1.2 
Dose Rationale and Risk/Benefits 
Metformin is mainly associated with gastro-intestinal side effects.  Previous trials have been 
done comparing metformin to a placebo that provided information about the frequency and 
magnitude of the main side effects and the contribution of GI symptoms to dropout rates.  It was 
found that gastrointestinal toxicity occurred more frequently in patients receiving metformin than 
placebo.  However lower doses of metformin (our dose is 1700mg/day) lead to less drop out than 
doses ≤ 2000mg/day. All patients are unlikely to respond equally to the chemoprevention effects 
of metformin. Evaluation of metformin response in vitro using lung epithelial cells derived from 
iPSCs offers a model to develop strategies for individualized chemoprevention. 
2 Study Objectives 
Primary objective for pilot study: 
1. To evaluate the feasibility of patient randomization, accrual, and tissue collection in a 
pilot study of metformin versus observation following resection of stage IA-IIIA lung 
squamous cell cancer for patients. 
2. To compare the 2-year recurrence free survival (RFS) rate between metformin and 
observation. 
Secondary objective(s) for pilot study: 
1. To develop the metformin sensitivity index based on iPS cell lines from the first 20 
patients randomized to the metformin arm. 
 
2. To apply the metformin sensitivity index on the remaining 25 patients randomized to 
metformin and the 45 observation patients (70patients total) to compare the 2-year RFS 
rate between metformin-sensitive and metformin-not-sensitive patients 
 
3. To compare adverse events between metformin and observation arms using CTCAE 
version 4. 
3 Study Design 
3.1 
General Design 
Patients will be identified and enrolled from Thoracic Surgical Clinics. Patients will undergo 
surgical resection with the collection of tumor tissue, normal lung tissue, blood, and skin 
biopsies.  For patients enrolled in the study that were found to have stage IA-IIIA SCC, starting 
less than 90 days  from the time of surgery, patients will be randomized to receive either 850 mg 
po BID of metformin or observation. Metformin dosing will include a 4 week ramp up of 850 mg 
po daily prior to starting the BID dose, for a total of 6 months of Metformin. Patients will be 
followed for 2 years from the time of surgery to evaluate 2-year RFS. We plan to randomize a 
total of 100 patients (50 per arm), such that 90 patients are evaluable for the primary endpoint.   
 


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3.2 
Embedded Correlative Studies 
Patients will be enrolled in the correlative studies as the volume of tissue permits. 
1. Derivation of fibroblast cultures from skin biopsy samples.  
Skin biopsies will be taken at the time of surgical resection. Biopsy samples taken in 
surgery will be taken as a 2mm x 2cm excision of a wedge of skin at the edge of the 
incision. Such excisions are frequently done as part of routine skin closure for optimal 
skin cosmesis following surgery. Samples are transported to the laboratory, and the 
epidermis and hypodermis removed. The dermis is cut into small pieces (<2 mm2) before 
plating in each well of a 6-well plate along with Dulbecco’s modified Eagle’s medium 
supplemented with 10% fetal calf serum, 1% L-glutamine and 1% 
penicillin/streptomycin. Within an average of nine days, dermal fibroblasts are visible by 
light microscopy. 
 
2. iPS cell reprogramming from skin fibroblasts.   
For defined metformin “responders” and “non-responders”, iPSCs will be generated. We 
plan to create a total of 50 iPS cell lines for subsequent in vitro differentiation and testing 
of metformin response. Fibroblast cell lines are plated at 105 per 24 wells then transduced 
with infectious supernatants bearing the stemness factors OCT3/4, SOX2, KLF4 and c-
MYC25 . Transduced fibroblasts are re-plated at confluence and iPS cells isolated after 
two weeks of clonal expansion. Cells are assessed by phase contrast microscopy for 
morphologic characteristics of iPS cells. iPS cell reprogramming will be performed in 
conjunction through the Regenerative Medicine Biotrust with our commercial partner 
ReGen Theranostics. 
 
3. Evaluation of genomic alterations in histologically normal airway epithelium, pre-
invasive lesions of lung SqCC, and invasive SqCC.   
DNA from biopsy specimens will be evaluated for DNA quantity and quality and 
subjected to mutation analysis using our panel of known genes. DNA will be prepared 
using standard protocols. A number of samples will also be used for exome sequencing as 
DNA quantities and funding permit. Data will be analyzed for the presence of mutations 
not present in germline DNA obtained via a blood sample. Mutation profiles will be 
compared between all patients receiving metformin versus placebo and correlated with 
clinical outcome.  The subject will give a 4ml blood sample (collected in EDTA tube) to 
be used as normal comparative sample of DNA. 
 
4. Biospecimen banking of blood, normal lung, lung tumor, and skin biopsy specimens and 
derivitives. 
All patients participating in the trial will be provided an opportunity to participate in 
Biospecimen banking for the correlative studies described above and future studies. 
Observation 


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Samples will be stored in the Mayo Clinic Lung Specimen Registry, Regenerative 
Medicine Biotrust repository, or in Dr. Wigle’s Thoracic Oncology Laboratory. 
4 Subject Selection Enrollment and Withdrawal 
4.1 
Inclusion Criteria 
• Suspected or biopsy proven Stage IA-IIIA lung squamous cell carcinoma (must be proven 
SCC at the time of surgery) 
• Medically fit for surgical resection (based on surgeon assessment) 
• Current or prior smoker 
• Age > 18 years old 
• Both Male and Female 
• Willing and able to consent to study, undergo study interventions, and take study drug 
• ECOG performance status 0, 1, 2 
• Subject must start Metformin within 90 days of surgery. 
4.2 
Exclusion Criteria 
• Currently taking metformin or other diabetic drugs 
• Current or previous congestive heart failure, renal failure or liver failure 
• Creatinine in Women of 1.4 or greater and Creatinine in Men of 1.5 or greater 
• Existing untreated or prior cancer <5 years from diagnosis 
• Received neo-adjuvant platinum-based chemotherapy or targeted therapy 
• Receiving adjuvant platinum-based chemotherapy or targeted therapy after surgical 
resection 
4.3 
Subject Recruitment, Enrollment and Screening 
• From the Principal Investigator or Co-Investigator clinical practices 
• Evaluation  of inclusion/exclusion criteria 
• Informed consent 
4.4 
Early Withdrawal of Subjects 
4.4.1 
When and How to Withdraw Subjects 
• Subject develops a diagnosis of diabetes  
• Failure of subject to adhere to protocol requirements 
• Subject decision to withdraw from the study (withdrawal of consent) 
4.4.2 
Data Collection and Follow-up for Withdrawn Subjects 
Even though a subject has withdrawn from the study, it may be important to 
collect some follow-up or survival data on such subjects throughout the protocol 
defined follow-up period. Such data is important to the integrity of the final study 
analysis since early withdrawal could be related to the safety profile of the study 
drug.  If a subject withdraws consent to participate in the study, for subject safety 
reasons, attempts should be made to obtain permission to collect follow up 
information whenever possible.  


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5 Study Drug  
5.1 
Description 
The metformin will be compounded and supplied in 850 mg capsules form by the Mayo Clinic 
Pharmacy, Research Support.   
5.2 
Treatment Regimen 
Metformin dosing will include a 4 week ramp up of 850 mg po daily prior to starting the BID 
dose.   
5.3 
Method for Assigning Subjects to Treatment Groups 
The randomization will occur using an envelope system that has been prepared by the statistical 
department.  A series of numbered envelopes will hold the designation of treatment arm.  After 
the subject is consented the next envelope in numerical order will be opened, randomly assigning 
the treatment arm, by the study team.  
5.4 
Preparation and Administration of Study Drug 
The metformin will be prepared by the Mayo Clinic Pharmacy, Research Support.  At the time of 
the visit it will be distributed by the study team.  Subsequent refills will be mailed to the subject 
by the pharmacy.  The patient will receive dosing instruction by the study team. 
 
Philip Christiansen, RPh 
 
 
 
Mayo Clinic Pharmacy, Research Support 
Mayo Clinic Pharmacy, Research Support 
 
538-0008 or pager 5-3523 
266-3472 or pager 127-03495 
 
 
mcpharmacyorss@mayo.edu  
christiansen.philip@mayo.edu 
5.5 
Subject Compliance Monitoring 
Subjects will be provided a medication diary in which they should track their administration of 
the metformin.  The study coordinator will make a monthly telephone call to assess the subject’s 
compliance.  Subjects who are found to be less than 90% compliant will be counseled in the 
importance of taking the treatment daily and the PI will be notified. 
5.6 
Prior and Concomitant Therapy 
The subject’s medications will be collected and reviewed prior to initiating the metformin or 
observation therapy to check for prior diabetes treatment.  Subjects will be excluded if the are 
receiving treatment with diabetic agents.  During the monthly telephone call the study 
coordinator will assess for any concomitant treatments with diabetic agents. 
5.7 
Packaging 
The metformin will be packaged by the Mayo Clinic Pharmacy, Research Support.  It will be 
distributed in 3 month increments of drug.  The initial doses will be distributed to the subject by 
the study team.  Refills will be sent to the subject by the Mayo Clinic Pharmacy, Research 
Support via mail.   


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5.8 
Receiving, Storage, Dispensing and Return 
5.8.1 
Storage 
The study agents will be stored by the Mayo Clinic Pharmcy, Research Support 
under their policies and procedures 
5.8.2 
Dispensing of Study Drug 
The pharmacy will be notified by the study team of subject enrollment and which 
arm the subject has been randomized to.  They will then dispense the appropriate 
agent to the subject. 
5.8.3 
Return or Destruction of Study Drug 
The remaining study agent will be returned to the study team following 6 months 
of metformin administration. At the completion of the study, there will be a final 
reconciliation of drug shipped, drug dispensed, drug returns, and drug remaining.  
This reconciliation will be logged on the drug reconciliation form, signed and 
dated.  Any discrepancies noted will be documented and investigated, prior to 
return or destruction of unused study drug.  Drug destroyed on site will be 
documented in the study files. 
6 Study Procedures 
6.1 
Visit 1 
The subject will be identified by the Thoracic Surgical Clinics.  The study coordinator will 
consent and enroll the subject.  The subject will have a blood sample taken for research. 
6.2 
Visit 2 
The subject will undergo surgical resection as part of their standard of care treatment.  
Stage IA-IIIA squamous cell carcinoma of the lung will be confirmed.  During the surgical 
resection the patient will undergo collection of tumor tissue, normal lung tissue, and skin 
biopsies for research.   
6.3 
Visit 3 
At the time of the subjects follow up (less than 90 days from the time of surgery) the 
subject will be seen be the study team.  Eligibility criteria will be assessed and if the 
subject is still eligible they will be randomized and receive their study treatment 
(metformin or observation).   
6.4 
Monthly Telephone Calls 
The study team will contact the subjects in the group taking Metformin monthly via 
telephone to assess drug compliance, adverse events, and any new diagnosis. 
6.5 
Half Yearly Follow Up  
The subjects will be followed every 6 months following surgery for a total of 2 years.  At 
the time of the first 6 month follow up the subjects receiving metformin will return any 
unused study drug and drug reconciliation will occur. 


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7 Statistical Plan 
7.1 
Statistical Methods 
All patients meeting the eligibility criteria, and who started treatment, will be considered 
evaluable for the 2 year RFS rate endpoint.  The proportion of 2 year RFS rates (along with the 
95% confidence interval) will be estimated within each arm by the number of patients who are 
recurrence-free and alive at 2 years divided by the total number of evaluable patients in each 
arm, and compared using a chi-squared test.  
 
Clinical data regarding recurrence-free survival (RFS) will be utilized for development of the 
metformin sensitivity index. Data collected will be summarized using descriptive statistics, 
including mean and standard deviation and median and inter quartile range for continuous 
variables, and using frequencies and percentages for categorical variables. Logistic regression 
models will be used to assess the impact of metformin sensitivity index metrics, treatment, and 
the interaction between the metformin sensitivity index metrics and treatment on the 2 year RFS 
status as the outcome of interest. 
 
Adverse events (AEs) will be compared between metformin and placebo using CTCAE version 
4. To evaluate the AE profiles associated with each intervention arm, the maximum grade for 
each type of AE will be recorded for each participant and frequency tables will be reviewed to 
determine the overall patterns.  The number and severity of AEs (overall and by intervention 
group) will be tabulated and summarized across all grades.  Chi-square tests will be used to 
compare the AE rates between metformin and placebo.   
8 Safety and Adverse Events 
8.1 
Definitions 
Unanticipated Problems Involving Risk to Subjects or Others (UPIRTSO) 
Any unanticipated problem or adverse event that meets the following three criteria:  
• Serious: Serious problems or events that results in significant harm, (which may be 
physical, psychological, financial, social, economic, or legal) or increased risk for the 
subject or others (including individuals who are not research subjects). These include: (1) 
death; (2) life threatening adverse experience; (3) hospitalization - inpatient, new, or 
prolonged; (4) disability/incapacity - persistent or significant; (5) birth defect/anomaly; (6) 
breach of confidentiality and (7) other problems, events, or new information (i.e. 
publications, DSMB reports, interim findings, product labeling change) that in the opinion 
of the local investigator may adversely affect the rights, safety, or welfare of the subjects 
or others, or substantially compromise the research data, AND 
• Unanticipated: (i.e. unexpected) problems or events are those that are not already 
described as potential risks in the protocol, consent document, not listed in the 
Investigator’s Brochure, or not part of an underlying disease. A problem or event is 
"unanticipated" when it was unforeseeable at the time of its occurrence. A problem or 
event is "unanticipated" when it occurs at an increased frequency or at an increased 
severity than expected, AND 
• Related: A problem or event is "related" if it is possibly related to the research procedures. 


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Adverse Event 
An untoward or undesirable experience associated with the use of a medical product (i.e. drug, 
device, biologic) in a patient or research subject. 
Serious Adverse Event 
Adverse events are classified as serious or non-serious.  Serious problems/events can be well 
defined and include; 
• death 
• life threatening adverse experience 
• hospitalization 
• inpatient, new, or prolonged; disability/incapacity 
• persistent or significant birth defect/anomaly 
 
and/or per protocol may be problems/events that in the opinion of the sponsor-investigator 
may have adversely affected the rights, safety, or welfare of the subjects or others, or 
substantially compromised the research data. 
 
All adverse events that do not meet any of the criteria for serious, should be regarded as non-
serious adverse events.  
 
Adverse Event Reporting Period 
Adverse events will be reported after the subject begins taking the metformin or starts the 
observation period.  The bronchoscopy and surgery are considered standard of care. 
 
Preexisting Condition 
A preexisting condition is one that is present at the start of the study.  A preexisting condition 
should be recorded as an adverse event if the frequency, intensity, or the character of the 
condition worsens during the study period. 
 
General Physical Examination Findings 
At screening, any clinically significant abnormality should be recorded as a preexisting 
condition.  At the end of the study, any new clinically significant findings/abnormalities that 
meet the definition of an adverse event must also be recorded and documented as an adverse 
event.  
 
Post-study Adverse Event 
All unresolved adverse events should be followed by the sponsor-investigator until the events are 
resolved, the subject is lost to follow-up, or the adverse event is otherwise explained.  At the last 
scheduled visit, the sponsor-investigator should instruct each subject to report, to the sponsor-
investigator, any subsequent event(s) that the subject, or the subject’s personal physician, 
believes might reasonably be related to participation in this study.  
 
Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization should be 
documented and reported as a serious adverse event unless specifically instructed otherwise in 


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this protocol.  Any condition responsible for surgery should be documented as an adverse event 
if the condition meets the criteria for an adverse event.  
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported as an 
adverse event in the following circumstances:  
• Hospitalization or prolonged hospitalization for diagnostic or elective surgical procedures 
for a preexisting condition.  Surgery should not be reported as an outcome of an adverse 
event if the purpose of the surgery was elective or diagnostic and the outcome was 
uneventful. 
• Hospitalization or prolonged hospitalization for therapy of the target disease of the study, 
unless it is a worsening or increase in frequency of hospital admissions as judged by the 
clinical investigator. 
8.2 
Recording of Adverse Events 
At each contact with the subject, the study team must seek information on adverse events by 
specific questioning and, as appropriate, by examination.  Information on all adverse events 
should be recorded immediately in the source document, and also on the appropriate adverse 
event worksheet.  All clearly related signs, symptoms, and abnormal diagnostic, laboratory or 
procedure results should recorded in the source document. 
 
All adverse events occurring during the study period must be recorded.  The clinical course of 
each event should be followed until resolution, stabilization, or until it has been ultimately 
determined that the study treatment or participation is not the probable cause.  Serious adverse 
events that are still ongoing at the end of the study period must be followed up, to determine the 
final outcome.  Any serious adverse event that occurs after the study period and is considered to 
be at least possibly related to the study treatment or study participation should be recorded and 
reported immediately. 
8.3 
Reporting of Serious Adverse Events and Unanticipated Problems 
When an adverse event has been identified, the study team will take appropriated action 
necessary to protect the study participant and then complete the Study Adverse Event Worksheet 
and log.  The sponsor-investigator will evaluate the event and determine the necessary follow-up 
and reporting required. 
8.3.1 
Sponsor-Investigator reporting: notifying the Mayo IRB 
The sponsor-investigator will report to the Mayo IRB any UPIRTSOs and Non-UPIRTSOs 
according to the Mayo IRB Policy and Procedures. 
 
8.4 
Medical Monitoring 
It is the responsibility of the Principal Investigator to oversee the safety of the study at his/her 
site.  This safety monitoring will include careful assessment and appropriate reporting of adverse 
events as noted above, as well as the construction and implementation of a site data and safety-
monitoring plan (see section 10  “Study Monitoring, Auditing, and Inspecting”).  Medical 
monitoring will include a regular assessment of the number and type of serious adverse events. 


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9 Data Handling and Record Keeping 
9.1 
Confidentiality 
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  
Those regulations require a signed subject authorization informing the subject of the following:  
• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of their PHI.  
In the event that a subject revokes authorization to collect or use PHI, the investigator, by 
regulation, retains the ability to use all information collected prior to the revocation of subject 
authorization.  For subjects that have revoked authorization to collect or use PHI, attempts 
should be made to obtain permission to collect at least vital status (long term survival status that 
the subject is alive) at the end of their scheduled study period. 
9.2 
Source Documents 
Source data is all information, original records of clinical findings, observations, or other 
activities in a clinical trial necessary for the reconstruction and evaluation of the trial.  Source 
data are contained in source documents.  Examples of these original documents, and data records 
include: hospital records, clinical and office charts, laboratory notes, memoranda, subjects’ 
diaries or evaluation checklists, pharmacy dispensing records, recorded data from automated 
instruments, copies or transcriptions certified after verification as being accurate and complete, 
microfiches, photographic negatives, microfilm or magnetic media, x-rays, subject files, and 
records kept at the pharmacy, at the laboratories, and at medico-technical departments involved 
in the clinical trial. 
9.3 
Case Report Forms 
The study case report form (CRF) is the primary data collection instrument for the study.  All 
data requested on the CRF must be recorded.  All missing data must be explained.  If a space on 
the CRF is left blank because the procedure was not done or the question was not asked, write 
“N/D”.  If the item is not applicable to the individual case, write “N/A”.  All entries should be 
printed legibly in black ink.  If any entry error has been made, to correct such an error, draw a 
single straight line through the incorrect entry and enter the correct data above it.  All such 
changes must be initialed and dated.  Do not erase or use “white-out” for errors.  For clarification 
of illegible or uncertain entries, print the clarification above the item, then initial and date it.  If 
the reason for the correction is not clear or needs additional explanation, neatly include the 
details to justify the correction. 
9.4 
Records Retention 
The sponsor-investigator will maintain records and essential documents related to the conduct of 
the study.  These will include subject case histories and regulatory documents as outlined in the 
Mayo Clinic Research Policy Manual –“Access to and Retention of Research Data Policy.” 


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10 Study Monitoring, Auditing, and Inspecting 
10.1 Study Monitoring Plan 
The investigator will allocate adequate time for such monitoring activities.  The Investigator will 
also ensure that the monitor or other compliance or quality assurance reviewer is given access to 
all the study-related documents and study related facilities (e.g. pharmacy, diagnostic laboratory, 
etc.), and has adequate space to conduct the monitoring visit. 
10.2 Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the IRB, the 
sponsor, and government regulatory agencies, of all study related documents (e.g. source 
documents, regulatory documents, data collection instruments, study data etc.).  The investigator 
will ensure the capability for inspections of applicable study-related facilities (e.g. pharmacy, 
diagnostic laboratory, etc.). 
 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable compliance offices. 
11 Ethical Considerations 
This study is to be conducted according to United States government regulations and 
Institutional research policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted local Institutional 
Review Board (IRB), in agreement with local legal prescriptions, for formal approval of the 
study.  The decision of the IRB concerning the conduct of the study will be made in writing to 
the sponsor-investigator before commencement of this study. 
 
All subjects for this study will be provided a consent form describing this study and providing 
sufficient information for subjects to make an informed decision about their participation in this 
study.  This consent form will be submitted with the protocol for review and approval by the IRB 
for the study.  The formal consent of a subject, using the Approved IRB consent form, must be 
obtained before that subject undergoes any study procedure.  The consent form must be signed 
by the subject or the subject’s legally authorized representative, and the individual obtaining the 
informed consent. 
12 Study Finances 
12.1 Funding Source 
This study is financed through a grant from the Alliance for Clinical Trials in Oncology.   
12.2 Conflict of Interest 
Any study team member who has a conflict of interest with this study (patent ownership, 
royalties, or financial gain greater than the minimum allowable by their institution, etc.) must 
have the conflict reviewed by a properly constituted Conflict of Interest Committee with a 
Committee-sanctioned conflict management plan that has been reviewed and approved by the 
study sponsor-investigator prior to participation in this study. 


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13 References 
American Cancer Society. Cancer facts and figures 2011. Atlanta, American Cancer Society; 
2011 
Boyle P, Levin B. World Cancer Report 2008. Lyon: International Agency for Research on 
Cancer, 2008. 
Bowker SL, Majumdar SR, Veugelers P, Johnson JA. Increased cancer-related mortality for 
patients with type 2 diabetes who use sulfonylureas or insulin. Diabetes Care 2006; 
29:254–8. 
Choi YL, Takeuchi K, Soda M, et al. Identification of novel isoforms of the EML4-ALK 
transforming gene in non-small cell lung cancer. Cancer Res. 68(13), 4971-6 (2008). 
Ding L, Getz G, Wheeler DA, et al: Somatic mutations affect key pathways in lung 
adenocarcinoma. Nature 455:1069-1075, 2008 
Drmanac R, Sparks AB, Callow MJ, et al. Human genome sequencing using unchained base 
reads on self-assembling DNA nanoarrays. Science. 2010 Jan 1; 327(5961):78-81. 
Evans JM, Donnelly LA, Emslie-Smith AM, Alessi DR, Morris AD. Metformin and reduced 
risk of cancer in diabetic patients. BMJ 2005; 330:1304-5. 
Goldstraw P, Crowley J, Chansky K, et al. The IASLC Lung Cancer Staging Project: proposals 
for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the 
TNM Classification of malignant tumours. J Thorac Oncol. 2(8):706-14 (2007). 
Goodgame B, Viswanathan A, Zoole J, et al. Risk of recurrence of resected stage I non-small 
cell lung cancer in elderly patients as compared with younger patients. J Thorac Oncol. 
2009 Nov; 4(11):1370-4. 
Goodwin PJ, Ligibel JA, Stambolic V. Metformin in breast cancer: time for action. J Clin 
Oncol 2009;27:3271–3. 
Hirsch HA, Iliopoulos D, Tsichlis PN, Struhl K. Metformin selectively targets cancer stem 
cells, and acts together with chemotherapy to block tumor growth and prolong 
remission. Cancer Res 2009;69:7507-11. 
Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer 
J Clin. 2011 Mar-Apr;61(2):69-90. 


A pilot study of metformin as a chemoprevention agent in non-small cell lung cancer 
           
 
 
Version 5 
 
 
Revised 11-10-2014 
Page 21 of 23 
 
CONFIDENTIAL 
Johnson L, Mercer K, Greenbaum D, Bronson RT, Crowley D, Tuveson DA, Jacks T. Somatic 
activation of the K-ras oncogene causes early onset lung cancer in mice. Nature. 2001 
Apr 26;410(6832):1111-6. 
Jones S, Chen WD, Parmigiani G, Diehl F, Beerenwinkel N, Antal T, Traulsen A, Nowak MA, 
Siegel C, Velculescu VE, Kinzler KW, Vogelstein B, Willis J, Markowitz SD. 
Comparative lesion sequencing provides insights into tumor evolution. Proc Natl Acad 
Sci U S A. 2008 Mar 18;105(11):4283-8. 
Kelsey CR, Marks LB, Hollis D, et al. Local recurrence after surgery for early stage lung 
cancer: an 11-year experience with 975 patients. Cancer. 2009 Nov 15;115(22):5218-
27. 
Kwak EL, Bang YJ, Camidge DR, et al. Anaplastic lymphoma kinase inhibition in non-small-
cell lung cancer.  N Engl J Med. 2010 Oct 28;363(18):1693-703. 
Landman GW, Kleefstra N, van Hateren KJ, Groenier KH, Gans RO, Bilo HJ. Metformin 
associated with lower cancer mortality in type 2 diabetes (ZODIAC-16). Diabetes Care 
2009. 
Lardinois D, Suter H, Hakki H, et al. Morbidity, survival, and site of recurrence after 
mediastinal lymph-node dissection versus systematic sampling after complete resection 
for non-small cell lung cancer. Ann Thorac Surg. 2005 Jul;80(1):268-74. 
Lee W, Jiang Z, Liu J, et al.. The mutation spectrum revealed by paired genome sequences 
from a lung cancer patient. Nature. 2010 May 27;465(7297):473-7. 
Liang P, Lan F, Lee AS, Gong T, Sanchez-Freire V, Wang Y, et al. Drug screening using a 
library of human induced pluripotent stem cell-derived cardiomyocytes reveals disease-
specific patterns of cardiotoxicity. Circulation. 2013;127:1677-91. 
Libby G, Donnelly LA, Donnan PT, Alessi DR, Morris AD, Evans JM. New users of 
metformin are at low risk of incident cancer: a cohort study among people with type 2 
diabetes. Diabetes Care 2009;32:1620–5. 
Lynch TJ, Bell DW, Sordella R, et al: Activating mutations in the epidermal growth factor 
receptor underlying responsiveness of nonsmall- cell lung cancer to gefitinib. N Engl J 
Med 350:2129-2139, 2004 


A pilot study of metformin as a chemoprevention agent in non-small cell lung cancer 
           
 
 
Version 5 
 
 
Revised 11-10-2014 
Page 22 of 23 
 
CONFIDENTIAL 
Medine CN, Lucendo-Villarin B, Storck C, Wang F, Szkolnicka D, Khan F, et al. Developing 
high-fidelity hepatotoxicity models from pluripotent stem cells. Stem Cells Transl Med. 
2013;2:505-9. 
Memmott RM, Mercado JR, Maier CR, Kawabata S, Fox SD, Dennis PA.  Metformin prevents 
tobacco carcinogen--induced lung tumorigenesis.  Cancer Prev Res (Phila).  2010 
Sep;3(9):1066-76. Epub 2010 Sep 1. 
Mok TS, Wu YL, Thongprasert S, et al: Gefitinib or carboplatin-paclitaxel in pulmonary 
adenocarcinoma. N Engl J Med 361:947-957, 2009 Nakamura H, Kawasaki N, Taguchi 
M, et al.  
Mordwinkin NM, Lee AS, Wu JC. Patient-specific stem cells and cardiovascular drug 
discovery. JAMA. 2013;310:2039-40. 
Paez JG, Jänne PA, Lee JC, et al: EGFR mutations in lung cancer: correlation with clinical 
response to gefitinib therapy. Science 304: 1497-1500, 2004 
Pollak M. Insulin and insulin-like growth factor signalling in neoplasia. Nat Rev Cancer 
2008;8:915-28. 
Shackelford DB, Abt E, Gerken L, Vasquez DS, Seki A, Leblanc M, et al. LKB1 inactivation 
dictates therapeutic response of non-small cell lung cancer to the metabolism drug 
phenformin. Cancer Cell. 2013;23:143-58. 
Shaw AT, Yeap BY, Solomon BJ, et al. Effect of crizotinib on overall survival in patients with 
advanced non-small-cell lung cancer harbouring ALK gene rearrangement: a 
retrospective analysis. Lancet Oncol. 2011 Oct;12(11):1004-12 
Shaw AT, Yeap BY, Mino-Kenudson M, et al. Clinical features and outcome of patients with 
non-small-cell lung cancer who harbor EML4-ALK. J Clin Oncol. 27(26), 4247-53 
(2009). 
Siegel, R., Ward, E., Brawley, O. and Jemal, A. (2011), Cancer statistics, 2011. CA: A Cancer 
Journal for Clinicians, 61: 212–236.  
Soda M, Choi YL, Enomoto M, et al: Identification of the transforming EML4-ALK fusion 
gene in non-small cell lung cancer. Nature 448:561-566, 2007 
Takahashi K, Tanabe K, Ohnuki M, Narita M, Ichisaka T, Tomoda K, et al. Induction of 
pluripotent stem cells from adult human fibroblasts by defined factors. Cell. 
2007;131:861-72. 


A pilot study of metformin as a chemoprevention agent in non-small cell lung cancer 
           
 
 
Version 5 
 
 
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Travis WD, Brambilla E, Noguchi M, et al. International association for the study of lung 
cancer/american thoracic society/european respiratory society international 
multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol. 2011 
Feb;6(2):244-85. 
Weir BA, Woo MS, Getz G, et al. Characterizing the cancer genome in lung adenocarcinoma. 
Nature 2007;450:893– 898. 
Wolf I, Sadetzki S, Catane R, Karasik A, Kaufman B. Diabetes mellitus and breast cancer. 
Lancet Oncol 2005;6:103–11. 
Yamanaka S. Induced pluripotent stem cells: past, present, and future. Cell Stem Cell. 
2012;10:678-84. 
Zakikhani M, Dowling R, Fantus IG, Sonenberg N, Pollak M. Metformin is an AMP kinase-
dependent growth inhibitor for breast cancer cells. Cancer Res 2006;66:10269-73.