Conditions: Breast Cancer
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 42
Healthy volunteers: no

Brief summary:
This is a non-randomized phase II trial of denosumab at 120 mg subcutaneous injection monthly in pre- and post-menopausal women diagnosed with stage 0-III breast cancer who are currently not receiving anticancer treatment with hormonal therapies, chemotherapy, or radiation. All patients will undergo quantification of breast density by MRI at baseline and after 6 months on denosumab. Because the therapeutic agent is an injectable drug, the investigators will conduct a single arm study with both pre- and post-treatment measurements to determine the extent of variability in breast density over time and a placebo treatment period or group will not be utilized. This is an investigator initiated trial and Amgen (SPONSOR) will provide the trial drug denosumab.

Detailed description:
According to the results of several studies footnoted in this protocol, there is now convincing evidence that extensive areas of radiographically-dense tissue in the breast is an independent risk factor for the development of breast cancer. Here, the investigators postulate that it is RANK ligand that mediates the association between breast density and risk of breast cancer for which progesterone is one of several factors that influence the availability of RANK ligand in mammary tissue to promote or sustain higher breast density. As such, the investigators hypothesize that inhibition of RANK ligand with the anti-RANK ligand antibody therapeutic agent denosumab will decrease breast density; a risk factor for breast cancer development. The investigators will test the primary hypothesis that RANK ligand inhibition by denosumab (Xgeva) given 120mg monthly to pre- and post-menopausal breast cancer patients will significantly decrease breast density over 6 months. Breast density will be assessed by magnetic resonance fat water imaging (MR-FW) of the breast. At the beginning of the study participants will be measured for a change in breast density by MRI between baseline 1 and baseline 2 (end of 3 months observation period). All patients will then receive 6 months of 120 mg denosumab subcutaneously every month with repeat MR imaging to obtain measurements after 6 months on denosumab. All participants will be asked to provide an optional core needle breast biopsy sample at baseline and after 6 months on denosumab.

Arms:
arm 1: 6 monthly subcutaneous injections of denosumab

Interventions: intervention 1: Denosumab
Intervention descriptions: intervention 1: monthly subcutaneous injections

Protocol document:
Prot_SAP_000.pdf: 
Page 21 of 23
1.
STUDY TITLE AND PROTOCOL VERSIONS
A PHASE II, SINGLE ARM CLINICAL STUDY OF DENOSUMAB EFFECT ON BREAST DENSITY AND 
BREAST TISSUE BIOMARKERS
Principal Investigators:
Alison Stopeck, M.D. (Stony Brook University, Stony Brook NY)
Clinical Study site:
PI Alison Stopeck, MD
Stony Brook Cancer Center
Lauterbur Drive
Stony Brook, NY 11794
Laboratory and Biomarker Study Site
Co-Investigator Patricia Thompson-Carino
Cedars Sinai Cancer Institute
Advanced Health Science Pavilion 
127 S San Vicente Blvd
Los Angeles, CA 90048
Amendment 
number
Protocol 
version
Version Date
Description
1
5
10/20/2015
Updated “Risks and Discomforts” section; removed cellulitis and 
edited the frequency of osteonecrosis of the jaw
2
6
12/18/2015
Modified the definition of menopause as “history of amenorrhea 
for at least one year or hormone levels (estradiol/FSH) consistent 
with postmenopausal status if post-hysterectomy status, or 
history of surgical/medical castration”; removed requirement of 
dentist visit to grant eligibility.
3
7
4/29/2016
Minor changes and clarifications to the Schedule of Events; 
introduced the “Breast and Bone Health” questionnaire; clarified 
validity of bloodwork for eligibility purposes; section 8.1 
“information on study agent” updated with new published efficacy 
and safety results; new UH research budget form 
4
8
10/28/2016
Removed osteopenia (T score < -1) as eligibility requirement; 
minor changes to the schedule of events (blood chemistry done 
at BL2, 4th injection and follow up visit)
5
9
12/19/2016
Title changed t
o “A Phase II, single arm clinical study of denosumab effect on 
breast density and breast tissue biomarkers”; section 27.2 is 
updated to reflect that we expect to complete the study with at 
least 20 evaluable women per group 
6
10
5/1/2017
Various risks and discomforts updates following Amgen release 
of yearly safety update; clarify that patients do not need calcium 
and/or vitamin D supplements if respective blood values are 
within range; increased overall payment to study subjects to max 
$250.
7
11
7/14/2017
Reduced number of blood investigations and assigned calcium 
and vitamin D to research budget
8
12
4/26/2018
Added patients on long term care with aromatase inhibitors to the 
study population; small edits to the analytical plan (no ADC or 
DW-MRI); specified blood investigations required to ascertain 
menopausal status in women who underwent surgical removal of 
1 or both ovaries in the previous 12 months; added a urine dip-
stick pregnancy test before each injection for women of 
reproductive potential. CTCAE v5 now in use for AEs
Approved: 3/3/2021
Expiration Date: 3/2/2022
Stony Brook University Human Subjects Committee (IRB)


Page 21 of 23
9
13
6/18/2018
Edited eligibility section to specify that women at elevated risk of 
developing breast cancer (e.g. hyperplasia or genetic risk) are not 
eligible for the study
10
14
9/11/2018
Removed the 3-month observation period. Reduced MRI 
schedule from 4 to 2 MRIs in total. Remove blood calcium STAT 
labs for injections 3, 4, 5 and 6. Dmab study injections can be 
administered at home by a trained nurse, unless risk factors for 
adverse reactions are present or low calcium. Range of follicular 
phase for premenopausal subjects is now defined as up to 14 
days from the start of the period.
Revised primary hypothesis and power estimation. Increased 
period of validity for baseline bloodwork. Updated risk of ONJ 
(section 10.1).
11
15
5/22/2019
Added 
exclusion 
criteria: 
thyroid/parathyroid 
surgery, 
malabsorption syndromes, hypoparathyroidism. Added additional 
calcium testing at injection #3 and 2 months (8 weeks) post last 
injection.
12
16
06/27/2019
Shortened washout period from chemotherapy/radiation from 3 to 
1 months
13
17
12/20/2019
Removed enrollment limitations relative to menopausal status 
14
18
05/05/2020
Removed requirement to document temperature in eCRFs during 
research visits. During COVID pandemic, will continue to obtain 
temperature readings per clinical guidelines prior to administering 
any study drug at home visit or at cancer center.  Will only treat 
afebrile subjects, but as temperature is not a safety test or an 
endpoint needed to reach study objectives will not document this 
result in eCRFs. 
15
19
01/05/2021
Edits to accommodate investigator Dr. Patricia Thompson’ 
moving her lab to Cedars Sinai (CA). Adding section “18.1 
COVID-19 risk mitigation and exceptions”. Edited section 28.4 to 
address data sharing modality with Cedars-Sinai (page 21)
2.
CONTACT INFORMATION
Principal Investigator:  Alison Stopeck, M.D.
Stony Brook Cancer Center
3 Edmund D. Pellegrino Road
Stony Brook, NY 11794-9447
Phone: 631-444-7217
Fax: 631-638-0915
Protocol Manager: Caterina Vacchi-Suzzi, PhD CCRP
Lauterbur Drive
Stony Brook, NY 11794
Phone: 631-216-2993
Caterina.vacchi-suzzi@stonybrookmedicine.edu
Approved: 3/3/2021
Expiration Date: 3/2/2022
Stony Brook University Human Subjects Committee (IRB)


Page 21 of 23
3.
TABLE OF CONTENTS
1.
STUDY TITLE AND PROTOCOL VERSIONS
1
2.
CONTACT INFORMATION
2
3.
TABLE OF CONTENTS
3
4.
PROTOCOL OVERVIEW
4
5.
STUDY RATIONALE AND BACKGROUND
5
5.1. Women still die from ER+ breast cancers...............................................................................5
5.2. Targeting RANKL for the prevention of breast cancer ............................................................5
5.3. Overall significance of the study .............................................................................................6
6.
STUDY HYPOTHESIS AND OBJECTIVES
6
6.1. Primary Objective:...................................................................................................................6
6.2. Planned Exploratory Objectives: .............................................................................................6
7.
PARTICIPANT POPULATION
7
8.
INFORMATION ON STUDY AGENTS
7
8.1. Denosumab.............................................................................................................................7
9.
RATIONALE FOR DRUG AND DOSE SELECTION
8
10. TOXICITY FOR DENOSUMAB REPORTED ADVERSE EVENTS AND IDENTIFIED RISKS 9
10.1.
Osteonecrosis of the Jaw (ONJ) ......................................................................................9
10.2.
Hypocalcemia ..................................................................................................................9
10.3.
Atypical femoral fracture ................................................................................................10
10.4.
Multiple vertebral fractures.............................................................................................10
10.5.
Hypersensitivity..............................................................................................................10
10.6.
Musculoskeletal pain......................................................................................................10
11. INFORMATION ON STUDY PROCEDURES
10
11.1.
Breast Biopsy Procedure ...............................................................................................10
11.2.
Risk associated with Breast Biopsy ...............................................................................11
11.3.
Breast Imaging Procedure .............................................................................................11
11.4.
FWR-MRI methods ........................................................................................................11
11.5.
Risk associated with Breast MRI ...................................................................................11
12. PARTICIPANT ELIGIBILITY
11
13. STUDY PARTICIPANT IDENTIFICATION
12
14. ASSIGNMENT TO STUDY GROUPS
12
15. STUDY PLAN AND SCHEDULE OF EVENTS
12
16. PARTICIPANT RECRUITMENT AND INFORMED CONSENT
13
17. SCREENING AND BASELINE VISIT PROCEDURES
13
18. TREATMENT PLAN AND EVENTS
14
18.1 COVID-19 pandemic risk mitigations and exceptions
14
19. DEFINITIONS
14
19.1Follow-up:..............................................................................................................................14
19.2End of Treatment: .................................................................................................................14
19.3End of Study:.........................................................................................................................15
19.4Withdrawal of Participant from Study: ...................................................................................15
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Expiration Date: 3/2/2022
Stony Brook University Human Subjects Committee (IRB)


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19.5Post-Intervention Evaluation and off-study monitoring:.........................................................15
20. AGENT ADMINISTRATION
15
21. CONCOMITANT MEDICATIONS
15
22. TOXICITY MONITORING AND RESPONSE PLAN
15
23. END OF TREATMENT PROCEDURES
16
24. URINE SAMPLE COLLECTION, PROCESSING AND ANALYSES
16
25. BLOOD SAMPLE COLLECTION, PROCESSING AND ANALYSES
16
25.1Clinical Blood Chemistry and Calcium Monitoring ................................................................16
25.2Blood Banking .......................................................................................................................16
26. DRUG FORMULATION AND PROCUREMENT
16
26.1Denosumab Physical and Chemical Characteristics.............................................................16
26.2Availability .............................................................................................................................17
26.3Agent Accountability..............................................................................................................17
26.4Packaging and Labels...........................................................................................................17
26.5Storage..................................................................................................................................17
27. STATISTICAL CONSIDERATIONS  
17
27.1Statistical analysis plan .........................................................................................................17
27.2Power Estimation ..................................................................................................................17
28. ADMINISTRATIVE CONSIDERATIONS
18
28.1Regulatory Board Review .....................................................................................................18
28.2Compliance with Protocol and Protocol Revisions................................................................18
28.3Participant Informed Consent................................................................................................18
28.4Data Management and Safety Monitoring.............................................................................18
29. DATA SAFETY AND MONITORING PLAN
18
29.1Protocol Data and Safety Monitoring Plan and Risk Level Designation................................18
29.1.1
Risk Level. .........................................................................................................................18
29.1.2
Identification of the DSMC obligated for oversight responsibilities:...................................19
29.1.3
Identification of the entity obligated for routine monitoring duties......................................19
29.1.4
Monitoring progress and data review process...................................................................19
30. DESCRIPTION AND REPORTING OF ADVERSE AND SERIOUS ADVERSE EVENTS
19
30.1Adverse Events .....................................................................................................................20
30.2Serious Adverse Events........................................................................................................20
30.3Reportable events .................................................................................................................20
30.4Plan for assuring data accuracy and protocol compliance....................................................21
30.5Additional Adverse Events Reporting....................................................................................21
31. PARTICIPANT PAYMENT
21
32. APPENDIX 1.1 and 1.2: Study Schedule for pre-menopausal and post-menopausal women 21
33. APPENDIX 2:  Reprints
21
34. APPENDIX 3: Common Toxicity Criteria, Version 5.0
21
35. APPENDIX 4: ECOG Performance Scale
21
36. APPENDIX 5: Abbreviations
21
37. APPENDIX 6: Xgeva® package insert
22
38. APPENDIX 7: Protocol Review Committee Approval letter
22
39. APPENDIX 8: Stony Brook Cancer Center PRMC policy
22
Approved: 3/3/2021
Expiration Date: 3/2/2022
Stony Brook University Human Subjects Committee (IRB)


Page 21 of 23
40. REFERENCES
22
4.
PROTOCOL OVERVIEW
This is a non-randomized phase II trial of denosumab at 120 mg subcutaneous injection monthly in pre- and 
post-menopausal women diagnosed with stage 0-III breast cancer who are currently in long term follow up care. 
Eligible participants may or may not be receiving anticancer treatment with aromatase inhibitors (either 
exemestane, letrozole or anastrozole), but must have completed all planned chemotherapy, or radiation for at 
least 1 month. All patients will undergo quantification of breast density by MRI at baseline  and after 6 months 
on denosumab. This is an investigator-initiated trial and Amgen will provide the trial drug, Xgeva®.
The primary endpoint of the study will be the change in breast density of the contralateral, uninvolved breast as 
measured by quantitative Fat Water Ratio mapping (FWR-MRI) comparing 6 months on denosumab (MRIEOS) to 
breast density by FWR-MRI at baseline (MRIBL). As changes in breast density in the contralateral, uninvolved 
breast will be the primary endpoint of the study, patients with bilateral breast cancer, bilateral mastectomies, or 
extensive breast implant in the contralateral breast will be ineligible. 
The following are planned exploratory endpoints.  
1) Change in tissue composition (epithelium, stroma and fat) after 6 months on denosumab as determined 
by paired biopsies performed pre and post denosumab therapy
2) Change in specific and global gene expression patterns in breast biopsy tissues after 6 months on 
denosumab 
3) Change in progestogen levels and the OPG/RANKL ratio after 6 months on denosumab
4) Circulating progestogen levels and the OPG/RANKL ratio will also be correlated to MRI-acquired fat-to-
water ratio at baseline and after 6 months of denosumab treatment.
For the tissue biomarkers, core needle biopsies will be obtained in a subset of women who consent to the optional 
procedure from the uninvolved contralateral breast at baseline and after 6 months of denosumab therapy. It is 
anticipated that ~75% women at baseline will provide tissue samples for cross sectional comparative analyses 
with MRI features at baseline and ~60% after 6 months on denosumab will agree to a second biopsy to provide 
tissue to conduct analyses of biomarker response to intervention. Tissue studies will include characterization of 
tissue histology (graded by cellularity and stromal elements) and molecular measures of proliferation and 
apoptosis. The attached schedule of events depicts the study schema and primary measurements to be 
conducted during the trial (Appendices 1.1 and 1.2).   
5.
STUDY RATIONALE AND BACKGROUND
5.1. Women still die from ER+ breast cancers 
Each year, more than 192,000 incident and 40,000 breast cancer deaths are recorded among women in the U.S. 
(1). Aromatase inhibitors (AIs) and selective ER modulators (i.e., tamoxifen) are effective in delaying or 
preventing the progression of ER+ disease in 50-70% of women diagnosed with ER+ tumors (2). AIs demonstrate 
modest, but consistently superior, efficacy for reducing risk of breast cancer events in postmenopausal women 
and are now the primary modality for adjuvant hormonal therapy in these patients (3). This success provides the 
proof of principle that breast cancer is a preventable disease.  In spite of significant success with hormone-
targeted therapies and improvements in selective use of chemotherapy, breast cancer remains a major cause 
of death in women.  This is partly due to the poor risk benefit ratio for the SERMS and AIs for primary prevention 
and the fact that there are currently no drug options for the prevention of ER negative disease, which tends to 
be more aggressive with early metastasis. 
5.2. Targeting RANKL for the prevention of breast cancer   
There is now convincing evidence that extensive areas of radiographically-dense tissue in the breast is an 
independent risk factor for the development of breast cancer (4-9). The presence of dense tissue that occupies 
Approved: 3/3/2021
Expiration Date: 3/2/2022
Stony Brook University Human Subjects Committee (IRB)


Page 21 of 23
more than 50 percent of the area of a mammographic image, which occurs in up to 30% of postmenopausal 
women, is associated with a three- to five-fold elevated risk of breast cancer. While strongly associated, the 
biological or mechanistic link between breast density and breast cancer risk has not been elucidated.  Of the 
factors that have been studied, menopause has the most profound effect on breast density with dramatic 
decreases observed in the 12 months following last menstruation. Progesterone as medroxyprogesterone 
acetate in combination with estrogen has a greater effect on breast density than estrogen only hormone therapy 
with decreases in breast density with agent withdrawal more evident with cessation of MPA + E than E alone. 
(Colacurci, Fornaro et al., Hofseth, Raafat et al. 1999) Postmenopausal hormone therapy, particularly 
combination therapies that include a progesterone component and, in particular, medroxyprogesterone acetate 
(MPA) prevent the decline in breast density and promote an increase in women with low breast density.  The 
effect of progesterone on the breast stroma and epithelial compartments, which collectively make up dense 
appearing tissue on a mammogram, are hypothesized, in part, to explain the higher risk of breast cancer among 
users of combination hormone therapy for menopausal symptoms. (Hofseth, Raafat et al. 1999, Campagnoli, 
Clavel-Chapelon et al. 2005, Narod 2011, Obr and Edwards 2012).  
More recently, it has been shown that progesterone upregulates the expression of RANK ligand in the breast 
and that by doing so is thought to act in the promotion of breast epithelial stem cells. (Obr and Edwards 2012)  
This effect has been postulated to explain the association between progesterone and breast cancer (see 
rationale for drug selection).  A number of factors have been shown to modulate the levels of RANK ligand, which 
is now hypothesized to act in the breast to promote the growth of mammary stem cells.  Here, we postulate that 
it is RANK ligand that mediates the association between breast density and risk of breast cancer for which 
progesterone is one of several factors that influence the availability of RANK ligand in mammary tissue to 
promote or sustain higher breast density.  As such, we hypothesize that inhibition of RANK ligand with the anti-
RANK ligand antibody therapeutic agent denosumab will decrease breast density, a risk factor for breast cancer 
development.   
5.3. Overall significance of the study 
This study will determine if therapeutic suppression of RANK ligand has a direct effect on breast tissue that is 
detectable as a decrease in breast density.  We will investigate the effect of denosumab on breast tissue using 
novel imaging approaches discussed below.  Secondarily, we will explore whether denosumab has direct effects 
on serum or breast tissue levels of OPG and RANK ligand gene expression and whether or not change in 
expression patterns correlates with change in breast density.  
6.
STUDY HYPOTHESIS AND OBJECTIVES
Our primary objective is to assess the effect of denosumab on breast density in pre and post-menopausal early 
stage breast cancer patients. Denosumab will be administered at 120 mg subcutaneously monthly for 6 months 
to pre and postmenopausal breast cancer patients, respectively with breast density assessed by magnetic 
resonance fat water imaging (FWR-MRI) of the breast. We will test the primary hypothesis that RANK ligand 
inhibition by denosumab (Xgeva) given 120mg q monthly will significantly decrease breast density over 6 months. 
The change in breast density from the baseline MRI (MRIBL) to the second MRI at the end of study visit (MRIEOS) 
(1 month after receiving the last denosumab study injection) will provide breast density measurements for 
determining change in breast density in women on intervention for 6 months (the primary objective).
6.1. Primary Objective: 
A comparison of the change in breast density as measured by MRI-acquired fat-to-water ratio (FWR-MRI) in the 
contralateral, unaffected breast pre- and post-denosumab (primary trial endpoint).
Hypothesis: At least 30% of women treated with denosumab will show a > 5% relative decrease in  breast 
density after 6 months denosumab treatment when compared to their baseline density. 
6.2. Planned Exploratory Objectives:
i.
Correlate baseline tissue characteristics (e.g., cellularity) and tissue biomarkers (e.g., Ki67, OPG, 
RANKL) to FWR-MRI to identify tissue correlates of MR image features at baseline. 
Approved: 3/3/2021
Expiration Date: 3/2/2022
Stony Brook University Human Subjects Committee (IRB)


Page 21 of 23
ii.
Explore change in mammary gland tissue architecture, cellularity and proliferation/apoptotic index in 
women consenting to serial biopsy pre and post-denosumab. 
iii.
Collect and bank urine and plasma for biomarker studies of denosumab effect on circulating OPG and 
RANKL concentrations and their ratio to each other.  
iv.
Collect and bank plasma for biomarker studies correlating hormone levels to baseline breast density
v.
Assess the levels of progesterone before and after denosumab treatment
7.
PARTICIPANT POPULATION 
Participants will be pre- and postmenopausal/perimenopausal women with early stage (stage 0-III) breast 
cancer, including having received biopsies for ductal or lobular carcinoma in situ, who are disease free at 
enrollment and who are at least 1 month post treatments including radiation, surgery and chemotherapy.  Women 
may or may not be on long-term hormonal therapy with aromatase inhibitors (e.g. letrozole, exemestane or 
anastrozole). We estimate a 10 % dropout rate prior to study conclusion (6 months imaging endpoints) for a total 
of 40 fully evaluable participants. As change in breast density is the primary outcome of the study, women are 
required to have a modifiable amount of breast density at baseline, based on mammographic evaluation within 
the last year. Thus, women with breast density in the unaffected breast described as scattered fibroglandular 
tissue, or greater, on mammography are eligible. Women with greater breast density (i.e. typically described as 
heterogeneously dense, mostly dense, etc. on mammography) are also eligible. The PI can evaluate the most 
recent mammograms and adjudicate the density for eligibility.
8.
INFORMATION ON STUDY AGENTS
8.1
 Denosumab  
Denosumab is a fully human monoclonal IgG2 antibody that binds with high affinity and specificity to RANK 
ligand (Kd 3 x 10-12 M). This binding prevents the activation of RANK and inhibits the formation, activation, and 
survival of osteoclasts, the result of which is a reduction in the number and function of osteoclasts and, 
consequently, a decrease in bone resorption and an increase in cortical and trabecular bone mass, volume, and 
strength (10). Denosumab is highly specific and binds only to RANK ligand and no other members of the tumor 
necrosis factor (TNF) family, including TNFα, TNFβ, TNF-related apoptosis-inducing ligand, or CD40 ligand 
(Elliott et al, 2006).
The safety and efficacy of denosumab for the prevention of skeletal-related events in patients with bone 
metastases from solid tumors was demonstrated in three international, randomized (1:1), double-blind, active-
controlled, non-inferiority trials comparing denosumab with zoledronic acid. In all three trials, patients were 
randomized to receive 120 mg denosumab subcutaneously every 4 weeks or 4 mg zoledronic acid intravenously 
(IV) every 4 weeks (dose adjusted for reduced renal function). Patients with creatinine clearance less than 30 
mL/min were excluded. In each trial, the main outcome measure was demonstration of noninferiority to time to 
first skeletal-related event (SRE) as compared to zoledronic acid. The breast cancer trial enrolled 2046 patients 
with advanced breast cancer and bone metastasis. Randomization was stratified by a history of prior SRE (yes 
or no), receipt of chemotherapy within 6 weeks prior to randomization (yes or no), prior oral bisphosphonate use 
(yes or no), and region (Japan or other countries). Forty percent of patients had a previous SRE, 40% received 
chemotherapy within 6 weeks prior to randomization, and 5% received prior oral bisphosphonates.  Median age 
was 57 years, 80% of patients were White, and 99% of patients were women. The median number of doses 
administered was 18 for denosumab and 17 for zoledronic acid.  Denosumab delayed the time to first SRE by 
18% and first or subsequent SRE by 23%.  Overall survival and progression-free survival were similar between 
arms in all three trials.
Recently published results from a placebo-controlled trial, involving 3425 postmenopausal, women with early-
stage HR-positive breast cancer currently receiving aromatase inhibitor therapy, confirmed that adjuvant 
denosumab reduced the risk of clinical fractures in this population, irrespective of their bone density status, at 
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Expiration Date: 3/2/2022
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Page 21 of 23
baseline (11). This study included over 900 patients treated with denosumab with normal bone mineral density 
at baseline who equally benefited from denosumab therapy compared to patients with osteopenia at baseline.  
More importantly, the same study found that after a median follow-up of four years, patients assigned to 
denosumab had an 18% reduced risk of disease recurrence or death compared with those assigned placebo 
(12). The ongoing double-blind placebo-controlled trial D-CARE (NCT01077154) randomized 4,509 women with 
stage II or III breast cancer to either denosumab 120mg monthly x 6 months (same regimen as in this study) and 
then continued therapy with q 3 months of Xgeva or a placebo for up to 5 years of treatment. Bone mineral 
density was not obtained at baseline and low bone mineral density was not an inclusion critieria.   From the 
population treated, it can be assumed that ~40-50% of the women who received denosumab treatment likely 
had normal bone density at baseline. Similarly, it can be assumed that a large fraction (~40-45%) of participants 
were pre-menopausal at accrual. The study started accrual in 2010 and reached its accrual goals in 2016.  Thus, 
all participants (over 2,250 women) randomized to denosumab received the agent for at least 6 months, and 
most have completed the 5 years of therapy. The study is reviewed for safety every 6 months by an external 
data and safety monitoring committee and no unusual safety signals have been reported with the study 
continuing as per protocol without revision.
Denosumab is FDA approved for prevention of skeletal-related events in patients with bone metastases from 
solid tumors, however its use in this protocol is investigational. The FDA has recognized an IND exemption for 
the use of denosumab in this study, in accordance to current regulations [21 CFR 312.2(b)].
9.
RATIONALE FOR DRUG AND DOSE SELECTION  
RANK may be expressed in human breast tumors and functional on breast cancer cells (13). Signaling through 
RANK/RANKL regulates the development of the mouse mammary gland during pregnancy. Transgenic mice 
overexpressing murine RANK exhibit increased mammary tumorigenesis relative to wild type mice in both 
induced (medroxyprogesterone acetate [MPA] + 1,7-dimethyl-benz(a) anthracene [DMBA]) and spontaneous 
(multiple pregnancies) models of mammary tumorigenesis (14). RANK expression is associated with an 
increased incidence of more extensive ductal hyperplasia and mammary intraepithelial neoplasia, an increased 
incidence of adenocarcinoma, as well as a shorter latency to tumor formation and increased numbers of tumors 
per gland in mouse (15). Conversely, inhibition of the RANK/RANKL axis reduces hormone-induced mammary 
epithelial proliferation and reduces the incidence of mammary tumors (14, 16). These observations support the 
hypothesis that inhibition of RANKL with denosumab may delay or prevent the development of breast cancer 
and/or disease recurrence in early-stage breast cancer.
Based on safety, pharmacokinetics and pharmacodynamic data from phase I, II and III studies, a dosing regimen 
of denosumab 120 mg SC Q4W for 6 months is proposed. Specifically, Study 20040113 tested five different 
dosing schedules of SC denosumab versus IV bisphosphonates in 255 patients with breast cancer and bone 
metastases: 30 mg, 120 mg or 180 mg SC given Q4W, and 60 mg or 180 mg given Q12W (17, 18). The regimen 
of 120 mg Q4W was associated with the greatest median reduction of the bone turnover marker, uNTX, at week 
13, the primary endpoint of the study. Unlike lower doses, a 120 mg Q4W schedule avoids low drug exposures, 
which could potentially translate into insufficient efficacy in some patients. Denosumab was found to be safe and 
well tolerated in all study arms.  As the duration of the study is only 6 months, long term and rare complications 
of denosumab therapy including ONJ and/or atypical fractures would be unexpected to occur.  In addition, treating 
at the maximal efficacious, yet safe dose of the drug will maximize our probability of discovering changes in breast 
density and/or tissue markers of breast risk that would foster the development of larger and longer duration trials 
of denosumab for preventing breast cancer recurrence.
Additionally, over 2,250 early stage breast cancer patients have been randomized to receive denosumab at 
120mg SC q month x 6 and then 120mg SC every 3 months for the next 4 and a half years (NCT01077154 
clinical trials.gov).  In this trial, decreased bone density was not an eligibility criteria and it can safely be assumed 
that many women (~40-50%) enrolled on this study had normal bone mineral density treated with this dose 
intensive schedule of denosumab. The trial completed accrual (study was enrolling patients from 2010-2016) 
and is in follow-up for the primary endpoint of bone metastases free survival (expected 2017).  Previously, 
denosumab was found to be superior to other bisphosphonates (zoledronic acid) in preventing skeletal-related 
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events in cancer patients with bone metastases, including breast, again irrespective of bone density (19). In this 
trial as well, no unexpected toxicity to denosumab was observed compared to zoledronic acid and the trial was 
never stopped or placed on hold by the external DSMB.  
Increasing evidence suggests that bone density at baseline does not alter the risk profile for short-term 
denosumab treatment. For this reason, we plan to enroll women regardless of their bone density in this trial 
involving 6 months of Denosumab therapy. However, we will continue to collect information on bone density at 
baseline, via DEXA scan as patients with low bone mineral density will receive known benefit from therapy.
Prolia (denosumab 60mg Q6mo) is commonly prescribed to patients in long term follow up care for breast cancer, 
especially those with hormone receptor positive disease and receiving anti-estrogen therapy. Treatment with 
aromatase inhibitors (anastrozole, exemestane, letrozole) does not alter breast density and does not increase 
the risk of side effects. 
10. TOXICITY FOR DENOSUMAB REPORTED ADVERSE EVENTS AND IDENTIFIED RISKS
The safety of Xgeva was evaluated in three randomized, double-blind, active controlled trials comparing 
denosumab to zoledronic acid for the prevention of skeletal related events in patients with bone metastasis from 
prostate cancer, breast cancer, or other solid tumors, or lytic bony lesions from multiple myeloma. A total of 2841 
patients received at least one dose of Xgeva (Appendix 6). The most common side effects attributable to 
denosumab were hypophosphatemia and hypocalcemia. Severe hyposphosphatemia (serum phosphorus less 
than 2 mg/dL) occurred in 15.4% of patients on denosumab compared to 7.4% of patients treated with the 
intravenous bisphosphonate zoledronic acid. Severe hypocalcemia (corrected serum calcium less than 7 mg/dL) 
occurred in 3.1% of patients treated with denosumab compared to 1.3% of patients treated with zoledronic acid.  
The most common side effects overall were fatigue/asthenia and nausea, but the majority of patients were also 
treated with chemotherapy on these trials. While no deaths from hypocalcemia have been reported in any of the 
phase 3 trials, rare (7) deaths have been described in patients with metastatic disease and co-morbidities or low 
serum calcium levels prior to initiation of denosumab therapy.  Patients with severe renal dysfunction (CrCl < 
30mL/min) are more likely to develop hypocalcemia. Data from these registration trials suggest renal 
insufficiency, nonadherence with vitamin D and calcium supplementation, prostate cancer, and lung cancer are 
risk factors for the development of grade 3 or 4 hypocalcemia.
In this trial, those patients with insufficient blood levels of calcium and/or vitamin D at baseline 1 will receive 
supplemental calcium 800 mg and vitamin D (minimum 1000 IU daily). All patients will have adequate vitamin D 
levels (25 hydroxy vitamin D >20 ng/mL) as quantified by serum levels prior to starting on therapy, be instructed 
on the symptoms of hypocalcemia, and have serum calcium levels measured prior to each denosumab dose to 
protect against the development of significant hypocalcemia.
10.1 Osteonecrosis of the Jaw (ONJ) 
In the primary treatment phases of the 3 pivotal phase 3 trials comparing denosumab to zoledronic acid for 
preventing SREs, ONJ was confirmed by an independent adjudication committee in 1.8% of patients receiving 
denosumab group and 1.3% of patients in the zoledronic acid group. When also including ONJ events occurring 
over an additional 4 months of blinded study in each trial, the incidence of confirmed ONJ was 2.2% in patients 
who received denosumab. The median time to ONJ was 14 months (range: 4 – 25). Risk factors for ONJ included 
tooth extraction (60%), and local tooth infection (48%) (20). 
The incidence of ONJ was more recently updated in 2016. In this publication, the patient-year adjusted incidence 
of confirmed ONJ was 1.1% in patients receiving long-term monthly denosumab therapy for either metastatic 
prostate or breast cancer during the first year of treatment with increasing incidence rates observed with longer 
durations of therapy. When considering only those patients being treated for metastatic breast cancer, the 
adjusted patient-year risk of ONJ was 0.9% for the first year of use (21). As our study limits denosumab 
administration to only 6 monthly doses or roughly half the 12 doses prescribed in these trials, the risk for ONJ in 
this study can be reasonably expected to be lower than the observed 0.9% incidence (or less than 10 out of 
10,000 patients).
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10.2 Hypocalcemia  
Denosumab can cause severe symptomatic hypocalcemia, and fatal cases have been reported from the 
postmarketing setting based on a recent review of cases.  Hypocalcemia needs to be corrected prior to initiating 
denosumab.  Calcium levels have to be monitored and all patients adequately supplemented with calcium and 
vitamin D.  If hypocalcemia occurs, additional short-term calcium supplementation may be necessary.  
10.3 Atypical femoral fracture  
Atypical femoral fracture has been reported with denosumab.  These fractures can occur anywhere in the femoral 
shaft from just below the lesser trochanter to above the supracondylar flare and are transverse or short oblique 
in orientation without evidence of comminution.  Atypical femoral fractures most commonly occur with minimal 
or no trauma to the affected area.  They may be bilateral and many patients report prodromal pain in the affected 
areas, usually presenting as dull, aching thigh pain, weeks to months before a complete fracture occurs.  During 
denosumab treatment, patients should be advised to report new or unusual thigh, hip or groin pain.  Patients 
presenting with such symptoms should be evaluated for an incomplete femoral fractures, and the contralateral 
femur should also be examined. 
10.4 Multiple vertebral fractures
There is a risk of for multiple vertebral fractures following discontinuation of Xgeva (denosumab 120mg) in 
subjects participating in ongoing clinical trials. These fractures are not due to bone metastases. The events 
occurred in post-menopausal women with malignancies who had previous fractures (vertebral or non-vertebral) 
or who had known osteoporosis. Xgeva’s effects on bone are known to be reversible and bone turnover increases 
after Xgeva is discontinued. Following discontinuation of Xgeva during study conduct or after study completion 
the Investigators should consider the individual subject’s risk for fractures and the benefit:risk ratio of initiating 
anti-resorptive therapy in accordance with local guidelines for managing osteoporosis.
10.5 Hypersensitivity  
Clinically significant hypersensitivity including anaphylaxis has been reported with use of denosumab.  Reactions 
may include hypotension, dyspnea, upper airway edema, lip swelling, rash, pruritus, and urticarial.  Clinically 
significant hypersensitivity has been identified as a contraindication for treatment with denosumab.  If an 
anaphylactic or other clinically significant allergic reaction occurs, appropriate therapy will be initiated and 
denosumab therapy permanently discontinued.
10.6 Musculoskeletal pain  
A safety assessment was performed on a cumulative review of clinical trial data and study serious adverse event 
and non-study adverse event reports of musculoskeletal pain.  Based on this assessment, musculoskeletal pain, 
including severe cases, has been identified as an adverse drug reaction based on data from the post marketing 
setting. 
11. INFORMATION ON STUDY PROCEDURES
During the study, participants will be asked to provide an optional breast biopsy at baseline (immediately prior to 
initiating denosumab therapy) and again at the end of study (EOS) visit, which will occur 1 month after receiving 
the 6th and last injection of denosumab therapy. Patients will undergo non-contrast, magnetic resonance imaging 
of the breast at baseline, and at the EOS visit as well. These procedures and their risks are described below. 
11.1 Breast Biopsy Procedure  
All participants will be asked to provide an optional core biopsy sample at baseline and after 6 months on 
denosumab; we estimate that ~75% will agree to the first and ~60% will agree to the second request, yielding 
approximately 12-13 pre- or postmenopausal participants with both baseline and 6-month on denosumab 
biopsies. For participants who consent to breast biopsy at baseline, the study subject will receive clinical orders 
to see a breast specialist (radiologist or surgeon) as a fee for service, and will use mammography images to 
identify two areas of increased radiographic density, located at least 2 cm apart, in the upper, outer quadrant of 
the contralateral (uninvolved) breast. For premenopausal women only, biopsies will be obtained during the luteal 
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phase of menses or days 18-24 after initiation of menses. Mammographically dense areas will be co-localized 
with ultrasound guidance, with their relative positions recorded by clock-face and linear distance away from the 
nipple. Under ultrasound guidance, a 14-gauge cutting needle will be used to obtain 8 tissue cores from one of 
the two identified high-density areas. Since 5-10 tissue cores are typically obtained during clinically indicated 
biopsy procedures, our tissue sampling protocol should not impose undue participant burden or risk.
 
11.2 Risk associated with Breast Biopsy  
A breast biopsy procedure will be offered to all participants as an optional procedure.  Potential risks associated 
with biopsy include: bleeding/bruising/hematoma formation at the biopsy site, pain at the site, rare instances of 
infection, and a small scar at the site.  The risk of significant bleeding complications requiring surgery or 
hospitalization is nil. However, there is a 30% risk of hematoma or bruising after breast biopsy that spontaneously 
resolves.
11.3 Breast Imaging Procedure  
All participants will undergo breast imaging by non-contrast MRI to obtain three-dimensional (3D) fat water ratio 
mapping at baseline (MRIBL) and at the EOS (MRIEOS) visit (6 months on study). All imaging procedures will 
adhere to FDA and OSHA guidelines. Images will be acquired on a Siemens 3T scanner with breast coils located 
at Stony Brook University Imaging Center. The MRI facility is shared by the hospital and research investigators. 
11.4 FWR-MRI methods 
Fat-water imaging will be performed on all patients. This method provides a robust lipid/water separation, which 
includes correction for field inhomogeneity and T2* decay. Data are acquired with various phase shifts between 
the fat and water signals. The separation of fat and water is then performed using an iterative algorithm (22). A 
6-echo gradient echo sequence will be used. 
11.5 Risk associated with Breast MRI  
The Magnetic Resonance Imaging protocols utilized in this study use standard magnetic fields and do not involve 
contrast reagents. Thus, there are no known risks to the participants from the imaging protocols.  However, 
patients with severe claustrophobia or electrically, magnetically, or mechanically activated implants 
(pacemakers, cochlear implants, etc.) are ineligible secondary to the increased risks from imaging inherent with 
their participation.   
12. PARTICIPANT ELIGIBILITY
Eligibility criteria will include: 

Women with first incidence of early stage (stages 0 – III) breast cancer, including DCIS and LCIS, who 
have completed all treatment, with the exception of aromatase inhibitors, and are cancer-free. Patients 
who do not have in situ or invasive cancers, but solely high risk lesions or are at increased risk of breast 
cancer (e.g. breast biopsies showing atypical ductal or lobular hyperplasia (ADH, ALH), with or without 
atypia, and/or genetic risk (i.e. BRCA 1/2 mutations)) do NOT qualify for the study.

Age ≥18 and ≤ 75 years

44 patients will be accrued as follows: either premenopausal as defined as regular menses (24-38 days) 
or postmenopausal/perimenopausal as defined by a history of amenorrhea for at least one year or 
hormone levels (estradiol/FSH) consistent with menopause if post-hysterectomy status, or history of 
surgical/medical castration, or having periods outside of the 24-38 days’ range. We estimate a 10% drop 
out rate.

Serum calcium or albumin-adjusted serum calcium must be ≥2.0mmol/L (8.0 mg/dL) and  2.9 mmol/L 
(11.5 mg/dL)

Vitamin D level (25-hydroxy vitamin D level) must be > 20 ng/mL at baseline 

At least 1 month post-surgery, -radiation or -chemotherapy

No prior or current use of IV bisphosphonates

No current use of oral bisphosphonates

Patients must have an unaffected, non-irradiated contralateral breast 
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
Significant breast density as determined by mammography and defined by the descriptive terms 
scattered fibroglandular tissue/densities, heterogeneously dense, or mostly dense tissue in the 
mammography report.

Adequate renal function defined as a serum creatinine < 1.5 x ULN or CrCl > 30mL/min

A willingness and ability to follow the study protocol, as indicated by provision of informed consent to 
participate

Willingness to being tested for current pregnancy and use of birth control while being treated with 
denosumab (pre-menopausal women only)
Exclusionary criteria will include:

Age > 75 or < 18 years

Subject has known sensitivity to any of the products to be administered during the study (e.g., mammalian 
derived products, denosumab, calcium, or vitamin D).

Patients have prior history or current evidence of osteonecrosis or osteomyelitis of the jaw.

Patients have active dental or jaw condition which requires oral surgery, including tooth extraction.

Patients have non-healed dental or oral surgery, including tooth extraction.

Patients with planned invasive dental procedures

Subject is pregnant or breast feeding, or planning to become pregnant within 5 months after the end of 
the treatment

Subject is of child bearing potential and is not willing to use, in combination with her partner, highly 
effective methods of contraception or abstinence during treatment and for 5 months after the end of 
treatment

Active infection with Hepatitis B, Hepatitis C, or Human Immunodeficiency virus (HIV)

Any condition or disorder that compromises the ability of the subject to provide written informed consent 
and/or comply with study procedures

History of claustrophobia

Have electrically, magnetically, or mechanically activated implants including cardiac pacemaker, cochlear 
implants, magnetic surgical clips or prostheses.

Patients have/had thyroid/parathyroid surgery, malabsorption syndromes, hypoparathyroidism
13. STUDY PARTICIPANT IDENTIFICATION
Participants who have been consented will be identified on study-related documentation and forms with a unique 
8 alphanumeric study identifier. These numbers will be issued to participants sequentially and no participant 
identification numbers will be re-assigned in the event that the participant is withdrawn from the study.
14. ASSIGNMENT TO STUDY GROUPS
The study will be a single institution, non-randomized trial.  All the consented participants will be given the study 
intervention. Perimenopausal women will be considered as postmenopausal, for the goals of this trial. In case of 
significant menstrual period frequency changes during the course of the study (e.g. premenopausal participants 
becoming peri-menopausal, or those resuming a regular period at the end of their breast cancer treatment, but 
originally enrolled as peri-postmenopausal), will be required to sign the consent of the new corresponding study 
group and visits will be scheduled accordingly for the remaining of the study. The coordinator will document 
schedule changes in a nurse’s note and an administrative tracking form. 
Patients who underwent hysterectomy without or unilateral salpingo-oophorectomy (removal of ovaries) in the 
previous 12 months will be tested for levels of estradiol, follicule-stimulating (FSH) hormone at screening, in 
order to determine their menopausal status. 
15. STUDY PLAN AND SCHEDULE OF EVENTS
The proposed study will be a non-randomized trial of pre- and postmenopausal women previously diagnosed 
with early stage breast cancer.  Women will receive denosumab 120 mg by subcutaneous injection monthly for 
6 months.  We will attempt to recruit all eligible patients from the breast cancer clinics of the Stony Brook Cancer 
Center. (Appendix 1.1 and 1.2: Schedule of Events).
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A total of 44 participants will receive denosumab 120 mg monthly for 6 months.  All participants will undergo two 
MR imaging studies during the study.  For the primary endpoints, participants will undergo MR Imaging at 
baseline and then again following 6 months on denosumab therapy.  For premenopausal women, all MRI scans 
will be performed within 14 days from the beginning of their menses to ensure the scan is performed during the 
follicular phase of their menstrual cycle. Blood and urine will be obtained at baseline, and after 3 and 6 months 
on denosumab for measures of RANK ligand and OPG as well as for future studies of effects of denosumab on 
urinary hormone metabolites.  Blood and urine will be obtained at the time of breast biopsy in all patients who 
consented to this procedure.
16. PARTICIPANT RECRUITMENT AND INFORMED CONSENT
Stony Brook Cancer Center staff not directly reporting to the PI Dr. Alison Stopeck will be responsible for 
identifying and recruiting candidate participants, evaluating their suitability for participation in the study, following 
participants during the treatment phase of the trial, monitoring participants for possible toxicity, and continuing 
to follow participants for subsequent toxicity during the post-treatment follow-up period.  
Recruitment will proceed under the auspices of our Clinical Trials Office.  Working in accordance with HIPAA 
regulations, study coordinators or treating medical staff who are not directly reporting to Dr. Alison Stopeck will 
identify potential participants and they will be screened for eligibility to the study.  Recruitment will occur in the 
breast cancer and high risk clinics of Stony Brook University.  
The research nurse will explain all aspects of the study in lay language to the potential eligible participants, 
answer all questions regarding the study, and confirm eligibility.  If the participant decides to participate in the 
study, she will be asked to review, sign and date the Informed Consent Form (ICF). The ICF has to be completed 
prior to initiating any study related procedures. The study agent will not be released to a participant who has not 
signed the ICF. Participants may terminate or withdraw from the study at any time and for any reason, including 
development of an adverse event (AE) or serious adverse event (SAE), noncompliance, medical 
contraindication, or desire without prejudice.
17. SCREENING AND BASELINE VISIT PROCEDURES
All participants will be asked to provide an optional core biopsy sample at their baseline visit.  For participants 
who consent to breast biopsy at baseline, the breast specialist at Stony Brook University (radiologist or surgeon), 
as a fee for service, will use mammography images to identify two areas of increased radiographic density, 
located at least 2 cm apart, in the upper, outer quadrant of the contralateral (uninvolved) breast. 
Mammographically dense areas will be co-localized with ultrasound guidance, with their relative positions 
recorded by clock-face and linear distance away from the nipple. Under ultrasound guidance, a 14-gauge cutting 
needle will be used to obtain up to 8 tissue cores from one of the two identified high-density areas. Since 5-10 
tissue cores are typically obtained during clinically indicated biopsy procedures, our tissue sampling protocol 
should not impose undue participant burden or risk. Representative FFPE (formalin fixed and paraffin embedded) 
specimens will be reviewed at Stony Brook University by pathology under the direction of Dr. Ken Shroyer, a 
board-certified anatomical pathologist who specializes in breast pathology. All research tissue cores are 
processed at Stony Brook University.  Evaluation of change in gene expression related to apoptotic, proliferation, 
and alternative biomarkers will be conducted in the laboratory of Dr. Thompson at Cedars Sinai Hospital, Los 
Angeles CA. All breast biopsies will be obtained 21 days +/- 3 days after the initiation of menses in 
premenopausal women to ensure that the biopsies are obtained during the luteal phase. A Material Transfer 
Agreement will be in place, covering shipping and receiving of study samples.
Blood chemistry results obtained up to 6 months prior to enrollment are considered valid for eligibility 
assessment. All other screening evaluations will be completed within 21 days of initiating the study.
The following events will occur at screening/baseline:  

Medical history including demographics (race, ethnicity, age, and etc.);

Review concomitant medication and supplement use in the past 30 days;

Vital signs (blood pressure, pulse);
•
Height and weight;
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•
Hematology (CBC/differential and platelet count) (results obtained up to 6 months prior to study initiation 
are valid for eligibility);
•
Chemistry panel (to include urea nitrogen, creatinine, ALT, AST, calcium, and phosphorus) (results 
obtained up to 6 months prior to study initiation are valid for eligibility);
•
Serum 25-hydroxy vitamin D level (serum vitamin D levels should be at or above 20 ng/mL). Additional 
vitamin D testing is not required unless clinically indicated). 
•
Serum calcium level
•
Quantification of estradiol, FSH and LH (for women who underwent hysterectomy within the previous 12 
months and at least 1 intact ovary)

Urine pregnancy test (pre-menopausal only) at each visit, ahead of treatment with denosumab
18. TREATMENT PLAN AND EVENTS
On study, injection visits will be scheduled every month (±10 days). The first 2 injections will be administered at 
Stony Brook Cancer Center, after ensuring that participants’ blood calcium is within the accepted range (between 
8.0mg/dL and 11.5 mg/dL). Upon patients’ request, the remainder of denosumab injections (injections 3 through 
6) will be administered at the participants’ homes. End of study (EOS) procedures (e.g. biopsy, MRI, research 
blood and urine etc.) will be conducted at the Cancer Center approximately 1 month after the 6th, and last, 
injection.  See Appendix 1.1 and 1.2 for a more detailed study plan.
 
The following events will occur on study.  

Denosumab 120 mg will be given subcutaneously at monthly intervals for a total of 6 injections

A chemistry panel (to include serum 25-hydroxy vitamin D, urea nitrogen, creatinine, ALT, AST, 
calcium, and phosphorus) will be performed at baseline.

Blood calcium levels will be checked before injections 1,  2, 3 and again approximately 8 weeks after 
the last denosumab injection. If serum calcium level is lower than 2.0 mmol/L (8.0 mg/dL) the 
participant will not receive the study drug and will be prescribed calcium supplements.  If symptomatic, 
the patient will be evaluated by a provider, or if asymptomatic their provider will be notified.  Once 
calcium levels are within range they may resume the study, but will be required to receive all study 
injections at the Cancer Center, and blood calcium levels will be measured and confirmed to be within 
range immediately prior to each injection.

Blood for serum OPG and RANK ligand levels will be obtained at baseline and at EOS visit (in 
premenopausal women, blood will be obtained during the luteal phase or days 18-24 after initiation 
of menses) (research blood)

A breast core biopsy at baseline and at the EOS visit for planned biomarker studies (OPG and RANK 
ligand) and storage for future studies (All breast biopsies will be obtained 21 days +/- 3 days after the 
initiation of menses in premenopausal women to ensure that the biopsies are obtained during the 
luteal phase. Urine and blood specimens will be obtained at the same time as breast biopsy for 
hormone levels).

Two non-contrast breast MRIs will be obtained over the course of this study (in premenopausal 
women breast MRI scans will be performed within 14 days from the beginning of menses, during the 
follicular phase) at baseline and again ~1 month after the 6th denosumab injection 

A urine sample for research biomarker studies will be obtained at baseline and at the EOS visit (in 
premenopausal women, urine will be obtained during the luteal phase or days 18-24 after initiation of 
menses) (research urine)

Vital signs (blood pressure, pulse);

Height and weight;

Review concomitant medications and supplements use in the past 30 days;

A 10 days’ window will be allowed for specimen collection and all procedures in postmenopausal 
women. 

18.1 COVID-19 pandemic risk mitigations and exceptions
Due to circumstances linked to the COVID-19 pandemic, we are implementing the following procedures, aimed 
at maximizing the safety of study subjects and staff and adherent to current hospital policies:
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-
Subjects who have any self-reported or documented symptoms compatible with COVID-19 infection 24 
hours prior to dosing or at the time of dosing, will not receive the study drug. Dosing will also be held at 
the discretion of the study investigator. Such situations will be documented, but will not be considered 
deviations. 
-
As currently specified in the protocol, subjects who miss two doses, for any reason, will be removed 
from the study and considered not evaluable. 
-
Subjects may elect to have their calcium tested at a lab of their choice ahead of dosing with study drug 
in in order to avoid coming to the Stony Brook Cancer Center.
-
However, if subjects’ insurance does not cover monthly calcium testing, subjects with normal, non-
decreasing, calcium values may skip the third blood calcium testing (i.e. ahead of third denosumab 
injection visit) at the discretion of study investigators, in order to limit contacts. This still constitutes a 
deviation reportable to the IRB. 
-
In order to minimize contact between study staff and subjects at the time of home visits, body 
measurements and vitals will not be documented.  This will not be considered a deviation and will not 
impact subjects’ safety or data integrity.
-
The final MRI/Biopsy may be postponed up to an additional 6 weeks based on COVID-19 precautions.
Subjects will be verbally notified of these changes and the communications will be documented in the subjects’ 
binders.
19. DEFINITIONS  
19.1 Follow-up: 
All participants will have a follow-up visit or telephone contact scheduled two months after the last 
dose of study medication/end-of-treatment to follow-up for AEs and SAEs that may have occurred 
during or after discontinuation from the study. AEs and SAEs probably or possibly caused by the 
study drug that are still ongoing at the time of discontinuation will continue to be followed weekly until 
resolution or stabilization of condition. Similarly, abnormal laboratory values probably or possibly 
caused by the study drug will be followed every 14 days until resolution or two months post last dose 
of study drug(s) whichever occurs first. 
  
19.2 End of Treatment: 
Study drug discontinuation is the time when study agent(s) administration is permanently 
discontinued for any reason.
19.3 End of Study: 
Defined as the time when a participant is permanently discontinued from any study evaluation for any 
reason.
19.4 Withdrawal of Participant from Study: 
Participants will be withdrawn from the study under the following circumstances: 

Study closure,

Unacceptable adverse event(s), as judged by the study physician, 

Participant decision to withdraw from the study or, in the judgment of the investigator, further 
participation would not be in the best interest of the participant,

The participant is noncompliant with study procedures
19.5 Post-Intervention Evaluation and off-study monitoring: 
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An end of study visit (EOS) visit will be scheduled ~1 month after the last denosumab injection or at 
early termination, if applicable. Calcium will be tested 2 months after the last injection at a follow up 
visit.
20. AGENT ADMINISTRATION
Denosumab - Study agent (Denosumab injectable, 120 mg active) will be nurse-administered. Toxicities 
associated with denosumab administration include pain at the injection site and symptoms of drug 
hypersensitivity including headache, rash, flushing, swelling, shortness of breath, nausea, or vomiting.  Clinically 
significant hypersensitivity including anaphylaxis has been reported with use of denosumab. Reactions may 
include hypotension, dyspnea, upper airway edema, lip swelling, rash, pruritus, and urticaria.  
21. CONCOMITANT MEDICATIONS
Patients may be instructed to take daily supplements of at least 800 mg calcium and at least 1000 IU of vitamin 
D, unless contraindicated or documented hypercalcemia (albumin-adjusted serum calcium >2.9mmol/L 
[11.5mg/dL] or ionized calcium >1.5mmol/L [6.0mg/dL] develops on study.
Due to differences in regional availability, a dosage form of Vitamin D that gives an equivalent of at least 1000 
IU daily may be given.
Patients on therapy with aromatase inhibitors will continue the treatment as clinically indicated. Changes in 
agent, dose or frequency will be captured in a Concomitant Medications Form, and reviewed at each study visit, 
and during the Follow Up phone call.
22. TOXICITY MONITORING AND RESPONSE PLAN

Administration of investigational product (denosumab) will be withheld for any subject who experiences 
a grade 3 or 4 adverse event per National Cancer Institute Common Terminology Criteria for Adverse 
Events (NCI CTCAE) reported by the investigator as related to investigational product, or osteonecrosis 
of the jaw (ONJ) as determined by the investigator or by an independent expert panel. Treatment may 
also be withheld upon discretion of the study doctor for any reason to remove risk or minimized discomfort 
to participants. Re-exposure to investigational product may occur when the event resolves to grade 1 or 
less or the subject’s baseline, and if the investigator and the sponsor agree subject safety will not be 
compromised. 

Osteonecrosis of the jaw (ONJ) can occur in subjects receiving denosumab. A dental examination with 
appropriate preventive dentistry should be considered prior to treatment with denosumab in patients with 
risk factors for ONJ.  Patients who are suspected of having or who develop ONJ while on denosumab 
should receive care by a dentist or oral surgeon.  Patients should be monitored for ONJ as part of routine 
clinical practice. Patients should be instructed to maintain good oral hygiene and avoid invasive dental 
procedures, if possible. Administration of investigational product (denosumab) will also be withheld 30 
days prior to any elective invasive oral/dental procedure.  Investigational product administration will be 
withheld until documented evidence of complete mucosal healing following any invasive oral/dental 
procedure. 

Participants that miss >2 doses of scheduled denosumab, regardless of cause, will discontinue study 
agent and proceed with end of treatment procedures.

There will be no dose modifications for toxicity during this study.
23. END OF TREATMENT PROCEDURES

Vital signs (Blood pressure, pulse);

Blood and urine samples for banking (research)

Review concomitant medications;

Review adverse events; 

End of Treatment procedures will be performed one month after the last study agent administration.   
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
Following discontinuation of study agent participants experiencing adverse events will be contacted 
weekly by telephone or clinic visit until resolution or stabilization of condition.  Abnormal laboratory values 
will be followed every 14 days until resolution or two months post last dose of study agent(s) whichever 
occurs first. 
24. URINE SAMPLE COLLECTION, PROCESSING AND ANALYSES
Urine will be collected at baseline visit, and at the end of study visit. Urine may be also collected at an 
intermediate visit (injection 4) if the participant elects to visit the clinic to receive her study drug.  All urine samples 
will be aliquoted in clinic the same day as collection and transported to the Thompson laboratory at Stony Brook 
Medical Center within 2 hours for storage at -80oC for future analyses. Following the relocation of Dr. Thompson’s 
laboratory to Cedars Sinai Hospital, Los Angeles, beginning January 2021, all previously and any newly collected 
urine samples will be transported to the Stony Brook Cancer Center Biobank where they will be stored at -80oC 
for future research. All urine specimens are labeled and tracked with a unique sample ID. The Thompson 
research lab developed and deployed Standard Operating Procedures that follow all regulations pertaining to 
lab safety, sample processing, specimen classification and repository management. These SOPs will be 
transferred to the Cancer Center Biobank under the direction of Dr. Richard Kew beginning January 2021.  
Subsequent urine biomarker studies conducted in the Thompson laboratory at Cedars Sinai Hospital will be 
conducted under a Material Transfer Agreement covering shipping, receiving and allocation of study samples.
25. BLOOD SAMPLE COLLECTION, PROCESSING AND ANALYSES
25.1 Clinical Blood Chemistry and Calcium Monitoring  
Blood for full clinical blood chemistry will be collected when enrollment is initiated following consent, at baseline. 
Before injections 1, 2, 3 and approximately 8 weeks after the last denosumab injection blood will be drawn to 
check calcium level. The chemistry panel, blood calcium, and pregnancy test are performed by a fee for service 
laboratory routinely utilized by the Cancer Center. The service lab holds current accreditation issued by the 
College of American Pathologists’ Laboratory Accreditation Program.  
25.2 Blood Banking  
Blood will be collected at baseline visit and EOS visit. Blood for research purposes may be also collected at an 
intermediate visit (injection 4) if the participant elects to visit the clinic to receive her study drug. All blood samples 
will be aliquoted in clinic the same day as collection and transported to the Thompson laboratory at Stony Brook 
Medical Center within 2 hours for storage at -80oC for future analyses.  Whole blood will be collected only once 
during the study at the first Baseline visit. Serum for banking will be collected in a Red top Vacutainer. Plasma 
for banking will be collected in a Lavender top EDTA Vacutainer. Whole blood will be collected from the same 
Lavender top EDTA Vacutainer. Vacutainer tubes are centrifuged the same day as collection. All blood 
specimens are labeled and tracked with a unique sample ID. All blood samples will be processed to serum and 
plasma and transported within 2 hours for storage in aliquots at -80°C for future analysis. All blood derived 
specimens will be stored in the Cancer Center Biobank. Following the relocation of Dr. Thompson’s laboratory 
to Cedars Sinai Hospital, Los Angeles, beginning January 2021, all previously and any newly collected blood 
sample products will be transported to the Stony Brook Cancer Center Biobank where they will be stored at -
80oC for future research. All urine specimens are labeled and tracked with a unique sample ID. The Thompson 
research lab developed and deployed Standard Operating Procedures that follow all regulations pertaining to 
lab safety, sample processing, specimen classification and repository management. These SOPs will be 
transferred to the Cancer Center Biobank under the direction of Dr. Richard Kew beginning January 2021.  
Subsequent future blood based biomarker studies conducted in the Thompson laboratory at Cedars Sinai 
Hospital will be conducted under a Material Transfer Agreement covering shipping, receiving and allocation of 
study samples.
26. DRUG FORMULATION AND PROCUREMENT
26.1 Denosumab Physical and Chemical Characteristics  
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Denosumab is a fully human monoclonal IgG2 antibody that binds with high affinity and specificity to RANK 
ligand (Kd 3 x 10-12 M). This binding prevents the activation of RANK and inhibits the formation, activation, and 
survival of osteoclasts, the result of which is a reduction in the number and function of osteoclasts and, 
consequently, a decrease in bone resorption and an increase in cortical and trabecular bone mass, volume, and 
strength. Denosumab is highly specific because it binds only to RANK ligand and does not bind to other members 
of the tumor necrosis factor (TNF) family, including TNFα, TNFβ, TNF-related apoptosis-inducing ligand, or CD40 
ligand. Denosumab has an approximate molecular weight of 147kDa and is produced in genetically engineered 
mammalian (Chinese hamster ovary) cells.  Denosumab will be supplied as a sterile, clear, colorless to slightly 
yellow, preservative-free liquid, in single-use 3.0 mL glass vials containing a deliverable dose of 1.7 mL. .
  
26.2 Availability 
Denosumab is available as 120mg/1.7mL in single-use vials and will be obtained from the Stony Brook Cancer 
Center Pharmacy and supplied by Amgen.  Study agent will be stored in the Stony Brook Cancer Center 
Pharmacy. Denosumab is a clear, colorless to pale yellow solution that may contain trace amounts of translucent 
to white proteinaceous particles.  Prior to administration, denosumab will be removed from the refrigerator and 
brought to room temperature by standing in the original container.  A 27-gauge needle will be used to withdraw 
and inject the entire contents of the vial subcutaneously into the upper arm, upper thigh, or abdomen of the 
subjects.  
26.3 Agent Accountability 
Stony Brook Cancer Center Pharmacy will maintain a careful record of the inventory and disposition of all agents 
received using the NCI Drug Accountability Record Form (DARF) or similar record. Duties include maintaining 
adequate records of receipt, dispensing and final disposition of study agent(s).  
26.4 Packaging and Labels 
Denosumab will be provided by Amgen and dispensed through the Stony Brook Cancer Center by a licensed 
oncology pharmacist and dispensed by the treating physician’s order.
26.5 Storage 
Study medication will be stored at room temperature (59° to 86° F), protected from environmental extremes and 
in a locked cabinet or room prior to being issued to participants.
27. STATISTICAL CONSIDERATIONS  
27.1 Statistical analysis plan 
The primary endpoint of the study is the change in breast density of the contralateral, uninvolved breast as 
measured by quantitative Fat Water Ratio (FWR-MRI) mapping after 6 months on denosumab compared to 
baseline. Statistical analysis for the primary endpoint will estimate the change in breast density between 0 and 
6 months, which is defined as (baseline BD-month 6 BD)/baseline BD. Percentages of patients who have at least 
5% drop in BD and corresponding 90% Blyth-Casella-Still confidence intervals (CI) will be reported.  
Analysis of the exploratory endpoints of changes in tissue composition, gene expression patterns, hormone 
levels and OPG/RANKL ratio will be performed using paired t-tests or Wilcoxon signed rank tests if the data are 
not normally distributed. Correlations between hormone levels and OPG/RANKL ratio with the FWR-MRI 
acquired MRI-derived BD values at baseline and 6 months after therapy will be estimated using linear mixed 
effect models for repeated measures where patient will be treated as a random effect. This model also allows to 
test if such correlation changes after intervention. Model assumption will be diagnosed and data transformation 
may be necessary to make the assumption met. 
   
27.2 Power Estimation
In this pilot study we assume an initial sample size of 44 either pre-menopausal or post-menopausal women and 
allow the possibility of ~10% dropout for the 6-month measurement. This results in about 40 evaluable women. 
The primary trial endpoint is defined as the difference in the change in FWR-MRI-derived BD after 6 months on 
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intervention. Our study hypothesis is that at least 30% patients in each group will have >5% drop in BD after 6-
month Denosumab therapy. Table 1 below shows the estimated rate of patients who had >5% drop and  its 
corresponding 95% Blyth-Casella-Still CIs using 40 evaluable patients. Table 1 suggests that if there are 18 out 
of 40 patients having >5% drop in BD, we are 90% confident to conclude that at least 31.7% patients will have 
>5% drop in BD after 6 months of Denosumab therapy. 
Table 1: Estimated rates of patients who have >5% drop in BD and corresponding 90% Blyth-Casella-Still 
confidence intervals based on 40 evaluable patients
# of patients having >5% drop in BD 
after 6 months of Denosumab therapy
Estimated rate
90% Blyth-Casella-Still CI
12
30%
18.5 – 43.3%
14
35%
23.4 – 48.3%
16
40%
26.9 – 54.2%
18
45%
31.7 – 59.1%
19
47.5%
35 – 61.5%
 
28. ADMINISTRATIVE CONSIDERATIONS
28.1 Regulatory Board Review 
The study protocol will be activated after review and approval by the Stony Brook Cancer Center Protocol Review 
Committee and the University’s Human Subjects Protection Program (IRB). Approval of this protocol by the IRB 
will also include approval of the protocol consenting document, or Informed Consent Form (ICF) and the 
accompanying HIPAA consenting instrument. 
28.2 Compliance with Protocol and Protocol Revisions 
Study PI and CO-PI will conduct the study as described in this protocol. Any protocol revisions made in 
amendments to the protocol by the Principal Investigator will be approved by the IRB prior to implementation, 
except where necessary to avoid imminent hazard to a study participant.  If an amendment alters the study 
design or increases the potential risk to the participant, the ICF will be revised and submitted for approval to the 
IRB. The revised ICF will be used to obtain consent from participants currently enrolled in the study or after 
withdrawal from the study if they are affected by the Amendment.
  
28.3 Participant Informed Consent 
All study participants will sign the most current ICF that has been approved by the IRB prior to enrollment on the 
study. Investigators will have ensured that participants are clearly and fully informed about the purpose, potential 
risks and any other critical issues regarding this clinical trial.
28.4 Data Management and Safety Monitoring 
Participant safety and data integrity will be monitored by the Stony Brook Cancer Center’s Data Safety and 
Monitoring Committee (DSMC) in conjunction with the Quality Assurance/Quality Control Program (QA/QC). The 
Protocol Review Committee approval letter, which states the frequency of data review, is attached in Appendix 
8.
Prior to study registration, a review of the potential participant’s eligibility will include a confirmation of the 
inclusion/exclusion criteria and proper execution of informed consent. All participants registered to this study will 
be entered into the Stony Brook Cancer Center database for accrual and treatment status tracking. In addition, 
a registration log will be maintained utilizing the pre-prepared form to keep track of study number, verification of 
consent, date of consent, and other relevant registration data. Electronic Case Report Forms (CRFs) will be 
utilized. All participant study files will be stored in a secure area limited to authorized staff.
The Principal Investigator will ensure the accuracy, completeness and timeliness of the data reported in these 
forms. Source documentation supporting the CRF data should indicate the participant’s participation in the trial 
and should document the dates and details of study procedures, adverse events, and participant status.
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The Stony Brook study team will generate a coded database and remove PHIs (the code will remain at SB) and 
send it via secure email communication to investigators at Cedars-Sinai. 
29. DATA SAFETY AND MONITORING PLAN
29.1 Protocol Data and Safety Monitoring Plan and Risk Level Designation.  
29.1.1 Risk Level.  
This trial has been designated as a medium risk study. Medium risk studies are intended to include all trials 
involving therapeutic intervention(s), which are not designated as high risk per NCI and the IND is not held by 
the investigator. 
29.1.2 Identification of the DSMC obligated for oversight responsibilities: 
The Stony Brook Cancer Center Data Safety and Monitoring Committee (DSMC) will provide ongoing oversight 
for this trial semi-annually. In addition, the investigators will convene an ad hoc DSMC comprised of Alexander 
Stessin MD, PhD, a radiation oncologist with expertise in breast cancer, a statistician (Erin Taub), and will be 
chaired by Marie Gelato, MD, PhD, an endocrinologist with expertise in osteoporosis and hypocalcemia. The ad 
hoc DSMC will initially convene after 10% of the projected accrual, or 4 patients, complete protocol therapy, and 
thereafter annually.  While no formal stopping rules are included in the protocol, accrual to the study will be 
suspended if 2 or more patients experience grade 3 or higher hypocalcemia or ONJ events. In the unlikely event 
that this occurs, the DSMC will be convened to review all safety data and make recommendations for either 
continuing the study with additional safety measures or terminating the study altogether. A dental expert will be 
added to the committee if 2 or more potential ONJ events are observed.
29.1.3 Identification of the entity obligated for routine monitoring duties 
Routine monitoring will be provided by the Quality Assurance/Quality Control (QA/QC) Program to ensure that 
the investigation is conducted according to protocol design and regulatory requirements. 
29.1.4 Monitoring progress and data review process 
Routine monitoring of participant data will be conducted at least every 6 months.
The first routine monitoring visit will include at a minimum

Informed consent cases enrolled, according to PRMC policy; 

Participant eligibility, up to two participants, according to PRMC policy;

Data review, up to two participants, according to PRMC policy.
All subsequent monitoring visits will consist of randomly selected participant cases based on current enrollment 
and include continuing review of previously selected cases, as applicable.  A monitoring visit report and follow-
up letter will be completed within two weeks of the routine monitoring visit; a copy will be maintained in the study 
file. A query/finding form will also be completed by the monitor to request additional source documentation, 
clarification, information or corrections to the CRF and/or regulatory records. The Clinical Research Coordinator 
or other applicable staff responsible for the study will be given a copy of this form for resolution of 
queries/findings. The query/finding form will be maintained with a copy of the visit report for follow-up at the next 
monitoring visit. 
The Principal Investigator will ensure the accuracy, completeness, legibility and timeliness of the data reported 
in the Case Report Form (CRF). Source documentation supporting the CRF data should indicate the participant’s 
participation in the trial and should document the dates and details of study procedures, adverse events, and 
participant status. Case report forms, which include the inclusion/exclusion criteria form, adverse event forms 
and serious adverse event forms should be completed with a black ball-point pen or typed. Corrections to the 
forms should not obscure the original entry and should be made by striking the incorrect information with a single 
line. Each strike should be accompanied by the initials of the corrector and the correction date. All participant 
forms and study files will be stored in a secure area limited to authorized staff. Note: Routine monitoring of 
regulatory documents and test article will be conducted at least annually. A process to implement study closure 
when significant risks or benefits is in place.
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30. DESCRIPTION AND REPORTING OF ADVERSE AND SERIOUS ADVERSE EVENTS
Serious adverse events (SAEs) and adverse events (AEs) will be monitored and discussed routinely using 
procedures described below. Cumulative SAE review is performed by the SAE Initial Trend Analysis Team 
monthly. This review not only identifies individual events but also identifies any patterns of adverse events in 
Investigator initiated trials. If there is concern for excessive risk/toxicity identified by the DSMB, the Committee 
may recommend suspension of accrual or study closure.
All SAEs (Death, A life-threatening adverse drug experience, inpatient hospitalization or prolongation of existing 
hospitalization, a persistent or significant disability/incapacity, a congenital anomaly/birth defect.) must be 
reported to Amgen Drug Safety within 24 hours of discovery or notification of the event. Initial SAE information 
and all amendments or additions must be recorded on an SAE Report form and faxed to Amgen at: Amgen 
Global Safety Fax:  888-814-8653.
30.1   Adverse Events 
An adverse event (AE) is any untoward medical occurrence in a participant or clinical investigation participant 
administered a pharmaceutical product and that does not necessarily have a causal relationship with this 
treatment. An AE can therefore be any unfavorable and unintended sign, symptom, or disease temporally 
associated with the use of a medicinal (investigational) product, whether or not related to the medicinal 
(investigational) product. 
Any adverse events grade 2, or greater, will be recorded on the adverse events record form and reviewed by the 
Principal Investigator.
Adverse events will be graded according to the NCI Common Terminology Criteria for Adverse Events (CTCAE) 
Version 5 
(https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Quick_Reference_5x7.
pdf)
And will address:

Grade

Relationship to study drug(not related, unlikely, possible, probable, definitely) 

Causality other than study drug (disease related, concomitant medication related, intercurrent illness, other)  

Date of onset, date of resolution

Frequency of event (single, intermittent, continuous)

Event outcome (resolved, ongoing, death)

Action taken (none, held, dose reduced, discontinued, medication given)
30.2   Serious Adverse Events 
A serious adverse event (SAE) is any untoward medical occurrence that at any dose: 

Results in death; 

Is life-threatening;

A new cancer

Requires in-patient hospitalization or prolongation of an existing hospital stay; 

Results in persistent disability or significant disability/incapacity, or:

Is a congenital anomaly/birth defect. 
Note: A SAE may also be an important medical event, in the view of the investigator that requires medical or 
surgical intervention to prevent one of the outcomes listed above. 
Serious adverse events will be captured beginning on Day 1 when participants consent to the study and 
continuing one month following the last dose of study agent. 
All serious adverse events, regardless of attribution, and any deaths will be reported within 24 hours of 
notification of the event to the DSMB Coordinator and to Amgen. All SAEs which meet the criteria for a reportable 
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event will be reported to Stony Brook University IRB within 10 working days of the event date or receipt of 
notification of the event.
30.3   Reportable events
Reportable events must meet all three of the following criteria:

Unanticipated or unexpected in nature, frequency or severity, AND

Related or possibly related to participation in the research (there is a reasonable possibility that it is 
related), AND

The event suggests that the research places participants or others at a greater risk of harm than was 
previously known or recognized (not already referenced in existing study documents, such as the 
protocol, consent form or Investigator’s Brochure).
All serious adverse events will be processed by the DSMB Coordinator monthly for initial trend analysis and fully 
reviewed by the DSMB, every six months. The DSMB coordinator will review the SAE reporting process to 
confirm reporting requirements are met.  
30.4   Plan for assuring data accuracy and protocol compliance 
Routine study activity and safety information will be reported to the DSMB every six months, or more frequently 
if requested. These reports will include:

Study activity, cumulative and for the period under review;

Safety (narrative description on non-serious and serious adverse events);

Predetermined protocol early stopping rules for efficacy/futility;   

Monitoring and protocol compliance;

Comments

Attachments (AE data reviewed by the PI to compile the report, SAE letters and reports, results of any 
review(s), applicable correspondence with the IRB or other regulatory agencies. 

Data, safety and study progress will be reported to:
Human Subjects Protection Program (IRB) at least annually;
SAEs will be reported to the Sponsor (Amgen) every 90 days.

Pregnancy:  The investigators must report pregnancy of a subject participating in the clinical trial to 
Amgen’s global Pregnancy Surveillance Program within 10 days of receiving notification of a pregnancy.  
Follow up case reports have to be provided as new information becomes available.  The Amgen 
Pharmacovigilance Program will seek to follow the pregnant woman throughout her pregnancy and her 
baby up to 12 months after the birth.   

The PI will immediately notify, in writing, the funding agency, if applicable, any action resulting in a 
temporary or permanent suspension of the study.
30.5   Additional Adverse Events Reporting 
All SAEs which meet the criteria for a reportable event will be reported to the Stony Brook University IRB and to 
the Sponsor within 10 working days of the event date or receipt of notification of the event.  
31. PARTICIPANT PAYMENT
Biopsies will be compensated with $100, and MRIs with $25, for a maximum total of $250 for participants 
undergoing MRI and biopsies, or $100 for MRI-only participants. Participants will not receive more than $100 
per visit, i.e. when an MRI and a biopsy are done on the same day. When biopsies and MRIs are scheduled on 
different days, participants can receive 2 separate payments of $100 and $25 respectively.
32. APPENDIX 1.1 and 1.2: Study Schedule for pre-menopausal and post-menopausal women 
33. APPENDIX 2:  Reprints
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34. APPENDIX 3: Common Toxicity Criteria, Version 5.0
https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Quick_Reference_5x7.p
df
35. APPENDIX 4: ECOG Performance Scale
http://www.npcrc.org/files/news/ECOG_performance_status.pdf
36. APPENDIX 5: Abbreviations
37. APPENDIX 6: Xgeva® package insert
38. APPENDIX 7: Protocol Review Committee Approval letter
39. APPENDIX 8: Stony Brook Cancer Center PRMC policy
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Expiration Date: 3/2/2022
Stony Brook University Human Subjects Committee (IRB)