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Statin Therapy Operates to Prevent (STOP) Heart Disease in Breast Cancer Survivors Trial Principal Investigator: Marc T. Goodman, Ph.D., M.P.H.  
Director, Cancer Prevention and Control Samuel Oschin Comprehensive Cancer Institute Cedars-Sinai Medical Center 8700 Beverly Boulevard, 1S37 Los Angeles, CA 90048 Telephone: (310) 423-6188 Fax: (310) 423-7182 E-mail: marc.goodman@cshs.org  
| Sub-Investigator(s):  Name       | Department/Division         |
|----------------------------------|-----------------------------|
| Janet Wei, M.D.                  | Cardiology                  |
| C. Noel Bairey Merz, M.D.        | Cardiology                  |
| Debiao Li, Ph.D.                 | Biomedical Imaging Research |
| Michael Nelson, Ph.D.            | Cardiology                  |
| Louise E. Thomson, M.D.          | Cardiac Imaging             |
| Philomena F. McAndrew, M.D.      | Hematology/Oncology         |
| Monica M. Mita, M.D., MSc.       | Hematology/Oncology         |
| Michael B. Van Scoy-Mosher, M.D. | Hematology/Oncology         |
| Mary El-Masry, M.D.              | Hematology/Oncology         |
| Heather McArthur, M.D., M.P.H.   | Hematology/Oncology         |
| Reva K. Basho, M.D.              | Hematology/Oncology         |
| Christine Pacheco Claudio, M.D.  | Cardiology                  |
| Panteha Rezaeian, M.D.           | Cardiology                  |  
Biostatistician: **Andre Rogatko, Ph.D.**  
| Study Agent:              | Atorvastatin calcium                              |
|---------------------------|---------------------------------------------------|
| Funding Source:           | California Breast Cancer Research Program (CBCRP) |
| Protocol Version:         | Protocol Version 3.1, November 29, 2017           |
| Initial Protocol Version: | Protocol Version 1.0, September 1, 2015           |
iit2015-12-goodman-stop
signature page

The signature below constitutes the approval of this protocol and the attachments, and provides the necessary assurances that this trial will be conducted according to all stipulations of the protocol, including all statements regarding confidentiality, and according to local legal and regulatory requirements and applicable U.S. federal regulations and ICH guidelines.  
Principal Investigator (PI) Name**: Marc T. Goodman, Ph.D., M.P.H.**
Signature: Date: Biostatistician Name: Signature: Date: Clinical Reviewer Name:
Signature: Date:
Department or Division Chair: Signature: Date:
iit2015-12-goodman-stop
table of contents

| TABLE OF CONTENTS                                                                                                                   |                                                                                                                                                            |
|-------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------|
| TABLE OF CONTENTS                                                                                                                   |                                                                                                                                                            |
| LIST OF ABBREVIATIONS                                                                                                               |                                                                                                                                                            |
| STUDY SCHEMA .                                                                                                                      |                                                                                                                                                            |
| STUDY SUMMARY                                                                                                                       |                                                                                                                                                            |
| BACKGROUND AND RATIONALE .                                                                                                          |                                                                                                                                                            |
| 1.0                                                                                                                                 |                                                                                                                                                            |
| 1.1                                                                                                                                 | S STUDY DISEASE                                                                                                                                            |
| l.2                                                                                                                                 | S STUDY AGENT                                                                                                                                              |
| l.3                                                                                                                                 | RATIONALE                                                                                                                                                  |
| 2.0                                                                                                                                 | STUDY OBJECTIVES AND ENDPOINTS ..........................................................................................................13                |
| 2.1                                                                                                                                 | Primary Objectives .                                                                                                                                       |
| 2.2                                                                                                                                 | Secondary Objectives .                                                                                                                                     |
| 2.3                                                                                                                                 | Primary Endpoint .                                                                                                                                         |
| 2.4                                                                                                                                 | Secondary Endpoints                                                                                                                                        |
| PARTICIPANT SELECTION                                                                                                               |                                                                                                                                                            |
| 3.0                                                                                                                                 |                                                                                                                                                            |
| 3.1                                                                                                                                 | Inclusion Criteria .                                                                                                                                       |
| 3.2                                                                                                                                 | Exclusion Criteria .                                                                                                                                       |
| 3.3                                                                                                                                 | Inclusion of Women and Minorities                                                                                                                          |
| 4.0                                                                                                                                 | STUDY PLAN .                                                                                                                                               |
| RE RE                                                                                                                               |                                                                                                                                                            |
| 4.1                                                                                                                                 |                                                                                                                                                            |
| 4.2                                                                                                                                 | S STUDY TREATMENT Protocol                                                                                                                                 |
| 4.3                                                                                                                                 | S STUDY MEASUREMENTS .                                                                                                                                     |
| 5.0                                                                                                                                 | AGENT ADMINISTRATION .                                                                                                                                     |
| 5.1                                                                                                                                 | Dose Regimen and Dose Groups                                                                                                                               |
| 5.2                                                                                                                                 | Study Agent Administration and Duration of Therapy                                                                                                         |
| 5.3                                                                                                                                 | R Run-in Procedures                                                                                                                                        |
| CONTRAINDICATIONS                                                                                                                   |                                                                                                                                                            |
| 5.4                                                                                                                                 |                                                                                                                                                            |
| 5.5                                                                                                                                 | CONCOMITANT Medications                                                                                                                                    |
| 5.6                                                                                                                                 | Dose Modification                                                                                                                                          |
| 5.7                                                                                                                                 | Adherence/Compliance .                                                                                                                                     |
| 6.0                                                                                                                                 | PHARMACEUTICAL INFORMATION .                                                                                                                               |
| 6.1                                                                                                                                 | S STUDY AGENT                                                                                                                                              |
| 6.2                                                                                                                                 | Reported Adverse Events and Potential Risks.                                                                                                               |
| 6.3                                                                                                                                 | Agent Availability, Packaging, and Labeling                                                                                                                |
| 6.4                                                                                                                                 | S STORAGE                                                                                                                                                  |
| 6.5                                                                                                                                 | Agent Accountability                                                                                                                                       |
| Blinding and Unblinding                                                                                                             |                                                                                                                                                            |
| 6.6                                                                                                                                 |                                                                                                                                                            |
| 7.0                                                                                                                                 | CLINICAL EVALUATIONS AND PROCEDURES                                                                                                                        |
| 7.1                                                                                                                                 | SCHEDULE OF Time and Events                                                                                                                                |
| 7.2                                                                                                                                 | Pre-Study Evaluation                                                                                                                                       |
| 7.3                                                                                                                                 | Baseline Testing and Evaluation During the Study Intervention ............................................................................26               |
| 7.4                                                                                                                                 | Evaluation at Completion of the Study Intervention .                                                                                                       |
| 7.5                                                                                                                                 | Post-intervention Follow-up Procedures .                                                                                                                   |
| 7.6                                                                                                                                 | RE REMOVAL OF SUBJECTS FROM STUDY                                                                                                                          |
| 7.7                                                                                                                                 | Methods for Clinical Procedures                                                                                                                            |
| 8.0                                                                                                                                 | MEASUREMENT OF EFFECT AND CRITERIA FOR EVALUATION ....................................32                                                                   |
| 8.1                                                                                                                                 | Prevention of Cardiotoxicity Due to Breast Cancer Treatment ............................................................................32                 |
| 8.2                                                                                                                                 | Methods for Evaluation of Cardiac Function .............................................................................................................32 |
| 8.3                                                                                                                                 | O OFF-Agent Criteria .                                                                                                                                     |
| 8.4                                                                                                                                 | O OFF-Study Criteria                                                                                                                                       |
| 9.0                                                                                                                                 | CORRELATIVE/SPECIAL STUDIES                                                                                                                                |
| 9.1                                                                                                                                 | RATIONALE FOR METHODOLOGY Selection                                                                                                                        |
| 9.2                                                                                                                                 | Laboratory Correlates and Biomarkers .                                                                                                                     |
| 9.3                                                                                                                                 | Specimen Banking                                                                                                                                           |
| STATISTICAL CONSIDERATIONS ......................................................................................................35 |                                                                                                                                                            |
| 10.0                                                                                                                                |                                                                                                                                                            |
| 10.1                                                                                                                                | S STUDY DESIGN/DESCRIPTION                                                                                                                                 |  
| Protocol Version 3.1, November 29, 2017                                                                                                                        |                                                                                                                                                                           |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 10.2                                                                                                                                                           | Sample Size and Accrual                                                                                                                                                   |
| 10.3                                                                                                                                                           | RANDOMIZATION AND INTERVENTION .                                                                                                                                          |
| 10.4                                                                                                                                                           | Endpoints/Statistical Considerations ..................................................................................................................................36 |
| STATISTICAL ANALYSIS PIAN                                                                                                                                      |                                                                                                                                                                           |
| 10.5                                                                                                                                                           |                                                                                                                                                                           |
| 10.6                                                                                                                                                           | Contamination (Cross-Over) and Drop-Outs                                                                                                                                  |
| 10.7                                                                                                                                                           | EVALUATION OF TOXICITY                                                                                                                                                    |
| 10.8                                                                                                                                                           | Evaluation of Response ................................................................................................................................................37 |
| 10.9                                                                                                                                                           | Interim Analysis .                                                                                                                                                        |
| 11.0                                                                                                                                                           | ADVERSE EVENTS .                                                                                                                                                          |
| 11.1                                                                                                                                                           | Experimental Therapy .                                                                                                                                                    |
| 11.2                                                                                                                                                           | A Adverse Event Monitoring .                                                                                                                                              |
| DEFINITIONS                                                                                                                                                    |                                                                                                                                                                           |
| 11.3                                                                                                                                                           |                                                                                                                                                                           |
| 11.4                                                                                                                                                           | Steps to Determine If an Adverse Event Requires Expedited Reporting .............................................................39                                       |
| Reporting Requirements for Adverse Events .............................................................................................................39      |                                                                                                                                                                           |
| 11.5                                                                                                                                                           |                                                                                                                                                                           |
| 11.6                                                                                                                                                           | S Stopping Rules ...............................................................................................................................................40        |
| 12.0                                                                                                                                                           | STUDY MANAGEMENT ...............................................................................................................................40                        |
| 12.1                                                                                                                                                           | CONFLICT OF INTEREST                                                                                                                                                      |
| 12.2                                                                                                                                                           | Institutional Review Board (IRB) Approval and Consent .................................................................................40                                 |
| 12.3                                                                                                                                                           | Registration Procedures                                                                                                                                                   |
| 12.4                                                                                                                                                           | Record Keeping and Data Management .................................................................................................................42                    |
| 12.5                                                                                                                                                           | DATA AND SAFETY MONITORING BOARD (DSMB)                                                                                                                                   |
| Executive Committee and Internal Advisory Board (IAB) ............................................................................42                           |                                                                                                                                                                           |
| 12.6                                                                                                                                                           |                                                                                                                                                                           |
| 12.7                                                                                                                                                           | A Adherence to the Protocol .......................................................................................................................................43     |
| Amendments to the Protocol .................................................................................................................................43 |                                                                                                                                                                           |
| 12.8                                                                                                                                                           |                                                                                                                                                                           |
| 12.9                                                                                                                                                           | RECORD RETENTION .                                                                                                                                                        |
| 12.10 Obligations of Investigators                                                                                                                             |                                                                                                                                                                           |
| REFERENCES                                                                                                                                                     |                                                                                                                                                                           |
| APPENDIX A .                                                                                                                                                   |                                                                                                                                                                           |
| APPENDIX B                                                                                                                                                     |                                                                                                                                                                           |  
| LIST OF ABBREVIATIONS  2-D echo 2-dimensional echocardiography  AC Anthracycline and cyclophosphamide  AC-T Anthracycline and cyclophosphamide followed by taxane  AC-TH Anthracycline and cyclophosphamide followed by taxane and Herceptin (trastuzumab)  ACE Angiotensin-converting-enzyme  ACEi Angiotensin-converting-enzyme inhibitor  AE Adverse event  ALT Alanine aminotransferase  ARB Angiotensin receptor blocker  AST Aspartate aminotransferase  BB β-blocker; beta blocker  BNP Brain natriuretic peptide; B-type natriuretic peptide  BRCA Gene mutation that elevates the risk of breast cancer  CABG Coronary artery bypass graft  CAD Coronary artery disease  CBDF Complete Blood Count and Automated Differential  CHF Congestive heart failure  CMPL Comprehensive Metabolic Panel  CMRI Cardiac magnetic resonance imaging  CO Cardiac output  CPK Creatine phosphokinase; creatine kinase  CrCl Creatinine clearance  CRO Clinical Research Office  CSd Diastole rate  CSs Systole rate  CSMC Cedars-Sinai Medical Center  CT Computerized tomography  CTCAE Common Terminology Criteria for Adverse Events  CVD Cardiovascular disease  DSMB Data and Safety Monitoring Board  ECG Electrocardiogram  ECOG Eastern Cooperative Oncology Group  EORTC European Organization for Research and Treatment of Cancer  ER Estrogen receptor  FDA Food and Drug Administration   |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|  
| Protocol Version 3.1, November 29, 2017   |                                                                            |
|-------------------------------------------|----------------------------------------------------------------------------|
| Gad                                       | Gadolinium                                                                 |
| GCS                                       | Global circumferential strain                                              |
| GTPase                                    | Guanosine triphosphatase                                                   |
| HDAC                                      | Histone deacetylase                                                        |
| HER2                                      | Human epidermal growth factor receptor 2                                   |
| HIPAA                                     | Health Insurance Portability and Accountability Act                        |
| HMG-CoA                                   | 3-hydroxy-3-methylglutaryl-coenzyme a                                      |
| Hs-CRP                                    | High sensitivity C-reactive protein                                        |
| Hs-TnT                                    | High sensitivity troponin                                                  |
| IAB                                       | Internal Advisory Board                                                    |
| ICF                                       | Informed Consent Form                                                      |
| IL-6                                      | Interleukin 6                                                              |
| IRB                                       | Institutional Review Board                                                 |
| IV                                        | Intravenous                                                                |
| LV                                        | Left ventricular                                                           |
| LVEDV                                     | Left ventricular end diastolic volume                                      |
| LVEF                                      | Left ventricular ejection fraction                                         |
| LVESV                                     | Left ventricular end systolic volume                                       |
| LVOT                                      | Left ventricular outflow tract                                             |
| MOLLI                                     | Modified Look-Looker Inversion Recovery                                    |
| MRS                                       | Magnetic resonance spectroscopy                                            |
| NADPH                                     | Nicotinamide adenine dinucleotide phosphate                                |
| PFR                                       | Peak filling rate                                                          |
| PR                                        | Progesterone receptor                                                      |
| Rac1                                      | Ras-related C3 botulinum toxin substrate 1                                 |
| ROS                                       | Reactive oxygen species                                                    |
| RCT                                       | Randomized controlled trial                                                |
| SAE                                       | Serious adverse event                                                      |
| SOCCI                                     | Samuel Oschin Comprehensive Cancer Institute                               |
| SSFP                                      | Steady-state-free-precession                                               |
| SV                                        | Systolic volume                                                            |
| TCH                                       | Taxotere (docetaxel), carboplatin, and Herceptin (trastuzumab)             |
| TCHP                                      | Taxotere (docetaxel), carboplatin, Herceptin (trastuzumab), and pertuzumab |
| tPFR                                      | Time to peak filling rate                                                  |
| UTR                                       | Peak rate of basal to apical untwisting                                    |
| WISE                                      | Women's Ischemia Syndrome Evaluation                                       |
study schema
statin therapy operates to prevent

Pre-Screen Medical Chart Review and Initial Determination of Eligibility Clinical research staff reviews medical charts of patients diagnosed with breast cancer and completes pre-screen eligibility checklist: age, HER2/ER/PR status, lab results, medical contraindications, prohibited medications, prior or current statin use Recruitment and Consent Oncologist introduces study to potentially eligible breast cancer patients recommended for trastuzumab treatment, with or without anthracycline. Patients receive study information packet; clinical research staff reviews study details with patient and contacts patient a few days later to answer questions. Patients who want to participate will be consented into the trial by one of the study physicians before any research procedures are initiated.  
Pre-Study Evaluations* Physical exam; symptom assessment; ECOG performance status; blood tests to confirm eligibility and safety of statin initiation; urine pregnancy test for women able to become pregnant; 2D-echocardiogram. **Patients with an abnormal**
2D-echocardiogram, AST/ALT > 3x ULN, creatinine > 1.8 mg/dL, or who are pregnant will be excluded.  
Final Determination of Eligibility Research staff completes full eligibility checklist for consented patients, retrieves support documents from medical charts.  
Oncologist, study cardiologist, or other physician-**investigator reviews patient's checklist, medical history, and supporting**
documentation. Clinical Research Office designee conducts final eligibility check prior to registration and randomization.  
Eligible, consented patients with breast cancer registered and randomized to atorvastatin or placebo (N=60)
Atorvastatin 20 mg, daily for 12 months
(N=30)
Placebo identical in color, consistency, and appearance to atorvastatin 20 mg, daily for 12 months (N=30)  
Visit 1^ - **Baseline measurements and Initiation of the Statin Intervention (from 2 weeks before the patient starts**
systemic breast cancer treatment (trastuzumab with or without anthracycline) up to 3 weeks after starting treatment)
Review medical history, medications, and laboratory test results; vital signs assessment; ECOG performance status; blood draw; urine pregnancy test for women able to become pregnant; cardiac magnetic resonance imaging (CMRI);
interviewer-administered questionnaire; self-administered QLQ-C30 and QLQ-BR23 quality of life questionnaire; review eligibility criteria; dispense study drug and diary Visit 2* (1 month ± 2 weeks after initiation of the statin intervention)
Review medical history, medications, and laboratory test results; physical exam; symptom assessment; ECOG
performance status; clinical labs for CBDF and CMPL; collect study drug and diary; assess compliance and adverse events; review study diary; review eligibility criteria; dispense study drug and diary Visit 3* (3 months ± 2 weeks after initiation of the statin intervention)
Same procedures as Visit 2 and follow-up 2D-echocardiogram Visit 4^ **(6 months ± 2 weeks after initiation of the statin intervention)**
Same procedures as Visit 1 and: collect study drug and diary; assess compliance and adverse events; review study diary Visit 5* (9 months ± 2 weeks after initiation of the statin intervention)
Same procedures as Visit 3 Visit 6^ **(12 months ± 2 weeks after initiation of the statin intervention)**
Same procedures as Visit 4 except no study drug dispense; collect study drug and diary
study schema
follow-up phone calls (day 30

Endpoints - **Evaluate the effect of atorvastatin use versus placebo after 12 months of intervention on changes in:**
1) Global circumferential strain (GCS), a sensitive measure of myocardial dysfunction, measured by cardiac magnetic resonance imaging (CMRI)
2) Other strain-related measures, myocardial diastolic function, and cardiac morphology, measured by cine CMRI and tissue tagging 3) Myocardial fibrosis and tissue viability, edema, and inflammation measured by CMRI T1 and T2 mapping values
*Pre-Study Evaluations and Visits 2, 3, and 5 are standard of care visits. ^Visits 1, 4, and 6 are research visits to collect endpoint data and will coincide with standard of care visits when possible.  
| STUDY SUMMARY  Title       | Statin Therapy Operates to Prevent (STOP) Heart Disease in Breast Cancer  Survivors Trial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |
|----------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Protocol Number            | IIT2015-12-Goodman-STOP                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 |
| Phase                      | Phase II                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |
| Methodology                | Randomized, double-blinded, placebo-controlled, Phase II trial of statin therapy  to ameliorate or prevent cardiac damage in women with newly diagnosed stage  1-3 breast cancer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
| Study Duration             | 3.5 years                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |
| Study Center(s)            | Cedars-Sinai Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |
| Objectives                 | Primary Objective: To evaluate the effect of atorvastatin intervention versus  placebo on a 1 year change from baseline on myocardial dysfunction in breast  cancer patients who have undergone trastuzumab treatment, with or without  anthracycline. The primary outcome is global circumferential strain (GCS), a  sensitive measure of myocardial dysfunction, which is predictive of future  cardiac events. Cardiac magnetic resonance imaging (CMRI) will be used to  measure GCS.  Secondary Objectives: To evaluate the effect of atorvastatin intervention versus  placebo on a 1 year change from baseline on: 1) other strain-related measures,  myocardial diastolic function, and cardiac morphology, measured by cine  CMRI and tissue tagging; and 2) myocardial fibrosis, edema, and inflammation  measured by T1 and T2 mapping values during the CMRI.                                                                                                               |
| Number of Subjects         | 60                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |
| Diagnosis and Main         | Newly diagnosed stage 1-3 breast cancer; histologically confirmed HER2, ER,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |
| Inclusion Criteria         | and PR status; minimum 18 years of age; recommended to undergo  trastuzumab treatment, with or without anthracycline. Patients will be eligible  for up to 3 weeks after starting treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            |
| Study Product(s), Dose,    | Atorvastatin 20 mg and placebo identical in color, consistency, and appearance                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          |
| Route, Regimen             | to atorvastatin; oral administration daily                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              |
| Duration of Administration | 12 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |
| Statistical Methodology    | Analyses will be conducted on an intention-to-treat basis on all patients who  complete the 12-month CMRI. The non-parametric Wilcoxon-Mann-Whitney  test will be used to test the equality of statin treatment (atorvastatin) to placebo  in reducing or preventing LV dysfunction through comparison of change in  GCS values (∆ length / original length, expressed as %) measured from 2 weeks  prior to start of systemic breast cancer treatment to 1 year post-initiation of the  statin intervention. The distribution of the covariates, including age, race, dose  of trastuzumab treatment (and anthracycline if applicable), laterality, radiation  dose, smoking status, BMI, baseline measures of fibrosis, hormone use, and  comorbid conditions, will be summarized and compared between the  intervention and control groups to assess the adequacy of the randomization.  Chance differences between groups will be adjusted for using multiple  regression modeling. |
study schema
background and rationale 1.1 study

Breast cancer is a devastating disease for women in the U.S., but death rates due to breast cancer are declining and there are now more than 3.1 million breast cancer survivors [1]. While aggressive screening and targeted, advanced treatment for breast cancer have had a measurable impact on survival, treatment has significant acute and chronic cardiotoxicity [2-4]. The risk of cardiovascular-related death is eight-fold higher for long-term cancer survivors than for the remaining population [5]. Clearly, the question of prevention and mitigation of iatrogenic cardiotoxicity among women with breast cancer assumes greater importance now that long-term disease-free survival has been achieved. An urgent need exists to intervene early in women with breast cancer using a cardioprotective agent to reduce therapy-related cardiotoxicity.  
  
Atorvastatin calcium [Figure 1], a synthetic lipidlowering agent, is an inhibitor of 3-hydroxy-3methylglutaryl-coenzyme A (HMG-CoA)
reductase. This enzyme catalyzes the conversion of HMG-CoA to mevalonate, an early and ratelimiting step in cholesterol biosynthesis. The empirical formula of atorvastatin calcium is (C 33 H 34 FN 2 O 5 ) 2 Ca•3H 2 O and its molecular weight is 1209.42. Atorvastatin calcium is a white to offwhite crystalline powder that is insoluble in Figure 1. Molecular Structure of Atorvastatin Calcium aqueous solutions of pH 4 and below. Atorvastatin calcium is very slightly soluble in distilled water, pH 7.4 phosphate buffer, and acetonitrile; slightly soluble in ethanol; and freely soluble in methanol.  
Atorvastatin calcium tablets for oral administration contain 10, 20, 40, or 80 mg atorvastatin and the following inactive ingredients: calcium carbonate; candelilla wax, FCC; croscarmellose sodium; hydroxypropyl cellulose, NF; lactose monohydrate; magnesium stearate; microcrystalline cellulose; Opadry White YS-1-7040
(hypromellose, polyethylene glycol, talc, titanium dioxide); polysorbate 80; and simethicone emulsion.  
Atorvastatin has a widely accepted tolerability profile with few serious side effects [6]. In the atorvastatin calcium tablets placebo-controlled clinical trial database of 16,066 patients (8,755 atorvastatin calcium tablets vs. 7,311 placebo) with a median treatment duration of 53 weeks, 9.7% of patients on atorvastatin calcium tablets and 9.5%
of the patients on placebo discontinued due to adverse reactions regardless of causality. The most commonly reported adverse reactions (incidence ≥ 2% and greater than placebo) regardless of causality, in patients treated with atorvastatin calcium tablets were: nasopharyngitis (8.3%), arthralgia (6.9%), diarrhea (6.8%), pain in extremity (6.0%), and urinary tract infection (5.7%) [7]. Potential, but uncommon side effects include muscle, liver, and kidney problems. Elevated levels of creatine kinase and rhabdomyolysis occur in < 1% of consumers.  
Atorvastatin calcium is prescribed for primary and secondary prevention of cardiovascular disease and thus is indicated for long-term use. Among several lipophilic statins in the market, atorvastatin is considered to have the most potent effect on cardiometabolic measures [8]. We propose to administer atorvastatin 20 mg daily for 12 months in this trial.
study schema
1.3 rationale

In spite of the substantial scientific literature that breast cancer treatment may be deleterious to the heart with long-term consequences to quality of life, there are few published results from randomized controlled trials
(RCTs) using cardioprotective agents to attenuate the cardiomyopathy associated with cancer therapeutics. The STOP Heart Disease in Breast Cancer Survivors Trial is designed to evaluate the effectiveness of statins to reduce or prevent trastuzumab-induced left ventricular (LV) dysfunction. Trastuzumab, a monoclonal antibody to the human epidermal growth factor receptor-2 (HER2/ErbB2), has become a potential cause of heart failure and cardiomyopathy among women treated for breast cancer, especially when given with anthracyclines [9].  
Statins and Cardioprotection. **The prophylactic and therapeutic use of cardioprotective agents, including statins,**
angiotensin-converting-enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), and β**-blockers (BB),**
have been reported to ameliorate cancer treatment cardiotoxicity, although evidence from RCTs in breast cancer patients have been limited. A recent review and meta-analysis of cardioprotective therapy to reduce adverse cardiac outcomes in cancer chemotherapy patients found that statins showed a similar efficacy compared to other cardioprotective agents [3]. Statins decrease CVD-related morbidity and mortality and are widely used for cardiovascular disease prevention [10]. In addition to cholesterol lowering anti-atherosclerotic effects, statins also exert pleiotropic effects that are anti-oxidative and may be cardioprotective, and therefore relevant to trastuzumab-induced cardiotoxicity [11]. While observational studies suggest that statins may attenuate chemotherapy-induced cardiac toxicity, this outcome has not been rigorously tested in a clinical trial. We hypothesize that the diverse and beneficial effects of statins will help protect the heart during trastuzumab treatment. Our multi-disciplinary research team will randomize newly diagnosed stage 1-3 breast cancer patients to prophylactic statin versus placebo and evaluate longitudinal structural and functional changes to the myocardium using CMRI. Our RCT with a longitudinal approach to studying detailed imaging changes of the myocardium from baseline through 12 months of treatment will elucidate pathophysiological pathways of myocardial damage and could lead to a new cardioprotection strategy in breast cancer treatment.  
Hypotheses. **We anticipate that trastuzumab treatment, with or without anthracycline treatment, will impair**
global circumferential strain (GCS) and diastolic function, and increase markers of fibrosis, edema, and/or inflammation. We hypothesize that after 12 months of intervention, participants randomized to atorvastatin will experience:
1) Less GCS impairment compared to the placebo group; 2) Less diastolic dysfunction compared to the placebo group; and 3) Less myocardial fibrosis, edema, and inflammation compared to the placebo group.  
Chemotherapy-Induced Cardiotoxicity. **Adverse cardiac events, including heart failure, myocardial ischemia,**
venous thromboembolism, and bradycardia may result from common breast cancer treatments [12]. The focus of our RCT is on the subacute cardiotoxic effect of trastuzumab therapy that has long-term consequences, especially diastolic LV dysfunction and subsequent risk of heart failure [5]. Cardiac risk is particularly elevated in breast cancer patients treated with a combination of anthracycline and trastuzumab. Early clinical trials showed that the addition of trastuzumab to anthracycline treatment for breast cancer led to a synergistic increase in cardiac symptoms from 13% to 27% compared to 2-8% of patients receiving trastuzumab or anthracyclines alone [13]. A recent analysis of a population-based cohort study of 12,500 women with invasive breast cancer demonstrated hazard ratios for heart failure and cardiomyopathy during treatment of 1.4 (1.1-1.8) in patients on anthracycline alone, 4.1 (2.3-7.4) in patients treated with trastuzumab alone, and 7.2 (5.0-10.4) in patients treated with both agents as compared to patients who received no chemotherapy [14].  
Trastuzumab. **Trastuzumab (Herceptin) targets the HER2/neu receptor which is overexpressed in 25% of breast**
cancer [15]. This receptor is also expressed at low levels in the heart and can be upregulated under stress [16]. Inhibition of the HER2 receptor contributes to cardiac injury in patients receiving trastuzumab, although mechanisms are still unclear. HER2 signaling is fundamental to cardiomyocyte development and survival [17]. HER2-knock out mice develop dilated cardiomyopathy progressing to systolic dysfunction, suggesting an important role for HER2 expression in maintaining cardiac function [18]. Trastuzumab is capable of inhibiting autophagy in human cardiomyocytes, leading to increased production of reactive oxygen species [19]. Trastuzumab down-regulation of the HER2 pathway has been linked to asymptomatic cardiac dysfunction and symptomatic congestive heart failure (CHF) [20]. A recent meta-analysis of five RCTs, found a RR of 5.8 (3.69.3) for the association of trastuzumab and all-grade CHF with a number needed to harm of 9 (for every 9 patients treated with trastuzumab one additional case of CHF will occur compared to placebo) [21]. While trastuzumabrelated cardiac dysfunction was initially thought to be reversible with no frank ultra-structural changes, advanced CMRI data shows myocyte damage with fibrosis and scarring [22]. In spite of the increased cardiac monitoring included to ensure patient safety in HER2-positive breast cancer patients, LV dysfunction occurs in up to 23% of patients receiving trastuzumab alone [15,20]; and in a joint analysis of two large clinical trials, 4.1% of patients receiving trastuzumab experienced CHF or cardiac death [15]. In a recent trial, 7% of women with HER2positive breast cancer had a decrease in LV ejection fraction (LVEF) >10% at 2 years, with CHF in 0.8% of patients [23]. A meta-analysis of three RCTs found a RR of 6.7 (4.9-9.2) for the association of trastuzumab with high grade decreased left ventricular ejection fraction (number needed to do harm was 3) [21]. These sequelae were amplified by the fact that cardiotoxicity was the leading cause of trastuzumab interruption: 5% of clinical trial participants in year 1 and 9% of participants in year 2 discontinued trastuzumab treatment, which has serious consequences for control of HER2-positive breast cancer [15]. Moreover, the cardiotoxic effects of trastuzumab will likely be greater in the community setting where the presence of comorbidities is higher than in carefully selected clinical trial patients. Indeed, a Medicare-based study found that the incidences of cardiomyopathy and heart failure were increased by >10% among elderly patients treated with trastuzumab compared to nontrastuzumab / non-anthracycline based therapy [24]. In another Medicare study [25], the 41% of patients who discontinued trastuzumab early - usually due to cardiovascular complications - were at higher risk of heart failure / cardiomyopathy, atrial fibrillation, and other cardiovascular events than were women who were able to tolerate the full course of trastuzumab.  
Anthracyclines. **Anthracyclines cause dose-dependent irreversible LV dysfunction likely resulting from oxidative**
stress and mitochondrial damage associated with myofibrillar disarray and necrosis [26]. Irreversible cardiotoxicity may progress to heart failure and death in breast cancer survivors [27]. It is thought that the acute decline in cardiac contractility caused by anthracyclines is dose-dependent, and that onset cardiomyopathy may occur in up to 5% of patients in the year following anthracycline therapy. The cardiotoxic effects of anthracycline (doxorubicin) treatment are dose-responsive, with heart failure noted in 26% of patients given the maximum lifetime cumulative dose of 550 mg / m2 **[12]. The BCIRG-006 trial compared doxorubicin plus**
cyclophosphamide followed by docetaxel (AC-T); AC-T plus one year trastuzumab (AC-TH); and a nonanthracycline-containing arm, docetaxel, carboplatin, and one year trastuzumab (TCH) among 3,222 HER2positive women with early breast cancer [28]. While the 10-year follow-up results suggested no difference in overall survival for the AC-TH compared with the TCH patients, the AC-TH patients experienced 5-fold more cardiac deaths and CHF events (p=0.0005) in the AC-TH arm (21 events) compared with the TCH arm (4 events) [9]. We are especially interested in the subgroup of women treated with both trastuzumab and anthracycline.  
Mechanisms for Treatment-Associated Cardiotoxicity. **Mechanisms for trastuzumab-induced cardiotoxicity**
are still being clarified, but it is thought that trastuzumab leads to heart failure by blocking the physiological actions of HER2 in the heart [29,30]. HER2 is essential for normal fetal cardiac development and cardiac-specific deletion of HER2 leads to cardiomyopathy in mice [20,31]. HER2 is present in cardiomyocytes and, in the presence of the ligand neuregulin-1, HER2 upregulates phosphoinositide-3-kinase (PI3K) signaling, AKT
activation, and the extracellular signal-regulated kinase (ERK1/2) mitogen-activated pathway; and HER2 suppresses apoptotic signaling. In the absence of HER2 signaling, cardiac dysfunction develops, characterized by mitochondrial dysfunction, excessive production of reactive oxygen species (ROS), opening of the mitochondrial permeability transition pore, and cell death [32,33]. Anthracyclines likely cause myofibrillar loss and cellular necrosis through direct injury and oxidative stress [34]. Anthracyclines target cellular topoisomerase-**2α and DNA**
to form a cleavage complex that triggers apoptosis in tumor cells [35]. The inhibition of topoisomerase-**2β by** anthracycline causes double-stranded breaks and death of cardiomyocytes. Topoisomerase-**2β inhibition also**
reduces p53 activation of the apoptotic pathway, and decreases expression of uncoupling proteins that regulate NADPH oxidase-mediated mitochondrial ROS production [4]. NADPH oxidase, an important cause of cardiovascular disease, consists of several protein components, including Rac1, a Rho guanosine triphosphatase (GTPase). Inhibition of Rac1 was found to protect mice from doxorubicin-induced myocardial dysfunction, while Rac1 overexpression led to decreased activity of histone deacetylases (HDAC), mimicking the effects of doxorubicin on p53-mediated apoptosis [36].  
Radiation-Induced Cardiotoxicity. **Cardiovascular toxicity resulting from radiotherapy for mostly left-sided**
breast cancer has been well-**documented, especially among women receiving whole heart doses of ≥ 5 gray, as** was common in the past [37]. Radiation-related injury may include structural damage to the heart, such as fibrosis, pericardial adhesions, microvascular damage and valvular stenosis, as well as damage to the coronary arteries [38]. Despite this, radiation to left-sided breast tumor was not found to be associated with congestive heart failure in a national population of elderly women with breast cancer [39]. The radiation dose to the heart has decreased substantially during the past decade, driven by medical advances such as accelerated partial breast irradiation [40]. Although tangential radiation treatment for left-sided breast cancer is now computed tomography
(CT)-guided, delivering the lowest dose of radiation for the shortest duration, coronary arteries in the field can be affected [41]. The degree to which improved radiotherapeutic technologies have ameliorated long-term risk of heart failure in breast cancer patients is unknown. We expect that randomization of patients to statin and placebo will balance the frequency of left-sided breast cancer and the relative radiation exposure to the heart. If by chance the radiation dose to the heart is imbalanced between the two groups, we will conduct a sensitivity analysis following our primary intention-to-treat analysis to investigate if variations in radiation dose affected the results of statin.  
Statins (3-hydroxy-3-methylglutaryl-CoA (HMG-CoA)) Inhibitors and Breast Cancer. **Statins, used**
primarily to reduce LDL-cholesterol by inhibiting the conversion of HMG-CoA to mevalonate, are well-tolerated with few serious side effects [6]. Statin use reduces the incidence of major vascular events, such as myocardial infarction, stroke and coronary revascularization, as well as overall mortality [10]; and this risk reduction extends to healthy individuals at low baseline risk of cardiovascular disease. Emerging evidence implicates an imbalance of angiogenic and antiangiogenic factors in hypertension and coronary artery disease [42,43] that can be normalized by statin treatment [44]. A key mechanism whereby statins can inhibit cardiotoxicity includes the reduced production of isoprenoid (e.g., farnesyl pyrophosphate, geranyl pyrophosphate), a necessary posttranslational modifier of the RAS superfamily of GTPase proteins, including Rac. Rac is an important activator of the NADPH oxidase [45]. When prenylated, Rac tethers co-activator p67 to the membrane and induces a conformational change leading to the assembly of NADPH oxidase complex and production of O2 **[46]. By**
inhibiting the prenylation of Rac1, statins have been shown to decrease ROS production, attenuating cardiac hypertrophy [47]. Statins also promote mitochondrial turnover, attenuating ROS production and accumulation of mtDNA mutations [48,49]. Statins may alter the expression of vascular growth factors, thereby improving the capillary network and reversing the anti-angiogenic effects of trastuzumab in the heart [50]. Taken together, these studies provide compelling evidence that statins regulate, either directly or indirectly, several signaling pathways implicated in cardiomyocyte damage. We hypothesize that the diverse and beneficial effects of statins will help protect the heart during cancer chemotherapy.  
Not all statins are expected to have a specific local effect on cardiomyocytes, as they vary in hepatoselectivity.  
Hydrophilic statins, such as rosuvastatin, accumulate in the liver, as they are taken into liver cells by carriermediated transporters that are expressed in hepatocytes. *Lipophilic statins* **such as atorvastatin enter cells in the**
hepatic and extrahepatic tissue via passive diffusion and do not accumulate in the liver, thus making it more available to other organs [51]. Congruent with this property, lipophilic statins were found to be associated with reduced recurrence of cancer in a large cohort of Danish women with stage I-III breast cancer, while hydrophilic statins did not have any impact on outcome [52]. Given these observations, we decided to select a lipophilic statin for our intervention. Among several lipophilic statins on the market, including atorvastatin, simvastatin, fluvastatin, and lovastatin, we have chosen atorvastatin not strictly for its greater lipid-lowering efficacy when compared to simvastatin [8], but also because of its anti-inflammatory and anti-apoptotic properties [53,54].  
Global Circumferential Strain (GCS). **Global circumferential strain (GCS) is a composite measure of the strain**
and relaxation of the heart during the systole and diastole. In a prospective follow-up of 84 women with HER2positive breast cancer treated with anthracyclines, taxanes and trastuzumab, both peak systolic longitudinal myocardial strain < 19% and ultrasensitive troponin I measured at the completion of therapy were the most predictive of subsequent cardiotoxicity, as defined by Cardiac Review and Evaluation Committee criteria [55]. In support of this finding, results from a study of 81 women undergoing trastuzumab and anthracycline treatment showed that a ≥ 11% reduction in global strain measured by echocardiography was strongly predictive of later reductions in ejection fraction [56]. The clinical relevance of myocardial strain in predicting long-term cardiac left ventricular (LV) dysfunction is further underscored by the significant 7.7% reduction in global strain observed up to 6 years following cessation of anthracycline therapy in 75 asymptomatic breast cancer survivors [57]. The global circumferential strain was also reported to be an independent predictor of future heart failure and cardiac death in patients with a previous episode of heart failure [58]. A meta-analysis of 1,500 cancer patients undergoing chemotherapy showed that early changes in myocardial strain precede significant change in left ventricular ejection fraction and that global strain measures can predict clinically diagnosed cardiotoxicity [27].  
Furthermore, in patients with a history of heart failure, each % increase in GCS was associated with a 15%
increase in the risk of future cardiac event, and GCS was a better predictor of future cardiac events than left ventricular ejection fraction [58].  
Cardiac Magnetic Resonance Imaging (CMRI). Evidenced-based guidelines for monitoring cardiotoxicity following breast cancer treatment are presently lacking [37]. Reliance on 2-dimensional echocardiography (2-D
echo) for the identification of cardiac damage is limited as it lacks the requisite sensitivity to detect subtle changes in LV function. Newer sophisticated echocardiographic imaging techniques, including myocardial strain imaging by 2D-speckle tracking, can identify early pre-clinical LV systolic dysfunction pre- and post-treatment [59].  
While speckle tracking echocardiography may be helpful, the quality is sonographer-dependent, limited by patient body habitus, and not available in all echocardiography labs. CMRI is considered the gold standard imaging technique for accurate quantification of LV morphology and function, and mitigates many of the limitations of echo. The addition of tissue tagging helps determine specific myocardial structural changes related to twist and torsion of the left ventricle during systole and diastole. CMRI can also detect fibrosis with late gadolinium enhancement and T1 mapping. MR tissue tagging utilizes selective radiofrequency pulses to generate a pattern of lines or a 'grid' through the tissue [Figure 2]. Because myocardial tags are formed Figure 2. MR tissue tagging by modification of the tissue magnetization itself, the 'tagged' tissue moves with the myocardium throughout the cardiac cycle allowing for highly accurate, regional quantification of tissue deformation (i.e. strain). Circumferential deformation mechanics provide a sensitive predictor and identification of heart failure and mortality than global LV parameters. Results from the Multi-Ethnic Study on Atherosclerosis (MESA) of an asymptomatic population showed that reductions in the shortening and lengthening of the LV circumference, known as circumferential strain, are associated with myocardial fibrosis and decreased systolic function [60].  
Similar alterations in circumferential strain assist in the prediction of heart failure and all-cause mortality, independent of preserved global ejection function [58,61]. Furthermore, circumferential strain has been demonstrated to be a sensitive detector of early cardiomyopathy in young muscular dystrophy patients who suffer from myocardial fibrosis [62], and is closely associated with mortality, hospital readmission, and sudden cardiac death in heart failure patients [58,63,64]. The combination of CMRI and 2D echocardiography provides an excellent opportunity to gain important mechanistic insight (i.e.  
tissue characterization by T1 mapping) and gold-standard verification (tissue tagging strain imaging) balanced by clinical feasibility and population health (2D echo). The use of CMRI to study the impact of a statin intervention on detailed structural and functional changes that occur as a result of breast cancer treatment is exciting, and findings can be directly translated to inform clinical care. This project has promise to provide mechanistic and immediately translatable strategies in the care of breast cancer survivors. Supporting Preliminary Data. The Barbra Streisand Women's Heart Center (The Heart Center) at Cedars-Sinai Medical Center (CSMC) focuses on the identification of female-pattern heart disease, developing new diagnostic tools, and advancing specialized care for women. The Heart Center is designed to help women reduce their chances of heart disease through prevention, including state-of-the-art screening and testing. The Cardio-
Oncology Program provides specialized clinical services dedicated to the heart health of cancer patients and survivors, including comprehensive cardiac risk assessment and stratification. These activities require close collaboration between oncologists and cardiologists and are strongly supported by the Cancer Institute and Heart Center. During the past few years, we have gained substantial experience in cardiac imaging, positioning ourselves for the successful implementation of the STOP Heart Disease in Breast Cancer Survivors Trial.  
CMRI Experience. We are fortunate to have internationally-recognized expertise in advanced cardiac imaging at CSMC and are among the few centers in the country with a research-dedicated MR scanner. We have a trackrecord of successful collaboration with the imaging group in studies using CMRI to advance the field of noninvasive cardiac imaging in women [65-67]. CMRI does not involve ionizing radiation, and therefore does not contribute to risk of second malignancy in this patient population. CMRI is uniquely suited to be 'one-stop shop' for cardiac imaging and can accurately quantify cardiac morphology (atrial and ventricular size and volume, valves, pericardium), function (both local and regional systolic and diastolic function), and tissue characteristics
(diffuse myocardial fibrosis, focal scar, and myocardial edema). In addition to measures of diastolic function such as peak filling rate (PFR) and time to peak filling rate (tPFR) that provide information about left ventricular (LV)
filling, the novel tissue tagging method provides additional information on myocardial twist and torsion. Through data collected in the National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study on diastolic dysfunction detected by CMRI we have demonstrated a relationship between chronic ischemia and diastolic dysfunction in women [68].  
Myocardial Fibrosis Imaging and Tissue Viability. CMRI
late gadolinium enhancement imaging assesses fibrosis and scarring. However, late gadolinium enhancement cannot detect diffuse patterns of fibrosis, nor can it provide insight into changes in tissue viability. T1 mapping directly addresses these limitations. Whereas native T1 mapping (without contrast)
provides quantitative information about the myocyte and interstitium, post-contrast T1 mapping can help to partition the myocardium into its cellular and interstitial components. Tl  
  
mapping has also been used to estimate the myocardial extracellular volume using Modified Look-Locker Inversion
(MOLLI) recovery images to characterize diffuse myocardial fibrosis [69,70]. We have extensive experience with each of these measurements and have used native T1 mapping to distinguish patients with ischemic heart disease or systemic lupus crythematosus from healthy age-matched controls [Figure 3]. Our imaging group can perform CMRI
acquisition with myocardial perfusion and T1 mapping for myocardial fibrosis in a single session [71]. These two unique capabilities make CMRI an ideal non-invasive tool for cardiotoxicity mechanistic pathway investigation. Subclinical LV Dysfunction with Anthracycline Therapy. Our group has extensive experience with CMRI
tissue tagging and the measurement of LV strain and tissue deformation [68,72-76]. We found substantial subclinical LV dysfunction in a breast cancer patient treated with 4 cycles of anthracycline therapy [Figure 4].  
Note that conventional metrics of LV morphology and function (ejection fraction, volumetric) are indistinguishable from baseline [Table 1]. However, MR tissue tagging shows marked increase in GCS (primary endpoint for the current trial) and decrease in LV twist mechanics (secondary endpoint for the current trial), that signal a reduced ability of the heart to contract.  
  
| Table 1. LV Dysfunction with Anthracycline   |      |       |
|----------------------------------------------|------|-------|
| Baseline Anthracycline                       |      |       |
| LV EDV, mL                                   | 17.7 | 130.0 |
| LV ESV, mL                                   | 47.5 | 54.3  |
| SV, mL                                       | 70.2 | 75.8  |
| LV EF, %                                     | 60   | 58    |
| CO, L/min                                    | 5.2  | 6.2   |
| LV mass, g                                   | 83.1 | 82.2  |
| LV Concentricity, g/mL                       | 0.71 | 0.63  |  
Importance of the Study. We now have ample evidence that women can have significant cardiac injury following chemotherapy and radiotherapy for breast cancer, yet we lack evidence-based guidelines for the prevention and management of pre-clinical and clinical cardiotoxicity [5]. Cardiac dysfunction secondary to treatment is an important morbidity and mortality concern among breast cancer survivors and will contribute to potentially avoidable health care costs. While monitoring LVEF measured by echocardiography is routine clinical practice, decreased LVEF is a late manifestation of myocardial injury. Early changes in cardiac function, myocardial injury, myocardial edema, and fibrosis are missed on echocardiography and there is concern that delaying diagnosis and treatment by ≥ 6 months **may reduce the benefit of heart failure treatment [3]. Presently,** there is little evidence regarding risk reduction schema to reduce myocardial injury during cancer treatment despite the existence of effective cardiovascular disease preventive strategies [77]. A recent meta-analysis showed that several medications, including statin, had efficacy for reducing the risk of cardiac injury in cancer patients
[3]. Statins are well-accepted and well-tolerated medications [6] and have demonstrated a reduction in mortality in primary and secondary prevention of cardiovascular diseases [10]. Our multi-disciplinary approach will allow us to integrate findings regarding structural changes to the myocardium with pre- and post-therapeutic functional and metabolic characteristics. We focus on women undergoing trastuzumab treatment (with or without anthracycline) for breast cancer because they will derive the greatest benefit from an early intervention to prevent cardiac injury. Our short-term follow-up will facilitate an examination of initial changes in cardiotoxicity among breast cancer survivors. Detailed imaging changes to the myocardium from baseline through one year of statin therapy will ultimately inform mechanistic pathways of treatment-induced myocardial damage.  
Our review of the literature and ClinicalTrials.gov identified no published RCT evaluating the benefit of early initiation of statin specifically in breast cancer patients. However, a number of past or ongoing studies (e.g., NCT 01022086, 00679874, 02306538, 02062983) have used CMRI to examine heart function in breast cancer patients treated with trastuzumab, supporting the utility of non-invasive imaging in the proposed RCT. Randomizing women planning to undergo breast cancer treatment to prophylactic therapy with statin, which is known to be inexpensive, well-tolerated, safe, effective and approved for prevention of cardiovascular disease, is a strength as it may make the trial more attractive to oncologists who are enrolling patients, as well as to potential subjects.  
Presently, no consensus-based guidelines exist for post-treatment cardiovascular disease monitoring of breast cancer survivors [77]. Subtle injury to cardiac muscle during breast cancer treatment that fails to heal following cessation of therapy is a critical health and quality of life concern among breast cancer survivors. This knowledge gap in the cardiovascular care of breast cancer patients is understandable in that these women are generally excluded from cardiac clinical trials. Evidence is needed regarding the benefit of implementing measures early to reduce or prevent cardiac injury among women with the most aggressive molecular subtypes of breast cancer. The management strategies being tested are logical and consistent with present clinical care of women at risk for cardiac disease, yet novel for the population. This short-term trial will document the feasibility of recruiting breast cancer patients to statin therapy, will evaluate efficacy and safety of this preventive strategy, and will inform the search for key biologic mechanisms and time course through which breast cancer treatment leads to myocardial dysfunction with future progression to ischemia and heart failure. Future studies will include longer follow-up to capture longer-term cardiotoxicity and larger numbers of breast cancer patients to optimize our cardioprotection strategies.
study schema
2.0 study objectives and endpoints

The objective of the *Statin Therapy Operates to Prevent* (STOP) Heart Disease in Breast Cancer Survivors *Trial* is to examine the effect of statin use versus placebo on myocardial functional and structural changes in 60 women diagnosed with stage 1-3 breast cancer recommended to undergo trastuzumab treatment, with or without anthracycline. We will conduct a randomized, double-blinded, placebo-controlled, Phase II trial of atorvastatin to ameliorate or prevent cardiac damage in women with newly diagnosed breast cancer. Detailed imaging changes to the myocardium from baseline through 12 months of follow-up will ultimately inform mechanistic pathways of treatment-induced myocardial damage. Our ultimate goal is to develop strategies that will attenuate the long-term cardiotoxicity from trastuzumab treatment.
study schema
2.1 primary objectives

2.1.1 To evaluate the effect of atorvastatin intervention versus placebo on a 1 year change from baseline in myocardial dysfunction in breast cancer patients who have undergone trastuzumab treatment, with or without anthracycline. The primary outcome is global circumferential strain (GCS), a sensitive measure of myocardial dysfunction, which is predictive of future cardiac events. Cardiac magnetic resonance imaging (CMRI) will be used to measure GCS.
study schema
2.2 secondary objectives

2.2.1 To evaluate the effect of atorvastatin intervention versus placebo on a 1 year change from baseline in other strain-related measures, myocardial diastolic function, and cardiac morphology, measured by cine CMRI and tissue tagging; 2.2.2 To evaluate the effect of atorvastatin intervention versus placebo on a 1 year change from baseline in myocardial fibrosis, edema, and inflammation measured by T1 and T2 mapping values during the CMRI.
study schema
2.3 primary endpoint

The primary endpoint is change in global circumferential strain (GCS) measured by CMRI. GCS is a composite measure of myocardial deformation as the heart contracts and relaxes. The equality of atorvastatin intervention to placebo in reducing or preventing left ventricular (LV) dysfunction will be assessed through comparison of change in GCS values measured from baseline (from 2 weeks before the patient starts systemic breast cancer treatment (trastuzumab with or without anthracycline) up to 3 weeks after starting treatment) to 12 months postinitiation of the statin intervention.
study schema
2.4 secondary endpoints

Secondary outcomes include additional global measures of cardiac function, diastolic function, cardiac morphology, and tissue viability. Differences in secondary outcomes from baseline to 12 months follow-up will be compared in the atorvastatin and placebo groups using a similar approach to the main outcome.  
2.4.1 Changes in other strain-related measures (global longitudinal strain (GLS), peak LV twist and torsion),
myocardial diastolic function (LV untwisting rate, diastolic strain rate) and cardiac morphology (mass, wall thickness, internal dimensions)
2.4.2 Changes in myocardial fibrosis and tissue viability, edema, and inflammation
study schema
3.0 participant selection 3.1 inclusion

3.1.1 **Female patients with newly diagnosed stage 1-3 breast cancer**  
3.1.2 **Histologically confirmed HER2, ER, and PR status** 3.1.3 **Recommended to undergo trastuzumab treatment, with or without anthracycline. Patients will be eligible**
for up to 3 weeks after starting treatment.  
3.1.4 **Age minimum 18 years**
3.1.5 **Able and willing to read, understand, and sign an informed consent form (ICF) and medical release form**
3.1.6 **Willing and able to comply with trial protocol and follow-up** 3.1.7 ECOG performance status 0-**1 (Karnofsky ≥ 70%; see Appendix A)**
study schema
3.2 exclusion criteria

3.2.1 **Prior use of statin medication within the past year**  
3.2.2 **Not using statin medication but is eligible for statin therapy based on the 2013 ACC/AHA guidelines**
(LDL cholesterol >190, or LDL <190 and ASCVD risk >7.5%; http://tools.acc.org/ASCVD-Risk-
Estimator/) and is > 50 years old; or is eligible for statin therapy based on the 2013 ACC/AHA guidelines and is 40-50 years old and wishes to be placed on statin therapy  
3.2.3 **History of adverse effects, intolerance, or allergic reactions attributed to statin medication**
3.2.4 **Current use of gemfibrozil, cyclosporine, clarithromycin, itraconazole, erythromycin, the hepatitis C**
protease inhibitor telaprevir, HIV protease inhibitors, colchicine, or red yeast rice 3.2.5 **Current use of any other investigational agent** 3.2.6 **Pregnant or intention to get pregnant during the next 18 months. Pregnant women are excluded from this**
study because atorvastatin is a lipid-lowering agent with the potential for teratogenic or abortifacient effects, and MRI is contraindicated in pregnant women.  
3.2.7 History of diabetes, severe lung disease, renal disease (creatinine > 1.8 mg/dL or CrCl ≤ 50 m**L/min), or**
hepatic disease (AST and ALT > 3 times upper normal limits)
3.2.8 **Abnormal baseline echocardiogram or cardiac MRI (detection of congenital heart disease; ischemic heart**
disease; moderate or severe valvular heart disease; cardiomyopathy; EF < 55%)
3.2.9 **Previously known or diagnosed heart disease (e.g. congenital; valvular; coronary artery disease; history of**
myocardial infarction or acute coronary syndrome; cardiomyopathy, including infiltrative, hypertensive, hypertrophic, dilated, constrictive pericarditis, or other cardiomyopathy)
3.2.10 **Left ventricular dysfunction (EF < 55%)** 3.2.11 **Prior non-cardiac illness with an estimated life expectancy < 4 years** 3.2.12 **Known active infection with HIV**
3.2.13 **Allergy or contraindication to MRI testing, including metallic parts in the body prohibiting MRI, prior**
gadolinium contrast reaction, or uncontrolled moderate hypertension (sitting blood pressure >160/95 mm Hg with measurements recorded on at least 2 occasions)
3.2.14 **Has metallic breast expanders in place at the time of screening** 3.2.15 **Concurrent illness which in the opinion of the investigators would compromise either the patient or the**
integrity of the data
study schema
3.3 inclusion of women and

Women and members of all races and ethnic groups are eligible for this trial. Men are excluded from the study because there are very few cases of male breast cancer.
study schema
4.0 study plan 4.1 recruitment

Women with newly diagnosed stage 1-3 breast cancer will be recruited from the Brandman Breast Center at Cedars-Sinai Medical Center (CSMC), the Tower Hematology Oncology Medical Group, and the offices of CSMC affiliated oncologists. Between January and June 2016, 61 women with breast cancer were recommended to undergo trastuzumab treatment at Cedars-Sinai. The number of women who received trastuzumab treatment may be greater because data collection guidelines do not require the Cancer Registry to collect individual agent names, and chemotherapy and immunotherapy agents are coded as notes in text fields only. Based on this patient population and the importance of our objectives to the breast cancer community, our recruitment goal of 60 women with newly diagnosed breast cancer [40 white (67%), 6 black (10%), 6 Asian (10%), 3 other race (5%), and 5 Hispanic (8%)] is feasible. This goal accounts for a ~25% participation rate among potentially eligible nonstatin users, with a final analytic sample of 48 women after 20% lost to follow-up [Figure 5]. Recruitment will occur over 24 months with an expected accrual rate of 2-3 participants per month.  
  
Each of the investigators, the advocate, and members of the Internal Advisory Board, brings substantial
experience with patient recruitment to the study and will insure that our recruitment goals are met. Dr. Mita (oncologist) and Ms. Travis-Teague (advocate) will work closely with our oncologists and surgeons in the recruitment effort. We will utilize physician education techniques such as physician mailings, presentations at CSMC conferences, and one-to-one referring physician-investigator interactions to enhance recruitment. An information leaflet that describes the study will be available in the clinic waiting rooms at the Brandman Breast Center, the Tower Hematology Oncology Medical Group, and the offices of CSMC affiliated oncologists. The leaflet will direct interested patients to speak with their treating oncologist for more information about the study.  
In order to better ensure that only those patients who may be eligible to participate in the research are approached with information about the study, the clinical research staff will identify potential participants via a review of participating oncologist-investigator schedules to identify breast cancer cases that would be appropriate to screen via medical records. Medical records will be reviewed for age, breast cancer diagnosis (stage; HER2, ER, and PR
status), medical contraindications, laboratory results, prior or current use of statin medication, and current use of prohibited concomitant medications. A protocol specific checklist will be used to identify basic inclusion and exclusion criteria. Research staff will indicate if the patient appears to meet the general criteria, i.e., yes or no response, and will not record specific test results or other detailed data points on the checklist. The names of the patients who appear to meet the study eligibility criteria will be recorded along with the name of their treating physician. Research staff will contact the oncologist-investigator and advise that the patient has been identified as a potential research participant, and the eligibility checklist will be forwarded to the oncologist for review.  
The treating oncologist will introduce the study to potentially eligible breast cancer patients recommended for trastuzumab treatment (with or without anthracycline) during the treatment planning visit after standard care options have been presented. Patients will receive a study information packet to take home that includes the study information leaflet, the IRB approved study informed consent form and HIPAA authorization, and the Learning More about Research Opportunities brochure to advise them of the voluntary nature of participation. Clinical research staff will be present at the clinic during this visit and will be available to review the study information packet with the patient. Patients will be encouraged to review the consent documents with family, friends, and/or other physicians. The patient will be told that the decision to join or not join the study will not affect the medical treatment that she receives, and that she can withdraw from the study at any time. The study coordinator will follow up with the patient a few days later by phone to address any additional questions.  
Patients who are interested and want to volunteer for the trial will be consented to participate in the study by the treating oncologist at their next standard of care visit, or by one of the study physician-investigators present during the patient's baseline pre-study standard of care echocardiogram appointment. Copies of the signed consent documents will be given to the patient and placed in the medical record. Because there is a short window of time
(1 week) for all the pre-treatment assessments before systemic breast cancer treatment is initiated, some potentially eligible patients may not be seen again by the treating oncologist until after they are no longer eligible for the study. In such cases, women who have had all their questions about the trial answered on the day they first learn about the study, and who wish to volunteer for the trial, may be consented to participate in the study the same day they are first informed of the research.  
After consent has been obtained, clinical research staff will complete a full eligibility checklist and compile the support documents from patient medical records, including laboratory reports, medical history, physician notes, and current medications list. The oncologist, study cardiologist, or other physician-investigator will review the patient's **eligibility checklist, medical history, and supporting documentation. Patients with a history of heart** disease or cardiomyopathy and patients > 50 years old who are eligible for statin therapy based on the 2013 ACC/AHA guidelines (LDL cholesterol >190, or LDL <190 and ASCVD risk >7.5%; http://tools.acc.org/ASCVD-Risk-Estimator/) will be excluded from the trial. Patients 40-50 years old who are eligible for statin therapy based on the 2013 ACC/AHA guidelines and want to be placed on statins will also be excluded. A Clinical Research Office (CRO) designee will conduct a final eligibility check prior to registration. Consented patients who qualify for the study after the pre-study eligibility evaluations and CRO confirmation of eligibility will be registered for the trial, enrolled in the study, randomized to the intervention (atorvastatin or placebo), and scheduled for Visit 1, the baseline testing.
study schema
4.2 study treatment protocol

All women will receive their usual care under the guidance of their oncologist. Importantly, this will include 2-D
echo to allow us to compare current screening practice with the innovative CMRI. Breast cancer patients scheduled for systemic breast cancer treatment are recommended to undergo a 2D-echocardiogram prior to starting treatment, and 3 months and 9 months after initiation of treatment for standard of care monitoring. There will be three research study visits (Visits 1, 4, and 6) to collect endpoint data: baseline measurements and initiation of the statin intervention, from 2 weeks before the patient starts systemic breast cancer treatment (trastuzumab with or without anthracycline) up to 3 weeks after starting treatment; and follow-up visits 6 and 12 months after initiation of the statin intervention. Each research visit will include a medical history, medications, and laboratory test results review; vital signs assessment and measurement of weight; ECOG performance status; blood draw; pregnancy test for women who are able to become pregnant (during the pre-study evaluations visit and at each research visit; see 4.3 Study Measurements for pregnancy test details); cardiac magnetic resonance imaging (CMRI); interviewer-administered questionnaire; quality of life assessments, QLQ-C30 and QLQ-BR23; eligibility criteria review; dispensing the study drug (atorvastatin or placebo, no dispense at 12-month visit; compliance and adverse events assessment; and review of the study diary.  
There will be three **additional encounters during standard of care oncologist visits (1 month, 3 months, and 9** months after initiation of the statin intervention) that include a medical history, medications, and laboratory test results review; physical exam; symptom assessment; ECOG performance status; clinical labs for a Complete Blood Count and Automated Differential (CBDF) and a **Comprehensive Metabolic Panel (CMPL); eligibility** criteria review; compliance and adverse events assessment; review of the study diary; and dispensing the study drug. See Section 7.0 Clinical Evaluations and Procedures for a detailed description of the study treatment protocol. Research visits will coincide whenever practicable with usual care clinic appointments to reduce travel time and increase compliance with the study protocol. The study visit will be scheduled as early in the morning as possible. Each subject will be offered $100 at the completion of each research study visit as reimbursement for their time, transportation, parking, and other expenses related to the study. Participants who complete all three research study visits will receive $300. A packet of material, including an appointment letter, a map, and parking instructions for the visit will be provided to the subject prior to the scheduled study visit. A day or two prior to the scheduled study visit, the participant will be contacted by telephone to confirm or reschedule her visit. If a subject misses her study visit, she will be called promptly to reschedule. The study coordinator will have a database which tracks active participants who do not have a scheduled visit or who have missed their targeted visit date. Study visits will be rescheduled for up to 3 months until the participant is considered lost to follow-up.
study schema
4.3 study measurements

Following is a brief description of study measurements. See Section 7.7 for a more detailed description.  
Cardiac magnetic resonance imaging (CMRI)**. CMRI will be performed at baseline and at the 6-month and 12-**
month research visits (Visits 1, 4, and 6). CMRI will be used to measure the primary outcome, global circumferential strain (GCS) and the secondary outcomes, myocardial diastolic function, and fibrosis. CMRI is a non-invasive, non-radiation imaging modality that is the gold standard cardiac imaging technique for cardiac structure (atrial and ventricular size and volume, valves, pericardium, edema, fibrosis) and function (myocardial blood flow quantification, systolic and diastolic function). CMRI can also detect myocardial fibrosis with late gadolinium enhancement and T1 mapping. Patients with claustrophobia may pre-medicate as needed prior to the CMRI. Women who have breast reconstruction surgery after enrollment/completion of the baseline visit that includes metallic breast expanders prohibiting MRI will not be required to do the CMRI while the breast expanders are in place.  
Blood specimen. **A blood specimen will be collected from each participant at every research visit. Less than 1**
mL of blood will be drawn for measurement of hematocrit and creatinine levels used for CMRI calculations, and 5 mL will be drawn for laboratory blood tests to monitor for potential adverse effects of the intervention. An additional (optional) 28 mL blood sample will be collected from subjects who consent to have their blood samples banked for future studies of blood biomarkers. Pregnancy test. **Because statins are known to be teratogenic and MRI is contraindicated in pregnant women,**
women < 60 years of age who have not had a menstrual period in the last 30 days will be required to have a urine pregnancy test during the pre-study evaluations and at every research visit. However, women who have had a hysterectomy, both ovaries removed, or a tubal ligation will not be required to have a pregnancy test.  
Physical assessment. **Participants will have a physical assessment at every standard of care and research study**
visit. Each assessment will include vital signs, including blood pressure, heart rate, and temperature; measurement of weight; and ECOG performance status. The oncologist will perform a physical exam and an interval symptom history at every standard of care visit. Medical record review. **Medical history, concomitant medications, and laboratory test results will be reviewed at**
every standard of care and research study visit. Specific information regarding the type of treatment regimen and dose received will be obtained through the electronic medical record, including Taxotere (docetaxel), carboplatin, and trastuzumab (TCH); TCH with pertuzumab (TCHP); and anthracycline and trastuzumab regimen doxorubicin (or epirubicin), cyclophosphamide, and taxane followed by **trastuzumab (AC-TH). Information regarding breast** or chest wall radiation, including right vs. left sided radiation, total dose, and number of fractions of radiation, as well as technique and dosimetry will be collected. BRCA mutation information will also be collected.  
Baseline and follow-up questionnaires. **A structured interview, developed for this investigation and including**
risk factor and clinical assessment, will be administered by the research staff at Visit 1 (baseline). The questionnaire will obtain information regarding race/ethnicity; education; anthropometry including weight at different decades of life; medical history, including history of cancer and BRCA testing; menstrual and pregnancy histories; use of oral contraceptives and hormones; adult recreational physical activity; tobacco smoking history; and history of alcoholic beverage consumption. A shorter questionnaire will be administered at the 6 and 12 month visits to assess changes in exposures and behaviors between visits.  
Quality of life and symptoms assessment**. We will measure quality of life and symptoms using the QLQ-C30**
and QLQ-BR23. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 is a 30item measure developed to assess the quality of life of cancer patients [78]. The measure includes three scales:
global health status, functional status (physical, role, emotional, cognitive, and social), and physical symptoms.  
The EORTC QLQ-BR23 is a 23-item measure specifically for patients with breast cancer that assesses disease symptoms and emotional problems related to breast cancer [79,80]. Participants will self-administer the QLQ-C30 and QLQ-BR23 assessments.
study schema
5.0 agent administration

Intervention will be administered on an outpatient basis. Reported agent adverse events (AEs) and potential risks are described in Section 6.2.
study schema
5.1 dose regimen and dose

- **Agent(s): Atorvastatin calcium and placebo** - **Daily dose(s) and regimen(s) for each agent: One capsule atorvastatin calcium 20 mg or placebo per day**
Sixty participants with newly diagnosed stage 1-3 breast cancer will be randomized into one of 2 groups: 30 participants will receive 20 mg atorvastatin and 30 participants will receive a placebo identical in color, consistency, and appearance to atorvastatin. Atorvastatin 20 mg and matching placebo will be supplied as overencapsulated capsules for oral administration.  
The recommended starting dose of atorvastatin is 10 to 20 mg once daily. The dosage range of atorvastatin calcium tablets is 10 to 80 mg once daily.
study schema
5.2 study agent administration and

Patients will self-administer one capsule of atorvastatin 20 mg or placebo daily. Atorvastatin calcium can be administered as a single dose at any time of the day, with or without food. Patients will be instructed to take the study agent at bedtime or with an evening meal. In the absence of treatment delays due to adverse events, treatment for each agent will extend for 12 months.
study schema
5.3 run-in procedures none. 5.4

Patients are advised not to consume grapefruit while on atorvastatin. Grapefruit contains one or more components that inhibit CYP 3A4 and can increase plasma concentrations of atorvastatin, especially with excessive grapefruit juice consumption (> 1 liter per day). Participants enrolled in the study will be instructed to avoid all forms of grapefruit (e.g., juice, fruit, grapefruit seed extract, dietary supplements containing grapefruit) during the trial. The combined use of atorvastatin with gemfibrozil, cyclosporine, lipid-modifying doses of niacin, azole antifungals, or strong CYP3A4 inhibitors (e.g., clarithromycin, itraconazole, erythromycin, the hepatitis C protease inhibitor telaprevir, or combinations of HIV protease inhibitors), and fibric acid derivatives) is contraindicated due to an increased risk for myopathy. Patients will be screened for contraindications to atorvastatin prior to enrollment in the study. Patients with known active infection with HIV will be excluded from the study. Patients will be advised not to use contraindicated medications during the study and will be excluded if use of any contraindicated medication is unavoidable. Concomitant medications will be reviewed at study visits and during follow-up telephone calls. Participants will be closely monitored for symptoms and side effects to the study drug and will be instructed to call the study doctor immediately if they have a serious adverse reaction.
study schema
5.5 concomitant medications

Medications known to interact with atorvastatin will be documented on the concomitant medication case report form (CRF) and will include start and stop date, dose and route of administration, and indication. Taking these medications would exclude the patient from study participation. These medications include: gemfibrozil, cyclosporine, clarithromycin, itraconazole, erythromycin, the hepatitis C protease inhibitor telaprevir, HIV protease inhibitors, colchicine, and red yeast rice. Any medications taken by the patient that are deemed clinically significant in relation to the study, including medications started, stopped, or dose-modified to treat AEs considered at least possibly related to the study drug, will also be recorded on the concomitant medication CRF.
study schema
5.6 dose modification

The study agent will be stopped in the event of an AE ≥ grade 3 considered **possibly, probably, or definitely** related to the study agent. The study agent will be restarted after resolution. One of the common side effects of statin medication is myalgia (muscle pain with normal CPK level), and rarely this is associated with statin myopathy (muscle weakness or other muscle injury with or without elevation in CPK level). In randomized controlled trials of standard dose statin therapy (including atorvastatin 20 mg), the risk is very low. We will measure levels of creatine phosphokinase (CPK) in the blood drawn at the first study visit to establish a patientspecific reference for this indicator of muscle toxicity. During the trial, if the participant reports unexplained muscle pain or weakness, CPK will be tested again to check for elevation. The cardiologist on trial will determine whether the symptoms or an elevation in CPK warrants the participant to discontinue taking the study drug. The study agent will be permanently discontinued in subjects who experience grade 3 or greater myopathy (unexplained muscle symptoms and **CPK > 5 times ULN) or persistent hepatotoxicity (ALT or AST > 3 times**
ULN) that is considered possibly, probably, or definitely related to the study agent.  
If a participant experiences elevated liver enzymes (AST/ALT > 3x ULN), we will continue the study agent and repeat the liver function tests (LFTs) 7-10 days later. If AST/ALT values resolve (≤ 3x ULN)**, the participant will**
continue on the study agent. If AST/ALT values are still elevated (> 3x ULN), the participant will discontinue the study agent. We will measure LFTs 4 weeks later. If AST/ALT values are still elevated (> 3x ULN), the study agent will be permanently discontinued. If AST/ALT values resolve (≤ 3x ULN)**, we will restart the study agent at**
half the dose, atorvastatin 10 mg or placebo, and continue to closely monitor all clinically obtained LFTs.
study schema
5.7 adherence/compliance

Compliance will be measured by pill (capsule) counts and patient diaries. Compliance is defined as 85% of the total dose with all doses of the study agent taken during the week before Visit 6 (the final visit). A patient diary will be used to monitor daily compliance (Appendix B). Participants will be instructed to record the time the study drug was taken each day in the diary, as well as any missed doses and potential side effects. Diaries will be reviewed and compliance will be assessed at every study visit. Phone calls will be made to study participants every four weeks (± 7 days) to monitor compliance. Participants will be asked if they missed any doses of medication, and the dates of all missed doses will be recorded. The study agent diary will be reviewed with participants at every visit. Participants who report having taken < 85% of the study drug doses between phone calls, or whose pill count at a study visit reveals < 85% compliance, will be called every two weeks (± 3 days) to monitor compliance until compliance resolves to at least 85%. The participant will be asked at registration if they would like to receive reminder emails or text messages regarding the study medication. Messages will be sent daily for the first week; in following weeks, messaging will be targeted to participants having difficulty remembering their dose. Since agent compliance is very important during the final week of the intervention, text/email messages will be sent to all study participants who opt to receive these reminders. In addition, phone calls will be made to all study participants during the week before their final visit (Visit 6) to remind them to take the study drug every day until the visit. Participants will also be reminded to bring any leftover study drugs and the study diary with them to every visit.  
Pill counts will be performed at Study Visits 2, 3, 4, 5, and 6 to assess compliance. If less than 85% of the dose has been consumed during the study period, the subject will be considered non-compliant. All participants that receive a study agent for any period of time will be evaluable for toxicity.
study schema
6.0 pharmaceutical information 6.1 study

Atorvastatin calcium, a synthetic lipid-lowering agent, is an inhibitor of 3-hydroxy-3-methylglutaryl-coenzyme A
(HMG-CoA) reductase. This enzyme catalyzes the conversion of HMG-CoA to mevalonate, an early and ratelimiting step in cholesterol biosynthesis.  
The empirical formula of atorvastatin calcium is (C33H34 FN2O5)2Ca•3H2**O and its molecular weight is 1209.42.** Atorvastatin calcium is a white to off-white crystalline powder that is insoluble in aqueous solutions of pH 4 and below. Atorvastatin calcium is very slightly soluble in distilled water, pH 7.4 phosphate buffer, and acetonitrile; slightly soluble in ethanol; and freely soluble in methanol. Atorvastatin calcium tablets for oral administration contain 10, 20, 40, or 80 mg atorvastatin and the following inactive ingredients: calcium carbonate; candelilla wax, FCC; croscarmellose sodium; hydroxypropyl cellulose, NF; lactose monohydrate; magnesium stearate; microcrystalline cellulose; Opadry White YS-1-7040 (hypromellose, polyethylene glycol, talc, titanium dioxide);
polysorbate 80; and simethicone emulsion.
study schema
6.2 reported adverse events and

The most common (incidence ≥ 5.0% in patients) **reported adverse events (AEs) are nasopharyngitis, arthralgia,**
diarrhea, pain in extremity, and urinary tract infection. Other AEs reported in clinical trials (< 5%) were dyspepsia, nausea, musculoskeletal pain, muscle spasms, myalgia, insomnia, and pharyngolaryngeal pain. Persistent increases in serum transaminases (to more than 3 x ULN) have occurred in 0.7% of patients who received atorvastatin calcium tablets in clinical studies (0.2% for atorvastatin 20 mg). One patient in clinical trials developed jaundice. Increases in liver function tests (LFT) in other patients were not associated with jaundice or other clinical signs or symptoms. Upon dose reduction, drug interruption, or discontinuation, transaminase levels returned to or near pretreatment levels without sequelae [7]. It is recommended that liver function tests be performed before initiating therapy with atorvastatin calcium, and thereafter when clinically indicated.  
Atorvastatin, like other statins, occasionally causes myopathy, defined as muscle aches or muscle weakness in conjunction with increases in creatine phosphokinase (CPK) values above 10 x ULN. Myopathy sometimes takes the form of rhabdomyolysis with or without acute renal failure secondary to myoglobinuria, and rare fatalities have occurred. Predi**sposing factors for myopathy include advanced age (≥ 65 years), female gender, uncontrolled**
hypothyroidism, and renal impairment. The concomitant use of higher doses of atorvastatin with certain drugs such as fibric acid derivatives, lipid-modifying doses of niacin, cyclosporine, and strong CYP3A4 inhibitors (e.g., clarithromycin, itraconazole, and HIV protease inhibitors) increases the risk of myopathy/rhabdomyolysis. Cases of myopathy, including rhabdomyolysis, have been reported with atorvastatin co-administered with colchicine, and caution should be exercised when prescribing atorvastatin with colchicine.  
The risk of myopathy, including rhabdomyolysis, is dose related. The risk of myopathy and rhabdomyolysis is increased by high levels of statin activity in plasma. Atorvastatin is metabolized by the cytochrome P450 isoform 3A4 (CYP3A4). Certain drugs which inhibit this metabolic pathway can raise the plasma levels of atorvastatin and may increase the risk of myopathy [6,81]. These include erythromycin, clarithromycin, the hepatitis C protease inhibitor telaprevir, and combinations of HIV protease inhibitors, including saquinavir plus ritonavir, lopinavir plus ritonavir, tipranavir plus ritonavir, darunavir plus ritonavir, fosamprenavir, and fosamprenavir plus ritonavir, or grapefruit products. Combination of these drugs with atorvastatin is contraindicated [Table 2] [7]. If short-term treatment with strong CYP3A4 inhibitors is unavoidable, therapy with atorvastatin must be suspended during the course of treatment.  
| Table 2. Drug Interactions Associated with Increased Risk of Myopathy/Rhabdomyolysis  Interacting Agents Prescribing Recommendations Cyclosporine, HIV protease inhibitors (tipranavir plus  ritonavir), hepatitis C protease inhibitor (telaprevir) Avoid atorvastatin  HIV protease inhibitor (lopinavir plus ritonavir) Use with caution and lowest dose necessary  Clarithromycin, itraconazole, HIV protease inhibitors  (saquinavir plus ritonavir*, darunavir plus ritonavir,  Do not exceed 20 mg atorvastatin daily  fosamprenavir, fosamprenavir plus ritonavir)  HIV protease inhibitor (nelfinavir)  Hepatitis C protease inhibitor (boceprevir) Do not exceed 40 mg atorvastatin daily  *Use with caution and with the lowest dose necessary   |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|  
- Other Lipid-Lowering Medications: Use with fibrate products or lipid-**modifying doses (≥1 g/day) of**
niacin increases the risk of adverse skeletal muscle effects. Caution should be used when prescribing with atorvastatin calcium tablets.  
- **Digoxin: Patients should be monitored appropriately.**
- **Oral Contraceptives: Values for norethindrone and ethinyl estradiol may be increased.**
- **Rifampin should be simultaneously co-administered with atorvastatin calcium tablets.**
- **Due to an increased risk of myopathy/rhabdomyolysis when HMG-CoA reductase inhibitors are coadministered with gemfibrozil, concomitant administration of atorvastatin calcium tablets with**
gemfibrozil should be avoided.
Increases in HbA1c and fasting serum glucose levels have been reported with HMG-CoA reductase inhibitors, including atorvastatin calcium.
study schema
6.3 agent availability packaging and

Atorvastatin 20 mg and matching placebo are investigational agents for oral administration supplied to investigators by the Cedars-Sinai Medical Center Department of Pharmacy. Generic atorvastatin 20 mg tablets will be over-encapsulated and the capsules will be filled with an inert excipient (generally lactose powder). The placebo capsules are identical looking capsules but only filled with lactose powder. The amount of lactose will range from 700 mg-1 g per capsule (less if the capsule contains an atorvastatin tablet). Atorvastatin and placebo will be packaged and labeled by the Cedars-Sinai Medical Center Department of Pharmacy Investigational Drug Service. Each bottle will be labeled with a one-part label identifying study specific information, such as study title, protocol number, dosing instructions, recommended storage conditions, the name and address of the distributor, randomization number, and a caution statement indicating that the agent is limited by United States law to investigational use only and the agent should be kept out of reach of children.  
The study agent will be dispensed to the participant five times: One bottle of 44 capsules (30-day supply + 14 days buffer) at baseline, one bottle of 74 capsules (60-day supply + 14 days buffer) at 1 month, and one bottle of 104 capsules (90-day supply + 14 days buffer) at 3 months, 6 months, and 9 months after initiation of the intervention.
study schema
6.4 storage

Study agents will be stored in a safe, secure, temperature monitored limited access drug storage area specifically for research medication at the Cedars-Sinai Medical Center Department of Pharmacy. Study agents shall be maintained at a controlled room temperature [between 15-25°C] by the Pharmacy and once dispensed, the subjects will be instructed to store the drug in their homes protected from light, heat, and moisture.
study schema
6.5 agent accountability

The Investigator is required to maintain adequate records of receipt, inventory, dispensing, and disposition of the study agent. This responsibility has been delegated to the study research pharmacist, Suwicha Limvorasak, Pharm.D., Investigational Drug Pharmacist at the Samuel Oschin Comprehensive Cancer Institute (SOCCI). The receipt record will include from whom the agent was received, date, quantity and batch or lot number. The dispensing record will note quantities and dates study agent was dispensed to and returned by each participant.
study schema
6.6 blinding and unblinding

The research pharmacist will manage the investigational agent. The blind will be maintained through the effort of the research pharmacist, and the pharmacy. Unblinding will only occur when it is deemed medically necessary. The date and reason for breaking the blind will be documented by the Principal Investigator.  
In the event that the Principal Investigator and treating physician have determined that it is medically necessary to unblind the participant due to life threatening or emergent clinical issues, a summary of the clinical history and request for unblinding will be forwarded to Dr. Howard Sandler, Medical Director, for final review and final approval. Documentation of unblinding approval will be provided to the research pharmacy and maintained in research chart.
study schema
7.0 clinical evaluations and procedures

| Visit 1^  (Baseline)  From 2  weeks before  patient starts systemic  breast cancer  treatment up  to 3 weeks  after starting  treatment:  initiation of  the statin  intervention   | FollowUp  Days 30 ±7,  60 ±7, and  90 ±7 after  completion  of the statin  intervention                                                                               |                                                                               |                                                                              |                                                                                |    |    |    |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------|-------------------------------------------------------------------------------|------------------------------------------------------------------------------|--------------------------------------------------------------------------------|----|----|----|
| Visit 2*  1 month  ± 2 weeks  after  initiation of  the statin  intervention                                                                                                        | Visit 3*  3 months  ± 2 weeks  after  initiation of  the statin  intervention | Visit 4^  6 months  ± 2 weeks  after  initiation of  the statin  intervention | Visit 5* 9 months  ± 2 weeks  after  initiation of  the statin  intervention | Visit 6^  12 months  ± 2 weeks  after  initiation of  the statin  intervention |    |    |    |
| PreStudy*                                                                                                                                                                                     |                                                                               |                                                                               |                                                                              |                                                                                |    |    |    |
| Study Procedures  Assess eligibility and recruitment                                                                                                                                | X                                                                             |                                                                               |                                                                              |                                                                                |    |    |    |
| Informed Consent and HIPAA  authorization                                                                                                                                           | X                                                                             |                                                                               |                                                                              |                                                                                |    |    |    |
| Registration and randomization to  atorvastatin or placebo                                                                                                                          | X                                                                             |                                                                               |                                                                              |                                                                                |    |    |    |
| Review inclusion/exclusion  criteria and study requirements                                                                                                                         | X                                                                             | X                                                                             | X                                                                            | X                                                                              | X  | X  |    |
| Review medical history,  medications, and laboratory test                                                                                                                           | X                                                                             | X                                                                             | X                                                                            | X                                                                              | X  | X  | X  |
| results  Demographics (birth date, race,  ethnicity, education)                                                                                                                     | X                                                                             | X                                                                             |                                                                              |                                                                                |    |    |    |
| Physical exam and symptom  assessment                                                                                                                                               | X                                                                             | X                                                                             | X                                                                            | X                                                                              |    |    |    |
| Vital signs, measure weight                                                                                                                                                         | X                                                                             | X                                                                             | X                                                                            | X                                                                              | X  | X  | X  |
| ECOG performance status                                                                                                                                                             | X                                                                             | X                                                                             | X                                                                            | X                                                                              | X  | X  | X  |
| 2D-echocardiogram1                                                                                                                                                                  | X                                                                             | X                                                                             | X                                                                            |                                                                                |    |    |    |
| Urine pregnancy test2                                                                                                                                                               | X                                                                             | X                                                                             | X                                                                            | X                                                                              |    |    |    |  
| Protocol Version 3.1, November 29, 2017                                                                                                                                                                    |                                                                               |                                                                               |                                                                              |                                                                                |    |    |    |    |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------|-------------------------------------------------------------------------------|------------------------------------------------------------------------------|--------------------------------------------------------------------------------|----|----|----|----|
| Visit 1^  (Baseline)  From 2  weeks before  patient starts systemic  breast cancer  treatment up  to 3 weeks  after starting  treatment:  initiation of  the statin  intervention                          | FollowUp  Days 30 ±7,  60 ±7, and  90 ±7 after  completion  of the statin  intervention                                                                               |                                                                               |                                                                              |                                                                                |    |    |    |    |
| Visit 2*  1 month  ± 2 weeks  after  initiation of  the statin  intervention                                                                                                                               | Visit 3*  3 months  ± 2 weeks  after  initiation of  the statin  intervention | Visit 4^  6 months  ± 2 weeks  after  initiation of  the statin  intervention | Visit 5* 9 months  ± 2 weeks  after  initiation of  the statin  intervention | Visit 6^  12 months  ± 2 weeks  after  initiation of  the statin  intervention |    |    |    |    |
| PreStudy*                                                                                                                                                                                                            |                                                                               |                                                                               |                                                                              |                                                                                |    |    |    |    |
| Study Procedures  Blood test: Complete Blood  Count and Automated Differential                                                                                                                             | X                                                                             | X                                                                             | X                                                                            | X                                                                              |    |    |    |    |
| (CBDF)  Blood test: Comprehensive  Metabolic Panel (CMPL)                                                                                                                                                  | X                                                                             | X                                                                             | X                                                                            | X                                                                              | X  | X  |    |    |
| Blood test: Lipid panel3                                                                                                                                                                                   | X                                                                             | X                                                                             | X                                                                            | X                                                                              |    |    |    |    |
| Blood test: Creatine  phosphokinase (CPK)                                                                                                                                                                  | X                                                                             |                                                                               |                                                                              |                                                                                |    |    |    |    |
| Blood tests: hematocrit and  creatinine4                                                                                                                                                                   | X                                                                             | X                                                                             | X                                                                            |                                                                                |    |    |    |    |
| Collect blood for future research5                                                                                                                                                                         | X                                                                             | X                                                                             | X                                                                            |                                                                                |    |    |    |    |
| Cardiac Magnetic Resonance  Imaging (CMRI)                                                                                                                                                                 | X                                                                             | X                                                                             | X                                                                            |                                                                                |    |    |    |    |
| Risk factor questionnaire                                                                                                                                                                                  | X                                                                             | X                                                                             | X                                                                            |                                                                                |    |    |    |    |
| QLQ-C30 and QLQ-BR23                                                                                                                                                                                       | X                                                                             | X                                                                             | X                                                                            |                                                                                |    |    |    |    |
| Dispense study agent and diary                                                                                                                                                                             | X                                                                             | X                                                                             | X                                                                            | X                                                                              | X  |    |    |    |
| Collect study agent and diary                                                                                                                                                                              | X                                                                             | X                                                                             | X                                                                            | X                                                                              | X  |    |    |    |
| Review study diary                                                                                                                                                                                         | X                                                                             | X                                                                             | X                                                                            | X                                                                              | X  |    |    |    |
| Assess compliance (pill count)                                                                                                                                                                             | X                                                                             | X                                                                             | X                                                                            | X                                                                              | X  |    |    |    |
| Assess adverse events                                                                                                                                                                                      | X                                                                             | X                                                                             | X                                                                            | X                                                                              | X  | X  |    |    |
| Telephone contact6                                                                                                                                                                                         | X                                                                             | X                                                                             | X                                                                            | X                                                                              | X  | X  | X  | X  |
| *Pre-Study evaluations and Visits 2, 3, and 5 are standard of care visits.  ^Visits 1, 4, and 6 are research visits to collect endpoint data and will coincide with standard of care visits when possible. |                                                                               |                                                                               |                                                                              |                                                                                |    |    |    |    |  
Blood test: Comprehensive  
Metabolic Panel (CMPL) X X X X X X  
Blood test: Lipid panel3 **X X X X**  
Blood test: Creatine  
phosphokinase (CPK) X  
Blood tests: hematocrit and  
creatinine4 **X X X**  
Collect blood for future research5 **X X X**  
Cardiac Magnetic Resonance  
Imaging (CMRI) X X X  
Risk factor questionnaire X X X QLQ-C30 and QLQ-BR23 X X X  
Dispense study agent and diary X X X X X  
Collect study agent and diary X X X X X Review study diary X X X X X  
Assess compliance (pill count) X X X X X  
Assess adverse events X X X X X X  
Telephone contact6 **X X X X X X X X**  
*Pre-Study evaluations and Visits 2, 3, and 5 are standard of care visits.  
^Visits 1, 4, and 6 are research visits to collect endpoint data and will coincide with standard of care visits when possible.  
1 A **2D-echocardiogram will be done for standard of care monitoring before the patient starts systemic breast cancer**  
treatment, and 3 months and 9 months after initiation of treatment.  
2 **Because statins are known to be teratogenic and MRI is contraindicated in pregnant women, women < 60 years of age**  
who have not had a menstrual period in the last 30 days will be required to have a urine pregnancy test at the pre-study  
evaluations and at Visits 1, 4, and 6. Women who have had a hysterectomy, both ovaries removed, or a tubal ligation will not be required to have a pregnancy test.  
3 **Lipid panel: If lipid panel results within the past 12 months are not available, a lipid panel will be done to confirm**  
eligibility prior to registration. The lipid panel will not be done at Visit 1 if a lipid panel was done at the pre-study evaluations or if lipid panel results within 30 days prior to the visit are available.  
4 **Less than 1 mL of blood will be drawn from each participant at Visits 1, 4, and 6 for measurement of hematocrit and**  
creatinine levels used for CMRI calculations.  
5 **Blood collection for future research: An additional (optional) 28 mL blood sample will be collected at Visits 1, 4, and 6**  
from participants who consent to have their blood samples banked for future studies of blood biomarkers.  
6 **Telephone contact every four weeks (± 7 days) during the intervention to assess compliance and adverse events. Followup telephone contact on days 30 ± 7, 60 ± 7, and 90 ± 7 after completion of the statin intervention to assess adverse events.**
study schema
7.2 pre-study evaluation

Assessments performed exclusively to determine eligibility for this study will be done only after obtaining informed consent. Assessments performed for clinical indications (not exclusively to determine study eligibility)
may be used for baseline values even if the studies were done before informed consent was obtained.
study schema
7.2.1 pre-screen medical chart review

Clinical research staff will identify potential participants via a review of participating oncologist-investigator schedules to identify breast cancer cases that would be appropriate to screen via medical records. A protocol specific checklist will be used to determine initial eligibility as specified in the inclusion and exclusion criteria. Medical records will be reviewed for:
1. **Age** 2. **Breast cancer diagnosis (stage; HER2, ER, and PR status)**
3. **Medical contraindications and laboratory results that impact inclusion in the study** 4. **Prior or current use of statin medication, and current use of prohibited concomitant medications**
Research staff will indicate if the patient appears to meet the general criteria, i.e., yes or no response, and will not record specific test results or other detailed data points on the checklist. The names of the patients who appear to meet the study eligibility criteria will be recorded along with the name of their treating physician. Research staff will contact the oncologist-investigator and advise that the patient has been identified as a potential research participant, and the eligibility checklist will be forwarded to the oncologist for review.
study schema
7.2.2 recruitment and consent

Potentially eligible patients with newly diagnosed stage 1-3 breast cancer will be scheduled for a consult with an oncologist.  
- **The oncologist will introduce the study to breast cancer patients recommended for trastuzumab treatment**
(with or without anthracycline) during the treatment planning visit after standard care options have been presented.  
- **Patients will receive a study information packet to take home that includes the study information leaflet,**
the IRB approved study informed consent form and HIPAA authorization, and the Learning More about Research Opportunities brochure to advise them of the voluntary nature of participation. Clinical research staff will be present at the clinic during this visit and will be available to review the study information packet with the patient.  
- **Patients will be encouraged to review the consent documents with family, friends, and/or other**
physicians. The patient will be told that the decision to join or not join the study will not affect the medical treatment that she receives, and that she can withdraw from the study at any time. The study coordinator will follow up with the patient a few days later by phone to address any additional questions.  
- **Patients who are interested and want to volunteer for the trial will be consented to participate in the study**
by the oncologist at their next standard of care visit, or by one of the study physician-investigators present during the patient's baseline pre-study standard of care echocardiogram.
Because there is a short window of time (1 week) for all the pre-treatment assessments before systemic breast cancer treatment is initiated, some potentially eligible patients may not be seen again by the treating oncologist until after they are no longer eligible for the study. In such cases, women who have had all their questions about the trial answered on the day they first learn about the study, and who wish to volunteer for the trial, may be consented to participate in the study the same day they are first informed of the research.
study schema
7.2.3 pre-study evaluations

Consented patients will undergo the following tests to confirm eligibility and safety of statin initiation:  
- Physical exam including vital signs assessment, measurement of height and weight
- **Symptom assessment and ECOG performance status** - Clinical labs for a Complete Blood Count and Automated Differential (CBDF) and a **Comprehensive**
Metabolic Panel (CMPL)
- **Lipid panel. If lipid panel results within the past 12 months are available, the lipid panel will not be**
required.  
- **Urine pregnancy test for women < 60 years of age who have not had a menstrual period in the last 30**
days. Women who have had a hysterectomy, both ovaries removed, or a tubal ligation will not be required to have a pregnancy test.  
- **Baseline 2D-echocardiogram**
Women who are pregnant, who have an abnormal 2D-echocardiogram, or who have AST/ALT > 3x ULN or creatinine > 1.8 **mg/dL will be excluded from the trial.**
study schema
7.2.4 final determination of eligibility

After consent has been obtained, clinical research staff will complete a full eligibility checklist and compile the support documents from patient medical records, including laboratory reports, medical history/physician notes, and current medications list. The oncologist, study cardiologist, or other physician-investigator will review the patient's **eligibility checklist, medical history, and supporting documentation.**
Patients with a history of heart disease or cardiomyopathy and patients > 50 years old who are eligible for statin therapy based on the 2013 ACC/AHA guidelines (LDL cholesterol >190, or LDL <190 and ASCVD risk >7.5%; http://tools.acc.org/ASCVD-Risk-Estimator/) will be excluded from the trial. Patients 40-50 years old who are eligible for statin therapy based on the 2013 ACC/AHA guidelines and want to be placed on statins will also be excluded.  
A Clinical Research Office (CRO) designee will conduct a final eligibility check prior to registration. Consented patients who qualify for the study after the pre-study eligibility evaluations and CRO confirmation of eligibility will be registered for the trial, randomized to the intervention (atorvastatin or placebo), and scheduled for Visit 1, the baseline testing.
study schema
7.3 baseline testing and evaluation

Visit 1 (baseline measurements) will occur from 2 weeks before the patient starts systemic breast cancer treatment
(trastuzumab with or without anthracycline) up to 3 weeks after starting treatment. Participants will be asked to refrain from eating for 3 hours before the visit. The following procedures will be performed during this visit:
1. **Review medical history, medications, and laboratory test results**
2. **Vital signs assessment and measurement of weight**
3. **ECOG performance status** 4. Blood collection for CMRI and clinical labs: **Less than 1 mL of blood will be drawn for measurement of**
hematocrit and creatinine levels used for CMRI calculations. Fasting for 3 hours prior to the CMRI is recommended. Five mL of blood **will be drawn for laboratory blood tests for a lipid panel and creatine** phosphokinase (CPK). If a lipid panel was done at the pre-study evaluations or if lipid panel results within 30 days prior to this visit are available, the lipid panel will not be done. A CMPL will not be required because one will be done at the pre-study evaluations.  
5. **Optional blood collection (28 mL) from participants who consent to have their blood samples banked for**
future studies of blood biomarkers 6. **Urine pregnancy test for women < 60 years of age who have not had a menstrual period in the last 30**
days. Women who have had a hysterectomy, both ovaries removed, or a tubal ligation will not be required to have a pregnancy test.  
7. **Cardiac magnetic resonance imaging (CMRI)** 8. **Interviewer-administered questionnaire to obtain demographic information (detailed race and ethnicity,**
education); medical history, including history of cancer and BRCA testing; reproductive history, oral contraceptives and hormones; alcoholic beverage consumption and tobacco smoking histories; physical activity; and anthropometry 9. **Self-administered QLQ-C30 and QLQ-BR23 to assess quality of life and symptoms** 10. **Review inclusion and exclusion criteria** 11. **Dispense the study agent and review instructions for how to take it** 12. Dispense the study diary and review **instructions for completing it**
study schema
7.3.2 visit 2 - month

A standard of care oncologist visit for routine monitoring will occur 1 month (± 2 weeks) after initiation of the statin intervention. The following procedures will be performed during this visit:
1. **Review medical history, medications, and laboratory test results**
2. **Physical exam including vital signs assessment and measurement of weight** 3. **Symptom assessment and ECOG performance status** 4. **Clinical labs for CBDF and CMPL** 5. **Review inclusion and exclusion criteria**
6. **Collect study agent and assess compliance (pill count)**
7. **Collect and review study diary** 8. **Assess adverse events** 9. **Dispense study agent and diary**
study schema
7.3.3 visit 3 - month

A standard of care oncologist visit for routine monitoring will occur 3 months (± 2 weeks) after initiation of the statin intervention. The following procedures will be performed during this visit:
1. **Review medical history, medications, and laboratory test results**
2. **Physical exam including vital signs assessment and measurement of weight**
3. **Symptom assessment and ECOG performance status** 4. **Clinical labs for CBDF and CMPL** 5. **Follow-up 2D-echocardiogram (may be on a different day)** 6. **Review inclusion and exclusion criteria**
7. **Collect study agent and assess compliance (pill count)** 8. **Collect and review study diary** 9. **Assess adverse events** 10. **Dispense study agent and diary**
study schema
7.3.4 visit 4 - month

A research visit will occur 6 months (± 2 weeks) after initiation of the statin intervention. Participants will be asked to refrain from eating for 3 hours before the visit. The following procedures will be performed during this visit. Participants with metallic breast expanders in place will not be required to do the 6-month CMRI and the blood collection for CMRI.  
1. **Review medical history, medications, and laboratory test results** 2. Vital signs assessment and measurement of weight  
3. **ECOG performance status** 4. Blood collection **for CMRI and clinical labs: Less than 1 mL of blood will be drawn for measurement of**
hematocrit and creatinine levels used for CMRI calculations. Fasting for 3 hours prior to the CMRI is recommended. **Five mL of blood will be drawn for laboratory blood tests for a CMPL and a lipid panel. If**
CMPL results within 30 days prior to this visit are available, the CMPL will not be done.  
5. **Optional blood collection (28 mL) from subjects who consent to have their blood samples banked for**
future studies of blood biomarkers 6. **Urine pregnancy test for women < 60 years of age who have not had a menstrual period in the last 30**
days. Women who have had a hysterectomy, both ovaries removed, or a tubal ligation will not be required to have a pregnancy test.  
7. **Cardiac magnetic resonance imaging (CMRI)** 8. **Interviewer-administered follow-up questionnaire to obtain information about changes in exposures and**
behaviors between visits 9. **Self-administered QLQ-C30 and QLQ-BR23 to assess quality of life and symptoms**
10. **Review inclusion and exclusion criteria**
11. **Collect study agent and assess compliance (pill count)** 12. **Collect and review study diary** 13. **Assess adverse events** 14. **Dispense study agent and diary**
study schema
7.3.5 visit 5 - month

A standard of care oncologist visit for routine monitoring will occur 9 months (± 2 weeks) after initiation of the statin intervention. The following procedures will be performed during this visit:
1. Review medical history, medications, **and laboratory test results** 2. **Physical exam including vital signs assessment and measurement of weight** 3. **Symptom assessment and ECOG performance status** 4. **Clinical labs for CBDF and CMPL** 5. **Follow-up 2D-echocardiogram (may be on a different day)**
6. **Review inclusion and exclusion criteria**
7. **Collect study agent and assess compliance (pill count)** 8. **Collect and review study diary** 9. **Assess adverse events** 10. **Dispense study agent and diary**
study schema
7.3.6 telephone calls and email/text

Study participants will be followed during the intervention via telephone calls every four weeks (± 7 days) by the clinical research staff to assess compliance and adverse events. Participants who report having taken < 85% of the study drug doses between phone calls, or whose pill count at a study visit reveals < 85% compliance, will be called every two weeks (± 3 days) to monitor compliance until compliance resolves to at least 85%. In addition, participants will receive a phone call the day before each scheduled research visit to remind them to refrain from eating for 3 hours prior to the visit. Participants will also be reminded to bring any leftover study drugs and the study diary with them to every visit. Study participants will also be called during the week before their final visit (Visit 6) to remind them to take the study drug every day until the visit appointment. Participants who opt to receive reminders for study medication intake via email or text messages will be contacted by the study staff during the first week of the study and further as needed. The study staff will send emails or text messages on cellular phone; participants will be encouraged to respond to these messages indicating if the study drug has been taken. These responses will be used to assess compliance and will be reviewed during phone contacts. For participants who miss more than one dose of the study drug in a week, the email/text reminders will continue further into dosing period. Since agent compliance is very important during the final week of the intervention, text/email messages will be sent to all study participants who opt to receive these reminders.  
The following information with be collected during the telephone calls:
- **Medication compliance review. Participants will be asked if they missed any doses of medication, and the**
dates of all missed doses will be recorded.  
- **Concomitant medication review** - **Adverse events. Participants will be asked if they have experienced any of the following symptoms to**
assess adverse events:
o **Joint pain** o **Mild muscle aches** o **Diarrhea**
o **Upper respiratory infection** o **Nausea**
o **Urinary tract infection (painful or difficult urination)** o **Pain in extremity (feet, ankles, hands, wrists)**
- **Additional symptoms experienced by participants will be recorded to assess adverse events**
study schema
7.4 evaluation at completion of

The final research visit will occur 12 months (± 2 weeks) after initiation of the statin intervention. Participants will be asked to refrain from eating for 3 hours before the visit. The following procedures will be performed during this visit. Participants with metallic breast expanders in place may be scheduled for the 12-month CMRI and blood collection for CMRI up to 3 months later (15 months) to allow for the final CMRI to be done.  
1. Review medical history, medications, **and laboratory test results** 2. **Vital signs assessment and measurement of weight**
3. **ECOG performance status** 4. Blood collection **for CMRI and clinical labs: Less than 1 mL of blood will be drawn for measurement of**
hematocrit and creatinine levels used for CMRI calculations. Fasting for 3 hours prior to the CMRI is recommended. Five mL of blood will be drawn for laboratory blood tests for a CMPL and a lipid panel. If CMPL results within 30 days prior to this visit are available, the CMPL will not be done.  
5. **Optional blood collection (28 mL) from subjects who consent to have their blood samples banked for**
future studies of blood biomarkers 6. **Urine pregnancy test for women < 60 years of age who have not had a menstrual period in the last 30**
days. Women who have had a hysterectomy, both ovaries removed, or a tubal ligation will not be required to have a pregnancy test.  
7. **Cardiac magnetic resonance imaging (CMRI)** 8. **Interviewer-administered follow-up questionnaire to obtain information about changes in exposures and**
behaviors between visits 9. **Self-administered QLQ-C30 and QLQ-BR23 to assess quality of life and symptoms**
10. **Collect study agent and assess compliance (pill count)** 11. **Collect and review study diary** 12. **Assess adverse events**
study schema
7.5 post-intervention follow-up procedures

Clinical research staff will make follow-up telephone calls to study participants on days 30 ± 7, 60 ± 7, and 90 ± 7 after completion of the statin intervention to assess symptoms and adverse events.
study schema
7.6 removal of subjects from

Patients can be taken off the study intervention and/or study at any time at their own request, or they may be withdrawn at the discretion of the investigator for safety, behavioral or administrative reasons. The reason(s) for discontinuation will be documented and may include: 7.6.1 Patient voluntarily withdraws (follow-up permitted);  
7.6.2 Patient withdraws consent (termination of intervention and follow-up); 7.6.3 Patient is unable to comply with protocol requirements; 7.6.4 Patient becomes ineligible for the trial; 7.6.5 Patient experiences toxicity that makes continuation in the protocol unsafe; 7.6.6 **Treating physician judges continuation on the study would not be in the patient's best interest;** 7.6.7 Patient becomes pregnant (pregnancy to be reported along same timelines as a serious adverse event);
7.6.8 Development of second malignancy (except for basal cell carcinoma or squamous cell carcinoma of the skin) that requires treatment, which would interfere with this study; 7.6.9 Lost to follow-up. If a research subject cannot be located to document survival after a period of 2 years, the subject may be considered "lost to follow-**up." All attempts to contact the subject during the two years**
must be documented and approved by the Data Monitoring Committee.
study schema
7.7 methods for clinical procedures

Cardiac magnetic resonance imaging (CMRI). **CMRI will be performed at each visit using the 3 Tesla system**
devoted to research. The protocols prepared and tested by Dr. Li's team will be used for imaging **[82-84].**
Comprehensive CMRI examination will include: (1) tomographic views in cine mode using electrocardiogram
(ECG) gated steady-state-free-precession (SSFP), (2) grid tag (tissue tagging) imaging, (3) scout imaging, (4)
single shot late gadolinium contrast enhancement, (5) T2 mapping, and (6) T1 mapping [Figure 6].  
  
  
Prior to the CMRI an IV will be inserted and a small blood sample (< 1 mL) will be drawn from participants. An i-STAT blood analyzer at the CSMC Research Imaging Core will be used to measure hematocrit and creatinine.  
The hematocrit value is used to calculate myocardial extracellular volume (ECV) with the T1 mapping. The creatinine value is used to calculate the glomerular filtration rate (GFR). If the GFR is < 60, the CMRI will be performed without gadolinium. Women < 60 years of age who have not had a menstrual period in the last 30 days will be required to have a urine pregnancy test before the CMRI. Women who have had a hysterectomy, both ovaries removed, or a tubal ligation will not be required to have a pregnancy test. The Research Imaging Core will do an onsite urine pregnancy test. Women who are pregnant will not undergo the CMRI. After the pregnancy test, hematocrit, and GFR have been evaluated, scout images will be obtained for ventricular short axis and whole heart imaging, followed by T2 mapping. Baseline pre-contrast short axis imaging will be performed for T1 mapping. This will be repeated at 12 minutes post-contrast. Cine imaging for calculation of left and right ventricular ejection fraction and characterization of regional wall motion will occur after administration of gadolinium contrast. This will be followed by single shot late gadolinium enhancement, and then T1 mapping at 12 minutes post-contrast. In brief, with the patient in the supine position, high resolution, perpendicular images through the chest will be collected to locate the heart. Images will be acquired with a breath-hold at the end of expiration. The time required for the entire MRI protocol will be approximately 75 minutes. Images will be evaluated by consensus of skilled interpreters trained in CMRI imaging. A cardiac imaging physician blinded to clinical information of the subjects will read the CMRIs and evaluate them for any incidental findings. Myocardial blood flow quantitation at rest and calculation of T1 relaxation time for the myocardium will be performed using in-house dedicated analysis software as previously published [85]. We will analyze T1 mapping using quantitative parametric images of myocardial extracellular blood volume using MOLLI recovery images to generate a ∆R1 map **[69]. Information on LV filling, peak filling rate (PFR), and time to peak filling rate (tPFR),** will be obtained by cine imaging. Quantitative analyses will use tissue tagging grid imaging for calculation of indices of strain and relaxation from systolic and diastolic optimized tagged cine images to obtain global circumferential strain (GCS), its time derivative in systole (CSs rate) and diastole (CSd rate), and the peak rate of basal to apical untwisting (UTR).  
Gadolinium Contrast (Gadavist). Intravenous contrast agents such as Gadavist are an extracellular gadoliniumbased chelate. All of the clinically approved intravenous contrasts that might be used in this study have excellent safety profiles and are commonly used in CMRI studies. Unlike iodinated contrast agents used in CT, gadoliniumbased CMRI contrast agents do not cause nephrotoxicity. Allergic reactions are extremely rare, but may be more common in persons with a history of allergic reactions to iodinated contrast. Studies support a rate of serious allergy reactions of 1 in 20,000.  
Blood specimen. **A blood specimen will be collected from each participant at Visits 1, 4, and 6. Participants will**
receive a phone call reminder the day before the visit to refrain from eating for 3 hours prior to the visit. Five mL of blood will be collected for laboratory blood tests into one 5 mL gold top SST tube. The time and date of the blood draw and of the participant's last meal will be recorded. **Blood tests will be done for a lipid panel at Visits** 1, 4, and 6. The lipid panel will not be done at Visit 1 if a lipid panel was done at the pre-study evaluations or if lipid panel results within 30 days prior to the visit are available. A CMPL will be done at Visits 4 and 6. A CMPL will not be required at Visit 1 because one will be done at the pre-study evaluations. If CMPL results within 30 days prior to Visit 4 or Visit 6 are available, the CMPL will not be done at that visit. Lab values within the past 30 days are sufficient for monitoring, and we wish to prevent patients having to undergo unnecessary repeat tests. A blood test for creatine phosphokinase (CPK) will be done at Visit 1 only. Depending on where the participant visit occurs, the blood testing will be done at the CSMC Clinical Laboratory or at the Tower Hematology Oncology Medical Group laboratory. Prior to the CMRI, less than 1 mL of blood will be drawn at the CSMC Research Imaging Core for measurement of hematocrit and creatinine levels used for CMRI calculations. An i-STAT blood analyzer at the Imaging Core will be used to measure the hematocrit and creatinine. Fasting for 3 hours prior to the CMRI is recommended for optimal contrast enhancement.  
An additional (optional) 28 mL blood sample will be collected before the CMRI from subjects who consent to have their blood samples banked for future studies of blood biomarkers. Fasting for 10 hours before the optional blood collection is recommended but is not required. The blood will be drawn at the CSMC Research Imaging Core into four vacutainers, including one 10 mL green top heparinized tube, one 10 mL red top serum tube, and two 4 mL lavender top EDTA tubes. The vacutainers will be placed on ice in a cooler and transported to the CSMC Clinical Research Office (CRO) Research Laboratory for processing within 2 hours of collection. The four vacutainers will be centrifuged as specified in the blood processing SOP. After centrifugation, cryovials will be prepared from the blood specimens including plasma, serum, red blood cells, and buffy coat for DNA extraction.  
Processed specimens will be stored at -80o**C for future studies of cardiac blood biomarkers. If the participant**
fasted for 10 hours prior to the visit for the optional blood collection, she may have a snack after the blood draw and before the CMRI if desired.
study schema
8.0 measurement of effect and

This randomized clinical trial aims to evaluate the impact of statin on preventing cardiotoxicity due to trastuzumab treatment (with or without anthracycline) in breast cancer patients. Cardiac function will be primarily measured by global circumferential strain (GCS), a sensitive measure of cardiac function, which is predictive of future cardiac events. Secondary outcomes will include additional global measures of cardiac function (e.g. left ventricular ejection fraction), cardiac morphology (mass, wall thickness, internal dimensions), diastolic function, and tissue viability (fibrosis, edema, inflammation). We anticipate that trastuzumab treatment will impair GCS, and increase markers of fibrosis, edema, and/or inflammation. We hypothesize that there will be less change in GCS and secondary outcomes measures with atorvastatin intervention compared to placebo.
study schema
8.2 methods for evaluation of

Cardiac MRI will be performed at baseline, 6 months and 12 months after randomization as outlined in Section 7.7. Imaging will include: (1) conventional cinematic imaging, to assess myocardial morphology and global function; (2) magnetic resonance tissue tagging, to assess GCS, along with other secondary endpoint measures like global longitudinal strain (GLS), peak left ventricular (LV) twist and torsion, as well as diastolic endpoints such as strain rate and untwisting rate; (3) T1 mapping (before and after the administration of gadolinium), to assess myocardial fibrosis and tissue viability; (4) T2 mapping, to assess myocardial edema and inflammation; and (5) late gadolinium enhancement, to assess focal scar.  
| Table 3. Summary of Endpoints Measured by Cardiac Magnetic Resonance Imaging (CMRI)  CMRI procedure Measurement  Cine-imaging + tissue tagging  Systolic function GCS (primary endpoint), GLS, peak LV twist and torsion  Diastolic function Untwisting rate  Cardiac function and morphology Left ventricular ejection fraction (LVEF), LV end diastolic  volume (LV EDV), LV end systolic volume (LV ESV),  cardiac output (CO), LV mass, LV concentricity  T1 mapping + Gadolinium enhancement Myocardial fibrosis and tissue viability, extracellular volume  T2 mapping Edema and inflammation   |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
study schema
8.3 off-agent criteria

Participants may stop taking study agent for the following reasons: completed the protocol-prescribed intervention, adverse event or serious adverse event, inadequate agent supply, noncompliance, concomitant medications, or medical contraindication. Participants will continue to be followed, if possible, for safety reasons and in order to collect endpoint data according to the schedule of events. As described in section 7.5, clinical research staff will follow participants by telephone on days 30 ± 7, 60 ± 7, and 90 ± 7 after the participant discontinues the study agent to assess symptoms and adverse events. Standard of care data (medical history, laboratory test results, concomitant medications, echocardiogram data) will continue to be collected via review of the participant's electronic medical record at the time points specified in the Schedule of Time and Events**. If**
feasible, we will conduct a research visit to collect final measurements for participants who permanently discontinue the study agent early. An end-of-study research visit will be conducted 12 months after initiation of the statin intervention (Visit 6). All CMRI procedures will be done at this visit. The blood collections for clinical labs and future research, and the follow-up risk and quality of life questionnaires, will not be done. The following procedures will be performed during the end-of-study visit:
1. Review medical history, medications, and laboratory test results 2. Vital signs assessment and measurement of weight 3. ECOG performance status 4. Blood collection for CMRI: Less than 1 mL of blood will be drawn for measurement of hematocrit and creatinine levels used for CMRI calculations.  
5. Urine pregnancy test for women < 60 years of age who have not had a menstrual period in the last 30 days. Women who have had a hysterectomy, both ovaries removed, or a tubal ligation will not be required to have a pregnancy test.  
6. Cardiac magnetic resonance imaging (CMRI)
study schema
8.4 off-study criteria

Participants may go 'off-study' for the following **reasons:**
- **Adverse Event** - **Death**
- **Lost to follow-up/Participant Withdrawal** - **Participant Refused Follow-up**
- **Physician Decision** - **Protocol Defined Follow-up Completed** - **Protocol Violation** - **Study Complete** - Ineligible
study schema
- other

Participants will continue to be followed, if possible, for safety reasons and in order to collect endpoint data according to the schedule of events. Participants will be removed from study agent if investigators feel it is in the interest of subject to do so. As described in section 7.5, clinical research staff will follow up by telephone on days 30 ± 7, 60 ± 7, and 90 ± 7 after the participant goes off-study to assess symptoms and adverse events. Standard of care data (medical history, laboratory test results, concomitant medications, echocardiogram data) will continue to be collected via review of the participant's electronic medical record at the time points specified in the Schedule of Time and Events. If feasible, we will conduct a research visit to collect final measurements for participants who go off-study early. An end-of-study research visit will be conducted 12 months after initiation of the statin intervention (Visit 6). All CMRI procedures will be done at this visit. The blood collections for clinical labs and future research, and the follow-up risk and quality of life questionnaires, will not be done. The following procedures will be performed during the end-of-study visit:
1. Review medical history, medications, and laboratory test results 2. Vital signs assessment and measurement of weight 3. ECOG performance status 4. Blood collection for CMRI: Less than 1 mL of blood will be drawn for measurement of hematocrit and creatinine levels used for CMRI calculations.  
5. Urine pregnancy test for women < 60 years of age who have not had a menstrual period in the last 30 days. Women who have had a hysterectomy, both ovaries removed, or a tubal ligation will not be required to have a pregnancy test.  
6. Cardiac magnetic resonance imaging (CMRI)
study schema
9.0 correlative/special studies 9.1 rationale

Cardiac magnetic resonance imaging (CMRI) is considered the gold standard imaging technique for accurate quantification of systolic and diastolic function, and the addition of tissue tagging helps determine specific myocardial structural changes related to twist and torsion of the left ventricle during systole and diastole. CMRI
can also detect fibrosis with late gadolinium enhancement and T1 mapping. Reliance on 2-dimensional echocardiography (2-D echo) for the identification of cardiac damage is limited as it lacks the requisite sensitivity to detect subtle changes in left ventricular (LV) function. Newer sophisticated echocardiographic imaging techniques, including myocardial strain and speckle tracking can identify early pre-clinical LV systolic dysfunction pre- and post-treatment, but the quality is sonographer-dependent and is limited by patient body habitus. Moreover, early myocardial injury, edema, and fibrosis are missed on echocardiography.
study schema
9.2 laboratory correlates and biomarkers

A blood specimen will be collected from participants at each research visit. Less than 1 mL of blood will be drawn for measurement of hematocrit and creatinine levels used for CMRI calculations. Five mL of blood will be collected for clinical blood tests. An additional (optional) 28 mL blood sample will be collected from subjects who consent to have their blood samples banked for future studies of blood biomarkers.  
Clinical blood tests (5 mL). **Blood tests will be done at all research visits for statin monitoring. A lipid panel will**
be done at Visits 1, 4, and 6. The lipid panel will not be done at Visit 1 if a lipid panel was done at the pre-study evaluations or if lipid panel results within 30 days prior to the visit are available. A CMPL will be done at Visits 4 and 6. A CMPL will not be required at Visit 1 because one will be done at the pre-study evaluations. If CMPL
results within 30 days prior to Visit 4 or Visit 6 are available, the CMPL will not be done at that visit. Creatine phosphokinase (CPK) will be measured at Visit 1 to establish a patient-specific reference for this indicator of muscle toxicity. During the trial, if the patient reports unexplained muscle pain or weakness, CPK will be tested again to check for elevation.  
Optional banked samples for future studies (28 mL). **Processed blood will be stored at -80°C for future studies**
of blood biomarkers. Future studies may include: (a) investigation of high-sensitivity troponin (hs-TnT), a biomarker of myocardial injury; (b) studies of two novel biomarkers of cardiac fibrosis, galectin-3 (GAL3) and apoptosis / inflammation, growth differentiation factor 15 (GDF15), which play regulatory roles in extracellular matrix remodeling and are associated with impaired cardiac function and chronic heart failure; (c) investigation of brain naturetic peptide (BNP), a biomarker of myocardial stretch; and (d) examination of pro-inflammatory markers IL-6 and hs-CRP.
study schema
9.3 specimen banking

Patients participating in this trial will be invited to participate in an optional repository study, MetaBank (Pro35861). Subjects who consent for MetaBank will provide an additional 28 mL of blood at each research visit, and the blood, as well as their leftover specimens collected during this trial, will be stored and maintained in the MetaBank for use in future research. Specimens will be retained in MetaBank freezers, equipped with temperature activated alarms, located in the Shuman Basement of the Davis Research Building at CSMC. Specimens will be stored indefinitely or until they are used up. If future use is denied or withdrawn by the patient, best efforts will be made to stop any additional studies and to destroy the specimens. The Principal Investigator will be responsible for reviewing and approving requests for clinical specimen from potential research collaborators outside of Cedars-Sinai Medical Center. Collaborators will be required to complete the MetaBank Data and Specimen Usage Agreement specifying the planned use of the specimens, and a Material Transfer Agreement that states specimens will only be released for use in disclosed research. Any data obtained from the use of clinical specimen will be the property of Cedars-Sinai Medical Center for publication and any licensing agreement will be strictly adhered to.  
The specimens, DNA, and their derivatives may have significant therapeutic or commercial value. The Informed Consent form contains this information and informs the subject that there is the potential for financial gain by Cedars-Sinai Medical Center, the investigator or a collaborating researcher or entity. The following information obtained from the subject's medical record may be provided to research collaborators when specimens are made available:
- **Diagnosis**
- **Collection time in relation to study treatment**
- Clinical outcome - **if available**
- **Demographic data**
study schema
10.0 statistical considerations 10.1 study

This phase II randomized, double-blinded, placebo-controlled trial evaluates the effect of statin use versus placebo on global circumferential strain (GCS), a measure of LV dysfunction, in women newly diagnosed with breast cancer using state-of-the-art imaging (CMRI). Secondary outcomes will include additional global measures of cardiac function (e.g. left ventricular ejection fraction), diastolic function, cardiac morphology (mass, wall thickness, internal dimensions), and tissue viability (fibrosis, edema, inflammation). Assuming a 20% drop-out rate, 60 women diagnosed with stage 1-3 breast cancer recommended to undergo trastuzumab treatment, with or without anthracycline, will be randomized to 12 months of atorvastatin intervention or placebo resulting in a final sample of 48 women completing both follow-up visits. Measurements will be taken at three time points: Baseline, from 2 weeks before the patient starts systemic breast cancer treatment (trastuzumab with or without anthracycline) up to 3 weeks after starting treatment; Follow-up, 6 months and 12 months post-initiation of the statin intervention. At each of the three time points, information regarding the participant's **medical history,** medication use, risk factors, physical functioning, and quality of life will be obtained as adjustment variables.
study schema
10.2 sample size and accrual

Sample size: Intervention = 60 (30 statin:30 placebo) randomized sample; Analytic sample after 20% drop out =
48 (24:24).  
The planned duration of accrual is 24 months with an expected accrual rate of 2-3 subjects per month. We anticipate that all evaluable participants will have completed all study procedures within three years. Power and precision arguments are provided below.
study schema
10.3 randomization and intervention

Randomization will be carried out by the SOCCI Research Pharmacy among consented subjects who meet all eligibility criteria after the eligibility evaluations and CRO confirmation of eligibility, and who are registered for the trial. A secure web-based system maintained by the Biostatistics and Bioinformatics Core at CSMC will randomly assign women to either statin or placebo based on sequences that minimize imbalances between the arms on diagnosis. Study personnel will be blinded to actual assignment. The randomization algorithm computes real-time marginal totals according to the method of Pocock and Simon [86], which ensures near equal allocation to the two treatment strategies. Intention-to-treat analysis is initiated at the time of randomization. Based on the literature cited above, a lipophilic statin, atorvastatin calcium, was selected for the intervention. Independent pharmacists will dispense either active or placebo atorvastatin according to the computer-generated assignment.  
The placebo is designed to be identical in color, consistency, and appearance to atorvastatin. Dosing and administration of atorvastatin will be consistent with the recommended regimen: 20 mg once a day.
study schema
10.4 endpoints/statistical considerations

Our primary outcome, global circumferential strain obtained by CMRI, is a composite measure of myocardial deformation as the heart contracts and relaxes. The non-parametric Wilcoxon-Mann-Whitney test will be used to test the equality of statin treatment (atorvastatin) to placebo in reducing or preventing LV dysfunction through comparison of change in GCS values (∆ length / original length, expressed as % / seconds) measured from 2 weeks prior to start of systemic breast cancer treatment to 1 year post-initiation of the statin intervention. Power calculations use a two group t-test based on previously published data [87], which indicate a standard deviation of 4.3 for baseline GCS and 3.1 for GCS 1 year post treatment initiation. A conservative estimate of the standard deviation of the difference of these two random variables will assume no correlation between pre- and post-treatment GCS, which gives an estimated standard deviation of 5.3 =√(4.32 + 3.12**). With 20%**
dropout rate, we plan to enroll a total of 60 patients with each group having 30 patients, leaving 24 per group after loss to follow up. Based on the asymptotic efficiency of a Mann-Whitney test under non-normal distributions in the groups, the minimum detectable differences in the power calculations have been done using an adjusted sample size that is 15% smaller than that anticipated, or 20 per group. Assuming the same standard deviation for both groups, a two-sided two sample t-test would allow us to detect a minimum detectable difference in means between treatment and placebo groups for the change in GCS ranging from 4.8 to 2.4 units depending on the actual post- versus pre-GCS correlation (0 to 0.8), assuming 80% power and a 5% significance level. Other minimum detectable differences that assume higher correlation between pre- and post-treatment GCS are shown in Table 4.  
Table 4. Minimum detectable differences for repeated measures design. A two-group t-test assumes 80% power, 5% significance, and 20 patients per group. It is also assumed that the standard deviation is 4.32 at baseline and 3.12 at 1 year post-treatment, and that the paired differences standard deviation is the same for treatment and placebo groups. Selected values of correlation between a pair of observations made on the same subjects are presented.  
Correlation of post vs. pre-GCS
Standard Deviation of post vs. pre-GCS
Minimum Detectable Difference 0 5.3 4.8 0.2 4.8 4.3 0.4 4.2 3.8 0.6 3.5 3.2 0.8 2.6 2.4
study schema
10.5 statistical analysis plan

Primary analyses **will be conducted on an intention-to-treat basis on all patients who complete the 12-month**
CMRI. The distribution of the covariates, including age, race, dose of trastuzumab treatment (and anthracycline if applicable), laterality, radiation dose, smoking status, BMI, baseline measures of fibrosis, hormone use, and comorbid conditions, will be summarized and compared between the intervention and control groups to assess the adequacy of the randomization. Chance differences between groups will be adjusted for using multiple regression modeling. The assumptions of the t-test and regression will be examined for the distribution of the difference in 1 year post-treatment initiation GCS minus pre-treatment GCS. Non-normal distribution or unequal variance between groups will be corrected using a transformation (e.g. log, arcsin, Box-Cox). If a transformation is inadequate for the t-test a Wilcoxon-Mann-Whitney test will be used instead. Patients may not receive a uniform dose of trastuzumab treatment, given that some patients may be enrolled for up to 3 weeks after starting systemic breast cancer treatment and patients undergoing an AC-TH regimen will receive anthracycline first, followed by trastuzumab. While our primary analysis will be with all patients assumed to have received homogeneous trastuzumab treatment, we plan to conduct sub-analyses in participants randomized to atorvastatin **to evaluate** whether patients who initiate statin after receiving one or more doses of trastuzumab treatment experience a different level of cardioprotection than patients who initiate statin before receiving any trastuzumab treatment.  
Secondary analyses. **Secondary analyses will compare the statin and placebo groups regarding differences from**
baseline to 12 months follow-up in the following outcomes using a similar approach to the main outcome: (1) myocardial structural changes through CMRI and pre- and post-gadolinium myocardial T1 values for fibrosis; and
(2) myocardial functional changes, through cine CMRI and tissue tagging. As described above, we will take note of any chance difference in covariates and adjust for factors in a multiple regression analysis. Assumptions of the regression models for GCS and two secondary outcome measures will be examined primarily through analysis of residuals after adjustment for potential covariates. If necessary, transformations to the outcomes will be made as described for the main analysis. Missing data. **Care will be taken to minimize missing data to the extent possible.**
Assuming ≤ **10% missing data, multiple imputation on covariates (not primary or secondary outcomes) will be** considered for statistical analysis. In the unlikely event of > 10% missing values, we will consider a missing data mechanism [88]. After diagnosing the possible missing data mechanism, we will evaluate the potential influence of missing data by conducting sensitivity analyses under several assumptions of missingness [89].
study schema
10.6 contamination (cross-over) and drop-outs

We anticipate some contamination from the statin intervention to placebo due to non-compliance and this will be monitored and managed through blood tests. We do not expect cross-over from the placebo to statin group as women will be aware that they might be on statins already and would not want to jeopardize their safety and care. However, current clinical guidelines for prescription of statins may also influence drop-outs among women who wish to reduce the risk of cardiovascular disease [10]. These guidelines recommend targeting women with cardiovascular disease, LDL cholesterol ≥ 190 mg/dL, and women ages 40**-75 years with diabetes or a 10-year** cardiovascular disease risk ≥ 7.5%. Most of these women would not meet th**e eligibility criteria for study**
participation. The drop-out rate is conservatively expected to be 20% from baseline to 1 year follow-up.
study schema
10.7 evaluation of toxicity

All participants will be evaluable for toxicity from the time of their first dose of atorvastatin.
study schema
10.8 evaluation of response

Changes in global circumferential strain obtained by CMRI will be evaluated for all randomized participants.