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An Open-Label Study to Characterize the Incidence and Severity of Diarrhea in Patients with Early-Stage HER2+ Breast Cancer Treated with Neratinib and Loperamide
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nct02400476

Study Protocol - Amendment 7.1 25-Jul-2019 An Open-Label Study to Characterize the Incidence and Severity of Diarrhea in Patients  
 with Early-Stage HER2+ Breast Cancer Treated with Neratinib and Loperamide  
| with Early-Stage HER2+ Breast Cancer Treated with Neratinib and Loperamide  Study Protocol Number: PUMA-NER-6201 Disease Condition: HER2-Positive Breast Cancer Sponsor's Investigational Product  Neratinib Tablets Name/Formulation: US IND Number 066783 EudraCT Number 2015-004374-15 Lead Investigator: Carlos Barcenas, MD, MSc Assistant Professor Department of Breast Medical Oncology Division of Cancer Medicine The University of Texas MD Anderson Cancer Center Houston, TX Sponsor: Puma Biotechnology, Inc. 10880 Wilshire Blvd, Suite 2150 Los Angeles, CA 90024 Phone: +1 424.248.6500  Fax: +1 424.248.6501  Sponsor's Medical Contact: Richard Bryce, MBChB, MRCGP, MFPM  Chief Medical & Scientific Officer  Phone: +1 424.248.6500 Date of Protocol Original 19-NOV-2014 Amendment 1 20-MAY-2015 Amendment 2 06-NOV-2015 Amendment 3 24-MAR-2016 Amendment 4 19-AUG-2016 Amendment 5 19-SEP-2017 Amendment 6 26-OCT-2017 Amendment 6.1 (Global) 30-APR-2018 Amendment 7 08-OCT-2018 Amendment 7.1 25-JUL-2019   |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|  
This document contains confidential information of Puma Biotechnology, Inc. This document must not be disclosed to anyone other than the study staff and members of the Independent Ethics Committee/Institutional Review Board. The information in this document cannot be used for any purpose other than the evaluation or conduct of the clinical investigation without the prior written consent of Puma Biotechnology, Inc.
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disclosure statement

This document contains information that is confidential and proprietary to the Sponsor. This information is being provided to you solely for the purpose of evaluating and/or conducting a clinical study for the Sponsor. You may disclose the contents of this document only to study personnel under your supervision, institutional review boards (IRBs)/independent ethics committees (IECs), or duly authorized representatives of regulatory agencies for this purpose under the condition that they maintain confidentiality. The contents of this document should not be used in any other clinical study, disclosed to any other person or entity, or published without the prior written permission of the Sponsor. The foregoing shall not apply to disclosure required by any regulations; however, you will give prompt notice to the Sponsor of any such disclosure. All other nonpublic information provided by the Sponsor, as well as any information that may be added to this document, also is confidential and proprietary to the Sponsor and must be kept in confidence in the same manner as the contents of this document.
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protocol synopsis

Name of Sponsor/Company: Puma Biotechnology, Inc. Name of Investigational Product: Neratinib tablets Name of Active Ingredient: Neratinib Title of Study: An Open-Label Study to Characterize the Incidence and Severity of Diarrhea in Patients with Early-Stage HER2+ Breast Cancer Treated with Neratinib and Loperamide Condition or Disease: HER2-positive Breast Cancer  
| Approximate Values Number of Patients   | Approximately 750   | Duration of Patient Participation   | 1 year   |
|-----------------------------------------|---------------------|-------------------------------------|----------|
| Number of Centers                       | Approximately 74    | Duration of Study                   | 7 years  |
| Objectives:                             |                     |                                     |          |  
Objectives:
Primary: The primary objective of this study is to characterize the incidence and severity of diarrhea in patients with early-stage HER2 overexpressed/amplified (HER2+) breast cancer treated with neratinib when administered with intensive loperamide prophylaxis, after prior treatment with trastuzumab.  
Secondary: The secondary objectives of this study are:
To assess the incidence of serious adverse events (SAEs) and other adverse events of special interest (AESI). To assess the incidence and severity of diarrhea after the administration of an anti-inflammatory agent (for patients enrolled under Amendment 3), a bile acid sequestrant (for patients enrolled under Amendment 4 and Amendment 5), or following 2 different dose-escalation regimens of neratinib (for patients enrolled under Amendment 6/6.1 and for patients enrolled starting with Amendment 7, respectively).
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exploratory

Exploratory objectives include:
For patients enrolled starting with Amendment 2:
To assess patient-reported health outcomes using the EuroQol 5D-5L (EQ-5D-5L) and the Functional Assessment of Cancer Therapy Breast (FACT-B) questionnaires.  
To collect biomarkers of disease from cell-free DNA (cfDNA) to evaluate their relationship to clinical recurrence of disease.  
For patients enrolled starting with Amendment 6:
Evaluation of stool bacterial diversity (microbiome)
For patients enrolled starting with Amendment 6.1:
To assess patient-reported health outcomes using the Rotterdam Symptom Checklist (RSCL)
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study design

This is an open-label, Phase 2 study that will investigate the incidence of diarrhea in HER2+ breast cancer patients receiving neratinib with intensive loperamide diarrhea prophylaxis, alone and in combination with an anti-inflammatory treatment or a bile acid sequestrant treatment, who have previously undergone a course of trastuzumab therapy in the adjuvant setting. Patients will receive:
Neratinib 240 mg orally once daily for thirteen (13) 28-day cycles. Loperamide daily for two (2) 28-day cycles and then as needed.  
For patients enrolled under Amendment 3, an anti-inflammatory treatment for 1 cycle and loperamide to be administered daily for two (2) 28-day cycles and then as needed, thereafter; For patients enrolled under Amendment 4, colestipol for 1 cycle and loperamide to be administered 1 cycle and then as needed, thereafter; For patients enrolled under Amendment 5, colestipol for 1 cycle and loperamide to be administered on an asneeded basis only.  
For patients enrolled under Amendment 6/6.1, 120 mg neratinib for Week 1 (C1D1 - C1D7), followed by 160 mg neratinib for Week 2 (C1D8 - C1D14), followed by 240 mg neratinib for Week 3 and thereafter (C1D15 to End-of-treatment [EOT]). Loperamide will be administered on an as-needed basis only.  
For patients enrolled starting with Amendment 7, 160 mg neratinib for the first 2 weeks (C1D1 - C1D14),
followed by 200 mg neratinib for the next 2 weeks (C1D15 - C1D28), followed by 240 mg neratinib thereafter (C2D1 to End-of-treatment [EOT]). Loperamide will be administered on an as-needed basis only.
Patients will receive neratinib for 13 cycles (364 days) or until disease recurrence (as determined by the Investigator), death, unacceptable toxicity, or other specified withdrawal criterion.  
The effect of the anti-inflammatory treatment budesonide and the bile acid sequestrant, colestipol, on the incidence, severity, and duration of diarrhea will be investigated in sequential patient cohorts using a sample size of approximately 64 patients per cohort. The anti-inflammatory cohort added in Amendment 3 will be assigned to receive budesonide 9 mg once daily with or without food for 28 days along with neratinib 240 mg /day (13 cycles) and intensive loperamide prophylaxis that will continue through the first 2 cycles (total 56 days), and then on an as-needed basis thereafter.  
Following the completion of enrollment of the patients receiving budesonide, neratinib, and intensive loperamide prophylaxis, the next cohort will be evaluated after receiving colestipol 2 g twice daily with or without food for 28 days, to be taken at least 2 hours after, but at least 4 hours before, neratinib 240 mg /day (13 cycles) and intensive loperamide prophylaxis. For this cohort, intensive loperamide prophylaxis will continue through the first cycle (total 28 days); for Cycle 2 and beyond, loperamide may be administered as needed (PRN). Following complete enrollment of the cohort treated with colestipol + intensive loperamide prophylaxis, all patients in the next cohort will be evaluated after receiving colestipol and neratinib with loperamide administered on a PRN basis only. Following complete enrollment of the cohort receiving neratinib + colestipol + loperamide PRN, all patients in the next cohort will be evaluated after receiving neratinib administered according to the following dose-escalation scheme:
120 mg neratinib for 1 week (C1D1 - C1D7), followed by 160 mg neratinib for Week 2 (C1D8 - C1D14), followed by 240 mg neratinib for Week 3 and thereafter (C1D15 to EOT). Loperamide is to be administered on a PRN basis only.  
Following complete enrollment of all patients in the 120 mg/160 mg/240 mg dose-escalation scheme, patients enrolled in the next cohort will be evaluated after receiving neratinib administered according to a second dose escalation scheme: 160 mg neratinib to be taken for the first 2 weeks (C1D1 - C1D14), followed by 200 mg neratinib to be taken for the next 2 weeks (C1D15 - C1D28), followed by 240 mg neratinib daily dose taken thereafter (C2D1 to EOT). Loperamide is to be administered on a PRN basis only.  
The Sponsor will regularly review accumulating safety data (by individual subject and in aggregate). Early termination of a cohort or the study may be permitted if data indicate that anti-diarrheal treatment is ineffective.  
Patients in all treatment groups will continue to complete the remaining 12 treatment cycles.  
The final analysis will be conducted after all patients have completed 13 cycles of study treatment or have met other specified withdrawal criterion (see Section 10). The study will end when all patients have been followed up for 28 days after the last dose of neratinib.
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study endpoints

The primary endpoint of the study is the incidence of Grade 3 or higher diarrhea.  
Secondary endpoints include the frequency distribution of the maximum grade incidence of diarrhea, the incidence and severity of diarrhea with and without anti-inflammatory agents, with and without a bile acid sequestrant, the effect of lower starting doses and dose escalation of neratinib on the incidence and severity of diarrhea; and the incidence of SAEs and AESIs.  
The exploratory endpoint of patient-reported health outcomes will be assessed by the EuroQol EQ-5D-5L, the FACT-B questionnaires (for patients enrolled starting with Amendment 2), and the RSCL (for patients enrolled starting with Amendment 6.1).  
The exploratory endpoint of disease biomarkers will consist of the biomarkers of disease recurrence (for patients enrolled starting with Amendment 2).  
The exploratory endpoint of evaluation of stool bacterial diversity, i.e., microbiome (for patients enrolled starting with Amendment 6/6.1).
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neratinib loperamide anti-inflammatory and bile

Neratinib: Six (6) 40 mg tablets (total dose 240 mg) orally, once daily with food, preferably in the morning, continuously for 13 cycles (364 days), except for patients enrolled under Amendment 6/6.1 who will receive neratinib in the dose escalation scheme detailed above (ie, total dose 120 mg daily for the first week, 160 mg daily for Week 2, and 240 mg daily for Week 3 and thereafter, until EOT), and except for patients enrolled under Amendment 7/7.1 who will receive neratinib in a second dose escalation scheme (ie, total dose 160 mg daily for the first 2 weeks, 200 mg daily for the following 2 weeks, and 240 mg daily thereafter until EOT)..  
Loperamide:  
For patients enrolled under the Original Protocol:
o Initial dose of 4 mg (2 tablets/capsules) with the first dose of neratinib, followed by 2 mg
(1 tablet/capsule) every 4 hours for the first 3 days. After the first 3 days, loperamide 2 mg every 6 to 8 hours through the first 2 cycles of therapy (56 days) from start of neratinib.  
For patients enrolled under Amendment 1  Amendment 3:
o For the first 14 days, loperamide 4 mg (2 tablets/capsules) will be self-administered orally by patients 3 times a day (total 12 mg a day). The initial dose of loperamide 4 mg will be self-administered orally with the first dose of neratinib.  
o After the first 14 days, loperamide 4 mg (2 tablets/capsules) will be self-administered orally twice a day
(total 8 mg a day) through the first 2 cycles of therapy (Day 56) from start of neratinib dosing For patients enrolled under Amendment 4:
o For the first 14 days. The initial dose of loperamide 4 mg will be self-administered orally with the first dose of neratinib, followed by loperamide 4 mg (2 tablets/capsules) self-administered orally by patients 3 times a day (total 12 mg a day).  
o After the first 14 days, loperamide 4 mg (2 tablets/capsules) will be self-administered orally twice a day
(total 8 mg a day), for 1 cycle [28 days], and then as needed (PRN) (not to exceed 16 mg per day).  
For patients enrolled under Amendment 5, Amendment 6, Amendment 6.1, Amendment 7, and Amendment 7.1:
o Loperamide 4 mg (2 tablets/capsules) will be self-administered orally by patients on a PRN basis only, from the start of neratinib dosing (not to exceed 16 mg per day).
Budesonide  
For patients enrolled under Amendment 3 and who participate in the evaluation of budesonide, patients will self-administer oral budesonide at a dose of 9 mg once daily for the first treatment cycle, to be taken with neratinib and intensive loperamide prophylaxis.  
Colestipol For patients enrolled under Amendment 4 and Amendment 5 and who participate in the evaluation of colestipol, patients will self-administer colestipol at a dose of 2 g twice daily for the first treatment cycle, to be taken at least 2 hours after, but at least 4 hours before neratinib and intensive loperamide prophylaxis
(Amendment 4) or loperamide PRN (Amendment 5). Colestipol is a bile acid sequestrant anion resin that has the potential to interact with co-administered medication. Precaution should be taken around the timing of administration to avoid drug-drug interaction. Please refer to Section 7.6 and Appendix 10 of the protocol for additional specific recommendations regarding the administration of concomitant medication including neratinib and loperamide, the investigation products in this protocol.
Patients must use a diary to record their intake of medicinal product as supplied by sponsor.
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diagnosis and main criteria for

Each patient will be entered into this study only if she/he meets all of the following criteria:  
1. Aged ≥18 years at signing of informed consent.  
2. Histologically confirmed stage 1 through stage 3c primary adenocarcinoma of the breast (Edge and Compton, 2010).  
3. Documented HER2 overexpression or gene-amplified tumor by a validated approved method (Wolff et al, 2013).  
4. Patients must have completed a course of prior adjuvant trastuzumab or experienced side effects that resulted in early discontinuation of trastuzumab that have since resolved.  
5. The last dose of trastuzumab must have been given >2 weeks and ≤1 year (365 days) from enrollment.  
6. Physician assessment confirming that the patient is negative for local or regional recurrence of disease or metastatic disease at the time of study entry, including:
a. Per standard of care, bone scan or positron emission tomography (PET) scan; required only if alkaline phosphatase (ALP) is ≥2 x upper limit of normal (ULN) and/or there are symptoms of metastatic bone disease. A confirmatory imaging study is required if the results from the bone scan are questionable.  
b. Per standard of care, computed tomography (CT), magnetic resonance imaging (MRI) or ultrasound of the abdomen and chest; required only if aspartate aminotransferase (AST)/alanine aminotransferase (ALT) or ALP is ≥2 x ULN.
Other radiologic assessments may be performed to rule out underlying breast cancer recurrence if indicated and as per standard of care (for patients enrolled starting with Amendment 6.1).  
7. Left ventricular ejection fraction (LVEF) ≥50% measured by multiple-gated acquisition scan (MUGA) or echocardiogram (ECHO).  
8. Eastern Cooperative Oncology Group (ECOG) status of 0 to 1. 9. Negative β-human chorionic gonadotropin (hCG) pregnancy test for premenopausal women of reproductive capacity (those who are biologically capable of having children) and for women less than 12 months after menopause. [Women are considered postmenopausal if they are ≥12 months without menses, in the absence of endocrine or anti-endocrine therapies.]
10. Women of childbearing potential must agree and commit to the use of a highly effective non-hormonal method of contraception, ie, intrauterine device, bilateral tubal ligation, vasectomized partner, or abstinence (only when it is the preferred lifestyle of the patient), from the time of informed consent until 28 days after the last dose of the investigational products. Man (male patient) with female partner of childbearing potential must agree and commit to use condom and the female partner must agree and commit to use a highly effective method of contraception (ie, any of the above methods, or for females, hormonal contraception associated with inhibition of ovulation) while on treatment and for 3 months after last dose of investigational products.  
11. Recovery (ie, to Grade 1 or baseline) from all clinically significant AEs related to prior therapies (excluding alopecia, neuropathy, and nail changes).  
12. Provide written, informed consent to participate in the study and follow the study procedures.  
Exclusion Criteria A patient will be excluded from this study if she/he meets any of the following criteria:
1. Clinical or radiologic evidence of local or regional recurrence of disease or metastatic disease prior to or at the time of study entry.  
2. Currently receiving chemotherapy, radiation therapy, immunotherapy, or biotherapy for breast cancer. 3. Major surgery within <30 days of starting treatment or received chemotherapy, investigational agents, or other cancer therapy, except hormonal therapy (eg, tamoxifen, aromatase inhibitors), <14 days prior to the initiation of investigational products.  
4. Active uncontrolled cardiac disease, including cardiomyopathy, congestive heart failure (New York Heart Association functional classification of ≥2; including individuals who currently use digitalis, beta-blockers, or calcium channel blockers specifically for congestive heart failure), unstable angina, myocardial infarction within 12 months of enrollment, or ventricular arrhythmia.  
5. QTc interval >0.450 seconds (males) or >0.470 (females), or known history of QTc prolongation or Torsade de Pointes (TdP).  
6. Screening laboratory assessments outside the following limits:  
| Laboratory Parameters                           | Required Limit for Exclusion                                                                                                            |
|-------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------|
| Absolute neutrophil count (ANC)                 | <1,000/µl (<1.0 x 109 /L)                                                                                                               |
| Platelet count                                  | <100,000/µl (<100 x 109 /L)                                                                                                             |
| Hemoglobin                                      | <9 g/dL                                                                                                                                 |
| Total bilirubin                                 | >1.5 x institutional upper limit of normal (ULN) (in case of  known Gilbert's syndrome, <2 x ULN is allowed)                            |
| Aspartate aminotransferase (AST) and/or alanine | >2.5 x institutional ULN                                                                                                                |
| aminotransferase (ALT)  Creatinine              | Creatinine clearance <30 mL/min (as calculated by  Cockcroft-Gault formulaa or Modification of Diet in Renal  Disease [MDRD] formulab ) |
| a. Cockcroft and Gault, 1976.                   |                                                                                                                                         |  
Creatinine Creatinine clearance <30 mL/min (as calculated by  
Cockcroft-Gault formulaaor Modification of Diet in Renal  
Disease [MDRD] formulab)  
a. Cockcroft and Gault, 1976. b. Levey et al, 1999.  
7. Active, unresolved infections.  
8. Patients with a second malignancy, other than adequately treated non-melanoma skin cancers, in situ  
melanoma or in situ cervical cancer. Patients with other non-mammary malignancies must have been disease-free for at least 5 years.  
9. Currently pregnant or breast-feeding.  
10. Significant chronic gastrointestinal disorder with diarrhea as a major symptom (eg, Crohn's disease, malabsorption, or Grade ≥2 National Cancer Institute [NCI] Common Terminology Criteria for Adverse Events Version 4.0 [CTCAE v.4.0] diarrhea of any etiology at baseline).  
11. Clinically active infection with hepatitis B or hepatitis C virus. 12. Evidence of significant medical illness, abnormal laboratory finding, or psychiatric illness/social situations that could, in the Investigator's judgment, make the patient inappropriate for this study.  
13. Known hypersensitivity to any component of the investigational products; known allergies to any of the medications or components of medications used in the trial.  
14. Unable or unwilling to swallow tablets.
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safety assessments

The primary endpoint is the incidence of Grade 3 or higher diarrhea. AEs and AESIs will be graded according to the National Cancer Institute Common Terminology Criteria (NCI CTCAE), version 4.0. SAEs and AESIs will be reported through 28 days after the last dose of investigational product and will be followed until resolution or until condition stabilizes. Should an Investigator be made aware of any SAEs occurring any time after the reporting period that may be causally related to neratinib's administration, it should be promptly reported. Safety will also be assessed based on medical history, vital sign measurements, physical examination findings, electrocardiogram results, MUGA or ECHO,
and laboratory assessments.
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other assessments

Patient Reported Health Outcomes Assessments The following questionnaires will be used to collect patient-reported health outcomes data:
1) EQ-5D-5L Health Questionnaire (for patients enrolled starting with Amendment 2) 2) FACT-B (for patients enrolled starting with Amendment 2)
3) RSCL (for patients enrolled starting with Amendment 6.1)
Patient-reported outcomes assessments will be performed at C1D1, C2D1, C4D1, C7D1, C10D1, and C13D28/EOT.  
Biomarkers (for patients enrolled starting with Amendment 2) cfDNA will be obtained from plasma samples collected at Screening, C7D1, C13D28 and/or at time of treatment discontinuation, and at disease recurrence; cfDNA will undergo molecular profiling to identify biomarkers of disease recurrence.
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microbiome evaluation (for patients enrolled

At select study centers, a stool swab will be collected at Screening, C2D1, and C4D1 and/or at time of treatment discontinuation if earlier than C4D1 for possible future assessments of microbiome to assess the effect that neratinib has on the microbiome (currently in US only).
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disease recurrence

Clinical documentation of recurrence, including recurrence site, radiographic, and/or pathologic procedures will be collected at end-of -treatment (EOT).
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statistical methods sample size

The first 120 patients will be under the Original Protocol, Amendment 1, and Amendment 2. The incidence of Grade 3 or higher diarrhea is assumed to be 15% in this study. A sample size of 120 patients will ensure that the width of the 95% Clopper-Pearson CI of the incidence of Grade 3 or higher diarrhea is no more than 18.5%. For example, if 18 out of the 120 patients are observed to have Grade 3 or higher diarrhea, the incidence and its 95% (2-sided) CIs will be 15.0% (9.1%, 22.7%) where the width of the CI is 13.5%.  
In addition to the analyses of the overall safety population, anti-diarrheal prophylaxis regimen-specific subgroup analyses will be performed as needed. Precision of the estimated 95% CIs for the regimen-specific subgroup(s) will be lower than what is provided above for the overall safety population. To further investigate treatments, cohorts were added. For patients enrolled under Amendment 3, the effect of budesonide + mandatory loperamide prophylaxis on the incidence, severity, and duration of diarrhea will be assessed. For patients enrolled under Amendment 4 and Amendment 5, the effect of colestipol + mandatory loperamide prophylaxis (Amendment 4) and colestipol + PRN loperamide (Amendment 5) will be assessed; for patients enrolled under Amendment 6/6.1 and under Amendment 7/7.1, the effect of the dose escalation regimen of neratinib will be assessed. The incidence of Grade 3 or higher diarrhea will be evaluated. A sample size of 64 patients will ensure that the width of the 95% Clopper-Pearson CI of the incidence of Grade 3 or higher diarrhea is no more than 26%. For example, if 7 out of the 64 patients are observed to have Grade 3 or higher diarrhea, the incidence and its 95% (2-sided)
CI will be 10.9% (4.5–21.2%) where the width of the CI is 17%. For each additional cohort, a sample size of 100 patients will ensure that the width of the 95% Clopper-Pearson CI of the incidence of Grade 3 or higher diarrhea is no more than 21%. For example, if 15 out of the 100 patients are observed to have Grade 3 or higher diarrhea, the incidence and its 95% (2-sided) CI will be 15.0% (8.7–23.5%) where the width of the CI is 15%. Cohorts will continue to enroll without interruption, in sequence. Thus enrollment may exceed initial projections.
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statistical analysis

The primary endpoint is the incidence of Grade 3 or higher diarrhea. The accompanying 2-sided 95% Clopper-Pearson CIs will be computed.
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safety

All patients who receive a dose of neratinib will be analyzed for safety. Treatment emergent AEs, SAEs, and AESIs, as well as select laboratory tests will be summarized. Deaths and discontinuation from study treatment will also be summarized.
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exploratory

Patient-related outcomes data (scores from the EQ-5D-5L, FACT-B, and RSCL questionnaires) will be summarized and plotted over time. Changes from baseline will be provided with both point estimates and CIs.  
Exploratory analyses will be conducted to evaluate the relationship between disease biomarkers identified from molecular profiling and indications of clinical disease recurrence. Microbiome evaluation from participating sites will be summarized at baseline, C2D1, C4D1, and/or at time of treatment discontinuation. No formal statistical analyses are planned of the microbiome data.  
All analyses of exploratory endpoints are descriptive and no formal testing is planned.
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interim analysis

An interim analysis is planned when approximately 120 patients enrolled under the Original protocol, Amendment 1, and Amendment 2, have completed at least 2 cycles (56 days) of neratinib with loperamide prophylaxis. The interim analysis will only include those 120 patients enrolled under the Original Protocol, Amendment 1, and Amendment 2.  
Other additional analyses by cohort, in addition to the interim analysis, may be carried out as required.  
Final Analysis:
The final analysis is planned when all patients have completed 13 cycles (364 days) of neratinib therapy or have discontinued the study.  
Schedule of Procedures:
A schedule of procedures is included in Appendix 1.  
| TABLE OF CONTENTS                                                                                                                                       |                                                                                                                                                         |
|---------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------|
| DISCLOSURE STATEMENT .                                                                                                                                  |                                                                                                                                                         |
| PROTOCOL SYNOPSIS                                                                                                                                       |                                                                                                                                                         |
| LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS..................................16                                                                      |                                                                                                                                                         |
| 1.                                                                                                                                                      |                                                                                                                                                         |
| 2.                                                                                                                                                      | INTRODUCTION ................................................................................................................................19         |
| 2.1.                                                                                                                                                    | Background                                                                                                                                              |
| 2.2.                                                                                                                                                    | ERBB2 Gene and Cancer ...............................................................................................................19                 |
| 2.2.1.                                                                                                                                                  | The Epidermal Growth Factor Receptor Family (ERBB) ..................................................19                                                 |
| ERBB2-positive Cancers ...............................................................................................................20                |                                                                                                                                                         |
| 2.2.2.                                                                                                                                                  |                                                                                                                                                         |
| 2.3.                                                                                                                                                    | Current Therapies Targeting ERBB Receptors .................................................................20                                          |
| 2.3.1.                                                                                                                                                  | Trastuzumab ...................................................................................................................................20       |
| 2.3.2.                                                                                                                                                  | Pertuzumab ........................................................................................................................................20   |
| 2.3.3.                                                                                                                                                  | Pertuzumab in Combination with Trastuzumab .................................................................20                                          |
| 2.3.4.                                                                                                                                                  | Ado-trastuzumab Emtansine........................................................................................................21                     |
| 2.3.5.                                                                                                                                                  | Other HER2-targeted Therapies ...........................................................................................................22             |
| Neratinib                                                                                                                                               |                                                                                                                                                         |
| 2.4.                                                                                                                                                    | Safety Profile of Neratinib in Monotherapy and Combination Therapy                                                                                      |
| 2.4.1.                                                                                                                                                  | Studies                                                                                                                                                 |
| 2.4.2.                                                                                                                                                  | Diarrhea Prophylaxis in Neratinib Clinical Studies                                                                                                      |
| 2.4.3.                                                                                                                                                  | Preliminary Clinical Activity of Neratinib ...........................................................................24                                |
| Study Rationale                                                                                                                                         |                                                                                                                                                         |
| 2.5.                                                                                                                                                    | Neratinib Dose Escalation Rationale .....................................................................................25                             |
| 2.5.1.                                                                                                                                                  |                                                                                                                                                         |
| 2.5.2.                                                                                                                                                  | Results of Preclinical Investigations.......................................................................................25                          |
| 2.5.3.                                                                                                                                                  | Rationale for use of an Anti-inflammatory Agent ................................................................25                                      |
| Rationale for Use of a Bile Acid Sequestrant ........................................................................26                                 |                                                                                                                                                         |
| 2.5.4.                                                                                                                                                  |                                                                                                                                                         |
| 2.5.5.                                                                                                                                                  | Enrollment ..........................................................................................................................................26 |
| 3.                                                                                                                                                      | STUDY OBJECTIVES ......................................................................................................................27               |
| Primary Objective ...................................................................................................................................27 |                                                                                                                                                         |
| 3.1.                                                                                                                                                    | Secondary Objectives .........................................................................................................................27        |
| 3.2.                                                                                                                                                    | Exploratory Objectives ..................................................................................................................27             |
| 3.3.                                                                                                                                                    |                                                                                                                                                         |
| 4.                                                                                                                                                      | INVESTIGATIONAL PLAN                                                                                                                                    |
| 4.1.                                                                                                                                                    | Overall Study Design                                                                                                                                    |
|                                                                                                                                                         | __                                                                                                                                                      |  
| 25-JUL-2019                                                                                                                                                                    |                                                                                                                                                   |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------|
| Neratinib Tablets (PB-272)                                                                                                                                                     |                                                                                                                                                   |
| Protocol:  PUMA-NER-6201                                                                                                                                                       | Amendment 7.1                                                                                                                                     |
| Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may b |                                                                                                                                                   |
| 4.2.                                                                                                                                                                           | Study Duration and Termination of Study                                                                                                           |
| Randomization and Blinding ....................................................................................................32                                              |                                                                                                                                                   |
| 4.3.                                                                                                                                                                           | STUDY POPULATION .                                                                                                                                |
| 5.                                                                                                                                                                             |                                                                                                                                                   |
| 5.1.                                                                                                                                                                           | Inclusion Criteria .                                                                                                                              |
| 5.2.                                                                                                                                                                           | Exclusion Criteria ......................................................................................................................34       |
| Patient Enrollment ...........................................................................................................................35                               |                                                                                                                                                   |
| 5.3.                                                                                                                                                                           |                                                                                                                                                   |
| 6.                                                                                                                                                                             | ADMINISTRATION OF NERATINIB, LOPERAMIDE,  ANTI-                                                                                                   |
| INFLAMMATORY, AND BILE ACID SEQUESTRANT TREATMENTS ..........36                                                                                                                |                                                                                                                                                   |
| Neratinib ...................................................................................................................................36                                |                                                                                                                                                   |
| 6.1.                                                                                                                                                                           |                                                                                                                                                   |
| 6.1.1.                                                                                                                                                                         | Neratinib Dose Adjustment ..................................................................................................36                    |
| 6.2.                                                                                                                                                                           | Loperamide ................................................................................................................................37     |
| Loperamide Dose Adjustment .................................................................................................39                                                 |                                                                                                                                                   |
| 6.2.1.                                                                                                                                                                         |                                                                                                                                                   |
| 6.3.                                                                                                                                                                           | BUDESONIDE ....................................................................................................................................39 |
| 6.4.                                                                                                                                                                           | Colestipol                                                                                                                                        |
| Packaging, Labeling, and Storage .....................................................................................41                                                       |                                                                                                                                                   |
| 6.5.                                                                                                                                                                           | Neratinib ..................................................................................................................................41    |
| 6.5.1.                                                                                                                                                                         |                                                                                                                                                   |
| 6.5.2.                                                                                                                                                                         | Loperamide ............................................................................................................................41         |
| 6.5.3.                                                                                                                                                                         | Budesonide ..............................................................................................................................41       |
| 6.5.4.                                                                                                                                                                         | Colestipol                                                                                                                                        |
| 6.6.                                                                                                                                                                           | Drug Accountability and Treatment Compliance* ...........................................................42                                       |
| 7.                                                                                                                                                                             | CONCOMITANT MEDICATIONS ....................................................................................43                                    |
| Permitted Concomitant Treatment.....................................................................................43                                                         |                                                                                                                                                   |
| 7.1.                                                                                                                                                                           | Required Loperamide Antidiarrheal Therapy..................................................................43                                     |
| 7.2.                                                                                                                                                                           |                                                                                                                                                   |
| 7.3.                                                                                                                                                                           | Anti-inflammatory Treatment                                                                                                                       |
| 7.4.                                                                                                                                                                           | Colestipol (Amendment 4 and Amendment 5)                                                                                                          |
| Prohibited Concomitant Treatment................................................................................48                                                             |                                                                                                                                                   |
| 7.5.                                                                                                                                                                           |                                                                                                                                                   |
| 7.6.                                                                                                                                                                           | Potential for Drug-Drug Interactions                                                                                                              |
| 7.6.1.                                                                                                                                                                         | Potential Drug-Drug Interactions with Neratinib ...........................................................49                                     |
| Potential for Drug-Drug Interactions with Budesonide .....................................................49                                                                   |                                                                                                                                                   |
| 7.6.2.                                                                                                                                                                         |                                                                                                                                                   |
| 7.6.3.                                                                                                                                                                         | Potential for Drug-Drug Interactions with Colestipol ......................................................50                                     |
| 7.7.7.                                                                                                                                                                         | T Treatment Compliance                                                                                                                            |
| STUDY ASSESSMENTS                                                                                                                                                              |                                                                                                                                                   |
| 8.                                                                                                                                                                             | Efficacy Assessment                                                                                                                               |
| 8.1.                                                                                                                                                                           |                                                                                                                                                   |  
| 25-JUL-2019                                                                                                                                                 |                                                                                                                                                         |              |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------|--------------|
| Neratinib Tablets (PB-272)                                                                                                                                  |                                                                                                                                                         |              |
| Protocol:  PUMA-NER-6201                                                                                                                                    | Amendment 7.1                                                                                                                                           |              |
| __                                                                                                                                                          |                                                                                                                                                         |              |
| 8.2.                                                                                                                                                        | Se                                                                                                                                                      |              |
| 8.2.1.                                                                                                                                                      | Clinical Endpoints and Definitions .                                                                                                                    |              |
| Laboratory Assessments ..................................................................................................................................51 |                                                                                                                                                         |              |
| 8.2.2.                                                                                                                                                      |                                                                                                                                                         |              |
| 8.2.3.                                                                                                                                                      | Vital Signs                                                                                                                                             |              |
| 8.2.4.                                                                                                                                                      | Physical Examination ................................................................................................................................53 |              |
| 8.2.5.                                                                                                                                                      | Electrocardiogram                                                                                                                                       |              |
| 8.2.6.                                                                                                                                                      | Left Ventricular Ejection Fraction (LVEF) .................................................................................53                           |              |
| 8.3.                                                                                                                                                        | O O TH                                                                                                                                                  |              |
| Health Outcomes Assessments                                                                                                                                 |                                                                                                                                                         |              |
| 8.3.1.                                                                                                                                                      |                                                                                                                                                         |              |
| 8.3.2.                                                                                                                                                      | Biomarkers                                                                                                                                              |              |
| 8.3.3.                                                                                                                                                      | Disease Recurrence                                                                                                                                      |              |
| 8.3.4.                                                                                                                                                      | Microbiome Evaluation (for patients enrolled starting with Amendment 6) .............54                                                                 |              |
| Protocol Deviations                                                                                                                                         |                                                                                                                                                         |              |
| 8.4.                                                                                                                                                        |                                                                                                                                                         |              |
| 8.5.                                                                                                                                                        | Study Drug Accountability/Patient Diary............................................................................................55                   |              |
| 8.5.1.                                                                                                                                                      | Study Medication Accountability                                                                                                                         |              |
| 8.5.2.                                                                                                                                                      | Patient Diary                                                                                                                                           |              |
| 9.                                                                                                                                                          | STUDY CONDUCT.                                                                                                                                          |              |
| 9.1.                                                                                                                                                        | Screening/Baseline .                                                                                                                                    |              |
| 9.2.                                                                                                                                                        | Active Treatment Phase .......................................................................................................................57        |              |
| Treatment Discontinuation or End-of-Treatment Assessments                                                                                                   |                                                                                                                                                         |              |
| 9.3.                                                                                                                                                        | Se                                                                                                                                                      |              |
| 9.4.                                                                                                                                                        |                                                                                                                                                         |              |
| 9.5.                                                                                                                                                        | Long-term Follow-up                                                                                                                                     |              |
| 9.6.                                                                                                                                                        | End of Study .                                                                                                                                          |              |
| PATIENT WITHDRAWAL AND REPLACEMENT .....................................................60                                                                  |                                                                                                                                                         |              |
| 10.                                                                                                                                                         |                                                                                                                                                         |              |
| 10.1.                                                                                                                                                       | Investigational Product Discontinuation                                                                                                                 |              |
| 10.2.                                                                                                                                                       | Withdrawal from the Study ...................................................................................................60                         |              |
| Procedures for Investigational Product Discontinuation/Study Withdrawal ..............61                                                                    |                                                                                                                                                         |              |
| 10.3.                                                                                                                                                       | Patient Replacement ......................................................................................................................61            |              |
| 10.4.                                                                                                                                                       |                                                                                                                                                         |              |
| 1.                                                                                                                                                          | PREMATURE TERMINATION OF STUDY ....................................................................62                                                   |              |
| 12.                                                                                                                                                         | STATISTICAL METHODS                                                                                                                                     |              |
| General Considerations                                                                                                                                      |                                                                                                                                                         |              |
| 12.1.                                                                                                                                                       |                                                                                                                                                         |              |
| 12.1.1.                                                                                                                                                     | Subgroups/Cohorts ........................................................................................................................63            |              |
| 12.2.                                                                                                                                                       | Study Patients ...............................................................................................................................63        |              |
| __                                                                                                                                                          | __                                                                                                                                                      |              |
| Puma Biotechnology                                                                                                                                          | Page 13 of 114                                                                                                                                          | CONFIDENTIAL |  
| 25-JUL-2019                                                                                                                             |                                                                                                                                                                |
|-----------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Neratinib Tablets (PB-272)                                                                                                              |                                                                                                                                                                |
| Protocol:  PUMA-NER-6201                                                                                                                | Amendment 7.1                                                                                                                                                  |
|                                                                                                                                         |                                                                                                                                                                |
| 12.2.1.                                                                                                                                 | Disposition of Patients .................................................................................................................63                    |
| 12.2.2.                                                                                                                                 | Demographic Data, Medical History, Baseline Characteristics, and                                                                                               |
| Concomitant Medications ..........................................................................................................63    |                                                                                                                                                                |
| 12.2.3.                                                                                                                                 | Treatment Compliance                                                                                                                                           |
| 12.3.                                                                                                                                   | Efficacy Analyses .......................................................................................................................63                    |
| 12.4.                                                                                                                                   | Safety Analysis .............................................................................................................................63                |
| 12.4.1.                                                                                                                                 | Statistical Methods                                                                                                                                            |
| 12.4.2.                                                                                                                                 | Adverse Events ............................................................................................................................64                  |
| 12.4.3.                                                                                                                                 | Laboratory Results                                                                                                                                             |
| 12.5.                                                                                                                                   | Exploratory Endpoints Analyses .........................................................................................64                                     |
| 12.5.1.                                                                                                                                 | Health Outcomes Assessments ................................................................................................64                                 |
| 12.5.2.                                                                                                                                 | Biomarkers Analyses .................................................................................................................64                        |
| 12.5.3.                                                                                                                                 | Microbiome Analyses ....................................................................................................................65                     |
| 12.6.                                                                                                                                   | Interim Analysis                                                                                                                                               |
| Determination of Sample Size ........................................................................................................65 |                                                                                                                                                                |
| 12.7.                                                                                                                                   |                                                                                                                                                                |
| 13.                                                                                                                                     | SAFETY DATA COLLECTION, RECORDING, AND REPORTING......................66                                                                                       |
| 13.1.                                                                                                                                   | Definitions ................................................................................................................................................66 |
| 13.1.1.                                                                                                                                 | Adverse Events .................................................................................................................................66             |
| 13.1.2.                                                                                                                                 | Abnormal Laboratory Results                                                                                                                                    |
| 13.1.3.                                                                                                                                 | Serious Adverse Events ...............................................................................................................67                       |
| 13.1.4.                                                                                                                                 | Hospitalization ..............................................................................................................................67               |
| Suspected Unexpected Serious Adverse Reaction ...........................................................68                             |                                                                                                                                                                |
| 13.1.5.                                                                                                                                 | Severity Assessment .....................................................................................................................68                    |
| 13.1.6.                                                                                                                                 |                                                                                                                                                                |
| 13.1.7.                                                                                                                                 | Causality Assessment ...............................................................................................................69                         |
| 13.1.8.                                                                                                                                 | Special Reporting Situations                                                                                                                                   |
| Reporting Adverse Events ............................................................................................................70 |                                                                                                                                                                |
| 13.2.                                                                                                                                   |                                                                                                                                                                |
| 13.3.                                                                                                                                   | Reporting Serious Adverse Events ..........................................................................................70                                  |
| 13.4.                                                                                                                                   | Pregnancy                                                                                                                                                      |
| Sponsor Reporting Requirements to Health Authorities and IRB/IEC ........................72                                             |                                                                                                                                                                |
| 13.5.                                                                                                                                   | ETHICAL, LEGAL, AND ADMINISTRATIVE ASPECTS .........................................73                                                                         |
| 14.                                                                                                                                     |                                                                                                                                                                |
| 14.1.                                                                                                                                   | Data Collection, Processing, and Monitoring .........................................................................73                                        |
| 14.1.1.                                                                                                                                 | Case Report Forms and Source Documentation ...................................................................73                                               |
| 14.1.2.                                                                                                                                 | Study Monitoring and Access to Source Documentation .....................................................73                                                    |
|                                                                                                                                         |                                                                                                                                                                |  
| Neratinib Tablets (PB-272)   | 25-JUL-2019                                                |
|------------------------------|------------------------------------------------------------|
| Protocol: PUMA-NER-6201      | Amendment 7.1                                              |
| 14.1.3.                      | Data Quality Assurance 74                                  |
| 14.1.4.                      | Data Processing 74                                         |
| 14.1.5.                      | Retention of Data and Study Records 74                     |
| 14.2.                        | Ethical Aspects 75                                         |
| 14.2.1.                      | Good Clinical Practice and Ethical Conduct of the Study 75 |
| 14.2.2.                      | Informed Consent Responsibilities 75                       |
| 14.3.                        | Other Study Administrative Aspects 76                      |
| 14.3.1.                      | Protocol Approval and Protocol Amendment 76                |
| 14.3.2.                      | Investigator Responsibilities 76                           |
| 14.3.3.                      | Patient Responsibilities 77                                |
| 14.3.4.                      | Financial Disclosure 78                                    |
| 14.3.5.                      | Publication Policy 78                                      |
| 15.                          | REFERENCE LIST 79                                          |
| 16.                          | SIGNATURE PAGES 84                                         |
| 17.                          | APPENDICES 87                                              |
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list of tables

| Table 1:   | Neratinib Diarrhea Incidence Without Loperamide Prophylaxis 23   |
|------------|------------------------------------------------------------------|
| Table 2:   | Neratinib Diarrhea Incidence Using Loperamide Prophylaxis 24     |
| Table 3:   | Dose Reduction Levels for Neratinib-Related Toxicity 36          |
| Table 4:   | Loperamide Dosing 38                                             |
| Table 5:   | Loperamide Dose Reduction Levels for Constipation 39             |
| Table 6:   | Budesonide Dosing 40                                             |
| Table 7:   | Colestipol Dosing 41                                             |
| Table 8:   | Laboratory Parameters 52                                         |
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list of figures

Figure 1: Study Design (Starting with Amendment 7) ..............................................................30  
| 1.             | LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS                                                                     |
|----------------|--------------------------------------------------------------------------------------------------------------------|
| Abbreviation   | Term/Definition                                                                                                    |
| ADL            | activities of daily living                                                                                         |
| AE             | adverse event                                                                                                      |
| AESI           | adverse events of special interest                                                                                 |
| Akt            | protein kinase B                                                                                                   |
| ALP            | alkaline phosphatase                                                                                               |
| ALT            | alanine aminotransferase                                                                                           |
| ANC            | absolute neutrophil count                                                                                          |
| AST            | aspartate aminotransferase                                                                                         |
| ATC            | Anatomical Therapeutic Chemical [Classification System]                                                            |
| BID            | twice daily                                                                                                        |
| BUN            | blood urea nitrogen                                                                                                |
| C              | Cycle                                                                                                              |
| CBC            | complete blood count                                                                                               |
| cfDNA          | cell-free DNA                                                                                                      |
| CFR            | Code of Federal Regulations                                                                                        |
| CI             | confidence interval                                                                                                |
| CRA            | clinical research associate                                                                                        |
| CRF            | case report form                                                                                                   |
| CSR            | clinical study report                                                                                              |
| CT             | computerized tomography                                                                                            |
| CTCAE          | Common Terminology Criteria for Adverse Events                                                                     |
| CYP            | cytochrome P450 enzyme                                                                                             |
| D              | Day                                                                                                                |
| DM1            | Emtansine                                                                                                          |
| ECG            | Electrocardiogram                                                                                                  |
| ECHO           | Echocardiogram                                                                                                     |
| ECOG           | Eastern Cooperative Oncology Group                                                                                 |
| eCRF           | electronic case report form                                                                                        |
| EGFR           | epidermal growth factor receptor (also known as HER)                                                               |
| EIU            | exposure-in-utero                                                                                                  |
| EMA            | European Medicines Agency (formerly EMEA)                                                                          |
| EOS            | end of study                                                                                                       |
| EOT            | end of treatment                                                                                                   |
| EQ-5D-5L       | EuroQol 5D-5L                                                                                                      |
| ERBB           | epidermal growth factor family of trans-membrane receptors (also known as HER)                                     |
| ERBB2 V-erb-b2 | avian erythroblastic leukemia viral oncogene homolog 2, neuro/glioblastoma derived  oncogene homolog (avian), HER2 |
| EU             | European Union                                                                                                     |
| FACT-B         | Functional Assessment of Cancer Therapy Breast Cancer                                                              |
| FDA            | Food and Drug Administration (United States)                                                                       |  
| Neratinib Tablets (PB-272)   | 25-JUL-2019                                                                                                                         |
|------------------------------|-------------------------------------------------------------------------------------------------------------------------------------|
| Protocol: PUMA-NER-6201      | Amendment 7.1                                                                                                                       |
| GCP                          | Good Clinical Practice                                                                                                              |
| GI                           | Gastrointestinal                                                                                                                    |
| GLP                          | Good Laboratory Practice                                                                                                            |
| Hb                           | Hemoglobin                                                                                                                          |
| hCG                          | β-human chorionic gonadotropin                                                                                                      |
| Hct                          | Hematocrit                                                                                                                          |
| HER                          | human epidermal growth factor receptor                                                                                              |
| HER2                         | human epidermal growth factor receptor 2 (neu [N ethyl nitrosourea stimulated] gene  product); also known as c erB2, ERBB2, or p185 |
| HIPAA                        | Health Insurance Portability and Accountability Act                                                                                 |
| HR                           | hormone receptor                                                                                                                    |
| IB                           | Investigator's Brochure                                                                                                             |
| IC50                         | concentration at which there is 50% inhibition                                                                                      |
| ICF                          | informed consent form                                                                                                               |
| ICH                          | International Conference on Harmonisation                                                                                           |
| IEC                          | Independent Ethics Committee                                                                                                        |
| IHC                          | Immunohistochemistry                                                                                                                |
| IM                           | intramuscular(ly)                                                                                                                   |
| IRB                          | Institutional Review Board                                                                                                          |
| IV                           | intravenous(ly)                                                                                                                     |
| LDH                          | lactate dehydrogenase                                                                                                               |
| LFT                          | liver function test                                                                                                                 |
| LLN                          | lower limit of normal                                                                                                               |
| LVEF                         | left ventricular ejection fraction                                                                                                  |
| MBC                          | metastatic breast cancer                                                                                                            |
| MDRD                         | modification of diet in renal disease                                                                                               |
| MedDRA                       | Medical Dictionary for Regulatory Activities                                                                                        |
| mmHg                         | millimeters mercury                                                                                                                 |
| MRI                          | magnetic resonance imaging                                                                                                          |
| MUGA                         | multiple-gated accession scan                                                                                                       |
| NCI                          | National Cancer Institute                                                                                                           |
| NSCLC                        | non-small cell lung cancer                                                                                                          |
| OS                           | overall survival                                                                                                                    |
| PB-272                       | Neratinib                                                                                                                           |
| PET                          | positron emission tomography                                                                                                        |
| PFS                          | progression-free survival                                                                                                           |
| P-gp                         | P-glycoprotein                                                                                                                      |
| PI3K                         | phosphoinositide 3-kinase                                                                                                           |
| PO                           | by mouth                                                                                                                            |
| PT                           | preferred term                                                                                                                      |
| PRN                          | Pro re nata (as needed)                                                                                                             |
| QOL                          | Quality of Life                                                                                                                     |
| QTc                          | QT interval, corrected for heart rate                                                                                               |
| RBC                          | red blood cell                                                                                                                      |  
| Neratinib Tablets (PB-272)   | 25-JUL-2019                                   |
|------------------------------|-----------------------------------------------|
| Protocol: PUMA-NER-6201      | Amendment 7.1                                 |
| RSCL                         | Rotterdam Symptom Checklist                   |
| SAE                          | serious adverse event                         |
| SC                           | subcutaneous(ly)                              |
| SmPC                         | Summary of Product Characteristics            |
| SOC                          | system organ class                            |
| SUSAR                        | suspected unexpected serious adverse reaction |
| T-DM1                        | trastuzumab emtansine                         |
| TdP                          | Torsade de Pointes                            |
| TID                          | three times daily                             |
| ULN                          | upper limit of normal                         |
| US                           | United States (of America)                    |
| WBC                          | white blood cell                              |
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2. introduction 2.1. background

Breast cancer is the most frequently diagnosed malignancy in women and the leading cause of cancer mortality in women worldwide. Breast cancer accounted for approximately 522,000 deaths worldwide in 2012, and the global incidence of new cases in women was approximately 1.67 million (International Agency for Research on Cancer, GLOBOCAN 2012).
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2.2. erbb2 gene and cancer

Members of the epidermal growth factor family of trans-membrane receptors (ERBB family) are potent mediators of normal cell growth and development and are expressed in various tissues of epithelial, mesenchymal and neuronal origin (Baselga et al, 2009). The ERBB family consists of 4 closely related type 1 trans-membrane tyrosine kinase receptors: epidermal growth factor receptor (EGFR; also known as HER1), ERBB2 (HER2), ERBB3 (HER3), and ERBB4 (HER4). Aberrant expression of HER1, HER2, and HER3 are linked to development of many epithelial cancers including colorectal, gastric, breast, and head and neck cancers. These membranespanning proteins receive extracellular signals from small peptide-ligand molecules, including epidermal growth factor-like molecules, transforming growth factor-α and neuregulins. Under normal physiological conditions, activation of the ERBB receptors is controlled by the spatial and temporal expression of their ligands (Yarden and Sliwkowski, 2001). Ligand binding triggers intracellular signaling through a complex and tightly controlled array of signaling pathways that together drive and regulate many cellular functions, including cell proliferation and organ development and repair. Binding of ligands to extracellular parts of HER1, HER3 and HER4 will result in dimerization and initiates a series of signaling cascades that includes mitogen-activated protein kinase, phosphoinositide 3-kinase (PI3K), Akt, and mammalian target of rapamycin (mTOR) (Garrett and Arteaga, 2011). Each receptor comprises an extracellular domain at which ligand binding occurs, an alpha-helical trans-membrane segment and an intracellular protein tyrosine kinase domain (Olayioye et al, 2000). Receptor dimerization is an essential requirement for signaling activity of these receptors and can occur between two different ERBB receptors (hetero-dimerization) or between two molecules of the same receptor (homo-dimerization) (Olayioye et al, 2000; Ferguson et al, 2003). ERBB homodimers weakly perpetuate signals compared with heterodimers (Yarden and Sliwkowski, 2001). As the natural ligand for HER2 has not been identified, the receptor is presumed to exert its effects via formation of heterodimers with other HER family members and it is thought to be the preferred dimerization partner for the other receptors (Rosen et al, 2010). In fact, heterodimer formation with HER2 has been shown to increase the affinity of ligand binding to the dimerization partner (Graus-Porta et al, 1997). Dimerization of HER3, which lacks intrinsic kinase activity, with HER2 induces phosphorylation of HER3, which then activates the PI3K and Akt pathways (Graus-Porta et al, 1997).
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2.2.2. erbb2-positive cancers

ERBB2 amplification and over-expression have been reported in 18 to 25% of human breast cancers and subsets of patients with ovarian and salivary gland tumors (Slamon et al, 1987; Vermeij et al, 2008; Cornolti et al, 2007). Approximately 15 to 20% (Ahn et al, 2012; Saini et al, 2011) of women with breast cancer are ERBB2-positive, which is associated with aggressive disease and poor prognosis (Slamon et al, 1987), including enhanced cell proliferation, reduced progression-free survival (PFS), and reduced overall survival (OS) (Slamon et al, 1987; Zhang et al, 2007; Badache and Goncalves 2006; Slamon et al, 1989). Compared with female breast cancer, male breast cancer cases are more often hormonal receptor (estrogen receptor/progesterone receptor) positive and HER2 negative, but treatment of male breast cancer patients follows the same indications as female postmenopausal breast cancer with surgery, systemic therapy and radiotherapy (Ottini et al, 2010). These observations have motivated the development of therapies targeting HER2.
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2.3. current therapies targeting erbb

Trastuzumab (Herceptin® Package Insert, Herceptin Summary of Product Characteristics
[SmPC], Herceptin Product Monograph), the first agent approved for treatment of HER2+ breast cancer, is a monoclonal antibody that binds to the juxtamembrane portion of the HER2/neu receptor, resulting in inhibition of tumor proliferation (Goldenberg, 1999). While the exact mechanism of action is uncertain, Junttila et al (2009) reported that trastuzumab induced dissociation of ligand independent HER2-HER3 heterodimers resulting in dephosphorylation of HER3 and inhibition of downstream signaling, and Park et al (2010) reported that the antitumor effects of trastuzumab also involved antibody-dependent, cell-mediated cytotoxicity.
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2.3.2. pertuzumab

Pertuzumab (Perjeta® Package Insert) is a humanized monoclonal antibody that binds HER2 at a different epitope of the HER2 extracellular domain (subdomain II) than trastuzumab (Baselga et al, 2012) thereby preventing HER2 from dimerizing with other ligand-activated HER receptors, most notably HER3 (Baselga and Swain, 2009; Agus et al, 2002). The HER2-HER3 heterodimer is considered to be the most potent signaling pair (Agus et al, 2002), driving cell proliferation in HER2+ cancer (Lee-Hoeflich et al, 2008; Hsieh and Moasser, 2007). In recent studies, the addition of pertuzumab to combination therapy has led to improvements in PFS in patients with HER2+ metastatic breast cancer (MBC) and higher response rates in the preoperative setting (Murphy and Morris, 2012).
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2.3.3. pertuzumab in combination with

Although treatment with trastuzumab in addition to chemotherapy (as compared with chemotherapy alone) significantly improves PFS and OS among patients with HER2+ MBC, in most patients, the disease progresses (Nahta and Esteva, 2007). Because pertuzumab and trastuzumab bind to different HER2 epitopes and have complementary mechanisms of action, the combination of these two agents, provide a more comprehensive blockade of HER2 signaling and result in greater antitumor activity than either agent alone in HER2+ tumor models (Lee-Hoeflich et al, 2008; Scheuer et al, 2009). In Phase 2 studies, a pertuzumab plus trastuzumab regimen showed activity in patients with HER2+ MBC (Baselga et al, 2010; Portera et al, 2008) and in patients with early breast cancer (Gianni et al, 2010).  
The Clinical Evaluation of pertuzumab and trastuzumab (CLEOPATRA) study assessed the efficacy and safety of pertuzumab plus trastuzumab plus docetaxel, as compared with placebo plus trastuzumab plus docetaxel (control group), as first-line treatment for patients with HER2+ MBC who had not received chemotherapy or biologic therapy for their metastatic disease (Baselga et al, 2012). At the final analysis (median follow-up of 50 months), treatment with pertuzumab plus trastuzumab plus docetaxel resulted in significant improvement in PFS and OS with an unprecedented increase of 15.7 months in median OS, compared with the control group (Swain et al, 2014). CLEOPATRA findings suggest that targeting HER2+ tumors with two anti-HER2 monoclonal antibodies that have complementary mechanisms of action results in a more comprehensive blockade of HER2 and highlights the clinical importance of preventing the ligand-dependent formation of HER2 dimers in order to silence HER2 signaling to the greatest extent possible (Baselga and Swain, 2009; Yarden and Sliwkowski, 2001). Pertuzumab received approval in the US in 2012 for use in combination with trastuzumab and docetaxel for the treatment of patients with HER2+ MBC who have not received prior anti HER2 therapy or chemotherapy for metastatic disease. In 2013, pertuzumab received approval for use in combination with trastuzumab and docetaxel for the neoadjuvant treatment of patients with HER2-positive, locally advanced, inflammatory or early-stage breast cancer (either greater than 2 cm in diameter or node positive) as part of a complete treatment regimen for early breast cancer.
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2.3.4. ado-trastuzumab emtansine

Ado-trastuzumab emtansine (T-DM1, Kadcyla® Package Insert) is an antibody-drug conjugate that combines HER2-targeted delivery of the potent microtubule polymerization inhibitor emtansine (DM1), a derivative of maytansine, with the antitumor activity of trastuzumab (Lewis Phillips et al, 2008; Remillard et al, 1975; Cassady et al, 2004; Widdison et al, 2006; Junttila et al, 2011). In T-DM1, trastuzumab and DM1 are covalently linked via a stable thioether linker
(N-maleimidomethyl) cyclohexane-1-carboxylate, which is thought to limit the exposure of normal tissue to DM1 (Krop et al, 2010; Burris et al, 2011). Antitumor activity was established in a proof of concept Phase 2 study of single-agent T-DM1 in patients with HER2+ MBC, who had progressed while receiving HER2-directed therapy (Burris et al, 2011). Furthermore, in a single-arm Phase 2 study, T-DM1 demonstrated efficacy in patients with HER2+ MBC who previously received all standard HER2-directed therapies (trastuzumab, lapatinib, an anthracycline, a taxane, and capecitabine) (Krop et al, 2012). Primary results from the EMILIA study (a Phase 3, randomized, multicenter study of T-DM1 compared with lapatinib plus capecitabine in patients with HER2+ locally advanced or MBC previously treated with a trastuzumab-based regimen and a taxane) showed a significant and clinically meaningful improvement with T-DM1 in PFS compared with lapatinib plus capecitabine (Verma et al, 2012). Other end points supported T-DM1 as an active and welltolerated novel therapy for HER2+ advanced breast cancer. T-DM1 is approved in the US for patients with HER2-positive MBC who have previously received trastuzumab and a taxane separately or in combination.
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2.3.5. other her2-targeted therapies

Other HER2-targeted agents include lapatinib, a small molecule tyrosine kinase inhibitor that targets the tyrosine kinase domains of both EGFR and HER2 (Rusnak and Gilmer, 2011). Trastuzumab and lapatinib have received approval from the United States (US) Food and Drug Administration (FDA) for the treatment of patients with advanced or metastatic HER2overexpressing breast cancer who have previously been treated with an anthracycline, a taxane, and trastuzumab.
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2.4. neratinib

Neratinib (PB-272) is a potent irreversible pan ERBB inhibitor. Neratinib is an orally available small molecule that inhibits ERBB1, ERBB2, and ERBB4 at the intracellular tyrosine kinase domains, a mechanism of action that is different from trastuzumab. Neratinib reduces ERBB1 and ERBB2 autophosphorylation, downstream signaling, and the growth of ERBB1 and ERBB2 dependent cell lines. Preclinical data suggest that neratinib will have antitumor activity in ERBB1- and/or ERBB2-expressing carcinoma cell lines, with cellular IC50 <100 nM (Rabindran et al, 2004). Neratinib may have advantages over other HER2 inhibitors due to its ability to irreversibly inhibit both HER1 and HER2. Breast cancer cells may become resistant to trastuzumab on the basis of extracellular domain truncation of HER2 receptor, which can no longer be recognized by the antibody (Xia et al, 2004), or because of coactivation of HER1 signaling (Rampaul et al, 2005; Zaczek et al, 2005). However, since neratinib acts on the intracellular tyrosine kinase domain, such cells are likely to maintain sensitivity to neratinib (Mosesson and Yarden, 2004). A summary of preclinical studies, human pharmacokinetic studies, and previous clinical studies of neratinib for treatment of HER2+ breast cancer are provided in the neratinib Investigator's Brochure (IB).
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2.4.1. safety profile of neratinib

Safety results from completed and ongoing clinical studies conducted in patients with breast cancer or other solid tumors show that neratinib is generally well tolerated with a consistent safety profile. Gastrointestinal (GI) disorders, such as diarrhea, nausea, and vomiting, account for the most-frequently reported treatment-emergent adverse events. Fatigue, decreased appetite, abdominal pain, headache, rash, and hepatotoxicity (abnormal liver function test) have also been reported in patients treated with neratinib. Refer to the neratinib IB Version 5.0 for more detailed information regarding benefits and identified and potential risks for patients, as well as for a summary of findings from neratinib nonclinical studies that potentially have clinical significance. Refer to Appendix 2 (Dose Adjustment Guidelines) for further information regarding the management of neratinib-related toxicities.
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2.4.2. diarrhea prophylaxis in neratinib

Although patients in studies 3144A1-201-WW, 3144A2-3003-WW, I-SPY2 and early cohorts of 10-005 received standard-of-care diarrhea management on occurrence of diarrhea, the studies did not mandate concomitant treatment with loperamide or other anti-diarrheal agents at the outset of neratinib therapy for prevention of neratinib-related diarrhea. In these studies, 28-39% of patients experienced Grade 3 or Grade 4 diarrhea Table 1). In ongoing neratinib clinical studies that are currently enrolling patients with solid tumors, prophylactic use of antidiarrheal medication is mandatory. Data for ongoing study PUMA-NER-4201 and the later cohorts of 10-005 are shown in Table 2. Among patients receiving prophylactic antidiarrheal medication in these studies, 12-16% of patients experienced Grade 3 or Grade 4 diarrhea. Table 1 illustrates diarrhea incidence in neratinib studies without loperamide prophylaxis. Table 2 illustrates diarrhea incidence in neratinib studies that use intensive loperamide prophylaxis.  
| Table 1:                                                                                                                                                                                 | Neratinib Diarrhea Incidence Without Loperamide Prophylaxis   |                         |             |           |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------|-------------------------|-------------|-----------|
| Study                                                                                                                                                                                    | Patients                                                      | Investigational Product | Patients    | Grade 3-4 |
| N                                                                                                                                                                                        | Diarrhea n (%)                                                |                         |             |           |
| 3144A1-201-WWa                                                                                                                                                                           | Locally  advanced                                             |                         |             |           |
| or HER2+ MBC                                                                                                                                                                             | neratinib 240 mg                                              | 66b                     | 21 (32%)    |           |
| 3144A2-3003-WW a                                                                                                                                                                         | Locally  advanced                                             |                         |             |           |
| or HER2+ MBC                                                                                                                                                                             | neratinib 240 mg                                              | 116                     | 33 (28%)    |           |
| (monotherapy arm)                                                                                                                                                                        |                                                               |                         |             |           |
| 3144A2-3004-WW                                                                                                                                                                           | Early stage                                                   |                         |             |           |
| HER2+ breast  cancer                                                                                                                                                                     | neratinib 240 mg                                              | 1408                    | 562 (39.9%) |           |
| (monotherapy arm)                                                                                                                                                                        |                                                               |                         |             |           |
| 10-005c                                                                                                                                                                                  | Triple-negative                                               | neratinib (240 mg) +    |             |           |
| or HER2+ MBC                                                                                                                                                                             | temsirolimus IV (once per  week)                              | 35                      | 10 (29%)    |           |
| I-SPY2d                                                                                                                                                                                  | HER2+/HRBreast Cancer                                                               | neratinib (240 mg) +    | 116         | 45 (39%)  |
| paclitaxel (once per week)                                                                                                                                                               |                                                               |                         |             |           |
| HER = human epidermal growth factor receptor; HR = hormone receptor; IV = intravenously; MBC = metastatic  breast cancer  a  Data from 3144A1-201-WW CSR and 3144A2-3003-WW interim CSR. |                                                               |                         |             |           |  
HER = human epidermal growth factor receptor; HR = hormone receptor; IV = intravenously; MBC = metastatic  
breast cancer  
a Data from 3144A1-201-WW CSR and 3144A2-3003-WW interim CSR.  
b Includes patients in Arm A with prior adjuvant trastuzumab therapy. c Patients without diarrhea prophylaxis; data cut-off 22-AUG-2014.  
d AACR Annual Meeting, Park et al, 2014.  
| Study                    | Patients                                    | Investigational Product   | Patients   | Grade 3-4  Diarrhea   |
|--------------------------|---------------------------------------------|---------------------------|------------|-----------------------|
| N                        | n (%)                                       |                           |            |                       |
| PUMA-NER4201a                          | Advanced or  metastatic  HER2-mutant  NSCLC | neratinib (240 mg)        | 17         | 2 (12%)b              |
| neratinib (240 mg) +     | 28                                          | 4 (14%)b                  |            |                       |
| temsirolimusc            |                                             |                           |            |                       |
| 10-005a                  | Triple-negative or                          | 51                        | 8 (16%)d   |                       |
| neratinib (240 mg) +     |                                             |                           |            |                       |
| HER2+ MBC                | temsirolimusc                               |                           |            |                       |
| Data cut-off 22-AUG-2014 |                                             |                           |            |                       |  
Data cut-off 22-AUG-2014 HER = human epidermal growth factor receptor; IV = intravenously; MBC = metastatic breast cancer; NSCLC = non-small cell lung cancer a To be compliant, patients with intensive diarrhea prophylaxis were to receive loperamide 4 mg with first dose of neratinib followed by loperamide 2 mg every 4 hours for the first 3 days. Thereafter, loperamide 2 mg every 6 to 8 hours until the end of the first cycle of therapy.  
b One (1) patient in each arm had Grade 3 diarrhea during Cycle 1; both patients were non-compliant with loperamide prophylaxis.  
c Temsirolimus 8 or 15 mg IV once per week.  
d Five (5) patients had Grade 3 diarrhea during Cycle 1; three (3) of these patients were noncompliant with loperamide prophylaxis.  
Refer to the neratinib IB Version 5.0 for more detailed information.
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2.4.3. preliminary clinical activity of

In Phase 1 and 2 clinical studies as a single agent or in combination with other anti-cancer agents, neratinib has shown anti-tumor activity in patients with HER2-positive/amplified breast cancer (Awada et al, 2013; Burstein et al, 2010; Chow et al, 2013; Saura et al, 2014). Analyses of the primary efficacy endpoint (disease-free survival, DFS) data from a randomized Phase 3 ExteNET trial (Extended Adjuvant Treatment with Neratinib [3144A2-3004-WW], Chan et. al., 2015) showed that neratinib reduced the risk of DFS events by 33% compared with placebo in women with HER2-positive locally advanced breast cancer who were treated with neratinib for 1 year after adjuvant trastuzumab. The one-sided p-value from the stratified log rank test was 0.005 indicating that DFS was significantly prolonged for patients randomized to the neratinib arm compared with the placebo arm. Furthermore, neratinib resulted in a statistically significant improvement in the secondary efficacy endpoint, DFS including ductal carcinoma in situ (DFS DCIS). Neratinib reduced the risk of DFS DCIS events by 37% compared with placebo. The one-sided-p value from the stratified log rank test was <0.001 indicating that DFS DCIS was significantly prolonged for patients randomized to the neratinib arm compared with the placebo arm.
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2.5. study rationale

The results shown in Table 1 and Table 2 suggest that the implementation of the intensive diarrhea management has resulted in a lower incidence of Grade 3 diarrhea. The rationale of this study is to collect safety data in patients with early-stage HER2-positive breast cancer who have completed a prior course of adjuvant trastuzumab in order to expand the safety profile of neratinib when given concomitantly with intensive antidiarrheal prophylaxis for 2 cycles. As of Amendment 4, starting with the group receiving colestipol, intensive loperamide prophylaxis is to be administered for 1 cycle (28 days), and then as needed (PRN) during Cycle 2 and thereafter. The duration for the administration of intensive loperamide prophylaxis was changed from 2 cycles to 1 cycle (28 days) in Amendment 4 since review of data for the incidence of new diarrhea indicated that the majority of episodes occur within the first 28 days of starting neratinib treatment. In Amendment 5, the study will investigate a bile acid sequestrant (colestipol) given in addition to the antidiarrheal medication loperamide, administered on a PRN basis, that may be effective in further lowering the incidence of Grade 3 diarrhea. The results will guide how to better manage neratinib-related diarrhea in this patient population.
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2.5.1. neratinib dose escalation rationale

Amendments 6 and 6.1, will investigate the effect on the incidence and severity of diarrhea of a lower dose of neratinib starting at 120 mg/day with a dose-escalation regimen. This dose escalation scheme is based on (1) a logistic regression model using ExteNET data that suggests the odds of having Grade 2 or higher diarrhea increase with increasing average daily dose of neratinib; and (2) the observation that Grade 3 diarrhea occurs most frequently in the first month after neratinib initiation, suggesting intestinal adaptation to neratinib exposure. By starting administration of neratinib at the lower dose of 120 mg in the first week (C1D1 to C1D7), followed by 160 mg in Week 2 (C1D8 to C1D14), reaching full treatment dose of 240 mg at Week 3 and then thereafter (C1D15 to EOT), patients may experience less early and severe episodes of neratinib-associated diarrhea and thereby achieve increased tolerability and adherence to neratinib treatment. Starting with Amendment 7, the study will investigate the effects of an alternate neratinib dose escalation regimen, starting with the introduction of 160 mg neratinib for the first two weeks of treatment. Subsequently, 200 mg neratinib will start for the next two weeks, allowing a stepwise approach that leads to reaching full dose neratinib 240 mg. By having a longer duration of 2 weeks at each dose level patients have the opportunity to acclimate to neratinib, which may increase tolerability and optimize the management of adverse effects. Accumulating data from PUMA-NER-6201 suggest that many patients who remain on neratinib therapy through the first month are able to remain on neratinib for the complete one year treatment course. Gut bacterial biodiversity will be evaluated from a stool swab at Screening, C2D1, and C4D1 and/or at time of treatment discontinuation to assess the effect that neratinib has on the microbiome.
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2.5.2. results of preclinical investigations

A rat model to investigate neratinib-associated diarrhea was developed and histopathology showed infiltration of polymorphonuclear cells and lymphocytes in the ileum and colon (unpublished data on file). This may suggest an inflammatory process that could be ameliorated with anti-inflammatory agents. Ongoing investigations into several interventions are proceeding in the rat model.
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2.5.3. rationale for use of

Budesonide will be investigated in the first pilot cohort as a proof-of-principle for the antiinflammatory effect. Budesonide has a high glucocorticosteriod (GCS) activity and substantial first-pass elimination (Package Insert-Uceris®(budesonide) tablets, Santarus, Inc.). The formulation contains budesonide in an extended release tablet core. The tablet core is enteric coated to protect dissolution in gastric juice which delays budesonide release until exposure to a pH ≥ 7 in the small intestine. Upon disintegration of the coating, the core matrix provides extended release of budesonide in a time dependent manner. Budesonide has a high glucocorticoid effect and a weak mineralocorticoid effect.
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2.5.4. rationale for use of

The bile acid sequestrant colestipol is a lipid lowering agent for oral use, that binds bile acids in the intestine forming a complex that is excreted in the feces (Package Insert-Colestid®
[colestipol], Pfizer). This non-systemic action results in a partial removal of bile acids from enterohepatic circulation, preventing their reabsorption. The formation of this complex may counteract neratinib induced diarrhea by slowing gastrointestinal transit time and by attenuating the possible irritant effect of bile acids on inflamed gastrointestinal lumen. Constipation is the major single adverse effect of colestipol and most instances are mild and transient. In animal model studies investigating neratinib induced diarrhea, initial observations suggest that there is a reduction in severe diarrhea when rats were administered a bile acid sequestrant during neratinib administration.
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2.5.5. enrollment

The projected numbers for enrollment have increased as of Amendment 5. The planned number had been 40 patients per additional cohort. Amendment 3 over-enrolled patients due to plans for continued investigation to a total of 64 patients. Amendment 4 over-enrolled, exceeding 40 patients to finally include a total of 136 patients. Amendment 5 though originally planned to include 64 patients enrolled 104 patients. Amendment 6 and Amendment 6.1 are currently enrolling patients and are projected to enroll approximately 64 patients. Amendment 7 and Amendment 7.1 are planned to enroll approximately 100 additional patients. Cohorts will continue to enroll without interruption, in sequence. Thus enrollment may exceed initial projections.
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3. study objectives 3.1. primary

The primary objective of this study is to characterize the incidence and severity of diarrhea in patients with early-stage HER2 overexpressed/amplified (HER2+) breast cancer treated with neratinib when administered with intensive loperamide prophylaxis, after prior treatment with trastuzumab.
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3.2. secondary objectives the secondary

To assess the incidence of serious adverse events (SAEs) and other adverse events of special interest (AESI).  
To assess the incidence and severity of diarrhea after the administration of an antiinflammatory agent (for patients enrolled under Amendment 3), a bile acid sequestrant (for patients enrolled under Amendment 4 and Amendment 5), or following 2 different dose escalation regimens of neratinib (for patients enrolled under Amendment 6 and for patients enrolled starting with Amendment 7, respectively).
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3.3. exploratory objectives the exploratory

For patients enrolled starting with Amendment 2:  
To assess patient reported outcomes using the EQ-5D-5L Health Questionnaire
(EQ-5D-5L) and the Functional Assessment of Cancer Therapy Breast (FACT-B) questionnaires.  
To collect plasma biomarkers to evaluate their relationship to clinical recurrence of disease.
For patients enrolled starting with Amendment 6:
Evaluation of stool bacterial diversity (microbiome)
For patients enrolled starting with Amendment 6.1:  
To assess patient-reported outcomes using the RSCL (for patients enrolled starting with Amendment 6.1)
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4.1. overall study design

This is an open-label, Phase 2 study that will investigate the incidence of diarrhea in HER2+ breast cancer patients receiving neratinib with intensive loperamide diarrhea prophylaxis, with and without an anti-inflammatory treatment or a bile acid sequestrant treatment and who have previously completed trastuzumab therapy in the adjuvant setting. Patients will receive:  
Neratinib 240 mg orally once daily with food for thirteen (13) 28-day cycles.  
Loperamide daily for two (2) 28-day cycles and then as needed.  
For patients enrolled under Amendment 3, an anti-inflammatory treatment for 1 cycle and loperamide to be administered daily for two (2) 28-day cycles and then as needed, thereafter; For patients enrolled under Amendment 4, colestipol for 1 cycle and loperamide to be administered 1 cycle and then as needed, thereafter; For patients enrolled under Amendment 5, colestipol for 1 cycle and loperamide to be administered on an as-needed basis only.  
For patients enrolled under Amendments 6 and 6.1, 120 mg neratinib for Week 1
(C1D1 - C1D7), followed by 160 mg neratinib starting for Week 2 (C1D8 - C1D14), followed by 240 mg neratinib starting at Week 3 and thereafter (C1D15 to EOT). Loperamide will be administered on an as-needed basis only.  
For patients enrolled starting with Amendment 7, 160 mg neratinib for the first 2 weeks (C1D1 - C1D14), followed by 200 mg neratinib for the next 2 weeks
(C1D15 - C1D28), followed by 240 mg neratinib thereafter (C2D1 to End-oftreatment [EOT]). Loperamide will be administered on an as-needed basis only.
Following a 28-day screening period (Section 9.1), eligible patients will be enrolled. Baseline assessments will be performed prior to Cycle 1/Day 1 dosing. Patients will then participate in the active treatment phase, consisting of thirteen (13) 28-day treatment cycles (Section 9.2). Neratinib and loperamide will be administered orally by patients as described in Section 6. Neratinib is to be taken continuously, in 28-day cycles, with no rest between cycles. The effect of the anti-inflammatory treatment, budesonide and the bile acid sequestrant colestipol on the incidence, severity, and duration of diarrhea will be investigated in sequential patient cohorts using a sample size of approximately 64 patients per cohort (Figure 1). The anti-inflammatory cohort added in Amendment 3 will be assigned to receive budesonide tablets 9 mg once daily with or without food for 28 days along with neratinib 240 mg/day (13 cycles) and intensive loperamide prophylaxis that will continue through the first 2 cycles (total 56 days), and on an as-needed basis thereafter. Following the planned completion of enrollment of the 40 patients receiving budesonide, neratinib, and intensive loperamide prophylaxis (final enrollment was 64 patients), the next
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4. investigational plan

cohort will be evaluated after receiving colestipol 2 g twice daily with or without food for 28 days, to be given at least 2 hours after, but at least 4 hours before, neratinib 240 mg/day (13 cycles) and intensive loperamide prophylaxis. For this cohort, intensive loperamide prophylaxis will continue only through the first cycle (28 days); for Cycle 2 and beyond, loperamide may be administered as needed (PRN). Following complete enrollment of the cohort treated with colestipol and intensive loperamide prophylaxis, all patients in the next cohort (approximately 64) will be evaluated after receiving colestipol and neratinib with loperamide administered on a PRN basis only. (Note: For Amendment 5 and Amendment 6, enrollment into the budesonide cohort and the first colestipol cohort is complete and the administration of mandatory loperamide prophylaxis is now also complete). Patients enrolled under Amendment 6/6.1 will be evaluated after receiving neratinib administered according to the following dose-escalation scheme: 120 mg neratinib for Week 1 (C1D1 - C1D7), followed by 160 mg neratinib starting at Week 2 (C1D8 - C1D14), followed by 240 mg neratinib starting at Week 3 and thereafter (C1D15 to EOT). Loperamide is to be administered on a PRN basis only. Following complete enrollment of all patients in the 120 mg/160 mg/240 mg dose-escalation scheme, patients enrolled under Amendment 7/7.1 will be evaluated after receiving neratinib administered according to a second dose escalation scheme: 160 mg neratinib to be taken for the first 2 weeks (C1D1 - C1D14), followed by 200 mg neratinib to be taken for the next 2 weeks (C1D15 - C1D28), followed by 240 mg neratinib daily dose taken thereafter (C2D1 to EOT). Loperamide is to be administered on a PRN basis only. The Sponsor will regularly review accumulating safety data (by individual subject and in aggregate). Early termination of a cohort or the study may be permitted if data indicate that anti-diarrheal treatment is ineffective. Patients in all treatment groups will continue to complete the remaining 12 treatment cycles. Analyses are further described in Section 12.4.1. Cohorts will continue to enroll without interruption, in sequence. Thus enrollment may exceed initial projections.
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figure 1 study design (starting

Early HER2+ Breast Cancer Received up to 1 year of adjuvant trastuzumab
.  
.  
Stage 1-3C  
  
Follow-up for safety  
  
| Neratinib dose        |
|-----------------------|
| escalation, scheme #1 |
| N=~64 patients        |
| *Amendment 6/6.1:     |
| Neratinib 120 mg/day  |
| × 1 wk, then 160      |  
  
  
| Neratinib 240 mg/day   | Neratinib 240 mg/day   | Neratinib 240 mg/day   | Neratinib 240 mg/day:   | Neratinib 240 mg/day     |
|------------------------|------------------------|------------------------|-------------------------|--------------------------|
| through 1 year         | through 1 year         | through 1 year         | through 1 year          | through 1 year           |
| Loperamide PRN         | Loperamide PRN         | Loperamide, PRN basis  | Loperamide PRN          | Loperamide PRN through   |
| through Cycle 13 with  | through Cycle 13 with  | oly, through Cycle 13  | through Cycle 13 with   | Cycle 13 with neratinib. |
| neratinib.             | neratinib.             | with neratinib.        | neratinib.              |                          |  
*Starting with Amendment 3, cohorts will be enrolled to receive the anti-inflammatory agent budesonidein combination with neratinib and loperamide. Patients enrolled uder Amendment 4 and Amendment 5 will be enrolled to receive the bile acid sequestrant colestipol. Patients enrolled under Amendment 6 will undergo dose escalation of neratinib for the first 3 weeks as indicated, along with loperamide on a PRN basis only. Patients enrolled under Amendment 7/7.1 will undergo dose escalation of neratinib for the first 4 weeks as indicated, along with loperamide on a PRN basis only. Early termination of a cohort or the study will be permitted if data indicate that anti-diarrheal treatment is ineffective. Cohorts will continue to enroll without interruption, in sequence. Thus enrollment may exceed initial projections.  
Clinic visits during the active treatment phase are planned on Day 1 of Cycle 1, 2, 3, 4, 7, and Cycle 10. End of Treatment (EOT) Visit is planned on Day 28 of Cycle 13, followed by Safety Follow-up Visit 28 days after the last dose of neratinib. Assessments required throughout the study are summarized in the Schedule of Procedures (Appendix 1).  
Patients may be discontinued from investigational product or from the study, as described in Section 10 and Section 11. The primary endpoint of the study is the incidence of Grade 3 or higher diarrhea. Secondary endpoints include the frequency distribution of the maximum grade incidence of diarrhea over time, the incidence and severity of diarrhea by anti-diarrheal treatment exposure; and the incidence of SAEs and AESIs. Additional exploratory endpoints consisting of patient-reported health outcomes and biomarkers of disease recurrence will be evaluated (for patients enrolled starting with Amendment 2). An interim analysis is planned when approximately 120 enrolled under the Original Protocol, Amendment 1, and Amendment 2 have completed at least 2 cycles (56 days) of neratinib with loperamide prophylaxis. The analysis will only include those 120 patients enrolled under the Original Protocol, Amendment 1, and Amendment 2. Other additional analyses by cohort may be carried out as required (Section 12.5). The final analysis is planned when all patients have either completed 13 cycles (364 days) of neratinib therapy or have discontinued from the study. For the Original protocol, Amendment 1, and Amendment 2, approximately 120 patients were to be enrolled at approximately 35-45 centers. See Section 12.7 for a discussion of sample size. For the 5 cohorts evaluating additional treatments added in Amendment 3 (budesonide), Amendment 4 and Amendment 5 (colestipol), Amendment 6/6.1 (neratinib dose escalation from 120 mg/day), and Amendment 7/7.1 (neratinib dose escalation from 160 mg/day), approximately 450 additional patients will be enrolled at approximately 74 centers. The approximate total enrollment will be 750 patients total. Patients are anticipated to participate in the study for approximately 1 year. This includes 1 month for screening, approximately 12 months for the active treatment phase, and safety follow-up visit 28 days after the last dose of neratinib. Patients who permanently discontinue treatment due to unacceptable toxicity will be followed-up for 28 days after the last dose of neratinib to collect any adverse events (AEs) (Section 9.4).
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4.2. study duration and termination

The approximate duration of the study is 7 years. Patients receive neratinib for 13 cycles (364 days) or until disease recurrence (as determined by the Investigator), death, unacceptable toxicity, or other specified withdrawal criterion. The final analysis will be conducted after all patients have completed 13 cycles of study treatment or have met other specified withdrawal criterion (see Section 10). The study will end when all patients have been followed up for 28 days after the last dose of neratinib. In the event that end of treatment (EOT) is declared earlier by the Sponsor, patients will be offered the opportunity to complete the 1-year course of treatment either through a treatment extension study or through a managed access program.
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5. study population 5.1. inclusion

Each patient will be entered into this study only if she/he meets all of the following criteria:
1. Aged ≥18 years at signing of informed consent.  
2. Histologically confirmed stage 1 through stage 3c primary adenocarcinoma of the breast
(Edge and Compton, 2010).  
3. Documented HER2 overexpression or gene-amplified tumor by a validated approved method (Wolff et al, 2013).  
4. Patients must have completed a course of prior adjuvant trastuzumab or experienced side effects that resulted in early discontinuation of trastuzumab that have since resolved.  
5. The last dose of trastuzumab must have been given >2 weeks and ≤1 year (365 days)
from enrollment.  
6. Physician assessment that the patient is negative for local or regional recurrence of disease or metastatic disease at the time of study entry, including Per standard of care, bone scan or positron emission tomography (PET) scan; required only if ALP is ≥2 x upper limit of normal (ULN) and/or there are symptoms of metastatic bone disease. A confirmatory imaging study is required if the results from the bone scan are questionable.  
Per standard of care computed tomography (CT), MRI or ultrasound of the abdomen and chest; required only if aspartate aminotransferase (AST)/alanine aminotransferase (ALT) or ALP is ≥2 x ULN.  
Other radiologic assessments may be performed to rule out underlying breast cancer recurrence if indicated and as per standard of care (for patients enrolled starting with Amendment 6.1).  
7. Left ventricular ejection fraction (LVEF) ≥50% measured by multiple-gated acquisition scan (MUGA) ECHO.  
8. ECOG status of 0 to 1. 9. Negative hCG pregnancy test for premenopausal women of reproductive capacity (those who are biologically capable of having children) and for women less than 12 months after menopause. [Women are considered postmenopausal if they are ≥12 months without menses, in the absence of endocrine or anti-endocrine therapies].  
10. Women of childbearing potential must agree and commit to the use of a highly effective non-hormonal method of contraception, ie, intrauterine device, bilateral tubal ligation, vasectomized partner, or abstinence (only when it is the preferred lifestyle of the patient), from the time of informed consent until 28 days after the last dose of the investigational products. Man (male patient) with female partner of childbearing potential must agree and commit to use condom and the female partner must agree and commit to use a highly effective method of contraception (ie, any of the above methods, or for females,
hormonal contraception associated with inhibition of ovulation) while on treatment and for 3 months after last dose of investigational products.  
11. Recovery (ie, to Grade 1 or baseline) from all clinically significant AEs related to prior therapies (excluding alopecia, neuropathy, and nail changes).  
12. Provide written, informed consent to participate in the study and follow the study procedures.
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5.2. exclusion criteria

A patient will be excluded from this study if she/he meets any of the following criteria.  
1. Clinical or radiologic evidence of local or regional recurrence of disease or metastatic disease prior to or at the time of study entry.  
2. Currently receiving chemotherapy, radiation therapy, immunotherapy, or biotherapy for breast cancer.  
3. Major surgery within <30 days of starting treatment or received chemotherapy, investigational agents, or other cancer therapy, except hormonal therapy (eg, tamoxifen, aromatase inhibitors), <14 days prior to the initiation of investigational products.  
4. Active uncontrolled cardiac disease, including cardiomyopathy, congestive heart failure
(New York Heart Association functional classification of ≥2; including individuals who currently use digitalis, beta-blockers, or calcium channel blockers specifically for congestive heart failure), unstable angina, myocardial infarction within 12 months of enrollment, or ventricular arrhythmia.  
5. QTc interval >0.450 seconds (males) or >0.470 (females), or known history of QTc prolongation or Torsade de Pointes (TdP).  
6. Screening laboratory assessments outside the following limits:  
| Laboratory Parameters                      | Required Limit for Exclusion                                                                                                            |
|--------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------|
| Absolute neutrophil count (ANC)            | <1,000/µl (<1.0 x 109 /L)                                                                                                               |
| Platelet count                             | <100,000/µl (<100 x 109 /L)                                                                                                             |
| Hemoglobin                                 | <9 g/dL                                                                                                                                 |
| Total bilirubin                            | >1.5 x institutional upper limit of normal (ULN) (in  case of known Gilbert's syndrome, <2 x ULN is  allowed)                           |
| Aspartate aminotransferase (AST) and/or    | >2.5 x institutional ULN                                                                                                                |
| Alanine aminotransferase (ALT)  Creatinine | Creatinine clearance <30 mL/min (as calculated by  Cockcroft-Gault formulaa or Modification of Diet in  Renal Disease [MDRD] formulab ) |
| a Cockcroft and Gault, 1976.               |                                                                                                                                         |  
7. Active, unresolved infections.  
8. Patients with a second malignancy, other than adequately treated non-melanoma skin cancers, in situ melanoma or in situ cervical cancer. Patients with other non-mammary malignancies must have been disease-free for at least 5 years.  
9. Currently pregnant or breast-feeding.
10. Significant chronic gastrointestinal disorder with diarrhea as a major symptom (eg, Crohn's disease, malabsorption, or Grade ≥2 National Cancer Institute [NCI] CTCAE v.4.0 diarrhea of any etiology at baseline).  
11. Clinically active infection with hepatitis B or hepatitis C virus. 12. Evidence of significant medical illness, abnormal laboratory finding, or psychiatric illness/social situations that could, in the Investigator's judgment, make the patient inappropriate for this study.  
13. Known hypersensitivity to any component of the investigational products; known hypersensitivity to salicylates; known allergies to any of the medications or components of medications used in the trial.  
14. Unable or unwilling to swallow tablets.
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5.3. patient enrollment

Enrollment will occur only after the patient has given written informed consent, all screening assessments have been completed, and the patient meets all eligibility criteria.
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6. administration of neratinib loperamide

Neratinib will be supplied as 40-mg, film-coated tablets packaged in bottles with desiccant. Neratinib (240 mg; provided as six 40-mg tablets) will be self-administered orally by patients on a daily basis, starting with Cycle 1/Day 1. Neratinib must be taken with food, preferably in the morning; however, neratinib may be taken in the evening. Neratinib will be given continuously for one year (364 days) in thirteen (13) 28-day cycles, with no rest between cycles. Patients enrolled under Amendment 6 and Amendment 6.1 will receive neratinib at a starting dose of 120 mg/day with dose escalation (ie, total dose 120 mg daily for Week 1, 160 mg daily for the Week 2, and 240 mg daily for Week 3 and thereafter, until EOT). Patients enrolled starting with Amendment 7 will receive neratinib 160 mg neratinib for the first 2 weeks (C1D1 - C1D14), followed by 200 mg neratinib for the next 2 weeks (C1D15 - C1D28), followed by 240 mg neratinib thereafter (C2D1 to EOT). Daily dosing should continue until a criterion for treatment withdrawal is met (see Section 10). For patients starting with Amendment 7, patients must use a diary to record intake of neratinib for every cycle (see Section 8.5.2).
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6.1.1. neratinib dose adjustment

Neratinib dose adjustment and/or discontinuation and/or management of toxicity should be performed according to Appendix 2 and Section 10.1. For patients enrolled under the dose-escalation schemes of Amendment 6/6.1, Amendment 7/7.1, during the dose escalation phase (240 mg neratinib), for any patient who experiences Grade ≥ 2 AE(s) leading to neratinib dose interruption which do not resolve to Grade ≤ 1, a review of the patient and the patient's adverse event profile must occur with the Sponsor's Medical Monitor to determine whether the patient should be allowed to continue in the study.  
Recommended dose reductions for the -1 and -2 dose levels of neratinib are listed in Table 3.  
| Dose Level      | Neratinib   |
|-----------------|-------------|
| Starting Dose   | 240 mg      |
| -1              | 160 mg      |
| -2              | 120 mg      |
| mg = milligrams |             |  
mg = milligrams Note: Dose reduction applies following completion of dose escalation to 240 mg (after C1D15) for patients enrolled starting with Amendment 6.  
If doses of neratinib are held, study procedures for that cycle will proceed on schedule as planned, without any delay. Missed dose(s) of neratinib (ie, any dose that is not administered within the protocol-defined administration window) will not be made up. **Note: Patients should** take one dose per calendar day. The dose adjustment guidelines represent the minimum set of measures the Investigator must follow. However, additional measures may be taken, as necessary, for certain patients per the Investigator's medical judgment. All dose modifications/adjustments should be documented in the patient's source file. Once the neratinib dose has been reduced for a patient, all subsequent cycles must be administered at that dose, unless further dose reduction is required. Dose re-escalation will only be permitted if explicitly approved in advance by the Sponsor. Evidence of this approval must be contained within the patient's source file. Patients must discontinue the investigational product if a criterion for withdrawal is met (see Section 10.1). Reintroduction of the discontinued investigational product at a later time during the active treatment phase is not permitted. Detailed rules for dose adjustments of neratinib in case of toxicity, including the dose levels to which the investigational product should be adjusted, are provided in Appendix 2.
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6.2. loperamide

For patients enrolled under the Original Protocol:  
Initial dose of 4 mg (2 tablets/capsules) with the first dose of neratinib, followed by 2 mg (1 tablet/capsule) every 4 hours for the first 3 days. After the first 3 days, loperamide 2 mg every 6 to 8 hours through the first 2 cycles of therapy (56 days) from start of neratinib.  
For patients enrolled under Amendment 1  Amendment 3: For the first 14 days, loperamide 4 mg (2 tablets/capsules) will be self-administered orally by patients 3 times a day (total 12 mg a day). The initial dose of loperamide 4 mg will be self-administered orally with the first dose of neratinib.  
After the first 14 days, loperamide 4 mg (2 tablets/capsules) will be self-administered orally twice a day (total 8 mg a day) through the first 2 cycles of therapy (Day 56) from start of neratinib dosing For patients enrolled under Amendment 4:
For the first 14 days, loperamide 4 mg (2 tablets/capsules) will be selfadministered orally by patients 3 times a day (total 12 mg a day). The initial dose of loperamide 4 mg will be self-administered orally with the first dose of neratinib.  
After the first 14 days, loperamide 4 mg (2 tablets/capsules) will be self-administered orally twice a day (total 8 mg a day) with the first dose of neratinib, for 1 cycle [28 days], and then as needed (not to exceed 16 mg per day).  
For patients enrolled under Amendment 5, Amendment 6, Amendment 6.1, Amendment 7, and Amendment 7.1:
Loperamide 4 mg (2 tablets/capsules) will be self-administered orally by patients on a PRN basis, from the start of neratinib dosing with a goal of titrating to 1-2 bowel movements a day (not to exceed 16 mg per day).
Patients enrolled under the Original Protocol can maintain the loperamide prophylaxis dose already initiated with a goal of titrating to 1-2 bowel movements a day. Recommended loperamide dosing by amendment is listed below in Table 4.  
| Table 4:                                                                                                       | Loperamide Dosing                                                                                                                                                                                                                                                                                                                          |
|----------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Day                                                                                                            | Loperamide Dose                                                                                                                                                                                                                                                                                                                            |
| Amendment 1 - Amendment 3 1-14                                                                                 | Daily dose of 12 mg in 3 divided doses of 4 mg                                                                                                                                                                                                                                                                                             |
| 15-56                                                                                                          | Daily dose of 8 mg in 2 divided doses of 4 mg                                                                                                                                                                                                                                                                                              |
| 57+                                                                                                            | Daily dose as needed (not to exceed 16 mg per day)                                                                                                                                                                                                                                                                                         |
| Amendment 4 Colestipol + loperamide intensive  prophylaxis cohort : 1-14                                       | Daily dose of 12 mg in 3 divided doses of 4 mg                                                                                                                                                                                                                                                                                             |
| 15-28                                                                                                          | Daily dose of 8 mg in 2 divided doses of 4 mg                                                                                                                                                                                                                                                                                              |
| 29+                                                                                                            | Daily dose as needed (not to exceed 16 mg per day)                                                                                                                                                                                                                                                                                         |
| Amendment 5 Colestipol + loperamide PRN All cycles                                                             | Loperamide 4 mg PRN                                                                                                                                                                                                                                                                                                                        |
| Amendment 6, Amendment 6.1,  Amendment 7, Amendment 7.1 Neratinib dose escalation +  loperamide PRN All cycles | Initial dose 4 mg (2 tablets/capsules) with the first bout of diarrhea Followed by: 2 mg (1 tablet/capsule) every 4 hours or after every  unformed stool (≤16 mg/day); continue loperamide at this frequency  until diarrhea-free for 12 hours. Then titrate loperamide (4 mg PRN) to keep diarrhea controlled (1-2  bowel movements/day). |  
For patients starting with Amendment 6.1, patients must use a diary to record intake of loperamide for the first 2 cycles (56 days) of the study. Loperamide pill counts will be conducted only during the first 2 cycles (56 days) of therapy (only during the first cycle [28 days], starting with the colestipol cohort under Amendment 4).
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6.2.1. loperamide dose adjustment

Patients are expected to take loperamide prophylaxis as directed. However, patients may require individualization of loperamide prophylaxis dose with the goal of titrating to 1-2 bowel movements a day.  
For patients who develop diarrhea during Cycles 1-2, loperamide should be increased up to a maximum of 16 mg a day (or during Cycle 1 or after, for patients enrolled under Amendment 4; thereafter, loperamide may be administered up to 16 mg per day, as described above in Section 6.2).  
If a patient is unable to tolerate loperamide due to symptomatic constipation, loperamide should be held until after the first bowel movement and then resumed at a dose reduced by one level.  
For recurrent symptomatic constipation events, hold loperamide until after the first bowel movement and then resume at a dose reduced to the next lower dose level.  
If a patient is unable to tolerate once-daily loperamide due to constipation, hold loperamide and discuss subsequent loperamide dosing with the Medical Monitor.  
Neratinib dosing should continue if loperamide is held.
Recommended dose reductions for loperamide are listed in Table 5.  
| Dose Level                                                                 | Loperamide Dose   | Tablets/Capsules per Day   |
|----------------------------------------------------------------------------|-------------------|----------------------------|
| 0                                                                          | 4 mg TID          | 6 tablets/capsules a day   |
| -1                                                                         | 4 mg BID          | 4 tablets/capsules a day   |
| -2                                                                         | 2 mg TID          | 3 tablets/capsules a day   |
| -3                                                                         | 2 mg BID          | 2 tablets/capsules a day   |
| -4                                                                         | 2 mg once a day   | 1 tablet/capsule a day     |
| Abbreviations: BID = twice daily; mg = milligrams; TID = three times daily |                   |                            |
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6.3. budesonide

For patients enrolled under Amendment 3 and who participate in the initial cohort that will evaluate budesonide, patients will self-administer oral budesonide at a dose of 9 mg once daily with or without food, for the first treatment cycle (28 days), to be taken with neratinib and intensive loperamide prophylaxis (Table 6). If a patient experiences an intolerable Grade 2 or higher AE deemed related to budesonide, dosing of budesonide should be held until the AE resolves to Grade 1 or lower and then restarting dosing will be considered. Neratinib and loperamide should be continued while budesonide dosing is being held. If the intolerable AE recurs, budesonide dosing should be discontinued and neratinib and loperamide continued.  
| Table 6:                                                                                                    | Budesonide Dosing                            | Suggested Dosing Time   |                  |
|-------------------------------------------------------------------------------------------------------------|----------------------------------------------|-------------------------|------------------|
| 7 a.m                                                                                                       | 3 p.m                                        | 9 p.m.                  |                  |
| Treatment Cohort                                                                                            | Budesonidea 9 mg                             |                         |                  |
| (budesonide) C1D1 through 28 days                                                                           | Neratinib 240 mg with  food Loperamide 4 mgb | Loperamide 4 mgb        | Loperamide 4 mgb |
| a Budesonide tablets 9 mg should be swallowed whole with water and not chewed, crushed, or broken. Patients |                                              |                         |                  |  
a Budesonide tablets 9 mg should be swallowed whole with water and not chewed, crushed, or broken. Patients should be advised to avoid the consumption of grapefruit juice for the duration of their budesonide therapy. The total daily dosage is 9 mg tablet taken orally in the morning.  
b Amendment 1 - Amendment 3: For the first 14 days, loperamide 4 mg is to be self-administered 3 times a day.  
After the first 14 days, loperamide 4 mg is to be self-administered twice a day through the first 2 cycles of therapy (Day 56). Thereafter, loperamide will be administered as needed (not to exceed 16 mg per day). Amendment 4:
After the first 14 days, loperamide 4 mg is to be self-administered twice a day through the first cycle only of therapy (Day 28). Amendment 5: loperamide is to be self-administered on an as-needed basis only from the beginning of neratinib treatment
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6.4. colestipol

For patients who participate in the evaluation of colestipol, patients will self-administer colestipol at a dose of 2 g twice daily for the first treatment cycle, to be taken at least 2 hours after, but at least 4 hours before, neratinib and intensive loperamide prophylaxis (Table 7). Colestipol is a bile acid sequestrant anion resin that has the potential to interact with co-administered medication. Precaution should be taken around the timing of administration to avoid drug-drug interaction. Please refer to Section 7.6 and Appendix 10 of the protocol for specific recommendations regarding the administration of concomitant medication.  
If a patient experiences an AE leading to dose interruption of any study treatment, all study treatments should be held until the AE resolves to Grade 1 or lower.
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table 7 colestipol dosing

| Suggested Dosing Times                                                                                               |                 |                 |        |       |
|----------------------------------------------------------------------------------------------------------------------|-----------------|-----------------|--------|-------|
| 7 a.m.                                                                                                               | 9 a.m.          | 2 p.m.          | 5 p.m. | 9p.m. |
| Treatment  Cohort  (colestipol) C1D1 through  28 days                                                                | Colestipola 2 g | Colestipola 2 g |        |       |
| Neratinib 240 mg  with food Loperamide                                                                               | Loperamide      | Loperamide      |        |       |
| 4 mgb                                                                                                                | 4 mgb           | 4 mgb           |        |       |
| a Colestipol tablets two (2) 1 g tablets should be taken orally twice daily for a total daily dose of 4 g. Important |                 |                 |        |       |  
Loperamide 4 mgb Loperamide 4 mgb Loperamide 4 mgb a Colestipol tablets two (2) 1 g tablets should be taken orally twice daily for a total daily dose of 4 g. Important precautions are provided in Appendix 10.  
b Amendment 1 - Amendment 3: Loperamide intensive prophylaxis is to be given during Cycle 1, during the initial 14-day dosing period. After Day 14, loperamide 4 mg twice daily, intensive prophylaxis is to be given during the balance of Cycle 1. For Cycle 2, loperamide may be administered PRN. Amendment 4: After the first 14 days, loperamide 4 mg is to be self-administered twice a day through the first cycle only of therapy (Day 28). Amendment 5: loperamide is to be self-administered on an as-needed basis only from the beginning of neratinib treatment.
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6.5. packaging labeling and storage

Neratinib will be supplied as 40-mg, film-coated tablets packaged in bottles with desiccant. Neratinib should be stored at 25°C (77°F) or below; do not freeze. Neratinib should be stored with desiccant. Excursions are permitted from 15°C (59°F) to 30°C (86°F). Neratinib should be stored in a secure location with limited access. Patients should be instructed to store neratinib in a safe place at room temperature.  
Detailed packaging information is available in the study reference manuals. Neratinib will be labeled according to local regulations and include the study number.
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6.5.2. loperamide

Commercially available loperamide will be provided to study sites by the Sponsor. Loperamide will be relabeled by the Sponsor, "For investigational use."
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6.5.3. budesonide

Commercially available budesonide will be provided to study sites by the Sponsor. Budesonide will be relabeled by the Sponsor, "For investigational use."
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6.5.4. colestipol

Commercially available colestipol will be provided to study sites by the Sponsor. Colestipol will be relabeled by the Sponsor, "For investigational use."
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6.6. drug accountability and treatment

The study site must maintain accurate records documenting dates and quantities of investigational product: neratinib, loperamide, budesonide, and colestipol received from the Sponsor. Records must also be maintained documenting dates and quantities (ie, pill counts) of neratinib, loperamide, budesonide and colestipol received, dispensed (per-patient), and returned (per-patient). Such documentation should permit a running log of the receipt and per-patient disposition of all investigational products on site. Any investigational products, neratinib, loperamide, anti-inflammatory, or bile acid sequestrant treatments accidentally or deliberately destroyed must also be documented. Throughout the study, reconciliation will be made between the amounts of investigational product: neratinib, loperamide, anti-inflammatory, and bile acid sequestrant treatments supplied, dispensed, returned, and subsequently destroyed or returned to the Sponsor. All investigational products, neratinib, loperamide, anti-inflammatory, and bile acid sequestrant treatments will be returned to Sponsor or its representative, or destroyed at the site in accordance with local standard operating procedures, as specified in writing by the Sponsor. Individual patient dosing compliance should be reviewed and documented at each study visit by study site staff. If patient non-compliance is noted, the patient should be re-instructed regarding proper dosing procedures in order to continue in the study. If repeated non-compliance is noted, additional steps may be taken, including withdrawal of the patient from the study (see Section 10.2). *reference to loperamide, budesonide and colestipol investigational product accountability and treatment compliance are related to the specific protocol amendment cohorts.
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7. concomitant medications

All concomitant medications and concomitant nonpharmacological treatments/therapies will be recorded from 30 days prior to the signing of the informed consent form (ICF) until the Safety Follow-up Visit occurring 28 days after the last dose of neratinib. This will include the start date, stop date, generic name, route of administration, dose and indication for treatment. At screening, patients will be asked what medications they have taken during the previous 30 days, which medications are ongoing at the time of screening, any medical conditions that require medication, and all prior cancer therapies. At each subsequent study visit, patients will be asked what concomitant medications they are currently taking.
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7.1. permitted concomitant treatment

Any palliative and/or supportive care for cancer-related symptoms, which are not otherwise specified in the list of prohibited medications (Section 7.5), or drugs with potential for drug-drug interactions (Section 7.6), or in the associated Appendices (Appendix 4, Appendix 5, Appendix 6, Appendix 9, and Appendix 10), including hormonal therapy (eg, tamoxifen, aromatase inhibitors) is permitted at the Investigator's discretion. Specifically, the following treatments are permitted during the study:  
Standard therapies for preexisting medical conditions and for medical and/or surgical complications. All medication(s) as well as dose and length of therapy should be recorded in the case report form (CRF).  
Adjuvant endocrine therapy is allowed for hormone receptor-positive disease.  
Bisphosphonates and receptor activator of nuclear factor kappa-B ligand inhibitors
(eg, denosumab), are allowed regardless of indication.
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7.2. required loperamide antidiarrheal therapy

Diarrhea is the major dose-limiting toxicity of neratinib with onset typically occurring early in the course of treatment (during the first few weeks of treatment). Prior to Amendment 5, primary prophylactic use of antidiarrheal medication was **mandatory** for all enrolled patients taking neratinib; starting with Amendment 5, and continuing in Amendment 6, Amendment 6.1, Amendment 7, and Amendment 7.1 primary prophylactic use of loperamide is no longer required. As noted in Section 6.2, loperamide is the recommended standard therapy to treat diarrhea in this study, and it is provided to the sites by the Sponsor. If alternative antidiarrheal medication is proposed, this should be discussed with the Medical Monitor and the reason documented in the source documents. Second-line antidiarrheal treatments and adjunctive therapies (eg, octreotide
[SANDOSTATIN®] (or equivalent as approved by the Sponsor) are also recommended for use when appropriate.  
The Investigator must review with the patient the **Patient Instructions** for the management of diarrhea and the **Patient Diary** used by the patient to record daily the number of stools, use of loperamide and/or other anti-diarrheals, and the use of investigational product for the first 2 cycles (56 days) of the study (see Section 8.5.2). Both the patient and the Investigator must sign the patient instructions for the management of diarrhea. The Patient Instructions and Patient Diary are to be handed to the patient before leaving the site with investigational product on or before Cycle 1/Day 1, with clear instructions to contact the Investigator in the event of *de novo* onset or persistent Grade ≥2 diarrhea to discuss the appropriate course of treatment. The Investigator must also complete and sign the **Investigator Checklist** on or before Cycle 1/Day 1.  
Documentation of any occurrences of loose stools or diarrhea must be as precise as possible and captured in the Patient Diary. For AE recording, documentation of "Intermittent" events of diarrhea is limited to Grade 1. If events of Grade 1 diarrhea are separated by 3 days without any diarrhea, then each event must be documented as separate AEs with corresponding start and stop dates. The entries on the Patient Diary should be reviewed together with the patient. If the patient has experienced diarrhea since the last visit, details of the daily number of unformed stools provided on the diary help to grade the diarrhea as precisely as possible (per NCI CTCAE v.4.0). Also, the daily dose of loperamide (or other antidiarrheals, if applicable) noted on the diary will be reviewed and recorded on the CRF. Loperamide (along with neratinib) will be dispensed directly by the site on or before Cycle 1/Day 1 and during subsequent visits as needed. It is very important to initiate treatment with loperamide concomitantly with the first dose of neratinib to minimize occurrence and severity of diarrhea.
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intensive prophylactic dosing instructions (patients

Inform patients that they will experience diarrhea while taking neratinib.  
Administer loperamide:
For the first 14 days, loperamide 4 mg (2 tablets/capsules) will be self-administered orally by patients three times a day (total 12 mg a day). The initial dose of loperamide 4 mg will be self-administered orally with the first dose of neratinib.  
After the first 14 days, loperamide 4 mg (2 tablets/capsules) will be self-administered orally twice a day (total 8 mg a day) through the first 2 cycles of therapy (Day 56) from start of neratinib dosing.  
o For patients in the treatment group receiving colestipol under Amendment 4, this regimen would be for the rest of the first cycle of therapy [Day 28], from the start of neratinib dosing.  
Patients enrolled under the Original Protocol can maintain the loperamide prophylaxis dose already initiated with a goal of titrating to 1-2 bowel movements a day.  
Thereafter, loperamide will be administered as needed (not to exceed 16 mg per day) (during Cycle 2 and beyond for patients in the treatment group receiving colestipol under Amendment 4).  
For patients who develop diarrhea during Cycles 1-2, loperamide should be increased up to a maximum of 16 mg a day (or during Cycle 1 or after, for patients enrolled under Amendment 4).  
For patients with persistent Grade 1 diarrhea (<4 stools per day above baseline) on a maximum dose of loperamide (16 mg a day), Lomotil® (diphenoxylate hydrochloride and atropine sulfate) 1 tablet (2.5 mg) every 6 to 8 hours may be added (or equivalent as approved by Sponsor).  
For Grade 2 diarrhea during Cycle 1 or Cycle 2 (4 to 6 stools per day above baseline, despite intensive anti-diarrheal therapy), consider adding octreotide (short-acting) 150 µg subcutaneous [SC] injection 3 times a day, or after initial dose of short-acting octreotide, if well tolerated, a single dose of octreotide LAR 20 mg by intramuscular (IM) injection (equivalent medication may be used with approval of the Sponsor).  
After resolution of diarrhea, loperamide prophylaxis can be increased in 2-mg increments with the goal of titrating to 1-2 bowel movements a day.
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prn dosing instructions (patients enrolled

Initial dose of 4 mg (2 tablets/capsules) with the first bout of diarrhea followed by 2 mg (1 tablet/capsule) every 4 hours or after every unformed stool (maximum 16 mg a day) and continue loperamide at this frequency until diarrhea-free for 12 hours.  
Then titrate the amount of loperamide used to keep diarrhea controlled (1-2 bowel movements/day).
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other instructions (all protocol versions)

The sites must contact the patient by phone at 1 day, 2 days, and 3 days after the first dose of neratinib:
1. to inquire about any diarrhea and about potential AEs; 2. to provide guidance to the patients for immediate and appropriate management of AEs, including diarrhea as specified in this protocol; 3. to confirm that the patients have loperamide available 4. to inquire about the first date of neratinib dosing; the Investigator/research staff must update the electronic CRF (eCRF) within 3 days of receipt of this information.
These phone calls are mandatory and must be recorded in the study chart together with response from the patient and action taken.  
Instruct patients to promptly report diarrhea symptoms.  
Instruct patient to record the number of stools per day and the dose of any anti-diarrheal medication taken each day (see Section 8.5).
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for new onset uncomplicated grade

For Cycle 3 and beyond for patients enrolled prior to Amendment 4; for Cycle 2 and beyond for the treatment group receiving colestipol under Amendment 4; after the start of dosing for the treatment group receiving colestipol under Amendment 5, and for treatment groups under Amendment 6, Amendment 6.1, Amendment 7, and Amendment 7.1:
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dietetic measures

Stop all lactose-containing products.  
Drink 8 to 10 large glasses of clear liquids per day (~2000 mL).  
Eat frequent small meals.  
Recommend low fat regimen enriched with bananas, rice, applesauce and toast until resolution of diarrhea.
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pharmacological treatment

Administer loperamide: initial dose of 4 mg (2 tablets/capsules) with the first bout of diarrhea followed by 2 mg (1 tablet/capsule) every 4 hours or after every unformed stool (maximum 16 mg a day) and continue loperamide at this frequency until diarrhea-free for 12 hours.  
For patients with persistent Grade 1 diarrhea on loperamide, Lomotil® (diphenoxylate hydrochloride and atropine sulfate) 1 tablet (2.5 mg) every 6 hours to 8 hours may be added (or equivalent as approved by the Sponsor).  
For Grade 2 diarrhea (4 to 6 stools per day above baseline, despite intensive antidiarrheal therapy), consider adding octreotide (short-acting) 150 µg subcutaneously (SC) three times daily (TID); or after initial dose of short-acting octreotide, if well tolerated, a single dose of octreotide LAR 20 mg intramuscularly (IM) (equivalent medication may be used with approval of the Sponsor).  
For patients enrolled starting with Amendment 6, other measures to consider for Grade 2 diarrhea (4 to 6 stools per day above baseline, despite intensive antidiarrheal therapy) should include:
Budesonide 9 mg orally (PO) once daily (QD) for 14 to 28 days.  
Colestipol 2 g twice daily (PO, BID) for 14 to 28 days.
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pharmacologic treatment

Administer loperamide: initial dose of 4 mg (2 tablets/capsules) with the first bout of diarrhea followed by 2 mg (1 tablet/capsule) every 4 hours or after every unformed stool (maximum 16 mg a day) and continue loperamide at this frequency until diarrhea-free for 12 hours. Then titrate the amount of loperamide used to keep diarrhea controlled (<4 stools/day).  
Administer octreotide [100-150 µg SC twice daily (BID) or intravenously (IV)
(25-50 µg/h) if dehydration is severe, with dose escalation up to 500 µg SC TID].  
Use IV fluids as appropriate. Consider prophylactic antibiotics as needed (eg, fluoroquinolones) especially if diarrhea is persistent beyond 24 hours or there is fever or Grade 3-4 neutropenia.
The Investigator or designee should contact the Sponsor or the Medical Monitor for advice if at any time there is a concern for the appropriate course of action for the management of diarrhea. Stool cultures should be done to exclude infectious causes of Grade 3 or Grade 4 diarrhea or diarrhea of any grade with complicating features (dehydration, fever, and/or Grade 3 or Grade 4 neutropenia) per the Investigator's discretion. Results from occult blood, fecal leukocyte stain, Clostridium difficile, Campylobacter, Salmonella, and *Shigella* testing, when performed, should be reported using the appropriate CRF. Colonoscopy with biopsy should be strongly considered for patients who have significant diarrhea. Results for appearance, histology, pathology, and cultures performed should be reported using the appropriate CRF. Patients with significant diarrhea who are unresponsive to medical treatment may require treatment interruption or dose reduction.
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7.3. anti-inflammatory treatment

For patients enrolled under Amendment 3, the effect of an anti-inflammatory treatment, specifically budesonide, will be tested to determine the effect on the incidence, severity, and duration of diarrhea. Following the completion of Cycle 1 by the first approximately 64 patients in the first treatment cohort who receive neratinib and intensive loperamide prophylaxis plus budesonide antiinflammatory treatment, the treatment cohort will be evaluated. The Sponsor will regularly review accumulating safety data (by individual subject and in aggregate). Early termination of a treatment cohort or the study may be permitted if data indicate that anti-inflammatory treatment is ineffective. Once enrollment in the cohort testing budesonide is complete, the next cohort will begin enrollment, to evaluate the bile acid sequestrant colestipol. The Patient Diary will be used by patients to record the daily use of budesonide treatment. Also, the daily dose of the anti-inflammatory treatment noted on the diary will be reviewed and recorded on the CRF. Budesonide (along with neratinib and loperamide) will be dispensed directly by the site on or before Cycle 1/Day 1 and during subsequent visits as needed. It is very important to initiate treatment with budesonide concomitantly with the first dose of neratinib and loperamide to minimize the occurrence and severity of diarrhea. Anti-inflammatory dosing instructions:
Budesonide  
For the first treatment cycle, budesonide will be self-administered orally by patients at a dose of 9 mg once daily either with or without food, for the first treatment cycle, and to be taken with neratinib and loperamide on the intensive prophylaxis schedule. Budesonide should be swallowed whole and not chewed, crushed or broken.
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7.4. colestipol (amendment 4 and

For patients enrolled under Amendment 4 and Amendment 5, the effect of the bile acid sequestrant, colestipol, on the incidence, severity, and duration of diarrhea will be investigated in a treatment cohort of 40 patients. Following the completion of Cycle 1 by the first approximately 40 patients in the first cohort who receive neratinib and intensive loperamide prophylaxis plus budesonide, patients in the next cohort will receive colestipol 2 g, twice daily, for 28 days. The Sponsor will regularly review accumulating safety data (by individual patient and in aggregate). Early termination of a cohort or the study may be permitted if data indicate that bile acid sequestrant treatment is ineffective for the treatment of diarrhea. The Patient Diary will be used by patients to record daily the use of colestipol. Also, the daily dose of colestipol noted on the diary will be reviewed and recorded onto the CRF. Colestipol (along with neratinib and loperamide) will be dispensed directly by the site on or before Cycle 1/Day 1 and during subsequent visits as needed. It is important to initiate treatment with the colestipol concomitantly with the first dose of neratinib to minimize the occurrence and severity of diarrhea.
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7.5. prohibited concomitant treatment

The following treatments are prohibited throughout the duration of the active (treatment) stage/phase of the study:  
Any concurrent chemotherapy, radiotherapy (including palliative radiotherapy),
surgery related to cancer, anticancer immunotherapy, or other anticancer treatments, except hormonal therapy (eg, tamoxifen, aromatase inhibitors), including other investigational agents.  
Systemic steroid use, by oral or parenteral route.
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7.6. potential for drug-drug interactions

Patients should avoid agents known to be strong cytochrome P450 (CYP) 3A4 inducers or inhibitors (eg, ketoconazole) for the duration of the active stage/phase of the study. Patients should also avoid grapefruit/grapefruit juice and herbal remedies, including St John's Wort. Refer to Appendix 4 for a list of inhibitors and inducers of CYP isoenzymes. If unavoidable, patients taking such agents should be monitored closely. Patients using drugs known to cause QT/QTc prolongation should be monitored closely with serial electrocardiograms (ECG) at the Investigator's discretion. Refer to Appendix 6 for a summary of drugs known to have a risk of causing QT/QTc prolongation, potentially causing Torsades de Pointes (TdP). Patients taking digoxin, a P-glycoprotein (P-gp) substrate with a narrow therapeutic window, should be monitored closely. The digoxin dose should be adjusted as needed, since neratinib is an inhibitor of P-gp. Co-administration of neratinib with digoxin could result in increased digoxin levels and associated digoxin toxicity. Refer to Appendix 5 for a list of substrates and inhibitors of P-gp. Patients taking oral coumarin-derivative anticoagulants (ie, warfarin and phenprocoumon) should be monitored closely and their anticoagulant dose adjusted as needed. The solubility of neratinib is pH dependent and treatments that alter gastrointestinal pH such as proton pump inhibitors (PPIs), H2-receptor antagonists, and antacids may lower the solubility of neratinib. It has been observed that a single 240-mg dose of neratinib combined with lansoprazole may decrease neratinib AUC by up to 70%. It is unknown whether separating PPI and neratinib doses reduce the interaction. If an H2-receptor antagonist such as ranitidine is required, neratinib should be taken at least 2 hours before the next dose of the H2-receptor antagonist and 10 hours after the H2-receptor antagonist dosing. If antacids are necessary, the antacid dose and the neratinib dose should be separated by 3 hours.
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7.6.2. potential for drug-drug interactions

For patients participating in Amendment 3, when taking budesonide with neratinib and loperamide during the first 28 days (Cycle 1) there should be close monitoring during the concomitant administration with ketoconazole (and itraconazole, ritonavir, saquinavir, or erythromycin), or any other CYP3A4 inhibitor for increased signs and/or symptoms of hypercorticism. Refer to Appendix 9 for contraindications, warnings, and precautions for budesonide. Avoid grapefruit juice, which is a known CYP3A4 inhibitor. Since the dissolution of the coating of budesonide is pH dependent, the release properties and uptake of the compound may be altered when budesonide is used after treatment with gastric acid reducing agents (PPI's, H2-receptor antagonists and antacids).
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7.6.3. potential for drug-drug interactions

For patients participating in Amendment 4, when taking colestipol with neratinib and lopermide during the first 28 days (Cycle 1), there should be attention to the time interval between the administration of colestipol tablets and any other medication. The interval for colestipol administration should be as long as possible from other concomitant medication. Patients should take other drugs at least one hour before or four hours after colestipol to avoid impeding their administration. Since colestipol is an anion exchange resin, this effect may be related to a strong affinity for anions other than the bile acids. In vitro studies have indicated that colestipol binds a number of drugs. Repeated doses of colestipol given prior to a single dose of propranolol in human trials have been reported to decrease propranolol absorption. Patients on propranolol and possibly other beta-blockers should be monitored when colestipol is added or deleted from the therapeutic regimen. Effects of the absorption of other beta-blockers have not been determined.  
Studies in humans show that the absorption of chorothiazide as reflected in urinary excretion is markedly decreased even when administered one hour before colestipol. The absorption of tetracycline, furosemide, penicillin G, hydrochlorothiazide, and gemfibrozil was significantly decreased when given simultaneously with colestipol. These drugs were not tested to determine the effect of administration one hour before colestipol. No lowering effect on blood levels in humans was noted when colestipol was administered with any of the following drugs: aspirin, clindamycin, clofibrate, methyldopa, nicotinic acid (niacin), tolbutamide, phenytoin or warfarin. Particular caution should be observed with digoxin preparations since ther are conflicting results for the effect of colestipol on the availability of digoxin and digitoxin. The potential for binding of these drugs if given concomitantly is present. Discontinuing colestipol could pose a hazard to health if a potentially toxic drug that is significantly bound to the resin has been titrated to a maintenance level while the patient was taking colestipol. Bile acid bind resins such as coletipol may also interfere with the absorption of oral phosphate supplements and hydrocortisone. A study has shown that cholestyramine binds bile acids and reduces mycophenolic acid exposure. As colestipol also binds bile acids, colestipol may reduce mycophenolic acid exposure and potentially reduce efficacy of mycophenolate mofetil. Refer to Appendix 10 for contraindications, warnings, and precautions for colestipol.
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8.2. safety assessments 8.2.1. clinical

The primary endpoint of the study is the incidence of Grade 3 diarrhea in patients with early-stage HER2+ breast cancer.  
Secondary safety endpoints include the frequency distribution of the maximum grade incidence of diarrhea, the incidence and severity of diarrhea by loperamide exposure, with and without anti-inflammatory treatment; and the incidence of SAEs and AESIs.
Refer to the Schedule of Procedures (Appendix 1) for time points. The following safety endpoints will be assessed: medical history, AEs, vital signs, detailed/brief (symptom-guided) physical examinations, 12-lead ECGs, LVEF (ECHO or MUGA), and laboratory evaluations. AEs and AESIs will be graded according to the NCI CTCAE, version 4.0. Serious AEs and AESIs will be reported until 28 days after the last dose of the investigational product and will be followed until resolution. Should an Investigator be made aware of any SAEs occurring any time after the reporting period that may be causally related to neratinib's administration, it should be promptly reported. More details on AEs can be found in Section 13. For patients starting with Amendment 6.1, the diary used for recording of investigational product intake will also be used by patients to document any other study treatment for the first 2 cycles (56 days) of the study (see Section 8.5.2). In case of diarrhea, it also serves to document the number of loose stools per day and use of loperamide/other antidiarrheal treatments taken.
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8.2.2. laboratory assessments

Laboratory testing will be performed in accordance with the Schedule of Procedures (Appendix 1). The institutional laboratory will analyze all hematology and routine blood chemistry samples collected. Samples will be analyzed at a facility meeting Good Laboratory Practice (GLP) requirements and using methods documented in a methods validation report. Screening laboratory results may be accepted as the baseline assessment if they are performed within 72 hours of initiation of protocol therapy. The following laboratory endpoints will be determined, as summarized in Table 8.  
| Hematology               | Hematocrit (Hct) Hemoglobin (Hb) Platelet count Red blood cell (RBC) count White blood cell (WBC) count, with differential   |                                                                                     |
|--------------------------|------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------|
| Clinical chemistry       | Albumin  Alkaline phosphatase  ALT AST Blood urea nitrogen  (BUN) Calcium Chloride  Creatinine Glucose (non-fasting)         | Lactate dehydrogenase (LDH) Magnesium Phosphorus Potassium  Sodium  Total bilirubin |
| Serum or urine pregnancy | In women of child-bearing capacity (at screening and within 72 hours prior to                                                |                                                                                     |
| test                     | C1D1, and monthly, including at the End-of-Treatment Visit and at the  Safety Follow-up Visit).                              |                                                                                     |
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table 8 laboratory parameters

For Amendment 4 and Amendment 5 patients who will be receiving colestipol, a baseline (occurring at Screen or C1D1) and C2D1 fasting lipid panel is required to assess total cholesterol, HDL-C, and triglycerides. All clinically important abnormal laboratory tests occurring during the study will be repeated at appropriate intervals until they return either to baseline or to a level deemed acceptable by the Investigator and the Sponsor Medical Monitor (or his/her designated representative), or until a diagnosis that explains them is made. Criteria for reporting abnormal laboratory values as AEs are summarized in Section 13.1.2. The total volume of blood collected from each patient during the course of the study will be approximately 40 mL, corresponding to approximately 10 mL blood during screening and 5 mL blood at subsequent visits.
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8.2.3. vital signs

The following vital signs will be assessed in accordance with the Schedule of Procedures (Appendix 1):
Blood pressure (systolic and diastolic; mmHg)  
Resting heart rate (beats per minute)
Body temperature (°C), [oral]
Respiration rate Weight (kg) Height (Screening only)
Vital signs will be measured after resting in a seated position for 5 minutes, prior to dosing.
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8.2.4. physical examination

Physical examinations will be performed in accordance with the Schedule of Procedures (Appendix 1). The brief (symptom-guided) physical examination will evaluate any clinically significant abnormalities; including worsening of medical history conditions.
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8.2.5. electrocardiogram

Single standard 12-lead digital ECGs will be performed in accordance with the Schedule of Procedures (Appendix 1). The ECG (measured after resting in a supine position for 5 minutes) will include heart rate, rhythm and RR, PR, QRS, and QTc intervals. The ECG will be read and interpreted at the investigational site for patient safety monitoring, and documentation stored with the source documents.
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8.2.6. left ventricular ejection fraction

MUGA scan or ECHO scans to determine LVEF will be performed in accordance with the Schedule of Procedures (Appendix 1), ie, within 4 weeks before Day 1 of Cycle 1 and at EOT, Cycle 13/Day 28. It is strongly recommended to use the same method of measurement for the same patient throughout the duration of the study.
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8.3. other study assessments

Assessments for health outcomes and biomarkers will only be collected for patients enrolled starting with Amendment 2.