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Comparison of paclitaxel in combination with cisplatin (TP), carboplatin (TC) or fluorouracil (TF) concurrent with radiotherapy for patients with local advanced esophageal squamous cell carcinoma: a three-arm phase III randomized trial (ESO-Shanghai 2)

For peer review only Journal: BMJ Open

Manuscript ID bmjopen-2017-020785

Article Type: Protocol

Date Submitted by the Author: 23-Nov-2017

Complete List of Authors: Ai, Dashan; Fudan University Shanghai Cancer Center, Department of Radiation Oncology; Shanghai Medical College, Fudan University, Department of Oncology Chen, Yun; Fudan University Shanghai Cancer Center, Department of Radiation Oncology; Shanghai Medical College, Fudan University, Department of Oncology Liu, Qi; Fudan University Shanghai Cancer Center, Department of Radiation Oncology; Shanghai Medical College, Fudan University, Department of Oncology Zhang, Junhua; Fudan University Shanghai Cancer Center, Department of

Radiation Oncology; Shanghai Medical College, Fudan University, http://bmjopen.bmj.com/ Department of Oncology Deng, Jiaying; Fudan University Shanghai Cancer Center, Department of Radiation Oncology; Shanghai Medical College, Fudan University, Department of Oncology Zhu, Hanting; Fudan University Shanghai Cancer Center, Department of Radiation Oncology; Shanghai Medical College, Fudan University, Department of Oncology Ren, Wenjia; Fudan University Shanghai Cancer Center, Department of Radiation Oncology; Shanghai Medical College, Fudan University, on September 26, 2021 by guest. Protected copyright. Department of Oncology Zheng, Xiangpeng; Huadong Hospital Affiliated to Fudan University, Department of Radiation Oncology Li, Yunhai; Fudan University Shanghai Cancer Center Minhang Branch Hospital, Department of Radiation Oncology Wei, Shihong; Gansu Province Cancer Hospital, Department of Radiation Oncology Ye, Jinjun; Jiangsu Cancer Hospital, Department of Radiation Oncology Zhou, Jialiang; Affiliated Hospital of Jiangnan University, Department of Radiation Oncology Lin, Qin; First Affiliated Hospital of Xiamen University, Department of Radiation Oncology Luo, Hui; Jiangxi Province Cancer Hospital, Department of Radiation Oncology Cao, Jianzhong; Shanxi Province Cancer Hospital, Department of Radiation Oncology Li, Jiancheng; Fujian Province Cancer Hospital, Department of Radiation

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1 2 3 4 Oncology Huang, Guang; Hainan Province People’s Hospital, Department of Radiation 5 Oncology 6 Wu, Kailiang; Fudan University Shanghai Cancer Center, Department of 7 Radiation Oncology; Shanghai Medical College, Fudan University, 8 Department of Oncology 9 Fan, Min; Fudan University Shanghai Cancer Center, Department of 10 Radiation Oncology; Shanghai Medical College, Fudan University, Department of Oncology 11 Yang, Huanjun; Fudan University Shanghai Cancer Center, Department of 12 Radiation Oncology; Shanghai Medical College, Fudan University, 13 Department of Oncology 14 Zhu, Zhengfei; Fudan University Shanghai Cancer Center, Department of 15 Radiation Oncology; Shanghai Medical College, Fudan University, 16 Department of Oncology For peerZhao, Weixin; reviewFudan University Shanghai only Cancer Center, Department of 17 Radiation Oncology; Shanghai Medical College, Fudan University, 18 Department of Oncology 19 Li, Ling; Fudan University Shanghai Cancer Center, Department of 20 Radiation Oncology; Shanghai Medical College, Fudan University, 21 Department of Oncology 22 Fan, Jianhong; Renhe Hospital, Department of Gynecology Badakhshi, Harun; Charite´ School of Medicine and Centre for Cancer 23 Medicine, Department of Radiation Oncology 24 Zhao, Kuaile; Fudan University Shanghai Cancer Center, Department of 25 Radiation Oncology; Shanghai Medical College, Fudan University, 26 Department of Oncology 27 esophageal squamous cell carcinoma, concurrent chemoradiotherapy, 28 Keywords: paclitaxel, cisplatin, carboplatin, fluorouracil 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 17 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Comparison of paclitaxel in combination with cisplatin (TP), carboplatin (TC) or 4 5 fluorouracil (TF) concurrent with radiotherapy for patients with local advanced 6 esophageal squamous cell carcinoma: a threearm phase III randomized trial 7 8 (ESOShanghai 2) 9 1, 2 1, 2 1, 2 1, 2 1, 2 10 Dashan Ai , Yun Chen , Qi Liu , Junhua Zhang , Jiaying Deng , Hanting 11 Zhu1, 2, Wenjia Ren1, 2, Xiangpeng Zheng3, Yunhai Li4, Shihong Wei5, Jinjun Ye6, 12 13 Jialiang Zhou7, Qin Lin8, Hui Luo9, Jianzhong Cao10, Jiancheng Li11, Guang Huang12, 14 1, 2 1, 2 1, 2 1, 2 1, 2 15 Kailiang Wu , Min Fan , Huanjun Yang , Zhengfei Zhu , Weixin Zhao , Ling 16 Li1, 2, JianhongFor Fan13, Harunpeer Badakhshi review14, Kuaile Zhao1, only2 17 18 1. Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 19 20 Shanghai, China 21 2. Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 22 23 China 24 25 3. Department of Radiation Oncology, Huadong Hospital Affiliated to Fudan 26 University, Shanghai, China 27 28 4. Department of Radiation Oncology, Fudan University Shanghai Cancer Center 29 30 Minhang Branch Hospital, Shanghai, China 31 5. Department of Radiation Oncology, Gansu Province Cancer Hospital, Lanzhou, 32 33 China http://bmjopen.bmj.com/ 34 35 6. Department of Radiation Oncology, Jiangsu Province Cancer Hospital, Nanjing, 36 China 37 38 7. Department of Radiation Oncology, Affiliated Hospital of Jiangnan University, 39 40 Wuxi, China 41 8. Department of Radiation Oncology, First Affiliated Hospital of Xiamen University, on September 26, 2021 by guest. Protected copyright. 42 43 Xiamen, China 44 45 9. Department of Radiation Oncology, Jiangxi Province Cancer Hospital, Nanchang, 46 China 47 48 10. Department of Radiation Oncology, Shanxi Province Cancer Hospital, Taiyuan, 49 50 China 51 11. Department of Thoracic Radiation Oncology, Fujian Province Cancer Hospital, 52 53 Fuzhou, China 54 12. Department of Radiation Oncology, Hainan Province People’s Hospital, Haikou, 55 56 China 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 17 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 13. Department of Gynecology, Renhe hospital, Shanghai, China 4 5 14. Department of Radiation Oncology, Charite´ School of Medicine and Centre for 6 Cancer Medicine, Berlin, Germany 7 8 Corresponding author: Kuaile Zhao, 270 Dongan Rd, Shanghai, 200032, China. Email: 9 10 [email protected]. Tel: +862164175590 11 Key words: esophageal squamous cell carcinoma, concurrent chemoradiotherapy, 12 13 paclitaxel, cisplatin, carboplatin, fluorouracil 14 15 Word counts: 2,316 words 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 17 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Abstract 4 5 Introduction: Concurrent chemoradiation is the standard therapy for patients with 6 local advanced esophageal carcinoma unsuitable for surgery. Paclitaxel is an active 7 8 agent against esophageal cancer and it has been proved as a potent radiation sensitizer. 9 10 There have been multiple studies evaluating paclitaxelbased chemoradiation in 11 esophageal cancer, the results of which are inspiring. However, which regimen, 12 13 among paclitaxel in combination with cisplatin (TP), carboplatin (TC) and 14 15 fluorouracil (TF) concurrent with radiotherapy, provides best prognosis with 16 minimum adverseFor events peer is still considered review far from resolved only and very few studies 17 18 focus on this field. The purpose of this study is to confirm the priority of TF to TP or 19 20 TC concurrent with radiotherapy in terms of overall survival and propose a feasible 21 and effective plan for patients with local advanced esophageal cancer. 22 23 Methods and analysis: ESOShanghai 2 is a threearm, multicenter, openlabeled, 24 25 randomized phase III clinical trial. The study was initiated in July 2015 and the 26 duration of inclusion will be 4 years. The study compares two pairs of regimen: TF 27 28 versus TP and TF versus TC concurrent with definitive radiotherapy for patients with 29 30 esophageal squamous cell carcinoma (ESCC). Patients with histologically confirmed 31 ESCC (clinical stage II, III or IVa based on the 6th UICCTNM classification) and 32 33 without any prior treatment of chemotherapy, radiotherapy or surgery against http://bmjopen.bmj.com/ 34 35 esophageal cancer will be eligible. A total of 321 patients will be randomized and 36 allocated in a 1:1:1 ratio to the three treatment groups. Patients are stratified by lymph 37 38 node status (N0, N1, M1a). The primary endpoint is overall survival and the 39 40 secondary endpoint is progressionfree survival and adverse events. 41 Ethics and dissemination: on September 26, 2021 by guest. Protected copyright. 42 43 This trial has been approved by the Fudan University Shanghai Cancer Center 44 45 Institutional Review Board. Trial results will be disseminated via peer reviewed 46 scientific journals and conference presentations. 47 48 Trial registration: Clinicaltrials.gov: NCT02459457 49 50 51 52 53 54 55 56 57 58 3 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 17 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Strengths and limitations of this study 4 5 First phase III randomized multicentered study comparing these three regimens 6 Stratification by lymph node status (N0, N1, M1a based on the 6th UICCTNM 7 8 classification) 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 4 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 17 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Introduction 4 5 Worldwide, esophageal cancer is the eighth most common cancer, which is 6 responsible for an estimated 455,800 new cases and 400,200 deaths in 2012.1 Since its 7 8 prognosis is dismal, much effort has been put into improving overall survival through 9 2 10 multimodality treatments, which consist of surgery, radiotherapy and chemotherapy. 11 Concurrent chemoradiation is the standard nonoperative therapy for local advanced 12 13 esophageal squamous cell carcinoma (ESCC).3 14 15 Paclitaxel is an active agent against esophageal cancer, with the response rate of 16 28% in ESCC,For and it haspeer been shown review to be a potent radiation only sensitizer.4 There have 17 18 been multiple studies evaluating paclitaxelbased chemoradiation in esophageal 19 20 cancer, for instance, paclitaxel/fluorouracil (TF) developed at The University of Texas 21 M.D. Anderson Cancer Center, and paclitaxel/cisplatin (TP) developed at Memorial 22 23 SloanKettering Cancer Center,5 6 with paclitaxel/carboplatin (TC) from CROSS 24 7 25 trial. In many preoperative studies, paclitaxelbased chemoradiotherapy has achieved 26 inspiring effect, the pathologic complete response rates of TPbased 27 28 chemoradiotherapy were 19%42%, 811 and of TCbased chemoradiotherapy was 29 7 30 49%. However, which regimen, among TF, TP and TCbased definitive 31 chemoradiotherapy, provides best prognosis with minimum adverse events is still 32 33 considered far from resolved and very few studies focus on this field. http://bmjopen.bmj.com/ 34 5 35 RTOG 0113 evaluated 2 different paclitaxelbased regimens (TP and TF). 36 Eightyfour patients were accrued to this study. Patients in arm A (TF) received 37 38 induction 5FU, cisplatin, and paclitaxel followed by radiation and concurrent 39 40 continuous infusion 5FU and weekly paclitaxel. Patients in arm B (TP) received 41 induction paclitaxel and cisplatin followed by radiation and concurrent weekly on September 26, 2021 by guest. Protected copyright. 42 43 cisplatin and 96hour infusion of paclitaxel. The median survival time was 28.7 44 45 months for patients in arm A (TF) and 14.9 months for patients in arm B (TP). Neither 46 arm achieved the hypothesized 1year survival rate of at least 77.5%. The main 47 48 deficiency of this study is the small sample size, but the effect of TF group is still 49 50 inspiring. 51 Another perspective multicenter randomize clinical trials from Europe12 showed 52 53 the overall survival of TCbased definitive chemoradiotherapy was comparable with 54 cisplatin/5FU(PF) as definitive concurrent chemoradiotherapy in esophageal cancer. 55 56 57 58 5 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 17 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 However, the toxicity rates were lower in the TC group together with higher treatment 4 5 compliance. 6 Based on RTOG 0113 and other reports, we designed a multicenter randomized 7 8 controlled phase III trial to confirm the priority of TF to TP and TF to TC concurrent 9 10 with radiotherapy in terms of overall survival for patients with local advanced 11 esophageal squamous cell carcinoma. Independent ethics committees of the 12 13 participating centers approved the study protocol. This trial has been registered with 14 15 ClinicalTrials.gov, number NCT02459457. 16 The trialFor is a threearm, peer multicenter, review openlabeled, randomizedonly phase III clinical 17 18 trial. The study was initiated in July 2015 and the duration of inclusion will be 4 years. 19 20 The study compares two pairs of regimen: TF versus TP and TF versus TC concurrent 21 with definitive radiotherapy in patients with esophageal squamous cell carcinoma. 22 23 24 25 26 Methods and analysis 27 28 29 30 Patient selection 31 To be eligible for this study, patient must fulfill all of the following criteria (Table 1): 32 33 http://bmjopen.bmj.com/ 34 Inclusion criteria 35 1. Histologically confirmed esophageal squamous cell carcinoma 36 37 2. Clinical stages II, III or IVa based on the 6th UICCTNM classification 38 39 3. No prior treatment of chemotherapy, radiotherapy or surgery against esophageal 40 cancer, except for noncurative resection by EMR/ESD. 41 on September 26, 2021 by guest. Protected copyright. 42 4. Aged 1875 years 43 44 5. Adequate organ functions for chemoradiation therapy 45 a) White blood cell (WBC) ≥3×109L 46 9 47 b) Absolute neutrophil counts (ANC) ≥1.5×10 L 48 49 c) Hemoglobin (Hb) ≥10gdl 50 d) Platelet (Plt) ≥100×109L 51 52 e) Total bilirubin <1.5 upper limit of normal (ULN) 53 f) Aspartate transaminase (AST) ≤2.5 ULN 54 55 g) Alanine aminotransferase (ALT) ≤2.5 ULN 56 57 58 6 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 17 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 h) Creatinine ≤1.5 ULN 4 5 6. ECOG PS of 02 6 7. Life expectancy ≥3 months 7 8 8. Written informed consent 9 10 11 Patients fulfilling any of the following criteria are ineligible for this study (Table 2). 12 13 Exclusion criteria 14 15 1. Esophageal perforation or hematemesis 16 For peer review only 17 2. Synchronous or metachronous malignancies (except for cutaneous 18 (nonmelanomas) carcinoma, thyroid papillary carcinoma, phase I seminoma or 19 20 cervical carcinoma in situ curatively treated and disease free for a minimum of 3 21 22 months) 23 3. Received thoracic, abdominal or craniocerebral surgery within 30 days 24 25 4. Enrolled in other clinical trials within 30 days 26 5. Unstable angina and/or congestive heart failure requiring hospitalization within 6 27 28 months 29 30 6. Severe psychiatric disease 31 7. Pregnancy, lactation or unwillingness to adopt contraception 32 33 8. Drug addiction http://bmjopen.bmj.com/ 34 35 9. Acquired immune deficiency syndrome (AIDS) based upon current CDC 36 definition 37 38 10. History of radiotherapy in the planning area 39 40 11. Other ineligible conditions according to researchers on September 26, 2021 by guest. Protected copyright. 41 42 43 Treatment 44 45 The treatment plan is shown in Figure 1. Patients receive radiotherapy combined 46 with concurrent chemotherapy. Radiotherapy begins on day 1, concurrent with the 47 48 beginning of cycle 1 of chemotherapy. 49 50 Same radiation therapy will be delivered in all three treatment groups. 51 Radiotherapy is delivered with photons (≥6 MV) to a total dose of 61.2Gy in 34 52 53 fractions. Patients will be treated 5 days per week at 1.8Gy/d. Threedimensional 54 55 conformal radiotherapy or intensity modulated radiotherapy is required. All patient 56 will be positioned in an individualized immobilization device in the treatment 57 58 7 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 17 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 position. 4 5 The definition of volumes will be in accordance with the 1993 ICRU Report #50 6 and 1999 ICRU Report #62. 7 8 The gross target volume (GTV) is defined as all known involved field, which 9 10 detected by endoscopic ultrasound, barium swallow or CT scan (whichever is larger). 11 The regional lymph nodes included in GTV is whose diameter more than 1cm (0.5cm 12 13 for lymph nodes at tracheoesophageal groove) or histologically proven metastatic 14 15 after puncture. 16 The superiorFor and peer inferior borders review of the clinical targetonly volume (CTV) are 3cm 17 18 beyond the primary tumor along the esophagus. The lateral, anterior and posterior 19 20 borders of the field are the same as GTV. 21 The superior, inferior, anterior, posterior and lateral borders of planning target 22 23 volume (PTV) are 1cm beyond CTV. Field next to the spinal cord could be slightly 24 25 adjusted in order to reduce the exposure of spinal cord. 26 As for target volume, tissue inhomogeneity correction is adopted and it is 27 28 required that more than 99% PTV receive 95% prescription dose and more than 95% 29 30 PTV receive 99% or more prescription dose. Highest and lowest point dose inside 31 PTV should be recorded. 32 33 When making the treatment plan, we should take normal organ dose restrictions http://bmjopen.bmj.com/ 34 35 into consideration as the following order: (Table 3) 36 37 38 Risk organ Contour regulation Dose restriction 39 40 Spinal cord All the layers of CT scan have Highest point dose less on September 26, 2021 by guest. Protected copyright. 41 to be contoured and the margin than 45Gy 42 43 of vertebra tube can be 44 45 regarded as that of planning 46 organ at risk volume. 47 48 Lung It is allowed to use automatic The volume of lung (PTV 49 50 tools in the delineation of excluded) receiving 20Gy 51 margin of lungs. (Trachea and or higher has to be less 52 53 bronchia must be contoured than 30% of the total lung 54 55 manually) volume, and the median 56 57 58 8 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 17 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 dose has to be less than 4 5 15Gy. 6 7 Heart The superior margin of heart The median dose has to be 8 consists of right atrium and less than 40Gy. 9 10 right ventricle, pulmonary 11 artery trunk, ascending main 12 13 aorta and superior vena cava 14 15 excluded. The inferior margin 16 For peeris at the level review of heart apex. only 17 18 19 20 21 Chemotherapy 22 23 Patients are randomly assigned to receive one of three therapies. 24 25 Arm A (TP) 26 Patients in arm A receive 4 courses of TP every 4 weeks. Details are as follows: 27 28 Paclitaxel: 175mg/m2/d, ivgtt over 3 hours, d1; Cisplatin: 25mg/m2/d, ivgtt, d13; 29 30 Arm B (TF) 31 Patients in arm B receive 6 courses of TF concurrent with radiotherapy every week 32 33 and 2 courses of TF adjuvant chemotherapy every 4 weeks. Details are as follows: http://bmjopen.bmj.com/ 34 2 2 35 Concurrent: paclitaxel 50mg/m /d, ivgtt over 3 hours, d1; 5FU 300mg/m , civ 96h, 36 d14 37 38 Adjuvant: paclitaxel 175 mg/m2/d, ivgtt over 3 hours, d1; 5FU 1800mg/m2, civ 72h, 39 40 d13 on September 26, 2021 by guest. Protected copyright. 41 Arm C (TC) 42 43 Patients in arm C receive 6 courses of TC concurrent with radiotherapy every week 44 45 and 2 courses of TC adjuvant chemotherapy every 4 weeks. Details are as follows: 46 Concurrent: paclitaxel 50mg/m2/d, ivgtt over 3 hours, d1; carboplatin AUC=2, ivgtt, 47 48 d1 49 2 50 Adjuvant: paclitaxel 175 mg/m /d, ivgtt over 3 hours, d1; carboplatin AUC=5, ivgtt, 51 d1 52 53 Patients receive premedication to prevent allergic reaction and significant nausea or 54 55 vomiting as indicated. 56 57 58 9 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 17 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Dose modifications 4 5 Radiotherapy interruption 6 If following toxicity is observed, radiotherapy has to be delayed until toxicity is no 7 8 more than grade 2. 9 9 9 10 WBC<2.0×10 /L or ANC<1.0×10 /L 11 Plt<50×109/L 12 13 Grade 3 or higher nonhematological toxicity 14 15 If following toxicity is observed, radiotherapy has to be delayed until complete 16 recovery. For peer review only 17 18 Mediastinal or thoracic infection with fever over 38.5℃ 19 20 It is allowed to suspend at most 2 weeks, or radiotherapy will be terminated. 21 22 23 Chemotherapy interruption and dose modifications 24 25 If following toxicity is observed on day 1, chemotherapy has to be delayed until 26 toxicity is no more than grade 1. 27 28 ANC<1.5×109/L 29 9 30 Plt<100×10 /L 31 Grade 2 or higher nonhematological toxicity, except for nausea, vomiting and 32 33 alopecia http://bmjopen.bmj.com/ 34 35 It is allowed to delay at most 2 weeks, or chemotherapy will be terminated. 36 Chemotherapy dose modifications are based on the greatest toxicity during the last 37 38 cycle. Any patients who need to make chemotherapy dose modifications will receive 39 40 the modified dose in the following cycles. 41 If modifications are needed, dose of paclitaxel, cisplatin, carboplatin and 5FU will on September 26, 2021 by guest. Protected copyright. 42 43 decreased by 25% from the planned dose for the first time and 50% for the second 44 45 time. It is allowed to make dose modifications at most twice, or chemotherapy will be 46 terminated. Details are as follows: 47 48 Dose modification of paclitaxel 49 9 50 Febrile neutropenia (ANC< 0.5×10 /L and fever over 38.3℃ or over 38.0℃ for 51 1h) 52 53 Grade 2 or higher peripheral neuropathy 54

55 56 Dose modification of cisplatin and carboplatin 57 58 10 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 17 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Febrile neutropenia (ANC< 0.5×109/L and fever over 38.3℃ or over 38.0℃ for 4 5 1h) 6 Grade 2 or higher peripheral neuropathy 7 8 Serum creatinine >3ULN 9 10 11 Dose modification of 5FU 12 13 Febrile neutropenia (ANC< 0.5×109/L and fever over 38.3℃ or over 38.0℃ for 14 15 1h) 16 Grade 3 Foror higher mucositispeer review only 17 18 19 20 The adverse events will be evaluated according to the National Cancer Institute 21 Common Terminology Criteria for Adverse Events (CTCAE version 4.0). All adverse 22 23 events, occurring during the course of the trial, which is from randomization until 28 24 25 days after end of treatment, regardless of relatedness to study medication, will be 26 recorded. Adverse events occurring later than 28 days after the end of treatment will 27 28 only be recorded if they are considered relevant. 29 30 31 Randomization 32 33 After the confirmation of eligibility criteria, patients will be randomly allocated in a http://bmjopen.bmj.com/ 34 35 1:1:1 ratio to the three treatment groups by a central randomization center (Fudan 36 University Shanghai Cancer Center, Shanghai, China). Patients will be stratified by 37 38 lymph node status (N0, N1, M1a). The SAS was used to generate a random 39 40 permutation sequence and produce patient randomization numbers. The data center 41 registers the enrollment, assigns a unique identification number to every participant, on September 26, 2021 by guest. Protected copyright. 42 43 and replies to the respective investigators. 44 45 46 Sample size calculation and statistical analysis 47 48 This threearm randomized trial is designed to confirm whether TF is superior to TP 49 50 or TC concurrent with radiotherapy in terms of overall survival. According to RTOG 51 0113 and other reports, median survival time of TF concurrent with radiotherapy for 52 5 13 53 esophageal cancer is 28.7 months while TP 14.9 months and TC 17.4 months . 54 According to the Schoenfeld and Richter’s method, the sample size of 107 patients 55 56 per arm (154 events in total) is required to warrant a power of 80% at a twosided α 57 58 11 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 17 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 level of 0.025 for the comparison between TP and TF with relatively smaller 4 5 difference, assuming an accrual period of 48 months, a minimum followup period of 6 24 months and a dropout rate of 10%14 15. The total sample size is planned as 321 7 8 patients (107 patients in each arm, a total of 231 events). 9 10 The median overall survival will be estimated with KaplanMeier method, and 11 logrank test will be used to compare the overall survival among treatment arms. We 12 13 will conduct a subgroup analyze to test whether the treatment effects differ among 14 15 subgroups (N0, N1, M1a). 16 For peer review only 17 18 Endpoints 19 20 The primary endpoint is overall survival in all randomized patients. Overall 21 survival is defined as time from the date of randomization until death. The secondary 22 23 endpoint is progression free survival (PFS) and adverse events. PFS is defined as the 24 25 time from the date of randomization to the date of progression or to the date of death, 26 whichever occurs first and disease progression will be evaluated according to 27 28 RECIST Version 1.1. Adverse events will be evaluated according to the National 29 30 Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 31 4.0). 32 33 http://bmjopen.bmj.com/ 34 35 Interim analysis 36 We plan to conduct two interim analyses. The first interim analysis will be conducted 37 38 independently from the study group when half of the planned number of patients are 39 40 enrolled and the second interim just after the planned patient accrual is completed. If 41 the superiority of one of test arms is demonstrated with an adjusted α level, the study on September 26, 2021 by guest. Protected copyright. 42 43 will be terminated. 44 45 In general, the interim reports will contain the following information: 46 1. Patient accrual rate with a projected completion date (while the study is still 47 48 accruing) 49 50 2. Total patients accrued 51 3. Distributions of important pretreatment and prognostic baseline variables 52 53 4. The frequencies and severity of adverse events by treatment arm. 54 5. Compliance rates of treatment delivery 55 56 6. Observed results with respect to the primary and secondary endpoints 57 58 12 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 17 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 4 5 Ethics and dissemination 6 This trial has been approved by the Fudan University Shanghai Cancer Center 7 8 Institutional Review Board (Ethics Committee of Fudan University Shanghai Cancer 9 10 Center：No.150514613). Written informed consent will be obtained from all 11 participants. Serious adverse events will be reported to the safety desk of the trial, the 12 13 Data and Safety Monitoring Board and trial sites. Trial results will be disseminated 14 15 via peer reviewed scientific journals and conference presentations. 16 For peer review only 17 18 Participating institutions (From east to west) 19 20 Fudan University Shanghai Cancer Center, Huadong Hospital Affiliated to Fudan 21 University, Fudan University Shanghai Cancer Center Minhang Branch, Affiliated 22 23 Hospital of Jiangnan University, Fujian Province Cancer Hospital, Jiangsu Province 24 25 Cancer Hospital, The First Affiliated Hospital of Xiamen University, Jiangxi Province 26 Cancer Hospital, Shanxi Province Cancer Hospital, Hainan Province People’s 27 28 Hospital, Gansu Province Cancer Hospital 29 30 31 Trial Status 32 33 The trial was initiated in July 2015 and is currently recruiting patients in all of the http://bmjopen.bmj.com/ 34 35 participating institutions above. 36 37 38 39 40 Reference: 41 1. Torre LA, Bray F, Siegel RL, et al. Global Cancer Statistics, 2012. Ca-Cancer J Clin on September 26, 2021 by guest. Protected copyright. 42 43 2015;65(2):87-108. 44 45 2. Enzinger PC, Mayer RJ. Esophageal cancer. N Engl J Med 46 2003;349(23):2241-52. 47 48 3. Herskovic A, Martz K, Alsarraf M, et al. Combined Chemotherapy and 49 50 Radiotherapy Compared with Radiotherapy Alone in Patients with Cancer 51 of the Esophagus. New Engl J Med 1992;326(24):1593-98. 52 53 4. Ajani JA, Ilson DH, Daugherty K, et al. Activity of Taxol in Patients with 54 55 Squamous-Cell Carcinoma and Adenocarcinoma of the Esophagus. J Natl 56 Cancer I 1994;86(14):1086-91. 57 58 13 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 17 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 5. Ajani JA, Winter K, Komaki R, et al. Phase II randomized trial of two 4 5 nonoperative regimens of induction chemotherapy followed by 6 chemoradiation in patients with localized carcinoma of the esophagus: 7 8 RTOG 0113. J Clin Oncol 2008;26(28):4551-56. 9 10 6. Schnirer II, Komaki R, Yao JC, et al. Pilot study of concurrent 11 5-fluorouracil/paclitaxel plus radiotherapy in patients with carcinoma of 12 13 the esophagus and gastroesophageal junction. Am J Clin Oncol-Canc 14 15 2001;24(1):91-95. 16 7. Shapiro J,For Van Lanschot peer JJB, Hulshof review MCCM, et al. Neoadjuvant only 17 18 chemoradiotherapy plus surgery versus surgery alone for oesophageal or 19 20 junctional cancer (CROSS): long-term results of a randomised controlled 21 trial. Lancet Oncol 2015;16(9):1090-98. 22 23 8. Safran H, Gaissert H, Akerman P, et al. Paclitaxel, cisplatin, and concurrent 24 25 radiation for esophageal cancer. Cancer Invest 2001;19(1):1-7. 26 9. Bains MS, Stojadinovic A, Minsky B, et al. A phase II trial of preoperative 27 28 combined-modality therapy for localized esophageal carcinoma: Initial 29 30 results. J Thorac Cardiov Sur 2002;124(2):270-77. 31 10. Urba SG, Orringer MB, Ianettonni M, et al. Concurrent cisplatin, paclitaxel, and 32 33 radiotherapy as preoperative treatment for patients with locoregional http://bmjopen.bmj.com/ 34 35 esophageal carcinoma. Cancer 2003;98(10):2177-83. 36 11. Lin CC, Hsu CH, Cheng JC, et al. Concurrent chemoradiotherapy with twice 37 38 weekly paclitaxel and cisplatin followed by esophagectomy for locally 39 40 advanced esophageal cancer. Ann Oncol 2007;18(1):93-98. 41 12. Honing J, Smit JK, Muijs CT, et al. A comparison of carboplatin and paclitaxel on September 26, 2021 by guest. Protected copyright. 42 43 with cisplatinum and 5-fluorouracil in definitive chemoradiation in 44 45 esophageal cancer patients. Ann Oncol 2014;25(3):638-43. 46 13. Mohammad NH, Hulshof MCCM, Bergman JJGHM, et al. Acute toxicity of 47 48 definitive chemoradiation in patients with inoperable or irresectable 49 50 esophageal carcinoma. Bmc Cancer 2014;14. 51 14. Lakatos E. Designing complex group sequential survival trials. Stat Med 52 53 2002;21(14):1969-89. 54 55 15. Lakatos E. Sample Sizes Based on the Log-Rank Statistic in Complex 56 Clinical-Trials. Biometrics 1988;44(1):229-41. 57 58 14 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 17 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Declarations 4 5 List of abbreviations 6 TP: Paclitaxel combined with cisplatin 7 8 TC: Paclitaxel combined with carboplatin 9 10 TF: Paclitaxel combined with fluorouracil 11 UICC: Union for International Cancer Control 12 13 ESCC: Esophageal squamous cell carcinoma 14 15 PF: Cisplatin combined with fluorouracil 16 AIDS: AcquiredFor immune peer deficiency reviewsyndrome only 17 18 RT: Radiotherapy 19 20 PTX: Paclitaxel 21 DDP: Cisplatin 22 23 CBP: Carboplatin 24 25 5FU: Fluorouracil 26 W: Week 27 28 ICRU: International Commission on Radiation Units and Measurements 29 30 GTV: Gross Target Volume 31 CTV: Clinical Target Volume 32 33 PTV: Planning Target Volume http://bmjopen.bmj.com/ 34 35 WBC: White Blood Cell 36 ANC: Absolute Neutrophil Counts 37 38 Hb: Hemoglobin 39 40 Plt: Platelet 41 ULN: Upper Limit of Normal on September 26, 2021 by guest. Protected copyright. 42 43 AST: Aspartate Transaminase 44 45 ALT: Alanine aminotransferase 46 47 48 49 50 Consent of publication 51 Not applicable 52 53 54 Declaration of interests 55 56 We declare no competing interests. 57 58 15 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 17 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 4 5 Funding 6 The study was supported by 2015 Prospective Clinical Research Fund of Fudan 7 8 University Shanghai Cancer Center. 9 10 11 Author’s contributions 12 13 D Ai was responsible for drafting the manuscript. Y Chen, Q Liu, J Zhang, J Deng, H 14 15 Zhu, W Ren, K Wu, M Fan, H Yang, Z Zhu, W Zhao, L Li were responsible for the 16 collection ofFor previous studypeer and putting review forward the conception. only X Zheng, Y Li, J Ye, 17 18 J Zhou, Q Lin, H Luo, J Cao, S Wei, J Fan, J Li, G Huang and H Badakhshi were 19 20 responsible for designing the details of the study. K Zhao was responsible for all 21 aspects of trial design, the protocol and trial conduct. All authors have read and 22 23 approved this manuscript. 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 16 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 17 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 Fig1. Treatment design of the ESO-Shanghai 2 trial. 30 RT=radiotherapy, PTX=paclitaxel, DDP=cisplatin, 5-Fu=fluorouracil, CBP=carboplatin, W=Week. 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

For peer review only Journal: BMJ Open

Manuscript ID bmjopen-2017-020785.R1

Article Type: Protocol

Date Submitted by the Author: 17-Mar-2018

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 24 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 4 Oncology Huang, Guang; Hainan Province People’s Hospital, Department of Radiation 5 Oncology 6 Wu, Kailiang; Fudan University Shanghai Cancer Center, Department of 7 Radiation Oncology; Shanghai Medical College, Fudan University, 8 Department of Oncology 9 Fan, Min; Fudan University Shanghai Cancer Center, Department of 10 Radiation Oncology; Shanghai Medical College, Fudan University, Department of Oncology 11 Yang, Huanjun; Fudan University Shanghai Cancer Center, Department of 12 Radiation Oncology; Shanghai Medical College, Fudan University, 13 Department of Oncology 14 Zhu, Zhengfei; Fudan University Shanghai Cancer Center, Department of 15 Radiation Oncology; Shanghai Medical College, Fudan University, 16 Department of Oncology For peerZhao, Weixin; reviewFudan University Shanghai only Cancer Center, Department of 17 Radiation Oncology; Shanghai Medical College, Fudan University, 18 Department of Oncology 19 Li, Ling; Fudan University Shanghai Cancer Center, Department of 20 Radiation Oncology; Shanghai Medical College, Fudan University, 21 Department of Oncology 22 Fan, Jianhong; Renhe Hospital, Department of Gynecology Badakhshi, Harun; Charite´ School of Medicine and Centre for Cancer 23 Medicine, Department of Radiation Oncology 24 Zhao, Kuaile; Fudan University Shanghai Cancer Center, Department of 25 Radiation Oncology; Shanghai Medical College, Fudan University, 26 Department of Oncology 27 Primary Subject 28 Oncology Heading: 29 30 Secondary Subject Heading: Oncology 31 esophageal squamous cell carcinoma, concurrent chemoradiotherapy, 32 Keywords:

paclitaxel, cisplatin, carboplatin, fluorouracil http://bmjopen.bmj.com/ 33 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 24 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Comparison of paclitaxel in combination with cisplatin (TP), carboplatin (TC) or 4 5 fluorouracil (TF) concurrent with radiotherapy for patients with local advanced 6 esophageal squamous cell carcinoma: a threearm phase III randomized trial 7 8 (ESOShanghai 2) 9 1, 2 1, 2 1, 2 1, 2 1, 2 10 Dashan Ai , Yun Chen , Qi Liu , Junhua Zhang , Jiaying Deng , Hanting 11 Zhu1, 2, Wenjia Ren1, 2, Xiangpeng Zheng3, Yunhai Li4, Shihong Wei5, Jinjun Ye6, 12 13 Jialiang Zhou7, Qin Lin8, Hui Luo9, Jianzhong Cao10, Jiancheng Li11, Guang Huang12, 14 1, 2 1, 2 1, 2 1, 2 1, 2 15 Kailiang Wu , Min Fan , Huanjun Yang , Zhengfei Zhu , Weixin Zhao , Ling 16 Li1, 2, JianhongFor Fan13, Harunpeer Badakhshi review14, Kuaile Zhao1, only2 17 18 1. Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 19 20 Shanghai, China 21 2. Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 22 23 China 24 25 3. Department of Radiation Oncology, Huadong Hospital Affiliated to Fudan 26 University, Shanghai, China 27 28 4. Department of Radiation Oncology, Fudan University Shanghai Cancer Center 29 30 Minhang Branch Hospital, Shanghai, China 31 5. Department of Radiation Oncology, Gansu Province Cancer Hospital, Lanzhou, 32 33 China http://bmjopen.bmj.com/ 34 35 6. Department of Radiation Oncology, Jiangsu Province Cancer Hospital, Nanjing, 36 China 37 38 7. Department of Radiation Oncology, Affiliated Hospital of Jiangnan University, 39 40 Wuxi, China 41 8. Department of Radiation Oncology, First Affiliated Hospital of Xiamen University, on September 26, 2021 by guest. Protected copyright. 42 43 Xiamen, China 44 45 9. Department of Radiation Oncology, Jiangxi Province Cancer Hospital, Nanchang, 46 China 47 48 10. Department of Radiation Oncology, Shanxi Province Cancer Hospital, Taiyuan, 49 50 China 51 11. Department of Thoracic Radiation Oncology, Fujian Province Cancer Hospital, 52 53 Fuzhou, China 54 12. Department of Radiation Oncology, Hainan Province People’s Hospital, Haikou, 55 56 China 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 24 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 13. Department of Gynecology, Renhe hospital, Shanghai, China 4 5 14. Department of Radiation Oncology, Charite´ School of Medicine and Centre for 6 Cancer Medicine, Berlin, Germany 7 8 Corresponding author: Kuaile Zhao, 270 Dongan Rd, Shanghai, 200032, China. Email: 9 10 [email protected]. Tel: +862164175590 11 Key words: esophageal squamous cell carcinoma, concurrent chemoradiotherapy, 12 13 paclitaxel, cisplatin, carboplatin, fluorouracil 14 15 Word counts: 2,856 words 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 24 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Abstract 4 5 Introduction: Concurrent chemoradiation is the standard therapy for patients with 6 local advanced esophageal carcinoma unsuitable for surgery. Paclitaxel is an active 7 8 agent against esophageal cancer and it has been proved as a potent radiation sensitizer. 9 10 There have been multiple studies evaluating paclitaxelbased chemoradiation in 11 esophageal cancer, the results of which are inspiring. However, which regimen, 12 13 among paclitaxel in combination with cisplatin (TP), carboplatin (TC) and 14 15 fluorouracil (TF) concurrent with radiotherapy, provides best prognosis with 16 minimum adverseFor events peer is still considered review far from resolved only and very few studies 17 18 focus on this field. The purpose of this study is to confirm the priority of TF to TP or 19 20 TC concurrent with radiotherapy in terms of overall survival and propose a feasible 21 and effective plan for patients with local advanced esophageal cancer. 22 23 Methods and analysis: ESOShanghai 2 is a threearm, multicenter, openlabeled, 24 25 randomized phase III clinical trial. The study was initiated in July 2015 and the 26 duration of inclusion will be 4 years. The study compares two pairs of regimen: TF 27 28 versus TP and TF versus TC concurrent with definitive radiotherapy for patients with 29 30 esophageal squamous cell carcinoma (ESCC). Patients with histologically confirmed 31 ESCC (clinical stage II, III or IVa based on the 6th UICCTNM classification) and 32 33 without any prior treatment of chemotherapy, radiotherapy or surgery against http://bmjopen.bmj.com/ 34 35 esophageal cancer will be eligible. A total of 321 patients will be randomized and 36 allocated in a 1:1:1 ratio to the three treatment groups. Patients are stratified by lymph 37 38 node status (N0, N1, M1a). The primary endpoint is overall survival and the 39 40 secondary endpoint is progressionfree survival and adverse events. 41 Ethics and dissemination: on September 26, 2021 by guest. Protected copyright. 42 43 This trial has been approved by the Fudan University Shanghai Cancer Center 44 45 Institutional Review Board. Trial results will be disseminated via peer reviewed 46 scientific journals and conference presentations. 47 48 Trial registration: Clinicaltrials.gov: NCT02459457 49 50 51 52 53 54 55 56 57 58 3 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 24 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Strengths and limitations of this study 4 5 First phase III randomized multicentered study comparing these three regimens 6 Stratification by lymph node status (N0, N1, M1a based on the 6th UICCTNM 7 8 classification) 9 10 No stratification for different centers 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 4 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 24 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Introduction 4 5 Worldwide, esophageal cancer is the eighth most common cancer, which is 6 responsible for an estimated 455,800 new cases and 400,200 deaths in 2012.1 Since its 7 8 prognosis is dismal, much effort has been put into improving overall survival through 9 2 10 multimodality treatments, which consist of surgery, radiotherapy and chemotherapy. 11 Concurrent chemoradiation is the standard nonoperative therapy for local advanced 12 13 esophageal squamous cell carcinoma (ESCC).3 14 15 Paclitaxel is an active agent against esophageal cancer, with the response rate of 16 28% in ESCC,For and it haspeer been shown review to be a potent radiation only sensitizer.4 There have 17 18 been multiple studies evaluating paclitaxelbased chemoradiation in esophageal 19 20 cancer, for instance, paclitaxel/fluorouracil (TF) developed at The University of Texas 21 M.D. Anderson Cancer Center, and paclitaxel/cisplatin (TP) developed at Memorial 22 23 SloanKettering Cancer Center,5 6 with paclitaxel/carboplatin (TC) from CROSS 24 7 25 trial. In many preoperative studies, paclitaxelbased chemoradiotherapy has achieved 26 inspiring effect, the pathologic complete response rates of TPbased 27 28 chemoradiotherapy were 19%42%, 811 and of TCbased chemoradiotherapy was 29 7 30 49%. However, which regimen, among TF, TP and TCbased definitive 31 chemoradiotherapy, provides best prognosis with minimum adverse events is still 32 33 considered far from resolved and very few studies focus on this field. http://bmjopen.bmj.com/ 34 5 35 RTOG 0113 evaluated 2 different paclitaxelbased regimens (TP and TF). 36 Eightyfour patients were accrued to this study. Patients in arm A (TF) received 37 38 induction 5FU, cisplatin, and paclitaxel followed by radiation and concurrent 39 40 continuous infusion 5FU and weekly paclitaxel. Patients in arm B (TP) received 41 induction paclitaxel and cisplatin followed by radiation and concurrent weekly on September 26, 2021 by guest. Protected copyright. 42 43 cisplatin and 96hour infusion of paclitaxel. The median survival time was 28.7 44 45 months for patients in arm A (TF) and 14.9 months for patients in arm B (TP). Neither 46 arm achieved the hypothesized 1year survival rate of at least 77.5%. The main 47 48 deficiency of this study is the small sample size, but the effect of TF group is still 49 50 inspiring. 51 Another retrospective multicenter randomize clinical trials from Europe12 52 53 showed the overall survival of TCbased definitive chemoradiotherapy was 54 comparable with cisplatin/5FU (PF) as definitive concurrent chemoradiotherapy in 55 56 57 58 5 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 24 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 esophageal cancer. However, the toxicity rates were lower in the TC group together 4 5 with higher treatment compliance. 6 Based on RTOG 0113 and other reports, we designed a multicenter randomized 7 8 controlled phase III trial to confirm the priority of TF to TP and TF to TC concurrent 9 10 with radiotherapy in terms of overall survival for patients with local advanced 11 esophageal squamous cell carcinoma. Independent ethics committees of the 12 13 participating centers approved the study protocol. This trial has been registered with 14 15 ClinicalTrials.gov, number NCT02459457. 16 The trialFor is a threearm, peer multicenter, review openlabeled, randomizedonly phase III clinical 17 18 trial. The study was initiated in July 2015 and the duration of inclusion will be 4 years. 19 20 The study compares two pairs of regimen: TF versus TP and TF versus TC concurrent 21 with definitive radiotherapy in patients with esophageal squamous cell carcinoma. 22 23 24 25 26 Methods and analysis 27 28 29 30 Patient selection 31 To be eligible for this study, patient must fulfill all of the following criteria (Table 1): 32 33 http://bmjopen.bmj.com/ 34 Inclusion criteria 35 1. Histologically confirmed esophageal squamous cell carcinoma 36 37 2. Clinical stages II, III or IVa based on the 6th UICCTNM classification 38 39 3. No prior treatment of chemotherapy, radiotherapy or surgery against esophageal 40 cancer, except for noncurative resection by EMR/ESD. 41 on September 26, 2021 by guest. Protected copyright. 42 4. Aged 1875 years 43 44 5. Adequate organ functions for chemoradiation therapy 45 a) White blood cell (WBC) ≥3×109L 46 9 47 b) Absolute neutrophil counts (ANC) ≥1.5×10 L 48 49 c) Hemoglobin (Hb) ≥10gdl 50 d) Platelet (Plt) ≥100×109L 51 52 e) Total bilirubin <1.5 upper limit of normal (ULN) 53 f) Aspartate transaminase (AST) ≤2.5 ULN 54 55 g) Alanine aminotransferase (ALT) ≤2.5 ULN 56 57 58 6 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 24 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 h) Creatinine ≤1.5 ULN 4 5 6. ECOG PS of 02 6 7. Life expectancy ≥3 months 7 8 8. Written informed consent 9 10 Table 1. Inclusion criteria 11

12 13 Patients fulfilling any of the following criteria are ineligible for this study (Table 2). 14 15 Exclusion criteria 16 For peer review only 17 1. Esophageal perforation or hematemesis 18 2. Synchronous or metachronous malignancies (except for cutaneous 19 20 (nonmelanomas) carcinoma, thyroid papillary carcinoma, phase I seminoma or 21 22 cervical carcinoma in situ curatively treated and disease free for a minimum of 3 23 months) 24 25 3. Received thoracic, abdominal or craniocerebral surgery within 30 days 26 4. Enrolled in other clinical trials within 30 days 27 28 5. Unstable angina and/or congestive heart failure requiring hospitalization within 6 29 30 months 31 6. Severe psychiatric disease 32 33 7. Pregnancy, lactation or unwillingness to adopt contraception http://bmjopen.bmj.com/ 34 35 8. Drug addiction 36 9. Acquired immune deficiency syndrome (AIDS) based upon current CDC 37 38 definition 39 40 10. History of radiotherapy in the planning area on September 26, 2021 by guest. Protected copyright. 41 11. Other ineligible conditions according to researchers 42 43 Table 2. Exclusion criteria 44 45 46 Treatment 47 48 The treatment plan is shown in Figure 1. Patients receive radiotherapy combined 49 50 with concurrent chemotherapy. Radiotherapy begins on day 1, concurrent with the 51 beginning of cycle 1 of chemotherapy. 52 53 Same radiation therapy will be delivered in all three treatment groups. 54 55 Radiotherapy is delivered with photons (≥6 MV) to a total dose of 61.2Gy in 34 56 fractions. Patients will be treated 5 days per week at 1.8Gy/d. Threedimensional 57 58 7 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 24 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 conformal radiotherapy or intensity modulated radiotherapy is required. All patient 4 5 will be positioned in an individualized immobilization device in the treatment 6 position. 7 8 The definition of volumes will be in accordance with the 1993 ICRU Report #50 9 10 and 1999 ICRU Report #62. 11 The gross target volume (GTV) is defined as all known involved field, which 12 13 detected by endoscopic ultrasound, barium swallow or CT scan (whichever is larger). 14 15 The regional lymph nodes included in GTV is whose diameter more than 1cm (0.5cm 16 for lymph nodesFor at tracheoesophagealpeer review groove) or histologically only proven metastatic 17 18 after puncture. 19 20 The superior and inferior borders of the clinical target volume (CTV) are 3cm 21 beyond the primary tumor along the esophagus. The lateral, anterior and posterior 22 23 borders of the field are the same as GTV. 24 25 The superior, inferior, anterior, posterior and lateral borders of planning target 26 volume (PTV) are 1cm beyond CTV. Field next to the spinal cord could be slightly 27 28 adjusted in order to reduce the exposure of spinal cord. 29 30 As for target volume, tissue inhomogeneity correction is adopted and it is 31 required that more than 99% PTV receive 95% prescription dose and more than 95% 32 33 PTV receive 99% or more prescription dose. Highest and lowest point dose inside http://bmjopen.bmj.com/ 34 35 PTV should be recorded. 36 When making the treatment plan, we should take normal organ dose restrictions 37 38 into consideration as the following order: (Table 3) 39 40 41 Risk organ Contour regulation Dose restriction on September 26, 2021 by guest. Protected copyright. 42 43 Spinal cord All the layers of CT scan have Highest point dose less 44 45 to be contoured and the margin than 45Gy 46 of vertebra tube can be 47 48 regarded as that of planning 49 50 organ at risk volume. 51 Lung It is allowed to use automatic The volume of lung (PTV 52 53 tools in the delineation of excluded) receiving 20Gy 54 55 margin of lungs. (Trachea and or higher has to be less 56 57 58 8 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 24 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 bronchia must be contoured than 30% of the total lung 4 5 manually) volume, and the mean 6 dose has to be less than 7 8 15Gy. 9 10 Heart The superior margin of heart The mean dose has to be 11 consists of right atrium and less than 40Gy. 12 13 right ventricle, pulmonary 14 15 artery trunk, ascending main 16 For peeraorta and review superior vena cava only 17 18 excluded. The inferior margin 19 20 is at the level of heart apex. 21 Table 3. Contour regulation and dose restriction of risk organs 22 23 24 25 Chemotherapy 26 Patients are randomly assigned to receive one of three therapies. 27 28 Arm A (TP) 29 30 Patients in arm A receive 4 courses of TP every 4 weeks. Details are as follows: 31 Paclitaxel: 175mg/m2/d, ivgtt over 3 hours, d1; Cisplatin: 25mg/m2/d, ivgtt, d13; 32 33 Arm B (TF) http://bmjopen.bmj.com/ 34 35 Patients in arm B receive 6 courses of TF concurrent with radiotherapy every week 36 and 2 courses of TF consolidation chemotherapy every 4 weeks. Details are as 37 38 follows: 39 2 2 40 Concurrent: paclitaxel 50mg/m /d, ivgtt over 3 hours, d1; 5FU 300mg/m , civ 96h, on September 26, 2021 by guest. Protected copyright. 41 d14 42 43 Consolidation: paclitaxel 175 mg/m2/d, ivgtt over 3 hours, d1; 5FU 1800mg/m2, civ 44 45 72h, d13 46 Arm C (TC) 47 48 Patients in arm C receive 6 courses of TC concurrent with radiotherapy every week 49 50 and 2 courses of TC consolidation chemotherapy every 4 weeks. Details are as 51 follows: 52 53 Concurrent: paclitaxel 50mg/m2/d, ivgtt over 3 hours, d1; carboplatin AUC=2, ivgtt, 54 55 d1 56 Consolidation: paclitaxel 175 mg/m2/d, ivgtt over 3 hours, d1; carboplatin AUC=5, 57 58 9 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 24 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 ivgtt, d1 4 5 Patients receive premedication to prevent allergic reaction and significant nausea or 6 vomiting as indicated. 7 8 9 10 Dose modifications 11 Radiotherapy interruption 12 13 If following toxicity is observed, radiotherapy has to be delayed until toxicity is no 14 15 more than grade 2. 16 WBC<2.0×10For9/L orpeer ANC<1.0×10 review9/L only 17 18 Plt<50×109/L 19 20 Grade 3 or higher nonhematological toxicity 21 If following toxicity is observed, radiotherapy has to be delayed until complete 22 23 recovery. 24 25 Mediastinal or thoracic infection with fever over 38.5℃ 26 It is allowed to suspend at most 2 weeks, or radiotherapy will be terminated. 27 28 29 30 Chemotherapy interruption and dose modifications 31 If following toxicity is observed on day 1, chemotherapy has to be delayed until 32 33 toxicity is no more than grade 1. http://bmjopen.bmj.com/ 34 9 35 ANC<1.5×10 /L 36 Plt<100×109/L 37 38 Grade 2 or higher nonhematological toxicity, except for nausea, vomiting and 39 40 alopecia 41 It is allowed to delay at most 2 weeks, or chemotherapy will be terminated. on September 26, 2021 by guest. Protected copyright. 42 43 Chemotherapy dose modifications are based on the greatest toxicity during the last 44 45 cycle. Any patients who need to make chemotherapy dose modifications will receive 46 the modified dose in the following cycles. 47 48 If modifications are needed, dose of paclitaxel, cisplatin, carboplatin and 5FU will 49 50 decreased by 25% from the planned dose for the first time and 50% for the second 51 time. It is allowed to make dose modifications at most twice, or chemotherapy will be 52 53 terminated. Details are as follows: 54 Dose modification of paclitaxel 55 56 Febrile neutropenia (ANC< 0.5×109/L and fever over 38.3℃ or over 38.0℃ for 57 58 10 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 24 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 1h) 4 5 Grade 2 or higher peripheral neuropathy 6

7 8 Dose modification of cisplatin and carboplatin 9 9 10 Febrile neutropenia (ANC< 0.5×10 /L and fever over 38.3℃ or over 38.0℃ for 11 1h) 12 13 Grade 2 or higher peripheral neuropathy 14 15 Serum creatinine >3ULN 16 For peer review only 17 18 Dose modification of 5FU 19 9 20 Febrile neutropenia (ANC< 0.5×10 /L and fever over 38.3℃ or over 38.0℃ for 21 1h) 22 23 Grade 3 or higher mucositis 24 25 26 The adverse events will be evaluated according to the National Cancer Institute 27 28 Common Terminology Criteria for Adverse Events (CTCAE version 4.0). All adverse 29 30 events, occurring during the course of the trial, which is from randomization until 28 31 days after end of treatment, regardless of relatedness to study medication, will be 32 33 recorded. Adverse events occurring later than 28 days after the end of treatment will http://bmjopen.bmj.com/ 34 35 only be recorded if they are considered relevant. 36 37 38 Randomization 39 40 After the confirmation of eligibility criteria, patients will be randomly allocated in a 41 1:1:1 ratio to the three treatment groups by a central randomization center (Fudan on September 26, 2021 by guest. Protected copyright. 42 43 University Shanghai Cancer Center, Shanghai, China). Patients will be stratified by 44 45 lymph node status (N0, N1, M1a). The SAS was used to generate a random 46 permutation sequence and produce patient randomization numbers. The data center 47 48 registers the enrollment, assigns a unique identification number to every participant, 49 50 and replies to the respective investigators. 51 52 53 Sample size calculation and statistical analysis 54 This threearm randomized trial is designed to confirm whether TF is superior to TP 55 56 or TC concurrent with radiotherapy in terms of overall survival. According to RTOG 57 58 11 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 24 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 0113 and other reports, median survival time of TF concurrent with radiotherapy for 4 5 13 5 esophageal cancer is 28.7 months while TP 14.9 months and TC 17.4 months . 6 According to the Schoenfeld and Richter’s method, the sample size of 107 patients 7 8 per arm (154 events in total) is required to warrant a power of 80% at a twosided α 9 10 level of 0.025 for the comparison between TP and TF with relatively smaller 11 difference, assuming an accrual period of 48 months, a minimum followup period of 12 13 24 months and a dropout rate of 10%14 15. The total sample size is planned as 321 14 15 patients (107 patients in each arm, a total of 231 events). 16 The medianFor overall survivalpeer will review be estimated with only KaplanMeier method, and 17 18 logrank test will be used to compare the overall survival among treatment arms. We 19 20 will conduct a subgroup analyze to test whether the treatment effects differ among 21 subgroups (N0, N1, M1a). 22 23 24 25 Endpoints 26 The primary endpoint is overall survival in all randomized patients. Overall 27 28 survival is defined as time from the date of randomization until death. The secondary 29 30 endpoint is progression free survival (PFS) and adverse events. PFS is defined as the 31 time from the date of randomization to the date of progression or to the date of death, 32 33 whichever occurs first and disease progression will be evaluated according to http://bmjopen.bmj.com/ 34 35 RECIST Version 1.1. Adverse events will be evaluated according to the National 36 Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 37 38 4.0). 39 40 41 Data collection on September 26, 2021 by guest. Protected copyright. 42 43 Participants will be seen at hospital or contacted by telephone, letters from 44 45 randomization to the end of treatment cycle, then at Month 3, 6, 9, 12, 15, 18, 21, 24, 46 30, 36, 42, 48, 54 and 60 after last treatment. Research staff at the hospitals will be 47 48 expected to complete trial CRFs which record evidence of primary and secondary out 49 50 come measures. 51 52 53 Interim analysis 54 We plan to conduct two interim analyses. The first interim analysis will be conducted 55 56 independently from the study group when half of the planned number of patients are 57 58 12 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 24 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 enrolled and the second interim just after the planned patient accrual is completed. If 4 5 the superiority of one of test arms is demonstrated with an adjusted α level, the study 6 will be terminated. 7 8 In general, the interim reports will contain the following information: 9 10 1. Patient accrual rate with a projected completion date (while the study is still 11 accruing) 12 13 2. Total patients accrued 14 15 3. Distributions of important pretreatment and prognostic baseline variables 16 4. The frequenciesFor and peerseverity of adverse review events by treatment only arm. 17 18 5. Compliance rates of treatment delivery 19 20 6. Observed results with respect to the primary and secondary endpoints 21 22 23 Patient and Public Involvement 24 25 Patients in this study will be recruited from the outpatient of participant centers. After 26 diagnosis and necessary clinical assessment, this clinical trial will be introduced to the 27 28 patients to get their approval. All the recruitment and conduct of this study will be the 29 30 responsible for doctors and other staffs. The only obligation of patients is to report 31 any discomfort during the process of this study. Trial results will be disseminated via 32 33 peer reviewed scientific journals and conference presentations rather than specifically http://bmjopen.bmj.com/ 34 35 notified to a single patient. No extra financial burden for patients if they are enrolled 36 in this trial because standard cost of three treatment plans are similar if patients 37 38 covered by the same insurance. 39 40 41 Ethics and dissemination on September 26, 2021 by guest. Protected copyright. 42 43 This trial has been approved by the Fudan University Shanghai Cancer Center 44 45 Institutional Review Board (Ethics Committee of Fudan University Shanghai Cancer 46 Center：No.150514613). Written informed consent will be obtained from all 47 48 participants. Serious adverse events will be reported to the safety desk of the trial, the 49 50 Data and Safety Monitoring Board and trial sites. Trial results will be disseminated 51 via peer reviewed scientific journals and conference presentations. 52 53 54 Participating institutions (From east to west) 55 56 57 58 13 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 24 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Fudan University Shanghai Cancer Center, Huadong Hospital Affiliated to Fudan 4 5 University, Fudan University Shanghai Cancer Center Minhang Branch, Affiliated 6 Hospital of Jiangnan University, Fujian Province Cancer Hospital, Jiangsu Province 7 8 Cancer Hospital, The First Affiliated Hospital of Xiamen University, Jiangxi Province 9 10 Cancer Hospital, Shanxi Province Cancer Hospital, Hainan Province People’s 11 Hospital, Gansu Province Cancer Hospital 12 13 14 15 Trial Status 16 The trial wasFor initiated inpeer July 2015 andreview is currently recruiting only patients in all of the 17 18 participating institutions above. 19 20 21 22 23 24 25 Reference: 26 1. Torre LA, Bray F, Siegel RL, et al. Global Cancer Statistics, 2012. Ca-Cancer J Clin 27 28 2015;65(2):87-108. 29 30 2. Enzinger PC, Mayer RJ. Esophageal cancer. N Engl J Med 31 2003;349(23):2241-52. 32 33 3. Herskovic A, Martz K, Alsarraf M, et al. Combined Chemotherapy and http://bmjopen.bmj.com/ 34 35 Radiotherapy Compared with Radiotherapy Alone in Patients with Cancer 36 of the Esophagus. New Engl J Med 1992;326(24):1593-98. 37 38 4. Ajani JA, Ilson DH, Daugherty K, et al. Activity of Taxol in Patients with 39 40 Squamous-Cell Carcinoma and Adenocarcinoma of the Esophagus. J Natl 41 Cancer I 1994;86(14):1086-91. on September 26, 2021 by guest. Protected copyright. 42 43 5. Ajani JA, Winter K, Komaki R, et al. Phase II randomized trial of two 44 45 nonoperative regimens of induction chemotherapy followed by 46 chemoradiation in patients with localized carcinoma of the esophagus: 47 48 RTOG 0113. J Clin Oncol 2008;26(28):4551-56. 49 50 6. Schnirer II, Komaki R, Yao JC, et al. Pilot study of concurrent 51 5-fluorouracil/paclitaxel plus radiotherapy in patients with carcinoma of 52 53 the esophagus and gastroesophageal junction. Am J Clin Oncol-Canc 54 55 2001;24(1):91-95. 56 7. Shapiro J, Van Lanschot JJB, Hulshof MCCM, et al. Neoadjuvant 57 58 14 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 24 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 chemoradiotherapy plus surgery versus surgery alone for oesophageal or 4 5 junctional cancer (CROSS): long-term results of a randomised controlled 6 trial. Lancet Oncol 2015;16(9):1090-98. 7 8 8. Safran H, Gaissert H, Akerman P, et al. Paclitaxel, cisplatin, and concurrent 9 10 radiation for esophageal cancer. Cancer Invest 2001;19(1):1-7. 11 9. Bains MS, Stojadinovic A, Minsky B, et al. A phase II trial of preoperative 12 13 combined-modality therapy for localized esophageal carcinoma: Initial 14 15 results. J Thorac Cardiov Sur 2002;124(2):270-77. 16 10. Urba SG,For Orringer peerMB, Ianettonni review M, et al. Concurrent only cisplatin, paclitaxel, and 17 18 radiotherapy as preoperative treatment for patients with locoregional 19 20 esophageal carcinoma. Cancer 2003;98(10):2177-83. 21 11. Lin CC, Hsu CH, Cheng JC, et al. Concurrent chemoradiotherapy with twice 22 23 weekly paclitaxel and cisplatin followed by esophagectomy for locally 24 25 advanced esophageal cancer. Ann Oncol 2007;18(1):93-98. 26 12. Honing J, Smit JK, Muijs CT, et al. A comparison of carboplatin and paclitaxel 27 28 with cisplatinum and 5-fluorouracil in definitive chemoradiation in 29 30 esophageal cancer patients. Ann Oncol 2014;25(3):638-43. 31 13. Mohammad NH, Hulshof MCCM, Bergman JJGHM, et al. Acute toxicity of 32 33 definitive chemoradiation in patients with inoperable or irresectable http://bmjopen.bmj.com/ 34 35 esophageal carcinoma. Bmc Cancer 2014;14. 36 14. Lakatos E. Designing complex group sequential survival trials. Stat Med 37 38 2002;21(14):1969-89. 39 40 15. Lakatos E. Sample Sizes Based on the Log-Rank Statistic in Complex 41 Clinical-Trials. Biometrics 1988;44(1):229-41. on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 15 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 24 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Declarations 4 5 List of abbreviations 6 TP: Paclitaxel combined with cisplatin 7 8 TC: Paclitaxel combined with carboplatin 9 10 TF: Paclitaxel combined with fluorouracil 11 UICC: Union for International Cancer Control 12 13 ESCC: Esophageal squamous cell carcinoma 14 15 PF: Cisplatin combined with fluorouracil 16 AIDS: AcquiredFor immune peer deficiency reviewsyndrome only 17 18 RT: Radiotherapy 19 20 PTX: Paclitaxel 21 DDP: Cisplatin 22 23 CBP: Carboplatin 24 25 5FU: Fluorouracil 26 W: Week 27 28 ICRU: International Commission on Radiation Units and Measurements 29 30 GTV: Gross Target Volume 31 CTV: Clinical Target Volume 32 33 PTV: Planning Target Volume http://bmjopen.bmj.com/ 34 35 WBC: White Blood Cell 36 ANC: Absolute Neutrophil Counts 37 38 Hb: Hemoglobin 39 40 Plt: Platelet 41 ULN: Upper Limit of Normal on September 26, 2021 by guest. Protected copyright. 42 43 AST: Aspartate Transaminase 44 45 ALT: Alanine aminotransferase 46 47 48 49 50 Consent of publication 51 Not applicable 52 53 54 Declaration of interests 55 56 We declare no competing interests. 57 58 16 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 24 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 4 5 Funding 6 The study was supported by 2015 Prospective Clinical Research Fund of Fudan 7 8 University Shanghai Cancer Center. 9 10 11 Author’s contributions 12 13 D Ai was responsible for drafting the manuscript. Y Chen, Q Liu, J Zhang, J Deng, H 14 15 Zhu, W Ren, K Wu, M Fan, H Yang, Z Zhu, W Zhao, L Li were responsible for the 16 collection ofFor previous studypeer and putting review forward the conception. only X Zheng, Y Li, J Ye, 17 18 J Zhou, Q Lin, H Luo, J Cao, S Wei, J Fan, J Li, G Huang and H Badakhshi were 19 20 responsible for designing the details of the study. K Zhao was responsible for all 21 aspects of trial design, the protocol and trial conduct. All authors have read and 22 23 approved this manuscript. 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 17 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 24 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Fig1. Treatment Design of the ESOShanghai 2 trial. 4 5 TP (arm A), TF (arm B) and TC (arm C) are TP, TF and TCbased definitive 6 chemoradiotherapy, respectively. 7 8 RT=radiotherapy, PTX=paclitaxel, DDP=cisplatin, 5Fu=fluorouracil, 9 10 CBP=carboplatin, W=Week. 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 18 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from http://bmjopen.bmj.com/

BMJ Open Page 20 of 24 For peer review only on September 26, 2021 by guest. Protected copyright. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 1

Addressed on Addressed number page

____3______3______None ______None ______17______17______None ______None ______17______17______17______17______None______None______None _ None __ BMJ Open http://bmjopen.bmj.com/ on September 26, 2021 by guest. Protected copyright. For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml applicable (see Item 21a for data monitoring committee) committee) monitoring data for 21a (seeItem applicable interpretation of data; writing of the report; and the decision to submit the report for publication, including including publication, for report the submit to decision the and report; of the writing ofdata; interpretation activities any ofthese over authority ultimate have will they whether adjudication committee, data management team, and other individuals or groups overseeing the trial, if trial, the overseeing groups or individuals other and managementteam, data committee, adjudication Description Description

5c 5c and analysis, management, collection, design; study in ifany, funders, sponsorand study of Role 5d 5d endpoint committee, steering centre, coordinating of the responsibilities and roles, Composition, 1 1 acronym trial if applicable, and, interventions, population, design, study the identifying title Descriptive ____1______5a 5a contributors protocol of roles and affiliations, Names, 5b sponsor trial forthe information contact and Name 2b 2b Set Data Registration Trial Organization WorldHealth fromthe items All No No 4 4 support other and material, financial, of types and Sources

Funding Funding Roles and and Roles responsibilities Protocol version version Protocol 3 identifier version and Date Title Title Trial registration registration Trial 2a registry intended of name registered, yet Ifname. not registry and identifier Trial Administrative information Administrative documents* related and protocol trial clinical a in address to items Recommended Checklist: 2013 SPIRIT Section/item Item Page 21 of 24 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 2 Page 22 of 24

_____12______12______12______12______9 ___ 9 ______None ______None ______10______10______9______9______6-7______6-7______13______13______6______6______5______5______6______6______ins and washouts), assessments, and visits for visits and assessments, washouts), and ins BMJ Open http://bmjopen.bmj.com/ on September 26, 2021 by guest. Protected copyright. For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml be collected. Reference to where list of study sites can be obtained obtained be can sites ofstudy list where to Reference collected. be allocation ratio, and framework (eg, superiority, equivalence, noninferiority, exploratory) exploratory) noninferiority, equivalence, superiority, (eg, framework and ratio, allocation participants. A schematic diagram is highly recommended (see Figure) Figure) (see recommended highly is diagram schematic A participants. Time schedule of enrolment, interventions (including any run- any (including interventions enrolment, of schedule Time efficacy and harm outcomes is strongly recommended recommended strongly is andharm outcomes efficacy median, proportion), and time point for each outcome. Explanation of the clinical relevance of chosen chosen of relevance clinical of the Explanation foroutcome. each point timeand proportion), median, pressure), analysis metric (eg, change from baseline, final value, time to event), method of aggregation (eg, aggregation methodof event), to time value, final baseline, from change (eg, metric analysis pressure), Primary, secondary, and other outcomes, including the specific measurement variable (eg, systolic blood blood (eg,systolic variable measurement specific the including outcomes, other and secondary, Primary, Relevant concomitant care and interventions that are permitted or prohibited during the trial trial the during prohibited or permitted are that interventions and care concomitant Relevant (eg, drug tablet return, laboratory tests) tests) laboratory return, tablet drug (eg, Strategies to improve adherence to intervention protocols, and any procedures for monitoring adherence adherence monitoring for procedures any and protocols, intervention to adherence improve to Strategies change in response to harms, participant request, or improving/worsening disease) disease) improving/worsening or request, participant harms, to response in change Criteria for discontinuing or modifying allocated interventions for a given trial participant (eg, drug dose drug (eg, participant trial given for a interventions allocated modifying or fordiscontinuing Criteria administered administered Interventions for each group with sufficient detail to allow replication, including how and when they will be be they will and when how including replication, allow to detail sufficient with group each for Interventions individuals who will perform the interventions (eg, surgeons, psychotherapists) psychotherapists) surgeons, (eg, interventions the perform will who individuals Inclusion and exclusion criteria for participants. If applicable, eligibility criteria for study centres and centres and criteriastudy for eligibility applicable, If for participants. criteria exclusion and Inclusion studies (published and unpublished) examining benefits and harms for each intervention intervention each for harms and benefits examining unpublished) and (published studies 13 13 12 12 11d 11d 11c 11c 11b 11b 11a 11a 10 10

6a 6a of relevant summary including trial, the forundertaking justification and question of research Description Participant timeline timeline Participant Outcomes Outcomes Interventions Interventions Eligibility criteria criteria Eligibility Study setting Study 9 will data where ofcountries list and hospital) academic clinic, community (eg, settings of study Description Methods: Participants, interventions, and outcomes outcomes and interventions, Participants, Methods: Introduction Introduction Background and Background rationale Objectives design Trial 7 8 hypotheses or 6b objectives Specific group), single factorial, crossover, group, parallel (eg, oftrial type including design of trial Description comparators of forchoice Explanation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 3

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on September 26, 2021 by guest. Protected copyright. For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml collected for participants who discontinue or deviate from intervention protocols protocols from intervention deviate or discontinue who forparticipants collected Plans to promote participant retention and complete follow-up, including list of any outcome data to to be data outcome of list any including follow-up, complete and retention participant promote to Plans Reference to where data collection forms can be found, if not in the protocol protocol inthe ifnot found, be can forms collection data where to Reference study instruments (eg, questionnaires, laboratory tests) along with their reliability and validity, if known. if known. validity, and reliability their with along tests) laboratory questionnaires, (eg, instruments study processes to promote data quality (eg, duplicate measurements, training of assessors) and a description of description a and assessors) of training measurements, duplicate (eg, quality data promote to processes Plans for assessment and collection of outcome, baseline, and other trial data, including any related related any including data, other trial and baseline, ofoutcome, collection and forassessment Plans allocated intervention during the the trial during intervention allocated If blinded, circumstances under which unblinding is permissible, and procedure for revealing a participant’s participant’s a forrevealing procedure and is permissible, unblinding which under circumstances blinded, If assessors, data analysts), and how how and analysts), data assessors, Who will be blinded after assignment to interventions (eg, trial participants, care providers, outcome outcome careproviders, participants, trial (eg, interventions to afterassignment blinded be will Who interventions interventions Who will generate the allocation sequence, who will enrol participants, and who will assign participants to to participants assign will andwho participants, enrol will who sequence, allocation the generate will Who opaque, sealed envelopes), describing any steps to conceal the sequence until interventions are assigned assigned are interventions until sequence the conceal to steps any describing envelopes), sealed opaque, Mechanism of implementing the allocation sequence (eg, central telephone; sequentially numbered, numbered, sequentially telephone; central (eg, sequence allocation the implementing of Mechanism or assign interventions interventions assign or (eg, blocking) should be provided in a separate document that is unavailable to those who enrol participants participants enrol who those to unavailable is that document separate a in provided be should blocking) (eg, factors for stratification. To reduce predictability of a random sequence, details of any planned restriction restriction planned ofany details sequence, random a of predictability reduce To forstratification. factors Method of generating the allocation sequence (eg, computer-generated random numbers), and list of any of list any and numbers), random computer-generated (eg, sequence allocation the of generating Method

Strategies for achieving adequate participant enrolment to reach target sample size size sample target reach to enrolment participant adequate forachieving Strategies clinical and statistical assumptions supporting any sample size calculations calculations samplesize any supporting assumptions statistical and clinical Estimated number of participants needed to achieve study objectives and how it was determined, including including determined, it was how and objectives study achieve to needed participants of number Estimated 18b 18b 18a 18a 17b 17b 17a 17a 16c 16c 16b 16b 16a 16a

15 15 14 14 Implementation Implementation mechanism mechanism concealment concealment generation generation Sequence Sequence Allocation Allocation

methods methods Data collection collection Data Methods: Data collection, management, and analysis and management, collection, Data Methods:

Blinding (masking) (masking) Blinding Methods: Assignment of interventions (for controlled trials) controlled (for interventions of Assignment Methods: Recruitment Recruitment Sample size size Sample

Allocation: Allocation: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 23 of 24 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 4 Page 24 of

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23 23 22 22 21b 21b 21a 21a 20c 20c 20b 20b 20a 20a 19 19 25 25 outcomes, criteria, eligibility to changes (eg, modifications protocol important communicating for Plans 24 24 approval (REC/IRB) board review committee/institutional ethics research seeking for Plans Protocol Protocol amendments Ethics and dissemination dissemination and Ethics Research ethics ethics Research approval Harms Harms

Data monitoring monitoring Data Methods: Monitoring Methods:

Statistical methods methods Statistical Data management management Data

Auditing Auditing 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 5

____ None ______None ______None ______None ______None ______None ______None ______None ______None ______None ______None ______None ______None ____ BMJ Open http://bmjopen.bmj.com/ on September 26, 2021 by guest. Protected copyright. For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml how (see Item 32) 32) (seeItem how studies, if applicable if applicable studies, trial afterthe and during, before, confidentiality protect to order in participation participation Provisions, if any, for ancillary and post-trial care, and for compensation to those who suffer harm from trial trial from harmsuffer who those to compensation for care,and post-trial and for ancillary ifany, Provisions, limit such access for investigators investigators for access such limit Statement of who will have access to the final trial dataset, and disclosure of contractual agreements that that agreements contractual of disclosure and dataset, trial final the to access have will of who Statement the public, and other relevant groups (eg, via publication, reporting in results databases, or other data data other or databases, results in reporting publication, via groups(eg, relevant other and public, the restrictions publication any including arrangements), sharing analysis in the current trial and for future use in ancillary studies, if applicable ifapplicable studies, ancillary in use future for and trial current the in analysis 26b 26b ancillary in specimens and biological data ofuseparticipant and collection for provisions consent Additional 31c 31c code andstatistical dataset, participant-level protocol, full the to access public for granting any, if Plans, ____ None ____ 31b 31b writers professional of use intended any and guidelines eligibility Authorship 28 28 site study each and trial overall forthe investigators principal for interests competing other and Financial ______17

31a 31a professionals, healthcare participants, to results trial communicate sponsorto and forinvestigators Plans 32 32 surrogates authorised and participants to given documentation related other formand consent Model 33 ____ None ____ molecular or forgenetic specimens biological of storage and evaluation, laboratory collection, for Plans 30 30 29 29

” license. license. ”Unported 3.0 Attribution-NonCommercial-NoDerivs Confidentiality 27 of Declaration interests maintained and shared, be collected, will participants andenrolled potential about information personal How Appendices consent Informed materials Biological specimens

*It is strongly recommended that this checklist be read in conjunction with the SPIRIT 2013 Explanation & Elaboration for important clarification on the items. items. the on clarification for important Elaboration & Explanation 2013 SPIRIT the with conjunction in read be thischecklist that recommended is strongly *It “ Dissemination policy Dissemination trial care trial Consent or assent assent or Consent 26a and surrogates, authorised or participants trial potential from assent or consent informed obtain will Who Amendments to the protocol should be tracked and dated. The SPIRIT checklist is copyrighted by the SPIRIT Group under the Creative Commons Commons Creative the under Group SPIRIT by the iscopyrighted checklist SPIRIT The dated. and tracked be should protocol the to Amendments Ancillary and post- and Ancillary Access to data data to Access 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 25 of 24 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

For peer review only Journal: BMJ Open

Manuscript ID bmjopen-2017-020785.R2

Article Type: Protocol

Date Submitted by the Author: 05-May-2018

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1 2 3 4 Oncology Huang, Guang; Hainan Province People’s Hospital, Department of Radiation 5 Oncology 6 Wu, Kailiang; Fudan University Shanghai Cancer Center, Department of 7 Radiation Oncology; Shanghai Medical College, Fudan University, 8 Department of Oncology 9 Fan, Min; Fudan University Shanghai Cancer Center, Department of 10 Radiation Oncology; Shanghai Medical College, Fudan University, Department of Oncology 11 Yang, Huanjun; Fudan University Shanghai Cancer Center, Department of 12 Radiation Oncology; Shanghai Medical College, Fudan University, 13 Department of Oncology 14 Zhu, Zhengfei; Fudan University Shanghai Cancer Center, Department of 15 Radiation Oncology; Shanghai Medical College, Fudan University, 16 Department of Oncology For peerZhao, Weixin; reviewFudan University Shanghai only Cancer Center, Department of 17 Radiation Oncology; Shanghai Medical College, Fudan University, 18 Department of Oncology 19 Li, Ling; Fudan University Shanghai Cancer Center, Department of 20 Radiation Oncology; Shanghai Medical College, Fudan University, 21 Department of Oncology 22 Fan, Jianhong; Renhe Hospital, Department of Gynecology Badakhshi, Harun; Charite´ School of Medicine and Centre for Cancer 23 Medicine, Department of Radiation Oncology 24 Zhao, Kuaile; Fudan University Shanghai Cancer Center, Department of 25 Radiation Oncology; Shanghai Medical College, Fudan University, 26 Department of Oncology 27 Primary Subject 28 Oncology Heading: 29 30 Secondary Subject Heading: Oncology 31 esophageal squamous cell carcinoma, concurrent chemoradiotherapy, 32 Keywords:

paclitaxel, cisplatin, carboplatin, fluorouracil http://bmjopen.bmj.com/ 33 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Comparison of paclitaxel in combination with cisplatin (TP), carboplatin (TC) or 4 5 fluorouracil (TF) concurrent with radiotherapy for patients with local advanced 6 esophageal squamous cell carcinoma: a threearm phase III randomized trial 7 8 (ESOShanghai 2) 9 1, 2 1, 2 1, 2 1, 2 1, 2 10 Dashan Ai , Yun Chen , Qi Liu , Junhua Zhang , Jiaying Deng , Hanting 11 Zhu1, 2, Wenjia Ren1, 2, Xiangpeng Zheng3, Yunhai Li4, Shihong Wei5, Jinjun Ye6, 12 13 Jialiang Zhou7, Qin Lin8, Hui Luo9, Jianzhong Cao10, Jiancheng Li11, Guang Huang12, 14 1, 2 1, 2 1, 2 1, 2 1, 2 15 Kailiang Wu , Min Fan , Huanjun Yang , Zhengfei Zhu , Weixin Zhao , Ling 16 Li1, 2, JianhongFor Fan13, Harunpeer Badakhshi review14, Kuaile Zhao1, only2 17 18 1. Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 19 20 Shanghai, China 21 2. Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 22 23 China 24 25 3. Department of Radiation Oncology, Huadong Hospital Affiliated to Fudan 26 University, Shanghai, China 27 28 4. Department of Radiation Oncology, Fudan University Shanghai Cancer Center 29 30 Minhang Branch Hospital, Shanghai, China 31 5. Department of Radiation Oncology, Gansu Province Cancer Hospital, Lanzhou, 32 33 China http://bmjopen.bmj.com/ 34 35 6. Department of Radiation Oncology, Jiangsu Province Cancer Hospital, Nanjing, 36 China 37 38 7. Department of Radiation Oncology, Affiliated Hospital of Jiangnan University, 39 40 Wuxi, China 41 8. Department of Radiation Oncology, First Affiliated Hospital of Xiamen University, on September 26, 2021 by guest. Protected copyright. 42 43 Xiamen, China 44 45 9. Department of Radiation Oncology, Jiangxi Province Cancer Hospital, Nanchang, 46 China 47 48 10. Department of Radiation Oncology, Shanxi Province Cancer Hospital, Taiyuan, 49 50 China 51 11. Department of Thoracic Radiation Oncology, Fujian Province Cancer Hospital, 52 53 Fuzhou, China 54 12. Department of Radiation Oncology, Hainan Province People’s Hospital, Haikou, 55 56 China 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 13. Department of Gynecology, Renhe hospital, Shanghai, China 4 5 14. Department of Radiation Oncology, Charite´ School of Medicine and Centre for 6 Cancer Medicine, Berlin, Germany 7 8 Corresponding author: Kuaile Zhao, 270 Dongan Rd, Shanghai, 200032, China. Email: 9 10 [email protected]. Tel: +862164175590 11 Key words: esophageal squamous cell carcinoma, concurrent chemoradiotherapy, 12 13 paclitaxel, cisplatin, carboplatin, fluorouracil 14 15 Word counts: 2,856 words 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Abstract 4 5 Introduction: Concurrent chemoradiation is the standard therapy for patients with 6 local advanced esophageal carcinoma unsuitable for surgery. Paclitaxel is an active 7 8 agent against esophageal cancer and it has been proved as a potent radiation sensitizer. 9 10 There have been multiple studies evaluating paclitaxelbased chemoradiation in 11 esophageal cancer, the results of which are inspiring. However, which regimen, 12 13 among paclitaxel in combination with cisplatin (TP), carboplatin (TC) and 14 15 fluorouracil (TF) concurrent with radiotherapy, provides best prognosis with 16 minimum adverseFor events peer is still considered review far from resolved only and very few studies 17 18 focus on this field. The purpose of this study is to confirm the priority of TF to TP or 19 20 TC concurrent with radiotherapy in terms of overall survival and propose a feasible 21 and effective plan for patients with local advanced esophageal cancer. 22 23 Methods and analysis: ESOShanghai 2 is a threearm, multicenter, openlabeled, 24 25 randomized phase III clinical trial. The study was initiated in July 2015 and the 26 duration of inclusion will be 4 years. The study compares two pairs of regimen: TF 27 28 versus TP and TF versus TC concurrent with definitive radiotherapy for patients with 29 30 esophageal squamous cell carcinoma (ESCC). Patients with histologically confirmed 31 ESCC (clinical stage II, III or IVa based on the 6th UICCTNM classification) and 32 33 without any prior treatment of chemotherapy, radiotherapy or surgery against http://bmjopen.bmj.com/ 34 35 esophageal cancer will be eligible. A total of 321 patients will be randomized and 36 allocated in a 1:1:1 ratio to the three treatment groups. Patients are stratified by lymph 37 38 node status (N0, N1, M1a). The primary endpoint is overall survival and the 39 40 secondary endpoint is progressionfree survival and adverse events. 41 Ethics and dissemination: on September 26, 2021 by guest. Protected copyright. 42 43 This trial has been approved by the Fudan University Shanghai Cancer Center 44 45 Institutional Review Board. Trial results will be disseminated via peer reviewed 46 scientific journals and conference presentations. 47 48 Trial registration: Clinicaltrials.gov: NCT02459457 49 50 51 52 53 54 55 56 57 58 3 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Strengths and limitations of this study 4 5 First phase III randomized multicentered study comparing these three regimens 6 Stratification by lymph node status (N0, N1, M1a based on the 6th UICCTNM 7 8 classification) 9 10 No stratification for different centers 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 4 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Introduction 4 5 Worldwide, esophageal cancer is the eighth most common cancer, which is 6 responsible for an estimated 455,800 new cases and 400,200 deaths in 2012.1 Since its 7 8 prognosis is dismal, much effort has been put into improving overall survival through 9 2 10 multimodality treatments, which consist of surgery, radiotherapy and chemotherapy. 11 Concurrent chemoradiation is the standard nonoperative therapy for local advanced 12 13 esophageal squamous cell carcinoma (ESCC).3 14 15 Paclitaxel is an active agent against esophageal cancer, with the response rate of 16 28% in ESCC,For and it haspeer been shown review to be a potent radiation only sensitizer.4 There have 17 18 been multiple studies evaluating paclitaxelbased chemoradiation in esophageal 19 20 cancer, for instance, paclitaxel/fluorouracil (TF) developed at The University of Texas 21 M.D. Anderson Cancer Center, and paclitaxel/cisplatin (TP) developed at Memorial 22 23 SloanKettering Cancer Center,5 6 with paclitaxel/carboplatin (TC) from CROSS 24 7 25 trial. In many preoperative studies, paclitaxelbased chemoradiotherapy has achieved 26 inspiring effect, the pathologic complete response rates of TPbased 27 28 chemoradiotherapy were 19%42%, 811 and of TCbased chemoradiotherapy was 29 7 30 49%. However, which regimen, among TF, TP and TCbased definitive 31 chemoradiotherapy, provides best prognosis with minimum adverse events is still 32 33 considered far from resolved and very few studies focus on this field. http://bmjopen.bmj.com/ 34 5 35 RTOG 0113 evaluated 2 different paclitaxelbased regimens (TP and TF). 36 Eightyfour patients were accrued to this study. Patients in arm A (TF) received 37 38 induction 5FU, cisplatin, and paclitaxel followed by radiation and concurrent 39 40 continuous infusion 5FU and weekly paclitaxel. Patients in arm B (TP) received 41 induction paclitaxel and cisplatin followed by radiation and concurrent weekly on September 26, 2021 by guest. Protected copyright. 42 43 cisplatin and 96hour infusion of paclitaxel. The median survival time was 28.7 44 45 months for patients in arm A (TF) and 14.9 months for patients in arm B (TP). Neither 46 arm achieved the hypothesized 1year survival rate of at least 77.5%. The main 47 48 deficiency of this study is the small sample size, but the effect of TF group is still 49 50 inspiring. 51 Another retrospective multicenter randomize clinical trials from Europe12 52 53 showed the overall survival of TCbased definitive chemoradiotherapy was 54 comparable with cisplatin/5FU (PF) as definitive concurrent chemoradiotherapy in 55 56 57 58 5 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 esophageal cancer. However, the toxicity rates were lower in the TC group together 4 5 with higher treatment compliance. 6 Based on RTOG 0113 and other reports, we designed a multicenter randomized 7 8 controlled phase III trial to confirm the priority of TF to TP and TF to TC concurrent 9 10 with radiotherapy in terms of overall survival for patients with local advanced 11 esophageal squamous cell carcinoma. Independent ethics committees of the 12 13 participating centers approved the study protocol. This trial has been registered with 14 15 ClinicalTrials.gov, number NCT02459457. 16 The trialFor is a threearm, peer multicenter, review openlabeled, randomizedonly phase III clinical 17 18 trial. The study was initiated in July 2015 and the duration of inclusion will be 4 years. 19 20 The study compares two pairs of regimen: TF versus TP and TF versus TC concurrent 21 with definitive radiotherapy in patients with esophageal squamous cell carcinoma. 22 23 24 25 26 Methods and analysis 27 28 29 30 Patient selection 31 To be eligible for this study, patient must fulfill all of the following criteria (Table 1): 32 33 http://bmjopen.bmj.com/ 34 Inclusion criteria 35 1. Histologically confirmed esophageal squamous cell carcinoma 36 37 2. Clinical stages II, III or IVa based on the 6th UICCTNM classification 38 39 3. No prior treatment of chemotherapy, radiotherapy or surgery against esophageal 40 cancer, except for noncurative resection by EMR/ESD. 41 on September 26, 2021 by guest. Protected copyright. 42 4. Aged 1875 years 43 44 5. Adequate organ functions for chemoradiation therapy 45 a) White blood cell (WBC) ≥3×109L 46 9 47 b) Absolute neutrophil counts (ANC) ≥1.5×10 L 48 49 c) Hemoglobin (Hb) ≥10gdl 50 d) Platelet (Plt) ≥100×109L 51 52 e) Total bilirubin <1.5 upper limit of normal (ULN) 53 f) Aspartate transaminase (AST) ≤2.5 ULN 54 55 g) Alanine aminotransferase (ALT) ≤2.5 ULN 56 57 58 6 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 h) Creatinine ≤1.5 ULN 4 5 6. ECOG PS of 02 6 7. Life expectancy ≥3 months 7 8 8. Written informed consent (Supplementary material) 9 10 Table 1. Inclusion criteria 11

12 13 Patients fulfilling any of the following criteria are ineligible for this study (Table 2). 14 15 Exclusion criteria 16 For peer review only 17 1. Esophageal perforation or hematemesis 18 2. Synchronous or metachronous malignancies (except for cutaneous 19 20 (nonmelanomas) carcinoma, thyroid papillary carcinoma, phase I seminoma or 21 22 cervical carcinoma in situ curatively treated and disease free for a minimum of 3 23 months) 24 25 3. Received thoracic, abdominal or craniocerebral surgery within 30 days 26 4. Enrolled in other clinical trials within 30 days 27 28 5. Unstable angina and/or congestive heart failure requiring hospitalization within 6 29 30 months 31 6. Severe psychiatric disease 32 33 7. Pregnancy, lactation or unwillingness to adopt contraception http://bmjopen.bmj.com/ 34 35 8. Drug addiction 36 9. Acquired immune deficiency syndrome (AIDS) based upon current CDC 37 38 definition 39 40 10. History of radiotherapy in the planning area on September 26, 2021 by guest. Protected copyright. 41 11. Other ineligible conditions according to researchers 42 43 Table 2. Exclusion criteria 44 45 46 Treatment 47 48 The treatment plan is shown in Figure 1. Patients receive radiotherapy combined 49 50 with concurrent chemotherapy. Radiotherapy begins on day 1, concurrent with the 51 beginning of cycle 1 of chemotherapy. 52 53 Same radiation therapy will be delivered in all three treatment groups. 54 55 Radiotherapy is delivered with photons (≥6 MV) to a total dose of 61.2Gy in 34 56 fractions. Patients will be treated 5 days per week at 1.8Gy/d. Threedimensional 57 58 7 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 conformal radiotherapy or intensity modulated radiotherapy is required. All patient 4 5 will be positioned in an individualized immobilization device in the treatment 6 position. 7 8 The definition of volumes will be in accordance with the 1993 ICRU Report #50 9 10 and 1999 ICRU Report #62. 11 The gross target volume (GTV) is defined as all known involved field, which 12 13 detected by endoscopic ultrasound, barium swallow or CT scan (whichever is larger). 14 15 The regional lymph nodes included in GTV is whose diameter more than 1cm (0.5cm 16 for lymph nodesFor at tracheoesophagealpeer review groove) or histologically only proven metastatic 17 18 after puncture. 19 20 The superior and inferior borders of the clinical target volume (CTV) are 3cm 21 beyond the primary tumor along the esophagus. The lateral, anterior and posterior 22 23 borders of the field are the same as GTV. 24 25 The superior, inferior, anterior, posterior and lateral borders of planning target 26 volume (PTV) are 1cm beyond CTV. Field next to the spinal cord could be slightly 27 28 adjusted in order to reduce the exposure of spinal cord. 29 30 As for target volume, tissue inhomogeneity correction is adopted and it is 31 required that more than 99% PTV receive 95% prescription dose and more than 95% 32 33 PTV receive 99% or more prescription dose. Highest and lowest point dose inside http://bmjopen.bmj.com/ 34 35 PTV should be recorded. 36 When making the treatment plan, we should take normal organ dose restrictions 37 38 into consideration as the following order: (Table 3) 39 40 41 Risk organ Contour regulation Dose restriction on September 26, 2021 by guest. Protected copyright. 42 43 Spinal cord All the layers of CT scan have Highest point dose less 44 45 to be contoured and the margin than 45Gy 46 of vertebra tube can be 47 48 regarded as that of planning 49 50 organ at risk volume. 51 Lung It is allowed to use automatic The volume of lung (PTV 52 53 tools in the delineation of excluded) receiving 20Gy 54 55 margin of lungs. (Trachea and or higher has to be less 56 57 58 8 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 bronchia must be contoured than 30% of the total lung 4 5 manually) volume, and the mean 6 dose has to be less than 7 8 15Gy. 9 10 Heart The superior margin of heart The mean dose has to be 11 consists of right atrium and less than 40Gy. 12 13 right ventricle, pulmonary 14 15 artery trunk, ascending main 16 For peeraorta and review superior vena cava only 17 18 excluded. The inferior margin 19 20 is at the level of heart apex. 21 Table 3. Contour regulation and dose restriction of risk organs 22 23 24 25 Chemotherapy 26 Patients are randomly assigned to receive one of three therapies. 27 28 Arm A (TP) 29 30 Patients in arm A receive 4 courses of TP every 4 weeks. Details are as follows: 31 Paclitaxel: 175mg/m2/d, ivgtt over 3 hours, d1; Cisplatin: 25mg/m2/d, ivgtt, d13; 32 33 Arm B (TF) http://bmjopen.bmj.com/ 34 35 Patients in arm B receive 6 courses of TF concurrent with radiotherapy every week 36 and 2 courses of TF consolidation chemotherapy every 4 weeks. Details are as 37 38 follows: 39 2 2 40 Concurrent: paclitaxel 50mg/m /d, ivgtt over 3 hours, d1; 5FU 300mg/m , civ 96h, on September 26, 2021 by guest. Protected copyright. 41 d14 42 43 Consolidation: paclitaxel 175 mg/m2/d, ivgtt over 3 hours, d1; 5FU 1800mg/m2, civ 44 45 72h, d13 46 Arm C (TC) 47 48 Patients in arm C receive 6 courses of TC concurrent with radiotherapy every week 49 50 and 2 courses of TC consolidation chemotherapy every 4 weeks. Details are as 51 follows: 52 53 Concurrent: paclitaxel 50mg/m2/d, ivgtt over 3 hours, d1; carboplatin AUC=2, ivgtt, 54 55 d1 56 Consolidation: paclitaxel 175 mg/m2/d, ivgtt over 3 hours, d1; carboplatin AUC=5, 57 58 9 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 ivgtt, d1 4 5 Patients receive premedication to prevent allergic reaction and significant nausea or 6 vomiting as indicated. 7 8 9 10 Dose modifications 11 Radiotherapy interruption 12 13 If following toxicity is observed, radiotherapy has to be delayed until toxicity is no 14 15 more than grade 2. 16 WBC<2.0×10For9/L orpeer ANC<1.0×10 review9/L only 17 18 Plt<50×109/L 19 20 Grade 3 or higher nonhematological toxicity 21 If following toxicity is observed, radiotherapy has to be delayed until complete 22 23 recovery. 24 25 Mediastinal or thoracic infection with fever over 38.5℃ 26 It is allowed to suspend at most 2 weeks, or radiotherapy will be terminated. 27 28 29 30 Chemotherapy interruption and dose modifications 31 If following toxicity is observed on day 1, chemotherapy has to be delayed until 32 33 toxicity is no more than grade 1. http://bmjopen.bmj.com/ 34 9 35 ANC<1.5×10 /L 36 Plt<100×109/L 37 38 Grade 2 or higher nonhematological toxicity, except for nausea, vomiting and 39 40 alopecia 41 It is allowed to delay at most 2 weeks, or chemotherapy will be terminated. on September 26, 2021 by guest. Protected copyright. 42 43 Chemotherapy dose modifications are based on the greatest toxicity during the last 44 45 cycle. Any patients who need to make chemotherapy dose modifications will receive 46 the modified dose in the following cycles. 47 48 If modifications are needed, dose of paclitaxel, cisplatin, carboplatin and 5FU will 49 50 decreased by 25% from the planned dose for the first time and 50% for the second 51 time. It is allowed to make dose modifications at most twice, or chemotherapy will be 52 53 terminated. Details are as follows: 54 Dose modification of paclitaxel 55 56 Febrile neutropenia (ANC< 0.5×109/L and fever over 38.3℃ or over 38.0℃ for 57 58 10 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 1h) 4 5 Grade 2 or higher peripheral neuropathy 6

7 8 Dose modification of cisplatin and carboplatin 9 9 10 Febrile neutropenia (ANC< 0.5×10 /L and fever over 38.3℃ or over 38.0℃ for 11 1h) 12 13 Grade 2 or higher peripheral neuropathy 14 15 Serum creatinine >3ULN 16 For peer review only 17 18 Dose modification of 5FU 19 9 20 Febrile neutropenia (ANC< 0.5×10 /L and fever over 38.3℃ or over 38.0℃ for 21 1h) 22 23 Grade 3 or higher mucositis 24 25 26 The adverse events will be evaluated according to the National Cancer Institute 27 28 Common Terminology Criteria for Adverse Events (CTCAE version 4.0). All adverse 29 30 events, occurring during the course of the trial, which is from randomization until 28 31 days after end of treatment, regardless of relatedness to study medication, will be 32 33 recorded. Adverse events occurring later than 28 days after the end of treatment will http://bmjopen.bmj.com/ 34 35 only be recorded if they are considered relevant. 36 37 38 Randomization 39 40 After the confirmation of eligibility criteria, patients will be randomly allocated in a 41 1:1:1 ratio to the three treatment groups by a central randomization center (Fudan on September 26, 2021 by guest. Protected copyright. 42 43 University Shanghai Cancer Center, Shanghai, China). Patients will be stratified by 44 45 lymph node status (N0, N1, M1a). The SAS was used to generate a random 46 permutation sequence and produce patient randomization numbers. The data center 47 48 registers the enrollment, assigns a unique identification number to every participant, 49 50 and replies to the respective investigators. 51 52 53 Sample size calculation and statistical analysis 54 This threearm randomized trial is designed to confirm whether TF is superior to TP 55 56 or TC concurrent with radiotherapy in terms of overall survival. According to RTOG 57 58 11 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 0113 and other reports, median survival time of TF concurrent with radiotherapy for 4 5 13 5 esophageal cancer is 28.7 months while TP 14.9 months and TC 17.4 months . 6 According to the Schoenfeld and Richter’s method, the sample size of 107 patients 7 8 per arm (154 events in total) is required to warrant a power of 80% at a twosided α 9 10 level of 0.025 for the comparison between TP and TF with relatively smaller 11 difference, assuming an accrual period of 48 months, a minimum followup period of 12 13 24 months and a dropout rate of 10%14 15. The total sample size is planned as 321 14 15 patients (107 patients in each arm, a total of 231 events). 16 The medianFor overall survivalpeer will review be estimated with only KaplanMeier method, and 17 18 logrank test will be used to compare the overall survival among treatment arms. We 19 20 will conduct a subgroup analyze to test whether the treatment effects differ among 21 subgroups (N0, N1, M1a). 22 23 24 25 Endpoints 26 The primary endpoint is overall survival in all randomized patients. Overall 27 28 survival is defined as time from the date of randomization until death. The secondary 29 30 endpoint is progression free survival (PFS) and adverse events. PFS is defined as the 31 time from the date of randomization to the date of progression or to the date of death, 32 33 whichever occurs first and disease progression will be evaluated according to http://bmjopen.bmj.com/ 34 35 RECIST Version 1.1. Adverse events will be evaluated according to the National 36 Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 37 38 4.0). 39 40 41 Data collection on September 26, 2021 by guest. Protected copyright. 42 43 Participants will be seen at hospital or contacted by telephone, letters from 44 45 randomization to the end of treatment cycle, then at Month 3, 6, 9, 12, 15, 18, 21, 24, 46 30, 36, 42, 48, 54 and 60 after last treatment. Research staff at the hospitals will be 47 48 expected to complete trial CRFs which record evidence of primary and secondary out 49 50 come measures. 51 52 53 Interim analysis 54 We plan to conduct two interim analyses. The first interim analysis will be conducted 55 56 independently from the study group when half of the planned number of patients are 57 58 12 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 enrolled and the second interim just after the planned patient accrual is completed. If 4 5 the superiority of one of test arms is demonstrated with an adjusted α level, the study 6 will be terminated. 7 8 In general, the interim reports will contain the following information: 9 10 1. Patient accrual rate with a projected completion date (while the study is still 11 accruing) 12 13 2. Total patients accrued 14 15 3. Distributions of important pretreatment and prognostic baseline variables 16 4. The frequenciesFor and peerseverity of adverse review events by treatment only arm. 17 18 5. Compliance rates of treatment delivery 19 20 6. Observed results with respect to the primary and secondary endpoints 21 22 23 Patient and Public Involvement 24 25 Neither patients nor public will be involved in the design, recruitment, outcome 26 measures and conduct of the study. Trial results will be disseminated via peer 27 28 reviewed scientific journals and conference presentations rather than specifically 29 30 notified to a single patient. 31 32 33 Ethics and dissemination http://bmjopen.bmj.com/ 34 35 This trial has been approved by the Fudan University Shanghai Cancer Center 36 Institutional Review Board (Ethics Committee of Fudan University Shanghai Cancer 37 38 Center：No.150514613). Written informed consent will be obtained from all 39 40 participants. Serious adverse events will be reported to the safety desk of the trial, the 41 Data and Safety Monitoring Board and trial sites. Trial results will be disseminated on September 26, 2021 by guest. Protected copyright. 42 43 via peer reviewed scientific journals and conference presentations. 44 45 46 Participating institutions (From east to west) 47 48 Fudan University Shanghai Cancer Center, Huadong Hospital Affiliated to Fudan 49 50 University, Fudan University Shanghai Cancer Center Minhang Branch, Affiliated 51 Hospital of Jiangnan University, Fujian Province Cancer Hospital, Jiangsu Province 52 53 Cancer Hospital, The First Affiliated Hospital of Xiamen University, Jiangxi Province 54 Cancer Hospital, Shanxi Province Cancer Hospital, Hainan Province People’s 55 56 Hospital, Gansu Province Cancer Hospital 57 58 13 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 4 5 Trial Status 6 The trial was initiated in July 2015 and is currently recruiting patients in all of the 7 8 participating institutions above. 9 10 11 12 13 14 15 Reference: 16 1. Torre LA, ForBray F, Siegel peer RL, et al. reviewGlobal Cancer Statistics, only 2012. Ca-Cancer J Clin 17 18 2015;65(2):87-108. 19 20 2. Enzinger PC, Mayer RJ. Esophageal cancer. N Engl J Med 21 2003;349(23):2241-52. 22 23 3. Herskovic A, Martz K, Alsarraf M, et al. Combined Chemotherapy and 24 25 Radiotherapy Compared with Radiotherapy Alone in Patients with Cancer 26 of the Esophagus. New Engl J Med 1992;326(24):1593-98. 27 28 4. Ajani JA, Ilson DH, Daugherty K, et al. Activity of Taxol in Patients with 29 30 Squamous-Cell Carcinoma and Adenocarcinoma of the Esophagus. J Natl 31 Cancer I 1994;86(14):1086-91. 32 33 5. Ajani JA, Winter K, Komaki R, et al. Phase II randomized trial of two http://bmjopen.bmj.com/ 34 35 nonoperative regimens of induction chemotherapy followed by 36 chemoradiation in patients with localized carcinoma of the esophagus: 37 38 RTOG 0113. J Clin Oncol 2008;26(28):4551-56. 39 40 6. Schnirer II, Komaki R, Yao JC, et al. Pilot study of concurrent 41 5-fluorouracil/paclitaxel plus radiotherapy in patients with carcinoma of on September 26, 2021 by guest. Protected copyright. 42 43 the esophagus and gastroesophageal junction. Am J Clin Oncol-Canc 44 45 2001;24(1):91-95. 46 7. Shapiro J, Van Lanschot JJB, Hulshof MCCM, et al. Neoadjuvant 47 48 chemoradiotherapy plus surgery versus surgery alone for oesophageal or 49 50 junctional cancer (CROSS): long-term results of a randomised controlled 51 trial. Lancet Oncol 2015;16(9):1090-98. 52 53 8. Safran H, Gaissert H, Akerman P, et al. Paclitaxel, cisplatin, and concurrent 54 55 radiation for esophageal cancer. Cancer Invest 2001;19(1):1-7. 56 9. Bains MS, Stojadinovic A, Minsky B, et al. A phase II trial of preoperative 57 58 14 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 combined-modality therapy for localized esophageal carcinoma: Initial 4 5 results. J Thorac Cardiov Sur 2002;124(2):270-77. 6 10. Urba SG, Orringer MB, Ianettonni M, et al. Concurrent cisplatin, paclitaxel, and 7 8 radiotherapy as preoperative treatment for patients with locoregional 9 10 esophageal carcinoma. Cancer 2003;98(10):2177-83. 11 11. Lin CC, Hsu CH, Cheng JC, et al. Concurrent chemoradiotherapy with twice 12 13 weekly paclitaxel and cisplatin followed by esophagectomy for locally 14 15 advanced esophageal cancer. Ann Oncol 2007;18(1):93-98. 16 12. Honing J,For Smit JK, Muijspeer CT, et al.review A comparison of carboplatinonly and paclitaxel 17 18 with cisplatinum and 5-fluorouracil in definitive chemoradiation in 19 20 esophageal cancer patients. Ann Oncol 2014;25(3):638-43. 21 13. Mohammad NH, Hulshof MCCM, Bergman JJGHM, et al. Acute toxicity of 22 23 definitive chemoradiation in patients with inoperable or irresectable 24 25 esophageal carcinoma. Bmc Cancer 2014;14. 26 14. Lakatos E. Designing complex group sequential survival trials. Stat Med 27 28 2002;21(14):1969-89. 29 30 15. Lakatos E. Sample Sizes Based on the Log-Rank Statistic in Complex 31 Clinical-Trials. Biometrics 1988;44(1):229-41. 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 15 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Declarations 4 5 List of abbreviations 6 TP: Paclitaxel combined with cisplatin 7 8 TC: Paclitaxel combined with carboplatin 9 10 TF: Paclitaxel combined with fluorouracil 11 UICC: Union for International Cancer Control 12 13 ESCC: Esophageal squamous cell carcinoma 14 15 PF: Cisplatin combined with fluorouracil 16 AIDS: AcquiredFor immune peer deficiency reviewsyndrome only 17 18 RT: Radiotherapy 19 20 PTX: Paclitaxel 21 DDP: Cisplatin 22 23 CBP: Carboplatin 24 25 5FU: Fluorouracil 26 W: Week 27 28 ICRU: International Commission on Radiation Units and Measurements 29 30 GTV: Gross Target Volume 31 CTV: Clinical Target Volume 32 33 PTV: Planning Target Volume http://bmjopen.bmj.com/ 34 35 WBC: White Blood Cell 36 ANC: Absolute Neutrophil Counts 37 38 Hb: Hemoglobin 39 40 Plt: Platelet 41 ULN: Upper Limit of Normal on September 26, 2021 by guest. Protected copyright. 42 43 AST: Aspartate Transaminase 44 45 ALT: Alanine aminotransferase 46 47 48 49 50 Consent of publication 51 Not applicable 52 53 54 Declaration of interests 55 56 We declare no competing interests. 57 58 16 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 4 5 Funding 6 The study was supported by 2015 Prospective Clinical Research Fund of Fudan 7 8 University Shanghai Cancer Center. 9 10 11 Author’s contributions 12 13 D Ai was responsible for drafting the manuscript. Y Chen, Q Liu, J Zhang, J Deng, H 14 15 Zhu, W Ren, K Wu, M Fan, H Yang, Z Zhu, W Zhao, L Li were responsible for the 16 collection ofFor previous studypeer and putting review forward the conception. only X Zheng, Y Li, J Ye, 17 18 J Zhou, Q Lin, H Luo, J Cao, S Wei, J Fan, J Li, G Huang and H Badakhshi were 19 20 responsible for designing the details of the study. K Zhao was responsible for all 21 aspects of trial design, the protocol and trial conduct. All authors have read and 22 23 approved this manuscript. 24 25 26 Data Sharing Statement 27 28 No additional unpublished data from the study are available. 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 17 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Fig1. Treatment Design of the ESOShanghai 2 trial. 4 5 TP (arm A), TF (arm B) and TC (arm C) are TP, TF and TCbased definitive 6 chemoradiotherapy, respectively. 7 8 RT=radiotherapy, PTX=paclitaxel, DDP=cisplatin, 5Fu=fluorouracil, 9 10 CBP=carboplatin, W=Week. 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 18 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Fig1. Treatment design of the ESO-Shanghai 2 trial. RT=radiotherapy, PTX=paclitaxel, DDP=cisplatin, 5- 31 Fu=fluorouracil, CBP=carboplatin, W=Week.

32 335x236mm (72 x 72 DPI) 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Informed Consent Form 4 5 Comparison of paclitaxel in combination with cisplatin (TP), carboplatin (TC) or 6 fluorouracil (TF) concurrent with radiotherapy for patients with local advanced 7 8 esophageal squamous cell carcinoma: a three-arm phase III randomized trial 9 10 (ESO-Shanghai 2) 11

12 13 You are being asked to take part in a clinical study. Please take your time to make 14 15 your decision about taking part. If you have any questions, you can ask your 16 study doctorFor for more peer explanation. review only 17 18 You are being asked to take part in this study because you have local advanced 19 20 esophageal squamous cell carcinoma. 21 22 23 Why is this study being done? 24 25 Concurrent chemoradiation is the standard therapy for patients with local advanced 26 esophageal carcinoma unsuitable for surgery. Paclitaxel is an active agent against 27 28 esophageal cancer and it has been proved as a potent radiation sensitizer. There have 29 30 been multiple studies evaluating paclitaxel-based chemoradiation in esophageal 31 cancer, the results of which are inspiring. However, which regimen, among paclitaxel 32 33 in combination with cisplatin (TP), carboplatin (TC) and fluorouracil (TF) concurrent http://bmjopen.bmj.com/ 34 35 with radiotherapy, provides best prognosis with minimum adverse events is still 36 considered far from resolved and very few studies focus on this field. The purpose of 37 38 this study is to confirm the priority of TF to TP or TC concurrent with radiotherapy in 39 40 terms of overall survival and propose a feasible and effective plan for patients with on September 26, 2021 by guest. Protected copyright. 41 local advanced esophageal cancer. 42 43 44 45 How many people will take part in the study? 46 About 321 people will take part in this study. 47 48 49 50 What will happen if I take part in this research study? 51 You will be randomized and allocated in a 1:1:1 ratio to the three treatment groups (TF, 52 53 TP or TC). You will receive radiotherapy combined with concurrent chemotherapy. 54 Radiotherapy will begin on day 1, concurrent with the beginning of cycle 1 of 55 56 chemotherapy. 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Radiation therapy 4 5 Same radiation therapy will be delivered in all three treatment groups. Radiotherapy 6 will be delivered with photons (≥6 MV) to a total dose of 61.2Gy in 34 fractions. You will 7 8 be treated 5 days per week at 1.8Gy/d. 9 10 11 Chemotherapy 12 13 Arm A (TP) 14 15 If you are in arm A, you will receive 4 courses of TP every 4 weeks. Details are as 16 follows: For peer review only 17 18 Paclitaxel: 175mg/m2/d, ivgtt over 3 hours, d1; Cisplatin: 25mg/m2/d, ivgtt, d1-3; 19 20 Arm B (TF) 21 If you are in arm B, you will receive 6 courses of TF concurrent with radiotherapy every 22 23 week and 2 courses of TF adjuvant chemotherapy every 4 weeks. Details are as 24 25 follows: 26 Concurrent: paclitaxel 50mg/m2/d, ivgtt over 3 hours, d1; 5-FU 300mg/m2, civ 96h, 27 28 d1-4

29 2 2 30 Adjuvant: paclitaxel 175 mg/m /d, ivgtt over 3 hours, d1; 5-FU 1800mg/m , civ 72h, 31 d1-3 32 33 Arm C (TC) http://bmjopen.bmj.com/ 34 35 If you are in arm C, you will receive 6 courses of TC concurrent with radiotherapy every 36 week and 2 courses of TC adjuvant chemotherapy every 4 weeks. Details are as 37 38 follows:

39 2 40 Concurrent: paclitaxel 50mg/m /d, ivgtt over 3 hours, d1; carboplatin AUC=2, ivgtt, d1 on September 26, 2021 by guest. Protected copyright. 41 Adjuvant: paclitaxel 175 mg/m2/d, ivgtt over 3 hours, d1; carboplatin AUC=5, ivgtt, d1 42 43 44 45 During each treatment, blood tests will be performed to monitor blood counts, kidney 46 function, liver function and electrolyte levels. Ultrasound, barium swallow and CT scan 47 48 with contrast will be performed to evaluate the status of disease. 49 50 51 How long will I be in the study? 52 53 After your treatment is completed, you will be seen in follow-up visits with your doctor 54 every 3 months in years 1-2, every 6 months in years 3-5 and then once a year for your 55 56 lifetime. 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Can I stop being in the study? 4 5 Yes. You can decide to stop at any time. Tell the study doctor if you are thinking about 6 stopping or decide to stop. He or she will tell you how to stop safely. 7 8 It is important to tell the study doctor if you are thinking about stopping so he or she can 9 10 evaluate any risks from the treatment. Another reason to tell your study doctor that 11 you are thinking about stopping is to discuss what follow-up care and testing could be 12 13 most helpful for you. 14 15 The study doctor may stop you from taking part in this study at any time if he/she 16 believes it isFor in your best peer interest, if youreview do not follow the only study rules, or if the study is 17 18 stopped. 19 20 21 What side effects or risks can I expect from being in the study? 22 23 You may have side effects while on the study. Everyone taking part in the study will be 24 25 watched carefully for any side effects. However, doctors don’t know all the side effects 26 that may happen. Side effects may be mild or very serious. There also is a risk of 27 28 death. 29 30 Risks and side effects related to the chemoradiotherapy 31 Soreness in throat or esophagus 32 33 Cough http://bmjopen.bmj.com/ 34 35 Vomiting 36 Nausea 37 38 Fatigue 39 40 Anorexia (loss of appetite) on September 26, 2021 by guest. Protected copyright. 41 Diarrhea 42 43 Numbness in arms and legs 44 45 Allergic reaction 46 Hair loss 47 48 Redness of irritation of the skin in the treatment area 49 50 Decrease in white blood cell counts and high risk of infection 51 Renal insufficiency, 52 53 54 Are there benefits to taking part in the study? 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Taking part in this study may or may not make your health better. While researchers 4 5 hope these treatment regimens will be more useful against cancer compared to the 6 usual treatment, there is no proof of this yet. We do know that the information from this 7 8 study will help researchers learn more about these combinations of drugs as a 9 10 treatment for cancer. This information could help future cancer patients. 11

12 13 Will my medical information be kept private? 14 15 We will do our best to make sure that the personal information in your medical record 16 will be kept private.For Your peer personal information review may be given only out if required by law. If 17 18 information from this study is published or presented at scientific meetings, your name 19 20 and other personal information will not be used. 21 22 23 What happens if I am injured because I took part in this study? 24 25 It is important that you tell your study doctor if you feel that you have been injured 26 because of taking part in this study. You will get medical treatment if you are injured as 27 28 a result of taking part in this study. You and/or your health plan will be charged for this 29 30 treatment. The study will not pay for medical treatment. 31 32 33 What are my rights if I take part in this study? http://bmjopen.bmj.com/ 34 35 Taking part in this study is your choice. You may choose either to take part or not to 36 take part in the study. If you decide to take part in this study, you may leave the study at 37 38 any time. No matter what decision you make, there will be no penalty to you and you 39 40 will not lose any of your regular benefits. Leaving the study will not affect your medical on September 26, 2021 by guest. Protected copyright. 41 care. You can still get your medical care from our center. 42 43 We will tell you about new information or changes in the study that may affect your 44 45 health or your willingness to continue in the study. 46 In the case of injury resulting from this study, you do not lose any of your legal rights to 47 48 seek payment by signing this form. 49 50 51 WHO CAN ANSWER MY QUESTIONS ABOUT THE STUDY? 52 53 You can talk to your study doctor about any questions or concerns you have about this 54 study. Contact your study doctor, Kuaile Zhao, at 021-64175590. 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Signature 4 5 6 I have been given a copy of all 5 pages of this form. I have read it or it has been 7 8 read to me. I understand the information and have had my questions answered. 9 10 I agree to take part in this study. 11

12 13 14 15 16 For peer review only 17 18 19 20 Participant: 21 22 23 ______24 25 Name of Participant Signature Date 26 27 28 29 30 Researcher: 31 32 33 ______http://bmjopen.bmj.com/ 34 35 Name of Participant Signature Date 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 1 Page 26 of 29

Addressed on Addressed number page

Funding Funding Roles and and Roles responsibilities Protocol version version Protocol 3 identifier version and Date Title Title Trial registration registration Trial 2a registry intended of name registered, yet Ifname. not registry and identifier Trial Administrative information Administrative documents* related and protocol trial clinical a in address to items Recommended Checklist: 2013 SPIRIT Section/item Item 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 2

6a 6a of relevant summary including trial, the forundertaking justification and question of research Description Participant timeline timeline Participant Outcomes Outcomes Interventions Interventions Eligibility criteria criteria Eligibility Study setting Study 9 will data where ofcountries list and hospital) academic clinic, community (eg, settings of study Description Methods: Participants, interventions, and outcomes outcomes and interventions, Participants, Methods: Introduction Introduction Background and Background rationale Objectives design Trial 7 8 hypotheses or 6b objectives Specific group), single factorial, crossover, group, parallel (eg, oftrial type including design of trial Description comparators of forchoice Explanation Page 27 of 29 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 3 Page 28 of 29

15 15 14 14 Implementation Implementation mechanism mechanism concealment concealment generation generation Sequence Sequence Allocation Allocation

methods methods Data collection collection Data Methods: Data collection, management, and analysis and management, collection, Data Methods:

Blinding (masking) (masking) Blinding Methods: Assignment of interventions (for controlled trials) controlled (for interventions of Assignment Methods: Recruitment Recruitment Sample size size Sample

Allocation: Allocation: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 4

Data monitoring monitoring Data Methods: Monitoring Methods:

Statistical methods methods Statistical Data management management Data

Auditing Auditing 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 29 of BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 5 Page 30 of 29

*It is strongly recommended that this checklist be read in conjunction with the SPIRIT 2013 Explanation & Elaboration for important clarification on the items. items. the on clarification for important Elaboration & Explanation 2013 SPIRIT the with conjunction in read be thischecklist that recommended is strongly *It “ Dissemination policy Dissemination trial care trial Consent or assent assent or Consent 26a and surrogates, authorised or participants trial potential from assent or consent informed obtain will Who Amendments to the protocol should be tracked and dated. The SPIRIT checklist is copyrighted by the SPIRIT Group under the Creative Commons Commons Creative the under Group SPIRIT by the iscopyrighted checklist SPIRIT The dated. and tracked be should protocol the to Amendments Ancillary and post- and Ancillary Access to data data to Access 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

For peer review only Journal: BMJ Open

Manuscript ID bmjopen-2017-020785.R3

Article Type: Protocol

Date Submitted by the Author: 09-Jul-2018

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 4 Oncology Huang, Guang; Hainan Province People’s Hospital, Department of Radiation 5 Oncology 6 Wu, Kailiang; Fudan University Shanghai Cancer Center, Department of 7 Radiation Oncology; Shanghai Medical College, Fudan University, 8 Department of Oncology 9 Fan, Min; Fudan University Shanghai Cancer Center, Department of 10 Radiation Oncology; Shanghai Medical College, Fudan University, Department of Oncology 11 Yang, Huanjun; Fudan University Shanghai Cancer Center, Department of 12 Radiation Oncology; Shanghai Medical College, Fudan University, 13 Department of Oncology 14 Zhu, Zhengfei; Fudan University Shanghai Cancer Center, Department of 15 Radiation Oncology; Shanghai Medical College, Fudan University, 16 Department of Oncology For peerZhao, Weixin; reviewFudan University Shanghai only Cancer Center, Department of 17 Radiation Oncology; Shanghai Medical College, Fudan University, 18 Department of Oncology 19 Li, Ling; Fudan University Shanghai Cancer Center, Department of 20 Radiation Oncology; Shanghai Medical College, Fudan University, 21 Department of Oncology 22 Fan, Jianhong; Renhe Hospital, Department of Gynecology Badakhshi, Harun; Charite´ School of Medicine and Centre for Cancer 23 Medicine, Department of Radiation Oncology 24 Zhao, Kuaile; Fudan University Shanghai Cancer Center, Department of 25 Radiation Oncology; Shanghai Medical College, Fudan University, 26 Department of Oncology 27 Primary Subject 28 Oncology Heading: 29 30 Secondary Subject Heading: Oncology 31 esophageal squamous cell carcinoma, concurrent chemoradiotherapy, 32 Keywords:

paclitaxel, cisplatin, carboplatin, fluorouracil http://bmjopen.bmj.com/ 33 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Comparison of paclitaxel in combination with cisplatin (TP), carboplatin (TC) or 4 5 fluorouracil (TF) concurrent with radiotherapy for patients with local advanced 6 esophageal squamous cell carcinoma: a three-arm phase III randomized trial 7 8 (ESO-Shanghai 2) 9 1, 2 1, 2 1, 2 1, 2 1, 2 10 Dashan Ai , Yun Chen , Qi Liu , Junhua Zhang , Jiaying Deng , Hanting 11 Zhu1, 2, Wenjia Ren1, 2, Xiangpeng Zheng3, Yunhai Li4, Shihong Wei5, Jinjun Ye6, 12 13 Jialiang Zhou7, Qin Lin8, Hui Luo9, Jianzhong Cao10, Jiancheng Li11, Guang Huang12, 14 1, 2 1, 2 1, 2 1, 2 1, 2 15 Kailiang Wu , Min Fan , Huanjun Yang , Zhengfei Zhu , Weixin Zhao , Ling 16 Li1, 2, JianhongFor Fan13, Harunpeer Badakhshi review14, Kuaile Zhao1, only2 17 18 1. Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 19 20 Shanghai, China 21 2. Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 22 23 China 24 25 3. Department of Radiation Oncology, Huadong Hospital Affiliated to Fudan 26 University, Shanghai, China 27 28 4. Department of Radiation Oncology, Fudan University Shanghai Cancer Center 29 30 Minhang Branch Hospital, Shanghai, China 31 5. Department of Radiation Oncology, Gansu Province Cancer Hospital, Lanzhou, 32 33 China http://bmjopen.bmj.com/ 34 35 6. Department of Radiation Oncology, Jiangsu Province Cancer Hospital, Nanjing, 36 China 37 38 7. Department of Radiation Oncology, Affiliated Hospital of Jiangnan University, 39 40 Wuxi, China 41 8. Department of Radiation Oncology, First Affiliated Hospital of Xiamen University, on September 26, 2021 by guest. Protected copyright. 42 43 Xiamen, China 44 45 9. Department of Radiation Oncology, Jiangxi Province Cancer Hospital, Nanchang, 46 China 47 48 10. Department of Radiation Oncology, Shanxi Province Cancer Hospital, Taiyuan, 49 50 China 51 11. Department of Thoracic Radiation Oncology, Fujian Province Cancer Hospital, 52 53 Fuzhou, China 54 55 12. Department of Radiation Oncology, Hainan Province People’s Hospital, Haikou, 56 China 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 13. Department of Gynecology, Renhe hospital, Shanghai, China 4 5 14. Department of Radiation Oncology, Charite´ School of Medicine and Centre for 6 Cancer Medicine, Berlin, Germany 7 8 Corresponding author: Kuaile Zhao, 270 Dongan Rd, Shanghai, 200032, China. Email: 9 10 [email protected]. Tel: +86-21-64175590 11 Key words: esophageal squamous cell carcinoma, concurrent chemoradiotherapy, 12 13 paclitaxel, cisplatin, carboplatin, fluorouracil 14 15 Word counts: 3,044 words 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Abstract 4 5 Introduction: Concurrent chemoradiation is the standard therapy for patients with 6 local advanced esophageal carcinoma unsuitable for surgery. Paclitaxel is an active 7 8 agent against esophageal cancer and it has been proved as a potent radiation sensitizer. 9 10 There have been multiple studies evaluating paclitaxel-based chemoradiation in 11 esophageal cancer, of which the results are inspiring. However, which regimen among 12 13 cisplatin(TP), carboplatin(TC) or fluorouracil(TF) in combination with paclitaxel) 14 15 concurrent with radiotherapy, provides best prognosis with minimum adverse events 16 is still unknownFor and very peer few studies review focus on this field. onlyThe purpose of this study is 17 18 to confirm the priority of TF to TP or TC concurrent with radiotherapy in terms of 19 20 overall survival and propose a feasible and effective plan for patients with local 21 advanced esophageal cancer. 22 23 Methods and analysis: ESO-Shanghai 2 is a three-arm, multicenter, open-labeled, 24 25 randomized phase III clinical trial. The study was initiated in July 2015 and the 26 duration of inclusion is expected to be 4 years. The study compares two pairs of 27 28 regimen: TF versus TP and TF versus TC concurrent with definitive radiotherapy for 29 30 patients with esophageal squamous cell carcinoma (ESCC). Patients with 31 histologically confirmed ESCC (clinical stage II, III or IVa based on the 6th 32 33 UICC-TNM classification) and without any prior treatment of chemotherapy, http://bmjopen.bmj.com/ 34 35 radiotherapy or surgery against esophageal cancer will be eligible. A total of 321 36 patients will be randomized and allocated in a 1:1:1 ratio to the three treatment groups. 37 38 Patients are stratified by lymph node status (N0, N1, M1a). The primary endpoint is 39 40 overall survival and the secondary endpoint is progression-free survival and adverse 41 events. on September 26, 2021 by guest. Protected copyright. 42 43 Ethics and dissemination: 44 45 This trial has been approved by the Fudan University Shanghai Cancer Center 46 Institutional Review Board. Trial results will be disseminated via peer reviewed 47 48 scientific journals and conference presentations. 49 50 Trial registration: Clinicaltrials.gov: NCT02459457 51 52 53 54 55 56 57 58 3 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Strengths and limitations of this study 4 5 Strength - This clinical trial is the first phase III randomized multi-centered study 6 comparing these three regimens. 7 8 Strength - In the randomization session, patients were stratified by lymph node 9 th 10 status (N0, N1, M1a based on the 6 UICC-TNM classification). 11 Limitation - There’s no stratification for different participation centers. 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 4 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Introduction 4 5 Worldwide, esophageal cancer is the eighth most common cancer, which is 6 responsible for an estimated 455,800 new cases and 400,200 deaths in 2012.1 Since its 7 8 prognosis is dismal, much effort has been put into improving overall survival through 9 2 10 multi-modality treatments, which consist of surgery, radiotherapy and chemotherapy. 11 Concurrent chemoradiation is the standard non-operative therapy for local advanced 12 13 esophageal squamous cell carcinoma (ESCC).3 14 15 Paclitaxel is an active agent against esophageal cancer, with the response rate of 16 28% in ESCC,For and it haspeer been shown review to be a potent radiation only sensitizer.4 There have 17 18 been multiple studies evaluating paclitaxel-based chemoradiation in esophageal 19 20 cancer, for instance, paclitaxel/fluorouracil (TF) developed at The University of Texas 21 M.D. Anderson Cancer Center, and paclitaxel/cisplatin (TP) developed at Memorial 22 23 Sloan-Kettering Cancer Center,5 6 with paclitaxel/carboplatin (TC) from CROSS 24 7 25 trial. In many preoperative studies, paclitaxel-based chemoradiotherapy has achieved 26 inspiring effects, the pathologic complete response rates of TP-based 27 28 chemoradiotherapy were 19%-42%, 8-11 and of TC-based chemoradiotherapy was 29 7 30 49%. However, which regimen, among TF, TP and TC-based definitive 31 chemoradiotherapy, provides best prognosis with minimum adverse events is still 32 33 unknown and very few studies focus on this field. http://bmjopen.bmj.com/ 34 5 35 RTOG 0113 evaluated 2 different paclitaxel-based regimens (TP and TF). 36 Eighty-four patients were accrued to this study. Patients in arm A (TF) received 37 38 induction 5-FU, cisplatin, and paclitaxel followed by radiation and concurrent 39 40 continuous infusion 5-FU and weekly paclitaxel. Patients in arm B (TP) received 41 induction paclitaxel and cisplatin followed by radiation and concurrent weekly on September 26, 2021 by guest. Protected copyright. 42 43 cisplatin and 96-hour infusion of paclitaxel. The median survival time was 28.7 44 45 months for patients in arm A (TF) and 14.9 months for patients in arm B (TP). Neither 46 arm achieved the hypothesized 1-year survival rate of at least 77.5%. The main 47 48 deficiency of this study is the small sample size, but the effect of TF group is still 49 50 inspiring. 51 Another retrospective multicenter randomize clinical trials from Europe12 52 53 showed the overall survival of TC-based definitive chemoradiotherapy was 54 55 comparable with cisplatin/5-FU (PF) as definitive concurrent chemoradiotherapy in 56 57 58 5 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 esophageal cancer. However, the toxicity rates were lower in the TC group together 4 5 with higher treatment compliance. 6 Based on RTOG 0113 and other reports, we designed a clinical trial to confirm 7 8 the priority of TF to TP and TF to TC concurrent with definitive radiotherapy in terms 9 10 of overall survival for patients with local advanced esophageal squamous cell 11 carcinoma. The trial is a three-arm, multicenter, open-labeled, randomized phase III 12 13 clinical trial. 14 15 16 Methods andFor analysis peer review only 17 18 19 20 Patient selection 21 To be eligible for this study, patient must fulfill all of the following criteria (Table 1): 22 23 24 Inclusion criteria 25 1. Histologically confirmed esophageal squamous cell carcinoma 26 27 2. Clinical stages II, III or IVa based on the 6th UICC-TNM classification 28

29 3. No prior treatments of chemotherapy, radiotherapy or surgery against esophageal 30 cancer, except for non-curative resection by EMR/ESD. 31 32 4. Aged 18-75 years http://bmjopen.bmj.com/ 33 34 5. Adequate organ functions for chemoradiation therapy 35 a) White blood cell (WBC) ≥3×109L 36 37 b) Absolute neutrophil counts (ANC) ≥1.5×109L 38 ≥ 39 c) Hemoglobin (Hb) 10g dl 40 d) Platelet (Plt) ≥100×109L 41 on September 26, 2021 by guest. Protected copyright. 42 e) Total bilirubin <1.5 upper limit of normal (ULN) 43 ≤ 44 f) Aspartate transaminase (AST) 2.5 ULN 45 g) Alanine aminotransferase (ALT) ≤2.5 ULN 46 47 h) Creatinine ≤1.5 ULN 48 49 6. ECOG PS of 0-2 50 7. Life expectancy ≥3 months, based on the judgment of doctors 51 52 8. Written informed consent (Supplementary material) 53 54 Table 1. Inclusion criteria 55 56 57 58 6 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Patients fulfilling any of the following criteria are ineligible for this study (Table 2). 4 5 Exclusion criteria 6 7 1. Esophageal perforation or hematemesis 8 2. Synchronous or metachronous malignancies (except for cutaneous 9 10 (non-melanomas) carcinoma, thyroid papillary carcinoma, phase I seminoma or 11 12 cervical carcinoma in situ curatively treated and disease free for a minimum of 3 13 months) 14 15 3. Received thoracic, abdominal or craniocerebral surgery within 30 days 16 4. EnrolledFor in other clinicalpeer trials withinreview 30 days only 17 18 5. Unstable angina and/or congestive heart failure requiring hospitalization within 6 19 20 months 21 6. Severe psychiatric disease 22 23 7. Pregnancy, lactation or unwillingness to adopt contraception 24 25 8. Drug addiction 26 9. Acquired immune deficiency syndrome (AIDS) based upon current CDC 27 28 definition 29 30 10. History of radiotherapy in the planning area 31 11. Other ineligible conditions according to researchers 32 33 Table 2. Exclusion criteria http://bmjopen.bmj.com/ 34 35 36 Treatment 37 38 The treatment plan is shown in Figure 1. Patients receive radiotherapy combined 39 40 with concurrent chemotherapy. Radiotherapy begins on day 1, concurrent with the on September 26, 2021 by guest. Protected copyright. 41 beginning of cycle 1 of chemotherapy. 42 43 Same radiation therapy will be delivered in all three treatment groups. According 44 45 to current clinical practice in China, radiotherapy is delivered with photons (≥6 MV) 46 to a total dose of 61.2Gy in 34 fractions. Patients will be treated 5 days per week at 47 48 1.8Gy/d. Three-dimensional conformal radiotherapy or intensity modulated 49 50 radiotherapy is required. All patient will be positioned in an individualized 51 immobilization device in the treatment position. 52 53 The definition of volumes will be in accordance with the 1993 ICRU Report #50 54 55 and 1999 ICRU Report #62. 56 The gross target volume (GTV) is defined as all known involved field, which 57 58 7 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 detected by endoscopic ultrasound, barium swallow or CT scan (whichever is larger). 4 5 The regional lymph nodes that have diameters more than 1cm (0.5cm for lymph nodes 6 at tracheoesophageal groove) or that have been histologically proven metastatic after 7 8 puncture are included in GTV. 9 10 The superior and inferior borders of the clinical target volume (CTV) are 3cm 11 beyond the primary tumor along the esophagus. The lateral, anterior and posterior 12 13 borders of the field are the same as GTV. 14 15 The superior, inferior, anterior, posterior and lateral borders of planning target 16 volume (PTV)For are 1cm peer beyond CTV. review Field next to the onlyspinal cord could be slightly 17 18 adjusted in order to reduce the exposure of spinal cord. 19 20 As for target volume, tissue inhomogeneity correction is adopted and it is 21 required that more than 99% PTV receive 95% prescription dose and more than 95% 22 23 PTV receive 99% or more prescription dose. Highest and lowest point dose inside 24 25 PTV should be recorded. 26 When making the treatment plan, we should take normal organ dose restrictions 27 28 into consideration as the following order: (Table 3) 29 30 31 Risk organ Contour regulation Dose restriction 32 33 Spinal cord All the layers of CT scan have Highest point dose less http://bmjopen.bmj.com/ 34 35 to be contoured and the margin than 45Gy 36 of vertebra tube can be 37 38 regarded as that of planning 39 40 organ at risk volume. on September 26, 2021 by guest. Protected copyright. 41 Lung It is allowed to use automatic The volume of lung (PTV 42 43 tools in the delineation of excluded) receiving 20Gy 44 45 margin of lungs. (Trachea and or higher has to be less 46 bronchia must be contoured than 30% of the total lung 47 48 manually) volume, and the mean 49 50 dose has to be less than 51 15Gy. 52 53 Heart The superior margin of heart The mean dose has to be 54 55 consists of right atrium and less than 40Gy. 56 57 58 8 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 right ventricle, pulmonary 4 5 artery trunk, ascending main 6 aorta and superior vena cava 7 8 excluded. The inferior margin 9 10 is at the level of heart apex. 11 12 Table 3. Contour regulation and dose restriction of risk organs 13 14 15 Chemotherapy 16 Patients Forare randomly peer assigned toreview receive one of three only therapies. 17 18 19 20 Arm A (TP) 21 Patients in arm A receive 4 courses of TP every 4 weeks. Details are as follows: 22 23 Paclitaxel: 175mg/m2/d, ivgtt over 3 hours, d1; Cisplatin: 25mg/m2/d, ivgtt, d1-3; 24 25 26 Arm B (TF) 27 28 Patients in arm B receive 6 courses of TF concurrent with radiotherapy every 29 30 week and 2 courses of TF consolidation chemotherapy every 4 weeks. Details are as 31 follows: 32 33 Concurrent: paclitaxel 50mg/m2/d, ivgtt over 3 hours, d1; 5-FU 300mg/m2, civ 96h, http://bmjopen.bmj.com/ 34 35 d1-4 36 Consolidation: paclitaxel 175 mg/m2/d, ivgtt over 3 hours, d1; 5-FU 1800mg/m2, civ 37 38 72h, d1-3 39 40 on September 26, 2021 by guest. Protected copyright. 41 Arm C (TC) 42 43 Patients in arm C receive 6 courses of TC concurrent with radiotherapy every 44 45 week and 2 courses of TC consolidation chemotherapy every 4 weeks. Details are as 46 follows: 47 48 Concurrent: paclitaxel 50mg/m2/d, ivgtt over 3 hours, d1; carboplatin AUC=2, ivgtt, 49 50 d1 51 Consolidation: paclitaxel 175 mg/m2/d, ivgtt over 3 hours, d1; carboplatin AUC=5, 52 53 ivgtt, d1 54 55 Patients receive premedication to prevent allergic reaction and significant nausea 56 or vomiting as indicated. 57 58 9 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Dose modifications 4 5 Radiotherapy interruption 6 If following toxicity is observed, radiotherapy has to be delayed until toxicity is 7 8 no more than grade 2. 9 9 9 10 WBC<2.0×10 /L or ANC<1.0×10 /L 11 Plt<50×109/L 12 13 Grade 3 or higher non-hematological toxicity 14 15 If following toxicity is observed, radiotherapy has to be delayed until complete 16 recovery. For peer review only 17 18 Mediastinal or thoracic infection with fever over 38.5℃ 19 20 It is allowed to suspend at most 2 weeks, or radiotherapy will be terminated. 21 22 23 Chemotherapy interruption and dose modifications 24 25 If following toxicity is observed on day 1, chemotherapy has to be delayed until 26 toxicity is no more than grade 1. 27 28 ANC<1.5×109/L 29 9 30 Plt<100×10 /L 31 Grade 2 or higher non-hematological toxicity, except for nausea, vomiting and 32 33 alopecia http://bmjopen.bmj.com/ 34 35 It is allowed to delay at most 2 weeks, or chemotherapy will be terminated. 36 Chemotherapy dose modifications are based on the greatest toxicity during the 37 38 last cycle. Any patients who need to make chemotherapy dose modifications will 39 40 receive the modified dose in the following cycles. 41 If modifications are needed, dose of paclitaxel, cisplatin, carboplatin and 5-FU on September 26, 2021 by guest. Protected copyright. 42 43 will decreased by 25% from the planned dose for the first time and 50% for the 44 45 second time. It is allowed to make dose modifications at most twice, or chemotherapy 46 will be terminated. Details are as follows: 47 48 Dose modification of paclitaxel 49 9 ℃ ℃ 50 Febrile neutropenia (ANC< 0.5×10 /L and fever over 38.3 or over 38.0 for 51 1h) 52 53 Grade 2 or higher peripheral neuropathy 54 55 56 Dose modification of cisplatin and carboplatin 57 58 10 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Febrile neutropenia (ANC< 0.5×109/L and fever over 38.3℃ or over 38.0℃ for 4 5 1h) 6 Grade 2 or higher peripheral neuropathy 7 8 Serum creatinine >3ULN 9 10 11 Dose modification of 5-FU 12 13 Febrile neutropenia (ANC< 0.5×109/L and fever over 38.3℃ or over 38.0℃ for 14 15 1h) 16 Grade 3 Foror higher mucositispeer review only 17 18 19 20 The adverse events will be evaluated according to the National Cancer Institute 21 Common Terminology Criteria for Adverse Events (CTCAE version 4.0). All adverse 22 23 events, occurring during the course of the trial, which is from randomization until 28 24 25 days after end of treatment, regardless of relatedness to study medication, will be 26 recorded. Adverse events occurring later than 28 days after the end of treatment will 27 28 only be recorded if they are considered relevant. 29 30 31 Randomization 32 33 After the confirmation of eligibility criteria, patients will be randomly allocated http://bmjopen.bmj.com/ 34 35 in a 1:1:1 ratio to the three treatment groups by a central randomization center (Fudan 36 University Shanghai Cancer Center, Shanghai, China). Patients will be stratified by 37 38 lymph node status (N0, N1, M1a). The SAS was used to generate a random 39 40 permutation sequence and produce patient randomization numbers. The data center 41 registers the enrollment, assigns a unique identification number to every participant, on September 26, 2021 by guest. Protected copyright. 42 43 and replies to the respective investigators. 44 45 46 Sample size calculation and statistical analysis 47 48 This three-arm randomized trial is designed to confirm whether TF is superior to 49 50 TP or TC concurrent with radiotherapy in terms of overall survival. According to 51 RTOG 0113 and other reports, median survival time of TF concurrent with 52 5 53 radiotherapy for esophageal cancer is 28.7 months while TP 14.9 months and TC 54 13 55 17.4 months . According to the Schoenfeld and Richter’s method, the sample size of 56 107 patients per arm (154 events in total) is required to warrant a power of 80% at a 57 58 11 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 two-sided α level of 0.025 for the comparison between TP and TF with relatively 4 5 smaller difference, assuming an accrual period of 48 months, a minimum follow-up 6 period of 24 months and a dropout rate of 10%14 15. The total sample size is planned 7 8 as 321 patients (107 patients in each arm, a total of 231 events). 9 10 The median overall survival will be estimated with Kaplan-Meier method, and 11 log-rank test will be used to compare the overall survival among treatment arms. We 12 13 will conduct a subgroup analyze to test whether the treatment effects differ among 14 15 subgroups (N0, N1, M1a). 16 For peer review only 17 18 Endpoints 19 20 The primary endpoint is overall survival in all randomized patients. Overall 21 survival is defined as time from the date of randomization until death. The secondary 22 23 endpoint is progression free survival (PFS) and adverse events. PFS is defined as the 24 25 time from the date of randomization to the date of progression or to the date of death, 26 whichever occurs first and disease progression will be evaluated according to 27 28 RECIST Version 1.1. Adverse events will be evaluated according to the National 29 30 Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 31 4.0). 32 33 http://bmjopen.bmj.com/ 34 35 Data collection 36 Participants will be seen at hospitals or contacted by telephone and letters from 37 38 randomization to the last treatment cycle, then at Month 3, 6, 9, 12, 15, 18, 21, 24, 30, 39 40 36, 42, 48, 54 and 60 after last treatment. Research staffs at the hospitals will be 41 expected to complete trial CRFs. on September 26, 2021 by guest. Protected copyright. 42 43 44 45 Interim analysis 46 We plan to conduct two interim analyses. The first interim analysis will be 47 48 conducted independently from the study group when half of the planned number of 49 50 patients are enrolled and the second interim just after the planned patient accrual is 51 completed. If the superiority of one of test arms (TF arm superior to TP arm or TC 52 53 arm) is demonstrated with an adjusted α level, the study will be terminated. 54 55 In general, the interim reports will contain the following information: 56 57 58 12 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 1. Patient accrual rate with a projected completion date (while the study is still 4 5 accruing) 6 2. Total patients accrued 7 8 3. Distributions of important pretreatment and prognostic baseline variables 9 10 4. The frequencies and severity of adverse events by treatment arm. 11 5. Compliance rates of treatment delivery 12 13 6. Observed results with respect to the primary and secondary endpoints 14 15 16 Patient and PublicFor Involvement peer review only 17 18 Neither patients nor public will be involved in the design, recruitment, outcome 19 20 measures and conduct of the study. Trial results will be disseminated via peer 21 reviewed scientific journals and conference presentations rather than specifically 22 23 notified to a single patient. 24 25 26 Ethics and dissemination 27 28 This trial has been approved by all participating centers including Fudan 29 30 University Shanghai Cancer Center Institutional Review Board (Ethics Committee of 31 Fudan University Shanghai Cancer Center: No.1505146-13). Written informed 32 33 consent will be obtained from all participants. Serious adverse events will be reported http://bmjopen.bmj.com/ 34 35 to the safety desk of the trial, the Data and Safety Monitoring Board and trial sites. 36 Trial results will be disseminated via peer reviewed scientific journals and conference 37 38 presentations. 39 40 41 Participating institutions (From east to west) on September 26, 2021 by guest. Protected copyright. 42 43 Fudan University Shanghai Cancer Center, Huadong Hospital Affiliated to Fudan 44 45 University, Fudan University Shanghai Cancer Center Minhang Branch, Affiliated 46 Hospital of Jiangnan University, Fujian Province Cancer Hospital, Jiangsu Province 47 48 Cancer Hospital, The First Affiliated Hospital of Xiamen University, Jiangxi Province 49 50 Cancer Hospital, Shanxi Province Cancer Hospital, Hainan Province People’s 51 Hospital, Gansu Province Cancer Hospital 52 53 54 55 Trial Status 56 57 58 13 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 The trial was initiated in July 2015 and is currently recruiting patients in all of the 4 5 participating institutions above. 6

7 8 9 10 11 Reference: 12 13 1. Torre LA, Bray F, Siegel RL, et al. Global Cancer Statistics, 2012. Ca-Cancer J Clin 14 15 2015;65(2):87-108. 16 2. Enzinger ForPC, Mayer peer RJ. Esophageal review cancer. N Engl J Medonly 17 18 2003;349(23):2241-52. 19 20 3. Herskovic A, Martz K, Alsarraf M, et al. Combined Chemotherapy and 21 Radiotherapy Compared with Radiotherapy Alone in Patients with Cancer 22 23 of the Esophagus. New Engl J Med 1992;326(24):1593-98. 24 25 4. Ajani JA, Ilson DH, Daugherty K, et al. Activity of Taxol in Patients with 26 Squamous-Cell Carcinoma and Adenocarcinoma of the Esophagus. J Natl 27 28 Cancer I 1994;86(14):1086-91. 29 30 5. Ajani JA, Winter K, Komaki R, et al. Phase II randomized trial of two 31 nonoperative regimens of induction chemotherapy followed by 32 33 chemoradiation in patients with localized carcinoma of the esophagus: http://bmjopen.bmj.com/ 34 35 RTOG 0113. J Clin Oncol 2008;26(28):4551-56. 36 6. Schnirer II, Komaki R, Yao JC, et al. Pilot study of concurrent 37 38 5-fluorouracil/paclitaxel plus radiotherapy in patients with carcinoma of 39 40 the esophagus and gastroesophageal junction. Am J Clin Oncol-Canc 41 2001;24(1):91-95. on September 26, 2021 by guest. Protected copyright. 42 43 7. Shapiro J, Van Lanschot JJB, Hulshof MCCM, et al. Neoadjuvant 44 45 chemoradiotherapy plus surgery versus surgery alone for oesophageal or 46 junctional cancer (CROSS): long-term results of a randomised controlled 47 48 trial. Lancet Oncol 2015;16(9):1090-98. 49 50 8. Safran H, Gaissert H, Akerman P, et al. Paclitaxel, cisplatin, and concurrent 51 radiation for esophageal cancer. Cancer Invest 2001;19(1):1-7. 52 53 9. Bains MS, Stojadinovic A, Minsky B, et al. A phase II trial of preoperative 54 55 combined-modality therapy for localized esophageal carcinoma: Initial 56 results. J Thorac Cardiov Sur 2002;124(2):270-77. 57 58 14 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 10. Urba SG, Orringer MB, Ianettonni M, et al. Concurrent cisplatin, paclitaxel, and 4 5 radiotherapy as preoperative treatment for patients with locoregional 6 esophageal carcinoma. Cancer 2003;98(10):2177-83. 7 8 11. Lin CC, Hsu CH, Cheng JC, et al. Concurrent chemoradiotherapy with twice 9 10 weekly paclitaxel and cisplatin followed by esophagectomy for locally 11 advanced esophageal cancer. Ann Oncol 2007;18(1):93-98. 12 13 12. Honing J, Smit JK, Muijs CT, et al. A comparison of carboplatin and paclitaxel 14 15 with cisplatinum and 5-fluorouracil in definitive chemoradiation in 16 esophagealFor cancer peer patients. review Ann Oncol 2014;25 only(3):638-43. 17 18 13. Mohammad NH, Hulshof MCCM, Bergman JJGHM, et al. Acute toxicity of 19 20 definitive chemoradiation in patients with inoperable or irresectable 21 esophageal carcinoma. Bmc Cancer 2014;14. 22 23 14. Lakatos E. Designing complex group sequential survival trials. Stat Med 24 25 2002;21(14):1969-89. 26 15. Lakatos E. Sample Sizes Based on the Log-Rank Statistic in Complex 27 28 Clinical-Trials. Biometrics 1988;44(1):229-41. 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 15 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Declarations 4 5 List of abbreviations 6 TP: Paclitaxel combined with cisplatin 7 8 TC: Paclitaxel combined with carboplatin 9 10 TF: Paclitaxel combined with fluorouracil 11 UICC: Union for International Cancer Control 12 13 ESCC: Esophageal squamous cell carcinoma 14 15 PF: Cisplatin combined with fluorouracil 16 AIDS: AcquiredFor immune peer deficiency reviewsyndrome only 17 18 RT: Radiotherapy 19 20 PTX: Paclitaxel 21 DDP: Cisplatin 22 23 CBP: Carboplatin 24 25 5-FU: Fluorouracil 26 W: Week 27 28 ICRU: International Commission on Radiation Units and Measurements 29 30 GTV: Gross Target Volume 31 CTV: Clinical Target Volume 32 33 PTV: Planning Target Volume http://bmjopen.bmj.com/ 34 35 WBC: White Blood Cell 36 ANC: Absolute Neutrophil Counts 37 38 Hb: Hemoglobin 39 40 Plt: Platelet 41 ULN: Upper Limit of Normal on September 26, 2021 by guest. Protected copyright. 42 43 AST: Aspartate Transaminase 44 45 ALT: Alanine aminotransferase 46 47 48 49 50 Consent of publication 51 Not applicable 52 53 54 55 Declaration of interests 56 We declare no competing interests. 57 58 16 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 4 5 Funding 6 The study was supported by 2015 Prospective Clinical Research Fund of Fudan 7 8 University Shanghai Cancer Center. 9 10 11 Author’s contributions 12 13 D Ai was responsible for drafting the manuscript. Y Chen, Q Liu, J Zhang, J Deng, H 14 15 Zhu, W Ren, K Wu, M Fan, H Yang, Z Zhu, W Zhao, L Li were responsible for the 16 collection ofFor previous studypeer and putting review forward the conception. only X Zheng, Y Li, J Ye, 17 18 J Zhou, Q Lin, H Luo, J Cao, S Wei, J Fan, J Li, G Huang and H Badakhshi were 19 20 responsible for designing the details of the study. K Zhao was responsible for all 21 aspects of trial design, the protocol and trial conduct. All authors have read and 22 23 approved this manuscript. 24 25 26 Data Sharing Statement 27 28 No additional unpublished data from the study are available. 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 17 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 29 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

1 2 3 Fig1. Treatment Design of the ESO-Shanghai 2 trial. 4 5 TP (arm A), TF (arm B) and TC (arm C) are TP-, TF- and TC-based definitive 6 chemoradiotherapy, respectively. 7 8 RT=radiotherapy, PTX=paclitaxel, DDP=cisplatin, 5-Fu=fluorouracil, 9 10 CBP=carboplatin, W=Week. 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 18 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 29 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from

32 80x56mm (300 x 300 DPI) 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 on September 26, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 29 BMJ Open

1 2 3 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 4 Informed Consent Form 5 Comparison of paclitaxel in combination with cisplatin (TP), carboplatin (TC) or 6 7 fluorouracil (TF) concurrent with radiotherapy for patients with local advanced 8 9 esophageal squamous cell carcinoma: a three-arm phase III randomized trial 10 11 (ESO-Shanghai 2) 12 13 14 You are being asked to take part in a clinical study. Please take your time to make 15 16 your decision about taking part. If you have any questions, you can ask your 17 18 study doctor forFor more explanation.peer review only 19 You are being asked to take part in this study because you have local advanced 20 21 esophageal squamous cell carcinoma. 22 23 24 25 Why is this study being done? 26 Concurrent chemoradiation is the standard therapy for patients with local advanced 27 28 esophageal carcinoma unsuitable for surgery. Paclitaxel is an active agent against 29 30 esophageal cancer and it has been proved as a potent radiation sensitizer. There have 31 32 been multiple studies evaluating paclitaxel-based chemoradiation in esophageal 33 34 cancer, the results of which are inspiring. However, which regimen, among paclitaxel 35 in combination with cisplatin (TP), carboplatin (TC) and fluorouracil (TF) concurrent 36

37 with radiotherapy, provides best prognosis with minimum adverse events is still http://bmjopen.bmj.com/ 38 39 considered far from resolved and very few studies focus on this field. The purpose of 40 41 this study is to confirm the priority of TF to TP or TC concurrent with radiotherapy in 42 terms of overall survival and propose a feasible and effective plan for patients with 43 44 local advanced esophageal cancer.

45 on September 26, 2021 by guest. Protected copyright. 46 47 48 How many people will take part in the study? 49 About 321 people will take part in this study. 50 51 52 53 What will happen if I take part in this research study? 54 55 You will be randomized and allocated in a 1:1:1 ratio to the three treatment groups (TF, 56 TP or TC). You will receive radiotherapy combined with concurrent chemotherapy. 57 58 Radiotherapy will begin on day 1, concurrent with the beginning of cycle 1 of 59 60 chemotherapy.

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1 2 3 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 4 Radiation therapy 5 Same radiation therapy will be delivered in all three treatment groups. Radiotherapy 6 7 will be delivered with photons (≥6 MV) to a total dose of 61.2Gy in 34 fractions. You will 8 9 be treated 5 days per week at 1.8Gy/d. 10 11 12 Chemotherapy 13 14 Arm A (TP) 15 16 If you are in arm A, you will receive 4 courses of TP every 4 weeks. Details are as 17 18 follows: For peer review only 19 Paclitaxel: 175mg/m2/d, ivgtt over 3 hours, d1; Cisplatin: 25mg/m2/d, ivgtt, d1-3; 20 21 Arm B (TF) 22 23 If you are in arm B, you will receive 6 courses of TF concurrent with radiotherapy every 24 25 week and 2 courses of TF adjuvant chemotherapy every 4 weeks. Details are as 26 follows: 27 28 Concurrent: paclitaxel 50mg/m2/d, ivgtt over 3 hours, d1; 5-FU 300mg/m2, civ 96h, 29 30 d1-4 31 2 2 32 Adjuvant: paclitaxel 175 mg/m /d, ivgtt over 3 hours, d1; 5-FU 1800mg/m , civ 72h, 33 34 d1-3 35 Arm C (TC) 36

37 If you are in arm C, you will receive 6 courses of TC concurrent with radiotherapy every http://bmjopen.bmj.com/ 38 39 week and 2 courses of TC adjuvant chemotherapy every 4 weeks. Details are as 40 41 follows: 42 Concurrent: paclitaxel 50mg/m2/d, ivgtt over 3 hours, d1; carboplatin AUC=2, ivgtt, d1 43 44 Adjuvant: paclitaxel 175 mg/m2/d, ivgtt over 3 hours, d1; carboplatin AUC=5, ivgtt, d1

45 on September 26, 2021 by guest. Protected copyright. 46 47 48 During each treatment, blood tests will be performed to monitor blood counts, kidney 49 function, liver function and electrolyte levels. Ultrasound, barium swallow and CT scan 50 51 with contrast will be performed to evaluate the status of disease. 52 53 54 55 How long will I be in the study? 56 After your treatment is completed, you will be seen in follow-up visits with your doctor 57 58 every 3 months in years 1-2, every 6 months in years 3-5 and then once a year for your 59 60 lifetime.

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1 2 3 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 4 Can I stop being in the study? 5 Yes. You can decide to stop at any time. Tell the study doctor if you are thinking about 6 7 stopping or decide to stop. He or she will tell you how to stop safely. 8 9 It is important to tell the study doctor if you are thinking about stopping so he or she can 10 11 evaluate any risks from the treatment. Another reason to tell your study doctor that 12 you are thinking about stopping is to discuss what follow-up care and testing could be 13 14 most helpful for you. 15 16 The study doctor may stop you from taking part in this study at any time if he/she 17 18 believes it is in yourFor best peer interest, if youreview do not follow theonly study rules, or if the study is 19 stopped. 20 21 22 23 What side effects or risks can I expect from being in the study? 24 25 You may have side effects while on the study. Everyone taking part in the study will be 26 watched carefully for any side effects. However, doctors don’t know all the side effects 27 28 that may happen. Side effects may be mild or very serious. There also is a risk of 29 30 death. 31 32 Risks and side effects related to the chemoradiotherapy 33 34  Soreness in throat or esophagus 35  Cough 36

37  Vomiting http://bmjopen.bmj.com/ 38 39  Nausea 40 41  Fatigue 42  Anorexia (loss of appetite) 43 44  Diarrhea

45 on September 26, 2021 by guest. Protected copyright. 46  Numbness in arms and legs 47 48  Allergic reaction 49  Hair loss 50 51  Redness of irritation of the skin in the treatment area 52 53  Decrease in white blood cell counts and high risk of infection 54 55  Renal insufficiency, 56

57 58 Are there benefits to taking part in the study? 59 60

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1 2 3 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 4 Taking part in this study may or may not make your health better. While researchers 5 hope these treatment regimens will be more useful against cancer compared to the 6 7 usual treatment, there is no proof of this yet. We do know that the information from this 8 9 study will help researchers learn more about these combinations of drugs as a 10 11 treatment for cancer. This information could help future cancer patients. 12 13 14 Will my medical information be kept private? 15 16 We will do our best to make sure that the personal information in your medical record 17 18 will be kept private.For Your peer personal information review may be onlygiven out if required by law. If 19 information from this study is published or presented at scientific meetings, your name 20 21 and other personal information will not be used. 22 23 24 25 What happens if I am injured because I took part in this study? 26 It is important that you tell your study doctor if you feel that you have been injured 27 28 because of taking part in this study. You will get medical treatment if you are injured as 29 30 a result of taking part in this study. You and/or your health plan will be charged for this 31 32 treatment. The study will not pay for medical treatment. 33 34 35 What are my rights if I take part in this study? 36

37 Taking part in this study is your choice. You may choose either to take part or not to http://bmjopen.bmj.com/ 38 39 take part in the study. If you decide to take part in this study, you may leave the study at 40 41 any time. No matter what decision you make, there will be no penalty to you and you 42 will not lose any of your regular benefits. Leaving the study will not affect your medical 43 44 care. You can still get your medical care from our center.

45 on September 26, 2021 by guest. Protected copyright. 46 We will tell you about new information or changes in the study that may affect your 47 48 health or your willingness to continue in the study. 49 In the case of injury resulting from this study, you do not lose any of your legal rights to 50 51 seek payment by signing this form. 52 53 54 55 WHO CAN ANSWER MY QUESTIONS ABOUT THE STUDY? 56 You can talk to your study doctor about any questions or concerns you have about this 57 58 study. Contact your study doctor, Kuaile Zhao, at 021-64175590. 59 60

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1 2 3 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 4 Signature 5 6 7 I have been given a copy of all 5 pages of this form. I have read it or it has been 8 9 read to me. I understand the information and have had my questions answered. 10 11 I agree to take part in this study. 12 13 14 15 16 17 18 For peer review only 19

20 21 Participant: 22 23 24 25 ______26 Name of Participant Signature Date 27 28 29 30 31 32 Researcher: 33 34 35 ______36

37 Name of Participant Signature Date http://bmjopen.bmj.com/ 38 39 40 41 42 43 44

45 on September 26, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 1 Page 26 of 29

Addressed on Addressed number page

____3______3______None ______None __ _ _None______None______None ______None ______17______17______17______17______None______None______None _ None __ BMJ Open http://bmjopen.bmj.com/ on September 26, 2021 by guest. Protected copyright. For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml applicable (see Item 21a for data monitoring committee) committee) monitoring data for 21a (seeItem applicable interpretation of data; writing of the report; and the decision to submit the report for publication, including including publication, for report the submit to decision the and report; of the writing ofdata; interpretation activities any ofthese over authority ultimate have will they whether adjudication committee, data management team, and other individuals or groups overseeing the trial, if trial, the overseeing groups or individuals other and team, management data committee, adjudication Description Description

Funding Funding Roles and and Roles responsibilities Protocol version version Protocol 3 identifier version and Date Title Title Trial registration registration Trial 2a registry intended of name registered, yet Ifname. not registry and identifier Trial Administrative information Administrative documents* related and protocol trial clinical a in address to items Recommended Checklist: 2013 SPIRIT Section/item Item 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 2

_____13______13______

_____13______13______12______12______9 _ __ _ 9 ______None ______None ______10______10______7-9______7-9______6-7______6-7______6______6______5______5______6______6______ins and washouts), assessments, and visits for visits and assessments, washouts), and ins BMJ Open http://bmjopen.bmj.com/ on September 26, 2021 by guest. Protected copyright. For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml be collected. Reference to where list of study sites can be obtained obtained be can sites ofstudy list where to Reference collected. be allocation ratio, and framework (eg, superiority, equivalence, noninferiority, exploratory) exploratory) noninferiority, equivalence, superiority, (eg, framework and ratio, allocation participants. A schematic diagram is highly recommended (see Figure) Figure) (see recommended highly is diagram schematic A participants. Time schedule of enrolment, interventions (including any run- any (including interventions enrolment, of schedule Time efficacy and harm outcomes is strongly recommended recommended strongly is andharm outcomes efficacy median, proportion), and time point for each outcome. Explanation of the clinical relevance of chosen chosen of relevance clinical of the Explanation foroutcome. each point timeand proportion), median, pressure), analysis metric (eg, change from baseline, final value, time to event), method of aggregation (eg, aggregation methodof event), to time value, final baseline, from change (eg, metric analysis pressure), Primary, secondary, and other outcomes, including the specific measurement variable (eg, systolic blood blood (eg,systolic variable measurement specific the including outcomes, other and secondary, Primary, Relevant concomitant care and interventions that are permitted or prohibited during the trial trial the during prohibited or permitted are that interventions and care concomitant Relevant (eg, drug tablet return, laboratory tests) tests) laboratory return, tablet drug (eg, Strategies to improve adherence to intervention protocols, and any procedures for monitoring adherence adherence monitoring for procedures any and protocols, intervention to adherence improve to Strategies change in response to harms, participant request, or improving/worsening disease) disease) improving/worsening or request, participant harms, to response in change Criteria for discontinuing or modifying allocated interventions for a given trial participant (eg, drug dose drug (eg, participant trial given for a interventions allocated modifying or fordiscontinuing Criteria administered administered Interventions for each group with sufficient detail to allow replication, including how and when they will be be they will and when how including replication, allow to detail sufficient with group each for Interventions individuals who will perform the interventions (eg, surgeons, psychotherapists) psychotherapists) surgeons, (eg, interventions the perform will who individuals Inclusion and exclusion criteria for participants. If applicable, eligibility criteria for study centres and centres and criteriastudy for eligibility applicable, If for participants. criteria exclusion and Inclusion studies (published and unpublished) examining benefits and harms for each intervention intervention each for harms and benefits examining unpublished) and (published studies 13 13 12 12 11d 11d 11c 11c 11b 11b 11a 11a 10 10

6a 6a of relevant summary including trial, the forundertaking justification and question of research Description Participant timeline timeline Participant Outcomes Outcomes Interventions Interventions Eligibility criteria criteria Eligibility Study setting Study 9 will data where ofcountries list and hospital) academic clinic, community (eg, settings of study Description Methods: Participants, interventions, and outcomes outcomes and interventions, Participants, Methods: Introduction Introduction Background and Background rationale Objectives design Trial 7 8 hypotheses or 6b objectives Specific group), single factorial, crossover, group, parallel (eg, oftrial type including design of trial Description comparators of forchoice Explanation Page 27 of 29 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2017-020785 on 21 October 2018. Downloaded from 3 Page 28 of 29

____ 12 ___ 12 ______11______11______None ______None ______None ______None ______11______11______11______11______11______11______None ______None ______11-12______11-12___ BMJ Open http://bmjopen.bmj.com/

15 15 14 14 Implementation Implementation mechanism mechanism concealment concealment generation generation Sequence Sequence Allocation Allocation

methods methods Data collection collection Data Methods: Data collection, management, and analysis and management, collection, Data Methods:

Blinding (masking) (masking) Blinding Methods: Assignment of interventions (for controlled trials) controlled (for interventions of Assignment Methods: Recruitment Recruitment Sample size size Sample

____ None ______None ____

____ None ______None ______11______11______12-13______12-13______None ______None ______None ______None ______12 ______12 _____12______12______None ______None ______13______13_____ BMJ Open http://bmjopen.bmj.com/ on September 26, 2021 by guest. Protected copyright. For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml analyses) to relevant parties (eg, investigators, REC/IRBs, trial participants, trial registries, journals, journals, registries, trial participants, trial REC/IRBs, investigators, (eg, parties relevant to analyses) regulators) from investigators and the sponsor sponsor the and frominvestigators Frequency and procedures for auditing trial conduct, if any, and whether the process will be independent independent be will process the and whether if any, conduct, trial forauditing procedures and Frequency events and other unintended effects of trial interventions or trial conduct conduct trial or interventions trial of effects unintended other and events Plans for collecting, assessing, reporting, and managing solicited and spontaneously reported adverse reported spontaneously and solicited managing and reporting, assessing, collecting, for Plans results and make the final decision to terminate the trial trial the terminate to decision final makethe and results Description of any interim analyses and stopping guidelines, including who will have access to these interim access to have will who including guidelines, stopping and analyses interim of any Description needed needed about its charter can be found, if not in the protocol. Alternatively, an explanation of why a DMC is not is not DMC a ofwhy explanation an Alternatively, theprotocol. in ifnot found, be can itscharter about whether it is independent from the sponsor and competing interests; and reference to where further details furtherdetails where to reference and interests; competing and sponsor from the isindependent it whether Composition of data monitoring committee (DMC); summary of its role and reporting structure; statement of statement structure; reporting and role of its summary (DMC); committee monitoring data of Composition statistical methods to handle missing data (eg, multiple imputation) imputation) multiple (eg, data missing handle to methods statistical Definition of analysis population relating to protocol non-adherence (eg, as randomised analysis), and any any and analysis), randomised as (eg, non-adherence protocol to relating population ofanalysis Definition Methods for any additional analyses (eg, subgroup and adjusted analyses) analyses) adjusted and subgroup (eg, analyses additional any for Methods statistical analysis plan can be found, if not in the protocol protocol the in iffound,not be can plan analysis statistical Statistical methods for analysing primary and secondary outcomes. Reference to where other details of the the of details other where to Reference outcomes. secondary and primary foranalysing methods Statistical procedures can be found, if not in the protocol protocol the in if not found, be can procedures (eg, double data entry; range checks for data values). Reference to where details of data management management data of details where to Reference values). data for checks range entry; data double (eg, Plans for data entry, coding, security, and storage, including any related processes to promote data quality quality data promote to processes related any including storage, and security, coding, entry, fordata Plans

Data monitoring monitoring Data Methods: Monitoring Methods:

Statistical methods methods Statistical Data management management Data

____ None ______None ______None ______None ______None ______None ______None ______None ______None ______None ______None ______None ______None ______None ____ BMJ Open http://bmjopen.bmj.com/ on September 26, 2021 by guest. Protected copyright. For peer review only For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml how (see Item 32) 32) (seeItem how studies, if applicable if applicable studies, trial afterthe and during, before, confidentiality protect to order in participation participation Provisions, if any, for ancillary and post-trial care, and for compensation to those who suffer harm from trial trial from harmsuffer who those to compensation for care,and post-trial and for ancillary ifany, Provisions, limit such access for investigators investigators for access such limit Statement of who will have access to the final trial dataset, and disclosure of contractual agreements that that agreements contractual of disclosure and dataset, trial final the to access have will of who Statement the public, and other relevant groups (eg, via publication, reporting in results databases, or other data data other or databases, results in reporting publication, via groups(eg, relevant other and public, the restrictions publication any including arrangements), sharing analysis in the current trial and for future use in ancillary studies, if applicable ifapplicable studies, ancillary in use future for and trial current the in analysis 26b 26b ancillary in specimens and biological data ofuseparticipant and collection for provisions consent Additional 31c 31c code andstatistical dataset, participant-level protocol, full the to access public for granting any, if Plans, ____ None ____ 31b 31b writers professional of use intended any and guidelines eligibility Authorship 28 28 site study each and trial overall forthe investigators principal for interests competing other and Financial ______17

31a 31a professionals, healthcare participants, to results trial communicate sponsorto and forinvestigators Plans 32 32 surrogates authorised and participants to given documentation related other formand consent Model __ 30 30 29 29 33 33 molecular or forgenetic specimens biological of storage and evaluation, laboratory collection, for Plans

*It is strongly recommended that this checklist be read in conjunction with the SPIRIT 2013 Explanation & Elaboration for important clarification on the items. items. on the clarification for important Elaboration & Explanation 2013 SPIRIT the with conjunction in read be thischecklist that recommended is strongly *It “ Biological Biological specimens Dissemination policy Dissemination trial care trial Consent or assent assent or Consent 26a and surrogates, authorised or participants trial potential from assent or consent informed obtain will Who Amendments to the protocol should be tracked and dated. The SPIRIT checklist is copyrighted by the SPIRIT Group under the Creative Commons Commons Creative the under Group SPIRIT by the iscopyrighted checklist SPIRIT The dated. and tracked be should protocol the to Amendments Ancillary and post- and Ancillary Access to data data to Access 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60