Liquid biopsy for prostate lesions

Active, not recruiting

Conditions: Neoplasms,

Registration Number: CTRI/2019/02/017863

Lead Sponsor: Datar Cancer Genetics Limited

Brief Summary: **1. Background:**

Cancers of the prostate are the second mostcommonly occurring cancer in men and the fourth most commonly occurring cancer.Risk factors for prostate cancers include age, hereditary factors (e.g.,germline mutations in BRCA gene), diet, obesity and inflammation of theprostate. The majority (~95%) of prostate malignancies are adenocarcinomaswhereas the remainder comprise of urothelial carcinoma, basal cell carcinoma,small cell carcinoma, lymphoma and sarcomas. Globally, there were ~1,300,000 newcases in 2018 accounting for 7.1% of all cancers1. Prostate cancersalso contributed to 360,000 deaths2,3, accounting for 3.8% of allannual cancer related mortalities. While the global age standardized incidencerates (ASR) for prostate cancers were around 30%1, the same forIndia was <10.6%1; however, projections indicate a potentialdoubling in number of cases by 20201. It is also hypothesized thatthe lower incidences in India, especially among non-urban population, may bedue to lower rate of detection rather than a low incidence rate1.Prostate cancers remain undetected for extended periods since they aregenerally slow-growing and asymptomatic until advanced stages. Though advancesin modalities for early screening, as well as an increased awareness, have ledto an increase in global ASR for incidence, developing regions continue toexhibit the disparity of relatively low ASR for incidence.

**2.****StudyRationale**

**Limitationsof the Current Gold Standard in Diagnosis and Monitoring**

Current modalities for screening and diagnosis ofprostate cancers include digital rectal examination (DRE), prostate biopsies,serological markers as well as radiological imaging. The DRE4 checksfor palpable growths in or enlargement of the prostate gland via the rectum.However, the absence of a palpable hard mass or the failure of DRE to detectthe same does not entirely rule out prostate malignancies. While the DRE is anon-invasive procedure, it may be associated with moderate risks of pain,discomfort and bleeding. Prostate biopsies are obtained surgically, e.g.,ultrasound or magnetic resonance imaging (MRI)-guided biopsy5, orvia fine needle-aspiration cytology6 (FNAC), where the needle isinserted via the rectum (transrectal), urethra (transurethral) or perineum(transperineal), to obtain tissue samples, for histopathological analysis anddetermination of the Gleason Score7 based on visual assessment oftumor cell differentiation. However prostate biopsies, especially FNAC, may beprone to false negatives and multiple sampling may be required for unambiguousestablishment of presence or absence of malignancy. Biopsies are associatedwith risks of pain, bleeding and infection at the site of puncture. It has alsobeen hypothesized that viable tumor cells may be mechanically displaced intothe vasculature during biopsies (or FNAC), and dissemination of thesecirculating tumor cells (CTCs) may contribute to development of distalmetastatic lesions. Radiological methods such as computed tomography (CT) andpositron emission tomography-computed tomography (PET-CT) scans have beenconsidered the de facto gold standard for detection and determination of extentof various solid organ malignancies. However, radiological methods of detectionare associated with risks of exposure to ionizing radiation from oral / IVcontrast as well as non-ionizing radiation from the instrument, as well as aninability to detect tumors less than 4 mm in diameter8,9. PET-CTwith 18F-fluorodeoxyglucose (FDG) tracer frequently encounters tracerartifacts due to higher FDG uptake in non-malignant tissue (e.g., inflammatorytissue / surgical scars), as well as due to retention in visceral organs suchas the kidney and urinary bladder â€“ these artifacts pose a challenge todiscerning true metastases from background uptake. Additionally, in case ofprostate malignancies, the accumulation of excreted tracer in the urinarybladder prevents analysis of the prostate-specific uptake due to anatomicalproximity. While Prostate-Specific Membrane Antigen (PSMA)-PET10scan appears to offer improved specificity over FDG-PET-CT, clinical studieshave not yet unambiguously established immunity of PSMA-PET from the same confoundingfactors that are routinely encountered in other radiological methods.

The identification of the serum Prostate SpecificAntigen (PSA) and its association with prostate malignancies led to thedevelopment of blood-based rapid *in vitro*diagnostic tests for determination of malignancy. This non-invasive diagnosticprocedure, based on analysis of 1-2 mL of peripheral blood, offered obviousadvantages (and reduced risks) as compared to invasive procedures such asbiopsies / FNAC. However, elevated PSA levels were also found to be associatedwith several noncancerous conditions, including age-related Benign ProstaticHyperplasia (BPH) contributing to a reduced specificity11.

**DistinctAdvantages of Liquid Biopsy-based Approaches**

Liquid biopsies open multiple opportunities indiagnosis of prostate malignancies due its non-invasive sampling method. Itenables longitudinal monitoring of disease evolution and treatment response.Further, it helps to address tumor heterogeneity as the nucleic acids analysedin liquid biopsy are released from all areas of tumor. Additionally, due toadvances in the sequencing technology, the scope of molecular analysisconducted in liquid biopsy as increased and has potential to reveal alldiagnostic, prognostic and therapy relevant molecular alterations. Like othermalignant neoplasms, prostate tumor cells release intracellularcomponentsinto circulation. Tumor-derivedbiomarkers include circulating tumor cells (CTCs), extracellular vesicles(e.g., exosomes) and cell-free nucleic acids which accumulate in plasma, serumand/or cerebrospinal fluid. Circulating cell-free tumor DNA (ctDNA) arefragments of DNA, released from dying tumor cells. The presence of ctDNA hasbeen correlated with overall tumor burden and disease activity. Presence ofcertain unique molecular signatures can help to distinguish between malignant /non-malignant disorders and has potential to indicate morphological type ofmalignant neoplasm. Much like non-malignant cells, viable tumor cells secreteextracellular vesicles called exosomes tumor cell derived mRNA, miRNA, othernucleic acids and proteins. These circulating biomarkers may be useful aseasily accessible diagnostic, prognostic and/or predictive biomarkers to guidepatient management. Thereby, this approach may help to circumvent problemsrelated to tumor heterogeneity and sampling error at the time of diagnosis.Liquid biopsies allow for serial monitoring of treatment responses and ofchanges in the molecular characteristics of the prostate malignancy over time.Liquid biopsy provides dynamic information not only regarding tumor burden tomonitor disease progression and treatment response, but also regarding geneticprofile to enable changes in management to match a constantly evolving tumor.

**ProStateTM â€“ an Integrative Platformfor Prostate Malignancies**

ProStateâ„¢is a liquid biopsy platform that detects prostate cancer derived molecularabnormalities in blood. Molecular characterization ofthe tumor via blood-derived biomarkers bypasses the painful and potentiallydebilitating procedures of obtaining tumor tissue via needle or surgical biopsies.ProStateâ„¢ incorporates characterization of CTCsand ctDNA.ProStateâ„¢ is a multi-coordinate platform whichevaluates >4000 mutations from over 50 genes and CTCs to predict presence ofprostate cancer. This integrative assessment of the tumor interactometranslates into a more meaningful clinical decision for the patient, ascompared to conventional means based on univariate analytics.

Theperformance evaluation and characterization of ProStateâ„¢ has been establishedand validated by Datar Cancer Genetics Limited in compliance with therequirements of CLIA as applicable for Single Laboratory Developed Tests.Reference cell lines obtained from ATCC were used as reference materials fordetermining the lower limit of variant detection, linearity, analyticalspecificity and sensitivity. Patient samples were collected after InstitutionalEthics Committee approval at the participating centers and the Ethics Committeeof Datar Cancer Genetics Limited. The protocols were conducted in accordancewith the Helsinki Declaration. 20 mL whole blood was collected from subjectswith enlarged prostate, elevated PSA or suspicious findings on DRE. CTCs aswell as ctDNA obtained from subjectsâ€™ peripheral blood were used for analysis.Clinical sensitivity for CTCs and ctDNA was 74.5% and 75%, respectively.

**3. OBJECTIVESAND OUTCOME MEASURES**

**3.1****PrimaryObjective:**

To evaluate utility of ProStateTM indistinguishing prostate malignancies from Benign Prostatic Hyperplasia.

Outcome Measure:Positive predictive value of ProStateTM to differentiate prostatemalignancies from Benign Prostatic Hyperplasia.

Evaluation Timepoint: Day 0(Blood sampling)

**3.2****SecondaryObjectives:**

To determine the grade (Gleason Score) of confirmed CaProstate.

Outcome Measure**:** Comparison ofGleason Score with molecular profiling of blood sample.

Evaluation Timepoint: Day 0(Blood sampling).

**4.****STUDYDESIGN**

**Study type:** Observational.

**Observational model:** Cohort.

**Time perspective:** Prospective.

**Estimated enrollment:** 300 Â± 15 cases.

**Start Date:** After clearance of ethics committee/IRB â€“tentatively January 2019.

**Estimated Primary Completion Date:** Six months from study initiation â€“ tentatively July2019 (which may be extended in case of insufficiency of volunteers / othercontingencies to be evaluated by PI and sponsor).

**Estimated Study Completion Date:** Two months from completion of study cohort â€“tentatively September 2019.

**Number of study groups/arms:** One.

**Subjects:** Therapy-naÃ¯ve subjects with enlargedprostate or elevated serum Prostate Specific Antigen or suspicious findings onDigital Rectal Examination.

**Name of study intervention(s):** None.

**Study Procedures**: Collection of peripheral blood.

**Study outline:**

| | |

| --- | --- |

|**Prior to Enrolment**

Â·   Screen potential participants by Inclusion and Exclusion Criteria.

Â·   Obtain Clinical History Documents (to be masked from DCGL).

|**On Enrolment**

Â·   Administer and Obtain Informed Consent.

Â·   Collect Blood sample.

|**Data Analysis**

Â·   Following completion of sample collection of entire study cohort, perform analysis of samples and data.

Detailed Description: Not available

Recruitment & Eligibility

Status: Closed to Recruitment of Participants

Sex: Male

Target Recruitment: 300

Inclusion Criteria

i.Patients with enlarged prostate or elevated PSA or suspicious DRE finding who are therapy naÃ¯ve.
ii.Age â‰¥ 50 years.
iii.Provision of signed and dated informed consent form.
iv.Stated willingness to comply with all study procedures.

Exclusion Criteria

Patients who fail to meet all of the above criteria for cases will be excluded.
Failing to meet any single criteria would be sufficient grounds for exclusion.
i.Age <50 years.
ii.Active or latent hepatitis B or active hepatitis C or any uncontrolled infection at screening, including (but not limited to) HIV, HPV or tuberculosis.
iii.Patient has an investigational medicinal product within the last 30 days of blood collection.
iv.Personal history of any cancer in the past.
v.Blood transfusion in past 1 month.
vi.(PET-)CT scan in past 14 days.
vii.Patients must have discontinued steroids â‰¥ 1 week prior to screening, NOTE: The following steroids are permitted (low dose steroid use is defined as prednisone 10 mg daily or less, or bioequivalent dose of other corticosteroid): a.Temporary steroid use for CT imaging in setting of contrast allergy, b.Low dose steroid use for appetite, c.Chronic inhaled steroid use, d.Steroid injections for joint disease, e.Stable dose of replacement steroid for adrenal insufficiency or low doses for non-malignant disease, f.Topical steroids.

Study & Design

Study Type: Observational

Study Design: Not specified

Primary Outcome Measures

Name	Time	Method
To evaluate utility of ProStateTM in distinguishing prostate malignancies from Benign Prostatic Hyperplasia.	Evaluation Timepoint: Day 0 (Blood sampling at the time of recruitment)
Outcome Measure: Positive predictive value of ProStateTM to differentiate prostate malignancies from Benign Prostatic Hyperplasia.	Evaluation Timepoint: Day 0 (Blood sampling at the time of recruitment)

Secondary Outcome Measures

Name	Time	Method
To determine the grade (Gleason Score) of confirmed Ca Prostate.	Outcome Measure: Comparison of Gleason Score with molecular profiling of blood sample.

Trial Locations

Locations (1): Datar Cancer Genetics Limited
🇮🇳
Nashik, MAHARASHTRA, India
Datar Cancer Genetics Limited
🇮🇳Nashik, MAHARASHTRA, India
Dr Dadasaheb Akolkar
Principal investigator
7387705888
dadasaheb.akolkar@datarpgx.com