Shifting the Cancer Screening Paradigm: The Rising Potential of Blood-Based Multi-Cancer Early Detection Tests

Breaking barriers in cancer diagnosis: unveiling the 4Ms of biosensors

Cancer, an insidious affliction, continues to exact a heavy toll on humanity, necessitating early detection and nuanced comprehension of its intricacies for effective treatment. Recent strides in micro and nanoscale electronic chip fabrication have revolutionized biosensor technology, offering promising avenues for biomedical and telemedicine applications. Micro Electromechanical System (MEMS)-based integrated circuits (ICs) represent a paradigm shift in detecting chemical and biomolecular interactions pertinent to cancer diagnosis, supplanting conventional methodologies. Despite the wealth of research on biosensors, a cohesive framework integrating Material, Mechanism, Modeling, and Measurement (4M) dimensions is often lacking. This review aims to synthesize these dimensions, exploring recent breakthroughs in biosensor design and development. Categorized based on electromechanical integration, material selection, and fabrication processes, these biosensors bridge crucial knowledge gaps within the research community. A comparative analysis of sensing methods in point-of-care (PoC) technology provides insights into their practicality and efficacy. Moreover, we critically evaluate biosensor limitations, pivotal in addressing challenges hindering their global commercialization.

Evaluation of an innovative multi-cancer early detection test: high sensitivity and specificity in differentiating cancer, inflammatory conditions, and healthy individuals

Background

Cancer is a leading cause of death worldwide, with early detection crucial for effective treatment. Traditional diagnostic methods, such as imaging and biopsies, are often limited by invasiveness, cost, and sensitivity. Blood-based multi-cancer early detection (MCED) tests offer a less invasive and potentially more comprehensive approach. Recently, a novel screening tool, the Carcimun® test was reported, detecting conformational changes in plasma proteins through optical extinction measurements. This study evaluates the Carcimun® test's performance, including participants with inflammatory conditions.

Methods

This prospective, single-blinded study included 172 participants: 80 healthy volunteers, 64 cancer patients (various types), and 28 individuals with inflammatory conditions (fibrosis, sarcoidosis, pneumonia) or benign tumors. Plasma samples were analyzed using the Carcimun® test. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.

Results

Mean extinction values were significantly higher in cancer patients (315.1) compared to healthy individuals (23.9) and those with inflammatory conditions (62.7) (p<0.001). The Carcimun® test distinguished these groups with high accuracy (95.4%), sensitivity (90.6%), and specificity (98.2%). Significant differences were found between healthy participants and cancer patients (p<0.001), and between cancer patients and those with inflammation (p<0.001).

Conclusion

The Carcimun® test achieved high accuracy, sensitivity, and specificity, effectively identifying cancer patients while minimizing false positives and negatives. By including participants with inflammatory conditions, we addressed a significant limitation of previous studies, demonstrating the test's robustness in real-world clinical scenarios. These findings underscore the potential of the Carcimun® test as a valuable tool for early cancer detection and screening.

Estimating the Burden of False Positives and Implementation Costs From Adding Multiple Single Cancer Tests or a Single Multi-Cancer Test to Standard-Of-Care Screening

BACKGROUND

Blood-based tests present a promising strategy to enhance cancer screening through two distinct approaches. In the traditional paradigm of "one test for one cancer", single-cancer early detection (SCED) tests a feature high true positive rate (TPR) for individual cancers, but high false-positive rate (FPR). Whereas multi-cancer early detection (MCED) tests simultaneously target multiple cancers with one low FPR, offering a new "one test for multiple cancers" approach. However, comparing these two approaches is inherently non-intuitive. We developed a framework for evaluating and comparing the efficiency and downstream costs of these two blood-based screening approaches at the general population level.

METHODS

We developed two hypothetical screening systems to evaluate the performance efficiency of each blood-based screening approach. The "SCED-10" system featured 10 hypothetical SCED tests, each targeting one cancer type; the "MCED-10" system included a single hypothetical MCED test targeting the same 10 cancer types. We estimated the number of cancers detected, cumulative false positives, and associated costs of obligated testing for positive results for each system over 1 year when added to existing USPSTF-recommended cancer screening for 100,000 US adults aged 50-79.

RESULTS

Compared with MCED-10, SCED-10 detected 1.4× more cancers (412 vs. 298), but had 188× more diagnostic investigations in cancer-free people (93,289 vs. 497), lower efficiency (positive predictive value: 0.44% vs. 38%; number needed to screen: 2062 vs. 334), 3.4× the cost ($329 M vs. $98 M), and 150× higher cumulative burden of false positives per annual round of screening (18 vs. 0.12).

CONCLUSIONS

A screening system for average-risk individuals using multiple SCED tests has a higher rate of false positives and associated costs compared with a single MCED test. A set of SCED tests with the same sensitivity as standard-of-care screening detects only modestly more cancers than an MCED test limited to the same set of cancers.

Epigenetic modifications of cfDNA in liquid biopsy for the cancer care continuum

This review provides a comprehensive overview of the latest advancements in the clinical utility of liquid biopsy, with a particular focus on epigenetic approaches aimed at overcoming challenges in cancer diagnosis and treatment. It begins by elucidating key epigenetic terms, including methylomics, fragmentomics, and nucleosomics. The review progresses to discuss methods for analyzing circulating cell-free DNA (cfDNA) and highlights recent studies showcasing the clinical relevance of epigenetic modifications in areas such as diagnosis, drug treatment response, minimal residual disease (MRD) detection, and prognosis prediction. While acknowledging hurdles like the complexity of interpreting epigenetic data and the absence of standardization, the review charts a path forward. It advocates for the integration of multi-omic data through machine learning algorithms to refine predictive models and stresses the importance of collaboration among clinicians, researchers, and data scientists. Such cooperative efforts are essential to fully leverage the potential of epigenetic features in clinical practice.

Transforming cancer screening: the potential of multi-cancer early detection (MCED) technologies

Early cancer detection substantially improves the rate of patient survival; however, conventional screening methods are directed at single anatomical sites and focus primarily on a limited number of cancers, such as gastric, colorectal, lung, breast, and cervical cancer. Additionally, several cancers are inadequately screened, hindering early detection of 45.5% cases. In contrast, Multi-Cancer Early Detection (MCED) assays offer simultaneous screening of multiple cancers from a single liquid biopsy and identify molecular changes before symptom onset. These tests assess DNA mutations, abnormal DNA methylation patterns, fragmented DNA, and other tumor-derived biomarkers, indicating the presence of cancer and predicting its origin. Moreover, MCED assays concurrently detect multiple cancers without recommended screening protocols, potentially revolutionizing cancer screening and management. Large trials have reported promising results, achieving 50-95% sensitivity and 89-99% specificity for multiple cancer types. However, challenges, regarding improving accuracy, addressing ethical issues (e.g., psychosocial impact assessment), and integrating MCED into healthcare systems, must be addressed to achieve widespread adoption. Furthermore, prospective multi-institutional studies are crucial for demonstrating the clinical benefits in diverse populations. This review provides an overview of the principles, development status, and clinical significance of MCED tests, and discusses their potential and challenges.

Shooting for the Moon: Can We Cut Cancer Mortality in Canada By 50% By 2050?

INTRODUCTION

The United States of America reignited their Cancer Moonshot Initiative in 2022 with an ambitious goal to reduce cancer mortality by 50% over the next 25 years. In this study, we estimated how and whether a similar cancer control initiative could be achieved in Canada.

METHODS

We used the OncoSim microsimulation suite to address three questions: (1) what is the expected mortality from cancer in Canada by 2050 given the current trends?; (2) what would be the maximal impact on reducing cancer mortality with prevention and increased screening activities? and, (3) if a 50% reduction in projected cancer mortality could not be achieved through the primary and secondary intervention efforts, what additional advancements and discoveries would be needed to fill the "lunar gap"? We modeled the joint impact of risk-factor reduction and screening, as well as the independent effects of prevention and screening alone, on projected cancer mortality.

RESULTS

Our models suggest that there will be an expected 133,395 cancer deaths in 2050 in Canada. Approximately 33% of these cancer deaths could be prevented by risk-factor reduction and increased screening programs by the year 2050. This would leave a "lunar gap" of about 16%-17% that would need to be bridged with novel discoveries in cancer risk prevention, early detection, and treatment.

CONCLUSION

While current knowledge and implementation of prevention and screening would have a considerable impact on a Canadian cancer moonshot, additional efforts are needed to implement cancer control initiatives and fuel additional discoveries to fill the gap.

Multi-cancer early detection tests for general population screening: a systematic literature review

Background

General population cancer screening in the United Kingdom is limited to selected cancers. Blood-based multi-cancer early detection tests aim to detect potential cancer signals from multiple cancers in the blood. The use of a multi-cancer early detection test for population screening requires a high specificity and a reasonable sensitivity to detect early-stage disease so that the benefits of earlier diagnosis and treatment can be realised.

Objective

To undertake a systematic literature review of the clinical effectiveness evidence on blood-based multi-cancer early detection tests for screening.

Methods

Comprehensive searches of electronic databases (including MEDLINE and EMBASE) and trial registers were undertaken in September 2023 to identify published and unpublished studies of multi-cancer early detection tests. Test manufacturer websites and reference lists of included studies and pertinent reviews were checked for additional studies. The target population was individuals aged 50-79 years without clinical suspicion of cancer. Outcomes of interest included test accuracy, number and proportion of cancers detected (by site and stage), time to diagnostic resolution, mortality, potential harms, health-related quality of life, acceptability and satisfaction. The risk of bias was assessed using the quality assessment of diagnostic accuracy studies-2 checklist. Results were summarised using narrative synthesis. Stakeholders contributed to protocol development, report drafting and interpretation of review findings.

Results

Over 8000 records were identified. Thirty-six studies met the inclusion criteria: 1 ongoing randomised controlled trial, 13 completed cohort studies, 17 completed case-control studies and 5 ongoing cohort or case-control studies. Individual tests claimed to detect from 3 to over 50 different types of cancer. Diagnostic accuracy of currently available multi-cancer early detection tests varied substantially: Galleri® (GRAIL, Menlo Park, CA, USA) sensitivity 20.8-66.3%, specificity 98.4-99.5% (three studies); CancerSEEK (Exact Sciences, Madison, WI, USA) sensitivity 27.1-62.3%, specificity 98.9- 99.1% (two studies); SPOT-MAS™ (Gene Solutions, Ho Chi Minh City, Vietnam) sensitivity 72.4-100%, specificity 97.0-99.9% (two studies); Trucheck™ (Datar Cancer Genetics, Bayreuth, Germany) sensitivity 90.0%, specificity 96.4% (one study); Cancer Differentiation Analysis (AnPac Bio, Shanghai, China) sensitivity 40.0%, specificity 97.6% (one study). AICS® (AminoIndex Cancer Screening; Ajinomoto, Tokyo, Japan) screens for individual cancers separately, so no overall test performance statistics are available. Where reported, sensitivity was lower for detecting earlier-stage cancers (stages I-II) compared with later-stage cancers (stages III-IV). Studies of seven other multi-cancer early detection tests at an unclear stage of development were also summarised.

Limitations

Study selection was complex; it was often difficult to determine the stage of development of multi-cancer early detection tests. The evidence was limited; there were no completed randomised controlled trials and most included studies had a high overall risk of bias, primarily owing to limited follow-up of participants with negative test results. Only one study of Galleri recruited asymptomatic individuals aged over 50 in the United States of America; however, study results may not be representative of the United Kingdom's general screening population. No meaningful results were reported relating to patient-relevant outcomes, such as mortality, potential harms, health-related quality of life, acceptability or satisfaction.

Conclusions

All currently available multi-cancer early-detection tests reported high specificity (> 96%). Sensitivity was highly variable and influenced by study design, population, reference standard test used and length of follow-up.

Future work

Further research should report patient-relevant outcomes and consider patient and service impacts.

Study registration

This study is registered as PROSPERO CRD42023467901.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR161758) and is published in full in Health Technology Assessment; Vol. 29, No. 2. See the NIHR Funding and Awards website for further award information.

Integrating Multi-Cancer Early Detection (MCED) Tests with Standard Cancer Screening: System Dynamics Model Development and Feasibility Testing

BACKGROUND

Cancer screening plays a critical role in early disease detection and improving outcomes. In Australia, established screening protocols for colorectal, breast and cervical cancer have significantly contributed to timely cancer detection. However, the recent introduction of multi-cancer early detection (MCED) tests arguably can disrupt current screening, yet the extent to which these tests provide additional benefits remains uncertain. We present the development and initial validation of a system dynamics (SD) model that estimates the additional cancer detections and costs associated with MCED tests.

AIM

This article describes the development of a simulation model built to evaluate the additional patient diagnoses and the economic impact of incorporating MCED testing alongside Australia's well-established standard of care (SOC) screening programs for colorectal, breast, cervical and lung cancers. The model was designed to estimate the additional number of patients diagnosed at each cancer stage (stage I, II, III, IV, or unknown) and the associated costs. This simulation model allows for the analysis of multiple scenarios under a plausible set of assumptions regarding population-level participation rates.

METHODS

An SD model was developed to represent the existing SOC national cancer screening pathways and to integrate potential clinical pathways that could be introduced by MCED tests. The SD model was built to investigate three scenarios for the use of MCED testing: firstly, to explore the viability of MCED testing as a substitute among individuals who are not opting for SOC screening for any reason; secondly, to implement MCED testing exclusively for individuals ineligible for SOC screening, yet have high-risk characteristics; and thirdly, to employ MCED testing after SOC screening to serve as a triaging/confirmatory tool for individuals receiving inconclusive test results. The three primary scenarios were constructed by varying diagnostic accuracy and uptake rates of MCED tests.

DISCUSSION

The clinical utility and outcomes of MCED testing for screening and early detection still lack comprehensive evidence. Nonetheless, this simulation model facilitates a thorough analysis of MCED tests within the Australian healthcare context, providing insights into potential additional detections and costs to the healthcare system, which may help prioritise future evidence development. The adaptable yet novel SD model presented herein is anticipated to be of considerable interest to industry, policymakers, consumers and clinicians involved in informing clinical and economic decisions regarding integrating MCED tests as cancer screening and early detection tools. The expected results of applying this SD model will determine whether using MCED testing in conjunction with SOC screening offers any potential benefits, possibly guiding policy decisions and clinical practices towards the adoption of MCED tests.

An appropriate DNA input for bisulfite conversion reveals LINE-1 and Alu hypermethylation in tissues and circulating cell-free DNA from cancers

The autonomous and active Long-Interspersed Element-1 (LINE-1, L1) and the non-autonomous Alu retrotransposon elements, contributing to 30% of the human genome, are the most abundant repeated sequences. With more than 90% of their sequences being methylated in normal cells, these elements undeniably contribute to the global DNA methylation level and constitute a major part of circulating-cell-free DNA (cfDNA). So far, the hypomethylation status of LINE-1 and Alu in cellular and extracellular DNA has long been considered a prevailing hallmark of ageing-related diseases and cancer. This study demonstrated that errors in LINE-1 and Alu methylation level measurements were caused by an excessive input quantity of genomic DNA used for bisulfite conversion. Using the minuscule DNA amount of 0.5 ng, much less than what has been used and recommended so far (500 ng-2 μg) or 1 μL of cfDNA extracted from 1 mL of blood, we revealed hypermethylation of LINE-1 and Alu in 407 tumour samples of primary breast, colon and lung cancers when compared with the corresponding pair-matched adjacent normal tissue samples (P < 0.05-0.001), and in cfDNA from 296 samples of lung cancers as compared with 477 samples from healthy controls (P < 0.0001). More importantly, LINE-1 hypermethylation in cfDNA is associated with healthy ageing. Our results have not only contributed to the standardized bisulfite-based protocols for DNA methylation assays, particularly in applications on repeated sequences but also provided another perspective for other repetitive sequences whose epigenetic properties may have crucial impacts on genome architecture and human health.

Efficient Cancer Biomarker Screening and Multicancer Detection Enabled by a Multidimensional Serum Proteomic Strategy

Biomarker discovery and application are paramount for the early diagnosis, treatment, and prognosis assessment of diseases. Novel proteomic strategies have been developed for high-efficiency biomarker screening. However, evaluating various strategies and applying them for the in-depth mining of biomarkers from blood need to be elucidated. Herein, we systematically evaluated the technical characteristics of three representative biomarker discovery strategies, including the most popular DIA proteomics, and two promising strategies targeting the cancer-secreted proteome or extracellular vesicle proteome, and integrated them into one multidimensional serum proteomic strategy. The results showed that the three strategies each have unique characteristics in terms of sensitivity, reproducibility, and protein coverage and are highly complementary in biomarker discovery. The integrated multidimensional serum proteomic strategy achieves deep and comprehensive coverage of the serum proteome, discovers more cancer markers, and helps achieve a more accurate multicancer (breast, lung, stomach, liver, and colorectum) diagnosis with 87.5% localization accuracy.

Multiomics biomarkers were not superior to clinical variables for pan-cancer screening

BACKGROUND

Cancer screening tests are considered pivotal for early diagnosis and survival. However, the efficacy of these tests for improving survival has recently been questioned. This study aims to test if cancer screening could be improved by biomarkers in peripheral blood based on multi-omics data.

METHODS

We utilize multi-omics data from 500,000 participants in the UK Biobank. Machine learning is applied to search for proteins, metabolites, genetic variants, or clinical variables to diagnose cancers collectively and individually.

RESULTS

Here we show that the overall performance of the potential blood biomarkers do not outperform clinical variables for collective diagnosis. However, we observe promising results for individual cancers in close proximity to peripheral blood, with an Area Under the Curve (AUC) greater than 0.8.

CONCLUSIONS

Our findings suggest that the identification of blood biomarkers for cancer might be complicated by variable overlap between molecular changes in tumor tissues and peripheral blood. This explanation is supported by local proteomics analyses of different tumors, which all show high AUCs, greater than 0.9. Thus, multi-omics biomarkers for the diagnosis of individual cancers may potentially be effective, but not for groups of cancers.

Bladder Adenocarcinoma in a Constellation of Multiple Site Malignancies: An Unusual Case and Systematic Review

BACKGROUND AND OBJECTIVES

Multiple primary malignant tumors represent a small percentage of the total number of oncological cases and can involve either metachronous or synchronous development and represent challenges in diagnosis, staging, and treatment planning. Our purpose is to present a rare case of bladder adenocarcinoma in a female patient with multiple primary malignant tumors and to provide systematic review of the available literature.

MATERIALS AND METHODS

A 67-year-old female patient was admitted with altered general condition and anuria. The past medical history of the patient included malignant melanoma (2014), cervical cancer (2017), colon cancer (2021), obstructive anuria (2023), and liver metastasectomy (2023). Transurethral resection of bladder tumor was performed for bladder tumors.

RESULTS

Contrast CT highlighted multiple pulmonary metastases, a poly nodular liver conglomerate, retroperitoneal lymph node, II/III grade left ureterohydronephrosis, and no digestive tract tumor masses. The pathological result of the bladder resection showed an infiltrative adenocarcinoma.

CONCLUSIONS

The difference between primary bladder adenocarcinoma tumor and metastatic colorectal adenocarcinoma is the key for the future therapeutic strategy. Identification and assessment of risk factors such as viral infection, radiotherapy, chemotherapy, smoking, and genetics are pivotal in understanding and managing multiple primary malignant tumors. Personalized prevention strategies and screening programs may facilitate the early detection of these tumors, whether synchronous or metachronous. The use of multicancer early detection (MCED) blood tests for early diagnosis appears promising. However, additional research is needed to standardize these techniques for cancer detection.

Development of a Serum Metabolome-Based Test for Early-Stage Detection of Multiple Cancers

BACKGROUND

Detection of cancer at the early stage currently offers the only viable strategy for reducing disease-related morbidity and mortality. Various approaches for multi-cancer early detection are being explored, which largely rely on capturing signals from circulating analytes shed by tumors into the blood. The fact that biomarker concentrations are limiting in the early stages of cancer, however, compromises the accuracy of these tests. We, therefore, adopted an alternate approach that involved interrogation of the serum metabolome with machine learning-based data analytics. Here, we monitored for modulations in metabolite patterns that correlated with the presence or absence of cancer. Results obtained confirmed the efficacy of this approach by demonstrating that it could detect a total of 15 cancers in women with an average accuracy of about 99%.

AIMS

To further increase the scope of our test, we conducted an investigator-initiated clinical trial involving a total of 6445 study participants, which included both cancer patients and non-cancer volunteers. Our goal here was to maximize the number of cancers that could be detected, while also covering cancers in both females and males.

METHODS AND RESULTS

Metabolites extracted from individual serum samples were profiled by ultra-performance liquid chromatography coupled to a high-resolution mass spectrometer using an untargeted protocol. After processing, the data were analyzed by our cancer detection machine-learning algorithm to differentiate cancer from non-cancer samples. Results revealed that our test platform could indeed detect a total of 30 cancers, covering both females and males, with an average accuracy of ~98%. Importantly, the high detection accuracy remained invariant across all four stages of the cancers.

CONCLUSION

Thus, our approach of integrating untargeted metabolomics with machine learning-powered data analytics offers a powerful strategy for early-stage multi-cancer detection with high accuracy.

TRIAL REGISTRATION

Registration No: CTRI/2023/03/050316.

Perceptions of Multicancer Detection Tests Among Primary Care Physicians and Laypersons: A Qualitative Study

INTRODUCTION

Multicancer detection tests (MCDs) are blood-based tests designed to detect multiple cancer types. It is currently unclear whether these cancer screening tests improve mortality. To understand awareness of MCDs among providers and patients, as well as explore how they perceive the benefits, harms, and acceptability of MCDs, we have undertaken a focus group study in primary care physicians (PCPs) and laypersons to explore knowledge, attitudes, and expectations of cancer screening using MCDs.

METHODS

We conducted six focus groups with 45 PCP participants and 12 focus groups with 80 layperson participants. Participants were identified via a consumer research firm and found eligible following the completion of a screener survey. Moderators used a semi-structured guide containing open-ended questions and prompts to facilitate the discussion. Recordings were transcribed and coded line by line using a codebook developed based on questions and emerging discussion concepts, and emergent themes were identified.

RESULTS

Both PCP and layperson participants felt the that benefits of MCDs included ease of use and potential ability to detect cancers early. However, they felt that additional data is needed to overcome some of the concerns related to MCDs. PCP participants expressed concerns related to lack of practice guidelines, cost of diagnostic follow-ups, privacy and insurance issues, fear/anxiety related to confirmation of MCD results, and malpractice liability related to perceived false negative test results. Layperson participants expressed concerns related to costs, insurance coverage, and privacy, as well as anxiety over the confirmation of a positive test result.

CONCLUSIONS

There is a major need for more rigorous data regarding MCDs to inform the development of guidelines for use as cancer screening tools.

Knowledge-map and research trends of circulating tumor cells in breast cancer: a scientometric analysis

Assessing circulating tumor cells (CTCs) in early-stage breast cancer patients can help identify relapse risk for timely interventions. Molecular analysis of CTCs can reveal vulnerabilities for personalized treatment options in metastatic breast cancer. This study aims to summarize CTCs in breast cancer research understanding and evaluate research trends. Extracted from the Web of Science Core Collection, publications on CTCs in breast cancer studies spanning from January 1, 2008, to December 21, 2023, were included. Co-authorships, references, and keywords were analyzed using Bibliometrix R packages and VOSviewer software. References and keywords burst detection were conducted with CiteSpace, and BICOMB was utilized to generate high-frequency keyword layouts. Biclustering analysis of the binary co-keyword matrix was performed using gCLUTO. 1747 articles focusing on CTCs in breast cancer were identified. The USA and the University of Texas MD Anderson Cancer Center demonstrated the highest productivity at the national and institutional levels, respectively. The journal "CANCERS" had the highest publication outputs on this subject. Pantel K emerged as the foremost author with the highest publication and co-citation counts. Analysis of co-keywords unveiled five prominent research areas concerning CTCs in breast cancer. The prognostic and predictive roles of CTCs in breast cancer have substantial implications for clinical practice. Nevertheless, precise assessment of CTCs, encompassing its quantities and attributes through advanced technologies, and its role in detecting minimal residual disease in breast cancer, continue to pose notable challenges. In conclusion, recent advancements and trends in CTCs research in breast cancer are examined through scientometric analysis in this study. The results provide valuable insights for the formulation of novel approaches in CTCs research, emphasizing the current research frontiers.

Targeting therapy-persistent residual disease

Disease relapse driven by acquired drug resistance limits the effectiveness of most systemic anti-cancer agents. Targeting persistent cancer cells in residual disease before relapse has emerged as a potential strategy for enhancing the efficacy and the durability of current therapies. However, barriers remain to implementing persister-directed approaches in the clinic. This Perspective discusses current preclinical and clinical complexities and outlines key steps toward the development of clinical strategies that target therapy-persistent residual disease.

Bridging the gap in cervical cancer screening for underserved communities: MCED and the promise of future technologies

Cervical cancer screening is a critical public health measure, especially vital for underserved communities where disparities in access and outcomes are pronounced. Despite the life-saving potential of regular screening, numerous barriers-including geographical isolation, cultural and linguistic challenges, and socioeconomic factors-severely hinder accessibility for these populations. Multicancer early detection (MCED) tests emerge as a potentially effective intervention, offering a less invasive, more accessible approach that could transform how screenings are conducted. This paper explores the existing challenges in traditional cervical cancer screening methods, the potential of MCED tests to address these barriers, and the implications of these technologies for global health equity. Through a comprehensive review, we highlight the need for culturally sensitive, tailored interventions and the importance of effectively overcoming logistical and financial difficulties to implement MCED tests. Despite the promise shown by MCED tests, the paper acknowledges significant implementation challenges, including cost, logistical obstacles, and the need for cultural acceptance and validation studies. This study emphasizes the necessity for equitable MCED test implementation strategies, highlighting the potential of these innovative technologies to advance global health equity in cervical cancer prevention.

Shifting the Cancer Screening Paradigm: Developing a Multi-Biomarker Class Approach to Multi-Cancer Early Detection Testing

Guideline-recommended screening programs exist for only a few cancer types. Although all these programs are understood to lead to reductions in cancer-related mortality, standard-of-care screening tests vary in accuracy, adherence and effectiveness. Recent advances in high-throughput technologies and machine learning have facilitated the development of blood-based multi-cancer cancer early detection (MCED) tests. MCED tests are positioned to be complementary to standard-of-care screening and they may broaden screening availability, especially for individuals who are not adherent with current screening programs and for individuals who may harbor cancers with no available screening options. In this article, we outline some key features that should be considered for study design and MCED test development, provide an example of the developmental pathway undertaken for an emerging multi-biomarker class MCED test and propose a clinical algorithm for an imaging-based diagnostic resolution strategy following MCED testing.

Understanding the Landscape of Multi-Cancer Detection Tests: The Current Data and Clinical Considerations

Multi-cancer detection (MCD) tests are blood-based assays that screen for multiple cancers concurrently and offer a promising approach to improve early cancer detection and screening uptake. To date, there have been two prospective interventional studies evaluating MCD tests as a screening tool in human subjects. No MCD tests are currently approved by the FDA, but there is one commercially available MCD test. Ongoing trials continue to assess the efficacy, safety, and cost implications of MCD tests. In this review, we discuss the performance of CancerSEEK and Galleri, two leading MCD platforms, and discuss the clinical consideration for the broader application of this new technology.

Progress and Outlook on Electrochemical Sensing of Lung Cancer Biomarkers

Electrochemical biosensors have emerged as powerful tools for the ultrasensitive detection of lung cancer biomarkers like carcinoembryonic antigen (CEA), neuron-specific enolase (NSE), and alpha fetoprotein (AFP). This review comprehensively discusses the progress and potential of nanocomposite-based electrochemical biosensors for early lung cancer diagnosis and prognosis. By integrating nanomaterials like graphene, metal nanoparticles, and conducting polymers, these sensors have achieved clinically relevant detection limits in the fg/mL to pg/mL range. We highlight the key role of nanomaterial functionalization in enhancing sensitivity, specificity, and antifouling properties. This review also examines challenges related to reproducibility and clinical translation, emphasizing the need for standardization of fabrication protocols and robust validation studies. With the rapid growth in understanding lung cancer biomarkers and innovations in sensor design, nanocomposite electrochemical biosensors hold immense potential for point-of-care lung cancer screening and personalized therapy guidance. Realizing this goal will require strategic collaboration among material scientists, engineers, and clinicians to address technical and practical hurdles. Overall, this work provides valuable insight for developing next-generation smart diagnostic devices to combat the high mortality of lung cancer.

Use of ctDNA in early breast cancer: analytical validity and clinical potential

Circulating free tumor DNA (ctDNA) analysis is gaining popularity in precision oncology, particularly in metastatic breast cancer, as it provides non-invasive, real-time tumor information to complement tissue biopsies, allowing for tailored treatment strategies and improved patient selection in clinical trials. Its use in early breast cancer has been limited so far, due to the relatively low sensitivity of available techniques in a setting characterized by lower levels of ctDNA shedding. However, advances in sequencing and bioinformatics, as well as the use of methylome profiles, have led to an increasing interest in the application of ctDNA analysis in early breast cancer, from screening to curative treatment evaluation and minimal residual disease (MRD) detection. With multiple prospective clinical trials in this setting, ctDNA evaluation may become useful in clinical practice. This article reviews the data regarding the analytical validity of the currently available tests for ctDNA detection and the clinical potential of ctDNA analysis in early breast cancer.

Perspectives on Clinical Adoption Barriers to Blood-Based Multi-Cancer Early Detection Tests across Stakeholders

Current United States Preventive Services Task Force (USPSTF) recommendations include routine screening for breast, cervical, colorectal, and lung cancer; however, two out of every three cancer cases occur in other indications, leading to diagnoses in advanced stages of the disease and a higher likelihood of mortality. Blood-based multi-cancer early detection (MCED) tests can impact cancer screening and early detection by monitoring for multiple different cancer types at once, including indications where screening is not performed routinely today. We conducted a survey amongst healthcare providers (HCPs), payers, and patients within the U.S. health system to understand the current utilization of cancer screening tests and the anticipated barriers to widespread adoption of blood-based MCED tests. The results indicated that the community favors the adoption of blood-based MCED tests and that there is broad agreement on the value proposition. Despite this recognition, the survey highlighted that there is limited use today due to the perceived lack of clinical accuracy and utility data, high out-of-pocket patient costs, and lack of payer coverage. To overcome the hurdles for future widespread adoption of blood-based MCED tests, increased investment in data generation, education, and implementation of logistical support for HCPs will be critical.

Mortality risk among adult americans living with cancer and elevated CRP

The role of C Reactive Protein (CRP) in predicting long-term outcomes among people living with cancer has not been well explored. We aimed to assess the role of elevated CRP in predicting all-cause mortality among a community-based sample of adult Americans living with cancer. The National Health and Nutrition Examination Survey, 1999-2010 was linked with mortality files up to December 2019 from the National Death Index. Sociodemographic and health-related variables of 30,711 participants (mean age=46.5 years) were analyzed to compute adjusted hazard ratios (HR) for all-cause mortality. The risk of mortality, in unadjusted analysis, was significantly higher among those with cancer compared to those without cancer 3.53 (95% CI= 3.13-3.98, p < 0.001). In adjusted analysis, when stratified by CRP levels (elevated=cutoff point at ≥2 mg/dL), among individuals with elevated CRP but no cancer history, the risk of mortality was significantly higher (HR=1.67, 95% CI=1.24-2.25) compared to those without cancer or elevated CRP. Among individuals with cancer but without elevated CRP as well, the risk of mortality was 20% higher compared to their counterparts. The highest risk of mortality was observed among those with both cancer and elevated CRP (HR=2.10, 95% CI=1.11-4.33). Age and income were significant predictors of these relationships. Among people living with cancer, CRP may serve as a marker for mortality and future studies should explore the pathways by which the risk of mortality may increase due to variation of CRP in cancer patients.

Application of 3D, 4D, 5D, and 6D bioprinting in cancer research: what does the future look like?

The application of three- and four-dimensional (3D/4D) printing in cancer research represents a significant advancement in understanding and addressing the complexities of cancer biology. 3D/4D materials provide more physiologically relevant environments compared to traditional two-dimensional models, allowing for a more accurate representation of the tumor microenvironment that enables researchers to study tumor progression, drug responses, and interactions with surrounding tissues under conditions similar to in vivo conditions. The dynamic nature of 4D materials introduces the element of time, allowing for the observation of temporal changes in cancer behavior and response to therapeutic interventions. The use of 3D/4D printing in cancer research holds great promise for advancing our understanding of the disease and improving the translation of preclinical findings to clinical applications. Accordingly, this review aims to briefly discuss 3D and 4D printing and their advantages and limitations in the field of cancer. Moreover, new techniques such as 5D/6D printing and artificial intelligence (AI) are also introduced as methods that could be used to overcome the limitations of 3D/4D printing and opened promising ways for the fast and precise diagnosis and treatment of cancer.

Phage Biosensor for the Classification of Metastatic Urological Cancers from Urine

Most of the annual 10 million cancer-related deaths are caused by metastatic disease. Survival rates for cancer are strongly dependent on the type of cancer and its stage at detection. Early detection remains a challenge due to the lack of reliable biomarkers and cost-efficient screening methods. Phage biosensors can offer a solution for early detection using non-invasive liquid biopsies. Here, we report the first results of the bifunctional phage biosensor to detect metastatic urological cancers from urine. A dye-sensitized phage library was used to select metastasis-related phage binders. After selection rounds, the most promising phage candidate was used to classify metastatic cancer from controls. Additionally, we applied one chemical sensor (phenoxazine non-fluorescent dye) to classify cancer from urine. A statistical significance (p = 0.0002) was observed between metastatic and non-metastatic cancer, with sensitivity of 70% and specificity of 79%. Furthermore, the chemical sensor demonstrated significance in detecting cancer (p < 0.0001) with a sensitivity of 71% and a specificity of 75%. Our data suggest a new promising field for urine biomarker research, and further evaluation with prospectively collected samples is ongoing. In conclusion, we report, for the first time, the potential of a chemical- and phage-based biosensor method to detect metastatic cancer using urine.

Beyond blood: Advancing the frontiers of liquid biopsy in oncology and personalized medicine

Liquid biopsy is emerging as a pivotal tool in precision oncology, offering a noninvasive and comprehensive approach to cancer diagnostics and management. By harnessing biofluids such as blood, urine, saliva, cerebrospinal fluid, and pleural effusions, this technique profiles key biomarkers including circulating tumor DNA, circulating tumor cells, microRNAs, and extracellular vesicles. This review discusses the extended scope of liquid biopsy, highlighting its indispensable role in enhancing patient outcomes through early detection, continuous monitoring, and tailored therapy. While the advantages are notable, we also address the challenges, emphasizing the necessity for precision, cost-effectiveness, and standardized methodologies in its broader application. The future trajectory of liquid biopsy is set to expand its reach in personalized medicine, fueled by technological advancements and collaborative research.

Emotion constructs and outcome measures following false positive breast screening test results: A systematic review of reporting clarity and selection rationale

OBJECTIVE

(i) To systematically identify constructs and outcome measures used to assess the emotional and mood impact of false positive breast screening test results; (ii) to appraise the reporting clarity and rationale for selecting constructs and outcome measures.

METHODS

Databases (MEDLINE, CINAHL, PsycINFO) were systematically searched from 1970. Studies using standardised and non-standardised outcome measures to evaluate the emotion or mood impact of false positive breast screening test results were eligible. A 15-item coding scheme was devised to appraise articles on clarity and rationale for selected constructs and measures.

RESULTS

Forty-seven articles were identified. The most investigated constructs were general anxiety and depression and disease-specific anxiety and worry. Twenty-two standardised general outcome questionnaire measures and three standardised disease-specific outcome questionnaire measures were identified. Twenty articles used non-standardised scales/items. Reporting of constructs and outcome measures was generally clear, but rationales for their selection were lacking. Anxiety was typically justified, but justification for depression was almost always absent. Practical and psychometric justification for selecting outcome measures was lacking, and theoretical rationale was absent.

CONCLUSIONS

Heterogeneity in constructs and measures, coupled with unclear rationale for these, impedes a thorough understanding of why there are emotional effects of false positive screening test results. This may explain the repeated practice of investigating less relevant outcomes such as depression. There is need to develop a consensual conceptual model of and standardised approach to measuring emotional impact from cancer screening test results, to address heterogeneity and other known issues of interpreting an inconsistent evidence base.

Cancer Screening: Present Recommendations, the Development of Multi-Cancer Early Development Tests, and the Prospect of Universal Cancer Screening

Cancer continues to pose a considerable challenge to global health. In the search for innovative strategies to combat this complex enemy, the concept of universal cancer screening has emerged as a promising avenue for early detection and prevention. In contrast to targeted approaches that focus on specific populations or high-risk individuals, universal screening seeks to cast a wide net to detect incipient malignancies in different demographic groups. This paradigm shift in cancer care underscores the importance of comprehensive screening programs that go beyond conventional boundaries. As our understanding of the complex molecular and genetic basis of cancer deepens, the need to develop comprehensive screening methods becomes increasingly apparent. In this article, we look at the rationale and potential benefits of universal cancer screening.

The promise and challenges of multi-cancer early detection assays for reducing cancer disparities

Since improvements in cancer screening, diagnosis, and therapeutics, cancer disparities have existed. Marginalized populations (e.g., racial and ethnic minorities, sexual and gender minorities, lower-income individuals, those living in rural areas, and persons living with disabilities) have worse cancer-related outcomes. Early detection of cancer substantially improves outcomes, yet uptake of recommended cancer screenings varies widely. Multi-cancer early detection (MCED) tests use biomarkers in the blood to detect two or more cancers in a single assay. These assays show potential for population screening for some cancers-including those disproportionally affecting marginalized communities. MCEDs may also reduce access barriers to early detection, a primary factor in cancer-related outcome disparities. However, for the promise of MCEDs to be realized, during their development and testing, we are obligated to be cautious to design them in a way that reduces the myriad of structural, systematic, and personal barriers contributing to disparities. Further, they must not create new barriers. Population studies and clinical trials should include diverse populations, and tests must work equally well in all populations. The tests must be affordable. It is critical that we establish trust within marginalized communities, the healthcare system, and the MCED tests themselves. Tests should be expected to have high specificity, as a positive MCED finding will trigger additional, oftentimes invasive and expensive, imaging or other diagnosis tests and/or biopsies. Finally, there should be a way to help all individuals with a positive test to navigate the system for follow-up diagnostics and treatment, if warranted, that is accessible to all.

Integrating Artificial Intelligence for Advancing Multiple-Cancer Early Detection via Serum Biomarkers: A Narrative Review

The concept and policies of multicancer early detection (MCED) have gained significant attention from governments worldwide in recent years. In the era of burgeoning artificial intelligence (AI) technology, the integration of MCED with AI has become a prevailing trend, giving rise to a plethora of MCED AI products. However, due to the heterogeneity of both the detection targets and the AI technologies, the overall diversity of MCED AI products remains considerable. The types of detection targets encompass protein biomarkers, cell-free DNA, or combinations of these biomarkers. In the development of AI models, different model training approaches are employed, including datasets of case-control studies or real-world cancer screening datasets. Various validation techniques, such as cross-validation, location-wise validation, and time-wise validation, are used. All of the factors show significant impacts on the predictive efficacy of MCED AIs. After the completion of AI model development, deploying the MCED AIs in clinical practice presents numerous challenges, including presenting the predictive reports, identifying the potential locations and types of tumors, and addressing cancer-related information, such as clinical follow-up and treatment. This study reviews several mature MCED AI products currently available in the market, detecting their composing factors from serum biomarker detection, MCED AI training/validation, and the clinical application. This review illuminates the challenges encountered by existing MCED AI products across these stages, offering insights into the continued development and obstacles within the field of MCED AI.

Breast Cancer Circulating Tumor Cells: Current Clinical Applications and Future Prospects

BACKGROUND

Identification and characterization of circulating tumor markers, designated as "liquid biopsies," have greatly impacted the care of cancer patients. Although more recently referring to circulating tumor DNA (ctDNA), the term liquid biopsy initially was coined to refer to any blood-borne biomarker related to malignancy, including circulating tumor cells (CTCs) in blood. In this manuscript, we review the specific state of the art of CTCs in breast cancer.

CONTENT

Liquid biopsies might play a clinical role across the entire spectrum of breast cancer, from risk assessment, prevention, screening, and treatment. CTC counts have been shown to carry clear, independent prognostic information in the latter situation. However, the clinical utility of CTCs in breast cancer remains to be determined. Nonetheless, in addition to CTC enumeration, analyses of CTCs provide tumor molecular information representing the entire, often-heterogeneous disease, relatively noninvasively and longitudinally. Technological advances have allowed the interrogation of CTC-derived information, providing renewed hope for a clinical role in disease monitoring and precision oncology.

SUMMARY

This narrative review examines CTCs, their clinical validity, and current prospects of clinical utility in breast cancer with the goal of improving patient outcomes.

Predictive Performance of Cell-Free Nucleic Acid-Based Multi-Cancer Early Detection Tests: A Systematic Review

BACKGROUND

Cancer-screening tests that can detect multiple cancer types, or multi-cancer early detection (MCED) tests, have emerged recently as a potential new tool in decreasing cancer morbidity and mortality. Most MCED assays are based on detecting cell-free tumor DNA (CF-DNA) in the blood. MCEDs offer the potential for screening for cancer organ sites with high mortality, both with and without recommended screening. However, their clinical utility has not been established. Before clinical utility can be established, the clinical validity of MCEDs, i.e., their ability to predict cancer status, must be demonstrated. In this study we performed a systematic review of the predictive ability for cancer of cell-free-nucleic acid-based MCED tests.

CONTENT

We searched PubMed for relevant publications from January 2017 to February 2023, using MeSH terms related to multi-cancer detection, circulating DNA, and related concepts. Of 1811 publications assessed, 61 were reviewed in depth and 20 are included in this review. For almost all studies, the cancer cases were assessed at time of diagnosis. Most studies reported specificity (generally 95% or higher) and overall sensitivity (73% median). The median number of cancer types assessed per assay was 5. Many studies also reported sensitivity by stage and/or cancer type. Sensitivity generally increased with stage.

SUMMARY

To date, relatively few published studies have assessed the clinical validity of MCED tests. Most used cancer cases assessed at diagnosis, with generally high specificity and variable sensitivity depending on cancer type and stage. The next steps should be testing in the intended-use population, i.e., asymptomatic persons.

Blood-Based Multi-Cancer Early Detection Tests (MCEDs) as a Potential Approach to Address Current Gaps in Cancer Screening

Screening and early detection is one of the most effective approaches to reduce the population-level impact of cancer. Novel approaches to screening such as multi-cancer early detection tests (MCEDs) may further reduce cancer incidence and mortality. Many MCEDs detect fragments of circulating DNA containing mutations that originated from tumour cells, thereby informing both the presence of cancer and the cell-type of origin. In this review, we examine the current evidence of MCEDs as a potential tool to improve population-based cancer outcomes. We review the role of MCEDs to address low participation rates, disparities among underserved populations, changing epidemiology of common cancers, and the absence of screening tests for many cancer types. MCEDs have the potential to increase participation in cancer screening programs, as they may be less invasive than other procedures, and can screen for multiple cancer types in one appointment. Additionally, due to the lack of specialized collection equipment needed for these tests, underscreened populations and targeted populations could gain greater access to screening. Finally, because MCEDs can detect cancer types without screening tests that are moderately common and increasing in western populations, efficacious tests for these sites could alleviate the cancer burden and improve patient outcomes. While these tests offer great promise, considerable limitations and evidence gaps must be addressed. Notable limitations include scenarios where early detection does not improve survival outcomes, the costs and impact on health care resources for false positives, and false reassurance with subsequent lack of adherence to existing screening protocols.

Public Perspectives on Multi-Cancer Early Detection: A Qualitative Study

BACKGROUND

Multi-cancer early detection tests (MCEDs) have the potential to identify over 50 types of cancer from a blood sample, possibly transforming cancer screening paradigms. Studies on the safety and effectiveness of MCEDs are underway, but there is a paucity of research exploring public views on MCEDs. We sought to explore public perspectives and understanding on the use of MCEDs in patient care.

METHODS

We conducted a cross-sectional, qualitative study using one-on-one, semi-structured interviews. Residents of the United States aged 45-70 years old were recruited through a survey panel and purposively sampled to maximize racial diversity. Interviews explored understanding of MCEDs and perspectives on their use. Interviews were analyzed using thematic analysis with deductive coding and semi-quantification.

RESULTS

Among 27 participants, mean age was 62 years (range 48-70) and most (63%) were non-white. Most participants had completed at least one cancer screening (89%). Participants had a positive impression of MCEDs (85%) and found the concept easy to understand (88%). They were enthusiastic about the convenience of MCEDs (30%) and thought they would improve "cancer outcomes" by looking for multiple cancers (70%) and facilitating early detection (33%). Participants emphasized the need to balance these benefits against potential harms, including inaccuracy (96%), cost (92%), test-related anxiety (56%), and lack of evidence of effectiveness (22%). Participants favored that MCEDs be delivered in primary care (93%). Participants worried that the potential benefits of MCEDs might not be equitably distributed (44%).

CONCLUSIONS

Members of the US public in this study expressed an interest in using MCEDs but had concerns regarding cost, accuracy, and potential inequitable access to the tests. Findings suggest that MCEDs that are found to be safe and effective will be acceptable to patients as a part of primary care, and underscore public interest in improving this technology.

Harnessing liquid biopsies: Exosomes and ctDNA as minimally invasive biomarkers for precision cancer medicine

Liquid biopsies have emerged as groundbreaking tools for minimally invasive monitoring of cancer, encompassing the analysis of Cell-Free DNA (cfDNA), circulating tumor DNA (ctDNA) and exosomes. This paradigm shift offers an emerging approach for understanding tumor dynamics, treatment responses, and disease progression. Leveraging advancements in molecular biology and technology, liquid biopsies enable clinicians to gain intricate insights from peripheral blood, thereby transforming the landscape of cancer care. This review describes the clinical impact, technological innovations, and recent evidence surrounding the integration of ctDNA and exosome analysis in cancer monitoring. Through early detection, real-time treatment response assessment, and the tracking of minimal residual disease, liquid biopsies have redefined the standards of precision oncology. Key advancements in ctDNA analysis, such as high-throughput sequencing and digital PCR, empower the detection of actionable mutations with high sensitivity. Concurrently, the characterization of exosomal cargo, facilitated by next-generation sequencing and mass spectrometry, unveils the molecular nuances of tumors. Recent studies underscore the utility of these approaches, demonstrating their efficacy in predicting relapse, guiding therapeutic decisions, and ultimately improving patient outcomes. As the field continues to evolve, liquid biopsies hold promise not only as diagnostic tools but also as agents of personalized medicine, enabling precise navigation of the intricate landscape of cancer with minimally invasiveness.

Primary Care Provider Receptivity to Multi-Cancer Early Detection Test Use in Cancer Screening

Multi-cancer early detection tests (MCEDs) are blood-based tests that detect biomarkers released or induced by cancer cells. If MCED tests are shown to be safe and effective in cancer screening, they are likely to be ordered and managed in primary care. To understand primary care providers' support for and concerns about the implementation and management of MCED testing, the research team developed a cross-sectional survey that was sent to 939 primary care providers (physicians, residents/fellows, and advanced practice providers) in a large academic health system in the greater Philadelphia area. The survey included standard items used to assess provider background characteristics and to measure provider awareness of challenges related to MCED test use (7 items), perceived competence in MCED testing (5 items), and receptivity to MCED test use in the future (4 items). A total of 351 (37.4%) primary care providers completed the survey. Among respondents, the awareness of challenges in MCED testing (mean = 3.95, sd = 0.64), perceived competence (3.67, sd = 0.85), and receptivity to MCED use in practice (mean = 3.62, 0.75) were moderately high. Multiple regression was performed to identify factors associated with receptivity to MCED testing. We found that provider number of years in practice (DATA), awareness of challenges related to MCED testing (DATA), and perceived competence in MCED test use (DATA) were positively and significantly associated with receptivity to MCED test use in practice. An exploratory factor analysis extracted two components: receptivity to MCEDs and awareness of challenges. Surprisingly, these factors had a positive correlation (r = 0.124, p = 0.024). Providers' perceived competence in using MCED tests and providers' experience level were significantly associated with receptivity to MCED testing. While there was strong agreement with potential challenges to implementing MCEDs, PCPs were generally receptive to using MCEDs in cancer screening. Keeping PCPs updated on the evolving knowledge of MCEDs is likely critical to building receptivity to MCED testing.

Multi-cancer early detection test in symptomatic patients referred for cancer investigation in England and Wales (SYMPLIFY): a large-scale, observational cohort study

BACKGROUND

Analysis of circulating tumour DNA could stratify cancer risk in symptomatic patients. We aimed to evaluate the performance of a methylation-based multicancer early detection (MCED) diagnostic test in symptomatic patients referred from primary care.

METHODS

We did a multicentre, prospective, observational study at National Health Service (NHS) hospital sites in England and Wales. Participants aged 18 or older referred with non-specific symptoms or symptoms potentially due to gynaecological, lung, or upper or lower gastrointestinal cancers were included and gave a blood sample when they attended for urgent investigation. Participants were excluded if they had a history of or had received treatment for an invasive or haematological malignancy diagnosed within the preceding 3 years, were taking cytotoxic or demethylating agents that might interfere with the test, or had participated in another study of a GRAIL MCED test. Patients were followed until diagnostic resolution or up to 9 months. Cell-free DNA was isolated and the MCED test performed blinded to the clinical outcome. MCED predictions were compared with the diagnosis obtained by standard care to establish the primary outcomes of overall positive and negative predictive value, sensitivity, and specificity. Outcomes were assessed in participants with a valid MCED test result and diagnostic resolution. SYMPLIFY is registered with ISRCTN (ISRCTN10226380) and has completed follow-up at all sites.

FINDINGS

6238 participants were recruited between July 7 and Nov 30, 2021, across 44 hospital sites. 387 were excluded due to staff being unable to draw blood, sample errors, participant withdrawal, or identification of ineligibility after enrolment. Of 5851 clinically evaluable participants, 376 had no MCED test result and 14 had no information as to final diagnosis, resulting in 5461 included in the final cohort for analysis with an evaluable MCED test result and diagnostic outcome (368 [6·7%] with a cancer diagnosis and 5093 [93·3%] without a cancer diagnosis). The median age of participants was 61·9 years (IQR 53·4-73·0), 3609 (66·1%) were female and 1852 (33·9%) were male. The MCED test detected a cancer signal in 323 cases, in whom 244 cancer was diagnosed, yielding a positive predictive value of 75·5% (95% CI 70·5-80·1), negative predictive value of 97·6% (97·1-98·0), sensitivity of 66·3% (61·2-71·1), and specificity of 98·4% (98·1-98·8). Sensitivity increased with increasing age and cancer stage, from 24·2% (95% CI 16·0-34·1) in stage I to 95·3% (88·5-98·7) in stage IV. For cases in which a cancer signal was detected among patients with cancer, the MCED test's prediction of the site of origin was accurate in 85·2% (95% CI 79·8-89·3) of cases. Sensitivity 80·4% (95% CI 66·1-90·6) and negative predictive value 99·1% (98·2-99·6) were highest for patients with symptoms mandating investigation for upper gastrointestinal cancer.

INTERPRETATION

This first large-scale prospective evaluation of an MCED diagnostic test in a symptomatic population demonstrates the feasibility of using an MCED test to assist clinicians with decisions regarding urgency and route of referral from primary care. Our data provide the basis for a prospective, interventional study in patients presenting to primary care with non-specific signs and symptoms.

FUNDING

GRAIL Bio UK.

Circulating Tumor DNA in Gastric Adenocarcinoma: Future Clinical Applications and Perspectives

Gastric cancer (GC) is still one of the most aggressive cancers with a few targetable alterations and a dismal prognosis. A liquid biopsy allows for identifying and analyzing the DNA released from tumor cells into the bloodstream. Compared to tissue-based biopsy, liquid biopsy is less invasive, requires fewer samples, and can be repeated over time in order to longitudinally monitor tumor burden and molecular changes. Circulating tumor DNA (ctDNA) has been recognized to have a prognostic role in all the disease stages of GC. The aim of this article is to review the current and future applications of ctDNA in gastric adenocarcinoma, in particular, with respect to early diagnosis, the detection of minimal residual disease (MRD) following curative surgery, and in the advanced disease setting for treatment decision choice and therapeutic monitoring. Although liquid biopsies have shown potentiality, pre-analytical and analytical steps must be standardized and validated to ensure the reproducibility and standardization of the procedures and data analysis methods. Further research is needed to allow the use of liquid biopsy in everyday clinical practice.

Tear nanoDSF Denaturation Profile Is Predictive of Glaucoma

Primary open-angle glaucoma (POAG) is a frequent blindness-causing neurodegenerative disorder characterized by optic nerve and retinal ganglion cell damage most commonly due to a chronic increase in intraocular pressure. The preservation of visual function in patients critically depends on the timeliness of detection and treatment of the disease, which is challenging due to its asymptomatic course at early stages and lack of objective diagnostic approaches. Recent studies revealed that the pathophysiology of glaucoma includes complex metabolomic and proteomic alterations in the eye liquids, including tear fluid (TF). Although TF can be collected by a non-invasive procedure and may serve as a source of the appropriate biomarkers, its multi-omics analysis is technically sophisticated and unsuitable for clinical practice. In this study, we tested a novel concept of glaucoma diagnostics based on the rapid high-performance analysis of the TF proteome by differential scanning fluorimetry (nanoDSF). An examination of the thermal denaturation of TF proteins in a cohort of 311 ophthalmic patients revealed typical profiles, with two peaks exhibiting characteristic shifts in POAG. Clustering of the profiles according to peaks maxima allowed us to identify glaucoma in 70% of cases, while the employment of artificial intelligence (machine learning) algorithms reduced the amount of false-positive diagnoses to 13.5%. The POAG-associated alterations in the core TF proteins included an increase in the concentration of serum albumin, accompanied by a decrease in lysozyme C, lipocalin-1, and lactotransferrin contents. Unexpectedly, these changes were not the only factor affecting the observed denaturation profile shifts, which considerably depended on the presence of low-molecular-weight ligands of tear proteins, such as fatty acids and iron. Overall, we recognized the TF denaturation profile as a novel biomarker of glaucoma, which integrates proteomic, lipidomic, and metallomic alterations in tears, and monitoring of which could be adapted for rapid non-invasive screening of the disease in a clinical setting.