1. A Novel Cost-Effective Strategy for Colorectal Cancer Screening with Higher Patient Compliance.
Motamed-Khorasani A; PhD , Small-Howard A; PhD , Beart R; MD 1 2 3
1
Neometrix Consulting Inc., Radient Pharmaceuticals Corp., Glendale Memorial Hospital
2 3
Abstract Study Purpose Results Conclusion References
Routine screening methods for colorectal cancer (CRC) have poor patient compliance The goal of this study was to determine whether the combined usage • The cut points were calculated as 1.3 ug/ml for DR-70, and 3 ng/ml • DR-70 blood biomarker is cleared to be used for monitoring of CRC 1. Zauber T et al. Evaluating test strategies for colorectal cancer screening. Anals of
and low sensitivity for early stages. The sensitivity rates are 19, 71, 76, and 83% for of DR-70 and CEA will improve the sensitivity to the point where it for CEA. Internal Medicine. 2008;1549:659-69.
Fecal Occult Blood test (FOBT), stool DNA test, colonoscopy/sigmoidoscopy, and treatment and recurrence.
can be used as a screening test. • The results showed sensitivity of 58.2% and specificity of 59.8% 2. Sharif et al. Colorectal cancer detection: time to abandon barium enema?
double-contrast barium enema; respectively. Biological markers have also been • The combined usage of DR-70 and CEA in CRC screening showed Frontline Gastroenterol. 2011;2:105-109.
tested including CEA (sensitivity of 38.7%); however, its utility in CRC screening is Materials and Methods for DR-70 and CEA combined. a significant clinical advantage in terms of sensitivity over each 3. Fenlon et al. A comparison of virtual and conventional colonoscopy for the
limited due to low sensitivity. Onko-Sure® is an FDA-cleared blood test for monitoring
of CRC treatment/recurrence. It measures the accumulation of Fibrin/Fibrinogen • A total of 662 age-matched serum samples were retrospectively • The sensitivity for the combined test was much better than that of marker alone. detection of colorectal polyps. N Engl J Med. 1999;341:1496-503).
Degradation products in the serum using anti-DR-70® antibody. The objective was to obtained through a serum bank in two arms including the each of the markers alone (54% higher sensitivity compared to that • The sensitivity Improvement was highest for stages I and II, which 4. Okholm M et al. Fibrin and fibrinogen degredation products in plasma of patients
determine whether DR-70® and CEA combination can improve the sensitivity such confirmed healthy control (n=351) and biopsy-confirmed primary of CEA alone). has important implications in patient treatment options, prognosis with colorectal adenocarcinoma. Dis Colon Rectum. 1996;39:1102-1106.
that it can be used as a cost-effective alternative to current screening methods yet CRC (n=311) groups.
ROC Analysis Results and survival rate due to early detection. 5. Oya M et al. Plasma D-dimer level in patients with colorectal cancer: its role as a
with a higher patient compliance. A total of 662 serum samples were retrospectively tumor marker. Surg Today. 1998;28(4):373-8.
• In the CRC group, the break down of the stages was as following:
obtained from a serum bank in two arms: confirmed healthy control (n=351) and • With a 3-times higher sensitivity for early stage CRC compared to
biopsy-confirmed CRC (n=311) groups. The samples were tested for DR-70® and • Stage I (n=79) • The ROC analysis for DR-70 to find the optimal cut point to 6. Wu D et al. Clinical performance of the AMDL DR-70 immunoassay kit for cancer
using FOBT, this approach should improve the CRC early stage detection. J Immunoassay 1998;19(1):63-72.
CEA. The results showed sensitivity of 58.2% and specificity of 59.8% for DR-70® and • Stage II (n=53) differentiate the normal vs. the cancer group showed that 1.3 ug/ml
diagnosis.
CEA combined. The sensitivity for the combined test was 55% higher than that of • Stage III (n=139) was the optimal cut point. 7. Wu Q et al. Application of the DR-70 detection in tumor of the digestive system.
CEA alone. A consistent improvement of sensitivity for the combined usage relative to • Stage IV (n=40) • Such early stage detection is less likely using routine approaches Shanghai J Lab Med 2001;(6):346-347.
• The DR-70 test performed with 38% sensitivity and 66.4%
CEA alone was observed with a sensitivity increase of 73%, 108%, 58% and 18% in for CRC screening because of low sensitivity and low patient 8. Blackwell K et al. Circulating D-dimer levels are better predictors of overall
CRC stage I, II, III and IV; respectively. The sensitivity of the combined test was 48%, • The average age range for the groups were as following: specificity at the cut point of 1.3 ug/ml. survival and disease progression than carcinoembryonic antigen levels in
compliance.
47%, 57% and 98% for stages I, II, III and IV. Combining DR-70® and CEA tests • Normal: 55.8 ± 11.8 years (n=351) • The cut point for CEA was considered 3 ng/ml (reported by the patients with metastatic colorectal carcinoma. cancer. 2004;101(1):77-82.
showed a significant clinical advantage in CRC screening over using each marker
alone. The sensitivity improvement was highest for stages I/II, which has important
• CRC: 59.1 ± 12.9 years (n=311) manufacturer and validated on many occasions in the refereed Discussion 9. Xu G et al. Relationship between plasma D-dimer levels and clinicopathologic
parameters in resectable colorectal cancer patients. World J Gastroenterol.
implications in patient treatment options, prognosis and survival rate due to this early • For each patient, the serum sample was tested for DR-70 and CEA publications).
• CEA is an adhesion molecule that is firmly attached to cancer 2004;10(6):922-923.
detection. With a 3 times higher sensitivity for early stage CRC compared to using concentrations. • Sensitivity, specificity, PPV and NPV were calculated for CEA and
FOBT, this approach should improve the CRC early stage diagnosis. Such early stage cells.24 Therefore, it is Less abundant in blood and more difficult to 10. Rucker P et al. Elevated Fibrinogen-Fibrin Degradation Products (FDP) in Serum
• For each patient, 10ul of serum was utilized for a duplicate testing CEA plus DR-70 based on the results of the ROC analysis (Table1). of Colorectal Cancer Patients. Analytical Letters. 2004;37:2965-2976.
detection is less likely using routine approaches, such as FOBT/FIT, for CRC be measured. This is the case, especially in early stages because
of the DR-70 concentration and the assay instruction was followed 11. Kerber A et al. The new DR-70 immunoassay detects cancer of the gastrointestinal
screening because of low sensitivity and low patient compliance.
Table 1. Sensitivity, Specificity, PPV and NPV. proteases stimulated during oncogenesis are required to release
according to the manufacturer. tract: a validation study. Aliment Pharmacol Ther. 2004;20:983-098.
the membrane-bound antigen from the cancer cells.
Introduction • The data were analyzed by receiver operating characteristics (ROC)
Sensitivity Specificity PPV NPV • There is no CRC screening test in the form of blood test. For many
12. Lee KH et al. Meaning of the DR-70 immunoassay for patients with the malignant
analysis to find the optimal cut point to differentiate the normal vs. tumor. Immune Network 2006;6(1):43-51.
For colorectal cancer (CRC), early diagnosis with prompt treatment can (%) (%) (%) (%) years (until 2008), CEA has been the only blood biomarker cleared
the cancer group. 13. Gieseler F et al. Activated coagulation factors in human malignant effusions and
lead to a better survival rate and quality of life for patients. Routine CEA 37.6 91.2 79.1 62.3 for CRC but only for monitoring and not screening due to low their contribution to cancer cell metastatsis and therapy. Thromb Haemost
screening methods for colorectal cancer (CRC) have poor patient • Sensitivity, specificity, positive predictive value (PPV) and negative
DR-70 + CEA 58.2 59.8 56.2 61.8 sensitivity. For this very reason, Onko-Sure® and its combination 2007;97(6):1023-1030.
compliance and low sensitivity for early stages. predictive value (NPV) were calculated for CEA, DR-70 and CEA
with CEA can be advantageous over CEA alone in detecting lower 14. Hundt S et al. Blood markers for early detction of colorectal cancer: A systematic
plus DR-70 based on the results of the ROC analysis. review. Cancer Epidemiol Biomarkers Prev 2007;16:1935-1953.
levels of the blood biomarker leading to an early diagnosis of CRC.
The sensitivity of Fecal Occult Blood test (FOBT) for adenomas is
• A sub-analysis of sensitivity, specificity, PPV and NPV was carried Figure 2. Comparison of Sensitivity. Therefore, it can be potentially used the only CRC screening test. 15. Kilic M et al. Prognostic value of plasma D-dimer levels in patients with colorectal
5-10% (smaller than 5 mm), 10-26% (6-10 mm) and 18-50% (larger than
10mm)1 . For CRC, FOBT has the sensitivity of 25-50%.1 out to compare CEA, DR-70 and CEA plus DR-70 in stages I, II, III Ensuring high patient compliance. cancer. Colorectal Dis. 2008;10(3):238-41.
and IV. 16. Shimwell NJ et al. Assessment of novel combinations of biomarkers for the
The sensitivity of Fecal Immunochemical Test (FIT) for adenomas is • Onko-Sure is a simple, non-invasive, ELISA-based assay in vitro
®
detection of colorectal cancer. Cancer Biomark. 2010;7(3):123-132.
2-8% (smaller than 5 mm), 8-24% (6-10 mm) and 16-48% (larger than Serum Sampling diagnostic (IVD) blood biomarker test for CRC.
% Sensitivity
17. Small-Howard A et al. Advantages of the AMDL-ELISA DR-70 (FDP) Assay over
10mm) .1 For CRC, FIT has the sensitivity of 50-87%.1 • Blood sample was obtained by venipuncture for each subject prior • There are 76 refereed publications from all over the world Carcinoembryonic Antigen for Monitoring Colorectal Cancer Patients. J
The sensitivity of flexible sigmoidoscopy (FS) for adenomas is 70-79% Immunoassay Immunochem. 2010;31(2):131-147.
to the initiation of the study. supporting this blood biomarker alone and in combination with
(smaller than 5 mm), 80-92% (6-10 mm) and 92-99% (larger than 10mm)1. • In the event of primary therapy, the blood was obtained prior to the other blood biomarkers for 19 different cancers. 18. Cordero OJ et al. Potential of soluble CD86 as a serum marker for colorectal
For CRC, FS has the sensitivity of 92-99%.1 cancer detection. World J Clin Oncol 2011;2(6):245-261.
original surgery. • It was cleared by US FDA in 2008 for monitoring of colorectal 19. Okholm M et al. Fibrin and fibrinogen degradation products in plasma of patients
The gold standard for screening is optical colonocsopy (OC) with • The sample was collected into a 10 ml red-cap tube without CEA DR-70 + CEA cancer treatment and recurrence. However, in combination with with colorectal adenocarcinoma. Dis Colon Rectum. 1996;39:1102-1106.
sensitivity of 70-79% (smaller than 5 mm), 80-92% (6-10 mm) and additives. Blood Biomarkers Tested CEA, it has the potential to be effectively used for CRC screening. 20. Ieko M et al. Soluble fibrin monomer degradation products as a potentially useful
92-99% (larger than 10mm) for adenomas.1 For CRC, OC has the • After the collection of the blood, as a routine procedure in the marker for hypercoagulable states with accelerated fibrinolysis. Clin Chim Acta.
• The sensitivity of the combined test is 58%, which is 55% better • Onko-Sure® measures the accumulation of the breakdown products
sensitivity of 92-99% .1 2007;386(1-2):38-45.
laboratory, the tube was allowed to stand for approximately 30 than the sensitivity of CEA alone (38%). This is considered clinically of Fibrin/Fibrinogen Degradation Products (FDP), including a
The sensitivity of Double-Contrast Barium Enema (DCBE) for adenomas minutes to 3 hours. unique cancer-related breakdown product called “Initial Plasmin 21. Rucker P et al. Elevated Fibrinogen-Fibrin Degradation Products (FDP) in Serum
important and raises the potential for this marker combination to be of Colorectal Cancer Patients. Analytical Letters. 2004;37:2965-2976.
is 81-85%.2 • Following this “standing time” the blood was spun for 10 minutes Degradation Product” (IPDP)21-23 in the serum using an antibody
used for screening of CRC.
22. Wu D et al. Clinical performance of the AMDL DR-70 immunoassay kit for cancer
The sensitivity of CT Colonography (CTC) or Virtual Colonoscopy for at 1,200g (or as recommended by the tube manufacturer) to against DR-70 tumor marker.
• Considering that there are not many FDA-cleared blood biomarkers detection. J Immunoassay 1998;19(1):63-72.
adenomas is 55% (smaller than 5 mm), 82% (6-10 mm) and 91% (larger separate the serum from the rest of the blood elements. • DR-70 is Freely diffusible in blood and therefore easy to measure
in the market for colorectal cancer, it is advised to combine CEA, 23. Kerber A et al. The new DR-70 immunoassay detects cancer of the gastrointestinal
than 10mm).3 For CRC, CTC has the sensitivity of 91%. 3 • The serum was transferred into a 2ml Corning cryovial. the routine colorectal cancer marker, with DR-70 to increase the even in low concentrations. tract: a validation study. Aliment Pharmacol Ther. 2004;20:983-098.
The FOBT and FIT tests have low sensitivity specially for smaller • Each tube was clearly labelled and dated. sensitivity of the test. 24. Charalabopoulos K et al. CEA levels in serum and BAL in patients suffering from
• Furthermore, CEA has approximately a 20% chance of false
lesions. The FS, OC, DCBE and CTC have higher sensitivity ; however, • Finally, the serum was stored at -80°C until all the samples were lung cancer: correlation with individuals presenting benign lung lesions and
• Improvement in early detection of CRC has important implications positive in smokers25; while, Onko-Sure® measurements are not healthy volunteers. Med Oncol. 2007;24:219-225.
the patient compliance for these tests is low dues to the a need for pre- ready for the ELISA. to patient treatment options, prognosis and survival rate. affected by smoking.
test preparation and difficulty of the procedure. 25. Kantrowitz M et al. False Positives and False Negatives in Tumor Marker Blood
There are also some biological markers that are being used for CRC Figure 1. Onko-Sure® Test Description. Figure 3. Comparison of the Changes in Sensitivity. • A combination of several tumor markers is well known to provide Tests. Cancer Points.
http://www.kantrowitz.com/cancerpoints/tumormarkerfalsepositives.html[01/06/20
including CEA (38-69% sensitivity) and CA19-9 (23-65%sensitivity); more accurate information about detection and monitoring of many
10 11:59:54 PM].
% Increased Sensitivity Compared to CEA
however, their utility in CRC screening is limited due to low sensitivity. different types of diseases including cancers.
• Cordero OJ et al. Potential of soluble CD86 as a serum marker for colorectal
These markers are mainly used to monitor the CRC treatment instead. • This was the case reported by many independent scientists for cancer detection. World J Clin Oncol 2011;2(6):245-261.
Onko-Sure® is a simple, in vitro diagnostic blood test that is US FDA combined CEA and DR-70 blood biomarkers as well. • Shimwell NJ et al. Assessment of novel combinations of biomarkers for the
cleared for monitoring CRC during treatment and for post-treatment detection of colorectal cancer. Cancer Biomark. 2010;7(3):123-132.
• Our results were also in line with the previously published
CRC recurrence monitoring. DR-70 sensitivity was reported as 50-80% manuscripts in the peer-reviewed journals showing an improved • Hundt S et al. Blood markers for early detection of colorectal cancer: A systematic
in different studies published in more than fifteen peer-reviewed review. Cancer Epidemiol Biomarkers Prev 2007;16:1935-1953.
sensitivity of the combined test compared to either of them.26-28
journals.4-18 The use of this tumor marker as a potential candidate for
CRC screening can potentially result in early diagnosis in CRC.
• Early diagnosis of malignancies is important for planning future Contact Information
• Onko-Sure® is a simple, non-invasive, ELISA-based assay in vitro therapeutic strategies which, if initiated without delay, aim either to
Fibrin and Fibrinogen Degradation Products (FDP): cure or to prolong disease-free survival and to improve the quality
diagnostic (IVD) blood biomarker test for monitoring of colorectal Radient Pharmaceuticals Corp.
•The production of Fibrin and Fibrinogen Degradation Products (FDP) cancer treatment and recurrence. of life of patients with cancer.
is restricted in healthy individuals by normal cells. 73% %108 %30 %58 %18 • If a new diagnostic test increases early detection of CRC when
• It was cleared by US FDA in 2008 for monitoring of colorectal
•However, cancer cells release proteolytic enzymes such as plasmin used adjunctively with other available diagnostic markers, the 2492 Walnut Ave., Suite 100 Tel: 714.505.4461
cancer treatment and recurrence. I II III IV Overall
Tustin, CA 92780-6953 Fax: 714.505.4464
and thrombin as they grow and metastasize and they also redirect the annual deaths due to CRC recurrence could be reduced due to
coagulation cascade which leads to overproduction of FDP in the • Onko-Sure® measures the accumulation of the breakdown products Combined CEA and DR-70 Test USA E-mail: info@radient-pharma.com
early detection and increased survival rates. URL: http://onko-sure.com
process of carcinogenesis.19 of Fibrin/Fibrinogen Degradation, including a unique cancer-related • The sensitivity of the combined test is much better than the
breakdown product called “Initial Plasmin Degradation Product” sensitivity of CEA alone in stages II, I, III and IV; respectively. This • Therefore, it is recommended that both CEA and Onko-Sure® be
•FDP level measurement is routinely performed for the detection of For further information contact: E-mail: sales@radient-pharma.com
coagulopathies; however, the current assays usually detect only one (IPDP)21-23 in the serum using an antibody against DR-70 tumor outstanding increased sensitivity specially in stages I and II has a used in combination for the detection and monitoring of CRC
out of the many FDP components (D-dimer).20 marker. clear clinical benefit for the patients (early detection of CRC). treatment /post-operational CRC recurrence.
Presented at the 2012 Gastrointestinal Cancers Symposium (ASCO), January 19-21 – San Francisco, CA Abstract ID # 88133