Study Rationale:

The major cause of high fatality of cancer is late stage at diagnosis. It is thought that progression of cancer from early to late stage disease is a prolonged process, which becomes highly fatal after reaching late stage. To improve outcomes of cancer, it is imperative to detect them early. Even when metastasis has initiated but is not yet evident radiologically, cancers can be cured in up to 50% of cases with systemic therapies. Once large, metastatic tumors are formed, however, current therapies are rarely effective.

Current screening modalities are mostly non-blood based (except PSA) and thus are invasive. This leads to decreased compliance to screening procedures and also are associated with sensitivity-specificity limitations. The approved tests for cancer detection include colonoscopy, mammography, LDCT and cervical cytology.

Efforts are being focused on evaluating blood based non-invasive screening tests. New blood tests for cancer must have very high specificity; otherwise, too many healthy individuals will receive positive test results, leading to unnecessary follow-up procedures and anxiety.

Current blood based screening tests under development mainly focus on cfDNA based approaches which detect somatic alterations in blood. However multiple studies have highlighted limitations of liquid biopsy sensitivity in early stages of cancers. Also emerging evidence of somatic alterations arising from clonal hematopoiesis of white blood cells, question the specificity of this approach. In addition, no studies have examined many healthy control individuals, which is essential for evaluation of the specificity of such tests. Liquid biopsies are also unable to identify underlying tissue of origin in majority of cases due to the fact that most somatic alterations are not cancer type specific.

Circulating tumor cells are the tumor cells which have detached from primary tumor site and have gained access to peripheral circulation. These may potentially lodge in distant organs giving rise to metastasis. Thus, CTC is a pre-requisite for disease spread and thus are detectable before late stage/metastatic disease develops. Also, CTCs have additional advantage of expressing tissue-of-origin specific markers in their cytoplasm/nucleus/membrane giving rise to feasibility of identification of primary tumor site. In certain cases, morphological classification into probable cancer type e.g. squamous vs adenocarcinoma may be feasible, giving better access to patient management in addition to the diagnosis.

Study Conduct

a.      STEP 0 (Recruitment and Consent):

Patients fulfilling eligibility criteria are recruited after providing detailed information about study protocol, its utility and limitations. Participant enters study only after providing written informed consent.

 b.      STEPS 1: (Screening procedure Non-cancer arm):

After consent, participants undergo screening procedures as proposed below-

Sr. No.	Investigation	Male	Female
1.	Mammography	-	Yes
2.	PAP Smear with HPV	-	Yes*
3.	LDCT	Yes	Yes
4.	PSA	Yes	-
5.	CA 19.9	Yes	Yes
6.	CA 125	-	Yes
7.	AFP	Yes	Yes
8.	CEA	Yes	Yes
9.	Clinical Examination	Yes	Yes
10.	CBC with peripheral smear examination	Yes	Yes
11.	15 ml blood sample collection for study protocol	Yes	Yes

* upto 65 years

 c.       STEP 3 (Data Evaluation):

The data from study analytes CTCs is compared with standard screening procedures, clinical examination and clinical history details to determine sensitivity and specificity of CTCs as a cancer screening tool.

For benign lesion arm and cancer arm, the data from study analytes CTCs is compared with histopathology examination report.

Ethical Considerations

Discussion on the ethics of the study:

The participation in the study is entirely voluntary and after providing appropriate consent.

There is no active ongoing intervention involved in current study as it involves only single point peripheral blood draw and approved standard cancer screening procedures.  Thus, this study will only offer advantage to its participants by offering approved cancer screening procedures. There will be no financial implications for the study participant.

Approvals:

The protocol, informed consent form, participant information sheet and any proposed advertising material will be submitted to an appropriate Research Ethics Committee (REC)/ Institutional review board (IRB) of host institution(s) for written approval. The PI will submit and, where necessary, obtain approval from the above parties for all substantial amendments to the original approved documents.

Participant Confidentiality:

The study staff will ensure that the participants’ anonymity is maintained. The participants will be identified only by a participant identification number on all study documents and any electronic database. All documents will be stored securely and only accessible by study staff and authorized personnel. The study will comply with the Data Protection Act, which requires data to be anonymised as soon as it is practical to do so.

Informed Consent Process:

Prior to the beginning of the trial, the investigator should have the IRB’s written approval for the protocol and the written informed consent form(s) and any other written information to be provided to the participants. Informed consent is a process that is initiated prior to the individual’s agreeing to participate in the study. Consent forms will be Institutional Review Board (IRB)-approved and the participant will be asked to read and review the document. The investigator will explain the study to the participant and answer any questions that may arise. A verbal explanation will be provided in terms suited to the participant’s comprehension of the purposes, procedures, and potential risks of the study and of their rights as research participants. Participants will have the opportunity to carefully review the written consent form and ask questions prior to signing. The participants should have the opportunity to discuss the study with their family or surrogates or think about it prior to agreeing to participate. The participant will sign the informed consent document prior to any procedures being done specifically for the study. Participants must be informed that participation is voluntary and that they may withdraw from the study at any time, without prejudice. A copy of the informed consent document will be given to the participants for their records. The informed consent process will be conducted and documented in the source document (including the date), and the form signed, before the participant undergoes any study-specific procedures. The rights and welfare of the participants will be protected by emphasizing to them that the quality of their medical care will not be adversely affected if they decline to participate in this study.

Financial Implications:

Study participant will be under no financial burden for the study sponsored cancer screening procedures.

General ethics for the conduct of the study:

The study will be conducted in compliance with the ICMR Statement on Human Experimentation, the Declaration of Helsinki and the International Committee of Harmonisation (ICH) Harmonised Tripartite Guidelines for Good Clinical Practice (GCP)

The Investigator or a person designated by him/her will collect informed consent from all participants, prior to which the Investigator or co-investigator must inform each participant of the objectives, benefits, risks and requirements of the study. He/she will also provide the participant with an information sheet in clear, simple language. The study participant will be allowed ample time to inquire about details of the study and to decide whether or not to participate in the study. The study will not commence until approval has been obtained from the DCGL Ethics Committee and CTRI registration is completed.