Decisive innovation in mCRC therapy selection Know more
The way in which therapy decisions are made for metastatic colorectal cancer (mCRC) patients is changing. Functional drug sensitivity testing (f-DST) offers a new approach by providing a clinically actionable assessment of truly personalized drug sensitivity profiles. The concept is straightforward. Starting from a biopsy of the patient’s tumor, we grow 3D-biological replicas in our central laboratory, and use them to evaluate the impact of individual drugs and complex combination therapies (doublets and triplet) for which no biomarkers exist. For the first time, you can obtain information that informs the way in which a patient’s tumor can respond to different chemotherapy backbones. It is our mission to improve patients’ outcomes by establishing individualized drug sensitivity profiling as routine practice in oncology, so that all treatment decisions are supported by a personal test. To this aim, we develop products for individualized therapy selection, and bring them through the regulatory and reimbursement pathways to make them available to healthcare professionals and their patients all over the world. That’s our journey. That’s what we do. Every day. Join us.
By 2040, the global burden will have grown to 3.2 million new cases per year – a rise of 68% – and is projected to increasingly affect young adults. Approximately 25% of all cases are diagnosed as Stage IV metastatic colorectal carcinoma (mCRC). While there is considerable progress in understanding the diverse biology of cancer and in identifying biomarkers towards some targeted therapies3,4,5, the fact is that, to a high degree, cancer phenotypes are driven by non-genetic mechanisms that present a challenge when deciding the best systemic chemotherapy for an individual patient. 5FU-based combination therapies remain the therapeutic backbone of systemic antineoplastic therapy, but these have not changed much in over 60 years. The majority of mCRC patients are treated with combinations of 5FU, leucovorin and oxaliplatin (FOLFOX), irinotecan (FOLFIRI), the combination of both (FOLFOXIRI), or regorafenib and trifluridine-tipiracil. Colorectal cancer (CRC) is the third most-deadly and fourth most-diagnosed cancer in the world1,2. In 2020, more than 1.9 million new cases and over 930,000 deaths were estimated to have occurred worldwide. Decisive innovation in therapy selection for stage IV mCRC Stage I Stage II Stage III Stage IV 18% 33% 24% approx. 25%
Functional drug sensitivity testing exposes biological replicas of a patient’s tumor (3D-microtumors) to drugs directly. This approach provides functional data that capture information on key tumor vulnerabilities, including those derived from altered epigenetic states or altered signaling pathways not necessarily driven by genomic anomalies. It is, therefore, the best option to guide therapy selection in the absence of biomarkers. CE-marked, and therefore approved and actionable immediately in clinical settings, the IndiTreat® family of products supports therapy decision-making in metastatic colorectal cancer and sets the stage for innovation and truly personalized management of patients. North America 10% Latin America 7% Africa 3% Europe 27% Asia 52% Oceania 1% 1 Rawla P, Sunkara T, Barsouk A. Epidemiology of colorectal cancer: incidence, mortality, survival, and risk factors. Prz Gastroenterol. 2019;14(2):89-103. doi: 10.5114/pg.2018.81072. Epub 2019 Jan 6. PMID: 31616522; PMCID: PMC6791134, 2 Morgan E, Arnold M, Gini A, Lorenzoni V, Cabasag CJ, Laversanne M, et al.: The global burden of colorectal cancer in 2020 and 2040: incidence and mortality estimates from GLOBOCAN. Gut, Published online 8 September 2022 - http://dx.doi. org/10.1136/gutjnl-2022-327736, 3 Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin. 2011; 61(2):69–90. https://doi. org/10.3322/caac.20107 PMID: 21296855, 4 Hanahan D, Weinberg RA. Hallmarks of cancer: the next generation. Cell. 2011; 144(5):646–674. https://doi.org/10.1016/j. cell.2011.02.013 PMID: 21376230, 5 Huang M, Shen A, Ding J, Geng M. Molecularly targeted cancer therapy: some lessons from the past decade. Trends Pharmacol Sci. 2014; 35(1):41–50. https://doi.org/10.1016/j.tips.2013.11.004 PMID: 24361003 Global distribution of new mCRC cases IndiTreat® pre-evaluates the impact of drugs for which there are no biomarkers on individual patients’ microtumors.
Only 20% of patients are suitable for targeted therapies Rapid diagnostic and tumor tissue-based workups are essential for all patients with an initial confirmation of mCRC. Delineating the precise stage of the disease is achieved by imaging techniques such as computed tomography (CT) or magnetic resonance imaging (MRI), and positron emission tomography (FDG-PET). Alongside standard histology and immunohistochemistry on sections of formalin-fixated, paraffinembedded (FFPE) tumor tissue, determining molecular tumor subtypes is the established state of the art1. While distinct molecular subtypes of mCRC can be efficiently addressed with innovative drugs, this is actionable only for a minority of patients. Over 80% of mCRC patients cannot be offered any additional therapies2 based on molecular biology. While, in certain situations, surgical intervention on the primary tumor and/or colorectal liver metastases can be curative, the mainstay of therapy for the vast majority of patients with mCRC remains the systemic administration of cytotoxic agents. Among those, 5FU (5-fluorouracil) has been and continues to be the backbone of mCRC treatment strategies3 since its introduction in 1957. First-line treatments Doublets The addition of oxaliplatin and/or irinotecan to a fluoropyrimidine improves response rates and survival. Therapy regimens combining 5FU, leucovorin and oxaliplatin or irinotecan are referred to as ‘doublets’. Triplets The strategy of combining the three active cytotoxic agents 5FU, oxaliplatin and irinotecan (FOLFOXIRI) is referred to as a ‘triplet’ and has been explored in mCRC with the main purpose of improving tumor shrinkage, and thus allowing complete resection of metastases. Approximately 25% of colorectal cancer patients have metastatic disease at diagnosis, and 50–60% develop metastases during the course of their disease. Overall, treatment options in a clinical stage IV situation are limited. Current Standard of Care for patients with mCRC
Biologics A cytotoxic regimen in mCRC patients in first-line settings can be complemented by anti-EGFR or anti-VEGF drugs. When combined with the mainstay cytotoxic doublet or triplet regimen, or as monotherapies in specific cases, biologics addressing the tumoral receptor EGFR (cetuximab and panitumumab) or the angiogenic factor VEGF (bevacizumab, ramucirumab, aflibercept) have demonstrated improved outcomes. Second-line treatments The cytotoxic therapy backbone of choice in second-line treatment depends mainly on the treatment received in first-line. With first-line oxaliplatin-based therapy, guidelines recommend second-line treatment with irinotecan with fluoropyrimidine or monotherapy. Conversely, those treated with a first-line based on irinotecan will often receive oxaliplatin-based treatment (FOLFOX or CAPOX) in second-line if no contraindications exist. Third- and further-line treatment In patients eligible for a third- or further-line of systemic cytotoxic therapy, treatment strategies consist of reintroducing the initial induction therapy if no progress was seen during the firstline chemotherapeutic regime. Regorafenib and trifluridine-tipiracil (TAS-102) are recommended in patients pre-treated with fluoropyrimidines, oxaliplatin, irinotecan and biologics, if available, or in earlier lines of therapy following oxaliplatin and irinotecan regimen failure, depending on local approvals. 1 Jensen et al.: Journal of Experimental & Clinical Cancer Research (2023) 42:115, 2 Flaherty KT et al.: J Clin Oncol. 2020;38:3883–94, 3 Cervantes A et al.: ESMO Guidelines Committee 2023. DOI: https://doi.org/10.1016/j.annonc.2022.10.003 The current standard of care is devoid of biomarkers to inform therapeutic choices among the main cytotoxic drug compounds.
Better understanding of cell-to-cell and cellto-extracellular matrix interactions has led to the use of 3-dimensional clusters, which are physiologically more relevant than single cell-based or two-dimensional approaches. In-vitro 3D-culturing allows tumor cell clusters to form complex 3D-microtumors that recapitulate the in-vivo architecture and genetic signature of original tumor tissues². Despite recent progress, across all cancers, only an estimated 7% of patients tested for genetic biomarkers can ultimately benefit from this genetic information¹. As a powerful, proven platform, functional drug sensitivity testing (f-DST) offers highquality assessment and comparison of responses among anticancer drugs of interest³. Functional drug sensitivity testing on the patient’s own 3D-microtumors therefore complements existing diagnostic efforts and Patient-derived tumor cells have shown great potential for basic and translational research and drug discovery1. Functional Drug Sensitivity Testing
provides a unique, individual and indispensable source of information for therapy decisionmaking. The advances in 3D-culture systems are also increasingly contributing to uncovering new mechanisms of disease progression², metastasis formation, and resistance. These technological advances are helping to identify the right treatment for each patient at each specific point of their treatment journey. 1 Feodoroff M et al.; SLAS Discov 2023 Mar;28(2):36-41. DOI 10.1016/j.slasd.2022.11.003, ² Jeppesen M et al.: PLoS ONE 12(9): e0183074, 2017. DOI 10.1371/journal. pone.0183074, ³ Lu DY et al.: Advances in Biomarker Sciences and Technology 2020, 2: 59-66. DOI 10.1016/j.abst.2020.11.001. Improve patient outcomes Avoid unnecessary toxity Avoid unnecessary costs What if you could tell in advance which patients will respond to which therapy?
The process The IndiTreat® test starts with the extraction of a patient’s tumor specimen through any of the standard methods. Fresh specimens (living cells) are shipped immediately in proprietary transportation containers to the specialized laboratory. Carefully processed and transferred into appropriate culture media at our laboratory, live tumor cell clusters grow and multiply under controlled conditions to form hundreds of sibling 3D-microtumors, known as tumoroids, which have been shown to preserve the colorectal adenocarcinomic histology and protein expression patterns of their original tumor2. The innovative approach is now to convert a tumor’s most harmful property – growth – into actionable diagnostic information – growth inhibition. This is achieved by better understanding the growth dynamics of metastatic tissue and its drug sensitivity in terms of growth behavior. For the actual drug sensitivity test phase, hundreds of cultivated tumoroids are precisely seeded into multiwell plates. These controlled environments contain defined concentrations of the antineoplastic drugs and drug combinations of interest. Growth inhibition is the key The tumoroids’ further growth, steady state or decline in the presence or the absence of the drug compounds in question is their biological response. Growth patterns are analyzed using imageanalysis and proprietary AI algorithms are converted into a “relative growth inhibition” score. Each patient sample is tested in multiple replicates and the process includes a positive and a negative control. The scores are compared to those of respective How it works. The process underpinning IndiTreat® Results from large cancer surveys show that the majority of deaths from solid tumors are caused by metastases1. It is the underlying spread of the tumor and metastatic growth that poses the vital threat.
reference populations for each compound or compound combination tested. The information is then compiled in an easily actionable report that is delivered to the treating physician within 21 days after tumor tissue sampling. The report The treating physician receives a simpleto-read and practical report showing the sensitivity of that patient’s tumoroids, classified as low, medium and high sensitivity profile for each of the drugs in the requested panel. This information can then be considered in the decision-making about which course of treatment to take. Examples of the growth inhibition curves and results-table provided in each IndiTreat® report 5FU FOLFOX FOLFIRI FOLFOXIRI Drug tested Low sensitivity Medium sensitivity High sensitivity 5-fluorouracil (5FU) • FOLFOX • FOLFIRI • FOLFOXIRI • Low Medium High Current patient Sensitivity 1 Dillekas H et al.: Cancer Med. 2019; 8: 5574–5576. https://doi.org/10.1002/cam4.2474, ² Jeppesen M et al.: 2017. PLoS ONE 12(9): e0183074. https://doi. org/10.1371/ journal.pone.018307 Test Requisition Sample Reception Tumoroid Generation Tumoroid Culture Tumoroid Biobank Drug Screening Image Analysis Patient Report Patient Treatment Result Validation IndiNet AI IndiBase LIMS Sample Flow Information Flow The IndiTreat® process flow If you would like to know more about our technology. please don’t hesitate to contact us via support@2curex.com
Our tests have been designed specifically to address the crucial decision-making points in the patient’s treatment journey. The information provided is used actively at these critical points in time to guide a healthcare professional’s decision as to which approved first- through third- and further-line drugs or drug combinations would best suit the individual patient. Our three IndiTreat® CRC tests are CE-marked and available immediately. Decisive innovation in mCRC treatment decision-making IndiTreat® CRC is an innovative in-vitro diagnostic tool that informs decisionmaking for those antineoplastic drugs and drug combinations in mCRC for which no biomarkers exist. IndiTreat® CRC Extend IndiTreat® CRC Start IndiTreat® CRC Explore mCRC patients Treatment sequence Extend Explore Start 3rd - furtherline 1st 2nd -line
Like patients differ, tumors tend to respond differently once exposed to prior lines of therapies. Exploring situations of disease progression after second-line treatment leads to considering a ‘re-challenge’ with drug combinations that have shown positive impact in the first line (FOLFOX, FOLFIRI and FOLFOXIRI). Other drugs like regorafenib or trifluridine-tipiracil are also available options. IndiTreat® CRC Extend provides information about the sensitivity of an individual patient’s tumoroids to the drugs and combinations used in third- and further-lines of systemic antineoplastic treatment. Please request our product sheet for IndiTreat® CRC Extend for details on the test, or take a look at www.inditreat.com. IndiTreat® CRC Extend – Drug panel Ordering Code: 2CX-01-CRC-01 FOLFOX regorafenib FOLFIRI trifluridine + tipiracil FOLFOXIRI IndiTreat® CRC Explore provides a rationale for off-label use of selected antineoplastics for treating further-line mCRC patients. It is suitable for those with tumor progression after at least two previous lines of systemic therapy and who may receive ’re-challenge’ therapy to which their tumors responded in firstline treatment. Therapeutic strategies with approved off-label drug regiments such as mitomycin C plus fluorouracil, for example, are also considered. IndiTreat® CRC Explore – Drug panel Ordering Code: 2CX-01-CRC-03 trifluridine-tipiracil mitomycin + 5FU regorafenib temozolamide + irinotecan gemcitabine + 5FU IndiTreat® CRC Start – Drug panel Ordering Code: 2CX-01-CRC-02 5-fluorouracil (5FU) FOLFIRI FOLFOX FOLFOXIRI Clinical data suggest that some patients respond better to FOLFOX followed by FOLFIRI while others respond better to FOLFIRI followed by FOLFOX, with significant differences in terms of long-term outcomes when the “right” sequence is chosen for an individual patient1. The IndiTreat® CRC Start test panel provides information about the sensitivity of a patient’s tumoroids to the typical drug combinations in first-line. Please request our product sheet for IndiTreat® CRC Start for details on the test, or take a look at www.inditreat.com. Sequence matters – get the best possible Start to maximise patient benefit Extend therapy decision-making boundaries for third- and further-line mCRC patients Explore additional options for third- and further-line patients 1 Abraham J P et al.: Clin Cancer Res. 2021; 27: 1174-8. https://doi: 10.1158/1078-0432.CCR-20-3286
Working together with our qualified distributors, we can effectively address local healthcare professionals and overcome barriers such as language, culture, local clinical practices and regulatory requirements. This enables us to efficiently bring the benefits of IndiTreat® to a larger number of patients across Europe. Leveraging existing knowledge, networks and infrastructure We are also building strong relationships with local healthcare professionals and providers, ensuring efficient access to IndiTreat®. Our distributors leverage their established infrastructure and logistical capabilities to minimize the operational complexities and ensure timely delivery of IndiTreat® reports. Additionally, our distributors provide scientific support via regular discussions with experts at 2cureX, training, and customer service, ensuring a seamless experience for healthcare professionals. Through our distributor-based business model, we are confident in our ability to effectively serve the diverse needs of European markets, bringing our innovative IVD test to the forefront for improved healthcare outcomes across the continent. Our groundbreaking In-Vitro Diagnostic (IVD) test IndiTreat® has quickly gained international attention. We are proud to provide support in over 20 countries across Europe through our network of commercial partners, and we are working to extend our reach very soon. Distributors. Partnering to offer local support and expertise
Regulation (EU) 2017/746 establishes the rules applicable within the EU concerning the placing on the market of In-Vitro Diagnostic (IVD) medical devices, including tests that ”provide information to predict treatment response or reactions”. The purpose of this regulation, which has been in force since May 26, 2022, is to ensure high standards of quality, performance, and safety for IVD medical devices. Manufacturers must develop and validate their devices according to specific requirements, maintain stringent quality management systems, file all the information of their products in a centralized European database, undergo audits by notified bodies, keep post-market surveillance systems and many other obligations. Continuous compliance is not only legally required, but a guarantee to users and patients. Products that fulfill the requirements are distinguished with the IVD CE mark. IndiTreat® CRC Start, Extend and Explore are CE IVD-marked tests. As a healthcare professional, you can use them to assess patient-derived tumoroids’ sensitivity to drugs and use that information to individualize the treatment strategy for your patients. Legally, safely, and efficaciously. The importance of CE-IVD marking
Innovation in mCRC is now. Be the change. Functional drug sensitivity testing is going to change the mCRC decision-making landscape. At 2cureX, we are building a comprehensive network of experts and thought leaders from every country in the EU. Together, we will create a community dedicated to implementing this innovation in daily clinical practice and fostering meaningful collaborations in functional drug sensitivity testing. This community will provide a forum to exchange ideas, engage in stimulating discussions, and create new relationships. Participants will be part of cuttingedge real-world data generation, emerging trends, and transformative innovations that will shape the future landscape of mCRC therapy management. Be part of the change. Implement the next level of decision-making so you can offer your patients the best possible treatment and outcomes. 2cureX Fruebjergvej 3 2100 Copenhagen Denmark support@2curex.com www.2curex.com www.inditreat.com 2CX-IND-BR-2023 Contact us directly at support@2curex.com We look forward to making a real difference. Together.
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