ColonSentry™Scientific Overview

July 2018

Copyright © 2018

In collaboration with

90% of CRC cases can be cured if detected early, BUT 5-year survival rate drops to 11% when it’s detected late

CRC is the 2nd leading cause of cancer death yet has the lowest screening compliance

American Cancer Society, Cancer Facts and Figures, 2018SEER Cancer Stats. Facts. 2018

“The most preventable yet leastprevented cancer.”- Journal or the National Cancer Institute

40% of average risk patients eligible for colorectal cancer (CRC) screening are non-compliant with colonoscopy, imaging and/or stool-based screening tests.

• Over 40% of Americans age 50 and older are not being screened for Colorectal cancer (CRC).

• Over 90% of CRC screening is with endoscopy, but only 1 in 4 colonoscopies will find a lesion.

• Less than 1 in 10 patients age 50 and older will return a stool FIT or FOBT collection kit to the office for testing.

• 60% of CRCs are detected in the later stages of the disease.

• The cost to treat late stage CRC is $120,000 Per Patient (PP) vs $33,000 if caught early.

• Is there a better way to get more people screened for CRC?

Source: American Cancer Society - Colorectal Cancer Facts & Figures 2014-2016 National Health Interview Survey Public Use Data File 2010, National Center for Health Statistics, Centers for Disease Control and Prevention.

Ignoring Non-Compliant Patients is No Longer an Option for Providers

Effect of CRC Location

Right Side Left SideCRC Death O.R. = 0.99Prevalence Ratio = 1.05

CRC Death O.R. = 0.33Prevalence Ratio = 0.33

Higher Risk Lower Risk

Healthcare Providers Are Actively Seeking Ways to Improve Cancer Screening & Bridge the Compliance Gap

Colorectal Cancer Screening Initiatives

Eighty By 18: American Cancer Society (ACS) has requested providers take the pledge to have 80% of their qualified populations screened forCRC by 2018.

Currently barely 60% of Patients have met that goal (ACS)

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• ColonSentry is an advanced blood-based molecular diagnostic that measures the expression of seven gene biomarkers for the early detection of colorectal cancer.

• This 7-gene, blood-based biomarker panel can stratify subjects according to their current relative risk across a broad range in an average-risk population.

• ColonSentry requires no fasting, dietary restrictions, or special instructions

• ColonSentry does not require patients to provide or handle any stool samples.

• ColonSentry is simple & convenient and blood can be drawn at an exam before patients leave the office.

The Science Behind the Test

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The peripheral blood transcriptome dynamically reflects system wide biology: a potential diagnostic toolJournal Laboratory Clinical Medicine 2006

Why use blood?• tissue-specific gene transcripts including beta-

myosin-heavy chain (heart specific) and insulin (specific to pancreatic islet beta cells) can be detected circulating blood cells

• suggest that although the expression level of genes may vary among different tissue or cell types, most genes may be expressed in the blood at a detectable level

• -blood cells can act as sentinels of disease and that could be used for the diagnosis/prognosis of disease (the "Sentinel Principle").

• Peripheral blood is an ideal surrogate tissue as it is readily obtainable and response to changes in the macro- and micro-environments is detectable as alterations in the levels of these gene transcripts

Chao S, Ying J, Liew G, Marshall W, Liew CC, Burakoff R. Blood RNA biomarker panel detects both left- and right-sided colorectal neoplasms: a case-control study. J Exp Clin Cancer Res. 2013 Jul 23;32:44. doi: 10.1186/1756-9966-32-44.

The Sentinel Principle® is a patent protected, platform technology which utilizes functional genomics to enable early identification of disease.

• Circulating blood reflects, in a detectable way, what is occurring throughout the body.

• As blood circulates communication occurs between cells in blood and tissue.

• Subtle changes that occur in cells due to injury or disease trigger detectable, specific changes in blood cell gene expression.

• Profiling these changes generates unique molecular signatures reflecting disease activity.

• These molecular signatures can be used to identify disease-specific blood biomarkers.

• These biomarkers are the foundation for ColonSentry’s highly sensitive and specific molecular diagnostic assay.

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The Science Behind ColonSentry:

Summary of the ColonSentry 7-Gene Risk Score Biological Activity

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Clinical Evidence

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Study Description Enrolled Subjects

Patient Population

Outcomes

IJC_2010 Develop a model to risk stratify average risk patients

N=10,000 North American Test performance: Sensitivity = 72%; Specificity=70%

JECCR_2010 Independent validation of North American model

N=210 Malaysian Test performance: Sensitivity = 61%; Specificity=77%

JECCR_2010 Ability to detect both left-sided and right-sided lesions

N=642 North American Detected left-sided 74%, and right-sided 85% lesions with an overall sensitivity of 78% at a specificity of 66%

Summary of Relevant Studies

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1. Marshall KW, Mohr S, Khettabi FE, Nossova N, Chao S, Bao W, Ma J, Li XJ, Liew CC. A blood-based biomarker panel for stratifying current risk for colorectal cancer. Int J Cancer. 2010 Mar 1;126(5):1177-86. doi: 10.1002/ijc.24910.

A Blood-based Biomarker Panel For Stratifying Current Risk For Colorectal CancerMarch 2010 - International Journal of Cancer

• >10,000 patient prospective study from North America

• 7-gene, blood-based biomarker panel that can stratify subjects according to their current relative risk in an average-risk population

• Quantitative gene expression assay using Real Time PCR

• Test performance: Sensitivity = 72%; Specificity=70%

Sample Collection

• Samples were collected from March 2005 to March 2008 at 25 centers located in Canada and the United States

• Patients enrolled at colonoscopy clinics and donated blood before the colonoscopy

• CONTROLS: samples from subjects with no pathology at colonoscopy

• CRC: blood samples were from colonoscopy-confirmed CRC patients, who had not undergone CRC treatment

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Study Methodology• >10,000 patient blood samples were collected in North America• Candidate CRC biomarkers were selected from 196 samples (97 CRC/99 controls)

using the Affymetrix GeneChip System. • qRT-PCR was performed on 642 samples to develop a 7-gene biomarker panel

using 112 CRC/120 controls (training set) and 202 CRC/208 controls (independent, blind test set).

• Panel performance characteristics and disease prevalence (0.7%) were then used to develop a scale assessing an individual's current risk of having CRC based on his/her gene signature.

• A 7-gene panel (ANXA3, CLEC4D, LMNB1, PRRG4, TNFAIP6, VNN1 and IL2RB) discriminated CRC in the training set (area under the receiver-operating-characteristic curve (ROC AUC), 0.80; accuracy, 73%; sensitivity, 82%; specificity 64%).

• The independent blind test set confirmed performance (ROC AUC, 0.80; accuracy, 71%; sensitivity, 72%; specificity, 70%).

• Individual gene profiles were compared against the population results and used to calculate the current relative risk for CRC.

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Patient Demographics

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CRC Biomarkers Differential Expression

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Training Patient Set

CRC Biomarkers Differential Expression

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Training Patient Set

Combined All Training and Test set data 314 CRC cases (red) and 328 controls (green).

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False positives who go onto a colonoscopy are not harmed as these patients should have already gotten a colonoscopy anyways under the CRC screening guidelines.

True Negative area under the green curve

False Negative area under the red curve

True Positive area under the red curve

False Positive area under the green curve

ColonSentry Test Performance Metrics

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A case-controlled validation study of a blood-based seven-gene biomarker panel for colorectal cancer in Malaysia Journal of Experimental & Clinical Cancer Research 2010

• Independent confirmation of the study conducted in North America

• Seven biomarker panel can discriminate CRC from controls in blood samples drawn from a Malaysian population

2. Yip KT, Das PK, Suria D, Lim CR, Ng GH, Liew CC. A case-controlled validation study of a blood-based seven-gene biomarker panel for colorectal cancer in Malaysia. J Exp Clin Cancer Res. 2010 Sep 16;29:128. doi: 10.1186/1756-9966-29-128.

Sample Collection

• Blood samples were taken from patients referred to colonoscopy clinics in Penang, Malaysia, over a two-year period from August 2007 to November 2009

• CONTROLS: samples from subjects with no pathology at colonoscopy

• CRC: blood samples were from colonoscopy-confirmed CRC patients, who had not undergone CRC treatment

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Gender and Age Distribution in the Study Samples

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Blood RNA biomarker panel detects both left- and right-sided colorectal neoplasms: a case–control studyJournal of Experimental & Clinical Cancer Research 2013

• effectiveness of colonoscopy is mostly confined to tumors on the left side of the colon (descending, sigmoid, rectum)

• seven-gene biomarker panel detected right-sided and left-sided CRC lesions across all cancer stages with a sensitivity of 78%

Chao S, Ying J, Liew G, Marshall W, Liew CC, Burakoff R. Blood RNA biomarker panel detects both left- and right-sided colorectal neoplasms: a case-control study. J Exp Clin Cancer Res. 2013 Jul 23;32:44. doi: 10.1186/1756-9966-32-44.

Left vs Right Performance

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Society• ColonSentry is intended to be used in asymptomatic patients to assess

whether they are at average or elevated risk of having colorectal cancer

• Average risk individuals are those who are asymptomatic without any signs or symptoms such as bleeding, abdominal pain, or change in bowel habits.

• Patients should not have a personal history of colorectal polyps, adenomas or cancer, or inflammatory bowel disease (Crohn’s disease, ulcerative colitis), or does not have a first degree relative with CRC or colon polyp syndrome.

• The American Cancer Society has recently recommended that CRC screening should start at age 45.

• Recent (2016) data suggests that 15% of colon cancers are diagnosed in patients younger than age 50, suggesting that CRC screening might need to start in patients as early as age 40.

Patient Selection and Intended Use

Why ColonSentry?

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Early CRC

detection

ScreeningColonoscopy

CRCScreening Compliance

RoutineCRCTesting

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Blood Tests Have 95% Patient Compliance

* U,S, national telephone survey June 2011 – joint collaboration Colon Cancer Alliance and Quest Diagnostics

$$ andLivesSaved

Current CRC Testing Algorithm

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CRC Testing Options

FOBT/FITFecal Test Repeat

everyyear

Low compliance

Colonoscopy----

Repeat every 10 years

Only 56.4% compliance

Positive Result

Negative Result

Repeat in 1-2 years

< 10% compliance

40% of population not getting screened

Algorithm With ColonSentry

CRC Testing Options

FOBT/FITFecal Test

----Repeat every

yearVery low

compliance

ColonSentryBlood Test

---Risk Stratify

Patients

Colonoscopy----

Repeat every 10 years

Motivates non-compliant patients that would never have considered a colonoscopy to get one

Repeat at next annual physical check

More colonoscopies performed on patients with increased risk of CRC = more cancers and polyps detected and removed

IncreasedRisk

Avg. / LowRisk

< 10% compliance

Blood test compliance 95%

ColonSentry can help increase compliance with colon cancer screening

Clinical Utility

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Sensitivity: ability to correctly identify those with the diseaseSpecificity: ability to identify those without the disease

Average Risk

1/140 1/70 1/50 1/28 1/14

Sensitivity 72%

Specificity 70%

Specificity88%

Specificity94%

Specificity97%

Specificity99%

How to interpret a resultExample 1: Patient has 1X current risk score. Patient has an approximate 1/140 chance of having CRC now (which is prevalence of disease).

Example 2: Patient has +2X current risk score. Patient has an approximate 1/70 chance of having CRC now.

1. International Journal of Cancer 2010. 126: 1177-1186; A blood-based biomarker panel for stratifying current risk for colorectal cancer

What is the Sensitivity and Specificity?

Elevated Risk

How to Interpret the ColonSentry Resultsto Guide Treatment

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Recommendations are Clear & Easy to Understand

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For further inquiries, please contact:

Nadeem Siddiqui, Ph.D.Chief Scientific Officer

245 First Street, Suite 1800Cambridge MA 02142 USAnadeem@oncorepharma.com+1 514.813.5455

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