Prevention of Colorectal Cancer Through Multiomics Blood Testing
Conditions: Colon Cancer, Rectal Cancer, Colon Neoplasm, Colon Diseases, Colon Lesion, Colon Polyp, Colorectal Cancer, Polyp, Adenoma, Rectal Diseases, Gastrointestinal Tract Cancers
Sponsor: Freenome Holdings Inc.

 
 
 
 
 
 
Study Name: PREEMPT CRC: Prevention of Colorectal 
Cancer Through Multiomics Blood Testing 
 
NCT Number: NCT04369053 
 
Date: April 5, 2021 

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PREEMPT CRC: Prevention of Colorectal Cancer Through
Multiomics Blood Testing
PROTOCOL NUMBER:
FRNM-004
SPONSOR:
Freenome Holdings, Inc.
279 East Grand Avenue, 5th floor
South San Francisco, CA 94080
VERSION NUMBER:
3
VERSION DATE:
05 April 2021
Confidential
This document contains proprietary and confidential information of Freenome Holdings, Inc. and
may not be reproduced or disclosed in whole or in part without written authorization from
Freenome Holdings, Inc.

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PREEMPT CRC: Prevention of Colorectal Cancer Through Multiomics Blood Testing
The information contained in this protocol and all other information relevant to the study are the
confidential and proprietary information of Freenome Holdings, Inc. (Freenome), and except as
may be required by federal, state or local laws or regulation, may not be disclosed to others
without prior written permission from Freenome.
I have read the protocol, including all appendices, and I agree that it contains all of the necessary
information for me and my staff to conduct this study as described. I will conduct this study as
outlined herein, in accordance with the regulations stated in the Federal Code of Regulations for
Good Clinical Practices and International Conference on Harmonization guidelines and will
make a reasonable effort to complete the study within the time designated.
I will provide all study personnel under my supervision copies of the protocol and any
amendments, and access to all information provided by Freenome or specified designees. I will
discuss the material with them to ensure that they are fully informed about the study.
Principal Investigator Name (printed)
Signature
_________________________________
_________________________________
Institution Name: _______________________________________________________
Date: ______________________________

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PROTOCOL SYNOPSIS
Title:
PREEMPT CRC: Prevention of Colorectal Cancer Through
Multiomics Blood Testing
Background:
Currently, there are different methods available for colorectal cancer
(CRC) screening, each with their own strengths and weaknesses.
Colonoscopy (CS) is highly sensitive, but is inconvenient and invasive,
and therefore less appealing. Non-invasive, stool-based approaches are
more convenient, but are also less accurate (especially for early-stage
disease and precancerous polyps), and require manipulating stools,
which can be unpleasant. Consequently, despite being widely
recommended, approximately one-third of age-eligible adults remain
unscreened for CRC, and cancer is often detected too late for
successful treatment. Freenome has developed a blood-based
multiomics screening test to detect advanced colorectal neoplasia
(ACN) that applies the power of artificial intelligence (AI) and
machine learning (ML) to multiomics plasma profiling. In a
prospective, multi-center clinical study, Freenome’s test demonstrated
high sensitivity (94%) and high specificity (94%) for early-stage (I/II)
CRC. The availability of such a highly accurate blood-based test should
help overcome some of the challenges with existing CRC screening
methods. This study aims to validate the performance of Freenome’s
test and support its regulatory approval.
Sites:
Approximately 130 sites internationally.
Population:
Subjects between the ages of 45 and 85 (inclusive) within 30 days of
enrollment who are at average risk of developing CRC. Enrollment will
be stopped when a sufficient number of evaluable CRC cases have
been diagnosed among the study population. Approximately 25,000
subjects will be enrolled, and an effort will be made to enroll
approximately 70% of subjects in the 65-85 age group.
Study Design:
This is an international multi-center validation study. Subjects who
meet eligibility criteria, provide informed consent, and provide a blood
sample will be enrolled in the study. The blood collection must be done
prior to undergoing bowel preparation for standard of care (SOC)

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screening CS. Subjects will have the option to have blood collection
done either at the study site or via mobile phlebotomy services, in
which case the subject can have blood collected in their home or other
location of preference. Subjects will have up to 50 mL of blood
collected. De-identified blood specimens will be sent to Freenome or a
designee for processing, testing, and storage. Specimens will be tested
by laboratory personnel blinded to the results of the SOC screening CS.
Subjects will undergo a SOC screening CS within 90 days of the blood
collection. Subjects and their health care providers will be blinded to
the results of Freenome’s test, which will not be used in clinical
management.
Objectives:
Primary:
●
The primary objectives of this study are to determine the
sensitivity (Sn) and specificity (Sp) of Freenome’s test for
colorectal adenocarcinoma using screening CS with
histopathology as the reference method
Secondary:
●
To evaluate the negative predictive value (NPV) of Freenome’s
test for CRC detection
●
To evaluate the positive predictive value (PPV) of Freenome’s
test for CRC detection
●
To evaluate the Sn of Freenome’s test for advanced adenoma
(AA)
Inclusion Criteria:
To be enrolled in this study, subjects must meet all of the following
criteria:
1.
45-85 years of age (inclusive) within 30 days of enrollment
(target ≥70% of subjects to be 65-85)
2.
Willing to undergo a SOC screening CS within 90 days of blood
collection
3.
Considered by a physician or healthcare provider to be
“average risk” for CRC

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4.
Able and willing to provide blood samples per protocol
5.
Able to comprehend and willing to sign and date the informed
consent document(s)
Exclusion Criteria:
Subjects will be excluded from enrolling into the study if any of the
following are met:
1.
Family history
1.1.
At least 1 first-degree relative diagnosed with CRC
before the age of 60 (Note: First-degree relatives include
parents, siblings and offspring.)
1.2.
At least 2 first-degree relatives diagnosed with CRC at
any age
1.3.
Known hereditary gastrointestinal cancer syndrome
including but not limited to the following:
1.3.1. Hereditary non-polyposis CRC syndrome
(HNPCC) or Lynch Syndrome
1.3.2. Familial adenomatous polyposis (FAP)
1.3.3. Cowden’s Syndrome
1.3.4. Juvenile Polyposis Syndrome
1.3.5. MUTYH-associated Polyposis
1.3.6. Peutz-Jeghers Syndrome
1.3.7. Serrated Polyposis Syndrome
2.
Personal history
2.1.
CRC or colorectal adenoma
2.2.
History of any malignancy (except for non-melanoma
skin cancer) at the time of enrollment, and for the 5
years preceding enrollment

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2.3.
Inflammatory bowel disease (IBD), including chronic
ulcerative colitis (CUC) and Crohn’s disease (CD)
2.4.
Total colonic resection
2.5.
Cystic fibrosis (CF)
2.6.
CS in the 9 years preceding enrollment with the
exception of an incomplete colonoscopy, or for a poor or
inadequate bowel prep
2.7.
Sigmoidoscopy or CT colonography in the 4 years
preceding enrollment
2.8.
Stool DNA testing in the 2 years preceding enrollment
2.9.
Fecal occult blood testing (FOBT) or fecal
immunochemical testing (FIT) in the 6
months
preceding enrollment
2.10.
Requiring an immediate or emergent colonoscopy for
the investigation of symptoms
2.11.
Solid organ or bone marrow transplantation
2.12.
Blood product transfusion in the 120 days preceding
enrollment
2.13.
Any trauma or surgery requiring
overnight inpatient
hospitalization in the 30 days preceding enrollment
3.
A medical condition which, in the opinion of the Investigator,
should preclude enrollment in the study
4.
Participated in or currently participating in a clinical research
study in which an experimental medication has been
administered during the 60 days up to and including the date of
providing informed consent or may be administered through the
time of the CS
5.
Known to be pregnant

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TABLE OF CONTENTS
DECLARATION OF THE INVESTIGATOR
3
PROTOCOL SYNOPSIS
4
TABLE OF CONTENTS
8
LIST OF ABBREVIATIONS
10
1.
INTRODUCTION
12
1.1
Background
12
1.2
Study Rationale
12
2.
STUDY OBJECTIVES
14
2.1
Primary
14
2.2
Secondary
14
3.
STUDY DESIGN
14
3.1
Study Overview
14
3.2
Population
15
3.3
Number of Subjects
15
3.4
Study Schema
15
3.5
Schedule of Assessments
16
4.
STUDY ELIGIBILITY
17
4.1
Inclusion Criteria
17
4.2
Exclusion Criteria
17
5.
STUDY PROCEDURES
19
5.1
Informed Consent and Enrollment
19
5.2
Colonoscopy, Histopathology, and Imaging Reports
19
5.3         Central Pathology
20
5.4
Data Collection
20
5.5
Blood Specimen Collection and Storage
21
6.
ADVERSE EVENTS
21

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6.1
Adverse Event (AE) Definition
21
6.2
Serious Adverse Event (SAE) Definition
21
6.3
Documenting Adverse Events/Serious Adverse Events
22
7.
STATISTICS
22
7.1
Evaluable Status
23
7.2
Histopathological Definitions
23
7.3
Study Endpoints and Test Performance Analyses
24
8.
ETHICAL, LEGAL, AND ADMINISTRATIVE RESPONSIBILITIES
26
8.1
Institutional Review Board
26
8.2
Informed Consent
26
8.3
Data Monitoring Committee
26
8.4
Protocol Deviations
27
8.5
Records Management
27
8.6
Source Documentation
27
8.7
Study Files and Record Retention
28
8.8
Study and Site Closure
28
9.
DATA QUALITY ASSURANCE
29
10.
REGULATORY AND ETHICAL CONSIDERATIONS
30
10.1
Good Clinical Practice
30
11.
CLINICAL STUDY REPORT AND PUBLICATION POLICY
30
12.
DISCONTINUATION
31
12.1
Subject Discontinuation/Withdrawal
31
12.2
Study Termination
31
13.
CONFIDENTIALITY
31
13.1
Subject De-Identification and Data Protection
31
14.
REFERENCES
32
15.
APPENDICES
34

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Appendix I Concomitant Medications for Data Collection
34
Appendix II Study Contact Information
35
Appendix III Protocol Version History
36

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LIST OF ABBREVIATIONS
AA
Advanced Adenoma
ACN
Advanced Colorectal Neoplasia
ACS
American Cancer Society
AE
Adverse Event
AI
Artificial Intelligence
AUC
Area under the curve
CD
Crohn’s Disease
CFR
Code of Federal Regulations
CIOMS
Council for International Organizations of Medical Sciences
CI
Confidence Interval
CRC
Colorectal Cancer
CRO
Contract Research Organization
CS
Colonoscopy
CTA
Clinical Trial Agreement
CUC
Chronic Ulcerative Colitis
DMARD
Disease-modifying anti-rheumatic drugs
DMC
Data Monitoring Committee
eCRF
Electronic Case Report Form
EDC
Electronic Data Capture

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FAP
Familial Adenomatous Polyposis
FAS
Full Analysis Set
FDA
Food and Drug Administration
FIT
Fecal Immunochemical Testing
FOBT
Fecal Occult Blood Testing
GCP
Good Clinical Practice
HNPCC
Hereditary Non-Polyposis Colorectal Cancer
IBD
Inflammatory Bowel Disease
ICH
International Conference on Harmonization
ID
Identification
IRB
Institutional Review Board
mL
Milliliters
ML
Machine Learning
NAA
Non-Advanced Adenoma
NCI
National Cancer Institute
NEG
Negative
NPV
Negative Predictive Value
NSAIDs
Nonsteroidal Anti-Inflammatory Drugs
PPV
Positive Predictive Value
ROC
Receiver Operating Characteristic

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SAE
Serious Adverse Event
SAP
Statistical Analysis Plan
SEER
Surveillance, Epidemiology, and End Results
Sn
Sensitivity
SOC
Standard of Care
Sp
Specificity
THC
Tetrahydrocannabinol
WGS
Whole Genome Sequencing

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1.
INTRODUCTION
1.1
Background
Colorectal cancer (CRC) is the fourth most frequently diagnosed cancer and the second leading
cause of cancer death in the United States. In 2019, an estimated 101,420 new cases of colon
cancer and 44,180 new cases of rectal cancer were expected to occur in the United States, and it
was estimated that 51,020 people would die from CRC.1 Screening for persons at average risk for
CRC typically begins at age 50, and individuals at average risk have traditionally been defined as
those aged ≥ 50 years without personal history of inflammatory bowel disease (IBD), adenomas,
or CRC; without a family history of CRC or advanced adenomas (AAs); and without symptoms
such as rectal bleeding.2-4 Registry data from the National Cancer Institute’s (NCI) Surveillance,
Epidemiology, and End Results (SEER) program indicated an increased incidence of CRC in
African Americans prior to age 50 years,5 which led to the recommendation in 2005 that CRC
screening in African Americans begin earlier, at age 45.3 More recently, epidemiologic reports
suggest that the incidence of CRC may be increasing in adults aged < 50 years,6-8 leading the
American Cancer Society (ACS) in 2018 to recommend considering CRC screening in adults
aged 45-49 years.9 Accordingly, some large commercial payers (e.g., Aetna) have begun
providing coverage for CRC screening in adults aged ≥ 45 years.
1.2
Study Rationale
Despite being widely recommended, more than one-third of age eligible adults remain
unscreened for CRC,10,11 and cancer is often detected too late for successful treatment, with
nearly 60% of CRC cases detected after regional or distant metastases.12 Currently, there are
different methods available for CRC screening, each with their own strengths and weaknesses.
Colonoscopy (CS) is highly sensitive, but is inconvenient and invasive, and therefore less
appealing. Non-invasive, stool-based approaches are more convenient, but are also less accurate
(especially for early-stage disease and precancerous polyps), and require manipulating stools,
which can be unpleasant.2,13
Blood-based screening tests for cancer could address some of the aforementioned challenges and
supplement or replace existing cancer screening methods. One area of interest is circulating
cell-free DNA (cfDNA), which includes both tumor-derived DNA (circulating tumor DNA, or
ctDNA) and DNA derived from non-tumor cells, such as hematopoietic and stromal cells.
Different screening approaches using cfDNA are being explored, with some proposing that
ctDNA-only based tests may enable sensitive and specific early detection of cancer.14-17
However, ctDNA generally represents ≤ 0.01-1.0% of all cfDNA in early-stage cancer, and even
lower in premalignant conditions, thus requiring clinically challenging volumes of blood (e.g.,
150-300 mL).18,19 These limitations are particularly important in early-stage cancer and
precancerous conditions, when the tumor is small, and the shedding of tumor DNA into the
blood may be minimal.

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An alternative to detection based solely on ctDNA is to look more broadly at cfDNA—both
tumor- and non-tumor-derived—and changes that early-stage cancer and precancerous lesions
may induce that are detectable in blood. There is growing evidence of interactions between
cancerous cells and other cells, including fibroblasts, platelets, and immune cells, especially
within the tumor microenvironment. Moreover, exploring signals beyond cfDNA alone, using a
multiomics approach that includes additional biomarkers (e.g., proteins, RNA, etc.), may be
necessary to achieve the clinical performance required for a blood-based screening test.
In the case of CRC, given its molecular heterogeneity, and biological differences between early-
and late-stage disease, detection may be better achieved using a multiomics approach that
includes assessing the genome, methylome, transcriptome, and proteome in plasma. For
example, proteins such as autoantibodies may enable detection of cancer at an early stage, before
the development of clinical symptoms.20,21 Conversely, measuring tumor-derived signals from the
genome and/or methylome may allow detection of CRC at later stages, when genetic and
epigenetic changes are more common. Therefore, combining different approaches may be
necessary for detection of all stages of CRC, as well as precancerous lesions. Applying artificial
intelligence (AI)/machine learning (ML) enables assessment of disease-related patterns from
multiple signals and the identification of relevant, low-dimensional features that generalize to the
screening population.22,23
Freenome’s early data were based on a single-analyte approach, namely whole genome
sequencing (WGS) of cfDNA. In brief, cfDNA alone was assessed for the detection of CRC
from 546 individuals with CRC and 271 non-cancer controls (i.e., individuals without a current
CRC diagnosis). In this cohort heavily weighted towards early-stage cancer (81% stage I/II), a
mean area under the curve (AUC) of 0.92 (95% confidence interval [CI] 0.91-0.93) was
achieved, with a mean sensitivity of 85% (95% CI 83-86%) at 85% nominal specificity.24 More
recently, this prototype single-analyte test was expanded to a multiomics test that demonstrated
improved performance, achieving 94% sensitivity and 94% specificity for early-stage (I/II)
colorectal adenocarcinoma in a multi-center prospective study that included average-risk
screening and case-control subjects (n=574) and an analyte training set (n=17) drawn from a
statistically-driven subset of AI-EMERGEⓇ(NCT03688906).25 These findings reinforce our
belief that successful early detection of advanced colorectal neoplasia (ACN) will require such
an ML-based multiomics approach, which also holds the promise of improving over time as
additional real-world testing data becomes available.
Freenome’s blood-based, multiomics test (hereafter referred to as “Freenome’s test”) for CRC
screening will enable improved adherence versus current CRC screening efforts, which remain
either invasive or stool-based. In addition, use of the test is expected to improve the
identification of clinically-actionable disease, defined as disease (i.e., ACN) for which
colonoscopic intervention has demonstrated health outcome benefit.26,27 This in turn will improve
the risk-benefit ratio for patients by increasing the likelihood that those patients directed by the
test to undergo a diagnostic CS, with its attendant costs and complications, will benefit from it.
The purpose of the current study is to validate Freenome’s test performance and support
regulatory approval.

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2. STUDY OBJECTIVES
2.1
Primary
●
The primary objectives of this study are to determine the sensitivity (Sn) and specificity
(Sp) of Freenome’s test for colorectal adenocarcinoma, using screening CS with
histopathology as the reference method.
2.2
Secondary
●
To evaluate the negative predictive value (NPV) of Freenome’s test for CRC detection
●
To evaluate the positive predictive value (PPV) of Freenome’s test for CRC detection
●
To evaluate the Sn of Freenome’s test for AA
3. STUDY DESIGN
3.1
Study Overview
This is an international multi-center study for the clinical validation of Freenome’s blood test to
detect ACN (i.e., CRC and AA). Subjects referred by a healthcare provider (HCP) for a standard
of care (SOC) screening CS and providing informed consent are eligible to participate based on
the study inclusion and exclusion criteria. Enrollment procedures should be completed within 30
days of signing consent. Should a patient fall outside of the 30-day window, these cases may be
escalated to Freenome (or designee) for approval on a case by case basis.
●
Subjects who provide informed consent, meet the eligibility criteria and provide the
blood sample for this study will be enrolled. Subjects will undergo blood collection and
will then have 90 days to complete a SOC screening CS. Maximum time allowed
between enrollment and CS will be 90 days. Subjects will have the option to have blood
collection done either at the clinical study site or by a study-provided mobile phlebotomy
service, in which case the subject can have blood collected in their home or location of
preference. Up to 50 mL of blood will be collected from each enrolled subject prior to the
bowel preparation for CS. Blood specimens will be used for the clinical and analytical
validation of Freenome’s test. Blood specimens will be de-identified and sent to
Freenome, or a designee, for processing, storage and testing. De-identified specimens and
residual specimens will be banked and may be utilized for additional analytical validation
testing by Freenome, to improve the current assay in the future, or to develop new assays.
Specimens will be used for research purposes only. Since Freenome’s test (and any future
testing using residual specimens) is currently investigational, results will not be shared
with Investigators or subjects.

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Study duration is comprised of the time between enrollment and a single study visit for a SOC
screening CS and should be no longer than 90 days.
Although no long-term follow-up is planned, subjects may also be contacted by site personnel up
to three (3) years following the completion of the study to gather additional information (e.g.,
any new cancer diagnoses).
3.2
Population
The study will enroll a representative sample of the population of subjects who are at average
risk for the development of CRC and will undergo CRC SOC screening CS from sites across the
U.S. and internationally.
3.3
Number of Subjects
Approximately 25
,000 subjects will be enrolled. Of the 25
,000 subjects, an effort will be
made to enroll approximately 70% of subjects in the 65-85 years age group. Enrollment will be
stopped when a sufficient number of evaluable cases of CRC have been diagnosed among the
study population.
3.4
Study Schema
Figure 1. Study Schema

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3.5
Schedule of Assessments
Table 1. Schedule of Assessments
Study Procedures
Enrollment
CS Visit
(and additional
reports)
Notes
Window
30 days
90 days
Informed Consent
X
Enrollment procedures should be completed within 30
days of signing consent
Evaluation of Inclusion
& Exclusion Criteria
X
Medical History /
Demographics
X
Lifestyle Information
X
Including but not limited to: history of tobacco product
use or history of and current information on alcohol
consumption and drugs of abuse including recreational
and prescribed, including THC.
Concomitant
Medications
X
Concomitant medications: (limited to the medications
listed in Appendix I) in the 30 days preceding enrollment
Weight and Height
X
Height and weight to be collected at enrollment; however,
patients will have up until the CS visit to complete.
Verbally reported measurements are acceptable.
Blood Collection
X
The blood collection should be done within 30 days of
signing consent. Should a patient fall outside of the
30-day window, these cases may be escalated to
Freenome (or designee) for approval on a case by case
basis. The blood collection must be done prior to bowel
preparation for the screening CS. Maximum allowed time
between blood collection and CS will be 90 days.
Colonoscopy
X
Subjects will be enrolled and will then have 90 days to
undergo a SOC screening CS following the blood
collection. The CS report must be provided.
Histopathology Report
X
If any lesions are present from the CS report, the
accompanying pathology report(s) must be provided.
Imaging Report,
Relevant
X
Subjects diagnosed with CRC will require any imaging
reports, post-surgery histopathology reports, and/or
operative notes required to accurately stage the cancer.

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Histopathology, or
Operative Notes
AEs/SAEs
X
Only blood collection related
Central histopathology
review
X
H&E slide(s), FFPE blocks or digital image(s) from
specific types of polyps resected or biopsied during the
screening CS will be required to be sent for central
pathology review.  Only a subset of polyps will require
such review and each site will be sent a list of cases to
send for central review.
*CS: colonoscopy; SOC: standard-of-care; AE: adverse event; SAE: serious adverse event; THC:
tetrahydrocannabinol
4. STUDY ELIGIBILITY
4.1
Inclusion Criteria
To be enrolled in this study, subjects must meet all of the following criteria:
1.
45-85 years of age (inclusive) within 30 days of enrollment (target ≥70% of subjects to be
65-85)
2.
Willing to undergo a SOC screening CS within 90 days of blood collection
3.
Considered by a physician or healthcare provider to be “average risk” for CRC
4.
Able and willing to provide blood samples per protocol
5.
Able to comprehend and willing to sign and date the informed consent document(s)
4.2
Exclusion Criteria
Subjects will be excluded from enrolling into the study if any of the following are met:
1.
Family history
1.1.
At least 1 first-degree relative diagnosed with CRC before the age of 60 (Note:
First-degree relatives include parents, siblings and offspring.)
1.2.
At least 2 first-degree relatives diagnosed with CRC at any age

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1.3.
Known hereditary gastrointestinal cancer syndrome including but not limited to
the following:
1.3.1.
Hereditary non-polyposis CRC syndrome (HNPCC) or Lynch Syndrome
1.3.2.
Familial adenomatous polyposis (FAP)
1.3.3.
Cowden’s Syndrome
1.3.4.
Juvenile Polyposis Syndrome
1.3.5.
MUTYH-associated Polyposis
1.3.6.
Peutz-Jeghers Syndrome
1.3.7.
Serrated Polyposis Syndrome
2.
Personal history
2.1.
CRC or colorectal adenoma
2.2.
History of any malignancy (except for non-melanoma skin cancer) at the time of
enrollment, and for the 5 years preceding enrollment
2.3.
Inflammatory bowel disease (IBD), including chronic ulcerative colitis (CUC)
and Crohn’s disease (CD)
2.4.
Total colonic resection
2.5.
Cystic fibrosis (CF)
2.6.
CS in the 9 years preceding enrollment with the exception of an incomplete
colonoscopy, or for a poor or inadequate bowel prep
2.7.
Sigmoidoscopy or CT colonography in the 4 years preceding enrollment
2.8.
Stool DNA testing in the 2 years preceding enrollment
2.9.
Fecal occult blood testing (FOBT) or fecal immunochemical testing (FIT) in the 6
months preceding enrollment
2.10.
Requiring an immediate or emergent colonoscopy for the investigation of
symptoms
2.11.
Solid organ or bone marrow transplantation
2.12.
Blood product transfusion in the 120 days preceding enrollment

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2.13.
Any trauma or surgery requiring
overnight inpatient
hospitalization in the 30
days preceding enrollment
3.
A medical condition which, in the opinion of the Investigator, should preclude enrollment
in the study
4.
Participated in or currently participating in a clinical research study in which an
experimental medication has been administered during the 60 days up to and including
the date of providing informed consent or may be administered through the time of the
CS
5.
Known to be pregnant
5. STUDY PROCEDURES
5.1
Informed Consent and Enrollment
Subjects must be able to provide informed consent prior to any study procedure. Subjects who
provide informed consent, meet the eligibility criteria and provide the blood sample for this
study will be enrolled.
5.2
Colonoscopy, Histopathology, and Imaging Reports
Each subject will undergo a SOC screening CS within 90 days of blood collection. Bowel
preparation and CS will be performed according to SOC at each site. The endoscopist will record
the quality of the bowel preparation after washing and suctioning. A CS that was limited in any
way but wherein a CRC was identified or wherein a partially obstructing CRC was identified,
will be included in the analyses.
For all non-CRC subjects, the following will apply:
A subject who has a bowel preparation rated as less than fair (i.e., poor or inadequate) will be
considered unevaluable and therefore excluded from analysis of all primary and secondary
endpoints. (Poor is defined as semisolid stool that could not be suctioned or washed away, and <
90% of mucosa is seen; inadequate is defined as needing repeat preparation or screening.)
A subject who has an incomplete CS will be considered unevaluable and therefore excluded from
analysis of all primary and secondary endpoints. (A complete CS will be defined as reaching the
cecum; reaching the junction between the small and large intestine if the cecum has been
resected; or reaching the neo-cecum. Cecal intubation will be documented by photographic
evidence and/or documentation of cecal intubation.)

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A non-CRC subject who has (1) a poor or inadequate bowel preparation or (2) an incomplete
CS may repeat the CS and continue as a subject for this study only if the repeat CS occurs within
90 days of the blood collection.
CS findings will be recorded on the CS reports in accordance with the standard of practice at
each site. Histopathological results will also be conducted according to usual practice at each
site. Results from the CS and, if performed, histopathology will be recorded in the clinical
database. All results (e.g., CS, histopathology, and imaging reports) will be collected,
de-identified, labeled with the subject ID and uploaded to a clinical study database. Personnel
generating any of these clinical reports will remain blinded to the results of Freenome’s test, and
vice versa.
The following required information will be collected once available:
●
CS report
●
If applicable, any histopathology report(s)
●
If applicable, any imaging reports or relevant histopathology or operative notes required
for cancer staging
5.3          Central Pathology
Each patient will have their respective CS report and (if applicable) local histopathology report
reviewed by a central pathologist in order to categorize the index lesion (if applicable) into the
histopathological categories described below in section 7.2 (i.e., CRC, AA, NAA, and NEG).
For all cases categorized as AA2.1, AA2.2, AA2.4, and AA2.5 and for 5% of NEG4.1, central
pathology review will be required. The sites will send H&E slides, formalin-fixed paraffin
embedded (FFPE) blocks or digital images for review of these specific cases.  When the
classification of the index lesion differs between the local histopathology result and the central
pathology result, the case will undergo review by an additional central pathologist to adjudicate
the final categorization of the index lesion.  Instructions will be included in the central pathology
manual.
H&E slides, FFPE blocks or digital images of the selected cases will be sent for central
pathology review as detailed above. (H&E slides are preferred.)  After analysis of the H&E
slides or H&E slides made from FFPE blocks, slides and/or blocks will be returned to sites.
Digital images will be stored in a secure site.
5.4
Data Collection
Refer to Section 3.5. Schedule of Assessments. The following information will be recorded in
the electronic case report form (eCRF) for each subject after consent at enrollment.

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●
Medical History / Demographics
●
Concomitant medications (specifically aspirin, estrogen, disease-modifying
anti-rheumatic drugs (DMARDs), biological agents, and COVID-19 vaccinations) in the
30 days preceding enrollment, as listed in Appendix I
●
Lifestyle information will be obtained either from the subject’s clinical record or
self-report, including but not limited to:
o
History of tobacco product use (i.e., cigarettes)
o
History of and current information on alcohol consumption and drugs of abuse
including recreational and prescribed, including tetrahydrocannabinol (THC)
●
Blood collection time and date
●
Height and weight
5.5
Blood Specimen Collection and Storage
Blood specimens collected for this study will be separate from any specimens collected for
SOC. Up to 50 mL of peripheral blood will be collected prior to the bowel preparation via
standard phlebotomy. Subjects will have the option to have blood collected either at the study
site or via mobile phlebotomy services, in which case the subject can have blood collected in
their home or location of preference. The blood collection tubes will be labeled using supplied
barcode labels which link to the unique study subject ID, as described in the study laboratory
manual.
Refer to the study laboratory manual for complete instructions on blood collection procedures,
labeling, handling, storage, and shipment.
Residual blood samples may be destroyed or, if the subject consents, archived for further
research. Clinical data and samples will be kept in a manner that preserves the anonymity of
subjects, using the subject ID as the only tracking information. Specimens will be stored for no
more than 20 years in Freenome’s biorepository or a similar commercial biorepository contracted
by Freenome, and may be used for future research, which may improve the researchers’
understanding of cancer or other diseases.

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6. ADVERSE EVENTS
6.1
Adverse Event (AE) Definition
Due to the study design and the nature of the blood collection process, the Sponsor does not
expect many adverse events (AEs) caused by or related to the blood collection.
Since the screening CS is being performed as SOC and is a routine part of patient care, subjects
are at no increased risk because of participation in this study. Thus, while adverse events may be
anticipated due to SOC screening CS, they are not regarded as study related.
For the purposes of this study, an AE is defined as any undesirable physical, psychological or
behavioral effect experienced during participation in the study that is related to the blood
collection for this study. As a result of blood collection, subjects may experience minor pain,
discomfort, bruising at the venipuncture site, or lightheadedness.
6.2
Serious Adverse Event (SAE) Definition
A serious adverse event (SAE) is any AE that meets any of the following criteria:
●
Death
●
A life-threatening illness or injury
●
Medical or surgical intervention to prevent permanent impairment of a body structure or
body function
●
Required inpatient hospitalization or prolongation of existing hospitalization
●
Persistent or significant disability/incapacity
Definition of Terms
Life threatening: An AE is life threatening if the subject was at immediate risk of death from the
event as it occurred (i.e., it does not include a reaction that if it had occurred in a more serious
form might have caused death). For example, drug-induced hepatitis that resolved without
evidence of hepatic failure would not be considered life threatening even though drug-induced
hepatitis can be fatal.
Hospitalization: AEs requiring hospitalization should be considered SAEs. Hospitalization for
elective surgery or routine clinical procedures that are not the result of an AE (e.g., elective
surgery for a pre-existing condition that has not worsened) need not be considered AEs or SAEs.
If anything untoward is reported during the hospitalization, that occurrence must be reported as
an AE, either 'serious' or 'non-serious' according to the usual criteria.

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In general, hospitalization signifies that the subject has been detained (usually involving at least
an overnight stay) at the hospital or emergency ward for observation and/or treatment that would
not have been appropriate in the physician's office or outpatient setting. When in doubt about
whether 'hospitalization' occurred or was necessary, the AE should be considered serious.
Disability/incapacity: An AE is incapacitating or disabling if the experience results in a
substantial and/or permanent disruption of the subject’s ability to perform normal life functions.
6.3
Documenting Adverse Events/Serious Adverse Events
Sites and mobile phlebotomists must observe normal SOC practices to protect the subjects'
health and safety during the specimen collection. For SAEs, at each occurrence, the event should
be reported to the regulatory body (the Institutional Review Board, IRB) within 1 business day of
Investigator knowledge of such event.
7. STATISTICS
If discrepancies exist between the text of the statistical analysis as planned in the protocol and
the final statistical analysis plan (SAP), a protocol amendment will not be issued, and the SAP
will prevail.
The SAP will be finalized prior to the end of clinical database lock for the study. Any changes to
the methods described in the final SAP will be described and justified in the clinical study report.
7.1
Evaluable Status
A subject may be considered unevaluable and therefore excluded from all primary and secondary
analyses if any of the following criteria are met: (Note this list is not exhaustive. Refer to the
SAP for details.)
●
No Freenome test result (for example, resulting from errors in labeling, improper
collection or handling, and poor specimen quality)
●
Missing any of the required reports, i.e. CS and, if applicable, histopathology and
imaging reports
●
Incomplete CS, or no photographic evidence or documentation of cecal intubation (unless
diagnosed with CRC)
●
Bowel preparation quality rated as poor or inadequate (unless diagnosed with CRC)
●
Subjects found to have occult IBD on CS
Unevaluable subjects will be assessed for bias as described in the SAP.

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7.2
Histopathological Definitions
For this study, the index lesion is considered to be the most clinically significant lesion, and the
hierarchy of clinical significance (and the categories of histopathological findings) is as follows:
1. CRC, all stages (I-IV)
2. Advanced adenoma (AA), including
2.1 Adenoma with carcinoma in situ or high-grade dysplasia, any size
2.2 Adenoma, villous growth pattern (≥ 25%), any size
2.3 Adenoma ≥ 1.0 cm in size
2.4 Serrated lesion, ≥ 1.0 cm in size (includes sessile serrated adenoma/polyp
(SSA/P) with or without cytological dysplasia and hyperplastic polyps ≥ 1.0 cm)
2.5 Traditional serrated adenoma (TSA), any size
3. Non-advanced adenoma (NAA)
3.1 ≥ 5 adenomas, all < 1.0 cm in size, non-advanced
3.2 <5 adenomas, < 1.0 cm in size, non-advanced
4. Negative (NEG)
4.1All SSA/P < 1.0 cm and HP < 1.0 cm not in sigmoid or rectum
4.2HP < 1.0 cm in the sigmoid or rectum
4.3Negative upon histopathological review
4.4No findings on colonoscopy, no histopathological review
Subjects will be placed into a category based on the most clinically significant lesion confirmed
by histopathology. Subjects with histopathological findings in categories 3.1-3.2 above will be
included in the Sp analysis as NAAs and 4.1-4.4 as NEGs. Those subjects in the NEG category
will include those subjects with a CS showing no findings (and hence no histopathology
submitted), non-neoplastic disease, and/or non-adenomatous (e.g., hyperplastic) polyps < 1 cm
in diameter.
7.3
Study Endpoints and Test Performance Analyses
7.3.1
Co-Primary Endpoint Effectiveness Analysis
The co-primary endpoint effectiveness analysis for the blood test Sn for CRC cases (SnCRC) is to
demonstrate whether the lower bound of the two-sided confidence interval for the point-estimate

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of SnCRC meets or exceeds 65%. The co-primary analysis for Freenome’s test SnCRC will be
performed using an exact binomial test to compute the two-sided 95% confidence lower bound
for the percentage of all Full Analysis Set (FAS) subjects identified with CRC from the CS and
confirmed histopathology with a positive Freenome test result. The FAS set will include those
study-eligible subjects who have an evaluable test result, and an evaluable CS result with
confirmed histopathology findings.
The co-primary effectiveness analysis for test Sp for NAA and NEG cases (SpNAA+NEG) is to
demonstrate whether the lower bound of the two-sided confidence interval for the point-estimate
of SpNAA+NEG meets or exceeds 85%. The co-primary analysis for Freenome’s test Sp for NAA
and NEG subjects in the FAS will be performed using an exact binomial test to compute the
two-sided 95% confidence lower bound.
Both lower bound conditions must be achieved for the study to be declared a success.
The robustness of significant results from the analysis of the primary endpoint will be assessed
by calculating the numbers of subjects whose test results would have to switch from positive to
negative and vice versa to obtain a result that was just significant. All enrolled but excluded
cases will be assessed for bias in the analyzed population by comparing the baseline
demographics for those included versus those excluded. Including the excluded cases with
various proportions of imputed results for the missing elements will be used to further
demonstrate the level of robustness of the significant result from the FAS set alone.
7.3.2
Secondary Endpoints and Analyses
NPV of Freenome’s test:
The analysis for Freenome’s test NPV for CRC cases (NPVNon-CRC) is to determine whether the
lower bound of the two-sided CI for the point-estimate of NPVNon-CRC meets or exceeds the
prevalence for Non-CRC in the study population. The analysis for Freenome’s test NPVNon-CRC
will be performed using an exact binomial test to compute the two-sided 95% confidence lower
bound for the rate among FAS subjects with a test-negative result for those identified without
CRC from CS and histopathology.
PPV of Freenome’s test:
The analysis for Freenome’s test PPV for CRC cases (PPVCRC) is to determine whether the lower
bound of the two-sided CI for the point-estimate of PPVCRC meets or exceeds the prevalence of
CRC in the study population. The analysis for Freenome’s test PPVCRC will be performed using
an exact binomial test to compute the two-sided 95% confidence lower bound for the rate among
FAS subjects with a test-positive result for those identified with CRC from CS and
histopathology.
Sensitivity of Freenome’s test for AA:

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The effectiveness analysis for Freenome’s test Sn for AA cases (Sn AA) is to determine whether
the lower bound of the two-sided CI for the point-estimate of SnAA meets or exceeds 25%. The
analysis for Freenome’s test SnAA will be performed using an exact binomial test to compute the
two-sided 95% confidence lower bound for the percentage of all FAS subjects identified with
AA from CS and histopathology with a test-positive result.
7.3.3 Sample Size Justification
The study should include a minimum of 48 evaluable adenocarcinoma cases meeting the
requirements for inclusion in the analysis set for the co-primary Sn endpoint. Assuming a
prevalence of 0.3
% CRC cases, the minimum number required in the FAS is approximately
48/0.3
% =
16,000 subjects. Allowing for a 30% unevaluable rate, this gives an enrollment
of 22,857
subjects. A sample size of 48 CRC achieves 90.4% power to rule out a Sn of 65%
using a one-sided exact test with a target significance level of 0.025. The actual significance
level achieved by this test is 0.025 (PASS 2019, v19.0.2).
If 48 CRC cases are tested, then at least 38 need to be positive by Freenome’s test to rule out a
lower bound of 2-sided 95% CI (Clopper-Pearson method) of 65%. The lower bound of 38/48 CI
is 65.1%.
7.3.4
Additional Analyses
Additional analyses include, for example, analysis of distribution of cancers by age, biological
sex, race, and ethnicity: Using a chi square or Fisher’s exact test of the observed incidence of
CRC (or CRC and AA) relative to the expectation from SEER incidence data will help assess the
representativeness of the study population.
Direct rate standardization will be used to project the Sn and Sp (for CRC and AA) of
Freenome’s test to the general population, males, females and subjects ≥ 65 years of age.
The distribution and receiver operating characteristic (ROC) curves for Freenome’s test score
among the FAS subject group separately will be included. The AUC of each curve will be
presented with its estimated 95% CI. For the same groups, the Sn and Sp of subject test scores
will be presented over the range of scores, with Youden’s J and number needed to misdiagnose
one (NNMD) superimposed on the figure.
More details of analyses will be described in the SAP.
7.3.5 Statistical Interim Analyses and Stopping Guidance
No interim data analyses of the study subjects’ test results will be performed, so no planned
sample size adjustment of the significance level due to interim analysis is needed.
Interim evaluation of test performance on samples other than those collected as part of this study
protocol will be performed. Sample size adjustments may be made accordingly with appropriate
supporting analysis and statistical justifications for those adjustments.

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Enrollment will be stopped when a sufficient number of evaluable CRC cases have been
diagnosed among the study population.
8. ETHICAL, LEGAL, AND ADMINISTRATIVE RESPONSIBILITIES
The procedures set out in this study protocol are designed to ensure that the study will be
conducted according to the principles of International Conference on Harmonization (ICH)/GCP
guidelines, as well as any local, regional, and country regulatory requirements.
8.1
Institutional Review Board
This protocol and consent form will be submitted to the governing IRBs. Before the study is
initiated, the Investigator/Institution will obtain dated approval from the IRB for any study
protocol/amendment(s), informed consent, and a statement from the IRB that they comply with
applicable ICH/GCP requirements. The IRB approval will identify the protocol version as well
as the documents reviewed.
8.2
Informed Consent
Subjects must be able to provide informed consent and meet all eligibility criteria prior to
enrollment. Only subjects who meet all eligibility criteria will be enrolled in this study. No
waivers of inclusion or exclusion criteria will be granted by the Investigator and/or Freenome or
its designee for any subject enrolled in the study.
8.3
Data Monitoring Committee
The study will have a Data Monitoring Committee (DMC) that will operate independently from
the Sponsor and the Principal Investigators. The primary responsibilities of the DMC are to
determine whether the required number of events (e.g., evaluable subjects diagnosed with CRC)
have been met to provide stopping guidance to the Sponsor. Details regarding DMC
responsibilities, membership, schedule and format of meetings, format for presentation of data,
access to interim data, method and timing of providing interim reports to the Sponsor, and other
issues relevant to committee operations will be described in the DMC charter.
8.4
Protocol Deviations
A protocol deviation is any change, divergence, or departure from the study design or procedures
of a clinical protocol that is under the Investigator’s control and that has not been approved by
the IRB. Upon discovery, the Principal Investigator is responsible for reporting protocol
deviations to the IRB or other local authority, if required by reporting guidelines, using the
standard reporting form. Protocol deviations and actions taken to resolve the deviations will be
noted on the designated study documents.

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8.5
Records Management
All study data will be recorded and maintained in a secure, validated electronic data capture
(EDC) database. The Investigator and study site will permit study-related monitoring, audits,
IRB review and regulatory inspection by providing authorized personnel from Freenome and its
representatives, the IRB, the FDA and other appropriate regulatory agencies direct access to all
study-related data as requested.
Direct access to examine, analyze, verify and reproduce any records, source documents or
reports are important to the evaluation of a clinical study. Any party with direct access should
take reasonable precautions to maintain the confidentiality of the study subjects and the
Freenome’s proprietary information.
All study documentation, including Informed Consent Forms and study logs, are to be kept by
the Investigator's site in a secured location. Records should be maintained for a minimum of 5
years. The site should inform Freenome or its designee prior to moving records to an off-site
location or destroying according to local practice. These records must be available for all types
of study-related monitoring, audits, IRB review, and regulatory inspections. Access to these files
is to be considered restricted and accessible only to the Principal Investigator(s), authorized
study personnel, and legally required regulatory inspectors.
8.6
Source Documentation
All data obtained during this study should be entered in the eCRFs promptly. All source
documents from which eCRF entries are derived should be placed in the patient’s records. eCRF
fields for which source documents will typically be needed include progress notes, CS,
histopathology and/or imaging reports. Documentation of sample collection, storage and
shipment will also be considered source documents for this study.
The eCRFs for each patient will be checked against source documents at the study site by the site
monitor.
Instances of missing or uninterpretable data will be discussed with the Investigator for resolution.
8.7
Study Files and Record Retention
The Investigator is responsible for ensuring that the Investigator site file is maintained.
The Investigator site file will contain, but is not limited to, the following information:
●
A current, signed version of the protocol and any previous versions of the protocol (if
applicable)
●
Protocol amendment(s) (if applicable)

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●
Curricula Vitae of Investigator(s) where required by law; Investigators must also
complete all regulatory documentation as required by the ICH/GCP and by local
regulations
●
Documentation of IRB approval of the protocol and any protocol amendment(s) (if
applicable)
●
All material correspondence between the Investigator, IRB, Freenome, and CRO relating
to study conduct
●
Delegation log/signature list of all staff completing eCRFs
8.8
Study and Site Closure
Freenome may close a study site or terminate the study at any time for any reason at its sole
discretion. The study may also be terminated if an Investigator, Freenome, or Freenome’s
designee becomes aware of conditions or events that suggest a possible hazard to subjects if the
study continues.
Conditions that may warrant termination of the study site or the study include, but are not limited
to:
●
Failure of the Investigator to comply with the protocol, the requirements of the IRB or
local health authorities, Freenome’s procedures, or GCP guidelines
●
Discovery of an unexpected, significant, or unacceptable risk to the subjects enrolled in
the study
●
Failure of a study site to enroll subjects at an acceptable rate
●
Decision on the part of Freenome to suspend or discontinue development of the study
intervention
Study sites will be closed upon study completion. A study site is considered closed when all
required documents and study supplies have been collected and a site closure visit has been
performed.

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9.
DATA QUALITY ASSURANCE
All subject data relating to the study will be recorded on printed or electronic eCRFs unless
transmitted to Freenome or designee electronically (e.g., laboratory data). The Investigator is
responsible for verifying that data entries are accurate and correct by electronically signing the
eCRF.
All data obtained during the study should be entered in the eCRFs promptly. All source
documents from which eCRF entries are derived should be placed in the subject’s medical
records.
Freenome (or designee) will oversee the progress of the clinical study to ensure that the study is
being conducted and recorded in accordance with the protocol, SOPs, and applicable ICH and
GCP principles and has followed all the applicable regulatory requirements. During site
initiation, appropriate study-specific training will be provided to the Investigator, co-Investigator
(if applicable), and all site personnel involved in the study by the monitor. Instances of missing
or uninterpretable data will be discussed with the Investigator for resolution. The review of
medical records will be performed in a manner to ensure that subject confidentiality is
maintained.
In accordance with ICH GCP guidelines, the Investigator must ensure provision of sufficient
time, reasonable space, and adequate qualified personnel and other support for study monitoring
visits. Moreover, regulatory authorities, IRBs, and/or Freenome’s Quality Assurance group (or
designee) may wish to perform additional source data checks and/or on-site audit inspections.
The Investigator must provide direct access to source data documents upon request during
study-related monitoring visits, audits, IRB review, and regulatory agency inspections, provided
that such visits, audits, reviews and inspections must be performed giving due consideration to
data protection and medical confidentiality. In addition, the Investigator will ensure that
Freenome and/or Freenome’s designee will receive the necessary support to complete these
activities.
The CRF Completion Guidelines, to be developed during the initiation phase of the study, will
provide detailed data entry instructions into the EDC system and guidance for query resolution.
The Data Management Plan will include edit check specifications according to GCP standards
and study-specific parameters.
The Investigator will make available for access all study-related records upon request from
Freenome (or designee), clinical monitor(s), auditors, and/or IRB in accordance with applicable
regulations. Audits may be conducted at any time during or after the study to ensure the validity
and integrity of the study data.
Each study site will maintain an Investigator study file which should contain, at minimum, the
protocol and any amendments thereto, the study laboratory manual, and any material
correspondence with the IRB and Freenome (or its designee), and other study-related documents.

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10. REGULATORY AND ETHICAL CONSIDERATIONS
10.1
Good Clinical Practice
The procedures set forth in this study protocol are designed to ensure that Freenome and
Investigators abide by all applicable laws, regulations and guidelines, including ICH Good
Clinical Practice (GCP) guidelines and international guidelines for ethical practices, including
the Declaration of Helsinki (1989) and the Council for International Organizations of Medical
Sciences (CIOMS) International Ethical Guidelines.
Before a subject is screened, the study protocol, including any amendments, the ICF, and any
other relevant documents must be approved by the IRB, in accordance with applicable laws,
regulations and guidelines.
It is the intent of Freenome to not permit any protocol modifications for this study. Protocol
modifications, except those intended to reduce immediate risk to study subjects, may be made
only by Freenome and may be implemented immediately, provided the IRB is notified within
5 days.
Any permanent change to the protocol must be handled as a protocol amendment. The
amendment must be submitted to the IRB and the Investigator must await approval before
implementing the changes. Freenome, or designee, will submit protocol amendments to the
appropriate regulatory authorities for approval.
The Investigator will also be responsible for providing oversight of the conduct of the study at
the site, including oversight of all personnel involved in the study, and adherence to all
applicable laws and regulations, as set forth in the Clinical Trial Agreement (CTA).
Personnel involved in conducting this study will be qualified by education, training, and
experience prior to performing their respective tasks.
The study will not use the services of study personnel against whom sanctions have been
invoked or who have engaged in scientific misconduct or fraud (e.g., loss of medical licensure,
debarment).
11.
CLINICAL STUDY REPORT AND PUBLICATION POLICY
Freenome is responsible for preparing and providing the appropriate regulatory authorities with
clinical study reports according to the applicable regulatory requirements.
Freenome’s publication policy is discussed in the Investigator's Clinical Trial Agreement.

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12.
DISCONTINUATION
12.1
Subject Discontinuation/Withdrawal
There are no specific criteria for discontinuation from the study. Subjects may
discontinue/withdraw from participation at any time. The Investigator may decide that a subject
should discontinue/withdraw from the study. In all instances of subject
discontinuation/withdrawal, the Investigator will ensure that all appropriate eCRF pages are
completed for any subject who is withdrawn from the study, including the date of and reason for
withdrawal from the study. The reason for withdrawal from the study will also be recorded in the
clinical records.
12.2
Study Termination
Sites will conduct this study in compliance with the protocol and all applicable regulatory and
legal requirements. Freenome reserves the right to terminate this study at any time for safety or
administrative reasons, either in its entirety or at individual sites, by providing notification to the
IRB or to the enrolling site at the time of termination.
13.
CONFIDENTIALITY
All information generated or obtained in this study is considered highly confidential and must
not be disclosed to any person or entity not directly involved with the study unless prior written
consent is gained from Freenome or its designee.
Identification of subjects and eCRFs shall be by study ID only. If required, the subject’s full
name may be made known to an authorized regulatory agency or other authorized official.
13.1 Subject De-Identification and Data Protection
Each subject will be de-identified by use of a unique study ID number that will be assigned
sequentially in order of enrollment. From the time of number assignment, the specimen must not
be labeled with any other identifier. This process must be conducted in accordance with
institutional privacy requirements and may therefore vary by site.
Investigator and study center must maintain the anonymity of participating subjects. Each subject
will be assigned a unique numerical subject ID number. Investigator and study center will
include only the numerical subject ID on any eCRFs or other subject records or other documents
that are transferred or submitted to Freenome or Freenome’s designee during the course of the
study and will redact the subject’s name and all other personally-identifiable subject information
from such documents.

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14.
REFERENCES
1.
American Cancer Society. Cancer Facts & Figures. Atlanta, GA: American Cancer
Society, Inc.; 2019.
2.
Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for Colorectal Cancer: US
Preventive Services Task Force Recommendation Statement. JAMA 2016;315:2564-75.
3.
Rex DK, Boland CR, Dominitz JA, et al. Colorectal Cancer Screening:
Recommendations for Physicians and Patients from the U.S. Multi-Society Task Force on
Colorectal Cancer. The American Journal of Gastroenterology 2017;112:1016-30.
4.
Provenzale D, Gupta S, Ahnen DJ, et al. NCCN Guidelines Insights: Colorectal Cancer
Screening, Version 1.2018. Journal of the National Comprehensive Cancer Network:
JNCCN 2018;16:939-49.
5.
Howlader N NA, Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z, Mariotto A,
Lewis DR, Chen HS, Feuer EJ, Cronin KA. SEER Cancer Statistics Review, 1975-2016.
Bethesda, MD: National Cancer Institute; 2019 April.
6.
Bailey CE, Hu CY, You YN, et al. Increasing disparities in the age-related incidences of
colon and rectal cancers in the United States, 1975-2010. JAMA Surgery
2015;150:17-22.
7.
Meester RGS, Peterse EFP, Knudsen AB, et al. Optimizing colorectal cancer screening by
race and sex: Microsimulation analysis II to inform the American Cancer Society
colorectal cancer screening guideline. Cancer 2018;124:2974-85.
8.
Peterse EFP, Meester RGS, Siegel RL, et al. The impact of the rising colorectal cancer
incidence in young adults on the optimal age to start screening: Microsimulation analysis
I to inform the American Cancer Society colorectal cancer screening guideline. Cancer
2018;124:2964-73.
9.
Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for
average-risk adults: 2018 guideline update from the American Cancer Society. CA: A
cancer journal for clinicians 2018;68:250-81.
10.
Shapiro JA, Klabunde CN, Thompson TD, Nadel MR, Seeff LC, White A. Patterns of
colorectal cancer test use, including CT colonography, in the 2010 National Health
Interview Survey. Cancer epidemiology, biomarkers & prevention: A publication of the
American Association for Cancer Research, cosponsored by the American Society of
Preventive Oncology 2012;21:895-904.
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15.
APPENDICES
Appendix I Concomitant Medications for Data Collection
Concomitant Medications for Data Collection:*
Covid-19 Vaccination
Aspirin
NSAIDs
Estrogen
DMARDs
Biological Agents
*Concomitant medications to be collected in the 30 days preceding enrollment
Examples of commonly used DMARDs:
hydroxychloroquine (Plaquenil)
leflunomide (Arava)
methotrexate (Trexall)
sulfasalazine (Azulfidine)
minocycline (Minocin)
Examples of commonly used Biological Agents:
abatacept (Orencia)
adalimumab (Humira)
anakinra (Kineret)
baricitinib (Olumiant)
certolizumab (Cimzia)
etanercept (Enbrel)
golimumab (Simponi)
infliximab (Remicade)
rituximab (Rituxan)
sarilumab (Kevzara)
tocilizumab (Actemra)

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Appendix III Protocol Version History
Protocol Version
Effective Date
Reason for Change
V1.0
04Feb2020
Initial Release
V2.0
20Jul2020
See Summary of Changes
V2.1
(administrative
note to file only)
02Oct2020
Amended Section 4.2: Exclusion Criteria 2.2 to
clarify the intent to exclude patients who have
any evidence of a malignancy in the five years
preceding enrollment.
V3.0
05April2021
See Summary of Changes