# Clinical utility of circulating tumor DNA sequencing with a large panel: a National Center for Precision Medicine (PRISM) study

Arnauld Bayle, Laïla Belcaid, Mihaela D. Aldea, Damien Vasseur, Florent Peyraud, Claudio Nicotra, Arthur Geraud, Madona Sakkal, Lauren Seknazi,

Luigi Cerbone, et al.

<figure><img src="image_1.png" /></figure>

## ► To cite this version:

Arnauld Bayle, Laïla Belcaid, Mihaela D. Aldea, Damien Vasseur, Florent Peyraud, et al. Clinical utility of circulating tumor DNA sequencing with a large panel: a National Center for Precision Medicine (PRISM) study. Annals of Oncology, 2023, 34 (4), pp.389-396. 10.1016/j.annonc.2023.01.008. hal-04233288

HAL Id: hal-04233288

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Submitted on 9 Jan 2026

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<figure><img src="image_2.png" /></figure>
# Clinical utility of circulating tumor DNA sequencing with a large panel: a National Center for Precision Medicine (PRISM) study

A. BAYLE<sup>1,2,3*</sup>, L. BELCAID<sup>1,4*</sup>, M. ALDEA<sup>6</sup>, D. VASSEUR<sup>7</sup>, F. PEYRAUD<sup>5</sup>, C. NICOTRA<sup>1</sup>, A. GERAUD<sup>1</sup>, M. SAKKAL<sup>1,6</sup>, L. SEKNAZI<sup>1</sup>, L. CERBONE<sup>6</sup>, F. BLANC-DURAND<sup>6</sup>, J. HADOUX<sup>6</sup>, F. MOSELE<sup>6</sup>, M. TAGLIAMENTO<sup>6</sup>, A. BERNARD-TESSIER<sup>6</sup>, B. VERRET<sup>26</sup>, C. SMOLENSCHI<sup>1</sup>, R. CLODION<sup>1</sup>, N. AUGER<sup>7</sup>, P. MARTIN ROMANO<sup>1</sup>, A. GAZZAH<sup>1</sup>, M. NGO Camus<sup>1</sup>, J. MICOL<sup>12</sup>, O. CARON<sup>13</sup>, A. HOLLEBECQUE<sup>1</sup>, Y. LORIOT<sup>1</sup>, B. BESSE<sup>2,6</sup>, L. LACROIX<sup>7</sup>, E. ROULEAU<sup>7</sup>, S. PONCE<sup>1</sup>, JC SORIA<sup>2,6</sup>, F. BARLESI<sup>2,6</sup>, F. ANDRE<sup>2,6</sup>, A. ITALIANO<sup>1,5,11</sup>

* AB and LB contributed to this work equally

## Affiliations:

## Correspondence to:

Antoine ITALIANO, MD, PhD

Antoine.italiano@gustaveroussy.fr

Gustave Roussy – Cancer Campus

Drug development department (DITEP)

114 rue Edouard Vaillant, 94805 Villejuif – France

Phone: +33 (0)1 42 11 58 95 / Fax: +33 (0)1 42 11 64 44

<footnote n="1"><sup>1</sup> Drug development department (DITEP) Gustave Roussy – Cancer Campus, Villejuif, France</footnote>

<footnote n="2"><sup>2</sup> Université Paris Saclay, Faculté de médecine, Le Kremlin Bicêtre, Paris, France.</footnote>

<footnote n="3"><sup>3</sup> Oncostat U1018, Inserm, Paris-Saclay University, labeled Ligue Contre le Cancer, Villejuif, France</footnote>

<footnote n="4"><sup>4</sup> Department of Oncology, Rigshospitalet, University of Copenhagen, Denmark</footnote>

<footnote n="5"><sup>5</sup> Department of Early Phase Trial Unit, Institut Bergonié Comprehensive Cancer Centre, Bordeaux, France.</footnote>

<footnote n="6"><sup>6</sup> Department of Cancer Medicine, Gustave Roussy, Villejuif, France.</footnote>

<footnote n="7"><sup>7</sup> Department of Medical Biology and Pathology, Gustave Roussy, Villejuif, France</footnote>

<footnote n="8"><sup>8</sup> Department of Medical Biology and Pathology, Institut Bergonié Comprehensive Cancer Centre, Bordeaux, France</footnote>

<footnote n="9"><sup>9</sup> Department of biostatistics, Institut Bergonié Comprehensive Cancer Centre, Bordeaux, France</footnote>

<footnote n="11"><sup>11</sup> University of Bordeaux, Bordeaux, France</footnote>

<footnote n="12"><sup>12</sup> Department of Hematology, Gustave Roussy, Villejuif, France</footnote>

<footnote n="13"><sup>13</sup> Department of Genetics, Gustave Roussy, Villejuif, France</footnote>
**ABSTRACT**

**Background:** Circulating tumor DNA (ctDNA) sequencing is a promising approach for tailoring therapy in cancer patients. We report hereby the results from a prospective study where we investigated the impact of comprehensive molecular profiling of ctDNA in patients with advanced solid tumors.

**Methods:** Genomic analysis was performed using the Foundation One Liquid CDx Assay (324 genes, tumor mutational burden [TMB], microsatellite instability status). Each individual genomic report was reviewed and discussed weekly by a multidisciplinary tumor board (MTB). Actionable targets were classified by ESCAT tier leading to molecular-based treatment suggestions wherever it was possible.

**Results:** Between Dec 2020 and Nov 2021, 1772 patients with metastatic solid tumors underwent molecular profiling. Median time to assay results was 12 days. Results were contributive for 1658 patients (94%). At least one actionable target was detected in 1059 patients (64%) with a total of 1825 actionable alterations including: alteration of the DNA damage repair response pathway (N=336, 18%), high TMB (> 16 mutations/Mb) (N= 243, 13%), *PIK3CA* mutations (N=150, 8%), *ERBB* family pathway alterations (N=127, 7%), *PTEN* alterations (N=95, 5%), *FGFR* alterations (N= 67, 4%) and *MET* activations (N=13, 0.7%). The MTB recommended a matched therapy for 597 patients (56%) with a total of 819 therapeutic orientations: clinical trials (N= 639, 78%), off label/compassionate use (N=81, 10%), approved drug (N=51, 6%) and early access program (N=48, 6%). In total, 122 patients (21%) were treated. Among the evaluable patients (N=107), 4 (4%) had complete response, 35 (33%) had partial response, 27 (25%) had stable disease and 41 (38%) a progressive disease as best response. Median progression free survival and median overall survival were 4.7 (95% CI 2.7-6.7 ) and 8.3 months (95% CI 4.7-11.9) respectively.

**Conclusions:** ctDNA sequencing with a large panel is an efficient approach to match advanced cancer patients with targeted therapies.

**KEY WORDS:** ctDNA, targeted therapy, ESCAT, precision medicine
## INTRODUCTION

During the last decade, molecular characterization of tumors has been associated with improved outcomes and quality of life of patients with cancer ¹. Previous studies²⁻⁷ have evaluated the clinical utility of molecular tests performed on tumor tissue. This approach has several limitations including technical failure due to poor quality or inadequate tissue quantity and risks of complications related to biopsy procedure⁸. Moreover, while the tissue biopsy may provide information about the genomic landscape of a specific tumor site, it do not allow to capture tumor heterogeneity which is hallmark of metastatic cancer ⁹⁻¹¹.

Due to the rapid development of high-throughput technologies such as next-generation sequencing (NGS), it is now possible to characterize the molecular profile of circulating tumor DNA (ctDNA)¹²,¹³. ctDNA profiling is noninvasive and representative of the whole molecular landscape of the patient's tumor¹⁴,¹⁵, challenging then the limitations of tissue biopsy. Accumulating evidence has emphasized the potential of ctDNA to detecting and monitor cancer¹⁶⁻¹⁸ and to identify mechanisms of resistance to anti-cancer agents¹⁹.

We have recently reported a systematic comparison of ctDNA vs tissue sequencing which showed the capacity of ctDNA for capturing clinically relevant alterations to guide therapy in cancer patients with high accuracy and rapid turnover results²⁰. However, no study has evaluated prospectively the benefit of ctDNA profiling to guide therapy in cancer patients and the outcome of patients with advanced cancer treated with ctDNA matched therapy as recommended by a molecular tumor board (MTB).

We report here the largest prospective study addressing these specific questions in patients with advanced solid tumors.

## PATIENTS AND METHODS
## Study Design and Procedure

Patients were included in the ongoing precision medicine study STING (NCT04932525, Gustave Roussy). Patients were eligible if they presented a locally advanced, unresectable, or metastatic solid tumor. All genomic results were discussed during a weekly molecular multidisciplinary board. All patients provided written consent for the genomic analyses. This study was approved by the Institutional Review Board.

## Genomic analysis

Genomic analysis was performed for each patient by using the Foundation One Liquid CDx Assay (324 genes, tumor mutational burden [TMB], microsatellite instability) <sup>21-23</sup>.

## FoundationOne® Liquid CDx

The FoundationOne Liquid CDx (F1LCDx) assay is performed on circulating cell-free DNA (cfDNA) isolated from plasma derived from anti-coagulated peripheral whole blood from patients with solid malignant neoplasms. Extracted cfDNA undergoes whole-genome shotgun library construction and hybridization-based capture of 324 cancer-related genes. All coding exons of 309 genes are targeted; select intronic or non-coding regions are targeted in fifteen of these genes. Hybrid-capture selected libraries are sequenced with deep coverage using the NovaSeq® 6000 platform. Sequence data are processed using a custom analysis pipeline designed to detect genomic alterations.

## Tumor Mutation Burden (TMB) and Microsatellite instability (MSI)

Mutational burden was calculated by counting somatic variants (single nucleotide and indels, including synonymous variants, excluding germline and driver mutations) with variant allele frequency (VAF) ≥5% in tissue (TMB) or ≥0.5% in ctDNA (bTMB). MSI score was assessed using 95 repetitive loci and principal component analysis (tissue) or >1,800
repetitive loci (plasma).

## Actionable alterations

Each individual genomic report was reviewed and discussed weekly by the multidisciplinary tumor board (MTB) of Gustave Roussy (Villejuif, France) which include medical oncologists, pathologists, molecular geneticists, bioinformaticians and study coordinators. Actionable targets were defined by the MTB according to the existing level of evidence (ESCAT tiers)²⁶ and matched therapies were proposed where possible.

## Statistical analysis

Descriptive statistics were used to describe population characteristics. Qualitative data are expressed with number and percentages. Quantitative data are expressed with mean, standard deviation, median, 1st and 3rd quartiles and range when applicable. Data were analyzed using the software R version 4.0.3. Study data were collected and managed using REDCap (Research Electronic Data Capture)²⁴,²⁵ hosted at Gustave Roussy. REDCap is a secure, web-based software platform designed to support data capture for research studies.

All patients were included in the STING (NCT04932525, Gustave Roussy) personalized medicine study and provided informed consent for liquid biopsy and data analysis. This study was approved by the Institutional Review Board of Gustave Roussy.

# RESULTS

## Patient characteristics

The CONSORT diagram of the study is illustrated in Fig1. A total of 1772 metastatic patients were included from December 2020 to November 2021 at Gustave Roussy
(Villejuif, France). Their characteristics are summarized in table 1. Median age was 63 years (interquartile range IQR: 54 – 71) and most patients (N= 1531, 86%) were in good general condition (ECOG performance status 0 or 1) when performing ctDNA profiling.

The five most frequent tumor types were non-small cell lung cancer (NSCLC) (n=291, 16%), prostate (n=199, 11%), colorectal (n=171, 10%), breast (n=171, 10%), and pancreas (n=131, 7%).

At the time of ctDNA profiling, 28.2% (n=500), 24.9% (n=442), 18.8% (n=333), 11.6% (n=205) and 16.25% (n=288) of the patients had received 0, 1, 2, 3 and ≥4 previous lines of systemic therapies respectively.

## Turnaround time and screen failure

Median time elapse between request and ctDNA results was 12 days (IQR: 10-13). The rate of testing failure was 6.4% (N=114).

## Molecular profile

Overall, 1658 (93.6%) patients had evaluable results for ctDNA profiling. The total number of cancer-related alterations and of variants of unknown significance were 7503 and 20459, respectively.

After exclusion of genes associated with Clonal Hematopoiesis of Indeterminate Potential (CHIP) (ASXL1, DNMT3A, TET2, JAK2, MPL, U2AF1, SF3B1), the five more frequent cancer related alterations were: TP53 (16.25%), ATM (8.21%), APC (5.9%), KRAS (4.2%) and PIK3CA (3.25%).

## MSI and TMB

MSI status and TMB were evaluable for 97.4% (N=1615) and 98.4% (N=1631) of patients respectively (Table1). Overall, 1.1% of patients (N=19) had MSI high tumors and 8.3% (N=138) of patients were blood-TMB (bTMB) high (with a cut-off of 16 mutations/mb).
>Actionable alterations and ESCAT classification

At least one actionable genetic aberration was detected in 1059 patients (64%) with a total of 1825 aberrations. The most frequent genetic aberrations were: mutations of genes involved in the DNA damage repair response pathway (N=336, 18%), high TMB (> 16 mutations/Mb) (N= 243, 13%), *PIK3CA* gene mutations (N=150, 8%), *ERBB* family of genes mutations and/or amplifications (N=127, 7%), *PTEN* gene alterations (N=95, 5%), *FGFR* gene mutations of fusions (N= 67, 4%) and *MET* mutations and/or amplification (N=13, 0.7%).

The 1825 genetic aberrations were classified as ESCAT I/II, IIIA, IIIB and IV<sup>26</sup> in 563 (31%), 439 (24%), 106 (6%) and 717 (39%) cases respectively.

*Molecular tumor board recommendations*

Overall, the MTB recommended a matched therapy for 597 patients (56%) with up to 1, 2, 3, 4 or 5 possible ctDNA-tailored treatment recommendations in 432 (72.4%), 117 (19.6%), 40 (6.7%), 7 (1.2%) and 1 (0.2%) patient respectively. The most frequent molecular targets among patients with a matched therapy recommendation are illustrated in Fig. 2.

The MTB performed 819 recommendations including: enrollment in genotype matched clinical trials (N= 639, 78%), off label/compassionate use of genotype matched drugs (N=81, 10%), genotype matched approved drugs for the indication (N=51, 6%) and genotype matched drug eligible to a national early access program (N=48, 6%) (Table 3).

In contrast, MTB did not make any recommendation for 462 patients (44%) despite the identification of 644 targetable alterations for the following reasons: no clinical trial available (N=421, 65%), genotype matched treatment already received by the patient
(N=169, 26%), worsening of performance status (N= 49, 8%) or other miscellaneous reasons (N=5, 0,8%) (Fig. 1).

### Outcomes of patients treated with a ctDNA matched therapy

In total, 122 patients were treated with a ctDNA matched therapy. The median follow-up was 9 months. 107 patients were evaluable for response as per RECIST 1.1 criteria²⁷. Among them, 4 (4%) had complete response, 35 (33%) a partial response, 27 (25%) stable disease and 41 (38%) progressive disease as best overall response as illustrated by the type of orientation (Fig. 3a) and by ESCAT tier (Fig. 3b). The alterations and the matched therapies for the patients with complete or partial response are illustrated in Suppl. Table 1.

Of note, among the 107 patients evaluable for response, 54/107 (50%) underwent also NGS of tumor tissue NGS result. The alteration identified by ctDNA was also found in tissue in 3 patients (75%), 20 patients (57%), 10 patients (37%) and 12 patients (29%) with complete response, partial response, stable disease and progressive disease respectively.

The ctDNA alteration was not found in tissue in 3 patients (9%) with partial response, 1 patient (4%) with stable disease and in 5 patients (12%) with progressive disease.

Median progression free survival and median overall survival were 4.7 (95% CI 2.7-6.7) and 8.3 months (95% CI 4.7-11.9) respectively (Table 4 and Figure 4).

Four hundred and seventy-five (475, 80%) patients did not receive the recommended treatment. The main reasons were: performance status decline or palliative care or death (N=123, 26%), no disease progression (N=79, 17%) and referral clinician's decision for another treatment (N=69, 15%) (Table 4).

## DISCUSSION
We report hereby the largest study investigating the clinical utility of ctDNA profiling for tailoring therapy in patients with advanced solid cancer. Our results showed that genomic profiling of ctDNA with a large panel is feasible in the routine setting and allows to obtain relevant molecular information in almost all patients (94%, 1659/1772) with a turnaround time of 12 days only. This is in contrast with tissue profiling analysis for which the rate of technical failure is > 15% and the median time to obtain results frequently > 30 days due the delay in recovering archival tumor tissue². The clinical utility of ctDNA based molecular profiling in patients with advanced cancer is illustrated by the identification of at least one actionable target in up to 60% of patients and by the favorable objective response rate which was of 36% among patients treated with a ctDNA matched therapy and evaluable for tumor response.

In contrast with previous smaller studies²⁸, each profile was discussed during a weekly MTB and each genomic aberration was classified as per ESCAT system to decrease the risk of misinterpretation of genetic results²⁶. The importance of this approach is illustrated by the significantly higher objective response rate observed in patients with ESCAT I/II aberration as illustrated in Fig 3b. ²⁹.

It should be acknowledged that as it was observed in previous precision medicine studies using a tissue-based strategy, a high proportion of patients with an identified actionable target did not receive therapy. The main reasons were performance status deterioration and non-disease progression on current therapy. This underlines the importance of improving the selection of patients undergoing genomic profiling and highlights the need for improved guidance about when to perform genomic profiling for patients with advanced cancer. Of note, a significant proportion (77/589, 13%) of patients were not treated with matched therapy just because eligibility criteria of relevant clinical trials required that the
molecular aberration was identified through tissue sequencing. Our results advocate for higher flexibility of inclusion criteria which should consider ctDNA results as robust as tissue-based profiling. Despite the advantages of ctDNA versus tissue in a clinical setting, this approach has also several limitations. Indeed, up to 20% of stage IV tumors do not shed ctDNA in the bloodstream leading to false negative result in plasma, even if the tumor may have targetable mutation <sup>30</sup>. Furthermore, clonal hematopoiesis-related mutations may be misinterpreted as solid tumors mutations when tumor-only sequencing was used for a variety of cancer types, as demonstrated in previous studies<sup>31</sup>. Such misinterpretation could ultimately impact patient care and treatment choice; emphasizing then the need for careful interpretation of ctDNA sequencing reports. Additionally, ctDNA sequencing is less sensitive than tissue sequencing in detecting fusion genes or copy number variations (amplifications of oncogenes or deletions of tumor suppressor genes) which may result in overlooking some potential actionable alterations <sup>20</sup>. Finally, implementation of ctDNA profiling in the routine setting requires standardization of preanalytical procedures together with education and training of hospital staff <sup>29</sup>. ctDNA sequencing with a large panel is an efficient approach to identify actionable alterations in patients with advanced cancer. Patients who may benefit from such molecular profiling should be carefully selected to improve the proportion of them who may effectively receive a matched therapy.

## ACKNOWLEDGEMENTS

We are grateful for Laetitia MILLIER, Zsofia BALOGH, Pascale CONAN, Laetitia SOULLIER, Tasnim HEDDOUI and to all the precision medicine team of Gustave Roussy for their help.

## FUNDING
FONDATION GUSTAVE ROUSSY. No grant number is applicable.

DISCLOSURE

**AI:** Received research grants from Astra Zeneca, Bayer, BMS, Chugai, Merck, MSD, Pharmamar, Novartis, Roche, and received personal fees from Epizyme, Bayer, Lilly, Roche, and Springworks.
**BB:** Received grants from AstraZeneca, Pfizer, Eli Lilly, Onxeo, Bristol Myers Squibb, Inivata, Abbvie, Amgen, Blueprint Medicines, Celgene, GlaxoSmithKline, Ignyta, Ipsen, Merck KGaA, MSD Oncology, Nektar, PharmaMar, Sanofi, Spectrum Pharmaceuticals, Takeda, Tiziana Therapeutics, Cristal Therapeutics, Daiichi Sankyo, Janssen Oncology, OSE Immunotherapeutics, BeiGene, Boehringer Ingelheim, Genentech, SERVIER, Tolero Pharmaceuticals.
**YL:** Received grants and personal fees from Janssen, during the conduct of the study; personal fees and non-financial support from Astellas, grants and personal fees from Sanofi, personal fees and non-financial support from Roche, personal fees and non-financial support from AstraZeneca, grants, personal fees and non-financial support from MSD, personal fees and non-financial support from BMS, personal fees from Clovis, personal fees and non-financial support from Seattle Genetics, personal fees from Incyte, personal fees from Pfizer.
**JCS:** is a current employee of AMGEN All other authors have declared no conflicts of interest.
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**Figure 1 : Flowchart**

**Figure 2 : Most frequent molecular targets among patients orientated**

**Figure 3 : Best responses (by type of orientation and by ESCAT)**

**Figure 4.** Kaplan Meier curves of progression-free (A) and overall survival (B) of patients with advanced cancer treated with a therapy matched based on ctDNA profiling
<figure><img src="image_3.png" /></figure>
Most frequent molecular targets among patients
orientated

<figure><img src="image_4.png" /></figure>
<figure><img src="image_5.png" /><figcaption>Fig 3B. Responses based on ESCAT (TMB included)</figcaption></figure>

N = 107

<figure><img src="image_6.png" /></figure>
A

<figure><img src="image_7.png" /></figure>

B

<figure><img src="image_8.png" /></figure>
<table><caption>Table 1 : Patients characteristics</caption><thead><tr><th></th><th></th><th>N=1772</th></tr></thead><tbody><tr><td>Number of patients</td><td></td><td></td></tr><tr><td>Gender</td><td>Male</td><td>932 52.6%</td></tr><tr><td></td><td>Female</td><td>840 47.4%</td></tr><tr><td>Age</td><td>Median (Q1 ; Q3)</td><td>Med=63 (54 ; 71)</td></tr><tr><td>Cancer Types</td><td>Digestive</td><td>505 28.5%</td></tr><tr><td></td><td>Thoracic</td><td>326 18.4%</td></tr><tr><td></td><td>Genito urinary</td><td>313 17.66%</td></tr><tr><td></td><td>Breast</td><td>171 9.65%</td></tr><tr><td></td><td>Gynaecological</td><td>103 5.81%</td></tr><tr><td></td><td>Endocrinology</td><td>94 5.3%</td></tr><tr><td></td><td>Head and Neck</td><td>89 5.02%</td></tr><tr><td></td><td>Sarcoma</td><td>62 3.5%</td></tr><tr><td></td><td>NET</td><td>44 2.48%</td></tr><tr><td></td><td>Dermatology</td><td>37 2.09%</td></tr><tr><td></td><td>ACUP</td><td>16 0.9%</td></tr><tr><td></td><td>CNS</td><td>8 0.45%</td></tr><tr><td></td><td>Other</td><td>4 0.22%</td></tr><tr><td>Number of metastatic lines</td><td>0</td><td>500 28.22%</td></tr><tr><td></td><td>1</td><td>442 24.94%</td></tr><tr><td></td><td>2</td><td>333 18.79%</td></tr><tr><td></td><td>3</td><td>205 11.57%</td></tr><tr><td></td><td>≥4</td><td>288 16.25%</td></tr><tr><td></td><td>Missing values</td><td>4 0.23%</td></tr><tr><td></td><td>Median(Q1;Q3)</td><td>1(0 ;3)</td></tr><tr><td>PS (at ctDNA)</td><td>0</td><td>721 40.69%</td></tr><tr><td></td><td>1</td><td>810 45.71%</td></tr><tr><td></td><td>2</td><td>156 8.8%</td></tr><tr><td></td><td>3</td><td>31 1.75%</td></tr><tr><td></td><td>4</td><td>11 0.62%</td></tr><tr><td></td><td>Missing values</td><td>43 2.43%</td></tr></tbody></table>

Q1: first quartile, Q3: third quartile, CNS: Central Nervous System, ACUP: AdenoCarcinoma of Unknown Primary, PS: Performance Status, NA: not available,
<table><caption>Table 2 : Molecular results</caption><thead><tr><th>Value</th><th></th><th>N</th><th>(%, IQR)</th></tr></thead><tbody><tr><td>Number of samples</td><td></td><td>1772</td><td></td></tr><tr><td>Screen fail</td><td></td><td>114</td><td>(6.43%)</td></tr><tr><td>Analyzable samples</td><td></td><td>1658</td><td>(93.57%)</td></tr><tr><td>Delay from demand and results (in days)</td><td>Median (Q1;Q3)</td><td>12</td><td>(10;13)</td></tr><tr><td>Cancer related alterations (top 5)</td><td></td><td>TP53 (16.25%)<br>ATM (8.21%)<br>APC (5.9%)<br>KRAS (4.2%)<br>PIK3CA (3.25%)</td><td></td></tr><tr><td>Cancer related</td><td>All</td><td>7503</td><td></td></tr><tr><td>Variants of unknown significance</td><td>All</td><td>20459</td><td></td></tr><tr><td>MMR Status</td><td>MSS</td><td>1596</td><td>(96.26%)</td></tr><tr><td></td><td>MSI</td><td>19</td><td>(1.15%)</td></tr><tr><td></td><td>Not evaluable</td><td>33</td><td>(1.99%)</td></tr><tr><td></td><td>Missing values</td><td>10</td><td>(0.6%)</td></tr><tr><td>TMB</td><td>High</td><td>138</td><td>(8.32%)</td></tr><tr><td></td><td>Low</td><td>1493</td><td>(90.05%)</td></tr><tr><td></td><td>Not evaluable</td><td>27</td><td>(1.63%)</td></tr><tr><td></td><td>Median (Q1;Q3)</td><td>3.79</td><td>(1;7.69)</td></tr></tbody></table>
<table><caption>Table 3 : Orientation in MTB based on ctDNA</caption><thead><tr><th>Results</th><th></th><th>Number (%)</th></tr></thead><tbody><tr><td>Total number of patients</td><td></td><td>1772</td></tr><tr><td>Contributive analysis</td><td>Yes</td><td>1658(94%)</td></tr><tr><td></td><td>No</td><td>114 (6%)</td></tr><tr><td>Patients with theragnostic alterations on ctDNA (excluding screen fail)</td><td>Yes</td><td>1059 (64%)</td></tr><tr><td></td><td>No</td><td>600 (36%)</td></tr><tr><td>Mean number of theragnostic genes / patient</td><td></td><td>1.7</td></tr><tr><td>Patients with therapeutic orientation</td><td>Yes</td><td>597 (57%)</td></tr><tr><td></td><td>No</td><td>462 (43%)</td></tr><tr><td>Type of orientation (N=819)</td><td></td><td></td></tr><tr><td>- Clinical Trial</td><td></td><td>639 (78%)</td></tr><tr><td>- Off label/ Compassionate drug</td><td></td><td>81 (10%)</td></tr><tr><td>- Market authorization approved drug</td><td></td><td>51 (6%)</td></tr><tr><td>- Early access program drug</td><td></td><td>48 (6%)</td></tr></tbody></table>
<table><caption>Table 4 : Outcome of patients oriented in MTB based on ctDNA</caption><thead><tr><th>Results</th><th></th><th>Number (%)</th></tr></thead><tbody><tr><td>Total number of patients oriented</td><td></td><td>589</td></tr><tr><td rowspan="2">Patients treated (among patients orientated)</td><td>Yes</td><td>122 (21%)</td></tr><tr><td>No</td><td>467 (79%)</td></tr><tr><td rowspan="4">Among patients treated : type of treatment</td><td>Clinical Trial</td><td>68 (56%)</td></tr><tr><td>Market authorization approved drug</td><td>21 (17%)</td></tr><tr><td>Off label/ Compassionate drug</td><td>19 (16%)</td></tr><tr><td>Early access program drug</td><td>14 (11%)</td></tr><tr><td rowspan="12">Among patients not treated : reasons</td><td>Performance decline or palliative care or death (after MTB)</td><td>123 (26%)</td></tr><tr><td>No progression (=Tumor control with standard treatment =no change in treatment strategy)</td><td>79 (17%)</td></tr><tr><td>Clinician decided for other treatment (= another line)</td><td>69 (15%)</td></tr><tr><td>Lost follow-up (e.g treated outside)</td><td>49 (10%)</td></tr><tr><td>If CT: Confirmation of mutation by tissue: not performed or failure</td><td>46 (10%)</td></tr><tr><td>If CT : Relevant trial on hold or no slots available in relevant trials or did not meet inclusion criteria</td><td>39 (8%)</td></tr><tr><td>If CT : mutation not found in tissue</td><td>31 (7%)</td></tr><tr><td>If CT: Relevant trial not open</td><td>19 (4%)</td></tr><tr><td>If CT : Patient refused inclusion in CT</td><td>3 (&lt;1%)</td></tr><tr><td>If compassionate or early access program: demand refused</td><td>3 (&lt;1%)</td></tr><tr><td>COVID</td><td>3 (&lt;1%)</td></tr><tr><td>Other</td><td></td></tr></tbody></table>