Leveraging Methylated DNA Markers (MDMs) in the Detection of Endometrial Cancer, Ovarian Cancer, and Cervical Cancer

Study Overview
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Brief Summary
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The overarching objective of this project is to develop a pan-gynecologic cancer detection test using gynecologic (unique endometrial, cervical, and ovarian cancer) cancer-specific methylated DNA markers and high-risk human papilloma virus (HR-HPV) detected in vaginal fluid and/or plasma. This proposal defines Phase II MDM-based cancer detection studies in endometrial cancer (EC) and endometrial hyperplasia with atypia (AEH) in tampon-collected vaginal fluid and 2) ovarian cancer (OC) in plasma and tampon-collected vaginal fluid. Additionally, it defines necessary Phase I MDM-based cancer detection and exploratory aims to test novel cervical cancer (CC) MDMs and test the specificity of cancer-specific MDMs among various common benign gynecologic pathologies.er detection and exploratory aims to test novel cervical cancer MDMs and test the specificity of cancer-specific MDMs among various common benign gynecologic pathologies.

Detailed Description
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Detection of endometrial, ovarian, and cervical cancers at an early stage vastly increases the chances of cure and may also avert morbidity secondary to surgical staging, radiation, and/or chemotherapy. Despite the great successes of cervical cancer screening, comparable early detection methods for other gynecologic cancers and their precursors are not available. While nearly 1.5 million women per year in the United States are evaluated for abnormal uterine bleeding (AUB) or postmenopausal bleeding (PMB), the most common symptom of endometrial cancer, most undergo an invasive diagnostic biopsy with the finding of benign etiology. Vaginal bleeding is often the only presenting symptom of women ultimately diagnosed with endometrial cancer (EC) or its precursor lesion, endometrial hyperplasia(EH). More than 90% of women with EC present with vaginal bleeding. Cervical cancer and cervical dysplasia can present as intermenstrual bleeding, post-coital bleeding, or other abnormal vaginal bleeding. However, most women who present with AUB or PMB have a benign etiology. There are approximately 70 million women ≥45 years of age in the United States based on the most recent census data. Between 4-11% of women will be worked up for perimenopausal AUB or PMB in their lifetime. As only 5-10% of those women will have an EC or EH, there is a great clinical need for a less invasive clinical diagnostic test that can reliably distinguish between benign uterine bleeding and bleeding associated with an underlying endometrial cancer, cervical cancer, or a precursor lesion.

Official Title
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Leveraging Methylated DNA Markers (MDMs) in the Detection of Endometrial Cancer, Ovarian Cancer, and Cervical Cancer: a Phase II Clinical Study

Conditions
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Cervical Dysplasia, Endometrial Cancer, Cervical Cancer, Atypical Endometrial Hyperplasia, Adnexal Mass, Ovarian Cancer

Intervention / Treatment
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* Diagnostic Test: Tampon Collection
* Diagnostic Test: Blood Collection


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria for Cohort 1: Women will be ≥45 years of age and meet at least one of the following criteria: Abnormal uterine bleeding Postmenopausal bleeding Exclusion Criteria for Cohort 1: Prior hysterectomy Current known pregnancy diagnosis Any prior pelvic or vaginal radiotherapy Any prior cancer (except basal cell skin cancer) within the past 5 years Chemotherapy within the past 5 years Current biopsy-proven cervical, vaginal, or vulvar cancer or lower genital tract dysplasia Current biopsy-proven endometrial cancer or endometrial hyperplasia - - Current biopsy-proven benign endometrial polyp Endometrial biopsy/sampling within the preceding 1 month showing benign endometrium Inclusion Criteria for Cohort 2: Women will be ≥18 years of age and meet at least one of the following criteria: Presence of biopsy-proven EC (any histology, including uterine carcinosarcoma) and surgical intervention planned. Surgical intervention can include any of the following: hysterectomy, D&C, hysteroscopic resection Biopsy showing AEH or EIN with surgical intervention planned. Surgical intervention can include any of the following: hysterectomy, D&C, hysteroscopic resection, etc) Exclusion Criteria for Cohort 2: Undergoing surgical procedure for recurrent or metastatic EC Receipt of preoperative neoadjuvant chemotherapy or radiotherapy for current EC diagnosis Prior hysterectomy Current known pregnancy diagnosis Prior or current biopsy-proven cervical cancer Presence of concomitant biopsy-proven cervical dysplasia Any prior pelvic or vaginal radiotherapy Any prior cancer (except basal cell skin cancer) within the past 5 years Chemotherapy within the past 5 years Prior intervention or surgery with intent to completely remove the target pathology Inclusion Criteria for Cohort 3: Women will be ≥18 years of age, have a cervix and meet at least one of the following criteria: History of current abnormal cervical/endocervical Pap test for which the patient is presenting for colposcopy Cervical mass identified on physical exam and patient referred for cervical biopsy, even if colposcopy not recommended or indicated Planned clinically indicated surgical excisional biopsy or removal of the cervix (cold knife cone, LEEP, hysterectomy) for abnormal Pap test, cervical dysplasia, cervical mass, or biopsy-proven invasive cervical cancer (adenocarcinoma, squamous cell carcinoma, adenosquamous carcinoma, or less common primary cervical carcinomas all eligible) Exclusion Criteria for Cohort 3: History of pelvic or vaginal radiotherapy Prior total hysterectomy (cervix removed) for any indication Current known pregnancy diagnosis Cervical mass biopsy-proven to be EC or a cancer metastatic from a non-cervical origin Any prior cancer (except basal cell skin cancer) within the past 5 years Chemotherapy within the past 5 years Patients presenting for colposcopy as part of lower genital tract dysplasia or cancer surveillance after prior curative intent treatment and no current Pap abnormality or cervical mass Prior intervention or surgery with intent to completely remove the target pathology Inclusion Criteria for Cohort 4: Women will be ≥45 years of age and should meet at least one of the following criteria: Undergoing hysterectomy with biopsy-proven or clinically presumed (based on imaging and/or clinical symptoms) benign gynecologic or uterine pathology of fibroids, endometriosis, adenomyosis, or benign endometrial polyps. Undergoing any gynecologic surgery in which a benign pathologic tissue diagnosis of fibroids, endometriosis, adenomyosis, or benign endometrial polyp is anticipated to be confirmed. Exclusion Criteria for Cohort 4: Endometrial biopsy or office hysteroscopy within 2 weeks preceding the planned gynecologic surgery procedure for fibroids, endometriosis, benign endometrial polyps, or adenomyosis Any surgery within the past 3 months Prior hysterectomy Current known pregnancy diagnosis Prior or current biopsy-proven gynecologic cancer Current biopsy-proven AEH/EIN, cervical, vaginal, or vulvar dysplasia Prior pelvic or vaginal radiotherapy Any prior cancer (except basal cell skin cancer) within the past 5 years Chemotherapy within the past 5 years Undergoing hysterectomy for prolapse without a coexisting known or presumed benign uterine pathologic diagnosis of fibroids, endometriosis, benign endometrial polyps, or adenomyosis Prior intervention or surgery with intent to completely remove the target pathology Inclusion Criteria for Cohort 5: Women will be ≥45 years of age and should meet the following criteria: Presenting for well-woman exam, ± Pap test No change in medical conditions, new diagnoses, or new medications within the past 6 months; Exclusion Criteria for Cohort 5: Pap test or cervical biopsy within the past 1 month Endometrial biopsy or office hysteroscopy within the past 1 month Any surgery within the past 3 months Prior hysterectomy Current known pregnancy diagnosis Prior or current biopsy-proven gynecologic cancer Current biopsy-proven AEH/EIN, cervical, vaginal, or vulvar dysplasia Prior pelvic or vaginal radiotherapy Any prior cancer (except basal cell skin cancer) within the past 5 years Chemotherapy within the past 5 years Criteria met for inclusion in any of the other study cohorts Inclusion Criteria for Cohort 6: Women ≥50 years of age and: Postmenopausal status At least 1 intact ovary Diagnosis of an adnexal mass or a clinical suspicion of early-stage ovarian cancer (including fallopian tube cancer) Planned surgery for the adnexal mass For tampon collection, patient must have a uterus, cervix and at least 1 intact fallopian tube* (without prior tubal ligation/occlusion) Exclusion criteria - Isolated Adnexal Mass cohort: (Cohort 6) Any current or prior cancer diagnosis (except basal cell or squamous cell skin cancer, non-gyn) Chemotherapy for cancer treatment within the past 5 years prior to collection Clinically-suspected advanced stage ovarian cancer (Stage III or IV) on presentation, if known prior to specimen collection Surgical candidates for recurrent ovarian cancer History of pelvic or vaginal radiation therapy Known current synchronous endometrial cancer or hyperplasia Known current cervical, vaginal, or vulvar dysplasia Inclusion criteria - OC Cohort: (Cohort 7) Women will be ≥18 years of age and meet the following criteria: Presence of clinically probable ovarian, fallopian tube, or primary peritoneal cancer (all under the umbrella of OC) based on clinical findings of any/all of the following: imaging showing adnexal and/or abdominal masses consistent with probable ovarian cancer, omental caking, elevated CA125, ascites, imaging-guided biopsy consistent with OC pathology Newly diagnosed with ovarian, fallopian tube or primary peritoneal cancer without neoadjuvant therapy At least one intact ovary For tampon collection, patient must have a uterus, cervix and at least 1 intact fallopian tube* (without prior tubal ligation/occlusion) Exclusion criteria - OC Cohort (Cohort 7): Patients with recurrent OC Any current or prior cancer diagnosis (except basal cell or squamous cell skin cancer, non-gyn) within the past 5 years Chemotherapy for cancer treatment within the past 5 years prior to collection History of pelvic or vaginal radiation therapy Known current synchronous endometrial cancer or hyperplasia Known current cervical, vaginal, or vulvar dysplasia

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Cohort 1 - AUB / PMB<br>Women ≥45 years of age, presenting with abnormal uterine bleeding (AUB) or post-menopausal bleeding (PMB). These presenting symptoms clinically warrant evaluation such as an endometrial biopsy to assess for underlying endometrial cancer, endometrial hyperplasia or other endometrial pathology. | Diagnostic Test: Tampon Collection<br>* A tampon will be self-inserted by each participant prior to any exams or procedures and removed after 40 minutes..<br>* Other names: Vaginal Fluid;Diagnostic Test: Blood Collection<br>* A blood sample will be collected from each participant prior to undergoing any exams or procedures.<br>|
| Cohort 2 - Biopsy-proven EC or AEH or EIN<br>Women ≥18 years of age with biopsy-proven endometrial cancer (EC), atypical endometrial hyperplasia (AEH), or endometrial intraepithelial neoplasia (EIN) presenting for surgical management of their endometrial pathology. | Diagnostic Test: Tampon Collection<br>* A tampon will be self-inserted by each participant prior to any exams or procedures and removed after 40 minutes..<br>* Other names: Vaginal Fluid;Diagnostic Test: Blood Collection<br>* A blood sample will be collected from each participant prior to undergoing any exams or procedures.<br>|
| Cohort 3 - Cervix pathology<br>Women ≥18 years of age presenting for a clinically indicated colposcopy, cervical biopsy, or surgical excision, as follow-up for an abnormal Pap test or cervical mass identified on physical exam. Final clinical diagnoses within this cohort may include mild cervical intraepithelial neoplasia (CIN 1), moderate and/or severe CIN (CIN 2/3), adenocarcinoma in situ (AIS), invasive cervical cancers (adenocarcinoma or squamous cell carcinoma), or possibly benign findings. | Diagnostic Test: Tampon Collection<br>* A tampon will be self-inserted by each participant prior to any exams or procedures and removed after 40 minutes..<br>* Other names: Vaginal Fluid;Diagnostic Test: Blood Collection<br>* A blood sample will be collected from each participant prior to undergoing any exams or procedures.<br>|
| Cohort 4 - Benign Uterine Pathology<br>Women with any of four benign gynecologic conditions including: uterine fibroids, benign endometrial polyps, adenomyosis and endometriosis. All women enrolled in this cohort will be undergoing clinically indicated gynecologic surgery (hysterectomy, myomectomy, polypectomy, or laparoscopic tissue excision) for the specific benign gynecologic condition. Verification of the final benign diagnosis will be based on pathology diagnosis of clinically-indicated tissue removed during surgery. | Diagnostic Test: Tampon Collection<br>* A tampon will be self-inserted by each participant prior to any exams or procedures and removed after 40 minutes..<br>* Other names: Vaginal Fluid;Diagnostic Test: Blood Collection<br>* A blood sample will be collected from each participant prior to undergoing any exams or procedures.<br>|
| Cohort 5 - Healthy Control Women<br>Healthy women ≥45 years of age presenting for well-woman exams to serve as a control group. These women will have no clinically evident gynecologic precancers, gynecologic cancers, or clinically evident or symptomatic benign gynecologic conditions. These women will not have known or clinically-suspected AUB, PMB, fibroids, endometriosis, benign endometrial polyps, or adenomyosis, nor will they have any active gynecologic or non-gynecologic acute medical conditions. | Diagnostic Test: Tampon Collection<br>* A tampon will be self-inserted by each participant prior to any exams or procedures and removed after 40 minutes..<br>* Other names: Vaginal Fluid;Diagnostic Test: Blood Collection<br>* A blood sample will be collected from each participant prior to undergoing any exams or procedures.<br>|
| Cohort 6- Isolated Adnexal Mass Cohort (ovarian or fallopian mass)<br>Women ≥50 years of age and postmenopausal (12 months since LMP or available blood hormone levels confirming postmenopausal status) and an isolated adnexal mass or isolated bilateral adnexal masses being surgically removed. These patients will have a final diagnosis of any of the following: benign ovarian neoplasm, borderline tumor of the ovary, or clinically early-stage OC. | Diagnostic Test: Tampon Collection<br>* A tampon will be self-inserted by each participant prior to any exams or procedures and removed after 40 minutes..<br>* Other names: Vaginal Fluid;Diagnostic Test: Blood Collection<br>* A blood sample will be collected from each participant prior to undergoing any exams or procedures.<br>|
| Cohort 7 - OC Cohort - Biopsy proven or clinically suspected ovarian cancer (OC)<br>Women ≥18 years of age with ovarian cancer (OC) (clinically probable based on distribution of pelvic/abdominal masses on imaging, elevated CA-125, ascites, and/or imaging-guided biopsy proven) presenting for neoadjuvant chemotherapy or primary surgical management (debulking or staging) of their OC. The umbrella of OC also includes fallopian tube cancer and primary peritoneal cancer. All histologies are eligible for enrollment. | Diagnostic Test: Tampon Collection<br>* A tampon will be self-inserted by each participant prior to any exams or procedures and removed after 40 minutes..<br>* Other names: Vaginal Fluid;Diagnostic Test: Blood Collection<br>* A blood sample will be collected from each participant prior to undergoing any exams or procedures.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Develop predictive models from a panel of EC-specific MDMs and validate their performance in identifying underlying EC and AEH within tampon-collected vaginal fluid in a larger, more diverse cohort. | Complete a phase II biomarker development study of a methylated DNA marker (MDM)-based endometrial cancer detection test performed on vaginal fluid collected via intravaginal tampon. The phase II aspect of this biomarker development study will narrow the number of endometrial cancer MDMs within the biomarker panel in order to optimize the next phase of test development. | 18 months | 
| Develop predictive models from a panel of OC-specific MDMs and validate their performance in identifying underlying OC within tampon-collected vaginal fluid and plasma in a larger, more diverse cohort. | Complete a phase II biomarker development study of a methylated DNA marker (MDM)-based ovarian cancer detection test performed on vaginal fluid collected via intravaginal tampon. The phase II aspect of this biomarker development study will narrow the number of ovarian cancer MDMs within the biomarker panel in order to optimize the next phase of test development. | 18 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Using 95% specificity cutoffs of the final tampon-based MDM EC panel, determine the false positive rate among women undergoing surgical removal of common benign gynecologic pathology | As part of this biomarker test development, understanding whether common non-cancerous uterine or gynecologic conditions may also lead to the finding of currently apparent endometrial cancer-specific MDMs in vaginal fluid is critical in determining specificity, positive predictive value, and negative predictive value of the test. | 18 months |