NEW YORK – UK-based liquid biopsy company Nonacus has been focused on non-invasive disease detection from its inception, taking its name from the Latin phrase meaning "no needle."
Although its initial products were in the prenatal health space, it soon realized most of its customers were using their technology for oncology applications, CEO Chris Sale said. Once Nonacus realized this, the firm crafted a research and development plan to build out its liquid biopsy platform – encompassing wet laboratory products, informatics, and analysis – and transition the firm's attention to cancer detection.
Its flagship test under that new focus, Galeas Bladder, launched globally earlier this month, was developed in collaboration with researchers at the University of Birmingham. Using patients' urine samples, the liquid biopsy test is intended to reduce the number of cystoscopies performed to diagnose bladder cancer, Andrew Feber, the firm's clinical director of R&D, noted. The foremost indication for a cystoscopy is blood in a patient's urine, but the procedure is expensive, invasive, and uncomfortable, he said, adding only about 10 percent of patients who undergo cystoscopies in the UK have bladder cancer, making majority of cystoscopies uninformative.
The company's goal was to develop a test to triage those patients and more rapidly identify patients with bladder cancer while also "providing a level of certainty" for those patients who don't have bladder cancer, Feber said. Nanacus also wanted to make the test as accessible as possible, and using urine provided a non-invasive sample type that patients can collect at home and send to a reference laboratory to perform the test.
In previous research, collaborators at the University of Birmingham used deep sequencing to identify more than 400 recurrent alterations in 23 genes that can identify about 96 percent of bladder cancers. The team built on that research to develop a next-generation sequencing-based panel that uses Nonacus' capture technology to analyze those markers, Feber said.
In a paper published last year in European Urology Oncology, the biomarker panel had an overall sensitivity of 87 percent and specificity of 85 percent in 591 samples from patients with hematuria, or blood in the urine, although those numbers varied slightly based on disease grade and stage. Sensitivity was 71 percent for patients with grade 1 bladder cancer, 87 percent for those with grade 2, and 97 percent for those with grade 3. For the paper, the libraries were sequenced on an Illumina NovaSeq platform.
The firm developed its library preparation and capture technologies in house, with a focus on low input and the goal of making sure as many copies of cell free DNA went into the end assay as possible, Sale said. While the company's platform also allows for the extraction of urinary cell-free DNA and was originally built for that purpose, Feber said, the Galeas bladder cancer panel utilizes cell pellet DNA instead because a lower percentage of urine samples overall yield enough cell-free DNA to run the assay.
The company has also developed its Galeas analysis software, which generates a report on the likeliness of bladder cancer based on the sequencing data from the sample.
Aadel Chaudhuri, an assistant professor of radiation oncology at Washington University School of Medicine in St. Louis who was not involved in the development of the test, said via email that urine is a "highly practical analyte" and that its "proximity to the bladder epithelium" gives urine-based tumor DNA analysis a "natural boost in sensitivity for localized bladder cancer compared to blood plasma."
However, he noted that studies suggest that urine cell-free DNA is more sensitive than pellet for detecting mutations that are present at lower variant allele fractions.
Chaudhuri also said that while the test "appears highly feasible and is more practical than standard cystoscopy" and the performance is strong, it might not be strong enough for clinical application and may be outperformed by other targeted hybrid capture assays, such as uCAPP-Seq, a high-throughput sequencing test developed by researchers at Stanford University.
Although Nonacus is initially focusing its marketing on early cancer detection, Feber noted that the technology has other applications in bladder cancer as well. Non-muscle invasive bladder cancer, the most common subtype, is unlikely to be fatal but often recurs, and in those patients the test can be moved out of the diagnostic realm and into surveillance and monitoring, he said. For patients with muscle-invasive bladder cancer, where the treatment often involves bladder removal, the test could be used to monitor minimal residual disease post-surgery and the response of a patient to different therapies.
Most of the firm's data is for the early detection of hematuria, which is why the company is focusing on that use case first, but it aims to build out its data in other settings over the next year, Feber said. It is also planning to submit the test for CE-IVD marking, but in the meantime it is commercializing the assay as a laboratory-developed test being run in its laboratory with the option for technology transfers so it can be performed in reference labs across the world. Sale noted that the company first wants to "enable as many laboratories [as possible] that are interested" to run the test, and then plans to aim for regulatory approvals in Europe and the US in the near future.
"We recognize that to be competitive in this space, ultimately we’re going to need a CE-marked test," Feber added. The company is also looking for partners to help provide access to the test across different territories.
Despite the aim to broaden its data for other settings, Nonacus is also running a clinical trial to collect additional data on its test's efficacy for early detection in hematuria patients, Feber said.
Future products utilizing Nonacus' technology are also in the works, with plans for more urine-based tests as well as blood-based assays, Feber said. Right now, the company is "looking at how we can exploit our urine-based assay to its best capabilities," with an emphasis on other urinary tract cancers, such as uterine and renal cancers. However, the technology is "cancer agnostic," meaning it can be used to analyze DNA from any source and apply to cancers where urine may not be the best sample type, so the company isn't ruling anything out for the future, he said. It is also looking at other indications in therapy monitoring through cell free DNA, he added.
The liquid biopsy market has exploded in recent years: major companies like Guardant Health, Natera, and NeoGenomics are carving out their own niches in the space, although much of their focus is on blood-based testing. But urine has also proven to be a popular sample type, as California-based firm Predicine received CE-IVD marking last year for its blood and urine liquid biopsy test and other firms, including Israeli startup Nucleix, Chinese company Prophet Genomics, and Swedish firm Elypta continue to develop urine-based tests for a variety of cancers. Meantime, Qiagen is working with Bio-Techne subsidiary Exosome Diagnostics to detect bladder cancer mutations in urine samples using digital PCR and exosome-based liquid biopsy.
Chaudhuri noted there are also commercially available tests for bladder cancer detection that use urine as a sample type, including Abbott's UroVysion Bladder Cancer Kit, which uses fluorescence in situ hybridization to detect certain chromosomal aneuploidies; Pacific Edge's Cxbladder, an RT-qPCR based suite of tests measuring five biomarkers combined with other clinical information; and Cepheid's Xpert Bladder Cancer Detection, which runs on the firm's GeneXpert platform and measures five mRNA targets in patients with hematuria.
He added that other researchers have also used cell pellets for urothelial cancers: a team including researchers from Howard Hughes Medical Institute, Johns Hopkins University, and Stony Brook University developed the uroSEEK test, which uses parallel sequencing assays for mutations in 11 genes and copy number changes on 39 chromosome arms.
Feber acknowledged that it is a "fast-paced and competitive market," but said that Nonacus is looking to distinguish itself by facilitating testing around the world and beyond wealthy nations by offering the test to other labs and ensuring testing doesn't have to be performed at one central laboratory. The goal is not to make the test "as cheap as possible, but to make it as accessible as possible while maintaining the sensitivity, specificity, and quality needed for clinical utility."
Galeas Bladder is intended to be cheaper than a cystoscopy, which tends to cost about £500 ($610) in the UK and range from $300 to $1,000 in the US. The company also aims to offer the test at a price lower than those offered by major competitors like Natera and Guardant, he said.
When the test is brought to the market in the US, the firm plans to seek reimbursement from major insurers in addition to offering the test via out-of-pocket provision, Sale said.
Although the test is still in its early days of commercialization, in Feber's view, the increasing pressure on clinicians and clinics performing cystoscopies will make the need for the assay obvious. "Using a test like this, we can not only identify patients quicker, but we can improve the patient pathway," he said.