Table 2.

Main ongoing clinical trials (N = 21) investigating the role of interventional circulating tumour DNA (ctDNA) to drive treatment decision-making in colorectal cancer (CRC) patients according to different clinical settings, suggesting potential future applications and developments.

Study (Code Identifiers) Location	Trial design Status	Estimated enrolment (N pts) ctDNA analysis	Main characteristics and inclusion criteria
Post-surgical resection with curative intent
PEGASUS (NCT04259944) Italy–Spain	Phase IIa Recruiting	140 LUNAR1 panel	• Resected stage III or T4N0 stage II colon cancer • ctDNA-guided adjuvant treatment: initially those ctDNA-positive will receive CAPOX while those negative capecitabine monotherapy; following treatment will be tailored on following ctDNA reassessment
OPTIMIZE (NCT04680260) Denmark	Randomised Phase II Not yet recruiting	350 NA	• Radical intended treatment for metastatic CRC with no evidence of further disease • Clinically eligible for adjuvant chemotherapy • ctDNA-guided post-surgical treatment
DYNAMIC-II (ACTRN12615000381 583) Australia	Phase III Recruiting	450 NA	• Resected stage II CRC • Pts will be randomly assigned to ctDNA treatment-guided group or not, and to those ctDNA-positive 5-FU will be given while to ctDNA-negative will be followed up
DYNAMIC-III trial (ACTRN12617001566325) Australia	Randomised Phase II/III	1000 NA	• Resected stage III colon cancer • ctDNA-negative pts in experimental arm will be de-escalated adjuvant treatment strategy and those ctDNA-positive will be escalated adjuvant treatment strategy; control will be treated as per SoC
MEDOCC-CrEATE (NL6281/NTR6455) Netherlands	Randomised TwiCs design Recruiting	1320 NGS PGDx elio panel	• Stage II colon cancer pts without indication for adjuvant treatment according to current guidelines • ctDNA-positive pts will be offered 8 cycles of adjuvant capecitabine plus oxaliplatin while ctDNA-negative pts and control group will be followed up
COBRA (NCT04068103 and NRG-GI005) USA	Phase II/III Recruiting	1408 LUNAR panel	• Stage IIA resected CRC • Pts in experimental arm II will receive adjuvant treatment (at investigator choice) if ctDNA-positive and surveillance if ctDNA-negative
IMPROVE-IT (NCT03748680) Denmark	Phase II randomised Recruiting	64 NA	• Stage I or II disease radically resected • Detectable ctDNA in post-operative plasma sample • No indication for adjuvant chemotherapy according to DCCG guidelines but standard adjuvant chemotherapy administered if ctDNA-positive
(NCT03436563) USA	Phase Ib/II Recruiting	74 NA	• Pts with detectable ctDNA following resection of all known liver metastases will receive treatment with an anti-PD-L1/TGFbetaRII Fusion Protein M7824 • Resected MSS metastatic CRC
ALTAIR (NCT04457297) Japan	Phase III Recruiting	240 Signatera panel	• Pts who undergone radical curative resection of the primary and metastatic tumours • Pts tested positive for ctDNA but with no evidence of disease at imaging will receive TAS-102 or placebo
VEGA (jRCT1031200006) Japan	Phase III Recruiting	1240 NA	• High‐risk stage II or low‐risk stage III (T1‐3 and N1) CRC, and ctDNA‐negative status at week 4 after surgery • Randomisation between surgery alone versus adjuvant CAPOX
BESPOKE (NCT04264702) USA	NA Recruiting	2000 Signatera panel	• Resected stage II or III colorectal cancer (CRC) • Pts may be recommended for adjuvant treatment or observation by their treating clinician
Neoadjuvant setting
SYNCOPE (NCT04842006) Finland	Randomised Not yet recruiting	93 NA	• LARC randomised to receive TNT using capecitabine/oxaliplatin and SCRT vs long course CRT using capecitabine • ctDNA and organoid-guided adjuvant therapy as experimental arm compared to SoC • Assessment of MRD after surgery and correlation with prognosis
Metastatic unresectable disease
(NCT03844620) USA	Phase II Recruiting	100 NA	• Pts clinically eligible for either regorafenib or trifluridin-tipiracil • Pts will continue treatment beyond 1st cycle depending on ctDNA results
(NCT04831528) China	Phase II Not yet recruiting	100 NA	• Pts must have failed after first-line treatment containing cetuximab • Individualised second-line targeted therapy based on ctDNA analysis
FOLICOLOR (NCT04735900) International	NA Recruiting	60 NPY Methylation	• Unresectable metastatic disease • Identification of PD by NPY Methylation in liquid biopsies • To assess response and progression to first-line FOLFOX/FOLFIRI treatment on liquid biopsy
NCT04509635 China	Phase III Not yet recruiting	50 NA	• RAS wt on ctDNA • Non-resectable liver metastases candidate to anti-EGFR rechallenge based on ctDNA results
LIBImAb (NCT04776655) Italy	Phase III Not yet recruiting	280 KRAS, NRAS and in BRAFV600 status assessment using the Idylla system (Biocartis)	• RAS/BRAF wt on solid tumour biopsy but with RAS mutant at liquid biopsy • To compare di efficacy of FOLFIRI + Cetuximab or Bevacizumab in tissue wt but liquid mutant RAS mCRC
NCT04224415 China	Phase II Not yet recruiting	35 RAS/BRAF status assessment	• First-line therapy of FOLFOX/FOLFIRI/FOLFOXIRI + Cetuximab effectively and the PFS is not less than 6 months • ≥4 months after the last time treated with Cetuximab • RAS/BRAF wt on ctDNA
PARERE (NCT04787341) Italy	Phase II Recruiting	214 IdyllaTM ctKRAS-NRAS-BRAF Mutation Test	• RAS and BRAF wt status of primary CRC or related metastasis • RAS and BRAF wt ctDNA at the time of screening • Previous first-line anti-EGFR-containing therapy with at least a PR or SD ≥ 6 months; ≥4 months elapsed between the end of first-line anti-EGFR administration and screening; ≥1 line of therapy between the end of first-line anti-EGFR administration and screening
NCT04775862 Saudi Arabia	Phase II Recruiting	60 RAS status assessment	• Baseline must be RAS/BRAF wt on solid tumour tissue • RAS wt on ctDNA • Tumour burden with <4 organ involvement
NCT03992456 USA	Phase II Recruiting	120 Guardant360 assay	• RAS and BRAF wt on tumour tissue taken from primary or metastatic site • PD after treatment with an anti-EGFR monoclonal antibody for at least 4 months • ≥ 90 days from the last anti-EGFR treatment • BRAF, EGFR, ERBB2, RAS, MET wt highest allele frequency reported for any gene mutation <2%

These studies were retrieved through an extensive search performed on ClinicalTrial.gov in October 2021. The Medical Subject Headings terms used were (“Colo-rectal Cancer” as condition/disease) and (“circulating tumor dna” as other terms).

ctDNA circulating tumour DNA, N number, pts patients, NA not available, CRC colorectal cancer, CAPOX capecitabine plus oxaliplatin, NGS next-generation sequencing, 5-FU 5-fluorouracil, SoC standard of care, DCCG Dutch Colorectal Cancer Group, LARC locally advanced rectal cancer, SCRT short course radiotherapy, CRT chemoradiotherapy, MRD minimal residual disease, FOLFOX 5-fluorouracil plus oxaliplatin, TNT total neoadjuvant treatment, cCR clinical complete response, PD progressive disease, MSS microsatellite stable, NPY Neuropeptide Y, wt wild-type.

^aMatched historical control 1:3 with TOSCA trial patients.