Early ctDNA dynamics as a surrogate for progression-free survival in advanced breast cancer in the BEECH trial.

BACKGROUND: Dynamic changes in circulating tumour DNA (ctDNA) levels may predict long-term outcome. We utilised samples from a phase I/II randomised trial (BEECH) to assess ctDNA dynamics as a surrogate for progression-free survival (PFS) and early predictor of drug efficacy. PATIENTS AND METHODS: Patients with estrogen receptor-positive advanced metastatic breast cancer (ER+ mBC) in the BEECH study, paclitaxel plus placebo versus paclitaxel plus AKT inhibitor capivasertib, had plasma samples collected for ctDNA analysis at baseline and at multiple time points in the development cohort (safety run-in, part A) and validation cohort (randomised, part B). Baseline sample ctDNA sequencing identified mutations for longitudinal analysis and mutation-specific digital droplet PCR (ddPCR) assays were utilised to assess change in ctDNA abundance (allele fraction) between baseline and 872 on-treatment samples. Primary objective was to assess whether early suppression of ctDNA, based on pre-defined criteria from the development cohort, independently predicted outcome in the validation cohort. RESULTS: In the development cohort, suppression of ctDNA was apparent after 8 days of treatment (P = 0.014), with cycle 2 day 1 (4 weeks) identified as the optimal time point to predict PFS from early ctDNA dynamics. In the validation cohort, median PFS was 11.1 months in patients with suppressed ctDNA at 4 weeks and 6.4 months in patients with high ctDNA (hazard ratio = 0.20, 95% confidence interval 0.083-0.50, P < 0.0001). There was no difference in the level of ctDNA suppression between patients randomised to capivasertib or placebo overall (P = 0.904) nor in the PIK3CA mutant subpopulation (P = 0.071). Clonal haematopoiesis of indeterminate potential (CHIP) was evident in 30% (18/59) baseline samples, although CHIP had no effect on tolerance of chemotherapy nor on PFS. CONCLUSION: Early on-treatment ctDNA dynamics are a surrogate for PFS. Dynamic ctDNA assessment has the potential to substantially enhance early drug development. CLINICAL REGISTRATION NUMBER: NCT01625286.

An evaluation of the challenges to developing tumor BRCA1 and BRCA2 testing methodologies for clinical practice.

Ovarian cancer patients with germline or somatic pathogenic variants benefit from treatment with poly ADP ribose polymerase (PARP) inhibitors. Tumor BRCA1/2 testing is more challenging than germline testing as the majority of samples are formalin-fixed paraffin embedded (FFPE), the tumor genome is complex, and the allelic fraction of somatic variants can be low. We collaborated with 10 laboratories testing BRCA1/2 in tumors to compare different approaches to identify clinically important variants within FFPE tumor DNA samples. This was not a proficiency study but an inter-laboratory comparison to identify common issues. Each laboratory received the same tumor DNA samples ranging in genotype, quantity, quality, and variant allele frequency (VAF). Each laboratory performed their preferred next-generation sequencing method to report on the variants. No false positive results were reported in this small study and the majority of methods detected the low VAF variants. A number of variants were not detected due to the bioinformatics analysis, variant classification, or insufficient DNA. The use of hybridization capture or short amplicon methods are recommended based on a bioinformatic assessment of the data. The study highlights the importance of establishing standards and standardization for tBRCA testing particularly when the test results dictate clinical decisions regarding life extending therapies.

Effect of different alcohols on stratum corneum kallikrein 5 and phospholipase A2 together with epidermal keratinocytes and skin irritation.

OBJECTIVES: The aim of this exploratory study was to investigate the effect of ethanol, isopropanol and n-propanol on stratum corneum (SC) enzymes and keratinocytes in vitro together with their effects on skin condition and function. METHODS: Activities of kallikrein 5 (KLK5) and phospholipase A2 (PLA2) as well as keratinocyte metabolic activity, interleukin-1α (IL-1α) and tumor necrosis factor-α (TNF-α) were measured in vitro in the presence and absence of the different alcohols. We also measured transepidermal water loss (TEWL), skin capacitance, visual dryness and visual redness on the volar forearms of 25 Caucasian women following application of the alcohols 20 and 100 times per day over a period of 14 days in a clinical study. RESULTS: Reduced activities of KLK5 and PLA2 were observed in the presence of the alcohols. The greatest denaturing effect was always observed for n-propanol (P < 0.001), and in the case of PLA2, the effect of isopropanol was greater than ethanol (P < 0.001). Equally, ethanol had the mildest effects on keratinocyte metabolic activity and cytokine secretion (P < 0.001) and n-propanol always produced the most severe changes in normal and differentiated keratinocytes. These in vitro findings supported the clinical results where the major effects were on the induction of skin irritation (increased dropout rates) and ranked the intolerance of the different alcohols as follows: n-propanol > isopropanol > ethanol. At the high application frequencies, the effect of the different alcohols on transepidermal water loss (TEWL) and skin capacitance was similar, but at the low application frequencies, n-propanol had a significant effect on TEWL and capacitance values (P < 0.05). Equally, n-propanol and isopropanol produced significantly more skin redness at the low application frequencies. CONCLUSIONS: Clearly, isopropanol and n-propanol caused significant SC and keratinocyte perturbation in vitro together with damage to skin condition and function in vivo whereas ethanol did not. As a result, we show that ethanol-based sanitizers are better tolerated by skin, particularly in high-use settings, than other alcohols and should be the active ingredient of choice.

The National Lung Matrix Trial: translating the biology of stratification in advanced non-small-cell lung cancer.

BACKGROUND: The management of NSCLC has been transformed by stratified medicine. The National Lung Matrix Trial (NLMT) is a UK-wide study exploring the activity of rationally selected biomarker/targeted therapy combinations. PATIENTS AND METHODS: The Cancer Research UK (CRUK) Stratified Medicine Programme 2 is undertaking the large volume national molecular pre-screening which integrates with the NLMT. At study initiation, there are eight drugs being used to target 18 molecular cohorts. The aim is to determine whether there is sufficient signal of activity in any drug-biomarker combination to warrant further investigation. A Bayesian adaptive design that gives a more realistic approach to decision making and flexibility to make conclusions without fixing the sample size was chosen. The screening platform is an adaptable 28-gene Nextera next-generation sequencing platform designed by Illumina, covering the range of molecular abnormalities being targeted. The adaptive design allows new biomarker-drug combination cohorts to be incorporated by substantial amendment. The pre-clinical justification for each biomarker-drug combination has been rigorously assessed creating molecular exclusion rules and a trumping strategy in patients harbouring concomitant actionable genetic abnormalities. Discrete routes of pathway activation or inactivation determined by cancer genome aberrations are treated as separate cohorts. Key translational analyses include the deep genomic analysis of pre- and post-treatment biopsies, the establishment of patient-derived xenograft models and longitudinal ctDNA collection, in order to define predictive biomarkers, mechanisms of resistance and early markers of response and relapse. CONCLUSION: The SMP2 platform will provide large scale genetic screening to inform entry into the NLMT, a trial explicitly aimed at discovering novel actionable cohorts in NSCLC. CLINICAL TRIAL ISRCTN: 38344105.

Cost-effectiveness analysis of health tapestry, a complex primary care program for older adults: a post-hoc analysis.

BACKGROUND: We initially reported on the cost-effectiveness of a 6-month randomized controlled implementation trial which evaluated Health TAPESTRY, a primary care program for older adults, at the McMaster Family Health Team (FHT) site and 5 other FHT sites in Ontario, Canada. While there were no statistically significant between-group differences in outcomes at month 6 post randomization, positive outcomes were observed at the McMaster FHT site, which recruited 40% (204/512) of the participants. The objective of this post-hoc study was to determine the cost-effectiveness of Health TAPESTRY based on data from the McMaster FHT site. METHODS: Costs included the cost to implement Health TAPESTRY at McMaster as well as healthcare resource consumed, which were costed using publicly available sources. Health-related-quality-of-life was evaluated with the EQ-5L-5L at baseline and at month 6 post randomization. Quality-adjusted-life-years (QALYs) were calculated under an-area-under the curve approach. Unadjusted and adjusted regression analyses (two independent regression analyses on costs and QALYs, seemingly unrelated regression [SUR], net benefit regression) as well as difference-in-difference and propensity score matching (PSM) methods, were used to deal with the non-randomized nature of the trial. Sampling uncertainty inherent to the trial data was estimated using non-parametric bootstrapping. The return on investment (ROI) associated with Health TAPESTRY was calculated. All costs were reported in 2021 Canadian dollars. RESULTS: With an intervention cost of $293/patient, Health TAPESTRY was the preferred strategy in the unadjusted and adjusted analyses. The results of our bootstrap analyses indicated that Health TAPESTRY was cost-effective compared to usual care at commonly accepted WTP thresholds. For example, if decision makers were willing to pay $50,000 per QALY gained, the probability of Health TAPESTRY to be cost effective compared to usual care varied from 0.72 (unadjusted analysis) to 0.96 (SUR) when using a WTP of $50,000/QALY gained. The DID and ROI analyses indicated that Health Tapestry generated a positive ROI. CONCLUSION: Health TAPESTRY was the preferred strategy when implemented at the McMaster FHT. We caution care in interpreting the results because of the post-hoc nature of the analyses and limited sample size based on one site.

Serial monitoring of genomic alterations in circulating tumor cells of ER-positive/HER2-negative advanced breast cancer: feasibility of precision oncology biomarker detection.

Nearly all estrogen receptor (ER)-positive (POS) metastatic breast cancers become refractory to endocrine (ET) and other therapies, leading to lethal disease presumably due to evolving genomic alterations. Timely monitoring of the molecular events associated with response/progression by serial tissue biopsies is logistically difficult. Use of liquid biopsies, including circulating tumor cells (CTC) and circulating tumor DNA (ctDNA), might provide highly informative, yet easily obtainable, evidence for better precision oncology care. Although ctDNA profiling has been well investigated, the CTC precision oncology genomic landscape and the advantages it may offer over ctDNA in ER-POS breast cancer remain largely unexplored. Whole-blood (WB) specimens were collected at serial time points from patients with advanced ER-POS/HER2-negative (NEG) advanced breast cancer in a phase I trial of AZD9496, an oral selective ER degrader (SERD) ET. Individual CTC were isolated from WB using tandem CellSearch® /DEPArray™ technologies and genomically profiled by targeted single-cell DNA next-generation sequencing (scNGS). High-quality CTC (n = 123) from 12 patients profiled by scNGS showed 100% concordance with ctDNA detection of driver estrogen receptor α (ESR1) mutations. We developed a novel CTC-based framework for precision medicine actionability reporting (MI-CTCseq) that incorporates novel features, such as clonal predominance and zygosity of targetable alterations, both unambiguously identifiable in CTC compared to ctDNA. Thus, we nominated opportunities for targeted therapies in 73% of patients, directed at alterations in phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA), fibroblast growth factor receptor 2 (FGFR2), and KIT proto-oncogene, receptor tyrosine kinase (KIT). Intrapatient, inter-CTC genomic heterogeneity was observed, at times between time points, in subclonal alterations. Our analysis suggests that serial monitoring of the CTC genome is feasible and should enable real-time tracking of tumor evolution during progression, permitting more combination precision medicine interventions.

Muscle gene expression associated with increased marbling in beef cattle.

The objective of this study was to identify specific bovine genes expressed within skeletal muscle that are associated with intramuscular fat deposition. Twenty-eight Angus-Simmental cross steers and heifers were harvested at the University of Illinois Meat Science Laboratory. Four pairs of animals were identified based on similar adjusted backfat thickness but differing amounts of intramuscular fat within each pair. RNA was extracted from muscle samples devoid of visible fat and microarray analysis was performed. Based on this analysis, 9 genes were selected and expression was subsequently confirmed by qPCR. Expression levels of MYH3, HOXD10, MXRA8, and CASQ2 were increased in animals with high marbling, whereas levels of NPNT, MRC1, DNER, and CYPB4 were decreased in high marbled animals. The remaining gene, ACTN2 was determined to be a false positive and was, therefore, excluded from further study. Despite the positive results of the preliminary study, associations between gene expression and intramuscular fat content did not extend to the larger population of cattle. A significant negative association existed between expression of MRC1 and marbling level (P = 0.04). Therefore, this study was unable to identify a particular skeletal muscle gene set whose expression correlated well with marbling levels in the larger population of beef cattle.

Homologous Recombination Repair Gene Mutation Characterization by Liquid Biopsy: A Phase II Trial of Olaparib and Abiraterone in Metastatic Castrate-Resistant Prostate Cancer.

BACKGROUND: Phase III randomized trial data have confirmed the activity for olaparib in homologous recombination repair (HRR) mutated metastatic castration-resistant prostate cancer (mCRPC) post next-generation hormonal agent (NHA) progression. Preclinical data have suggested the potential for a combined effect between olaparib and NHAs irrespective of whether an HRR gene alteration was present. NCT01972217 was a randomised double-blind Phase II study which evaluated olaparib and abiraterone versus placebo and abiraterone in mCRPC patients who had received prior chemotherapy containing docetaxel. The study showed that radiologic progression was significantly delayed by the combination of olaparib and abiraterone regardless of homologous recombination repair mutation (HRRm) status. The study utilized tumour, blood (germline), and circulating tumour DNA (ctDNA) analysis to profile patient HRRm status, but tumour tissue provision was not mandated, leading to relatively low tissue acquisition and DNA sequencing success rates not representative of real-world testing. PATIENTS AND METHODS: Further analysis of germline and ctDNA samples has been performed for the trial to characterize HRRm status more fully and robustly analyse patient response to treatment. RESULTS: Germline and plasma testing increased the HRRm characterized population from 27% to 68% of 142 randomized patients. Tumour-derived variants were detectable with high confidence in 78% of patients with a baseline plasma sample (71% of randomized patients). There was high concordance across methodologies (plasma vs. tumour; plasma vs. germline). The HR for the exploratory analysis of radiographic progression-free survival was 0.54 (95% CI: 0.32-0.93) in favour of olaparib and abiraterone in the updated HRR wild type (HRRwt) group (n = 73) and 0.62 (95% CI: 0.23-1.65) in the HRRm group (n = 23). CONCLUSION: Our results confirm the value of plasma testing for HRRm status when there is insufficient high-quality tissue for multi-gene molecular testing. We show that patients with mCRPC benefit from the combination of olaparib and abiraterone treatment regardless of HRRm status. The combination is currently being further investigated in the Phase III PROpel trial.

Selective AKT kinase inhibitor capivasertib in combination with fulvestrant in PTEN-mutant ER-positive metastatic breast cancer.

Five to ten percent of ER+ metastatic breast cancer (MBC) tumors harbor somatic PTEN mutations. Loss of function of this tumor-suppressor gene defines a highly aggressive, treatment-refractory disease for which new therapies are urgently needed. This Phase I multipart expansion study assessed oral capivasertib with fulvestrant in patients with PTEN-mutant ER+ MBC. Safety and tolerability were assessed by standard methods. Plasma and tumor were collected for NGS and immunohistochemistry analyses of PTEN protein expression. In 31 eligible patients (12 fulvestrant naive; 19 fulvestrant pretreated), the 24-week clinical benefit rate was 17% in fulvestrant-naive and 42% in fulvestrant-pretreated patients, with objective response rate of 8% and 21%, respectively. Non-functional PTEN was centrally confirmed in all cases by NGS or immunohistochemistry. Co-mutations occurred in PIK3CA (32%), with less ESR1 (10% vs 72%) and more TP53 (40% vs 28%) alterations in fulvestrant-naive versus fulvestrant-pretreated patients, respectively. PTEN was clonally dominant in most patients. Treatment-related grade ≥3 adverse events occurred in 32% of patients, most frequently diarrhea and maculopapular rash (both n = 2). In this clinical study, which selectively targeted the aggressive PTEN-mutant ER+ MBC, capivasertib plus fulvestrant was tolerable and clinically active. Phenotypic and genomic differences were apparent between fulvestrant-naive and -pretreated patients.Trial registration number for the study is NCT01226316.

Profiling of Circulating Free DNA Using Targeted and Genome-wide Sequencing in Patients with SCLC.

INTRODUCTION: SCLC accounts for approximately 250,000 deaths worldwide each year. Acquisition of adequate tumor biopsy samples is challenging, and liquid biopsies present an alternative option for patient stratification and response monitoring. METHODS: We applied whole genome next-generation sequencing to circulating free DNA (cfDNA) from 39 patients with limited-stage (LS) SCLC and 30 patients with extensive-stage SCLC to establish genome-wide copy number aberrations and also performed targeted mutation analysis of 110 SCLC associated genes. Quantitative metrics were calculated for copy number aberrations, including percent genome amplified (PGA [the percentage of genomic regions amplified]), Z-score (a measure of standard deviation), and Moran's I (a measure of spatial autocorrelation). In addition CellSearch, an epitope-dependent enrichment platform, was used to enumerate circulating tumor cells (CTCs) from a parallel blood sample. RESULTS: Genome-wide and targeted cfDNA sequencing data identified tumor-related changes in 94% of patients with LS SCLC and 100% of patients with extensive-stage SCLC. Parallel analysis of CTCs based on at least 1 CTC/7.5 mL of blood increased tumor detection frequencies to 95% for LS SCLC. Both CTC counts and cfDNA readouts correlated with disease stage and overall survival. CONCLUSIONS: We demonstrate that a simple cfDNA genome-wide copy number approach provides an effective means of monitoring patients through treatment and show that targeted cfDNA sequencing identifies potential therapeutic targets in more than 50% of patients. We are now incorporating this approach into additional studies and trials of targeted therapies.

Radio rotation period of jupiter.

The results of observations of Jupiter at 18 megacycles per second indicate that the apparent rotation period drifts cyclically about a constant mean value. The most probable drift period appears to be 11.9 years, Jupiter's orbital period. The mean rotation period during one orbital period is about 0.3 second longer than that of the system III (1957.0) period. This is in close agreement with the rotation period deduced from decimetric observations and probably represents the true rotation period of the magnetic field. The cyclic drift in the rotation period of source A at 18 megacycles per second is explained on the basis of beaming of the escaping radiation at an angle 6 degrees north of the magnetic equator. The apparent rotation period of source A depends on the rate of change of the Jovicentric declination of Earth.

Planetary radio astronomy observations from voyager 1 near saturn.

The Voyager 1 planetary radio astronomy experiment detected two distinct kinds of radio emissions from Saturn. The first, Saturn kilometric radiation, is strongly polarized, bursty, tightly correlated with Saturn's rotation, and exhibits complex dynamic spectral features somewhat reminiscent of those in Jupiter's radio emission. It appears in radio frequencies below about 1.2 megahertz. The second kind of radio emission, Saturn electrostatic discharge, is unpolarized, extremely impulsive, loosely correlated with Saturn's rotation, and very broadband, appearing throughout the observing range of the experiment (20.4 kilohertz to 40.2 megahertz). Its sources appear to lie in the planetary rings.

Planetary radio astronomy observations from voyager 2 near jupiter.

The Voyager 2 Planetary Radio Astronomy experiment to Jupiter has confirmed and extended to higher zenomagnetic latitudes results from the identical experiment carried by Voyager 1. The kilometric emissions discovered by Voyager 1 often extended to 1 megahertz or higher on Voyager 2 and often consisted of negatively or, less frequently, positively drifting narrowband bursts. On the basis of tentative identification of plasma wave emissions similar to those detected by Voyager 1, the plasma torus associated with Io appeared somewhat denser to Voyager 2 than it did to Voyager 1. We report here on quasiperiodic sinusoidal or impulsive bursts in the broadcast band range of wavelengths (800 to 1800 kilohertz). A Faraday effect appears at decametric frequencies, which probably results from propagation of the radiation near its sources on Jupiter. Finally, we discuss the occurrence of decametric emission in homologous arc families.

Voyager 1 planetary radio astronomy observations near jupiter.

We report results from the first low-frequency radio receiver to be transported into the Jupiter magnetosphere. We obtained dramatic new information, both because Voyager was near or in Jupiter's radio emission sources and also because it was outside the relatively dense solar wind plasma of the inner solar system. Extensive radio spectral arcs, from above 30 to about 1 megahertz, occurred in patterns correlated with planetary longitude. A newly discovered kilometric wavelength radio source may relate to the plasma torus near Io's orbit. In situ wave resonances near closest approach define an electron density profile along the Voyager trajectory and form the basis for a map of the torus. Detailed studies are in progress and are out-lined briefly.

Voyager 2 radio observations of uranus.

Within distances to Uranus of about 6 x 10(6) kilometers (inbound) and 35 x 10(6) kilometers (outbound), the planetary radio astronomy experiment aboard Voyager 2 detected a wide variety of radio emissions. The emission was modulated in a period of 17.24 +/- 0.01 hours, which is identified as the rotation period of Uranus' magnetic field. Of the two poles where the axis of the off-center magnetic dipole (measured by the magnetometer experiment aboard Voyager 2) meets the planetary surface, the one closer to dipole center is now located on the nightside of the planet. The radio emission generally had maximum power and bandwidth when this pole was tipped toward the spacecraft. When the spacecraft entered the nightside hemisphere, which contains the stronger surface magnetic pole, the bandwidth increased dramatically and thereafter remained large. Dynamically evolving radio events of various kinds embedded in these emissions suggest a Uranian magnetosphere rich in magnetohydrodynamic phenomena.

Voyager planetary radio astronomy at neptune.

Detection of very intense short radio bursts from Neptune was possible as early as 30 days before closest approach and at least 22 days after closest approach. The bursts lay at frequencies in the range 100 to 1300 kilohertz, were narrowband and strongly polarized, and presumably originated in southern polar regions ofthe planet. Episodes of smooth emissions in the frequency range from 20 to 865 kilohertz were detected during an interval of at least 10 days around closest approach. The bursts and the smooth emissions can be described in terms of rotation in a period of 16.11 +/- 0.05 hours. The bursts came at regular intervals throughout the encounter, including episodes both before and after closest approach. The smooth emissions showed a half-cycle phase shift between the five episodes before and after closest approach. This experiment detected the foreshock of Neptune's magnetosphere and the impacts of dust at the times of ring-plane crossings and also near the time of closest approach. Finally, there is no evidence for Neptunian electrostatic discharges.

Hyperamylasaemia in ureteric colic.

Hyperamylasaemia is classically associated with acute pancreatitis. Hyperamylasaemia may be associated with many other clinical conditions. However, ureteric colic has never been reported to cause hyperamylasaemia. We describe a 47-year-old woman who presented with an atypical history of left ureteric colic. Radiological investigations confirmed an upper ureteric stone with urinary extravasation. At presentation, the serum amylase was elevated but normalised after 24 h. In conclusion, ureteric colic may cause hyperamylasaemia and this is likely a result of pancreatic irritation due to urinary extravasation. Patients presenting with ureteric colic and elevated concentrations of serum amylase should raise the clinical suspicion of urinary extravasation.

The relationship of carcass measurements to carcass composition and intramuscular fat in Spanish beef.

Forty beef carcasses were classified for conformation and fatness. Besides, carcass weight, fat thickness (FT), carcass dimension, marbling by computer image analysis and ultrasound readings was recorded to complement grading. For predicting intramuscular fat (IMF) content, FT, number of intramuscular flecks and conformation increased R(2)-value from 0.19 to 0.64 compared to conformation alone. For visual marbling, ultrasound readings and thoracic depth (TD) increased the R(2)-value from 0.24 to 0.57 compared to fatness score (FS). The best variables for predicting weight of fabricated subprimals were carcass weight or compactness which is a function of carcass weight (R(2) between 0.94 and 0.63). Fatness score was poorer than FT for predicting yield of subprimals cuts from round (R(2)=0.16 vs. 0.50) and ultrasound readings for less valuable subprimals (R(2)=0.31 vs. 0.39). These results showed that other variables could be used in combination with carcass fatness or conformation to achieve a more accurate estimation of fat and carcass yield.

Characterization of striping in fresh, enhanced pork loins.

To investigate the striping phenomenon in fresh, enhanced pork, a series of experiments were undertaken to identify possible causes of the problem. No one factor (individual brine components, brine pH, ingredient concentration, enhancement pressure, meat and brine pH, or enhancement level) was specifically identified, which could be used to reduce the severity of the striping problem. Furthermore, tumbling the product for 2h, did not reduce the amount of striping, indicating once striping has occurred, it is permanent. Evaluation of the striping pattern indicates that the stripes are formed not only at the needle injection site, but also follow the muscle fiber orientation. The use of darker pork provided more of a contrast when evaluating striping, thus exacerbating the perceived level of striping.

Optimisation of robust singleplex and multiplex droplet digital PCR assays for high confidence mutation detection in circulating tumour DNA.

Liquid biopsies offer the potential to monitor cancer response and resistance to therapeutics in near real-time. However, the plasma cell free DNA (cfDNA) level can be low and the fraction of circulating tumour DNA (ctDNA) bearing a mutation - lower still. Detection of tumour-derived mutations in ctDNA is thus challenging and requires highly sensitive and specific assays. Droplet digital PCR (ddPCR) is a technique that enables exquisitely sensitive detection and quantification of DNA/RNA markers from very limiting clinical samples, including plasma. The Bio-Rad QX200 ddPCR system provides absolute quantitation of target DNA molecules using fluorescent dual-labelled probes. Critical to accurate sample analysis are validated assays that are highly specific, reproducible, and with known performance characteristics, especially with respect to false positives. We present a systematic approach to the development and optimisation of singleplex and multiplex ddPCR assays for the detection of point mutations with a focus on ensuring extremely low false positives whilst retaining high sensitivity. We also present a refined method to determine cfDNA extraction efficiency allowing for more accurate extrapolation of mutational levels in source samples. We have applied these approaches to successfully analyse many ctDNA samples from multiple clinical studies and generated exploratory data of high quality.