Science or Scam?

Plus a Short Case Study

Case Study: Uric acid Request Objectives Specimen on Ice? 1. Interpret low uric acid levels when using these levels to monitor particular 2nd shift – green top tube on ice drug therapy. uric acid requested 2. Discuss the history and current status of the company/laboratory Theranos – what do we know about testing using a Physician contacted for reason single drop of blood.

Case Study: Uric acid Request Select Lab Results Specimen on Ice? Time/Day Uric Acid Ca Phos K

0 8.6 10.2 3.3 3.8 Patient: 9 y/o female with lymphoblastic lymphoma being treated with 0600/1 6.2 9.4 3.4 3.0

rasbuticase to prevent tumor lysis 1900/2 1.7 6.7 8.2 3.7 syndrome (TLS) during chemotherapy /3 0.8 8.8 6.2 4.2

Ref range 3.4-7.0 8.8-10.8 3.0-5.4 3.3-4.5

1 Questions What is TLS? Tumor Lysis Syndrome What is TLS and what are lab results observed? Life threatening condition

What is rasburicase? Chemotherapy causes massive release of intracellular contents Why was the sample submitted on ice? into bloodstream

TLS--What Lab Results Select Lab Results

Typically Observed? Time/Day Uric Acid Ca Phos K

Hyperuricemia 0 8.6 10.2 3.3 3.8 Hyperkalemia 0600/1 6.2 9.4 3.4 3.0

Hyperphosphatemia 1900/2 1.7 6.7 8.2 3.7

Hypocalcemia /3 0.8 8.8 6.2 4.2

Often causes acute renal failure Reference 3.4-7.0 8.8-10.8 3.0-5.4 3.3-4.5 Range

What Is Rasburicase? Monitoring Rasburicase

Drug given to convert serum uric acid to Measure uric acid in rasburicase-treated more soluble allantoin thereby reducing patients risk of uric acid crystal & stone formation To ensure that the drug is working A recombinant urate oxidase

2 Why Was Specimen Select Lab Results Submitted on Ice? Time/Day Uric Acid Ca Phos K

0 8.6 10.2 3.3 3.8 Drug continues to oxidize uric acid in 0600/1 6.2 9.4 3.4 3.0 blood after sample collected

1900/2 1.7 6.7 8.2 3.7

/3 0.8 8.8 6.2 4.2 Ice minimizes uric acid destruction after collection Reference 3.4-7.0 8.8-10.8 3.0-5.4 3.3-4.5 Range Reference: Platteborze PL & Wilhelms KW. Request for Uric Acid Analysis on an Iced Specimen. Clin Chem 2015, 61:9; 1212-1213.

THERANOS: SCIENCE OR SCAM

Who is ? Elizabeth Holmes - on 2015 Lists Founder & CEO Theranos

#121 Forbes 400 Richest in 1984 Born in Washington DC America 2002 Entered Stanford #6 America’s Richest ($4.5 billion) chemical engineering Entrepreneurs under 40 research pharmaceutical- #1 America’s Self-Made Women chip technology #72 Power Women Summer – Singapore for #360 Billionaires (world) SARS testing Patent application 2003 Dropped out Stanford to start company-Theranos

3 Elizabeth Holmes What is Theranos? Patents as of 2014 () Private very secretive In her name: company 18 U.S. Raised $400-750 million from investors 66 non-U.S. Valued at $9 billion As co-inventor: Contracts/Partners: , Cleveland >100 patent Clinic, Capital BlueCross in PA, HER applicatications vendor Practice Fusion

Theranos Mission Theranos Intentions Source: www.Theranos.com Our mission is to make actionable Low cost tests (half of Medicare/Medicaid information accessible to everyone at reimbursement rates) the time it matters. Performed on portable instrument they By making actionable information accessible to developed for in-house use only— everyone in the world at the time it matters Edison most, we are working to facilitate the early detection and prevention of disease, and Small volume sampling (in nanotainer; empower people everywhere to live their best typically <150 microliters vs >1.5 mL ) possible lives. Patients have ready access to results

Nanotainer Collection Device Theranos Touts Transparency

In Pricing: lists prices online at www.theranos.com

NO TRANSPARENCY IN TESTING Source: Have not released any information www.theranos.com about testing device—no peer-reviewed publications about technology

4 Theranos Board of Directors Theranos Board of Directors From Wikipedia From Wikipedia 2013: 3 directors (chem engineer; pharma & * (Senators) & biotech executive; financier) left Riley (Bechtel Group chair BOD)* Current Directors have diplomatic or (ex Wells Fargo CEO) military backgrounds: William Foege (ex director of CDC)* (sec of state) General James Mattis (ret USMC) (sec of defense) Admiral (ret USN) George Schultz (sec of state) *added in 2014

Theranos Officers Theranos Timeline

Elizabeth Holmes, Chairman, CEO and 2003 Company Founded as “Real-Time Founder Cures” Early on claimed to be Sunny Balwani: President and COO - pharmacogenomics realm company Director; entrepreneur & computer 2005 Dr hired—produced 23 scientist. Dropped out of Computer patents (19 with Holmes co-inventor) Science program at . April 2012 Theranos opens CA lab in Palo Worked for Lotus Development Alto then later added 2nd CA lab in Corporation, Microsoft, started business- Newark to-business ecommerce company

Theranos Timeline 2012 Theranos and Military

Department of Defense evaluating system Holmes met Mattis in 2011-- he wanted Official questioned technology and FDA project -- testing in battlefield environment inquiry looked into intent to distribute its By June 2012 evaluation of Theranos tests without FDA clearance testing apparently started Theranos: didn’t need FDA approval-- it was July-August: A deputy director in regulatory a review for a military research project & compliance launched inquiry including Holmes appealed to Gen. James Mattis to FDA intervene

5 Theranos and Military Theranos Timeline: 2013

Holmes asked Mattis to intervene & he sent May 2013 Dr. Gibbons commits suicide request through channels November 13, 2013: announces Walgreens agreement to open 42 Field demonstration never occurred “wellness centers” in Walgreens pharmacies in AZ (over next 2 years) plus 2 in CA and 1 in PA for samples June 2013 retired General Mattis joined collection & processing Theranos’s board of directors

Selected Test Costs from Current Selected Test Costs from Test Menu (~200 tests offered) Current Test Menu other labs hCG, urine pregnancy test $4.31 $18-42 Basic Metabolic Profile $5.76 $14-22.60 Hepatitis C (HCV) Genotype $117.96 Blood Type (ABO/RhD) $4.06 $10-24 (details coming soon)

CBC with auto differential $5.29 $11-19 Ova and parasites $6.06 $43 PT/INR $2.68 $7-18 CBC with no differential $4.41 $18.50 Urinalysis, Auto $1.53 $19.50- Comprehensive Metabolic Panel $7.19 $17-27.40 23.50

Source: www.theranos.com Source: www.theranos.com

Theranos Timeline: 2014 Theranos Timeline: 2014

July 22: leases 20,000 sq foot space in December: Former employee complains Phoenix/Scottsdale area to regulators that Edison device used for only 15 tests

6 Theranos Timeline: 2015 Theranos CLIA waiver for HSV-1

February 17 JAMA editorial by Dr. John Can put device (1 foot ***Picture here of Ioannidis called upon Theranos to be high, 1.5 feet wide, 2 Device*** more forthcoming about its equipment & feet deep with 8” x 5” * BUT THERANOS touch pad; Edison?) testing methods—”stealth research” HAS POLICY OF offsite NOT ALLOWING July 2: FDA approves HSV-1 test as waived DEVICE TO BE test—announced July 16; waiver for HSV Pursuing 120 other PHOTOGRAPHED test and test system tests on same device

How To Operate Device Analysis Time: From Fortune.com 7/16/15 article From Fortune.com 7/16/15 article Insert nanotainer into plastic cartridge “The company says the potassium test (watch case size) ordinarily takes 20 minutes, while the Clicks if orientation correct Ebola test takes “more than an hour.” Open front of analyzer using control pad Put cartridge (“like old VCR”) At the time Theranos was seeking Results wired by wifi, ethernet, cell- or emergency approval from FDA for its satellite-phone to Theranos’s databases DNA-based Ebola test

Scottsdale AZ Lab Inspected Scottsdale AZ Lab Inspected by AZ DHS April 2, 2015 4 Deficiencies Cited Uses traditional instrumentation & venous Proficiency Testing blood (not nanotainer & Edison) Instrument validation Humidity levels outside of acceptable Lab Director: Daniel Young, PhD limits engineering MIT – Vice President; specialty: dynamic modeling of Dating of blood-sample collections biological systems

7 Scottsdale AZ Lab Inspected Scottsdale AZ Lab Inspected Deficiencies Cited: PT Deficiencies Cited: PT Did not perform PT testing for Corrective Action: ethsuximide, primidone, quinidine 1. Notified agencies and tobramycin 2. Hired supervisor to oversee Stopped testing for these but failed to proficiency testing notify PT supplier & state regulators Cited Director for not meeting standards of “overall management & direction”

Deficiencies Cited: Deficiencies Cited: Instrument Validation Instrument Validation Unable to provide back-up data Corrective Action: showing full validation of 3 Instruments validated (3rd time per instruments Theranos) and data provided Theranos: Validated instruments at Newark, CA lab before shipping to FINAL INSPECTION OUTCOME: ALL AZ; Manufacturers confirmed CORRECTIVE ACTION ACCEPTED working properly but no data available

Everything Going Good: May 5, 2015 Darling of Wall Street Announces addition of “reference lab”

Apparent addition of Newark CA lab but not specified in announcement made at Pepperdine graduation speech by Holmes

8 October 16, 2015 October 16, 2015 Wall Street Journal (WSJ) Wall Street Journal (WSJ) “Hot Startup Theranos Has Struggled Edison used for only 15 tests not all With the Blood-Test Technology” tests—performing 190 tests on By traditional instrumentation Some physicians didn’t trust results Included information from 4 former Dr. Gibbons widow says husband “told employees and others me nothing was working” PT samples tested on Edison & conventional instruments

PT Testing Patient Testing Wall Street Journal (WSJ) Wall Street Journal (WSJ) Edison and conventional instruments About 60 of tests run on traditional instruments gave different results for “vitamin D, 2 used special dilution methods causing thyroid hormones and prostate cancer” results to fall below approved ranges Mr. Balwani ordered personnel to report Former employees claim some K results PT results from other instruments and to critically high use Edison for those 4 tests for patients Article cites other examples of abnormal Formal complaint April 2014 to New York Theranos results followed by normal results State Department of Health from other labs

Theranos Responses to WSJ Theranos Responses to WSJ

Edison use: “not using for all tests”; won’t PT testing: on “left-over PT samples”; say how many citing “trade secrets” unique technology has no peer group Did delete from website: “Many of our and thrown off by preservatives in PT tests require only a few drops of blood” and “usually only 3 tiny micro-vials per Dilution: “methods for preparing samples sample” for analysis are trade secrets and Reason given: “for marketing accuracy” cannot be revealed

9 Theranos Proficiency Testing Theranos Proficiency Testing From Theranos website as of 4/19/16 From Theranos website as of 4/19/16 “Theranos undergoes continuous “To date in 2015, Theranos Proficiency proficiency testing on blinded samples Testing met or surpassed performance from leading organizations, including goals 98% of the time for CAP and API the College of American Pathologists across hundreds of assays. Theranos is (CAP) and the American Proficiency leading the lab industry in transparency Institute (API). “ by publishing Proficiency Testing performance statistics.”

October 16, 2015 FDA Report October 27, 2015

Theranos suspends use of its Had inspected 2 Theranos CA labs (Palo proprietary finger-prick blood Alto & Newark) from August 25 to September 16th collection device nanotainer in Results in report: response to questions raised by 1. Theranos nanotainer an “uncleared FDA. medical device” 2. Deficiences in Theranos’ quality- assurance processes such as supplier qualifications

FDA and the Laboratory FDA and Testing

Questionable whether FDA can regulate Companies submit testing instruments and direct to consumer testing since tests the tests on those instruments for aren’t drugs, vaccines or medical devices approval in order to be able to sell to labs Theranos (and genetics companies) claim For consumer genetics testing FDA warned they don’t have to be FDA approved for 23andMe using saliva collection device direct to consumer testing BUT Theranos as “medical device” did submit many tests and its Edison to FDA

10 FDA and Testing November 2015

Laboratory Developed Tests (LDTs)--FDA Theranos seeks to hire Laboratory hasn’t made its final ruling Director Theranos tests would conceivably be LDTs Current Director: Dr. Sunil Dhawan, a when performed on Edison and maybe dermatologist (21 yrs supervising lab on conventional instrumentation if don’t affiliated with his dermatology practice) follow manufacturer’s recommendation By January 2016 hired Kingshuk Das, MD for sample (not diluting routinely, etc) (also associate med director of UCLA clinical labs) and a Technical Consultant

Related Article Published December 20, 2015 December 2015 Wall Street Journal reports that Theranos is being investigated by CMS and by the FDA due to complaints by 2 former Can You Use employees Fingerprick Blood for Complaint to CMS: company aware of Edison’s inaccurate results since 2013 All Tests? Complaint to FDA: company under reported frequency of Edison breaking down

Drop-to-Drop Variation in Goals of Study: DETERMINE Components of Fingerprick Blood Drop-to-drop variability in blood Ref. Bond MM, Richards-Kortum RR. parameters obtained from fingerprick Drop-to-Drop Variation in the Cellular blood Components of Fingerprick Blood. Am J Clin Pathol, 2015; 144: 885-894. Minimum volume of blood needed to reduce variability to acceptable levels Department of Bioengineering, Rice for clinical decision making (ex. Anemia) University, Houston TX

11 Study: Drop-to-Drop Variation in Study: Drop-to-Drop Variation in Components of Fingerprick Blood Components of Fingerprick Blood 11 donors (14 recruited; 3 rejected because CBC results compared to results from of milking or clots); 1 fingerprick venous blood drawn before fingerstick Wipe away 1st drop; collect 6 successive drops (20 microliter capillary tubes) Also compared drop-to-drop variation in Measured: Hgb, total WBC count, 3-part hemoglobin measured on POCT WBC differential, platelet count on HemoCue 201+ ; 10 successive drops-- Beckman Coulter AcT diff2 10 microliter samples collected directly into HemoCue cuvette

RESULTS Hgb: 6 Drops RESULTS Hgb: Venous Blood 6 Drops Fingerprick

Normalized by subtracting Hgb of last drop from each in order eliminate baseline differences in donors Hgb

RESULTS: 6 Drops RESULTS: CV Variation in Venous vs Fingerprick Blood Hgb for Venous vs Fingerprick

CONCLUSION: average CV for successive drops of fingerprick blood for Hgb analysis was between 2.3 and 3.4 greater than for small volumes of venous blood

12 Results for WBC WBC & 3-Part Differential CVs

CONCLUSION: WBC & Results for Platelets 3-Part Differential CVs Average CV for successive drops of fingerprick blood was higher than that of venous blood controls for parameters by amount shown below: WBC 3.9 to 5.7 times higher Lymphocytes 1.4 to 3.0 times higher Granulocyte 3.2 to 7.7 times higher Hard to compare monocytes because of low absolute counts

Variation in Platelets Study: Drop-to-Drop Variability Measurement on POCT Device 7 donors 1 drop wiped away 10 successive drops (~10 microliters each) Analyzed on POCT hemoglobin analyzer (HemoCue 201+) CONCLUSION: average CV for successive Analyzer variability determined using drops of fingerprick blood for platelet venous blood analysis was 4 times greater than for small volumes of venous blood

13 Results for POCT Hgb Results for POCT Hgb

CONCLUSION: average CV for successive drops of fingerprick blood for Hgb was 2.2 to 5 times higher than for small volumes of venous blood

STUDY CONCLUSIONS STUDY CONCLUSIONS

These data suggest caution when using For clinical decision making, we measurements from a single drop of recommend using fingerprick blood to fingerprick blood. assess hemoglobin or WBC concentration only when the degree of variability is acceptable. Our data suggest caution in using small volume sample devices for Hgb and WBC tests for clinical decision making, such as determining anemia status.

CMS LETTER TO CA LAB BACK TO OUR STORY JANUARY 2016 re November CMS survey

Meanwhile back at Theranos

14 CMS LETTER TO CA LAB CMS LETTER TO CA LAB JANUARY 2016 JANUARY 2016

Later Information Reported Deficiencies Cited about This Inspection Report Theranos failed to adequately correct 43 of 45 deficiencies cited 1 deficiency: failure to provide evidence that corrected reports sent to patients who got flawed test results 1 article speculates that Hematology Deficiency cited was for erroneous PT results

Jan 24, 2016 Wall Street Journal January 29, 2016

Reports on CMS inspection deficiencies Walgreens suspends service in Palo Alto Theranos told Walgreens its outsourcing store and directs Theranos to do all highly complex tests to UCSF & ARUP testing from any Walgreens store in AZ Since mid-November Theranos sent lab or to an accredited outside lab >1200 tests to UCSF Capital BlueCross stops drawing blood in UCSF charges Theranos >$300 for PA retail store comprehensive metabolic profile – Cleveland Clinic says no study of Thernos Theranos charges $7.19 at sites vs other labs has begun

15 22 Tests ( *4 calculated) Requiring Only Peer Reviewed Article Small Sample Volumes: Concerning Theranos March 30, 2016 The Journal of Clinical CBC: RBC, WBC, Hgb, hct*,MCV, MCH*, Investigation (JCI) MCHC*, RDW*, Plt, Neut, Lymph, Mono, Authors from Mt. Sinai Hospital, NY Eosin, Baso 60 Healthy Adults (19-71yo); 4 collections in Lipids: total cholesterol, LDLc, HDLc, 6.5 hrs (venipuncture VP;fingerstick FS;FS;VP) triglycerides 22 Tests: CBC; Lipid Panel; Chemistry CRP, Phosphate, Uric Acid, T bilirubin 3 Labs: LabCorp (Phoenix); Quest (Tempe & San Juan Capistrano); Theranos Kidd BA et al. Evaluation of direct-to-consumer low-volume lab tests in healthy adults. JCI doi:10.1172/JCI86318 Kidd BA et al. Evaluation of direct-to-consumer low-volume lab tests in healthy adults. JCI doi:10.1172/JCI86318

Study Design & Sample Results Collection • Theranos sample collection has higher sample rejection rates Samples collected in Phoenix, AZ • Theranos reports more measures outside their normal range Kidd BA et al. • Testing services show nonequivalent Evaluation of direct-to- test results consumer low-volume lab tests in healthy • Intersubject & interservice variability adults. JCI dominate lab test results doi:10.1172/JCI86318

Kidd BA et al. Evaluation of direct-to-consumer low-volume lab tests in healthy adults. JCI doi:10.1172/JCI86318

Results: Theranos sample collection Results: Theranos reports more has higher sample rejection rates measures outside their normal range

Theranos rejected sample 12.5 times more than LabCorp or Quest Percentage of results reported outside of lab’s reference range: Theranos returned missing data for 4 of 6 LabCorp 8.3% subjects; LabCorp returned missing data Quest 7.5% for 1 subject Theranos 12.2%

Kidd BA et al. Evaluation of direct-to-consumer low-volume lab tests in healthy adults. JCI doi:10.1172/JCI86318

Kidd BA et al. Evaluation of direct-to-consumer low-volume lab tests in healthy adults. JCI doi:10.1172/JCI86318

16 Results: Theranos reports more Results: Testing services show measures outside their normal range nonequivalent test results

CBC results Theranos 1.6 times more likely to report abnormal result than other 2 labs LabCorp consistently lower for WBC & hct

Theranos higher neutrophils & monocytes This ratio ranged from 1.6 (LDL chol) to 4.5 (lymphocyte counts) MCHC and RDW different for all 3 labs

Kidd BA et al. Evaluation of direct-to-consumer low-volume lab tests in healthy adults. JCI doi:10.1172/JCI86318 Kidd BA et al. Evaluation of direct-to-consumer low-volume lab tests in healthy adults. JCI doi:10.1172/JCI86318

Results: Testing services show Lipid results: nonequivalent test results Theranos CBC results lower for total LabCorp consistently lower for WBC & hct Cholesterol, Theranos higher neutrophils & monocytes HDLc, and LDLc MCHC and RDW different for all 3 labs

Kidd BA et al. Evaluation of direct-to-consumer low-volume lab tests in healthy adults. JCI doi:10.1172/JCI86318

Results: Intersubject & interservice variability dominate lab test results

Looked at 4 sources of variability: *Subject *Testing service (lab) Collection Time Technical Reproducibility

* Greatest variability

Kidd BA et al. Evaluation of direct-to-consumer low-volume lab tests in healthy adults. JCI doi:10.1172/JCI86318

17 April 7, 2016 Theranos Announces Scientific & Medical Advisory Board 8 well recognized and respected laboratory and medical experts Includes 4 former Presidents of AACC Former Director of CDC 3 review sessions held during which attendees reviewed R&D reports including assay validations

April 13, 2016 news Ban Considered: from owning CMS letter of March 18th it was considering: or operating clinical lab for 2 yrs

• Revoking CLIA certificate Elizabeth Holmes--Founder/CEO • Fining Theranos up to $10,000/day • Suspending or cancelling approval to Ramesh Sunny Balwani-Owner/President/COO receive Medicare payments • Banning Holmes, Balwani,& Dhawan from Dr. Sunil Dhawan-former Medical Director owning or operating a clinical lab for 2 years Note: Sanction letter not released while CMS reviewing Theranos request for redaction of trade secrets

April 19, 2016 Status to Date New York Times and Bloomberg Theranos had 10 days to respond to Theranos under criminal investigation March 18 letter and they responded by Security and Exchange Commission & US Attorney’s Office for Northern Calif CMS reviewing response Walgreens and NY State Department of Health received subpoenas Some people said investigation is whether Theranos misled government officials

18 April 18, 2016 Maria Shriver Appeals Process If Ban Upheld Interviews Holmes on Today Show Some sanctions take effect within 8 days “I feel devastated” Revoking CA license could take 60 days If appeal keep license through appeal “Taken approach to rebuild lab from start” Appeals to administrative law judege & then departmental appeals board Brought in new Lab Director and Advisory CMS has not lost a case like this from Board 2001 to end of 2010

SCIENCE OR SCAM? TO BE CONTINUED

Questions Thank you for your attention

19 20