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Checkpoint inhibitors targeting programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) have revolutionized cancer therapy across many indications including urothelial carcinoma (UC). Because many patients do not benefit, a better understanding of the molecular mechanisms underlying response and resistance is needed to improve outcomes. We profiled tumors from 2,803 UC patients from four late-stage randomized clinical trials evaluating the PD-L1 inhibitor atezolizumab by RNA sequencing (RNA-seq), a targeted DNA panel, immunohistochemistry, and digital pathology. Machine learning identifies four transcriptional subtypes, representing luminal desert, stromal, immune, and basal tumors. Overall survival benefit from atezolizumab over standard-of-care is observed in immune and basal tumors, through different response mechanisms. A self-supervised digital pathology approach can classify molecular subtypes from H&E slides with high accuracy, which could accelerate tumor molecular profiling. This study represents a large integration of UC molecular and clinical data in randomized trials, paving the way for clinical studies tailoring treatment to specific molecular subtypes in UC and other indications., Competing Interests: Declaration of interests All Genentech-affiliated authors are shareholders in Roche. H.H., S. Mariathasan., and R.B. are listed on a pending patent related to this work. P.G. is consulting for 4D Pharma, Aadi Bioscience, Asieris Pharmaceuticals, Astellas, AstraZeneca, BostonGene, Bristol Myers Squibb, CG Oncology, Dyania Health, Exelixis, Fresenius Kabi, G1 Therapeutics, Genentech, Gilead Sciences, Guardant Health, ImmunityBio, Infinity Pharmaceuticals, Janssen, Lucence, Merck KGaA, Mirati Therapeutics, MSD, Pfizer, PureTech, QED Therapeutics, Regeneron, Roche, Seattle Genetics, Silverback Therapeutics, Strata Oncology, UroGen Pharma, and receives institutional research funding from ALX Oncology, Acrivon Therapeutics, Bavarian Nordic, Bristol Myers Squibb, Clovis Oncology, Debiopharm Group, G1 Therapeutics, Gilead Sciences, GSK, Merck KGaA, Mirati Therapeutics, MSD, Pfizer, QED Therapeutics. E. Sokol. is an employee at Foundation Medicine and a shareholder in Roche. M.D.G. receives research funding from Bristol Myers Squibb, Novartis, Dendreon, Astra Zeneca, Merck, Genentech, and acts as Advisory Board/Consultant for Bristol Myers Squibb, Merck, Genentech, AstraZeneca, Pfizer, EMD Serono, SeaGen, Janssen, Numab, Dragonfly, GlaxoSmithKline, Basilea, UroGen, Rappta Therapeutics, Alligator, Silverback, Fujifilm, Curis, Gilead, Bicycle, Asieris, Abbvie, Analog Devices, Veracyte. T.P. receives honararia and research funding from Roche, Astellas, Seagen, MSD, Merck-Serono, BMS, Pfizer, Ipsen, AZ, Johnson and johnson, Mashup-Media, Exelixis, Eisai, Natera, FMI, Novartis, Bayer. J. Rosenberg is a Consultant for Aadi Bioscience; Alligator Bioscience; Astellas; AstraZeneca Pharmaceuticals LP; Boehringer Ingelheim Pharmaceuticals Inc; Bristol-Myers Squibb Company; Century Therapeutics Inc; EMD Serono Inc; Emergence Therapeutics; Genentech, a member of the Roche Group; Gilead Sciences Inc; Imvax Inc; Jiangsu Hengrui Medicine Co Ltd; Eli Lilly; Merck; Mirati Therapeutics Inc; Pfizer Inc; Seagen Inc; Tyra Biosciences, has Grant/Research support from Seagen Inc, Genentech/Roche, Astellas, Acrivon and receives honoraria from Pfizer Inc, EMD-Serono Inc, MJH Life Sciences, Research to Practice, Clinical Care Options. M.S.v.d.H. receives research funding from Bristol Myers Squibb, AstraZeneca, 4SC and Roche, and consultancy fees from Bristol Myers Squibb, Roche, Merck Sharp & Dohme, Merck, AstraZeneca, Pfizer, Janssen and Seattle Genetics, which were all paid to the Netherlands Cancer Institute., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Enzalutamide after abiraterone progression is commonly used in metastatic castration-resistant prostate cancer despite a low rate of clinical benefit. Analyzing IMbassador250, a phase III trial assessing enzalutamide with or without atezolizumab after abiraterone, we hypothesized that baseline and early changes in circulating tumor DNA (ctDNA) tumor fraction (TF) may identify patients more likely to exhibit survival benefit from enzalutamide., Experimental Design: ctDNA was quantified from plasma samples using a tissue-agnostic assay without buffy coat sequencing. Baseline ctDNA TF, changes in ctDNA TF from baseline to cycle 3 day 1 (C3D1), and detection at C3D1 alone were compared with overall response rate, radiographic progression-free survival (rPFS), median OS (mOS), and 50% reduction in PSA., Results: ctDNA TF detection at baseline and/or C3D1 was associated with shorter rPFS and OS in 494 evaluable patients. Detection of ctDNA TF at C3D1, with or without detection at cycle 1 day 1, was associated with worse rPFS and mOS than lack of detection. When ctDNA TF and PSA response at C3D1 were discordant, patients with (ctDNA TF undetected/PSA not reduced) had more favorable outcomes than (ctDNA TF detected/PSA reduced; mOS 22.1 vs. 16 months; P < 0.001)., Conclusions: In a large cohort of patients with metastatic castration-resistant prostate cancer receiving enzalutamide after abiraterone, we demonstrate the utility of a new tissue-agnostic assay for monitoring molecular response based on ctDNA TF detection and dynamics. ctDNA TF provides a minimally invasive, complementary biomarker to PSA testing and may refine personalized treatment approaches., (©2024 The Authors; Published by the American Association for Cancer Research.)

Reproducible and standardised neurological assessment scales are important in quantifying research outcomes. These scales are often performed by non-neurologists and/or non-clinicians and must be robust, quantifiable, reproducible and comparable to a neurologist's assessment. COVID-CNS is a multi-centre study which utilised the Neurological Impairment Scale (NIS) as a core assessment tool in studying neurological outcomes following COVID-19 infection. We investigated the strengths and weaknesses of the NIS when used by non-neurology clinicians and non-clinicians, and compared performance to a structured neurological examination performed by a neurology clinician. Through our findings, we provide practical advice on how non-clinicians can be readily trained in conducting reproducible and standardised neurological assessments in a multi-centre study, as well as illustrating potential pitfalls of these tools., Competing Interests: Declaration of competing interest T.S. is the Director of The Pandemic Institute which has received funding from Innova and CSL Seqirus and Aviva and DAM Health. T.S. was an advisor to the GSK Ebola Vaccine programme and the Siemens Diagnostic Programme. T.S. Chaired the Siemens Healthineers Clinical Advisory Board. T.S. Co-Chaired the WHO Neuro-COVID task force and sat on the UK Government Advisory Committee on Dangerous Pathogens, and the Medicines and Healthcare Products Regulatory Agency (MHRA) Expert Working Group on Covid-19 vaccines. T.S. Advised to the UK COVID-19 Therapeutics Advisory Panel (UK-TAP). T.S. was a Member of COVID-19 Vaccines Benefit Risk Expert Working Group for the Commission on Human Medicines (CHM) committee of the Medicines and Healthcare products Regulatory Agency (MHRA). T.S. has been a member of the Encephalitis Society since 1998 and President of the Encephalitis Society since 2019., (Copyright © 2024. Published by Elsevier Ltd.)

Emerging technologies focused on the detection and quantification of circulating tumor DNA (ctDNA) in blood show extensive potential for managing patient treatment decisions, informing risk of recurrence, and predicting response to therapy. Currently available tissue-informed approaches are often limited by the need for additional sequencing of normal tissue or peripheral mononuclear cells to identify non-tumor-derived alterations while tissue-naïve approaches are often limited in sensitivity. Here we present the analytical validation for a novel ctDNA monitoring assay, FoundationOne®Tracker. The assay utilizes somatic alterations from comprehensive genomic profiling (CGP) of tumor tissue. A novel algorithm identifies monitorable alterations with a high probability of being somatic and computationally filters non-tumor-derived alterations such as germline or clonal hematopoiesis variants without the need for sequencing of additional samples. Monitorable alterations identified from tissue CGP are then quantified in blood using a multiplex polymerase chain reaction assay based on the validated SignateraTM assay. The analytical specificity of the plasma workflow is shown to be 99.6% at the sample level. Analytical sensitivity is shown to be >97.3% at ≥5 mean tumor molecules per mL of plasma (MTM/mL) when tested with the most conservative configuration using only two monitorable alterations. The assay also demonstrates high analytical accuracy when compared to liquid biopsy-based CGP as well as high qualitative (measured 100% PPA) and quantitative precision (<11.2% coefficient of variation)., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Stock and Employment from Foundation Medicine, Inc: D.R.Z., A.F., Y.H., C.G., M.C., C.X., D.J., B.W., P.P., W.C., P.H., J.H., L.D., A.Y. Stock and Employment from Natera: E.R., J.S., A.K., W.G., G.B., C.H., R.R., L.R., D.H., D.S., V.P., M.D., S.F. Stock and Employment from F. Hoffmann-La Roche: C.C., N.D., V.D., P.G., S.M. Honararia- Astellas, Pfizer, Seagen, BMS, Roche, Astra-Zeneca, MSD, Natera, Merck Serono, Johnson and Johnson - T.P. This does not alter our adherence to PLOS ONE policies on sharing data and materials, (Copyright: © 2024 Zollinger et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Tiragolumab, an anti-TIGIT antibody with an active IgG1κ Fc, demonstrated improved outcomes in the phase 2 CITYSCAPE trial (ClinicalTrials.gov: NCT03563716 ) when combined with atezolizumab (anti-PD-L1) versus atezolizumab alone 1 . However, there remains little consensus on the mechanism(s) of response with this combination 2 . Here we find that a high baseline of intratumoural macrophages and regulatory T cells is associated with better outcomes in patients treated with atezolizumab plus tiragolumab but not with atezolizumab alone. Serum sample analysis revealed that macrophage activation is associated with a clinical benefit in patients who received the combination treatment. In mouse tumour models, tiragolumab surrogate antibodies inflamed tumour-associated macrophages, monocytes and dendritic cells through Fcγ receptors (FcγR), in turn driving anti-tumour CD8 + T cells from an exhausted effector-like state to a more memory-like state. These results reveal a mechanism of action through which TIGIT checkpoint inhibitors can remodel immunosuppressive tumour microenvironments, and suggest that FcγR engagement is an important consideration in anti-TIGIT antibody development., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

In metastatic urothelial cancer (mUC), cisplatin versus carboplatin leads to durable disease control in a subset of patients. The IMvigor130 trial reveals more favorable effects with atezolizumab combined with gemcitabine and cisplatin (GemCis) versus gemcitabine and carboplatin (GemCarbo). This study investigates the immunomodulatory effects of cisplatin as a potential explanation for these observations. Our findings indicate that improved outcomes with GemCis versus GemCarbo are primarily observed in patients with pretreatment tumors exhibiting features of restrained adaptive immunity. In addition, GemCis versus GemCarbo ± atezolizumab induces transcriptional changes in circulating immune cells, including upregulation of antigen presentation and T cell activation programs. In vitro experiments demonstrate that cisplatin, compared with carboplatin, exerts direct immunomodulatory effects on cancer cells, promoting dendritic cell activation and antigen-specific T cell killing. These results underscore the key role of immune modulation in cisplatin's efficacy in mUC and highlight the importance of specific chemotherapy backbones in immunotherapy combination regimens., Competing Interests: Declaration of interests M.D.G. has received grants or contracts from Bristol Myers Squibb, Novartis, Dendreon, AstraZeneca, and Merck; and has received consulting fees from Bristol Myers Squibb, Merck, Genentech Inc., AstraZeneca, Pfizer, EMD Serono, Seagen, Janssen, Numab, Dragonfly, GlaxoSmithKline, Basilea, UroGen, RapptaTherapeutics, Alligator, Silverback, Fujifilm, and Curis. X.G., D.R., A.S.R., H.M.S., R.B., K.Y., E.V., R.H., C.-J.H., Y.L., D.V., P.W., I.M., S.S., R.J., and S.M. are employees of Genentech Inc., and hold stocks or stock options in Roche/Genentech Inc. H.L. is an employee of Hoffmann-La Roche Ltd, Canada. L.W., J.Z., and H.Y. are employees of Sema4. E.H. was employed at Immunai during study conduct. R.H.H. and E. Kiner are employees of Immunai. A.B. has served as a consultant or advisor to Roche, Bristol Myers Squibb, MSD, and Pfizer; has received honoraria from Bristol Myers Squibb, MSD, and Pfizer; and has received educational and research grants from Pfizer, Pierre-Fabre, and Bristol Myers Squibb. M.D.S. has received consulting fees from AAA, Accord, Amgen, Astellas, AstraZeneca, Basilea, Bayer, Bioclin, Bristol Myers Squibb, Eisai, Ferring, Immunomedics, Ipsen, Janssen, MSD, Merck, Novartis, Pfizer, Pierre Fabre Oncology, Roche, Sandoz, Sanofi, and Seagen; has received payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from AAA, Accord, Amgen, Astellas, AstraZeneca, Basilea, Bayer, Bioclin, Bristol Myers Squibb, Eisai, Ferring, Immunomedics, Ipsen, Janssen, MSD, Merck, Novartis, Pfizer, Pierre Fabre Oncology, Roche, Sandoz, Sanofi, and Seagen; has received support for attending meetings and/or travel from AAA, Accord, Amgen, Astellas, AstraZeneca, Basilea, Bayer, Bioclin, Bristol Myers Squibb, Eisai, Ferring, Immunomedics, Ipsen, Janssen, MSD, Merck, Novartis, Pfizer, Pierre Fabre Oncology, Roche, Sandoz, Sanofi, and Seagen; has participated in a Data Safety Monitoring Board or Advisory Board for Roche, Orion, and CR-UK; and has other financial or non-financial interests by having worked on the ESMO guidelines on bladder cancer and the German S3 Leitlinie Blasenkarzinom. I.D.D. has participated in a Data Safety Monitoring Board or Advisory Board for Roche/Genentech Inc. (WO30070 [IMvigor130] international steering committee; unpaid) and Merck/Pfizer (APAC GU Advisory Board; unpaid: honoraria are invoiced by and paid directly to ANZUP Cancer Trials Group); and has a leadership or fiduciary role in the ANZUP Cancer Trials Group (as a Director and Board Chair; unpaid). J.A.A. has received third-party service as collaboration in the selection, and management of administrative requirements for the participation of SOGUG centers in the study from SOGUG during the conduct of the study; speaking or consulting fees from Bristol Myers Squibb, MSD, Roche, Astellas, Janssen Cilag, Pfizer, Novartis, and Bayer outside the submitted work; travel support from Bristol Myers Squibb, MSD, Roche, and Janssen Cilag outside the submitted work; research funding (from SOGUG) outside the submitted work from Bristol Myers Squibb, Novartis, and Pierre Fabre; and has participated in industry-sponsored clinical trials for Bristol Myers Squibb, MSD, Roche, Astellas, Janssen Cilag, Pfizer, and Novartis outside the submitted work. E. Kikuchi has received grants or contracts (through his institution) from Takeda, Nippon Kayaku, and Taiho; has received consulting fees from Chugai, Nippon Kayaku, MSD, Takeda, Pfizer, Astellas, Bristol Myers Squibb, and Yansen; has received payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Takeda, Nippon Kayaku, and Taiho; and has received consulting fees from Chugai, Nippon Kayaku, MSD, Takeda, Taiho, AstraZeneca, Pfizer, Astellas, Bristol Myers Squibb, and Yansen. S.B. is an employee of Roche Products Ltd, UK, holds stocks or stock options in Roche, and has other financial or non-financial interests in Roche. C.L. is an employee of Roche Products Ltd, UK, holds stocks or stock options in Roche, and has other financial or non-financial interests in Roche. P.C.B. has participated in advisory boards for Janssen, Merck, Roche/Genentech Inc., Bristol Myers Squibb, Urogen, EMD Serono, Bayer, Astellas, AbbVie, AstraZeneca, Ferring, H3-Biomedicine, Sanofi, Pfizer, Prokarium, Protara Therapeutics, Stimit, and Verity; has received payment or honoraria as a speaker from Janssen, Bayer, Ferring, H3-Biomedicine, and Pfizer; has participated in clinical trials for Roche/Genentech Inc., Bristol Myers Squibb, and AstraZeneca; and has received non-financial support (scientific collaboration on bladder cancer genomics/transcriptomics) from Decipher Biosciences/Veracyte. E.G. has received grants or contracts from Astellas, AstraZeneca, Ipsen, Merck KGaA, and Pfizer; has received payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Astellas, AstraZeneca, Bayer, Bristol Myers Squibb, Eisai, Esteve, Ipsen, Janssen, Lilly, Merck KGaA, MSD, Pfizer, Raffo, and Roche; and has received support for attending meetings and/or travel from Roche, AstraZeneca, Bristol Myers Squibb, Pfizer, and Merck KGaA., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Interim results from IMvigor010 showed an overall survival (OS) benefit for adjuvant atezolizumab (anti-PD-L1) versus observation in patients with circulating tumor DNA (ctDNA)-positive muscle-invasive urothelial carcinoma (MIUC)., Objective: To report updated OS and safety by ctDNA status., Design, Setting, and Participants: This ad hoc analysis from a global, open-label, randomized, phase 3 trial (NCT02450331) included intention-to-treat (ITT) population with evaluable cycle 1 day 1 (C1D1) ctDNA samples., Intervention: Atezolizumab (1200 mg every 3 wk) or observation for ≤1 yr., Outcome Measurements and Statistical Analysis: OS, relapse rates, and safety by ctDNA status were assessed., Results and Limitations: Among 581 of 809 ITT patients included, 214 (37%) were ctDNA positive. Atezolizumab did not improve OS versus observation in ITT patients (hazard ratio [HR] 0.91 [95% confidence interval {CI} 0.73-1.13]; median follow-up 46.8 mo [interquartile range, 36.1-53.6]). In the observation arm, ctDNA positivity versus negativity was associated with shorter OS (HR 6.3 [95% CI 4.3-9.3]). The ctDNA positivity identified patients with an OS benefit favoring atezolizumab versus observation (HR 0.59 [95% CI 0.42-0.83]). A greater reduction in ctDNA levels with atezolizumab (C3D1) was associated with longer OS (100% clearance, 60.0 mo [95% CI 35.5-not estimable]; 50-99% reduction, 34.3 mo [95% CI 15.2-not estimable]; <50% reduction, 19.9 mo [95% CI 16.4-32.2]). The ctDNA positivity at C1D1 + C3D1 was associated with relapse with greater sensitivity than C1D1 alone (68% vs 57%). Adverse events were more frequent with atezolizumab than with observation, regardless of ctDNA status. A study limitation was its exploratory design., Conclusions: Evidence suggests that ctDNA positivity in MIUC predicts a benefit with atezolizumab. An in-progress prospective study will further evaluate these findings., Patient Summary: Among patients with urothelial cancer after surgery, survival was poorer if tumor-derived DNA was detected in their bloodstream; these patients' survival was longer with atezolizumab versus observation. Bloodstream tumor-derived DNA may identify patients who benefit from atezolizumab., (Copyright © 2023. Published by Elsevier B.V.)

Introduction: Circulating tumor DNA (ctDNA) detection postoperatively may identify patients with urothelial cancer at a high risk of relapse. Pragmatic tools building off clinical tumor next-generation sequencing (NGS) platforms could have the potential to increase assay accessibility., Methods: We evaluated the widely available Foundation Medicine comprehensive genomic profiling (CGP) platform as a source of variants for tracking of ctDNA when analyzing residual samples from IMvigor010 (ClinicalTrials.gov identifier NCT02450331), a randomized adjuvant study comparing atezolizumab with observation after bladder cancer surgery. Current methods often involve germline sampling, which is not always feasible or practical. Rather than performing white blood cell sequencing to filter germline and clonal hematopoiesis (CH) variants, we applied a bioinformatic approach to select tumor (non-germline/CH) variants for molecular residual disease detection. Tissue-informed personalized multiplex polymerase chain reaction-NGS assay was used to detect ctDNA postsurgically (Natera)., Results: Across 396 analyzed patients, prevalence of potentially actionable alterations was comparable with the expected prevalence in advanced disease (13% FGFR2/3 , 20% PIK3CA , 13% ERBB2 , and 37% with elevated tumor mutational burden ≥10 mutations/megabase). In the observation arm, 66 of the 184 (36%) ctDNA-positive patients had shorter disease-free survival [DFS; hazard ratio (HR) = 5.77; 95% confidence interval (CI), 3.84-8.67; P < 0.0001] and overall survival (OS; HR = 5.81; 95% CI, 3.41-9.91; P < 0.0001) compared with ctDNA-negative patients. ctDNA-positive patients had improved DFS and OS with atezolizumab compared with those in observation (DFS HR = 0.56; 95% CI, 0.38-0.83; P = 0.003; OS HR = 0.66; 95% CI, 0.42-1.05). Clinical sensitivity and specificity for detection of postsurgical recurrence were 58% (60/103) and 93% (75/81), respectively., Conclusion: We present a personalized ctDNA monitoring assay utilizing tissue-based FoundationOne ® CDx CGP, which is a pragmatic and potentially clinically scalable method that can detect low levels of residual ctDNA in patients with resected, muscle-invasive bladder cancer without germline sampling., Competing Interests: TP received honoraria from advisory/consultancy roles with AstraZeneca, BMS, Exelixis, Incyte, Ipsen, Merck, MSD, Novartis, Pfizer, Seattle Genetics, Merck Serono EMD Serono, Astellas, Johnson & Johnson, Eisai, Mashup Ltd, and Roche; institutional research funding support from AstraZeneca, Roche, BMS, Exelixis, Ipsen, Merck, MSD, Novartis, Pfizer, Seattle Genetics, Merck Serono EMD Serono, Astellas, Eisai, and Johnson & Johnson; and travel, accommodation, and expenses support from Roche, Pfizer, MSD, AstraZeneca, and Ipsen. AY, HN, RM, AF, DZ, YH, CX, OG, GO, and PH are employees of Foundation Medicine, a wholly owned subsidiary of Roche, and have equity interest in Roche. VA, HW, and AA are employees of Natera, Inc., and reports stock ownership in Natera. CC, ND, VD, PG, SM, ES, and ZA are employees of Genentech and have equity interest in Roche., (Copyright © 2023 Powles, Young, Nimeiri, Madison, Fine, Zollinger, Huang, Xu, Gjoerup, Aushev, Wu, Aleshin, Carter, Davarpanah, Degaonkar, Gupta, Mariathasan, Schleifman, Assaf, Oxnard and Hegde.)

The immune phenotype of a tumour is a key predictor of its response to immunotherapy 1-4 . Patients who respond to checkpoint blockade generally present with immune-inflamed 5-7 tumours that are highly infiltrated by T cells. However, not all inflamed tumours respond to therapy, and even lower response rates occur among tumours that lack T cells (immune desert) or that spatially exclude T cells to the periphery of the tumour lesion (immune excluded) 8 . Despite the importance of these tumour immune phenotypes in patients, little is known about their development, heterogeneity or dynamics owing to the technical difficulty of tracking these features in situ. Here we introduce skin tumour array by microporation (STAMP)-a preclinical approach that combines high-throughput time-lapse imaging with next-generation sequencing of tumour arrays. Using STAMP, we followed the development of thousands of arrayed tumours in vivo to show that tumour immune phenotypes and outcomes vary between adjacent tumours and are controlled by local factors within the tumour microenvironment. Particularly, the recruitment of T cells by fibroblasts and monocytes into the tumour core was supportive of T cell cytotoxic activity and tumour rejection. Tumour immune phenotypes were dynamic over time and an early conversion to an immune-inflamed phenotype was predictive of spontaneous or therapy-induced tumour rejection. Thus, STAMP captures the dynamic relationships of the spatial, cellular and molecular components of tumour rejection and has the potential to translate therapeutic concepts into successful clinical strategies., (© 2023. The Author(s).)