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BackgroundPoly(adenosine diphosphate-ribose) polymerase inhibitors target cancers with defects in homologous recombination repair by synthetic lethality. New therapies are needed to reduce recurrence in patients with BRCA1 or BRCA2 germline mutation-associated early breast cancer.MethodsWe conducted a phase 3, double-blind, randomized trial involving patients with human epidermal growth factor receptor 2 (HER2)-negative early breast cancer with BRCA1 or BRCA2 germline pathogenic or likely pathogenic variants and high-risk clinicopathological factors who had received local treatment and neoadjuvant or adjuvant chemotherapy. Patients were randomly assigned (in a 1:1 ratio) to 1 year of oral olaparib or placebo. The primary end point was invasive disease-free survival.ResultsA total of 1836 patients underwent randomization. At a prespecified event-driven interim analysis with a median follow-up of 2.5 years, the 3-year invasive disease-free survival was 85.9% in the olaparib group and 77.1% in the placebo group (difference, 8.8 percentage points; 95% confidence interval [CI], 4.5 to 13.0; hazard ratio for invasive disease or death, 0.58; 99.5% CI, 0.41 to 0.82; P

PURPOSE Some gastric cancers harbor MET gene amplifications that can be targeted by selective MET inhibitors to achieve tumor responses, but resistance eventually develops. Savolitinib, a selective MET inhibitor, is beneficial for treating patients with MET-driven gastric cancer. Understanding the resistance mechanisms is important for optimizing postfailure treatment options. PATIENTS AND METHODS Here, we identified the mechanisms of acquired resistance to savolitinib in 3 patients with gastric cancer and MET-amplified tumors who showed a clinical response and then cancer progression. Longitudinal circulating tumor DNA (ctDNA) is useful for monitoring resistance during treatment and progression when rebiopsy cannot be performed. RESULTS Using a next-generation sequencing 100-gene panel, we identified the target mechanisms of resistance MET D1228V/N/H and Y1230C mutations or high copy number MET gene amplifications that emerge when resistance to savolitinib develops in patients with MET-amplified gastric cancer. CONCLUSION We demonstrated the utility of ctDNA in gastric cancer and confirmed this approach using baseline tumor tissue or rebiopsy.

Background A high percentage of small cell lung cancer (SCLC) cases harbor cell cycle-related gene mutations and RICTOR amplification. Based on underlying somatic mutations, the authors have conducted a phase 2 biomarker-driven, multiarm umbrella study. Methods The SCLC Umbrella Korea StudiES (SUKSES) is an adaptive platform trial that undergoes continual modification according to the observed outcomes. This study included 286 patients with SCLC who failed platinum therapy and who had known genomic profiles based on a predesigned screening trial. Patients with MYC amplification or CDKN2A and TP53 co-alterations were allocated to adavosertib (SUKSES protocol C [SUKSES-C]; 7 patients) and those with RICTOR amplification were allocated to vistusertib (SUKSES-D; 4 patients). Alternatively, patients who were without any predefined biomarkers were assigned to a non-biomarker-selected arm: adavosertib (SUKSES-N1; 21 patients) or AZD2811NP (SUKSES-N3; 15 patients). Results Patients in the SUKSES-C and SUKSES-N1 arms demonstrated no objective response. Three patients presented with stable disease (SD) in SUKSES-C and 6 patients in SUKSES-N1. The median progression-free survival (PFS) was 1.3 months (95% confidence interval, 0.9 months to not available) for SUKSES-C and 1.2 months (95% CI, 1.1-1.4 months) for SUKSES-N1. Patients in the SUKSES-D arm demonstrated no objective response and no SD, with a PFS of 1.2 months (95% CI, 1.0 months to not available). The SUKSES-N3 arm had 5 patients with SD and a PFS of 1.6 months (95% CI, 0.9-1.7 months), without an objective response. Grade≥3 adverse events (graded according to National Cancer Institute Common Terminology Criteria for Adverse Events [version 4.03]) were observed as follows: 3.2% in the SUKSES-C and SUKSES-N1 arms and 50.0% in the SUKSES-D arm. Target-related neutropenia (grade≥3) was observed in approximately 60.0% of patients in the AZD2811NP arm using the current dosing schedule. Conclusions To the best of the authors' knowledge, the current study is the first biomarker-driven umbrella study conducted in patients with recurrent SCLC. Although the current study demonstrated the limited clinical efficacy of monotherapy, novel biomarker approaches using other cell cycle inhibitor(s) or combinations warrant further investigation.

The VIKTORY (targeted agent eValuation In gastric cancer basket KORea) trial was designed to classify patients with metastatic gastric cancer based on clinical sequencing and focused on eight different biomarker groups (RAS aberration, TP53 mutation, PIK3CA mutation/amplification, MET amplification, MET overexpression, all negative, TSC2 deficient, or RICTOR amplification) to assign patients to one of the 10 associated clinical trials in second-line (2L) treatment. Capivasertib (AKT inhibitor), savolitinib (MET inhibitor), selumetinib (MEK inhibitor), adavosertib (WEE1 inhibitor), and vistusertib (TORC inhibitor) were tested with or without chemotherapy. Seven hundred seventy-two patients with gastric cancer were enrolled, and sequencing was successfully achieved in 715 patients (92.6%). When molecular screening was linked to seamless immediate access to parallel matched trials, 14.7% of patients received biomarker-assigned drug treatment. The biomarker-assigned treatment cohort had encouraging response rates and survival when compared with conventional 2L chemotherapy. Circulating tumor (ctDNA) analysis demonstrated good correlation between high MET copy number by ctDNA and response to savolitinib. Significance: Prospective clinical sequencing revealed that baseline heterogeneity between tumor samples from different patients affected response to biomarker-selected therapies. VIKTORY is the first and largest platform study in gastric cancer and supports both the feasibility of tumor profiling and its clinical utility. This article is highlighted in the In This Issue feature, p. 1325

Purpose: This study reports the safety, tolerability, MTD, recommended phase II dose (RP2D), pharmacokinetic/pharmacodynamic profile, and preliminary antitumor activity of ceralasertib combined with carboplatin in patients with advanced solid tumors. It also examined exploratory predictive and pharmacodynamic biomarkers. Patients and Methods: Eligible patients (n = 36) received a fixed dose of carboplatin (AUC5) with escalating doses of ceralasertib (20 mg twice daily to 60 mg once daily) in 21-day cycles. Sequential and concurrent combination dosing schedules were assessed. Results: Two ceralasertib MTD dose schedules, 20 mg twice daily on days 4–13 and 40 mg once daily on days 1–2, were tolerated with carboplatin AUC5; the latter was declared the RP2D. The most common treatment-emergent adverse events (Common Terminology Criteria for Adverse Events grade ≥3) were anemia (39%), thrombocytopenia (36%), and neutropenia (25%). Dose-limiting toxicities of grade 4 thrombocytopenia (n = 2; including one grade 4 platelet count decreased) and a combination of grade 4 thrombocytopenia and grade 3 neutropenia occurred in 3 patients. Ceralasertib was quickly absorbed (tmax ∼1 hour), with a terminal plasma half-life of 8–11 hours. Upregulation of pRAD50, indicative of ataxia telangiectasia mutated (ATM) activation, was observed in tumor biopsies during ceralasertib treatment. Two patients with absent or low ATM or SLFN11 protein expression achieved confirmed RECIST v1.1 partial responses. Eighteen of 34 (53%) response-evaluable patients had RECIST v1.1 stable disease. Conclusions: The RP2D for ceralasertib plus carboplatin was established as ceralasertib 40 mg once daily on days 1–2 administered with carboplatin AUC5 every 3 weeks, with pharmacokinetic and pharmacodynamic studies confirming pharmacodynamic modulation and preliminary evidence of antitumor activity observed.

PURPOSE Some gastric cancers harbor MET gene amplifications that can be targeted by selective MET inhibitors to achieve tumor responses, but resistance eventually develops. Savolitinib, a selective MET inhibitor, is beneficial for treating patients with MET-driven gastric cancer. Understanding the resistance mechanisms is important for optimizing postfailure treatment options. PATIENTS AND METHODS Here, we identified the mechanisms of acquired resistance to savolitinib in 3 patients with gastric cancer and MET-amplified tumors who showed a clinical response and then cancer progression. Longitudinal circulating tumor DNA (ctDNA) is useful for monitoring resistance during treatment and progression when rebiopsy cannot be performed. RESULTS Using a next-generation sequencing 100-gene panel, we identified the target mechanisms of resistance MET D1228V/N/H and Y1230C mutations or high copy number MET gene amplifications that emerge when resistance to savolitinib develops in patients with MET-amplified gastric cancer. CONCLUSION We demonstrated the utility of ctDNA in gastric cancer and confirmed this approach using baseline tumor tissue or rebiopsy.

DNA-dependent protein kinase (DNA-PK) is a critical player in the DNA damage response (DDR) and instrumental in the non-homologous end-joining pathway (NHEJ) used to detect and repair DNA double-strand breaks (DSBs). We demonstrate that the potent and highly selective DNA-PK inhibitor, AZD7648, is an efficient sensitizer of radiation- and doxorubicin-induced DNA damage, with combinations in xenograft and patient-derived xenograft (PDX) models inducing sustained regressions. Using ATM-deficient cells, we demonstrate that AZD7648, in combination with the PARP inhibitor olaparib, increases genomic instability, resulting in cell growth inhibition and apoptosis. AZD7648 enhanced olaparib efficacy across a range of doses and schedules in xenograft and PDX models, enabling sustained tumour regression and providing a clear rationale for its clinical investigation. Through its differentiated mechanism of action as an NHEJ inhibitor, AZD7648 complements the current armamentarium of DDR-targeted agents and has potential in combination with these agents to achieve deeper responses to current therapies., DNA-dependent protein kinase (DNA-PK) plays a major role in the DNA damage response upon double-strand break formation. Here, the authors show that the DNA-PK inhibitor AZD7648, enhances the activity of radiotherapy, chemotherapy and the PARP inhibitor olaparib in multiple mouse tumour models.

Genomic profiling of tumours in patients in clinical trials enables rapid testing of multiple hypotheses to confirm which genomic events determine likely responder groups for targeted agents. A key challenge of this new capability is defining which specific genomic events should be classified as 'actionable' (that is, potentially responsive to a targeted therapy), especially when looking for early indications of patient subgroups likely to be responsive to new drugs. This Opinion article discusses some of the different approaches being taken in early clinical development to define actionable mutations, and describes our strategy to address this challenge in early-stage exploratory clinical trials.

DNA-dependent kinase (DNA-PK) plays an important role in the cellular response to DNA damage through the detection and repair of double strand breaks, and is a critical component of the DNA damage response (DDR). Double strand breaks can be induced by a range of agents, including chemotherapy, radiation or PARP inhibitors such as olaparib (Lynparza), and thus a DNA-PK inhibitor is likely to sensitise to these agents. DNA-PK inhibitors may also be effective as monotherapy in tumours with high endogenous levels of DNA damage resulting from defects in other DNA repair pathways. Our screening strategy focussed on identifying hits with good selectivity versus structurally related kinases. Significant improvements were made to permeability, metabolic stability and PK properties, whilst improving potency and selectivity with a structure-guided approach. This optimisation resulted in AZD7648, which is a potent inhibitor of DNA-PK (0.6 nM in biochemical assay, 89 nM in A549 cells) and >100x selective against 396 other kinases in a Thermofisher selectivity panel. In addition, AZD7648 has good crystalline solubility, metabolic stability and predictable pharmacokinetics in preclinical species. In murine xenograft models, PD was assessed using pRPA (S4/8) and was potently inhibited (in vivo IC50 = 52 nM). Tumour growth inhibition was observed with AZD7648 as monotherapy, and regressions were observed in combination with either olaparib or radiation. The efficacy observed when combining AZD7648 with olaparib was correlated to free cover over the in vivo IC90. AZD7648 is a potent and highly selective DNA-PK inhibitor, with good crystalline solubility, permeability and metabolic stability, good bioavailability and predictable pharmacokinetics in preclinical species, and potent knockdown of pRPA and regressions in murine xenograft models when combining with olaparib or radiation. These features make AZD7648 a suitable clinical candidate, and clinical studies evaluating AZD7648 as a potential cancer treatment are planned in 2019. Citation Format: Frederick W. Goldberg, Elaine Cadogan, Raymond Finlay, Antonio Ramos Montoya, David Beattie, Gillian Lamont, Charlene Fallan, Jacqueline Fok, Mercedes Vazquez-Chantada, Derek Barratt, Emma Dean, Jane Norris, Andrew Campbell, Anna Cronin, Joanna Harding, Attilla Ting, Simon Hollingsworth, Barry Davies. Discovery and first structural disclosure of AZD7648: A potent and selective DNA-PK inhibitor [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr DDT01-02.

DNA-dependent kinase (DNA-PK) is a nuclear serine/threonine protein kinase complex that is a key component of the non-homologous end joining (NHEJ) process. DNA-PK plays an important role in the cellular response to DNA damage through the detection and repair of DNA double strand breaks (DSB). Cancer therapies such as ionising radiation (IR) or topoisomerase II inhibitors (doxorubicin) generate DSB which can be repaired by homologous recombination (HR) or non-homologous end-joining (NHEJ). It can therefore be hypothesised a DNA-PK inhibitor would potentiate the activity of these agents. We have developed a highly potent and selective inhibitor of DNA-PK, AZD7648, which inhibits IR-induced DNA-PK S2056 auto phosphoryalation with an IC50 = 92 nM in A549 non-small cell lung cancer (NSCLC) cells. AZD7648 is a potent radiosensitiser where treatment in combination with IR led to a concentration-dependent reduction of the colony survival capacity of A549 and H1299 NSCLC cells (DEF37 at 100 nM = 1.7 and 2.5, respectively). In A549 cells, AZD7648 (≥1 µM) in combination with 2Gy IR for 48 hours led to a significant accumulation of cells arrested in the G2/M of the cell cycle, a 4-fold increase in micronuclei formation, and 3-fold induction of γH2AX, pATM S1981 and 53BP1 foci formation compared with IR alone. AZD7648 was also found to combine synergistically with doxorubicin in a panel of ovarian and triple negative breast cancer (TNBC) cell lines in cell growth inhibition assays when applying the Loewe additivity model (synergy scores 4 - 35). In vivo the combination of AZD7648 with IR (5x 2Gy) induced tumour regression in H1299 and A549 NSCLC xenografts in a dose-dependent manner (84 and 11% regression respectively), while monotherapy treatment only achieved tumour growth inhibition. In these two models the increased activation by IR of three primary DNA-PK pharmacodynamic markers, pDNAPK (S2056), pRPA32 (S4/8) and γH2AX, was inhibited by AZD7648 treatment (70-90% inhibition 2 h after IR + AZD7648). Similarly, liposomal doxorubicin (2.5 mg/kg weekly) in combination with AZD7648 (37.5 mg/kg bid) induced tumour regressions in the BT474c ER+ breast cancer xenograft model and in a TNBC PDX model (63% and 33% regression respectively), while monotherapy treatments only achieved tumour growth inhibition. These data confirm that DNA-PK inhibition with AZD7648 enhances the efficacy of a range of DSB inducing agents in vitro and in vivo, providing a clear rationale for its clinical investigation. Citation Format: Jacqueline H. Fok, Antonio Ramos-Montoya, Neil James, Mercedes Vazquez-Chantada, Valeria Follia, Ankur Karmokar, Anna Staniszewska, Lenka Oplustil O’Connor, Emma Dean, Simon J. Hollingsworth, Barry R. Davies, Elaine B. Cadogan. AZD7648, a potent and selective inhibitor of DNA-PK, potentiates the activity of ionising radiation and doxorubicin in vitro and causes tumour regression in xenograft models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3512.

DNA-dependent kinase (DNA-PK) is a nuclear serine/threonine protein kinase complex and a key component of the non-homologous end joining (NHEJ) process. DNA-PK plays an important role in the cellular response to DNA damage through the detection and repair of double strand breaks (DSB). DSB can be induced by a range of agents, including chemotherapy and radiation. The PARP inhibitor olaparib has also been shown to induce DSB as a consequence of trapping PARP proteins at sites of damaged DNA. Therefore, we hypothesised that DNA-PK inhibitors may combine therapeutically with PARP inhibitors. AZD7648 is a highly potent and selective inhibitor of DNA-PK (pDNA-PK cell IC50 = 92 nM) The combination treatment of AZD7648 with olaparib for 10 - 12 days in vitro leads to at least 20% greater cell growth inhibition compared with either agents as monotherapies in a panel of cell lines with deficiencies in the ATM pathway (e.g. cells lacking ATM protein or where ATM substrates are not phosphorylated after exposure to DSB inducing agents). This effect is also seen in isogenic ATM knock-out (KO) FaDu head and neck and A549 non-small cell lung cancer cell lines. At concentrations of AZD7648 (0.6 - 2 µM) and olaparib (1 µM) that have monotherapy activity in the ATM KO cells but not in their wild-type counterparts (WT), the combination treatment enhanced the G2/M cell cycle arrest caused by olaparib and led to greater levels of micronuclei formation as detected using high-content immunofluorescece assays (mean per cell: FaDu WT = 0.1, FaDu ATM KO = 0.4). This was associated with a larger quantity of chromosomal aberrations in the ATM KO versus WT cells following combination treatment detected by metaphase spread analysis (mean per cell: FaDu ATM KO = 5.5, FaDu WT = 1.2). The same phenotype was observed in A549 ATM KO versus WT cell lines. In vivo, continuous dosing of AZD7648 (75 mg/kg bid) in combination with olaparib (100 mg/kg qd) inhibited the growth of FaDu WT tumours by ~60%. However, in the FaDu ATM KO tumours complete regressions were seen after 70 days of dosing and no re-growth was detected up to 220 days later. Additionally, in PDX models of breast, lung, ovarian and head and neck cancer this combination showed tumour growth inhibition (50-100%) in 13 models and regression in 5 models, only one of these five models being ATM pathway deficient. These data confirm that DNA-PK inhibition using AZD7648 enhances the efficacy of olaparib in vitro and in vivo, providing a clear rationale for its clinical investigation. Citation Format: Antonio Ramos-Montoya, Jacqueline H. Fok, Neil James, Valeria Follia, Mercedes Vazquez-Chantada, Paul Wijnhoven, Lenka Oplustil O’Connor, Ankur Karmokar, Anna Staniszewska, Emma Dean, Simon J. Hollingsworth, Barry Davies, Elaine B. Cadogan. AZD7648, a potent and selective inhibitor of DNA-PK, potentiates activity of the PARP inhibitor olaparib resulting in sustained anti-tumour activity in xenograft and PDX models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3506.

DNA-dependent kinase (DNA-PK) is a nuclear serine/threonine protein kinase complex that is a key component of the non-homologous end joining (NHEJ) process. DNA-PK plays an important role in the cellular response to DNA damage through the detection and repair of DNA double strand breaks (DSB) and is a critical component of the DNA Damage Response (DDR). DSB can be induced by a range of agents, including chemotherapy, radiation or Poly ADP Ribose Polymerase (PARP) inhibitors such as olaparib, and thus a DNA-PK inhibitor is likely to sensitize to these agents. DNA-PK inhibitors may also be effective as monotherapy in tumors with high endogenous levels of DNA damage resulting from defects in other DNA repair pathways. We have developed a highly potent and selective inhibitor of DNA-PK, AZD7648 (pDNA-PK IC50 in A549 cells = 92 nM). AZD7648 shows broad growth inhibitory activity across a panel of 244 cancer cell lines (GI50 1.3 - 30 µM). Consistent with known synthetic lethal interactions with DNA-PK, AZD7648 shows a 10-13-fold greater growth inhibitory effect in FaDu head and neck and A549 non-small cell lung cancer cell lines with ATM knocked out (KO) by zinc finger nuclease or CRISPR respectively compared to their isogenic wild-type counterparts (WT). This growth inhibition is associated with increased levels of DNA damage as measured by micronuclei formation detected using high-content immunofluorescence (2-fold increase vs DMSO at 2 µM AZD7648). Moreover, a 6-fold increase in chromosomal breaks are detected in the ATM KO cells using metaphase spread analysis (mean breaks/cell: FaDu ATM KO = 1.7, ATM WT = 0.28) In vivo, monotherapy treatment with AZD7648 (75-100 mg/kg bid) inhibited tumor growth in a panel of 14 PDX and 2 xenograft models, derived from breast, lung, ovarian and head and neck cancers. This included models with and without loss of ATM. Treatment with AZD7648 resulted in dose-dependent inhibition of the phosphorylation of DNA-PK (S2056), RPA32 (S4/8) and nuclear γH2AX in FaDu ATM KO xenografts, where AZD7648 75mg/kg inhibited γH2AX and phosphorylation of DNA-PK (S2056) and RPA32 (S4/8) by 71, 98 and 95% respectively at 2 h after dosing. These data confirm that DNAPK inhibition using AZD7648 has potent pharmacodynamic and monotherapy anti-tumor activity in a range of pre-clinical models. This includes, but is not restricted to, models with engineered and endogenous loss of ATM. Citation Format: Elaine B. Cadogan, Jacqueline H. Fok, Antonio Ramos-Montoya, Neil James, Valeria Follia, Mercedes Vazquez-Chantada, Paul Winjhoven, Lenka Oplustil O’Connor, Ankur Karmokar, Anna Staniszewska, Emma Dean, Simon J. Hollingsworth, Barry Davies. AZD7648: A potent and selective inhibitor of DNA-PK with pharmacodynamic and monotherapy anti-tumor activity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3505.

TPS1112 Background: TNBC comprises ≈15% of invasive breast cancer cases and alterations in BRCA1/ 2 are associated with ≈5% of all BCs. Ola (a poly ADP-ribose polymerase inhibitor [PARPi]) is approved for treating pts with HER2-negative metastatic BC with a germline BRCA mutation (g BRCAm), demonstrating an improvement in progression-free survival (PFS). Alterations in other non- BRCA1/2 homologous recombination repair (HRR)-related genes (non- BRCA HRRm) may also confer sensitivity to Ola therapy in pts with TNBC. Ola, AZD1775 (a WEE1 checkpoint inhibitor) and AZD6738 (an ataxia telangiectasia and Rad3-related protein inhibitor) target DNA damage repair and cell cycle regulation. Preclinical studies in TNBC models show synergistic antitumor effects of Ola+AZD1775 and Ola+AZD6738, vs Ola monotherapy supporting the clinical evaluation of these combinations. Methods: VIOLETTE is a global, multicenter, open-label, phase II study (NCT03330847) randomising 1:1:1 450 pts with advanced TNBC to 3 treatment arms: 1) Ola 200 mg bid daily + AZD1775 150 mg bid D1-3, D8-10 q21, 2) Ola 300 mg bid daily + AZD6738 160 mg qd D1-7 q28, or 3) Ola 300 mg bid daily q28. All pts will be stratified by prior platinum exposure. Each treatment arm of ≈150 pts will be comprised of 3 biomarker strata of ≈50 pts each (A: BRCAm; B: non- BRCA HRRm; C: non-HRRm). Centralized tumor molecular testing will be deployed to detect mutation(s) in 15 HRR genes. Eligible pts will have received 1-2 prior lines of chemotherapy for metastatic disease, including an anthracycline or taxane. Exclusion criteria include prior PARPi therapy. The primary endpoint is PFS (each combination vs Ola alone) assessed by blinded, independent central review (RECIST v1.1). Secondary endpoints are objective response rate, duration of response, change in tumor size, and overall survival for comparisons between combinations and for each combination vs Ola alone; drug exposure; and safety and tolerability. The first prespecified futility analysis in Stratum C has met the recruitment target and will be assessed by unblinded review April 2019. Clinical trial information: NCT03330847.

Targeted therapies provide clinical benefit and improved therapeutic index. They have a growing prominence in patient management and focus in drug development. Their development is fuelled by our deepening knowledge of complex disease phenotypes and the need for improvement in new therapeutic efficacy. Extrapolation of the biological discovery through to new therapy targeting the causal biological variants to drive clinical gain is challenging. Here, we review the impact of germline mutations on targeted therapies. Historically, germline changes have contributed most to our understanding of disease mechanisms, drug metabolism and exposure, the latter of which has enabled safer positioning of therapies, such as clopidogrel and irinotecan. Similarly, prescreening for germline variants can avoid potentially fatal hypersensitivity reactions with abacavir. However, germline mutations continue to emerge as a central player in targeting therapeutics; ivacaftor drives partial restoration of mucus secretion in cystic fibrosis patients harbouring specific mutations, and treatment with olaparib exploits germline mutations in BRCA genes to drive synthetic lethality as an anti-cancer mechanism. Central is definition of the causal link, association or contribution to the biological variance – and that we believe it is drugable for therapeutic gain. The demand for better therapies to treat modern diseases provides the appetite for continued investigation of the biological variance associated with germline mutations, inevitably leading to increased impact on the development of targeted therapeutics. Copyright © 2013 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Bruton tyrosine kinase (BTK) is an essential kinase in the B-cell receptor (BCR) signalling pathway. Acalabrutinib is a potent and highly selective irreversible BTK inhibitor that received accelerated approval by FDA for the treatment of Relapsed/Refractory Mantle Cell Lymphoma. It is proposed to be combined with the Ataxia telangiectasia and Rad3-related (ATR) kinase inhibitor AZD6738, in a Phase I/II proof of concept clinical trial to assess safety and efficacy in patients with B-cell malignancies. ATR is a key regulator of DNA replication, repair and cell cycle checkpoints. The Activated B-Cell (ABC) subtype of Diffuse Large B-Cell Lymphoma (DLBCL) is associated with chronic active BCR signalling, and given our previous identification of sensitivity to AZD6738 in ABC-DLBCL cell lines, we hypothesised that combination with acalabrutinib may have additional therapeutic benefit. Here we report preliminary data to support combination efficacy in models of ABC-type DLBCL. The growth inhibitory and cell kill effect of AZD6738 and acalabrutinib in combination was assessed in 3 ABC and 4 GCB DLBCL cell lines. Combination activity and cell kill was detected specifically in the ABC-type TMD8 cell line. Using flow cytometry, we show that the cell kill effects of the drug combination were dependent on dose and schedule. Single agent treatment with 5 nM acalabrutinib or 0.5 µM AZD6738 for 72 h, caused cell death in 12% and 17% of cells respectively. The equivalent doses given in combination for 72 h induced cell death in 39% of cells, indicative of a greater than additive effect. Cell killing was increased with longer co-exposure to the combination, shown by an increase in cell death from 18% at 24 h, to 30% at 48 h. Acalabrutinib is dosed on a BID schedule, thus we tested whether its activity in combination with AZD6738 was affected by pre- or post-addition of acalabrutinib. A 24 h pre-treatment of cells with acalabrutinib, followed by the combination of AZD6738 and acalabrutinib for 48 h resulted in 20% cell death, whereas 48 h combination treatment followed by 24 h acalabrutinib monotherapy caused a similar 27% increase in death, suggesting that combination efficacy is not dependent on sequence of drug administration. Furthermore, the mRNA expression of BTK target genes in ABC-DLBCL cell lines was modulated by acalabrutinib, however there was no additional modulation to this pathway by the combination with AZD6738, suggesting the two agents kill cells through different mechanisms of action. In the TMD8 xenograft mouse model, daily dosing of AZD6738 (25 mg/kg) with twice daily dosing of acalabrutinib (20 mg/kg) was well tolerated and resulted in complete and durable tumor regressions (8/8 tumors), whereas single agent treatments resulted in tumor growth delay. Collectively, our preliminary data support a rationale for combining BTK and ATR inhibitors for an effective and alternative treatment option in ABC-DLBCL. Citation Format: Lucy A. Young, Oona Delpuech, Brandon Willis, Alexandra Bussey, Zena Wilson, Michelle Dupont, Carlos Grajales, Andrew Bloecher, Todd Covey, Kate Wills, Alan Lau, Simon J. Hollingsworth. Preclinical efficacy of the ATR inhibitor AZD6738 in combination with the BTK inhibitor acalabrutinib in ABC-DLBCL models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr LB-263.

The poly(ADP-ribose polymerase) (PARP) inhibitor olaparib is FDA approved for the treatment of BRCA-mutated ovarian cancers. Olaparib inhibits PARP function during DNA single-strand-break repair and also by trapping of PARP on DNA to create lesions. These complexes cause replication-associated DNA damage including stalling and collapse of DNA replication forks. Cells which have lost BRCA1/2-dependent homologous recombination repair are highly sensitive to olaparib. In addition, other DNA damage response (DDR) pathways mediated by the ataxia telangiectasia mutated (ATM) and ataxia telangiectasia mutated and Rad3-related (ATR) kinases are hypothesised to be important survival pathways in response to PARP inhibitor treatment. Here we show that olaparib combines synergistically with the orally bioavailable ATR inhibitor AZD6738, in vitro, leading to cell death in ATM-deficient backgrounds. The growth inhibitory and cell kill effect of a range of concentrations of AZD6738 (0.01-1 µM) and olaparib (0.03-3 µM) were assessed using the Loewe model of additivity in the isogenic ATM knockout (KO) and wildtype (WT) FaDu head and neck cancer cell lines. The combination of AZD6738 and olaparib induced cell death in the ATM KO cells across a wide range of concentrations, with 3 µM olaparib plus 1 µM AZD6738 inducing 84% cell kill, in contrast to only 37% growth inhibition in the ATM WT cells. The observed combination synergy in the ATM KO cells is a result of increased DNA replication-associated DNA damage together with abrogation of the G2-M checkpoint activated by olaparib. Olaparib treatment led to a 10 and 20% increase in G2 cells at 24 hours in the ATM KO and ATM WT FaDu cell lines respectively, however co-administration of AZD6738 (0.1-0.3 µM) completely released the olaparib treated cells from the G2 arrest. DNA metaphase spread analysis showed that combination treatment with olaparib (1 µM) plus AZD6738 (0.1 µM) in the ATM KO cells caused 12.8 chromosomal DNA aberrations per cell compared to 4.4 or 3.3 aberrations per cell when treated with olaparib or AZD6738 alone respectively (n = 2). In contrast, in the ATM WT cells the olaparib plus AZD6738 combination treatment caused only 1.5 chromosomal aberrations per cell. Collectively, these data show that olaparib-induced DNA damage activates an ATR-dependent G2-M checkpoint allowing time to repair damaged DNA, and that AZD6738 abrogates this checkpoint, permitting cells to undergo mitosis in the presence of DNA damage leading to increased chromosomal aberrations. These data provide a mechanistic understanding of the combination and supports the clinical line of sight for the development of AZD6738 in combination with olaparib. Citation Format: Rebecca Lloyd, Katarynza Falenta, Paul W. Wijnhoven, Christophe Chabbert, Jonathan Stott, James Yates, Alan Y. Lau, Lucy A. Young, Simon J. Hollingsworth. The PARP inhibitor olaparib is synergistic with the ATR inhibitor AZD6738 in ATM deficient cancer cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 337.

Introduction: AZD6738 is a potent inhibitor of the ATR protein kinase that is being tested in patients with solid malignancies. In Phase I dose escalation studies, AZD6738 was dosed as monotherapy (continuous schedule from 40 - 480 mg per day), or in combination (intermittent schedule from 80 - 320 mg per day) with olaparib, durvalumab, carboplatin, or radiation. In those studies, thrombocytopenia was the main dose limiting toxicity and changes in peripheral monocytes and proliferating T-cells were seen with AZD6738, with up to 80% decrease on-drug and return to baseline upon cessation of dosing. This effect on monocytes and proliferating T cells was not observed with either single agent olaparib or durvalumab. Based on these observations, we developed two PKPD models linking AZD6738 dose, AZD6738 plasma exposure, and differential blood cell counts to support dose and schedule selection. Methods and Results: The first model characterized the quantitative relationship between the plasma exposure of AZD6738 monotherapy, and the difference between monocyte decrease (on-target activity) and platelet decrease (on-target toxicity). This model was a sigmoid function and predicted biological activity starting at exposures of 2.5 ug/mL (aligned with the in vitro IC90 in LoVo cells, and obtained in ≥ 50% of patients with 80 mg per day) increasing in a concentration dependent manner to 10 ug/mL (obtained in almost all patients dosed at 480 mg per day), after which negligible monocyte response over platelet decrease was observed. Those data were consistent with the preclinical observations which showed tumour regression after at least 3-day concomitant treatment of olaparib and AZD6738 at exposure maintaining IC90 [1]. The second model was a PK-safety model describing the temporal relationship between circulating platelets and exposure of AZD6738 administered in combination with olaparib dosed at 300 mg twice daily continuously. This model allowed generation of various platelet/ time profiles in the most sensitive patient group (10% of the patients) for different AZD6738 doses and schedules. The simulations indicated that, for doses considered biologically relevant by the first model, a period of 21-days free of AZD6738 is needed to give full recovery of potential thrombocytopenia in a 28-day cycle. Conclusion: Using monocyte and proliferative T-cell decreases as biological activity indicators and platelet decrease as a safety indicator, we quantified the exposure/activity/safety relationship for AZD6738. The recommended Phase II dose of AZD6738 (in combination with olaparib) was then driven by maintaining maximally active exposure consistent with manageable safety. Reference: [1]. 2017 AACR Abstract 2494. Acknowledgements: T.A. Yap (The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK) and J.C. Soria (Institut Gustave Roussy, Paris, France) Citation Format: Alienor Berges, S. Y. Amy Cheung, Andrew J. Pierce, Emma Dean, Brunella Felicetti, Nathan Standifer, Simon Smith, James Yates, Alan Lau, Christine Stephens, Matthew Krebs, Kevin Harrington, Simon J. Hollingsworth. PK-Biomarker-Safety modelling aids choice of recommended Phase II dose and schedule for AZD6738 (ATR inhibitor) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT118.

Background: AZD6738 is a potent selective oral ATR inhibitor. Therapeutic combinations aim to inhibit ATR-dependent cycle arrest and repair induced by the PARP inhibitor Olaparib (Ola), and to exploit DNA damage-induced immune responses with the anti-PD-L1 antibody Durvalumab (Durva). Here we present the results of the ongoing Phase I study D5330C00004 (NCT02264678) dose escalation combinations of AZD6738 with Ola or Durva. Methods: A trial assessing AZD6738 in combination with continuous Ola tablets or Durva IV infusion per 28-day cycle. Pharmacokinetic (PK) and pharmacodynamic evaluations were conducted. Results: 70 pts with advanced cancer were treated with +Ola (45 pts) or +Durva (25 pts). Tumor types included breast, ovary, prostate, pancreas, lung, HNSCC and gastric cancers. +Ola: AZD6738 was assessed in 10 cohorts from 60 mg od to 240 mg bd for 5-14 days (D), co-dosing with Ola 100-300 mg bd continuously. All causality toxicity occurring in ≥20% subjects (pts with ≥G3 events) included: thrombocytopenia (5 pts), anemia (7 pts), neutropenia (6 pts), fatigue (1 pt), decreased appetite (1 pt), nausea, vomiting, constipation, diarrhea and cough. Thrombocytopenia and neutropenia were dose- and schedule limiting toxicities (DLTs). The Recommended Phase 2 Dose is AZD6738 160 mg od D1-7 + Ola 300 mg bd D1-28. Of 39 evaluable pts, 1 RECIST complete response (CR), 5 partial responses (PR) and 1 unconfirmed (uPR) were observed in pts with advanced breast (3 pts), ovarian, prostate, pancreatic and ampullary cancer and BRCA1/2 mutations independent of ATM status. Dose expansions are ongoing in pts with advanced gastric and breast cancer. +Durva: AZD6738 was evaluated in 5 cohorts with 1-2 weeks monotherapy run-in, followed by Durva 1500 mg on D1 + AZD6738 80-240 mg od or bd for 1 (D22-28) or 2 (D15-28) weeks. Toxicity occurring in ≥20% subjects included: anemia (≥G3 in 1 pt), fatigue, nausea, decreased appetite, cough, vomiting, dizziness, pruritus, constipation, diarrhea, musculoskeletal chest pain and dyspnea. One DLT of thrombocytopenia was observed. Of 21 pts, 1 RECIST CR, 2 PRs and 1 uPR were observed in pts with advanced NSCLC (3 pts) and HNSCC (1 pt), independent of tumor PD-L1 expression. Peripheral monocytes and proliferating T-cells were suppressed; both rebounding to levels ≥ baseline during the off-drug interval. GM-CSF increased reciprocally to on-target decreases in monocytes. Preliminary PK data showed rapid absorption of AZD6738 with peak plasma concentration ≈1.5h post dose, a biphasic decline with an elimination half-life of 11h. Despite ≈45% variability in clearance, there was dose proportionality and no evidence of drug-drug interaction with Ola or Durva. Conclusions: The combinations of AZD6738 with Ola or Durva were tolerated in dose escalation with preliminary signals of antitumor activity in pts with advanced solid tumors. Citation Format: Matthew G. Krebs, Juanita Lopez, Anthony El-Khoueiry, Yung-Jue Bang, Sophie Postel-Vinay, Wassim Abida, Louise Carter, Wen Xu, Seock-Ah Im, Andrew Pierce, Paul Frewer, Alienor Berges, S.Y. Amy Cheung, Christine Stephens, Brunella Felicetti, Emma Dean, Simon J. Hollingsworth. Phase I study of AZD6738, an inhibitor of ataxia telangiectasia Rad3-related (ATR), in combination with olaparib or durvalumab in patients (pts) with advanced solid cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT026.

Background: The annual incidence of head and neck cancers is >550,000 cases worldwide and approximately 90% are HNSCC. Treatment for locoregionally advanced (stage III/IV) HNSCC involves primary surgery, radiation and/or chemotherapy. Cancer cells with DDR defects can activate the immune system and immunotherapy (IO) has shown therapeutic benefit in pts with advanced recurrent HNSCC. This study assesses the immunological effects of DDR agents in both tumor tissue and peripheral blood samples to inform optimal combinations with IO therapies. The overall hypothesis is that DDR agents will convert an “immunologically cold” tumor into an “immunologically hot” tumor that is both responsive to IO and improved prognosis. Objectives: The primary objective is to assess immune activation due to DDR inhibition by monitoring the induction of genes interacting with the immune system and potentially linked to prognosis. The secondary objective is to assess increasing prevalence of tumor infiltrating CD8+ and CD3+ T-cells also linked to prognosis. Exploratory measurements of tumour proliferative and DDR-relevant markers, peripheral T/B/NK and regulatory T cells, key immuno-regulatory cytokines, TCR repertoire, levels of circulating tumour cells and relevant genomic changes in both tumour and circulating tumour DNA will be conducted. Safety and tolerability of the investigational agents is also monitored. Methods: This ongoing, randomised multi-centre, window of opportunity biomarker study is enrolling patients with newly diagnosed, treatment naïve, HNSCC suitable for surgical resection followed by radiotherapy and/or chemotherapy (NCT03022409). Two oral DDR agents are currently under evaluation as monotherapy: AZD6738 is a potent selective inhibitor of the serine/threonine-specific protein kinase, ataxia telangiectasia and Rad3-related protein (ATR), and olaparib is a poly-ADP ribose polymerase (PARP) inhibitor. Eligible pts are randomised to receive a DDR agent for between 10 to 21 days (D), followed by surgery. After surgery, pts do not receive further investigational treatment and attend a follow-up visit at D31. Tumor tissue is collected pre- (archival diagnostic biopsy) and post-treatment (surgical specimen), and evaluated for changes in key biomarkers related to immune response and DNA damage inhibition. If surgery is scheduled between D11-21 (+3D) following three successive days of DDR agent, an on-treatment biopsy is also required between D10-12. Pts undergo a weekly assessment for adverse events, hematology, biochemistry, and electrocardiogram. Plasma samples are also included to characterise the pharmacokinetics of each agent, relative to any biomarker changes observed. Enrolment commenced in December 2017 and the study is designed to permit the addition of treatment arms, including different combinations, sequences and doses. Citation Format: Umamaheswar Duvvuri, Emma Dean, Paul Frewer, Alienor Berges, S. Y. Cheung, Christine Stephens, Musaddiq Khan, Simon J. Hollingsworth, Andrew J. Pierce. A pre-surgical window of opportunity study to investigate the biomarker effects of DNA damage response (DDR) agents in patients (pts) with head and neck squamous cell carcinoma (HNSCC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT135.

4061Background: This trial was a phase II study with selumetinib (AZD6244)/docetaxel as second-line treatment for metastatic GC patients with MEK signature or RAS gene alterations as part of the GC...

TPS1116Background: Invasive BC is diagnosed in > 255,000 pts in the US annually, and TNBC comprises ≈15% of cases. Alterations in BRCA1/2 are associated with ≈5% of all BCs. Ola (a poly ADP-ribose ...

The drivers of precision medicine are clear: for patients (and physicians) - more options, durable clinical benefit, reduced exposure to non-effective drugs and potential to leverage current scientific and technological advances; for the pharmaceutical industry - the potential to tackle core challenges in discovering and developing better and more efficacious medicines, to reduce rates of attrition in drug development and to reduce development costs; for healthcare systems and payers - improved efficiency through the provision of effective care and avoiding ineffective treatments. Oncology has been at the vanguard, the improvements gained in patient survival notable. However, the increasing number of molecular subgroups requires an equally increasing number (and new generation) of highly selective agents targeting inevitably lower incidence molecular segments. Innovative trial designs (umbrella/basket studies) are emerging as a patient-centric approach to drug development, and the rise in public-private partnerships, cross-industry, government and non-profit sector collaborations is enabling implementation of complex clinical trial designs. This poses significant challenges for healthcare systems and regulatory approval. Further substantial evolution of policy and processes, particularly regulatory requirements for approval for new therapeutics, are required.

© 2015 Macmillan Publishers Limited. All rights reserved. An enhanced understanding of the molecular pathology of disease gained from genomic studies is facilitating the development of treatments that target discrete molecular subclasses of tumours. Considerable associated challenges include how to advance and implement targeted drug-development strategies. Precision medicine centres on delivering the most appropriate therapy to a patient on the basis of clinical and molecular features of their disease. The development of therapeutic agents that target molecular mechanisms is driving innovation in clinical-trial strategies. Although progress has been made, modifications to existing core paradigms in oncology drug development will be required to realize fully the promise of precision medicine.

A rapid expansion in precision medicine founded on the potential for durable clinical benefit through matching a drug to a predictive marker used to select patients has driven the development of targeted drugs with accompanied companion diagnostics for patient selection. Oncology has been at the forefront, with the improvements in patient survival notable. Increasing numbers of molecular subgroups require an equally increasing number (and new generation) of highly selective agents targeting inevitably lower incidence molecular segments, posing significant challenges for drug development. Innovative trial designs (umbrella or basket studies) are emerging as patient-centric approaches and public-private partnerships, cross-industry, government and non-profit sector collaborations are enabling implementation. Success will require continued innovation, new paradigms in oncology drug development and market approval and continued collaboration.

4024 Background: The VIKTORY trial is a biomarker-based umbrella trial in GC. Methods: See table below. Results: From June 2014 to Jan 2017, 432 metastatic gastric cancer patients were enrolled. 124 (28.7%) were treated on one of the associated study protocols. At January 2017, 25 pts were allocated to selumetinib/paclitaxel arm, 25 to AZD1775/paclitaxel arm, 16 to AZD5363/paclitaxel arm, 16 to vistusertib/paclitaxel arm, 4 to savolitinib monotherapy, 19 to savolitinib/docetaxel arm, 19 to phase I AZD6738/paclitaxel arm. Initial efficacy signals have been seen in several arms (selumetinib/paclitaxel, 6 of 21 evaluable patients in PR). Correlative analyses between molecular signatures and treatment response are ongoing and will be presented at the meeting. For vistusertib/paclitaxel in the biomarker negative arm, we found RICTOR amplification as a promising predictive biomarker for response. Two (of three) GC patients with RICTOR amplification achieved PR to vistusertib/paclitaxel. Conclusions: This is one of the first attempts to undertake a biomarker-driven trial in metastatic GC. 28.7% of the patients were guided to one of the parallel arms based on molecular screening outcomes. We were able to identify potential molecular targets in the biomarker-negative arm, for further assessment in new protocols. Clinical trial information: 02299648. [Table: see text]

e14063 Background: AZD6738 is a potent, selective inhibitor of the ataxia telangiectasia and Rad3-related (ATR) serine/threonine-specific protein kinase with good selectivity against other phosphatidylinositol 3-kinase-related kinase (PIKK) family members. To support dose/schedule guidance through mathematical modelling of clinical pharmacokinetic/pharmacodynamic relationships, we sought to determine quantitative pharmacodynamic effects of AZD6738 in peripheral blood with respect to drug exposure. Methods: We assessed peripheral blood cell subpopulations in clinical studies of AZD6738 used either as a monotherapy, a combination with the PARP-1 inhibitor olaparib and in combination with the PD-L1 inhibitor durvalumab through both blood analyser and flow cytometry characterization. Peripheral pharmacokinetics of AZD6738 were also assessed. Results: Levels of peripheral monocytes were suppressed in a dose-dependent manner for the duration of AZD6738 dosing resulting in a decrease of up to 80% within the first 7 consecutive days of AZD6738 treatment; these results were consistent across studies. Upon cessation of an AZD6738 dosing interval monocyte levels return to baseline values within 14 days; in combination with durvalumab there is a trend for the rebound in monocyte counts to surpass baseline levels by up to 20%. Monocyte suppression is specific to AZD6738 and not found with either single agent olaparib or single agent durvalumab, possibly attributable to defective base excision repair in monocytes and lack of PARP-1. Monocytes were found to be the most sensitive cell type to AZD6738 treatment compared with neutrophils, platelets, haemoglobin or lymphocytes. Conclusions: This drug effect of AZD6738 is consistent with natural clearance of peripheral monocytes under suppression of monocyte precursor proliferation in the bone marrow, suggestive of a change in the equilibrium between production and elimination of peripheral monocytes. Used as a surrogate marker of target inhibition, a mathematical model of the AZD6738/monocyte dose-exposure-response relationship is described and has been used to inform AZD6738 Phase 2 dose and schedule.

We define a companion diagnostics (CDx)5 test as any diagnostic tool that guides the selection of patient treatment. In the US, these tests include diagnostics cleared by the Food and Drug Administration (FDA), as well as laboratory-developed tests (LDTs) run in CLIA-accredited laboratories. The answer to the title's question is obviously in the affirmative. We discuss the growing need to improve, accelerate, and standardize oncology CDx that benefit patients. Recent advances in our understanding of the mutational landscape of cancers have led to the rapid development of targeted therapies for pathogenomic targets. At the same time, advances in next-generation sequencing (NGS) have revealed the complexity of heterogeneous cancers. With the fast pace of change occurring in clinical oncology, flexible approaches to CDx development are needed while test accuracy is maintained for delivering precision medicine to patients. The remarkable efficacies of new targeted therapies have recently changed the paradigm for oncology to one of matching the right patient with the right therapy (1). This approach requires robust laboratory testing of patient samples. FDA-cleared tests exist for a limited number of markers (Table 1). In contrast, LDTs developed in CLIA-certified laboratories are used for >2000 genetic tests (2). LDTs are currently used in oncology for patient care and in clinical trials, which are now evaluating >500 agents targeting >100 genomic alterations. View this table: Table 1. Select list of CDx used for selection of targeted therapies.a The recent success in the development of 2 targeted therapies, crizotinib and vemurafenib, exemplifies the CDx process in which the FDA has co-cleared a diagnostic test (3, 4). The development of the CDx included analytical validation and elements of quality systems (good manufacturing practice, design control, personnel, software, instrumentation, and other parameters) as critical components of the regulatory package. The tests were used to recruit patients to pivotal phase II trials for the presence of the mutation/gene fusion. The …