Twenty-five years with companion diagnostics.

For decades, pharmacotherapy has been hampered by significant patient variability, and the inability to predict outcomes at the individual patient level has negatively affected its value. However, progress in molecular medicine has led to an increased understanding of the pathophysiology and mechanisms of action of drugs, thereby enabling the development of predictive biomarkers. Companion diagnostics (CDx) belongs to the group of predictive biomarkers, which the Food and Drug Administration (FDA) defines as an in vitro diagnostic device that provides information that is essential for the safe and effective use of a corresponding therapeutic product. In September 1998, 25 years ago, the FDA approved the first CDx assay, the HercepTest, an immunohistochemical (IHC) assay for the detection of HER2 protein expression. This assay is linked to the use of the monoclonal antibody trastuzumab in the treatment of HER2 positive breast cancer. The HercepTest is not the only CDx developed. Currently, more than 60 drugs or drug combinations, primarily in hematology and oncology, have been approved by the FDA, with CDx assays linked to their use. The current article briefly discusses the subject of CDx and provides an overview of its evolution over the past 25 years, with particular emphasis on the United States.

A Companion Diagnostic With Significant Clinical Impact in Treatment of Breast and Gastric Cancer.

The development of trastuzumab (Herceptin®) was one of the most significant cancer drug development projects of the 20th century. Not only was it a scientific and medical achievement but it also paved the way for the drug-diagnostic codevelopment model, where a predictive biomarker assay is developed in parallel to the drug. One of the challenges in the development of trastuzumab was to select the right patient population likely to respond and here, it was critical to have access to an accurate, robust and reliable assay for detection of HER2 overexpression in tumors. In the clinical development of trastuzumab, a clinical trial assay (CTA), developed by Genentech, was used for selection of HER2 positive patients. However, during the phase III trial with trastuzumab, a new optimized IHC assay, HercepTest™ was designed and developed by Dako. In the final stage of its development, a comparative study with the CTA was conducted in order to show concordance between the two assays. In September 1998, the Food and Drug Administration (FDA) simultaneously granted approval to trastuzumab and HercepTest™. The assay has been used for patient selection in a number of significant breast cancer clinical trials such as the HERA, CLEOPATRA, EMILIA and more. In these trials, HercepTest™ demonstrated its clinical utility in the neoadjuvant, adjuvant, and metastatic setting as well as in relation to different types of HER2 targeted therapies. Likewise, the assay was used for selection of HER2 positive gastric cancer patients in the important ToGA trail. HercepTest™ was the first companion diagnostic ever approved by the FDA, and more than 20 years of use has documented its clinical impact.

Companion diagnostics for targeted cancer drugs - clinical and regulatory aspects.

Companion diagnostics (CDx) holds the promise of improving the predictability of the oncology drug development process and become an important tool for the oncologist in relation to the choice of treatment for the individual patient. A number of drug-diagnostic co-development programs have already been completed successfully, and in the clinic, the use of several targeted cancer drugs is now guided by a CDx. This central role of the CDx assays has attracted the attention of the regulators, and especially the US Food and Drug Administration has been at the forefront in relation to developing regulatory strategies for CDx and the drug-diagnostic co-development project. For an increasing number of cancer patients the treatment selection will depend on the result generated by a CDx assay, and consequently this type of assay has become critical for the care and safety of the patients. In order to secure that the CDx assays have a high degree of analytical and clinical validity, they must undergo an extensive non-clinical and clinical testing before release for routine patient management. This review will give a brief introduction to some of the scientific and medical challenges related to the CDx development with specific emphasis on the regulatory requirements in different regions of the world.

The Regulation of Companion Diagnostics: A Global Perspective.

The emerging trend of validated biomarkers, otherwise known as companion diagnostics (CDx), is playing a key role in helping pharmaceutical companies acquire rapid regulatory approval of their targeted therapeutics while saving on development time and costs. In today's challenging regulatory arena, diagnostics-led treatment can improve the reimbursement and market access for drugs. All of this has prompted research in the use of such biomarkers with targeted therapeutics for predicting response to therapy, hence beginning the revolution of personalized medicine. With the current target area being oncology, other therapeutic areas are also now being explored. As an increasing number of pharmaceutical firms are penetrating the CDx arena and looking to partner with diagnostics developers, this does not come without its challenges. The codevelopment process is complex, and many hurdles may need to be crossed before a perfect model can be achieved. To add further to the complexity, the global regulatory landscape for CDx is in a state of flux, making it extremely challenging for industry to keep up with the increasing demands of the regulators. This article provides an overview of the changing regulatory landscape for CDx in some of these key markets and an insight to deal with the challenges associated with developing a successful global regulatory strategy for a CDx product. The views presented in this article are mainly from a diagnostics perspective.

Biopharmaceutical industry perspectives on the business prospects for personalized medicine.

AIM: Personalized medicine is entering its second decade, yet the role it will play in addressing the biopharmaceutical industry's productivity gap and the rising cost of healthcare is still a matter of speculation. So what does the biopharmaceutical industry itself say about the business prospects for personalized medicine? MATERIALS & METHODS: The authors conducted interviews with 20 science and business experts from 13 companies to find out. In this article, particular attention is paid to drug-diagnostic codevelopment, so-called companion diagnostics. RESULTS: The results of the interviews are discussed in light of perspectives from various stakeholders available from the literature in the public domain. In brief, biopharmaceutical acknowledges the many difficulties that plague this path to product development with particular concern for knowledge gaps in the scientific base, the timing of studies during development, as well as the regulatory, reimbursement and commercial hurdles that can thwart approval, launch and market uptake. CONCLUSION: Nonetheless, personalized medicine in general and companion diagnostics in particular are believed to be an increasingly sustainable business proposition with expectations for rapid market growth in the near term.

EU policies in personalized medicine-related technologies.

Against the background of a number of first drug-diagnostic co-products developed and introduced into the European market, European decision-makers feel impelled to react and position themselves in the field of personalized medicine. Their reactions cover a broad range, from the analysis of knowledge requirements for market approval to the need for translational activities and the possible contribution of pharmacogenetics to public health. This article summarizes the current positions of European institutions, based on literature review and expert consultation for three items associated with personalized medicine: biobanks, genetic diagnostics and drug-diagnostic co-products, and provides an outlook on requirements for an effective future European policy on personalized medicine.