companion diagnostics, personalized medicine and drug ... - s2 - benda...• complementary...

Norbert Benda

Companiondiagnostics,personalizedmedicineanddrugregulation

Disclaimer:Views expressed in this presentation are the author's personal views and not necessarily the views of BfArM

N Benda | Companion Diagnostics| 06 November 2017 | /42

EU regulation:• a device which is essential for the safe and effective use of a

corresponding medicinal product to identify, before and/or during treatment • patients who are most likely to benefit from the corresponding

medicinal productor

• patients likely to be at increased risk of serious adverse reactions as a result of treatment with the corresponding medicinal product

FDA:• in‐vitro companion diagnostic device that provides information essential

for the safe and effective use of a corresponding therapeutic product• complementary diagnostics: test identifying a biomarker‐defined subset

of patients that responds differentially to a drug and aids in the risk/benefit assessment for individual patients

Companion diagnostics (CDx)


Upcoming EMA regulation


EMA regulation


FDA regulation


• companion diagnostics:• diagnostic medical device• requires conformity assessment by notified bodies• defines population to be treated

• investigational therapeutic product • new pharmaceutical product• requires approval by medicines agency

• to be effective and safe in a well defined population• co‐development of companion diagnostics and new medicine

• new biomarker + companion diagnostics to determine patients to be treated

or• new diagnostics (“generic” or “me‐too” ) for known biomarker

Companion diagnostics and regulation


Companion diagnostics used as a• prognostic biomarker

• identify patients with good/bad prognosis• patients with unfavorable predicted outcome expected to

potentially profit from new treatment

• predictive biomarker• identify patients that benefit differentially to a drug

• patients with larger expected treatment difference to control• patients with less drug related side effects

Companion diagnostics (CDx) and prognostic/predictive biomarker


Predictive and prognostic biomarker

BM ‐ BM +

Outcome

Predictive non‐prognostic Biomarker

Active drug Placebo

BM ‐ BM +

Outcome

Predictive and prognostic Biomarker

Active drug Placebo

BM ‐ BM +

Outcome

Non‐predictive non‐prognostic Biomarker

Active drug Placebo

BM ‐ BM +

Outcome

Prognostic non‐predictive Biomarker

Active drug Placebo


• diagnostic test:• identify diseased patients

• companion diagnostics:• identify patients that profit (differentially) from treatment

• potential relation:• diagnostic test to identify diseased patients with expected

unfavorable outcome (death, tumor progression, etc.) • expected unfavorable outcome (if untreated)

patients considered eligible for treatment • however: no evidence that patients defined by diagnostic test would

benefit from treatment compared to control

Companion vs usual diagnostics


different conceptions of diagnostic properties• Properties of assay, e.g.

• Sens = Pr( test + | true positive BM status ), etc.• Properties w.r.t. to outcome, e.g.

• Sens = Pr( BM + | unfavorable outcome if untreated )• PPV = Pr( unfavorable outcome if untreated | BM + )

• however: not fully informative w.r.t. predictive biomarker / differential treatment effect

• Properties w.r.t. to differential outcome, e.g.• Sens = Pr( BM + | response under active and no response under

placebo )• however: usually not identifiable

Companion diagnostics: Diagnostic properties


• Using (genetic) biomarkers to define subgroups of patients with• improved efficacy• improved tolerability• improved benefit/risk

• Stratification according to biomarker defined patient characteristics• stratified medicine = precision medicine

• Biomarker to select patients that are likely to respond to treatment

≠• Biomarker as a surrogate to measure response to treatment

Companion diagnostics and personalized/stratified medicine: Biomarker defined subgroups


• Unique therapies• e.g. implants using rapid prototyping, (stem) cell therapy• complex /expensive therapies impeding large clinical trials

• Stratification according to specific patient characteristics• e.g. biomarker defined subpopulation

• Individualized regimen• dose adjustment by age/weight/renal function• individual dose titration• etc.

Personalized/individualized/stratified medicine


• Cetuximab• treatment of colorectal cancer in patients with wild‐type K‐ras

mutation• Trastuzumab

• treatment of HER‐2‐positive breast cancer• Gefitinib

• treatment of NSCLC in patients with EGFR mutation

Stratified therapies: Examples


• Example: Gefitinib (IRESSA)• IPASS Study: Gefitinib vs Paclitaxel

• progression‐free survival (PFS)• BM+: HR = 0.482, 95% ci (0.362; 0.642)• BM‐: HR = 2.853 , 95% ci (2.048; 3.975)

• overall response rate (ORR)• BM+: OR = 2.751, 95% ci (1.646; 4.596)• BM‐: OR = 0.036, 95% ci (0.005; 0.273)

• overall survival (OS)• BM+: HR = 0.776, 95% ci (0.500; 1.202)• BM‐: HR = 1.384 , 95% ci (0.915; 2.092)

Stratified therapies


• Conventional development:• looking for a safe and effective treatment in a given

population/indication• Stratified medicine

• looking for a treatment and a population where this treatment is safe and effective

• given a broader population: • looking for a subgroup in which benefit is more favorable

than in the complementary group= Looking for positive treatment x subgroup interaction= Looking for a treatment and a predictive biomarker

• Development: Exploration and confirmation

Biomarker used for stratified therapies


1. empirical investigation of evidence on subgroup effects 2. comparing exploratory statistical methods for subgroup identification 3. method assessment based on regulatory criteria4. method development

• modelling between‐study heterogeneity 5. assessment of regulatory consequences of between‐study heterogeneity6. combining exploratory and confirmatory subgroup identification in

clinical development• using adaptive enrichment designs and basket trials.

7. updated comprehensive biomarker classification 8. systematic assessment of European SmPCs and the FDA drug labels

Research project on biomarker defined populationsUniversity Medical Centre Göttingen – BfArM (2016 ‐ 2019)


• Looking for most promising interaction• predictive biomarker (BM)• inconsistency between subgroups

• in‐vitro / clinical randomize‐all studies• Positive interaction re.

• efficacy• tolerability

• Questions/issues• optimized strategy may consider multiple biomarkers• repeatability of the diagnostic tool / adjudication process• interaction may relate to a surrogate endpoint• relevant interaction size• positive interaction in efficacy but negative interaction in

tolerability?

Stratified therapies: Exploration


• Treatment x subgroup interaction• implies treatment x subject interaction

• treatment effect varies across subject• may be difficult to verify w/o within‐subject comparison/cross‐over• interaction tests w.r.t. subgroups often lack power

• S. Senn (Mastering variation: variance components and personalised medicine, SiM 2015): • “Thus, I am not claiming that elements of individual response can hardly

ever be identified. I am claiming that the effort necessary, whether in design or analysis, is rarely made .. “

• “In short, the business of personalising medicine is likely to be difficult. We already know that it has turned out to be much more difficult than many thought it would be.”

Stratified therapies


Differentiate Setting 1 Setting 2

Any subject‐by‐treatment interaction?

pA=0.9pC=0.5

pA=0.9pC=0.5

pA=0.9pC=0.5

pA=0.9pC=0.5

pA=0.9pC=0.5

pA=0.9pC=0.7

pA=0.9pC=0.7

pA=0.7pC=0.5

pA=0.7pC=0.5

pA=0.9pC=0.7

pA=0.9pC=0.5

pA=0.7pC=0.5

pA=0.7pC=0.7

pA=0.7pC=0.7

pA=0.7pC=0.7

pA=0.7pC=0.7pA=0.7

pC=0.7

pA=0.7pC=0.7

Subpopulation 1

Subpopulation 2

pA=0.9pC=0.7

pA=0.9pC=0.7

pA=0.7pC=0.5

pA=0.7pC=0.5

pA=0.9pC=0.7

pA=0.7pC=0.5

individual subjects

responseC= 0observingresponseA= 1


Or ?Setting 3


pA=0.9pC=0.5

pA=0.7pC=0.7

Subpopulation 1

Subpopulation 2

e.g.50% always respond to A and C40% always respond to A10% always respond to none

population

• between subject variability • vs

• within subject variability


ObserveSetting 1


pA=0.9

pC=0.5

pA=0.7

pC=0.7

Subpopulation 1

Subpopulation 2

covariate(biomarker) < c

biomarker > c

lots of biomarker options:chance finding ?


• Regulatory requirement• confirm efficacy in subgroup (BM+) in an independent Phase III

trial with proper type‐1 error control• show positive benefit risk in BM+• plausibility for a reduced efficacy in BM ̶

• Study design options• study in BM+ only

• (some) other data in BM ̶ needed• stratification in BM+ and BM ̶• adaptive design that decides at interim for BM+ or all

Stratified therapies: Confirmation


Stratified therapies: Confirmation, what confirmation?


Study in BM + only• Issues

• population size• information on BM ̶

• Population size• weaker requirements depending on medical need

• increased model assumptions / type‐1 error• Information on BM ̶

• usefulness of the biomarker• justification to exclude BM ̶

• usually no confirmatory proof of effect irrelevance in BM ̶



Adaptive design to decide on BM+ • Interim analysis to decide on subgroup or all

• fully pre‐specified BM subgroup• two null hypotheses

• no effect in all• no effect in BM +

• multiplicity adjustment required• p‐value combination test allows for free decision rule

• decision rule may use external information• Bayesian rules could be applied (e.g. Brannath et al SiM 2009)

• some information on BM ̶ generated• usefulness of the biomarker



Possible adaptive designs• Predefined subgroup to be decided on at interim• no subgroup definition or refinement at interim to limit the number of hypotheses to

be tested

• use of all data with adequate multiplicity adjustment

• Adaptive signature design • adjust for full population vs (any) subpopulation

• if full population is unsuccessful • use first stage to define subpopulation

• use second stage to confirm

• Biomarker adaptive threshold design• Adjust for full population vs biomarker defined subpopulation with any threshold b of

biomarker score B

• If full population is unsuccessful

• use resampling methods to analyse Z* = max{Z(b)} for test statistic Z



Stratified design BM + and BM ‐• Full information on different effect sizes

• usefulness of biomarker tested• exclusion or inclusion of BM – justified

• Borrowing strength from BM –• safety may be concluded from total population

• biological plausibility required• efficacy may be extrapolated based on covariates

• but difficult to justify when fundamental difference assumed



• Internal consistency• assessing homogeneity or heterogeneity

• evaluating interaction subgroup x treatment• Predefined confirmatory subgroup analysis

• designed to assess efficacy in subgroup• Exclusion of subgroups in successful trials

• optimizing the study population

Role of subgroups in pivotal trials in general


• Assessment of interaction / different effect sizes• interaction test less informative

• lack of power• scale dependency

• in general, descriptive assessment

scale dependency:• equal treatment effects on risk difference means different

effect sizes on odds ratios and vice versa• decision on multiplicative or additive model may not be well

justified

Stratified therapies: Issues


Predictive BM w.r.t. to odds ratio but not w.r.t. risk difference:

Predictive and prognostic biomarker: Scale dependency

Subgroup Response probability (placebo)

Response probability (verum)

Risk difference Odds ratio

BM ‐ 0.50 0.65 0.15 1.86

BM + 0.75 0.90 0.15 3.00


Issues in stratified design• Potential selection bias of treatment effect

• when deciding on BM+ or all• adaptive design alleviates selection bias

• Success in BM+ but no clear interaction• exclusion of BM ‐may not be informative and may be challenged• proof of irrelevance in BM – would require large sample sizes

Stratified therapies: Issues


• Approval related to (CDx, drug) pair• change in CDx influences benefit‐risk in selected patients• change in CDx may change subgroup‐by‐treatment interaction

• changing “usefulness”• Approval related to evaluated effect/risk in selected patients only

• similar drugs with same effects may be approved in different patients due to different development strategies• e.g. NSCLC

• Pembrolizumab approved in PD‐L1 + patients• Nivolumab approved in all

• active drug comparisons may require evaluation of overall benefit in full population• comparison of treatment strategies ?

• (drug A in BM + and SoC in BM –) vs. (drug B in all)

Companion diagnostics: Issues


• Average effect in BM + and BM ‐• cut‐off determines

• effect size in BM – and BM +• subgroup‐by‐treatment interaction

BM cut‐off

outcome

BM distribution biomarker

cut‐off

active

placebo


• new diagnostics: effects may change• larger measurement error

larger measurement error variance ‐ smaller interaction / benefit

BM cut‐off

outcome

BM distribution biomarker

cut‐off

active

placebo


• Biomarker/CDx defined subgroups Stratified therapies • main focus of the current discussion• based on predictive biomarkers• requires the identification of relevant interaction

(biomarker/subgroup‐by‐therapy interaction)• repeatability of the adjudication process paramount• may not be restricted to one biomarker only

• discrimination procedures related to multiple biomarkers could be optimized

Summary (1)


• Promise of stratified therapies depends on• size of the interaction• further restriction appears less promising

• residual variability limits the precision of precision medicine• In general more evidence required to support selection

• generally weak evidence on the usefulness of the selection• blurred by different sources of variability

• Confirmatory strategies based on• pivotal study in subgroup only• adaptive design to decide on subgroup or all• stratified design

• borrowing information from BM– to be further justified• e.g. similar safety profile ?

Summary (2)


• Companion diagnostics (CDx) to identify biomarker related subgroups• co‐development (CDx, drug)• approval related to benefit‐risk in BM+ determined by CDx

• change in CDx may change benefit‐risk• lack of evaluation in the overall population according to the

treatment strategy • separate approvals of CDx as a medical device and drug

• common regulatory strategies required

Summary (3)

companion diagnostics, personalized medicine and drug ... - s2 - benda...• complementary...

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