Vinflunine

Astellas Pharmaceutical Group (Tokyo Stock Exchange: 4503, President and Chief Executive Officer: Naoki Okamura, "Astellas") announced on August 20 that the Center for Drug Evaluation (CDE) of the China National Drug Administration has approved Vientumab for injection (trade name: Vientumab is indicated for the treatment of locally advanced or metastatic uroepithelial carcinoma (mUC) in adult patients who have previously received platinum-containing chemotherapy and programmed death receptor-1 (PD-1) or programmed death ligand-1 (PD-L1) inhibitors.   Urothelial carcinoma is a serious and common cancer that affects the lower urinary tract (including the bladder and urethra) as well as the upper urinary tract (including the ureters and renal pelvis). In 2022, more than 92,000 patients in China were diagnosed with bladder cancer, of which about 41,000 patients sadly died. Survival rates are particularly poor for patients with advanced or metastatic urothelial cancer, so new treatments are urgently needed to extend patients' lives.   Professor Guo Jun, Director of the Department of Melanoma and Sarcoma and Urologic Oncology, Peking University Cancer Hospital, pointed out: "On August 13, 2024, the National Medical Products Administration (NMPA) officially approved Vientumab for injectable use in adult patients with locally advanced or metastatic uroepithelial carcinoma who have previously received platinum-containing chemotherapy and programmed death receptor-1 (PD-1) or programmed death ligand-1 (PD-L1) inhibitors. The approval is based on a global Phase 3 registration study and a bridging study in the Chinese population. This is a landmark event that marks the accessibility of new antibody-drug conjugate (ADC) therapies for the entire population of UC."   Ahsan Arozullah, MD, MPH, senior vice president and head of oncology area Development at Astellas, said: "We are committed to driving scientific advances that will significantly change the course of cancer care around the world. The approval of Veentumab by the Center for Drug Evaluation (CDE) of the China National Drug Administration provides another treatment option for patients with locally advanced or metastatic urothelial carcinoma in China, and patients are expected to have better treatment outcomes as a result."   Data from the global study EV-301 and its Chinese bridging study EV-203 support CDE's approval of Veentumab. The randomized Phase 3 study EV-301 supports the worldwide registration of Veentumab. The EV-203 study (NCT04995419) is a single-arm, open-label, multicenter phase 2 study in Chinese patients with locally advanced or metastatic uroepithelial carcinoma who have previously been treated with PD-1/PD-L1 inhibitors and platinum-containing chemotherapy. The results showed that EV-203 met its primary endpoint, which was a confirmed objective response rate (ORR) as assessed by an Independent Review Committee (IRC) in patients treated with Veentumab monotherapy compared to historical controls (37.5% [n/N=15/40; 95% confidence interval: 22.7-54.2]) was statistically significant. Efficacy and pharmacokinetic data from the study were consistent with global data, and safety results showed mostly grade 1-2 treatment-related adverse events.   Astellas has already reflected the impact of the approval of Veentumab in China in its financial forecast for fiscal year 2024 (ending March 31, 2025).   About the EV-203 study The Phase II clinical trial of EV-203 (NCT04995419) is a multicenter, single-arm bridging study conducted in China to evaluate the efficacy, safety, and pharmacokinetics of Veentumab in Chinese patients. The study included a total of 40 patients with locally advanced or metastatic urothelial carcinoma who had previously been treated with platinum-containing chemotherapy and PD-1/PD-L1 inhibitors.   The primary endpoint of the trial was met, and the confirmed objective response rate in patients treated with Veentumab monotherapy was 37.5% as assessed by an independent review board (n/N=15/40, 95% confidence interval [CI] : 22.7-54.2). Of these, 1 patient achieved a complete response (2.5%) and 14 patients achieved a partial response (35%).   No new safety signals were found in the study. The majority of veentumab treatment-related adverse events were grade 1-2, with 2 patients discontinuing treatment due to treatment-related adverse events (acute coronary syndrome and hyperglycemia/rash).   About the EV-301 study The EV-301 clinical trial (NCT03474107) is a global multicenter, open, randomized Phase III trial designed to evaluate the efficacy of Veentutuzumab compared to chemotherapy (docetaxel, paclitaxel, or vinflunine). Efficacy and safety in the treatment of 608 patients with locally advanced or metastatic urothelial carcinoma who had previously received platinum-containing chemotherapy and PD-1/L1 inhibitors. The primary endpoint was overall survival (OS), and secondary endpoints included progression-free survival (PFS), overall response rate (ORR), duration of response (DOR), and disease control rate (DCR), as well as safety/tolerability and quality of life parameters.   The EV-301 study showed that median overall survival was longer in the veentumab group than in chemotherapy (12.88 and 8.97 months, respectively; Risk ratio: 0.70; 95% confidence interval: 0.56 to 0.89; p=0.001), the progression-free survival was also longer than that in the chemotherapy group (5.55 months vs. 3.71 months, respectively; Hazard ratio: 0.62; 95% confidence interval: 0.51 to 0.75; P<0.001). The incidence of treatment-related adverse events was similar between the two groups (93.9% in the veentumab group and 91.8% in the chemotherapy group). The incidence of grade 3 and above adverse events was also similar in both groups (51.4% and 49.8%, respectively). The results were published in the New England Journal of Medicine.   About bladder cancer and urothelial cancer Urothelial cancer, or bladder cancer, originates in urothelial cells, which are found in the urethra, bladder, ureter, renal pelvis, and some other organs. Urothelial carcinoma accounts for 90% of all bladder cancer cases and may also occur in the renal pelvis, ureter and urethra. If bladder cancer has spread to surrounding organs or muscles, it is called locally advanced disease. If the tumor has spread to other parts of the body, it is called metastatic disease. About 12% of cases have locally advanced or metastatic urothelial carcinoma at diagnosis.   In China, the incidence of bladder cancer ranked 11th among all cancers in 2022, with more than 92,000 new cases estimated that year. The five-year prevalence of bladder cancer in China is estimated at 2.5 per 100,000 cases, or 276,102 cases. Continuous treatment and monitoring make bladder cancer one of the most expensive cancers to treat, with the highest costs compared to other malignancies.   About Bexoft (generic name Vientumab for injection) Veentumab is a first-of-its-kind antibody-drug conjugate (ADC) that targets the Nectin-4 protein, which is expressed on the cell surface and is highly expressed in bladder cancer. Non-clinical studies have shown that by binding to cells expressing the Nectin-4 protein, the anti-tumor component monomethyloratatin E (MMAE) is internalized and released into cells, causing cell proliferation arrest (cell cycle arrest) and programmed cell death (apoptosis), thereby exerting its anticancer activity.   Ongoing research The EV-302 clinical trial (NCT04223856) is an open-label, randomized, controlled Phase 3 clinical trial designed to evaluate the combination of veentutuzumab and pabolizumab compared to platinum-containing chemotherapy. Efficacy in patients with untreated locally advanced or metastatic urothelial carcinoma (la/mUC) suitable for cisplatin or carboplatin therapy is not limited by PD-L1 expression.   The EV-103 clinical trial (NCT03288545) is an ongoing multi-cohort, open-label, multi-center phase 1b/2 clinical trial. To investigate the efficacy of veentuzumab alone or in combination with pabolizumab and/or chemotherapy in the treatment of first - or second-line locally advanced or metastatic urothelial carcinoma and in patients with myoinvasive bladder cancer (MIBC).   The EV-104 trial (NCT05014139) is a Phase 1 study designed to explore the feasibility of using Veentumab in patients with non-myoinvasive bladder cancer (NMIBC). The study was divided into two parts, evaluating dose escalation and dose extension of veentumab as postoperative monotherapy.   Studies of the combination of Vientumab and pabolizumab in different stages of uroepithelial cancer, including two Phase 3 trials EV-304 (NCT04700124, also known as the KEYNOTE-B15 trial) and EV-303 (NCT03924895, also known as the KEYNOTE-905 trial), Both were targeted at muscular invasive bladder cancer. The EV-202 trial (NCT04225117) is an ongoing, multi-cohort, open-label, multicenter phase 2 clinical trial investigating the efficacy of Veentumab alone in previously treated patients with advanced solid tumors. The trial also included a cohort studying the combination of veentuzumab and pabolizumab in previously untreated relapsed and metastatic head and neck squamous cell carcinoma.   About Astellas Astellas Pharmaceutical Group is a global pharmaceutical company with operations in more than 70 countries and regions. The company is pursuing a "Focus Area Approach" to address unmet medical needs by focusing on physiological mechanisms and treatments to identify opportunities for continued development of new drugs. At the same time, the company is looking beyond prescription drugs to create Rx+® medical solutions by combining expertise and knowledge with cutting-edge technology from external partners in different fields. Through these efforts, Astellas is committed to being at the forefront of the ever-changing healthcare industry, translating scientific advances into value for patients. More detailed information, please visit the website https://www.astellas.com/en.   About Astellas' partnership with Pfizer Astellas and Pfizer jointly develop and commercialize Veentumab on a 50:50 basis worldwide. In the United States, Astellas and Pfizer jointly promote PADCEV® (enfortumab vedotin-ejfv). Pfizer is responsible for the commercialization and registration of the product in the Americas (excluding the United States). Astellas is responsible for the commercialization and registration of the product outside the Americas.

First pan FGFR kinase inhibitor to be approved in the European Economic Area, for adults with unresectable or metastatic urothelial carcinoma and susceptible FGFR3 alterations Approval based on THOR results, showing 36 percent reduction in risk of death with erdafitinib versus chemotherapy 1 BEERSE, Belgium I August 23, 2024 I Janssen-Cilag International NV, a Johnson & Johnson company, today announced that the European Commission (EC) has approved BALVERSA ® (erdafitinib) as a once-daily oral monotherapy for the treatment of adult patients with unresectable or metastatic urothelial carcinoma (mUC), harbouring susceptible fibroblast growth factor receptor 3 (FGFR3) genetic alterations who have previously received at least one line of therapy containing a programmed death receptor-1 (PD-1) or programmed death-ligand 1 (PD-L1) inhibitor in the unresectable or metastatic treatment setting. 2 “Bladder cancer is one of Europe’s most common cancers and the need for innovative treatment options for people living with unresectable or metastatic urothelial carcinoma remains high,” said Yohann Loriot, M.D., Ph.D., Institut Gustave Roussy and University of Paris-Saclay, France.* “Erdafitinib is a novel, targeted therapy that has been shown to significantly improve overall and progression-free survival for patients with FGFR3 alterations, who, until now, have had limited options available.” Europe has the highest rate of bladder cancer compared to all continents globally, with nearly a quarter of a million people diagnosed in 2022, 3 representing a 10 percent increase from 2020. 4 Urothelial carcinoma (UC) is the most common form of bladder cancer, 5 and up to 20 percent of patients with mUC have FGFR alterations. 6 Prognosis remains particularly poor for patients with mUC, with only eight percent of people diagnosed at a late metastatic stage surviving for five years. 7,8 “This important milestone emphasises the vital role of targeted therapies in addressing the unique genetic and disease characteristics of patients living with urothelial cancer, and reinforces our dedication to advancing cutting-edge, precision treatments in oncology,” said Henar Hevia, Ph.D., Senior Director, EMEA Therapeutic Area Lead, Oncology, Johnson & Johnson Innovative Medicine. “The approval of erdafitinib as a precision therapy further highlights the importance of FGFR testing for all patients with metastatic urothelial cancer, and the need for a multi-disciplinary team approach to optimise outcomes for each patient.” Erdafitinib received EC approval based on results from Cohort 1 of the Phase 3 THOR study ( NCT03390504 ), evaluating the efficacy and safety of erdafitinib (n=136) versus chemotherapy (n=130) in patients with advanced or mUC with select FGFR alterations who have progressed on or after one or two prior treatments, at least one of which includes an anti-PD-(L)1 agent. 1,9 In June 2023, based on the recommendation of the independent data safety monitoring committee, the THOR study was stopped following the interim efficacy analysis and all patients randomised to chemotherapy (docetaxel or vinflunine) were offered the opportunity to receive erdafitinib as crossover therapy. 1 The results demonstrate that a median overall survival (OS) of over one year was achieved in patients receiving erdafitinib at the data cut-off, marking a significant improvement as compared to those in the chemotherapy arm (12.1 months vs. 7.8 months; hazard ratio [HR]=0.64; 95 percent confidence interval [CI]**, 0.44-0.93; P=0.0050). 2 Treatment with erdafitinib also showed an improvement in median progression-free survival (PFS) compared to chemotherapy of 5.6 months versus 2.7 months (HR=0.58; 95 percent CI**, 0.41-0.82; P=0.0002) and confirmed overall response rate (ORR) of 35.3 percent versus 8.5 percent. 2 Serious treatment-related adverse events (TRAEs) were observed in 13.3 percent of patients who received erdafitinib and 24.1 percent of patients randomised to chemotherapy. 1 Grade 3 or higher adverse events (TRAEs) were observed in 45.9 percent of patients on erdafitinib and 46.4 percent on chemotherapy. 1 Amongst patients who received erdafitinib, 8.1 percent had TRAEs that led to discontinuation of therapy, versus 13.4 percent of patients who received chemotherapy. 1 TRAEs leading to death were reported in one patient who received erdafitinib and six patients who received chemotherapy. 1 “The EC approval of erdafitinib reflects our unwavering commitment to transforming outcomes for people living with unresectable or metastatic urothelial carcinoma,” said Kiran Patel, M.D., Vice President, Clinical Development, Solid Tumours, Johnson & Johnson Innovative Medicine. “We look forward to continuing our research and development efforts to bring new hope and improved outcomes to more patients in the future.” #ENDS# About the THOR Study THOR ( NCT03390504 ) is a Phase 3 randomised, open-label, multicentre study evaluating the efficacy and safety of erdafitinib. All patients included in the study had metastatic or unresectable UC, 9 with selected FGFR genetic alterations and showed disease progression during or after one or two prior lines of treatment. 9 The study compared erdafitinib in two cohorts; erdafitinib versus standard of care chemotherapy (investigators choice of docetaxel or vinflunine) after at least one line of treatment including an anti-PD-(L)1 agent (Cohort 1); 9 and erdafitinib compared to pembrolizumab after one prior treatment not containing an anti-PD-(L)1 agent (Cohort 2). 9 The trial consists of a screening step, a treatment phase (from randomisation until disease progression, intolerable toxicity, withdrawal of consent or decision by investigator to discontinue treatment) and a post-treatment follow-up (from end-of-treatment to participants death, withdrawal of consent, lost to follow-up, study completion for the respective cohort, whichever comes first). 9 A long-term extension period is already operational following the clinical cut-off date of the final analysis of each cohort and eligible patients are continuing to benefit from the study intervention. 9 The primary endpoint of the study is OS, with secondary endpoints being PFS, ORR, duration of response (DOR), patient-reported outcomes, safety and pharmacokinetics (PK). 9 Results from Cohort 1 were presented at the 2023 American Society of Clinical Oncology (ASCO) Annual Meeting, 1 with findings from Cohort 2 presented at the 2023 European Society of Medical Oncology (ESMO) congress. 10 About Erdafitinib Erdafitinib is a pan-fibroblast growth factor receptor (FGFR) tyrosine kinase inhibitor approved for the treatment of adult patients with unresectable or metastatic urothelial carcinoma (UC), harbouring susceptible FGFR3 genetic alterations who have previously received at least one line of therapy containing a PD-1 or PD-L1 inhibitor in the unresectable or metastatic treatment setting. 2,11 Erdafitinib is also being evaluated in the Phase 1 study/BLC1003 ( NCT05316155 ) 12 in patients with non-muscle invasive or muscle invasive bladder cancer with selected FGFR alterations, given via an intravesical targeted releasing system (TAR-210). 12 In addition, the Phase 3 MoonRISe-1 /BLC3004 ( NCT06319820 ) study is evaluating TAR-210 versus single agent intravesical chemotherapy in participants with intermediate risk non-muscle invasive bladder cancer. 13 In addition to the EC approval, in January 2024 Johnson & Johnson obtained U.S. Food and Drug Administration (FDA) full approval of erdafitinib for the treatment of adult patients with locally advanced or mUC with susceptible FGFR3 genetic alterations, whose disease has progressed on or after at least one line of prior systemic therapy, based upon Cohort 1 of the Phase 3 THOR study. 14 In 2008, Janssen Pharmaceutica NV entered into an exclusive worldwide licence and collaboration agreement with Astex Pharmaceuticals to develop and commercialise erdafitinib. 15 For a full list of adverse events and information on dosage and administration, contraindications and other precautions when using erdafitinib, please refer to the Summary of Product Characteristics. 2 ▼ In line with EMA regulations for new medicines, erdafitinib is subject to additional monitoring. About Urothelial Carcinoma Urothelial carcinoma (UC) starts in the innermost lining of the bladder. 16 Almost all bladder cancers – more than 90 percent – are UCs. 17 Up to one in five patients (20 percent) diagnosed with mUC have a fibroblast growth factor receptor (FGFR) genetic alteration. 8 FGFRs are a family of receptor tyrosine kinases that can be activated by genetic alterations in a variety of tumour types, and these alterations may lead to increased tumour cell growth and survival. 18 FGFRs play a key role in several biological processes, including tissue repair, inflammatory response and metabolism. 19 Fusions or mutations in the genes that control FGFR (known as FGFR1–4 alterations) may lead to the development and progression of certain cancers by increasing tumour cell growth and survival. 20 Patients with advanced UC, including FGFR-driven tumours, face a poor prognosis and the need for innovative therapies remains high. 21 The five-year survival rate for patients with metastatic bladder cancer that has spread to distant parts of the body is currently 8 percent. 22 About FGFR Testing Testing for somatic mutations and fusions in FGFR genes can identify patients with urothelial carcinoma who may be eligible for treatment with FGFR-targeted therapies such as erdafitinib. 23 Identification of actionable FGFR alterations may allow for utilisation of biomarker-guided therapy. 24 FGFR testing to detect gene mutations and fusions can be performed using validated laboratory developed tests involving polymerase chain reaction (PCR) and next-generation sequencing (NGS) techniques as recommended in the ESMO 2024 and EAU 2024 guidelines. 24,25,26 These guidelines recommend early molecular/genomic testing, ideally at diagnosis of advanced bladder cancer, to facilitate treatment decision-making and prevent delays in administering later lines of therapy. 26,27 About Johnson & Johnson At Johnson & Johnson, we believe health is everything. Our strength in healthcare innovation empowers us to build a world where complex diseases are prevented, treated, and cured, where treatments are smarter and less invasive, and solutions are personal. Through our expertise in Innovative Medicine and MedTech, we are uniquely positioned to innovate across the full spectrum of healthcare solutions today to deliver the breakthroughs of tomorrow, and profoundly impact health for humanity. Learn more at https://www.twitter.com/JNJInnovMedEMEA . Follow us at www.linkedin.com/company/jnj-innovative-medicine-emea for our latest news. Janssen-Cilag International NV and Janssen Pharmaceutica NV are Johnson & Johnson companies. *Professor Loriot has provided consulting, advisory, and speaking services to Johnson & Johnson; they have not been paid for any media work. **Repeated confidence intervals are provided. References 1 Loriot Y, et al. Phase 3 THOR study: Results of erdafitinib (erda) versus chemotherapy (chemo) in patients (pts) with advanced or metastatic urothelial cancer (mUC) with select fibroblast growth factor receptor alterations (FGFRalt). J Clin Oncol 2023;41(17). Available at: https://doi-org.libproxy1.nus.edu.sg/10.1200/JCO.2023.41.17_suppl.LBA4619 . Accessed August 2024. 2 Balversa ® (erdafitinib). Summary of Product Characteristics. Accessed August 2024. 3 Globocan 2022. Europe Cancer Factsheet. Available at: https://gco-iarc-who-int.libproxy1.nus.edu.sg/media/globocan/factsheets/cancers/30-bladder-fact-sheet.pdf. Accessed August 2024. 4 Globocan 2020. Europe Cancer Factsheet. Available at: https://gco.iarc.fr/today/data/factsheets/populations/908-europe-fact-sheets.pdf . Accessed August 2024. 5 Cancer.net. Bladder cancer: introduction. Available at: https://www.cancer.net/cancer-types/bladder-cancer/introduction#:~:text=Urothelial%20carcinoma%20(or%20UCC)%20accounts,that%20line%20the%20urinary%20tract . Accessed August 2024. 6 Fernandez E, et al. Prognostic value and clinical significance of FGFR genomic alterations (GAs) in metastatic urothelial cancer patients. J Clin Med 2022;11(15):4483. 7 Cancer.gov. Bladder Cancer Prognosis and Survival Rates – NCI (2023). Available at: https://www.cancer.gov/types/bladder/survival. Accessed August 2024. 8 Montazeri K & Bellmunt J. Erdafitinib for the treatment of metastatic bladder cancer. Expert Review of Clinical Pharmacology. 2020;13(1):1-6. 9 Clinicaltrials.gov. A Study of Erdafitinib Compared With Vinflunine or Docetaxel or Pembrolizumab in Participants With Advanced Urothelial Cancer and Selected Fibroblast Growth Factor Receptor (FGFR) Gene Aberrations (THOR). Available at: https://classic.clinicaltrials.gov/ct2/show/NCT03390504?term=NCT03390504&draw=2&rank=1 . Accessed August 2024. 10 Loriot Y, et al. Erdafitinib Prolongs Survival in Patients with Metastatic Urothelial Carcinoma and FGFR Alterations After Previous Anti–PD1(-L1) Treatment. Available at: https://www.esmo.org/oncology-news/erdafitinib-prolongs-survival-in-patients-with-metastatic-urothelial-carcinoma-and-fgfr-alterations-after-previous-anti-pd1-l1-treatment . Accessed August 2024. 11 Tabernero J, et al. Phase I dose-escalation study of JNJ-42756493, an oral pan-fibroblast growth factor receptor inhibitor, in patients with advanced solid tumours. J Clin Oncol. 2015;33:3401–3408.5 12 Clinicaltrials.gov. Study of Erdafitinib Intravesical Delivery System for Localized Bladder Cancer. Available at: https://classic.clinicaltrials.gov/ct2/show/NCT05316155 . Accessed August 2024. 13 Clinicaltrials.gov. A study to evaluate TAR-210 versus single agent intravesical cancer treatment in participants with bladder cancer. Available at: https://classic.clinicaltrials.gov/ct2/show/NCT06319820 . Accessed August 2024. 14 JnJ.com. U.S. Food and Drug Administration Grants Full Approval for BALVERSA ® to Treat Locally Advanced or Metastatic Bladder Cancer with Select Genetic Alterations. Available at: https://www.jnj.com/media-center/press-releases/u-s-food-and-drug-administration-grants-full-approval-for-balversa-to-treat-locally-advanced-or-metastatic-bladder-cancer-with-select-genetic-alterations . Accessed August 2024. 15 Astex Therapeutics Limited. Astex Announces New Drug Discovery Alliance with Janssen Pharmaceutica N.V. 2008. Available at: https://astx.com/wp-content/uploads/2016/11/ASTX_News_2008_6_9_General_Releases.pdf . Accessed August 2024. 16 Tanaka M, Sonpavde G. Diagnosis and Management of Urothelial Carcinoma of the Bladder. Postgraduate Medicine 2011;123(3):43-55. 17 Milojevic B, et al. Urothelial carcinoma: Recurrence and risk factors. J BUON 2015;20(2):391-8. 18 Presta M, et al. Fibroblast growth factors (FGFs) in cancer: FGF traps as a new therapeutic approach. Pharmacol Ther  2017;179:171-187. 19 Xie Y, et al. FGF/FGFR signaling in health and disease. Sig Transduct Target Ther 2020;5(181):1-38. 20 Katoh M. Fibroblast growth factor receptors as treatment targets in clinical oncology. Nat Rev Clin Oncol 2019;16(2):105-122. 21 Loriot Y, et al. Erdafitinib in Locally Advanced or Metastatic Urothelial Carcinoma. N Engl J Med 2019;381(4):338-348. 22 American Cancer Society. Survival Rates for Bladder Cancer. Available at: https://www.cancer.org/cancer/types/bladder-cancer/detection-diagnosis-staging/survival-rates.html . Accessed August 2024. 23 De Luca A, et al. FGFR fusions in cancer: from diagnostic approaches to therapeutic intervention. Int J Mol Sci 2020;21(18):6856. 24 Schmidt KT, et al. Precision oncology medicine: the clinical relevance of patient-specific biomarkers used to optimize cancer treatment. J Clin Pharmacol 2016;56(12):1484–1499. 25 Witjes J.A. et al. EAU guidelines on muscle-invasive and metastatic bladder cancer. Available at: https://uroweb.org/guidelines/muscle-invasive-and-metastatic-bladder-cancer . Accessed August 2024. 26 Powles T et al. ESMO Clinical Practice Guideline interim update on first-line therapy in advanced urothelial carcinoma. Annals of Oncology 2024;35(6): 485-490. 27 Powles T, et al. Bladder cancer: ESMO clinical practice guideline for diagnosis, treatment and follow-up. Ann Oncol 2022;33(3):244–258.​ SOURCE: Johnson & Johnson