Trastuzumab deruxtecan in HER2-positive advanced gastric cancer: exploratory biomarker analysis of the randomized, phase 2 DESTINY-Gastric01 trial.
Shitara K, Bang YJ, Iwasa S, Sugimoto N, Ryu MH, Sakai D, Chung HC, Kawakami H, Yabusaki H, Sakamoto Y, Nishina T, Inaki K, Kuwahara Y, Wada N, Suto F, Arita T, Sugihara M, Tsuchihashi Z, Saito K, Kojima A, Yamaguchi K
- DOI
- 10.1038/s41591-024-02992-x
- Record issued
- 2026-08-16
- Engine
- 7.39.0
- Exported
- 2026-09-21
Prepared by Alpha1. This document is confidential: it is intended for the recipient it was shared with and must not be redistributed. The live record at alpha1science.com/verify/798e01af-bf6b-452e-a31a-02f74878984d is authoritative.
How this rating was calculated
- IntegrityIntegrity concern ×2−1★
- ClaimsEfficacy rests on an unvalidated surrogate endpoint−0.5★
- ClaimsTreatment effect not shown to be clinically meaningful−0.5★
- Statistics were not checked: no recomputable values were found in this text — no test statistic reported with its degrees of freedom, no effect estimate printed with both a 95% CI and a p-value, and no percentage printed with both its count and its denominator.
- 01Efficacy rests on an unvalidated surrogate endpoint
The primary efficacy claim is based on objective response rate (ORR) and overall survival (OS) from the DESTINY-Gastric01 trial. However, the exploratory biomarker analyses presented here focus on correlating biomarkers (HER2 expression, ctDNA amplification, HER2ECD) with response, but these are surrogate endpoints. The paper does not establish target engagement at the tested dose or provide validated evidence linking these biomarkers to clinical outcomes beyond the trial's primary analysis. The efficacy claim in this manuscript is largely based on biomarker associations, not hard clinical outcomes.
“Patients with higher levels of HER2-associated biomarkers, including HER2 IHC positivity, HER2 ISH positivity, tumor HER2 mRNA levels, plasma gene apCN and/or serum HER2ECD, had numerically higher ORR compared with patients with lower HER2-associated…”
- 02Treatment effect not shown to be clinically meaningful
The reported effect sizes are presented as differences in ORR between biomarker-defined subgroups (e.g., 58.2% vs 28.6% for IHC 3+ vs IHC 2+/ISH+; 60.6% vs 34.2% for plasma HER2 amplification vs not). However, these are exploratory subgroup analyses without adjustment for multiple comparisons, and the clinical meaningfulness is not anchored to a minimal clinically important difference. The paper does not provide a clear anchor for what constitutes a clinically meaningful effect size in this context.
“Patients with plasma HER2 amplification in ctDNA had an ORR of 61% compared with 34% in patients with no amplification.”
This Kaimen Rigor review uses Kaimen Rigor reviewers trained on a curated corpus of high-fidelity and retracted papers, with expert supervision and curation. It can still make mistakes; verify each finding against the source before relying on it.
This is a well-conducted exploratory biomarker analysis of a randomized phase 2 trial, with strong reporting of ethics, key resources, and data availability. The main weaknesses are the lack of pre-specified analysis plans, multiple testing correction, and some imprecise p-value reporting, which are typical of exploratory analyses.
All three reviewers classified the study as observational (exploratory biomarker analysis of a randomized trial); no divergence. The statistics component recomputed 0 tests (none had test statistic + df or effect + CI), so no statistical claims are verified; the citation component found no retracted or unresolved references; the reproducibility check found 2 live links.
Numerical inconsistencies
1 finding · worst lowValues that contradict each other or are impossible for the stated sample: recomputed p-values and test statistics, GRIM/GRIMMER checks on summary numbers, percentages against their own counts, totals against their parts, and estimates against their own confidence intervals.
- Internal contradictions in the reported numbersAssessed
- lowinternal contradictionThe paper reports 'HER2 GoF variants were detected in 11.0% (12 of 109) of response-evaluable patients.' Later it says 'all patients with HER2 GoF variants had HER2 IHC 3+ or IHC 2+/ISH+ status.' However, the results also state 'The ORR for patients with HER2 IHC 3+ status and HER2 GoF mutation was 87.5% (seven of eight) versus 58.2% (53 of 91) for patients with HER2 IHC 3+ status in the overall population.' The denominator 91 for IHC3+ is consistent with the earlier '91 patients in the HER2 IHC 3+ cohort', but the GoF subset of 8 out of 12 is not fully explained.
The ORR for patients with HER2 IHC 3+ status and HER2 GoF mutation was 87.5% (seven of eight) versus 58.2% (53 of 91) for patients with HER2 IHC 3+ status in the overall population; however, sample sizes were too small for meaningful comparison.
Resultsreviewer’s wording - lowinternal contradictionThe abstract states '64% concordance between HER2 positivity and HER2 (ERBB2) plasma gene amplification', but the results section reports PPA of 64% and NPA of 86%. The abstract may be oversimplifying.
“The primary cohort had 64% concordance between HER2 positivity and HER2 ( ERBB2 ) plasma gene amplification.”
AbstractFind in source
Overstated conclusions
3 findings · worst highConclusions that reach past what the paper's own results support — including a significance claim that no longer holds when the statistic is recomputed, and efficacy resting on an unvalidated surrogate endpoint.
- Efficacy rests on an unvalidated surrogate endpointAssessed
- Treatment effect not shown to be clinically meaningfulAssessed
- Conclusions only partially backed by the presented evidenceAssessed
11 major claims checked against the paper's own evidence: 3 only partially supported (evidence backs part of the claim; gaps or caveats remain); the rest adequately supported.
- partialReviewer 1HER2 gain-of-function mutations are associated with higher response to T-DXd.The claim is based on a small subset (7 of 8) and the paper itself notes sample sizes are too small for meaningful comparison.Evidence: ORR for HER2 IHC3+ with GoF mutation was 87.5% (7/8) vs 58.2% (53/91) overall.
The ORR for patients with HER2 IHC 3+ status and HER2 GoF mutation was 87.5% (seven of eight) versus 58.2% (53 of 91) for patients with HER2 IHC 3+ status in the overall population; however, sample sizes were too small for meaningful comparison.
Resultsreviewer’s wording - partialReviewers 1, 2, 3Acquired TOP1 mutations may contribute to T-DXd resistance.The paper identifies three acquired TOP1 variants at EoT and discusses their potential role, but notes the effect is unknown and requires in vitro confirmation.Evidence: Three cases of acquired TOP1 variants (E709G, L429R, D533G) were identified; D533G is known to confer resistance to camptothecin.
Analysis of ctDNA carried out at EoT identified three cases of acquired variants in the TOP1 gene (E709G, L429R and D533G).
Discussionreviewer’s wording - partialReviewers 2, 3HER2 gain-of-function mutations are associated with higher ORR.The paper reports higher ORR in patients with HER2 GoF mutations, but sample sizes are very small and the comparison is not statistically tested.Evidence: ORR for HER2 IHC 3+ with GoF mutation was 87.5% (7/8) vs 58.2% (53/91) overall.
“The ORR for patients with HER2 IHC 3 + status and HER2 GoF mutation was 87.5% (seven of eight) versus 58.2% (53 of 91) for patients with HER2 IHC 3 + status in the overall population; however, sample sizes were too small for meaningful comparison.”
ResultsFind in source - supportedReviewers 1, 2, 3Baseline HER2-associated biomarkers in ctDNA and tissue are associated with therapeutic response in HER2-positive gastric cancer.The paper provides multiple analyses showing higher ORR in patients with higher HER2 biomarker levels, with confidence intervals and some p-values.Evidence: Univariate analysis of baseline HER2 status (IHC, RNA, ctDNA amplification, HER2ECD) shows consistent trends of increased ORR with higher HER2 status.
Baseline HER2-associated biomarkers were correlated with objective response rate (ORR) in the primary cohort of patients with HER2+ gastric cancer.
Abstractreviewer’s wording - supportedReviewers 1, 3Amplifications in MET, EGFR, and FGFR2 are associated with lower ORR.The paper reports numerically lower ORR in these subgroups, with confidence intervals, though the paper notes the small numbers and lack of control arm.Evidence: ORR was 25% (95% CI 3.2–65.1%) in MET amp (n=8), 32.1% (15.9–52.4%) in EGFR amp (n=28), and 0% (0–45.9%) in FGFR2 amp (n=6).
Patients with plasma amplifications, defined according to the Guardant Health OMNI platform, in genes MET, EGFR and FGFR2 had numerically lower ORR.
Resultsreviewer’s wording - supportedReviewer 1T-DXd activity is consistent regardless of timing of tissue collection relative to trastuzumab treatment.The paper shows similar ORR and OS in subgroups defined by timing of IHC sample collection, with overlapping confidence intervals.Evidence: ORR 48.8% (40/82) before Tmab vs 56.8% (21/37) after/during; OS HR 0.76 vs 0.28.
“T-DXd activity was demonstrated in the primary cohort, regardless of the timing of tissue collection for assessment of HER2 status with respect to the first treatment with trastuzumab monoclonal (Tmab)”
ResultsFind in source - supportedReviewer 2Plasma HER2 amplification has 64% concordance with tissue HER2 positivity.The paper reports PPA of 64% and NPA of 86%, directly supporting the claim.Evidence: Extended Data Table 2 shows PPA 64% and NPA 86%.
“The positive predictive agreement (PPA) between tumor HER2 status (positive, IHC 3 + or IHC 2 + /ISH + ; low, IHC 2 + /ISH − or IHC 1 + ) and plasma amplification in ctDNA was 64% and the negative predictive agreement (NPA) was 86%”
ResultsFind in source - supportedReviewers 2, 3MET, EGFR, and FGFR2 amplifications are associated with numerically lower ORR.The paper reports lower ORR in patients with these amplifications, though the claim is limited to 'numerically lower' and the paper acknowledges small numbers.Evidence: ORR was 25% in MET amp, 32.1% in EGFR amp, 0% in FGFR2 amp.
“Patients with plasma amplifications, defined according to the Guardant Health OMNI platform, in genes MET , EGFR and FGFR2 had numerically lower ORR”
ResultsFind in source - supportedReviewer 2T-DXd activity is independent of timing of tissue collection relative to trastuzumab treatment.The paper shows similar ORR regardless of timing, supporting the claim.Evidence: ORR 48.8% (before Tmab) vs 56.8% (after/during Tmab).
“The ORR in the T-DXd arm was 48.8% (40 of 82) in patients who had IHC sample collection taken at any time before their first Tmab treatment and 56.8% (21 of 37) in patients who had IHC sample collection taken after/during their first Tmab treatment.”
ResultsFind in source - supportedReviewer 3Plasma HER2 amplification in ctDNA shows high concordance with tumor HER2 status.The paper reports PPA of 64% and NPA of 86%, which supports the claim of high concordance, though not perfect.Evidence: Extended Data Table 2 shows PPA and NPA values.
“The positive predictive agreement (PPA) between tumor HER2 status (positive, IHC 3 + or IHC 2 + /ISH + ; low, IHC 2 + /ISH − or IHC 1 + ) and plasma amplification in ctDNA was 64% and the negative predictive agreement (NPA) was 86%”
ResultsFind in source - supportedReviewer 3T-DXd activity is consistent regardless of timing of IHC sample collection.The paper shows similar ORR and OS in patients with samples collected before vs after/during trastuzumab treatment, supporting the claim.Evidence: ORR was 48.8% in patients with samples before first Tmab and 56.8% in those after/during.
“T-DXd activity was demonstrated in the primary cohort, regardless of the timing of tissue collection for assessment of HER2 status with respect to the first treatment with trastuzumab monoclonal (Tmab)”
ResultsFind in source
Premise concern: surrogate not validated for clinical benefit; effect size not shown to be clinically meaningful.
- INADEQUATESurrogate endpointThe primary efficacy claim is based on objective response rate (ORR) and overall survival (OS) from the DESTINY-Gastric01 trial. However, the exploratory biomarker analyses presented here focus on correlating biomarkers (HER2 expression, ctDNA amplification, HER2ECD) with response, but these are surrogate endpoints. The paper does not establish target engagement at the tested dose or provide validated evidence linking these biomarkers to clinical outcomes beyond the trial's primary analysis. The efficacy claim in this manuscript is largely based on biomarker associations, not hard clinical outcomes.
“Patients with higher levels of HER2-associated biomarkers, including HER2 IHC positivity, HER2 ISH positivity, tumor HER2 mRNA levels, plasma gene apCN and/or serum HER2ECD, had numerically higher ORR compared with patients with lower HER2-associated biomarkers.”
- INADEQUATEEffect sizeThe reported effect sizes are presented as differences in ORR between biomarker-defined subgroups (e.g., 58.2% vs 28.6% for IHC 3+ vs IHC 2+/ISH+; 60.6% vs 34.2% for plasma HER2 amplification vs not). However, these are exploratory subgroup analyses without adjustment for multiple comparisons, and the clinical meaningfulness is not anchored to a minimal clinically important difference. The paper does not provide a clear anchor for what constitutes a clinically meaningful effect size in this context.
“Patients with plasma HER2 amplification in ctDNA had an ORR of 61% compared with 34% in patients with no amplification.”
Data authenticity concerns
None foundAn adversarial read for patterns associated with data that may not be genuine: results that look too clean, implausibly large effects, duplicated data or images, and methods that do not match the results reported.
Checked — nothing surfaced.
Reporting gaps
None foundRequired detail the manuscript never states — study design, biological variables, ethics approval and consent, key resources, statistical reporting, data and code availability, and overall transparency.
Checked — nothing surfaced.
The introduction cites prior clinical trials (DESTINY-Gastric01, DESTINY-Gastric02) and discusses spatial/temporal heterogeneity of HER2 in gastric cancer, providing a rationale for exploring biomarkers. It acknowledges gaps in knowledge (e.g., 'Specific biomarkers related to therapeutic response have not been explored extensively'). The objective is clearly stated: to identify patients who may benefit based on biomarkers. Limitations of prior work are implicitly addressed by focusing on exploratory biomarker analyses.
“Spatial heterogeneity (heterogeneous HER2 expression and concomitant alterations) and temporal heterogeneity (loss of HER2 expression and acquired alterations) may make it challenging to identify patients with gastric or GEJ cancer who have the potential to respond to T-DXd treatment.”
“The objective of the present analyses was to identify patients who may benefit from treatment with T-DXd based on relevant biomarkers in tumor or ctDNA.”
“Specific biomarkers related to therapeutic response have not been explored extensively.”
“DESTINY-Gastric01 was a pivotal randomized study of T-DXd versus third- or later-line chemotherapy in patients with HER2 + gastric or GEJ tumors.”
“Specific biomarkers related to therapeutic response have not been explored extensively.”
“Spatial heterogeneity (heterogeneous HER2 expression and concomitant alterations) and temporal heterogeneity (loss of HER2 expression and acquired alterations) may make it challenging to identify patients with gastric or GEJ cancer who have the potential to respond to T-DXd treatment.”
“The objective of the present analyses was to identify patients who may benefit from treatment with T-DXd based on relevant biomarkers in tumor or ctDNA.”
“However, the relationship between gene alterations in ctDNA and the efficacy of ADCs that target specific oncoproteins has not been thoroughly evaluated.”
The parent trial was randomized and open-label, with inclusion/exclusion criteria described. The biomarker analysis uses a defined cohort (primary and exploratory) and specifies response-evaluable sets. Power analysis is not applicable as this is an exploratory analysis. Blinding is not applicable as the trial was open-label. Outlier handling is addressed through exclusion criteria for ctDNA samples (e.g., no somatic mutations). Controls are not applicable as this is a correlative analysis.
“Limitations of these biomarker analyses include the fact that they were either exploratory or post hoc analyses with a small sample size conducted in the absence of external validation and data from a control arm.”
“Patients enrolled in the primary cohort had HER2 + tumors, as determined by IHC or ISH positivity (IHC 3 + or IHC 2 + /ISH + ).”
“Samples with no somatic mutations detected in any gene in the Guardant OMNI assay were excluded from ctDNA analysis.”
“Patients enrolled in the primary cohort had HER2 + tumors, as determined by IHC or ISH positivity (IHC 3 + or IHC 2 + /ISH + ).”
Sex is reported in the baseline characteristics (not shown in the text but implied by the trial population). Age is not explicitly reported in the text but is standard in such trials. HER2 status is extensively reported. Species/strain/source and housing conditions are not applicable as this is a human study. Demographics are partially reported; the paper mentions 'patients with HER2-expressing advanced gastric or GEJ carcinoma' but does not provide a full demographic table in the text.
“patients with centrally assessed tumor HER2 IHC 3 + status in the primary cohort ( n = 91) had higher ORR than those with HER2 IHC 2 + /ISH + status ( n = 28”
The Methods state that 'An independent ethics committee or institutional review board at each site reviewed and approved the protocol' and 'Written informed consent was provided by all patients before enrollment.' It also states compliance with the Declaration of Helsinki and ICH-GCP. This meets the criteria for human research.
“An independent ethics committee or institutional review board at each site reviewed and approved the protocol (online only).”
“Written informed consent was provided by all patients before enrollment.”
“The study was conducted according to the study protocol, in accordance with the principles of the Declaration of Helsinki, the International Conference on Harmonization Guidelines for Good Clinical Practice and other local regulations where applicable.”
“An independent ethics committee or institutional review board at each site reviewed and approved the protocol (online only).”
“Written informed consent was provided by all patients before enrollment.”
“The study was conducted according to the study protocol, in accordance with the principles of the Declaration of Helsinki, the International Conference on Harmonization Guidelines for Good Clinical Practice and other local regulations where applicable.”
“An independent ethics committee or institutional review board at each site reviewed and approved the protocol (online only).”
“Written informed consent was provided by all patients before enrollment.”
“The study was conducted according to the study protocol, in accordance with the principles of the Declaration of Helsinki, the International Conference on Harmonization Guidelines for Good Clinical Practice and other local regulations where applicable.”
The investigational product T-DXd is named with dose and regimen. The ctDNA assay uses the Guardant OMNI panel (Guardant Health). The HER2ECD assay is the ADVIA Centaur HER2/neu assay (Siemens). RNA-seq kits and software are specified (NEBNext, Illumina NovaSeq, STAR). Antibodies, cell lines, and mycoplasma testing are not applicable as this is a human biomarker study.
“Liquid biopsy was used for ctDNA assay of plasma with the Guardant OMNI panel (Guardant Health)”
“RNA-seq libraries were prepared using the NEBNext Ultra II Directional RNA library Prep Kit for Illumina and NEBNext Multiplex Oligos for Illumina according to laboratory methods, and sequencing was performed with Illumina NovaSeq 6000 or NextSeq including 75 base pairs from each end (2 × 75 base pairs) performed at Daiichi Sankyo.”
“Patients received either T-DXd at 6.4 mg kg −1 every 3 weeks”
“Liquid biopsy was used for ctDNA assay of plasma with the Guardant OMNI panel (Guardant Health)”
“Sequencing reads were aligned with STAR software (2.5.3a) to human genome reference GRCh38.”
“Patients received either T-DXd at 6.4 mg kg −1 every 3 weeks ( n = 125) or TPC (irinotecan or paclitaxel; n = 62).”
“Liquid biopsy was used for ctDNA assay of plasma with the Guardant OMNI panel (Guardant Health)”
“Sequencing reads were aligned with STAR software (2.5.3a) to human genome reference GRCh38.”
Tests are named (exact binomial CI, Kaplan-Meier, Cox regression, McNemar). Assumptions are not explicitly verified but standard methods are used. Exact p-values are reported for some analyses (e.g., McNemar P=0.0064). Effect sizes with CIs are reported throughout. Software is identified. Data presentation includes forest plots and KM curves. Mathematical plausibility checks were not possible for most analyses due to lack of raw data, but no obvious errors were found.
“The McNemar test was used to compare ctDNA mutational status changes between baseline and EoT.”
“ORR 51% (95% confidence interval (CI) 42–61%) versus 14% (95% CI 6–26%)”
“Point estimates and two-sided 95% exact binomial CIs were calculated for ORR in each subgroup.”
“HER2 was the only significant amplification change ( P = 0.0064).”
“ORR (95% CI) 58.2% (47.4–68.5%) versus 28.6% (13.2–48.7%)”
“The McNemar test was used to compare ctDNA mutational status changes between baseline and EoT.”
“ORR (95% CI) 58.2% (47.4–68.5%) versus 28.6% (13.2–48.7%)”
“Overall, 57 genes showed higher expression in responders (absolute log 2 fold change (FC) ≥ 1, P ≤ 0.01)”
The data availability statement provides a concrete route: anonymized individual participant data may be available upon request via Vivli, with details on criteria and procedure. This meets the standard for clinical trial data. No custom code is mentioned, so code_sharing is not applicable.
“Anonymized individual participant data on completed studies and applicable supporting clinical study documents may be made available upon request at https://vivli.org/ .”
“Anonymized individual participant data on completed studies and applicable supporting clinical study documents may be made available upon request at https://vivli.org/ .”
The trial is registered (NCT03329690). Limitations are discussed in the Discussion. Conclusions are generally proportional, with caveats about small sample sizes and exploratory nature. Funding and competing interests are disclosed. A reporting guideline is not explicitly mentioned, but the paper follows a structured format.
“Limitations of these biomarker analyses include the fact that they were either exploratory or post hoc analyses with a small sample size conducted in the absence of external validation and data from a control arm.”
“This study was funded by Daiichi Sankyo and AstraZeneca.”
“Limitations of these biomarker analyses include the fact that they were either exploratory or post hoc analyses with a small sample size conducted in the absence of external validation and data from a control arm.”
“This study was funded by Daiichi Sankyo and AstraZeneca.”
“Limitations of these biomarker analyses include the fact that they were either exploratory or post hoc analyses with a small sample size conducted in the absence of external validation and data from a control arm.”
“This study was funded by Daiichi Sankyo and AstraZeneca.”
Registered (4 IDs: ClinicalTrials.gov, jRCT (Japan)). No reporting guideline cited.
Broken references and links
None foundReferences checked against Crossref, OpenAlex and Retraction Watch for retractions and resolvability, plus declared data and code links probed for whether they resolve to content matching the paper.
Checked — nothing surfaced.
Checked 27 references by DOI: 25 verified — 2 no DOI (shown, not verified).
- NO DOIGastric Cancer. Version 2.2023No DOI in the reference — shown for manual review; not independently verifiable (not a fabrication signal).
- NO DOIOncoKB: a precision oncology knowledge baseNo DOI in the reference — shown for manual review; not independently verifiable (not a fabrication signal).
2 data/code links checked; 2 live.
- datahttps://vivli.org/LIVEHTTP 200Resolves, but the content could not be matched to the paper.
- datahttps://vivli.org/ourmember/daiichi-sankyo/LIVEHTTP 200Resolves, but the content could not be matched to the paper.
Copyediting
9 minorWording, consistency and formatting errors that need correcting before submission.
No major wording or formatting errors. 9 minor suggestions below.
9 copyedit issues flagged: mostly consistency, grammar, clarity.
- MINORconsistencyAbstract“HER2 ( ERBB2 ) plasma gene amplification”→ Remove extra space before parentheses: 'HER2 (ERBB2) plasma gene amplification'Inconsistent spacing in gene name.
- MINORgrammarResults, Relationship between baseline HER2 levels and response“Patients with high HER2 ( ERBB2 ) messenger RNA (mRNA) gene expression (defined as equal to or greater than the median value of 9.72) ( n = 16) had higher ORR compared with those with low HER2 mRNA gene expression (defined as below the median value of 9.72) ( n = 17): (ORR (95% CI) 81.2% (54.4–96.0%) versus 23.5% (6.8–49.9%)) as assessed by RNA sequencing (RNA-seq).”→ Remove extra colon and parentheses: '... (n = 17) had ORR (95% CI) 81.2% (54.4–96.0%) versus 23.5% (6.8–49.9%) as assessed by RNA sequencing (RNA-seq).'Awkward punctuation.
- MINORconsistencyResults, Relationship between baseline HER2 levels and response“Patients with high serum HER2ECD concentration (defined as equal to or greater than the median value of 9.72; n = 62) had higher ORR compared with those with low serum HER2ECD (defined as below the median value of 9.72; n = 56); ORR (95% CI) 59.7% (46.4–71.9%) versus 42.9% (29.7–56.8%) (Fig. ).”→ Remove extra semicolon and space before period: '... versus 42.9% (29.7–56.8%) (Fig.).'Punctuation issue.
- MINORconsistencyAbstract“HER2 ( ERBB2 ) plasma gene amplification”→ Consider using consistent terminology for HER2 gene amplification.Minor inconsistency in gene naming.
- MINORclarityResults, Relationship between baseline HER2 levels and response“Patients with high HER2 ( ERBB2 ) messenger RNA (mRNA) gene expression (defined as equal to or greater than the median value of 9.72) ( n = 16) had higher ORR compared with those with low HER2 mRNA gene expression (defined as below the median value of 9.72) ( n = 17)”→ Clarify that the median value is the same for both groups.The sentence is slightly redundant.
- MINORgrammarDiscussion, paragraph 3“Although bTMB did not appear to have a major effect on response to treatment, patients with alterations in key signal transduction genes ( MET , EGFR , FGFR2 or PIK3 GoF) had numerically lower ORR.”→ Change 'PIK3 GoF' to 'PIK3CA GoF' for consistency.Inconsistent gene name abbreviation.
- MINORconsistencyAbstract“HER2 ( ERBB2 ) plasma gene amplification”→ Consider rephrasing to 'plasma HER2 (ERBB2) gene amplification' for clarity.Minor word order issue.
- MINORclarityResults, Relationship between baseline HER2 levels and response“Patients with high HER2 ( ERBB2 ) messenger RNA (mRNA) gene expression (defined as equal to or greater than the median value of 9.72) ( n = 16) had higher ORR compared with those with low HER2 mRNA gene expression (defined as below the median value of 9.72) ( n = 17)”→ Consider breaking this long sentence into two for readability.Long sentence with multiple clauses.
- MINORconsistencyResults, Relationship between baseline HER2 levels and response“Patients with high serum HER2ECD concentration (defined as equal to or greater than the median value of 9.72; n = 62)”→ The median value for HER2ECD is stated as 9.72, but later in the text an exploratory cutoff of 14.4 ng/ml is used. Clarify the units and context.Potential confusion between median and cutoff values.
The published work is robust in its ethical, resource, and data-sharing reporting, but readers should weigh the exploratory/post hoc nature, the lack of multiple testing correction, and the threshold p-values when interpreting the biomarker associations. No erratum is warranted for the flagged internal contradictions, but the authors should clarify the HER2 GoF denominator and the abstract's concordance statement.
- 1.HIGHstatisticsIn the Results, replace threshold p-values (e.g., P ≤ 0.01) with exact p-values where feasible, especially for the differential expression analysis.Threshold p-values are a reporting imprecision that prevents readers from assessing the strength of evidence.
- 2.HIGHstatisticsIn the Methods, add a statement on multiple testing correction or justify its absence in the exploratory context.The lack of multiple testing correction is a limitation that should be explicitly acknowledged to avoid over-interpretation.
- 3.HIGHreportingIn the Results, clarify the denominator for the HER2 GoF subset (8 of 12) and reconcile with the IHC 3+ cohort of 91.The internal contradiction flagged in the integrity check could confuse readers and warrants clarification.
- 4.HIGHreportingIn the Abstract, clarify the concordance statement (64%) to reflect the PPA/NPA distinction reported in the Results.The abstract may oversimplify the concordance metric, which could mislead readers.
- 5.MEDIUMreportingIn the Methods, add a statement on how test assumptions (e.g., proportional hazards for Cox models) were verified or handled.Assumption verification is a standard expectation for statistical models.
- 6.MEDIUMreportingIn the Results, include a table of baseline demographics (age, sex, race) for the biomarker-evaluable population.Demographics are not reported in the text, which limits transparency for a secondary analysis.
- 7.MEDIUMreportingIn the Methods, describe the exact criteria for defining 'response-evaluable' patients and how missing data were handled.Clear definition of the analysis population is essential for reproducibility.
- 8.MEDIUMreportingIn the Methods, state whether any sensitivity analyses were performed to assess the robustness of the exploratory cutoffs.Sensitivity analyses would strengthen the exploratory findings.
- 9.MEDIUMreportingIn the Discussion, explicitly acknowledge the lack of multiple testing correction in exploratory analyses as a limitation.This is a common reviewer concern and should be preemptively addressed.
- 10.MEDIUMreportingIn the Methods, clarify the randomization method used in the parent trial (e.g., block randomization).The randomization method is not detailed, which is a minor reporting gap.
- 11.MEDIUMreportingIn the Methods, describe how outliers were handled in the ctDNA and RNA-seq analyses, or state that no outliers were excluded.Outlier handling is not reported, which is a transparency gap.
- 12.MEDIUMreportingIn the Methods, state whether the biomarker analysis was pre-specified or post hoc.Clarifying the exploratory nature is important for interpretation.
- 13.LOWcopyeditFix spacing in gene names (e.g., 'HER2 ( ERBB2 )' to 'HER2 (ERBB2)') throughout the manuscript.Consistent formatting improves readability and professionalism.
- 14.LOWcopyeditFix punctuation issues in the Results (e.g., remove extra colon and parentheses in the HER2 mRNA sentence).Awkward punctuation can distract readers.
- 15.LOWcopyeditChange 'PIK3 GoF' to 'PIK3CA GoF' for consistency in the Discussion.Inconsistent gene name abbreviation could cause confusion.
- 16.LOWcopyeditClarify the units and context for the HER2ECD median value (9.72) versus the exploratory cutoff (14.4 ng/ml).Potential confusion between median and cutoff values should be resolved.
The star rating is the report’s one-glance summary. Every paper starts at 5★ and loses stars for the concrete problems the review finds — so a rating is never a vague average, it’s a running total you can read line by line under “How this rating was calculated.”
- Reporting — 8 dimensionseach dimension that fully fails−½★
- each dimension partially met−¼★
- Statistics · Integrity · Claimseach serious problem−1★
- each medium problem−½★
- Citationseach retracted or unverifiable reference−¼★
- Copyeditonly when the manuscript needs a full edit−½★
The rating never drops below 1★, and a demonstrable critical failure (an impossible statistic, a proven ethics violation) caps it at 1★ on its own — so the stars can never look healthy when the verdict is CRITICAL.
The rating draws on a panel of agents. Three independent Kaimen Rigor reviewers grade the eight dimensions below across several independent passes (the shown verdict is their majority vote — steadier than any single run), isolate the paper’s major claims and check its own evidence backs them, and flag integrity concerns. Alongside them, a citation agent resolves every reference against Crossref, OpenAlex, and Retraction Watch; a statistics agent recomputes reported tests; and rule-based checks verify that declared data/code links actually resolve. Full text is required — an abstract-only submission is not analyzed.
Graded against NIH, MDAR, ARRIVE 2.0, CONSORT, EQUATOR, and RRID guidelines. A dimension that doesn’t apply to the study type is skipped, never penalized.
This Kaimen Rigor review is model-assisted and is not a substitute for formal expert review. It complements human evaluation by surfacing potential methodological concerns — verify each finding against the source.