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Clinical Validation of a Candidate Biomarker for Neurological or Neuromuscular Disorders (U44 Clinical Trial Optional)


A biomarker is a defined characteristic that is measured as an indicator of a normal biological process, pathogenic process, or responses to an exposure or intervention, including therapeutic interventions. Biomarker modalities are diverse, and can include ‘omics, imaging, behavioral, digital and physiologic endpoints. Because the measurement of the biomarker is integral to defining the biomarker, it is necessary to describe the biomarker in terms of its biological source or matrix, measurable features, and the analytic method used to measure it (“detection method”). Biomarkers are critical to the discovery and development of therapeutics and can serve a variety of functions such as verifying therapeutic target engagement, improving trial design by patient stratification, and facilitating clinical care decisions. Despite the active pace of discovery of novel biomarker candidates, few biomarkers progress beyond discovery to the robust analytical and clinical validation needed for use in Phase II and Phase III clinical trials. Thus, there is a critical need to advance validation of biomarkers to improve public health, particularly for disorders of the nervous system where advancing therapeutics from discovery to the market are notoriously challenging. Validation of biomarkers for all neurological and neuromuscular disorders within NINDS’ mission are within scope and may include a context of use focused on any part of the age spectrum. This NOFO is intended to address the gap in biomarker validation by encouraging rigorous clinical validation of the biomarker detection method for one or two specified context(s) of use. Definitions of terms used in this NOFO : Context of Use (COU): A statement that fully and clearly describes the way the biomarker is expected to be used. The COU should include the biomarker category (susceptibility/risk, diagnostic, monitoring, prognostic, predictive, pharmacodynamic/response, or safety), the modality, method of detection, and clinical population characteristics. Context of use statements are discussed extensively in the Framework for Defining Evidentiary Criteria for Biomarker Qualification developed by the Biomarkers Consortium: Concept: In a regulatory context, the concept is the aspect of an individual’s clinical, biological, physical, or functional state, or experience that the assessment is intended to indicate or reflect. Detection method: The method(s) used for measuring the biomarker(s). Analytical Validation: A process to establish that the performance characteristics of a test, tool, or instrument are acceptable in terms of its sensitivity, specificity, accuracy, precision, and other relevant performance characteristics using a specified technical protocol (which may include specimen collection, handling and storage procedures). This is validation of the test’s, tool’s, or instrument’s technical performance to measure the biomarker(s) of interest. Clinical Validation: A process to establish that the test, tool, or instrument acceptably identifies, measures or predicts the concept of interest. Clinical validation establishes the data needed to reach conclusions or interpret the results of the biomarker(s) readout, and the level of confidence for these interpretations. Composite biomarkers/biomarker signatures: when more than one biomarker is being validated for the same context of use (e.g., a panel of biomarkers, or set of features used as a composite indicator). Clinical Outcome Assessment (COA): a measure that describes or reflects how a patient feels, functions, or survives (includes patient-reported outcomes, observer-reported outcomes, clinician-reported outcomes, and performance outcomes). Digital Biomarker: The term “digital biomarker” is widely used to mean assessments that include both biological processes (such as changes in heart rate or galvanic skin response) as well as performance assessments (such as measurements derived from accelerometers). Both digital biomarkers and digital performance assessment are within scope of this NOFO, however other patient-reported outcomes, observer-reported outcomes, and clinician reported outcomes are not within scope. Biomarker categories as defined in the Biomarkers, EndpointS, and Other Tools (BEST) Resources ( include: Monitoring biomarkers to track the success of a therapeutic intervention or the disease progression Diagnostic biomarkers used to detect or confirm presence of a disease or condition of interest or to identify individuals with a subtype of the disease. Prognostic biomarkers for predicting outcomes Predictive biomarkers for differentiating individuals based on favorable or unfavorable effect from a therapeutic or other intervention Pharmacodynamic/response biomarker that indicates biologic activity of a medical product or environmental agent without necessarily drawing conclusions about efficacy or disease outcome or necessarily linking this activity to an established mechanism of action. Safety biomarkers to indicate the likelihood, presence, or extent of an adverse effect Susceptibility/risk biomarkers that indicate the potential for developing a disease or medical condition in an individual who does not currently have a clinically apparent disease. Research Objectives This NOFO supports research to conduct clinical validation of a biomarker or biomarker signature or composite biomarker for one or two specified context(s) of use. For the purpose of this NOFO, the term “Biomarker(s)” will be used interchangeably with biomarker signature and composite biomarkers. Premise for the utility of the biomarker(s) should include evidence that the biomarker(s) has undergone preliminary testing in an appropriate clinical population, using either prospective or retrospective data or samples, and shows sufficient clinical sensitivity and specificity and/or association with the biological concept of interest to warrant additional investment. In addition, applications to this NOFO should include evidence that the detection method for the biomarker has already been developed and subjected to initial evaluation of precision and analytical sensitivity. This NOFO supports analytical validation research that plans to optimize and standardize the detection method and rigorously test the analytic and pre-analytic variables to evaluate and reduce sources of variability when measuring the biomarker. Earlier stage research that still needs to conduct clinical proof of concept studies to establish the relationship between candidate biomarkers with a concept of interest (with or without detection method development) should consider applying to the companion NOFO, PAR-22-089 “Development of Biomarkers or Biomarker Signatures for Neurological and Neuromuscular Disorders”. Alternatively, studies that are seeking to conduct final analytical validation research should consider the companion NOFO “Clinical Validation of Biomarkers for Neurological and Neuromuscular conditions”. This funding opportunity uses a cooperative agreement, milestone driven mechanism that enables significant input from NIH staff to assist investigators with preparing and evaluating their analytical validation strategy through milestone negotiation. The Analytical Validation NOFOs and companion Clinical Validation NOFOs are designed to help gather the data package needed for clinical trial readiness and may be used to support a submission to the FDA’s Biomarker Qualification Submission or to the FDA’s Center for Devices and Radiological Health, if applicable. For more information on the Biomarker Qualification program see: Application Characteristics One or two clearly defined context(s) of use A strong justification for the clinical and/or research need of the biomarker(s) and the detection method for the context(s) of use. Justification of feasibility, including potential added clinical burden and cost, of incorporating the biomarker into clinical trials or clinical practice (as appropriate for the context(s) of use). A clear and well justified study design and statistical design(s) A direct comparison to existing biomarkers or clinical outcome assessments used for the same COU, if applicable. A multi-site design to demonstrate reliable results across sites in a sufficiently representative cohort, or a strong scientific justification why only one site is needed. Evidence of scientific rigor in the supporting literature underlying the premise, the preliminary data, as well as in the research strategy, design, execution, and interpretation of the proposed studies. A clear and feasible timeline with quantitative annual milestones that demonstrate continued feasibility and progress towards the project’s success (see section IV “Other Project Information”) A team management plan (see section IV “Other Project Information”) A Plan for Enhancing Diverse Perspectives (PEDP) (see section IV “Other Project Information”) If applicable, an Intellectual Property (IP) plan (see section IV “Other Project Information”) Clinical Validation should include the following metrics with use of FDA guidance standards appropriate for the Context of Use Sensitivity and specificity of the biomarker within the Context of Use, including methods for binary and/or continuous analysis. Area Under the Curve (AUC) as determined by Receiver Operator Characteristic (ROC) Analysis Estimation of the prevalence of the marker within subjects or patients for the intended clinical context. Establishing the appropriate thresholds or reference ranges for the biomarker for decision making within the context of use. Positive Predictive Value (the probability that a positive screening test result is true, taking into account the prevalence of the disease or condition in the population being measured). Negative Predictive Value (the probability that a negative screening test result is true, taking into account the prevalence of the disease or condition in the population being measured). Collaborations and Consultants Multidisciplinary collaboration among scientific investigators, clinical scientists, disease/biology matter experts, statisticians, regulatory expertise, and other academic/industry experts relevant to the context of use in the application as well as clinical and laboratory staff are an integral part of the application. Investigators are also encouraged to form collaborations/obtain consultants with individuals knowledgeable in relevant regulatory processes and/or statisticians knowledgeable in clinical trial design. Leveraging Existing Resources Where applicable, applicants are encouraged to leverage existing research resources for their studies. Such resources may include clinical biospecimen samples from the NINDS Human Biospecimen and Data Repository (BioSEND; or other existing biospecimen, imaging and data repositories. Leveraging the resources of ongoing clinical trials or clinical studies supported through other Federal or private funds is also encouraged. Rigor, Reproducibility, Data Sharing and Intellectual Property NINDS, as part of NIH, strives for rigor and transparency in all research it funds. For this reason, NINDS explicitly emphasizes the NIH application instructions related to rigor and transparency ( and provides additional guidance to the scientific community ( For example, the biological rationale for the proposed experiments must be based on rigorous and robust supporting data, which means that data should be collected via methods that minimize the risk of bias and be reported in a transparent manner. If previously published or preliminary studies do not meet these standards, applicants should address how the current study design addresses the deficiencies in rigor and transparency. Proposed experiments should likewise be designed in a manner that minimizes the risk of bias and ensures validity of experimental results. To improve reproducibility and community uptake, investigators are generally expected to share code/scripts, analytic tools/statistical models, protocols/processes and metadata before the end of the project’s period of performance. If there is a plan to commercialize aspects of the project such as analytic software, applicants should consult with their tech transfer office when developing the data sharing plan and intellectual property plan. Budgets should reflect any costs associated with these efforts. Information on many available NIH supported or frequently used repositories is available at: Applicants collecting biofluid samples from prospectively enrolled study participants are encouraged to share samples through the NINDS biomarker repository, BioSEND ( ) to provide the broader scientific community with a data resource for hypothesis generation and test validation. Applicants should contact BioSEND to incorporate sharing plans and cost in their application. Pre-Application Consultation Applicants are strongly encouraged to consult with NINDS Program Staff early on during the planning for an application. This early contact will provide an opportunity to discuss and clarify NINDS policies and guidelines, including the scope of the project relative to the NINDS mission and intent of this NOFO. These discussions can also provide any needed clarification regarding development of an appropriate timeline and milestone plan and guidance for requesting approval of budgets that exceed $500,000 direct cost in any given year. Funding Considerations Applications within the top scoring meritorious range will be considered for funding. Within that range, priority may be placed on applications that fill a critical program gap to ensure biomarker development that is reflective of the breadth of disorders and conditions within NINDS’s mission. Additionally, priority will be given to biomarkers that: 1) address an unmet medical need, 2) are supported by a strong biological rationale, 3) include a carefully designed plan for performance evaluation, 4) include a plan for standardization of samples and data collection for use in validation and 5) provide a strong justification for the utility of the biomarker in the clinical setting or for use in clinical trial design. Plan for Enhancing Diverse Perspectives (PEDP) This NOFO requires a Plan for Enhancing Diverse Perspectives (PEDP) as described in NOT-MH-21-310,submitted as Other Project Information as an attachment (see Section IV). Applicants are strongly encouraged to read the NOFO instructions carefully and view the available PEDP guidance material. The PEDP will be assessed as part of the scientific and technical peer review evaluation, as well as considered among programmatic matters with respect to funding decisions. Applications Not Responsive to this NOFO Non-responsive studies include: clinical trials or clinical research where the primary intent is to develop therapeutic agents or devices, clinical trials or clinical research to evaluate a therapeutic agent or device’s clinical safety, efficacy, effectiveness, and/or clinical management, pre-clinical research using animal models, applications where the primary intent is to validate clinical outcome assessments rather than biomarkers, applications that do not specify the context(s) of use, applications that do not include milestones, applications that are not within the NINDS mission STTR applications will not be accepted. Non-responsive applications will be administratively withdrawn without review
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