DESCRIPTION: Learn who may qualify for cancer immunotherapy in Turkey, which PD-L1, MSI, TMB and NGS tests may be required, and how treatment is planned.

 

KEYWORD:

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- TMB test Turkey

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- immunotherapy for cancer in Turkey

 

 

Immunotherapy for Cancer in Turkey: Who Is Eligible, Which Tests Are Needed, and How Is Treatment Planned?

 

Immunotherapy has changed the treatment of several cancers by helping the immune system recognise and attack cancer cells. However, it is not suitable for every patient or every tumour.

 

Whether a patient may benefit from immunotherapy depends on several factors, including:

 

The type and stage of cancer:

- The tumour’s pathological and molecular characteristics

- Previous cancer treatments

- Biomarker results

- The patient’s general condition and organ function

- Existing autoimmune diseases or other medical conditions

- The approved treatment options for that particular cancer

 

For international patients considering immunotherapy in Turkey, the first step should therefore be a detailed oncology assessment—not simply selecting a drug based on its name or another patient’s experience.

 

This guide explains how immunotherapy works, which tests may be required, how eligibility is assessed and what patients should consider before travelling for treatment.

 

 

What Is Cancer Immunotherapy?

 

The immune system normally identifies and removes abnormal cells. Cancer cells, however, can develop mechanisms that help them avoid immune detection or suppress the body’s immune response.

 

Immunotherapy aims to improve the immune system’s ability to recognise, target or control cancer.

 

There are several types of cancer immunotherapy:

 

Immune checkpoint inhibitors

Checkpoint inhibitors are among the most widely used forms of immunotherapy. They block signals that cancer cells may use to prevent immune cells from attacking them.

 

Important immune checkpoints include:

- PD-1

- PD-L1

- CTLA-4

 

Depending on the cancer, checkpoint inhibitors may be given alone or combined with chemotherapy, targeted therapy or another immunotherapy medicine.

 

Monoclonal antibodies

Some monoclonal antibodies attach to specific targets on cancer cells. They may mark those cells for destruction by the immune system or interfere with signals that help the cancer grow.

 

Not every monoclonal antibody is classified in the same way, and its role depends on the molecular characteristics of the cancer.

 

T-cell therapies

T-cell therapies involve collecting or modifying immune cells so that they can better recognise cancer.

 

CAR T-cell therapy is an example. It is mainly used for certain blood cancers and requires highly specialised centres, laboratory processing and close monitoring.

 

It should not be confused with checkpoint inhibitor treatment used for many solid tumours.

 

Cancer vaccines and immune modulators

Some treatments stimulate a broader immune response or train the immune system to recognise particular cancer-associated targets. Their availability and indications vary considerably.

 

 

Which Cancers Can Be Treated With Immunotherapy?

 

Immunotherapy may be considered in selected patients with cancers such as:

- Non-small cell lung cancer

- Melanoma and certain other skin cancers

- Kidney cancer

- Bladder and urinary tract cancers

- Head and neck cancers

- Hodgkin lymphoma

- Liver cancer

- Stomach and gastro-oesophageal junction cancer

- Cervical cancer

- Breast cancer in selected settings

- Colorectal and other cancers with specific biomarkers

- Some endometrial cancers

- Certain solid tumours with MSI-H, dMMR or other qualifying characteristics

 

Being diagnosed with one of these cancers does not automatically mean that immunotherapy is appropriate.

 

The exact indication may depend on the cancer subtype, stage, previous treatment, biomarker result and whether immunotherapy is being considered before surgery, after surgery, for locally advanced disease or for metastatic cancer.

 

 

Who May Be Eligible for Immunotherapy?

 

An oncologist generally evaluates the following areas before recommending treatment.

 

1. Confirmed cancer diagnosis

The pathology report must confirm the type and subtype of cancer. In some cases, the pathology slides or tissue blocks should be reviewed again by a specialist pathologist.

 

A pathology review can be especially important when:

 

- The original diagnosis is uncertain

- The cancer has unusual characteristics

- The available report lacks important biomarker information

- The patient has received different treatment recommendations

- The tissue sample was obtained several years earlier

 

2. Cancer stage and current disease status

Recent imaging may be needed to determine:

 

- Where the cancer is located

- Whether it has spread

- How quickly it is progressing

- Whether previous treatment has worked

- Whether surgery or radiotherapy remains an option

 

The most appropriate imaging may include CT, MRI, PET-CT or other disease-specific examinations.

 

3. Approved treatment setting

An immunotherapy medicine may be appropriate for one cancer but not another. It may also be approved only at a particular stage or treatment line.

 

For example, the same medicine may be used:

 

- As the first systemic treatment for one cancer

- Only after chemotherapy for another cancer

- Together with chemotherapy in a specific setting

- After surgery to reduce the risk of recurrence

- Before surgery in selected patients

- Only when a qualifying biomarker is present

 

The treatment decision should therefore be based on the complete clinical situation and current oncology guidance.

 

4. Biomarker results

Some immunotherapy decisions require or are strengthened by biomarker testing. Important biomarkers may include PD-L1, MSI, MMR and TMB.

 

A biomarker result can help guide treatment, but it does not guarantee that treatment will work.

 

5. General health and organ function

The oncology team may assess:

 

- Daily activity and performance status

- Liver and kidney function

- Blood-cell levels

- Thyroid and other endocrine function

- Heart and lung health

- Current infections

- Neurological symptoms

- Nutritional condition

- Other medicines being taken

 

Patients must be medically stable enough to receive treatment and to manage potential immune-related side effects.

 

 

Which Tests May Be Needed Before Immunotherapy?

 

Not every patient needs every test. Testing should be selected according to the cancer type, available tissue and proposed treatment.

 

 

PD-L1 Testing

PD-L1 is a protein that may be present on cancer cells or immune cells around the tumour. Some cancers use the PD-1/PD-L1 pathway to weaken the immune response.

 

PD-L1 is usually measured by immunohistochemistry using tumour tissue.

 

Results may be reported using measures such as:

 

- Tumour Proportion Score, or TPS

- Combined Positive Score, or CPS

- Immune-cell scoring methods

 

The appropriate scoring system and threshold depend on the cancer, medicine and approved indication.

 

A “PD-L1-positive” result is therefore not a universal category. A result that supports one treatment decision may not have the same meaning for another cancer or medicine.

 

 

Does a high PD-L1 result guarantee a response?

No. A high result may increase the likelihood of benefit in some clinical situations, but it does not guarantee that the cancer will respond.

 

Similarly, a low or negative PD-L1 result does not always exclude immunotherapy. Some patients may still receive it as part of a combination or for an indication in which PD-L1 is not required.

 

 

MSI and MMR Testing

Mismatch repair, or MMR, is a cellular system that helps correct errors occurring when DNA is copied.

 

When this repair system is deficient, the condition is called deficient mismatch repair, or dMMR. This can lead to microsatellite instability-high status, known as MSI-H.

 

MSI or MMR status may be assessed through:

 

- Immunohistochemistry

- PCR-based testing

- Next-generation sequencing

 

MSI-H or dMMR may help identify patients who could benefit from certain checkpoint inhibitors. These findings can be relevant in colorectal, endometrial, stomach and several other cancers.

 

In some situations, MSI-H or dMMR may support a treatment decision based on the tumour’s molecular feature rather than only the organ where the cancer began.

 

MMR deficiency may also indicate the need for genetic counselling in selected patients, particularly when an inherited cancer syndrome is suspected.

 

 

Tumour Mutational Burden

Tumour mutational burden, or TMB, estimates the number of mutations present within a defined amount of tumour DNA.

 

A tumour with a high mutational burden may produce more abnormal proteins that the immune system can potentially recognise. For certain patients and treatment settings, TMB may help inform immunotherapy eligibility.

 

However:

 

- TMB is not equally useful in every cancer

- Results may vary between testing platforms

- Sample quality can affect the result

- A high result does not guarantee treatment success

- The result must be interpreted alongside the patient’s diagnosis and medical history

 

TMB should preferably be measured through a validated test suitable for the proposed treatment decision.

 

 

Next-Generation Sequencing

Next-generation sequencing, or NGS, can analyse many cancer-related genes at the same time.

 

NGS may identify:

 

- Targetable gene alterations

- MSI status

- TMB, depending on the panel

- Resistance-related findings

- Alterations that help classify the tumour

- Clinical-trial options where appropriate

 

NGS is not only used to find reasons to prescribe immunotherapy. It may also reveal a target for another treatment that should be considered before or instead of immunotherapy.

 

This can be particularly important in cancers where a recognised molecular driver may make targeted therapy the preferred initial option.

 

 

Tissue Biopsy or Liquid Biopsy?

 

Most pathology and PD-L1 testing requires tumour tissue. Tissue may come from:

 

- The original surgery

- A core-needle biopsy

- A recent biopsy of a metastatic lesion

- A stored pathology block

 

A liquid biopsy analyses tumour-related DNA circulating in the blood. It may be useful when:

 

- Tumour tissue is unavailable

- Obtaining another tissue biopsy carries significant risk

- The available tissue is insufficient for molecular testing

- A rapid molecular assessment is needed

- Treatment resistance is being investigated

 

A liquid biopsy does not completely replace tissue analysis. Some cancers release very little tumour DNA into the bloodstream, so a negative blood test does not always mean that no relevant alteration is present.

If the liquid-biopsy result is negative or inconclusive, tissue testing may still be recommended.

 

 

Baseline Blood Tests and Medical Assessments

 

Before starting treatment, the oncology team may request:

 

- Complete blood count

- Liver-function tests

- Kidney-function tests

- Thyroid tests

- Blood glucose

- Electrolytes

- Adrenal or pituitary-related hormone tests when indicated

- Infection screening when clinically appropriate

- Pregnancy testing when relevant

- Baseline CT, MRI or PET-CT

- Heart or lung assessment for selected patients

 

These results create a baseline for monitoring changes during treatment.

 

 

Immunotherapy Alone or With Chemotherapy?

 

Neither approach is universally better.

 

Immunotherapy alone may be appropriate when:

 

- There is a qualifying biomarker

- The cancer type and treatment setting support monotherapy

- The expected balance of benefit and risk is favourable

- Chemotherapy is not required as part of the recommended regimen

 

A combination with chemotherapy may be recommended when:

 

- Clinical evidence supports a higher response rate

- The cancer requires faster disease control

- PD-L1 expression is low or absent but combination treatment remains appropriate

- The approved treatment protocol includes both therapies

 

Combination treatment may increase the possibility of chemotherapy-related and immune-related side effects. The decision should reflect the cancer’s characteristics, disease burden, symptoms and the patient’s overall health.

 

 

How Is an Immunotherapy Plan Prepared in Turkey?

 

A properly prepared treatment plan generally involves several stages.

 

Step 1: Medical-record review

The patient submits available records, including:

 

- Pathology reports

- Pathology slides or tissue-block information

- Imaging reports

- Imaging files in DICOM format

- Previous treatment summaries

- Operation reports

- Radiotherapy details

- Molecular and genetic test results

- Recent blood tests

- Current medicines and medical conditions

 

 

Step 2: Specialist assessment

The records are reviewed by an oncology specialist with relevant experience in the specific cancer type.

 

The doctor determines whether:

 

- The diagnosis is sufficiently confirmed

- Additional pathology review is needed

- Biomarker testing is complete

- The disease must be restaged

- Immunotherapy is a medically appropriate option

- Another treatment should be considered first

 

 

Step 3: Pathology and molecular testing

Missing or outdated tests may be requested. In some cases, a new biopsy may be required if the stored tissue is inadequate or no longer represents the current disease.

 

 

Step 4: Multidisciplinary discussion

Complex cases may be discussed by a tumour board involving medical oncology, surgery, radiology, radiation oncology, pathology and other relevant specialties.

 

 

Step 5: Written treatment proposal

The treatment proposal should explain:

 

- The recommended medicine or combination

- The reason for the recommendation

- The treatment schedule

- Tests needed before the first dose

- Expected monitoring

- Important risks and side effects

- Approximate duration

- Estimated hospital costs

- How follow-up will be managed after the patient returns home

 

 

How Is Immunotherapy Given?

 

Depending on the treatment, immunotherapy may be administered:

 

- Through an intravenous infusion

- By injection

- Orally

- Directly into a specific body cavity in selected conditions

- Through specialised cellular-treatment procedures

- Checkpoint inhibitors are commonly given as intravenous infusions at defined intervals.

 

The exact schedule depends on the medicine, cancer type, dose and approved protocol. Treatment may be administered every few weeks, but there is no single schedule for all patients.

 

 

How Long Does Treatment Continue?

 

Treatment duration depends on:

 

- The type and stage of cancer

- The medicine being used

- Whether treatment is given before or after surgery

- Response to treatment

- Side effects

- Disease progression

- The maximum duration used in the relevant protocol

 

Some patients receive a fixed number of cycles. Others continue until disease progression, unacceptable side effects or completion of a defined treatment period.

 

Longer treatment is not automatically better. The decision should be made by the treating oncologist based on benefit, safety and current medical evidence.

 

 

How Is the Response Monitored?

 

Monitoring may include:

 

- Physical examinations

- Blood tests

- CT, MRI or PET-CT scans

- Evaluation of cancer-related symptoms

- Assessment for immune-related side effects

- Additional disease-specific tests

 

Immunotherapy can sometimes produce response patterns that differ from those seen with chemotherapy. However, apparent growth on a scan should not automatically be assumed to be a temporary immune response.

 

The oncologist must consider the scan, symptoms, laboratory results and speed of disease progression before deciding whether treatment should continue.

 

 

What Are the Possible Side Effects?

 

Immunotherapy can cause side effects because an activated immune system may attack healthy organs and tissues.

 

Common symptoms may include:

 

- Fatigue

- Skin rash

- Itching

- Diarrhoea

- Nausea

- Reduced appetite

- Joint or muscle discomfort

- Changes in thyroid function

 

More serious immune-related reactions can affect:

 

- Lungs, causing pneumonitis

- Bowel, causing colitis

- Liver, causing hepatitis

- Kidneys, causing nephritis

- Thyroid, pituitary or adrenal glands

- Pancreas and blood-sugar regulation

- Heart, causing myocarditis

- Nervous system

- Skin

- Eyes

- Blood cells

 

These complications are less common, but some can become severe if they are not recognised and treated promptly.

 

 

Symptoms that should be reported urgently

 

Patients should contact their oncology team immediately if they develop:

 

- New or worsening shortness of breath

- Persistent cough

- Chest pain or an irregular heartbeat

- Severe or persistent diarrhoea

- Blood in the stool

- Strong abdominal pain

- Yellowing of the eyes or skin

- Dark urine

- Severe weakness or dizziness

- Persistent or intense headache

- Confusion or unusual sleepiness

- Vision changes

- Major changes in thirst or urination

- Severe rash, blistering or peeling skin

- Sudden muscle weakness or numbness

 

Immune-related side effects can appear during treatment or after treatment has ended. Patients should always tell another doctor that they have received immunotherapy, even if their last dose was several weeks or months earlier.

 

Patients should not attempt to manage suspected immune-related reactions without medical advice. Early assessment can prevent a mild problem from becoming serious.

 

 

Immunotherapy and Autoimmune Disease

 

Patients with conditions such as rheumatoid arthritis, inflammatory bowel disease, lupus, multiple sclerosis or autoimmune thyroid disease require individual assessment.

 

Immunotherapy may:

 

- Trigger a flare of the existing condition

- Cause a new immune-related complication

- Require changes to immunosuppressive medicines

- Be unsuitable when the autoimmune disease is severe or poorly controlled

 

An autoimmune diagnosis does not always exclude treatment, but the risks and possible alternatives must be reviewed carefully.

 

 

Immunotherapy After an Organ Transplant

 

Checkpoint inhibitors can increase the risk that the immune system will attack a transplanted organ.

 

Patients with a kidney, liver, heart or other solid-organ transplant need a highly specialised risk assessment. The potential cancer benefit must be considered alongside the risk of organ rejection and loss of transplant function.

 

Such treatment should never be planned without close coordination between oncology and the transplant team.

 

 

Steroids and Immunosuppressive Medicines

 

Patients should inform their oncologist about all medicines, especially:

 

- Corticosteroids

- Immunosuppressants

- Biological medicines

- Medicines used for autoimmune conditions

- Anti-rejection medication

- Herbal products and supplements

- Some of these medicines may affect immune function, interact with treatment or indicate an underlying condition that changes the safety assessment.

 

Patients should not stop prescribed steroids or other medicines without medical advice.

 

 

Pregnancy, Fertility and Breastfeeding

 

Some immunotherapy medicines may harm an unborn baby or create pregnancy-related risks.

 

Patients who are pregnant, may become pregnant, are breastfeeding or wish to preserve fertility should discuss this with the oncology team before treatment.

 

The doctor may recommend:

 

- Pregnancy testing

- Effective contraception during and after treatment

- Fertility-preservation consultation

- Temporary or permanent interruption of breastfeeding

 

The required precautions and their duration depend on the medicine being used.

 

 

How Much Does Immunotherapy Cost in Turkey?

 

There is no single price for cancer immunotherapy.

 

The total cost may depend on:

 

- The specific medicine

- Dose and treatment schedule

- Patient weight where relevant

- Number of planned cycles

- Whether chemotherapy or another medicine is added

- Pathology review

- PD-L1, MSI, TMB or NGS testing

- Imaging and blood tests

- Hospital and infusion services

- Management of complications

- Length of stay in Turkey

 

Patients should request a written, case-specific estimate after their medical records have been reviewed.

 

A quotation should clarify what is included, what may be charged separately and whether the price refers to one cycle or the complete proposed treatment period.

 

 

Can Treatment Continue After Returning Home?

 

In many cases, some or all of the treatment may be continued in the patient’s home country if:

 

- The medicine is available there

- A local oncologist agrees to assume care

- The same treatment protocol can be followed

- Records and test results are transferred

- A plan exists for monitoring and emergencies

- This should be arranged before travelling.

The Turkish treatment centre and the patient’s local oncologist should ideally agree on:

 

- The treatment schedule

- Required laboratory tests

- Timing of response scans

- Dose delays or stopping rules

- Management of immune-related side effects

- How urgent medical questions will be handled

 

Continuity of care is particularly important with immunotherapy because some adverse reactions require rapid investigation and treatment.

 

 

Travelling to Turkey for Immunotherapy

 

Before making travel arrangements, patients should confirm:

 

- Whether an in-person examination is required

- Which original documents or tissue materials to bring

- Whether additional tests will be completed in Turkey

- How long they need to stay

- Whether they are medically fit to fly

- Who will manage complications after returning home

- Whether travel insurance covers cancer-related care

- Whether a companion is advisable

 

Patients who are medically unstable or experiencing severe symptoms may need treatment locally before travelling.

 

 

How Recmed Medical Tourism Can Assist

 

Recmed Medical Tourism is a medical-travel coordination service. Recmed does not diagnose cancer, prescribe medicines or replace the treating oncology team.

 

Depending on the patient’s needs, coordination support may include:

 

1. Collecting and organising medical records

2. Identifying an appropriate oncology specialist or hospital in Turkey

3. Arranging review of pathology, imaging and previous treatments

4. Coordinating PD-L1, MSI, TMB or NGS testing when requested by the medical team

5. Organising an online or in-person specialist consultation

6. Obtaining a written treatment proposal and estimated costs

7. Scheduling hospital appointments and examinations

8. Coordinating airport and local transfers

9. Assisting with accommodation and interpreter arrangements

10. Helping transfer discharge records and follow-up recommendations to the patient

11. All diagnoses and treatment decisions are made by licensed doctors and healthcare institutions.

 

 

Medical Records Needed for an Immunotherapy Review

 

Patients can usually begin by providing:

 

- Pathology report

- Available molecular test results

- PD-L1, MSI, MMR or TMB results

- Pathology-block and slide information

- Recent CT, MRI or PET-CT reports

- Imaging files in DICOM format

- Previous chemotherapy records

- Previous immunotherapy or targeted-therapy records

- Surgery and radiotherapy reports

- Recent blood-test results

- List of current medicines

- Details of autoimmune diseases, infections or organ transplantation

- A short summary of current symptoms and general condition

 

Complete and clearly organised records can make the initial assessment more reliable and reduce unnecessary delays.

 

 

Questions to Ask the Oncologist

 

Before starting treatment, consider asking:

 

- Why are you recommending immunotherapy for my cancer?

- Is this treatment approved for my diagnosis and treatment stage?

- Do I need PD-L1, MSI, MMR, TMB or NGS testing?

- Is my current tissue sample adequate?

- Should the pathology be reviewed again?

- Are there targetable mutations that should be considered first?

- Should immunotherapy be given alone or with chemotherapy?

- What is the realistic goal of treatment in my case?

- How and when will the response be measured?

- Which side effects require urgent attention?

- Does my autoimmune condition or transplant history change the risk?

- How long is treatment expected to continue?

- Can treatment be continued in my home country?

- What is included in the cost estimate?

- Who should I contact if symptoms develop after I return home?

 

 

Frequently Asked Questions

 

Is immunotherapy better than chemotherapy?

Not in every situation. Immunotherapy and chemotherapy work differently. The most appropriate choice depends on the cancer type, stage, biomarkers, symptoms and previous treatments.

 

Some patients receive immunotherapy alone, while others benefit from a combination. In certain cancers, chemotherapy, targeted therapy, surgery or radiotherapy may be more appropriate.

 

 

Can immunotherapy cure stage 4 cancer?

Some patients with advanced cancer achieve long-lasting disease control, but immunotherapy cannot be described as a guaranteed cure.

 

The chance of benefit varies widely between cancers and patients. The oncologist should explain the treatment goal and expected outcomes for the individual case.

 

 

Can I receive immunotherapy if my PD-L1 result is negative?

Possibly. A negative result does not exclude immunotherapy in every cancer.

 

Eligibility depends on the cancer, medicine, treatment line, other biomarkers and whether immunotherapy is being used alone or in a combination.

 

 

How quickly does immunotherapy work?

Response time varies. Some patients improve within the first treatment cycles, while others take longer. Some cancers do not respond.

 

Response should be evaluated through scheduled examinations and imaging rather than symptoms alone.

 

 

Does immunotherapy cause hair loss?

Checkpoint inhibitors do not usually cause the same pattern of hair loss commonly associated with many chemotherapy medicines. However, hair or skin changes can occur.

 

If immunotherapy is combined with chemotherapy, hair loss may result from the chemotherapy component.

 

 

What happens if immunotherapy causes severe side effects?

Treatment may be delayed or stopped. The patient may need corticosteroids or other immune-suppressing treatment, specialist consultation or hospital care.

 

Early reporting is essential. Treatment decisions depend on which organ is affected and how severe the reaction is.

 

 

Can immunotherapy be used after previous cancer treatment?

Yes, in some cases. It may be used after surgery, chemotherapy, radiotherapy or targeted therapy, depending on the cancer and approved indication.

 

Previous treatment and any related toxicity must be reviewed before a recommendation is made.

 

 

Can Recmed guarantee that I am eligible or that treatment will work?

No. Eligibility can only be determined by the responsible medical specialists after reviewing the patient’s records and condition.

 

No coordinator, doctor or hospital can ethically guarantee that cancer treatment will produce a particular result.

 

 

Request an Immunotherapy Case Review

 

If you are considering immunotherapy for cancer in Turkey, you may send your medical records to Recmed Medical Tourism for coordination of an oncology review.

 

The first objective is to determine:

 

- Whether the diagnosis and stage are sufficiently documented

- Whether biomarker testing is complete

- Whether immunotherapy is medically appropriate

- Whether another treatment should be prioritised

- Which hospital or specialist is suitable for the case

- What additional examinations may be required

- What the proposed treatment and estimated costs include

 

A personalised review is more reliable than selecting a hospital or treatment based only on general online information.

 

 

Medical Disclaimer

This article is provided for general educational purposes and does not constitute medical advice, diagnosis or a treatment recommendation.

 

Immunotherapy eligibility, medicine selection and side-effect management must be determined by licensed oncology specialists after reviewing the patient’s complete medical information. Patients should not start, stop or change cancer treatment based solely on online content.

 

 

Medical-Review Sources

• National Cancer Institute: Immunotherapy to Treat Cancer
  https://www.cancer.gov/about-cancer/treatment/types/immunotherapy
• National Cancer Institute: Immune Checkpoint Inhibitors
  https://www.cancer.gov/about-cancer/treatment/types/immunotherapy/checkpoint-inhibitors
• National Cancer Institute: Immunotherapy Side Effects
  https://www.cancer.gov/about-cancer/treatment/types/immunotherapy/side-effects
• National Cancer Institute: Biomarker Testing for Cancer Treatment
  https://www.cancer.gov/about-cancer/treatment/types/biomarker-testing-cancer-treatment
• U.S. Food and Drug Administration: Companion Diagnostic Devices
  https://www.fda.gov/medical-devices/in-vitro-diagnostics/list-fda-authorized-companion-diagnostic-devices-in-vitro-and-imaging-tools