Ten years of marketing approvals of anticancer drugs in Europe: regulatory policy and guidance documents need to find a balance between different pressures

Despite important progress in understanding the molecular factors underlying the development of cancer and the improvement in response rates with new drugs, long-term survival is still disappointing for most common solid tumours. This might be because very little of the modest gain for patients is the result of the new compounds discovered and marketed recently. An assessment of the regulatory agencies' performance may suggest improvements. The present analysis summarizes and evaluates the type of studies and end points used by the EMEA to approve new anticancer drugs, and discusses the application of current regulations. This report is based on the information available on the EMEA web site. We identified current regulatory requirements for anticancer drugs promulgated by the agency and retrieved them in the relevant directory; information about empirical evidence supporting the approval of drugs for solid cancers through the centralised procedure were retrieved from the European Public Assessment Report (EPAR). We surveyed documents for drug applications and later extensions from January 1995, when EMEA was set up, to December 2004. We identified 14 anticancer drugs for 27 different indications (14 new applications and 13 extensions). Overall, 48 clinical studies were used as the basis for approval; randomised comparative (clinical) trial (RCT) and Response Rate were the study design and end points most frequently adopted (respectively, 25 out of 48 and 30 out of 48). In 13 cases, the EPAR explicitly reported differences between arms in terms of survival: the range was 0–3.7 months, and the mean and median differences were 1.5 and 1.2 months. The majority of studies (13 out of 27, 48%) involved the evaluation of complete and/or partial tumour responses, with regard to the end points supporting the 27 indications. Despite the recommendations of the current EMEA guidance documents, new anticancer agents are still often approved on the basis of small single arm trials that do not allow any assessment of an ‘acceptable and extensively documented toxicity profile’ and of end points such as response rate, time to progression or progression-free survival which at best can be considered indicators of anticancer activity and are not ‘justified surrogate markers for clinical benefit’. Anticipating an earlier than ideal point along the drug approval path and the use of not fully validated surrogate end points in nonrandomised trials looks like a dangerous shortcut that might jeopardise consumers' health, leading to unsafe and ineffective drugs being marketed and prescribed. The present Note for Guidance for new anticancer agents needs revising. Drugs must be rapidly released for patients who need them but not be at the expense of adequate knowledge about the real benefit of the drugs.

Tobacco dependence in the general population in Italy

BACKGROUND

Measures of tobacco dependence are mainly used in the clinical setting, but limited information is available on tobacco dependence on a population level.

MATERIALS AND METHODS

To obtain estimates of tobacco dependence on a population level, a six-item Fagerstrom questionnaire was used in two surveys, conducted in 2002-2003 on a sample of 6773 individuals aged 15 years or over, representative of the Italian adult population.

RESULTS

Overall, 27.1% of Italian adults described themselves as current cigarette smokers (32.2% of men, 22.4% of women). Of all smokers, 42.8% were classified as very low dependent, 28.6% as low dependent, 11.0% as intermediate, 13.8% as high and only 3.8% as very high dependent. The proportions of very low/low dependent were 67.4% in men and 76.8% in women. Those of high/very high dependent smokers were 21.4% in men and 12.5% in women, but only 2.8% at age 15-17 years and 8.4% at age 18-24 years. Only 23% of smokers, moreover, found it difficult to avoid smoking in places where smoking was forbidden.

CONCLUSIONS

The observation that over two-thirds of smokers on a population level in Italy report low or very low dependence has useful implication for intervention on stopping smoking, particularly in the young, who appear to be low dependent. However, in this age group cessation rates were comparatively low.

A mortality cohort study among workers in a graphite electrode production plant in Italy

BACKGROUND

Graphite electrode manufacturing workers are exposed to coal tar and its volatiles containing a variety of polycyclic aromatic hydrocarbons (PAH), silica and graphite dusts, and asbestos.

AIMS

To investigate mortality from cancer and other diseases among workers in a graphite electrode production plant in Italy.

METHODS

A total of 1291 males actively employed between 1 January 1950 and 31 December 1989 who had worked at the plant for at least one year were studied. The follow up extended from 1950 to 1997. Standardised mortality ratios (SMR) and their 95% confidence intervals (CI) were computed using mortality rates for the Italian and regional male population.

RESULTS

Excess mortality was observed for all causes (SMR 1.44, CI 1.32 to 1.56), all cancers (SMR 1.27, CI 1.07 to 1.50), liver cancer (SMR 4.19, CI 2.68 to 6.23), silicosis (SMR 66.39, CI 52.56 to 82.7), and cirrhosis and other chronic diseases of the liver (SMR 1.87, CI 1.31 to 2.59) in comparison with the national male population. When regional rates were used to calculate the number of expected deaths, SMRs remained higher for silicosis (SMR 57.32, 42.11 to 76.22), and liver cancer (SMR 2.57, 1.57 to 3.97). Mortality from silicosis was increased in workers hired at young ages (<25 years, SMR 81.79; 25-34 years, SMR 82.73), and in workers aged <45 at death (SMR 333.3, CI 159.8 to 613). Mortality from liver cancer increased threefold (SMR 3.11, CI 1.78 to 5.05) in workers with more than 10 years of employment at the plant during the manufacture of Karbate products.

CONCLUSIONS

Results support the association between excess mortality from silicosis and occupational exposure to siliceous sands experienced during graphite electrode manufacturing. The observed excess mortality from liver cancer is compatible, to some extent, with exposures that may have occurred during the manufacture of phenolic and furfuryl resins treated products, although a role of lifestyle factors and viral infections cannot be excluded.

[Exposure to neurotoxic metals and prevalence of parkinsonian syndrome in the area of Brescia]

The prevalence of parkinsonian syndromes was studied in the province of Brescia (Northern Italy), in order to verify its possible increase in the surroundings of ferroalloy plants located in a valley of the pre-Alps. A case-list of subjects affected by these disturbances was identified using four different sources of information: a) registers from local medical clinics; b) admission charts from local hospitals; c) consumption of levodopa; d) NHS list of exemption from prescription payment, due to the illness. Exploratory data show a frequency of parkinsonian disturbances among the residents in the surroundings of the ferroalloy plants and downwind (crude prevalence = 358/100,000 population, standardized for age and sex = 438) significantly higher (s.m.r, = 1.58; C.I. = 1.41-1.76) than the entire Province (crude prevalence 246/100,000). This preliminary result could indicate the interaction of prolonged environmental exposure to heavy metals, such as manganese, and genetic factors, potentially relevant in this mountain population.

Does a drug do better when it is new?

BACKGROUND

When assessing a new, promising therapeutic approach, a clinician's perception of a drug's effectiveness may be shaped by different kinds of phenomena, and among them, a favorable attitude towards new treatments, and as a result a tendency to overestimate their efficacy (wish bias).

MATERIALS AND METHODS

A retrospective study of published randomized clinical trials of doxorubicin-based chemotherapy for advanced breast cancer was carried out. Global (complete plus partial) response rate over time with allowance for type of drug regimen (mono- or polychemotherapy) and prior adjuvant therapies was assessed in the doxorubicin-containing arm using multivariate logistic regression analysis.

RESULTS

Twenty-nine studies published from 1975 to 1999 were retrieved for a total of 2234 women with advanced breast cancer enrolled in the doxorubicin-containing arms. There was a significant decrease in response rate to doxorubicin as first-line treatment over time that resisted adjustment for important differences in therapeutic management [odds ratio for global response = 0.89, 95% confidence interval (CI) 0.81 to 0.99].

CONCLUSIONS

Although only one drug (doxorubicin) in one clinical context (advanced breast cancer) has been analyzed, our findings support the use of double blind methodology whenever possible when assessing subjective endpoints and encourage further studies aimed at defining the clinical relevance of a wish bias in medicine.

Modulating the profit motive to meet needs of the less-developed world

The success, despite the problems, of academic/industrial collaborations over the past decade owes much to the profit motive. However, market-driven research and development has little to offer patients in the less-developed world. Some flexibility has already been demonstrated on drugs for orphan (rare or under-researched) diseases. Many diseases in less-developed countries are not rare. Academic researchers should be encouraging the establishment of funding for basic and clinical research that is directed at patients' needs in the less-developed world and that is independent of a commercial ethos.

Psychotropic drug use in Italy, 1984-99: the impact of a change in reimbursement status

After years of corruption surrounding drug reimbursement, in 1994, a change in drug reimbursement status was implemented in Italy according to cost-effectiveness criteria. The aim of this study was to assess the impact of these changes on the use of psychotropic drugs. National trends in antipsychotic, antidepressant and benzodiazepine prescriptions were analysed from 1984 to 1999. During the study period, prescriptions of antipsychotic drugs were stable from 1984 to 1994 but, in the subsequent 5 years, increased by 54%. Although the use of atypical compounds in 1999 accounted for only 6% of total antipsychotics sold, the cost of these new drugs accounted for almost one-half the total antipsychotic expenditure. The use of benzodiazepines increased by 53%. In 1999, the psychotropic drugs lorazepam and alprazolam were the most sold by value. From 1984 to 1999, the total antidepressants sold increased by 55%. Although the use of selective serotonin reuptake inhibitors and newer antidepressants in 1999 accounted for less than 50% of total antidepressants sold, the cost of these drugs accounted for 65% of total antidepressant expenditure. This analysis highlights specific areas of concern which should become the object of public health programs.

Health-related quality of life (HR-QOL) and regulatory issues. An assessment of the European Agency for the Evaluation of Medicinal Products (EMEA) recommendations on the use of HR-QOL measures in drug approval

Interest in measuring qualitative aspects of life that are most closely related to health and healthcare has increased in recent years. Methods of describing patients' subjective health status now incorporate standardised measures, and several psychometric measures are available. Despite the thousands of empirical and conceptual papers in the medical and pharmacological literature on health-related quality of life (HR-QOL), the value of such measures in the regulatory process is still being debated. We conducted an assessment to understand and document the position of the European Agency for the Evaluation of Medicinal Products (EMEA) on the use of HR-QOL measures in studies conducted for regulatory purposes. Official documents produced and circulated by the EMEA containing recommendations on trial design, conduct and analysis for sponsors and scientific experts were independently reviewed by authors to document the position of the Agency on the specific topic of HR-QOL. All documents found in the Agency website on 30 September 1999 were identified and then assessed to: (i) identify diseases or drugs for which formal HR-QOL assessment is recommended; (ii) identify measures and methods recommended; and (iii) evaluate the reliability of recommendations across documents. Of the 189 documents retrieved, none focused directly on health-related quality of life. A few explicit recommendations were identified for 13 specific drugs or conditions. These recommendations were mostly general and vague, and used nonstandard terminology. In addition, terminology and recommendations were not consistent across documents and, in at least one case, were in contrast with the US Food and Drug Administration (FDA) guidelines. EMEA guidelines incorporating quality-of-life outcomes are welcomed but it is obvious that more detailed guidance is required. Closer collaboration between the EMEA and the FDA is also recommended. Experts from different disciplines should be involved in the preparation of such documents to assure the necessary technical expertise and the representativeness of the various counterparts.

Inflammatory cytokines and related genes are induced in the rat hippocampus by limbic status epilepticus

Limbic status epilepticus was induced in rats by unilateral 60-min electrical stimulation of the CA3 region of the ventral hippocampus. As assessed by RT-PCR followed by Southern blot analysis, transcripts of interleukin-1beta, interleukin-6, interleukin-1 receptor antagonist and inducible nitric oxide synthase were significantly increased 2 h after status epilepticus in the stimulated hippocampus. Induction was maximal at 6 h for interleukin-1beta (445%), interleukin-6 (405%) and tumour necrosis factor-alpha (264%) and at 24 h for interleukin-1 receptor antagonist (494%) and inducible nitric oxide synthase (432%). In rats with spontaneous seizures (60 days after status epilepticus), interleukin-1beta mRNA was still higher than controls (241%). Immunocytochemical staining of interleukin-1beta, interleukin-6 and tumour necrosis factor-alpha was enhanced in glia with a time-course similar to that of the respective transcripts. Sixty days after status epilepticus, interleukin-1beta immunoreactivity was increased exclusively in neurons in one third of the animals. Multiple intracerebroventricular injections of interleukin-1 receptor antagonist (0.5 microg/3 microL) significantly decreased the severity of behavioural convulsions during electrical stimulation and selectively reduced tumour necrosis factor-alpha content in the hippocampus measured 18 h after status epilepticus. Thus, the induction of spontaneously recurring seizures in rats involves the activation of inflammatory cytokines and related pro- and anti-inflammatory genes in the hippocampus. These changes may play an active role in hyperexcitability of the epileptic tissue.

Does placebo help establish equivalence in trials of new antidepressants?

Clinical trials of new antidepressants usually compare a new drug to a reference antidepressant and to a placebo. The placebo is intended to validate the trial in the case of a no-difference outcome, i.e., it helps in assessing equivalence. The aim of the present paper is to test whether placebo has indeed helped establish equivalence of effect in comparative trials of new antidepressants. We carried out an example of sample size determination first in a trial to show a difference between the new and control drug, and second in a trial to assess equivalence between two competing drugs. Finally, we retrospectively calculated the maximum difference accepted as equivalence of effect in published trials of new antidepressants. Assuming a response rate to antidepressants of 70%, 294 subjects for each treatment group are needed to show a 10% difference between two antidepressant drugs and more than 1,300 to assess equivalence at a 5% level of delta, the maximum difference acceptable as equivalence of effect. The level of delta in published trials of new antidepressants ranges between 12 and 43%, suggesting they cannot claim to demonstrate equivalence of effect. Therefore, the presence of a placebo arm for comparison didn't help establish whether both drugs really worked the same way. Comparative trials of new antidepressants should adopt a two-arm design, a suitable number of patients and a high standard in the experimental design in order to minimise possible control-event rate variation.

Glutamic acid, twenty years later

This review examines progress in understanding the physiologic functions of glutamic acid in the body since the first symposium on glutamic acid physiology and biochemistry was held at the Mario Negri Institute in Milan in 1978. The topics reviewed, although not exhaustive, include the metabolism of glutamic acid, umami taste, the role of glutamic acid as a neurotransmitter, glutamate safety and the development of new drugs resulting from the knowledge of the neurodegeneration induced by high doses of glutamic acid.