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Cho D, Cheyne S, Lord SJ, Simes J, Lee CK. Extrapolating evidence for molecularly targeted therapies from common to rare cancers: a scoping review of methodological guidance. BMJ Open 2022; 12:e058350. [PMID: 35820758 PMCID: PMC9274540 DOI: 10.1136/bmjopen-2021-058350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Cancer is increasingly classified according to biomarkers that drive tumour growth and therapies developed to target them. In rare biomarker-defined cancers, randomised controlled trials to adequately assess targeted therapies may be infeasible. Extrapolating existing evidence of targeted therapy from common cancers to rare cancers sharing the same biomarker may reduce evidence requirements for regulatory approval in rare cancers. It is unclear whether guidelines exist for extrapolation. We sought to identify methodological guidance for extrapolating evidence from targeted therapies used for common cancers to rare biomarker-defined cancers. DESIGN Scoping review. DATA SOURCES Websites of health technology assessment agencies, regulatory bodies, research groups, scientific societies and industry. EBM Reviews-Cochrane Methodology Register and Health Technology Assessment, Embase and MEDLINE databases (1946 to 11 May 2022). ELIGIBILITY CRITERIA Papers proposing a framework or recommendations for extrapolating evidence for rare cancers, small populations and biomarker-defined cancers. DATA EXTRACTION AND SYNTHESIS We extracted framework details where available and guidance for components of extrapolation. We used these components to structure and summarise recommendations. RESULTS We identified 23 papers. One paper provided an extrapolation framework but was not cancer specific. Extrapolation recommendations addressed six distinct components: strategies for grouping cancers as the same biomarker-defined disease; analytical validation requirements of a biomarker test to use across cancer types; strategies to generate control data when a randomised concurrent control arm is infeasible; sources to inform biomarker clinical utility assessment in the absence of prospective clinical evidence; requirements for surrogate endpoints chosen for the rare cancer; and assessing and augmenting safety data in the rare cancer. CONCLUSIONS In the absence of an established framework, our recommendations for components of extrapolation can be used to guide discussions about interpreting evidence to support extrapolation. The review can inform the development of an extrapolation framework for biomarker-targeted therapies in rare cancers.
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Affiliation(s)
- Doah Cho
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Saskia Cheyne
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Sarah J Lord
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
- School of Medicine, The University of Notre Dame Australia, Sydney Campus, Darlinghurst, New South Wales, Australia
| | - John Simes
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Chee Khoon Lee
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
- Cancer Care Centre, St George Hospital, Kogarah, New South Wales, Australia
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Adeniyi O, Hwang M, Sun J, Schuck RN. Premarket assessment of molecular alterations in drug targets: a case study of 2020 drug approvals. Pharmacogenomics 2022; 23:397-404. [PMID: 35440173 PMCID: PMC9121192 DOI: 10.2217/pgs-2022-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Molecular alterations in drug targets may result in differential drug activity. Therefore, the authors aimed to characterize how molecular alterations in drug targets were assessed during drug development. Materials & methods: The authors analyzed nonclinical and clinical study reports submitted to the US FDA for novel drugs approved in 2020 to determine if in vitro studies, animal models or clinical studies assessed molecular alterations in the drug target. Results & conclusion: Assessment of the impact of molecular alterations in drug targets on drug activity varies considerably depending on the type of assessment and therapeutic area. Premarket assessment of drug target molecular alterations is common in the oncology setting, less frequent in the genetic disease setting and rare for other diseases.
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Affiliation(s)
| | - Mary Hwang
- University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA
| | - Jielin Sun
- US Food & Drug Administration, Silver Spring, MD 20903, USA
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Miller KL, Fermaglich LJ, Maynard J. Using four decades of FDA orphan drug designations to describe trends in rare disease drug development: substantial growth seen in development of drugs for rare oncologic, neurologic, and pediatric-onset diseases. Orphanet J Rare Dis 2021; 16:265. [PMID: 34107994 PMCID: PMC8191002 DOI: 10.1186/s13023-021-01901-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 05/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Orphan drug designations are a useful proxy to investigate trends in rare disease drug development. Drug developers must receive a designation before they are eligible for the economic incentives of the Orphan Drug Act in the United States. We created a database of all orphan drugs designated between 1983 and 2019 that included numerous drug characteristics, including therapeutic area. In addition, we constructed a "broad disease" categorization of designations as an alternative to therapeutic area, based on disease etiology and age of onset rather than organ system. By looking at the pattern of orphan drug designations over the past four decades, this analysis studied the impact of the evolving rare disease drug development landscape and considers the future of rare disease therapies over the coming decades. RESULTS Between 1983 and 2019, a total of 5099 drugs and biologics received orphan drug designation. Designations more than doubled between the 1980s and 1990s, almost doubled between the 1990s and 2000s, and almost tripled in number between the 2000s and 2010s. The top three therapeutic areas represented in the orphan drug designations were: oncology (1910, 37%), neurology (674, 13%), and infectious diseases (436, 9%). The broad disease categorization found that the proportion of designations for pediatric-onset diseases has increased in the most recent decade to 27%. CONCLUSIONS Analysis of the last four decades of orphan drug designation indicates seismic shifts have occurred in the rare disease drug development space. The number of designations granted more than quadrupled between the 1990s and 2010s. While these substantial increases led to growth in the absolute number of designations within all therapeutic areas (bar one) and broad disease categories, the relative proportions have seen considerable change over time. In the most recent decade, there have been notable increases in the proportion of drugs in oncology, pediatric-onset diseases, and neurologic disorders. The dramatic rise in overall orphan designations over the past four decades suggests we may continue to see an upward trajectory in designations leading to an increased number of approvals for drugs and biologics designed specifically for diagnosing, preventing, and treating rare diseases in the coming decades.
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Affiliation(s)
- Kathleen L Miller
- Office of Orphan Products Development, Office of the Commissioner, US Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA.
| | - Lewis J Fermaglich
- Office of Orphan Products Development, Office of the Commissioner, US Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - Janet Maynard
- Office of Orphan Products Development, Office of the Commissioner, US Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
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Sabusap CM, Joshi D, Simhaev L, Oliver KE, Senderowitz H, van Willigen M, Braakman I, Rab A, Sorscher EJ, Hong JS. The CFTR P67L variant reveals a key role for N-terminal lasso helices in channel folding, maturation, and pharmacologic rescue. J Biol Chem 2021; 296:100598. [PMID: 33781744 PMCID: PMC8102917 DOI: 10.1016/j.jbc.2021.100598] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/15/2021] [Accepted: 03/25/2021] [Indexed: 12/14/2022] Open
Abstract
Patients with cystic fibrosis (CF) harboring the P67L variant in the cystic fibrosis transmembrane conductance regulator (CFTR) often exhibit a typical CF phenotype, including severe respiratory compromise. This rare mutation (reported in <300 patients worldwide) responds robustly to CFTR correctors, such as lumacaftor and tezacaftor, with rescue in model systems that far exceed what can be achieved for the archetypical CFTR mutant F508del. However, the specific molecular consequences of the P67L mutation are poorly characterized. In this study, we conducted biochemical measurements following low-temperature growth and/or intragenic suppression, which suggest a mechanism underlying P67L that (1) shares key pathogenic features with F508del, including off-pathway (non-native) folding intermediates, (2) is linked to folding stability of nucleotide-binding domains 1 and 2, and (3) demonstrates pharmacologic rescue that requires domains in the carboxyl half of the protein. We also investigated the "lasso" helices 1 and 2, which occur immediately upstream of P67. Based on limited proteolysis, pulse chase, and molecular dynamics analysis of full-length CFTR and a series of deletion constructs, we argue that P67L and other maturational processing (class 2) defects impair the integrity of the lasso motif and confer misfolding of downstream domains. Thus, amino-terminal missense variants elicit a conformational change throughout CFTR that abrogates maturation while providing a robust substrate for pharmacologic repair.
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Affiliation(s)
- Carleen Mae Sabusap
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Disha Joshi
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Luba Simhaev
- Department of Chemistry, Bar-Ilan University, Ramat-Gan, Israel
| | - Kathryn E Oliver
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Marcel van Willigen
- Department of Cellular Protein Chemistry, Utrecht University, Utrecht, Netherlands
| | - Ineke Braakman
- Department of Cellular Protein Chemistry, Utrecht University, Utrecht, Netherlands
| | - Andras Rab
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Eric J Sorscher
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Jeong S Hong
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
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Boxer AL, Gold M, Feldman H, Boeve BF, Dickinson SLJ, Fillit H, Ho C, Paul R, Pearlman R, Sutherland M, Verma A, Arneric SP, Alexander BM, Dickerson BC, Dorsey ER, Grossman M, Huey ED, Irizarry MC, Marks WJ, Masellis M, McFarland F, Niehoff D, Onyike CU, Paganoni S, Panzara MA, Rockwood K, Rohrer JD, Rosen H, Schuck RN, Soares HD, Tatton N. New directions in clinical trials for frontotemporal lobar degeneration: Methods and outcome measures. Alzheimers Dement 2020; 16:131-143. [PMID: 31668596 PMCID: PMC6949386 DOI: 10.1016/j.jalz.2019.06.4956] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Frontotemporal lobar degeneration (FTLD) is the most common form of dementia for those under 60 years of age. Increasing numbers of therapeutics targeting FTLD syndromes are being developed. METHODS In March 2018, the Association for Frontotemporal Degeneration convened the Frontotemporal Degeneration Study Group meeting in Washington, DC, to discuss advances in the clinical science of FTLD. RESULTS Challenges exist for conducting clinical trials in FTLD. Two of the greatest challenges are (1) the heterogeneity of FTLD syndromes leading to difficulties in efficiently measuring treatment effects and (2) the rarity of FTLD disorders leading to recruitment challenges. DISCUSSION New personalized endpoints that are clinically meaningful to individuals and their families should be developed. Personalized approaches to analyzing MRI data, development of new fluid biomarkers and wearable technologies will help to improve the power to detect treatment effects in FTLD clinical trials and enable new, clinical trial designs, possibly leveraged from the experience of oncology trials. A computational visualization and analysis platform that can support novel analyses of combined clinical, genetic, imaging, biomarker data with other novel modalities will be critical to the success of these endeavors.
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Affiliation(s)
- Adam L. Boxer
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, CA
| | | | - Howard Feldman
- Department of Neurosciences, University of California San Diego, San Diego, CA
| | | | | | | | - Carole Ho
- Denali Therapeutics, San Francisco, CA
| | | | | | | | | | | | | | | | - Earl Ray Dorsey
- Center for Health and Technology, University of Rochester, Rochester, NY
| | - Murray Grossman
- Department of Neurology, University of Pennsylvania, Philadelphia, PA
| | - Edward D. Huey
- Departments of Psychiatry and Neurology, Columbia University, NY
| | | | - William J. Marks
- Clinical Neurology, Verily Life Sciences, South San Francisco, CA
| | - Mario Masellis
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, University of Toronto, ON, Canada; Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada
| | | | - Debra Niehoff
- Association for Frontotemporal Degeneration, Radnor, PA
| | - Chiadi U. Onyike
- Department Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins University, Baltimore, MD
| | - Sabrina Paganoni
- Healey Center for ALS, Massachusetts General Hospital, Boston, MA
| | | | - Kenneth Rockwood
- Division of Geriatric Medicine, Dalhousie University, Halifax, NS
| | - Jonathan D. Rohrer
- Dementia Research Centre, UCL Institute of Neurology, Queen Square, London, UK
| | - Howard Rosen
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, CA
| | - Robert N. Schuck
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, FDA, Silver Spring, MD
| | | | - Nadine Tatton
- Association for Frontotemporal Degeneration, Radnor, PA
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Joshi D, Ehrhardt A, Hong JS, Sorscher EJ. Cystic fibrosis precision therapeutics: Emerging considerations. Pediatr Pulmonol 2019; 54 Suppl 3:S13-S17. [PMID: 31715091 PMCID: PMC6871648 DOI: 10.1002/ppul.24547] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/08/2019] [Indexed: 11/11/2022]
Abstract
Small molecules that address fundamental defects underlying cystic fibrosis (CF), including modulators such as the approved drugs ivacaftor, lumacaftor, tezacaftor, and elexacaftor, have advanced dramatically over the past few years and are transforming care and prognosis among individuals with this disease. The new treatment strategies are predicated on established scientific insight concerning pathogenesis, and applying "personalized" or "precision" interventions for specific abnormalities of the cystic fibrosis transmembrane conductance regulator (CFTR). Even with the advent of highly effective triple drug combinations-which hold great promise for the majority of patients with CF worldwide-barriers to precision therapy remain. These include refractory CFTR variants (premature truncation codons, splice defects, large indels, severe missense mutations, and others) not addressed by available modulators, and access to leading-edge therapeutic compounds for patients with ultrarare forms of CF. In addition to describing the remarkable progress that has occurred regarding CF precision medicine, this review outlines some of the remaining challenges. The CF experience is emblematic of many conditions for which personalized interventions are actively being sought.
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Affiliation(s)
- D Joshi
- Emory University School of Medicine Department of Pediatrics, and Children’s Healthcare of Atlanta, GA, USA
| | - A Ehrhardt
- Emory University School of Medicine Department of Pediatrics, and Children’s Healthcare of Atlanta, GA, USA
| | - JS Hong
- Emory University School of Medicine Department of Pediatrics, and Children’s Healthcare of Atlanta, GA, USA
| | - EJ Sorscher
- Emory University School of Medicine Department of Pediatrics, and Children’s Healthcare of Atlanta, GA, USA
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Waldman SA, Terzic A. Health Care Evolves From Reactive to Proactive. Clin Pharmacol Ther 2019; 105:10-13. [PMID: 30597564 DOI: 10.1002/cpt.1295] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Scott A Waldman
- Division of Clinical Pharmacology, Department of Pharmacology and Experimental Therapeutics, Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Andre Terzic
- Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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8
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Abstract
Molecular defects in the cystic fibrosis gene prompt creative approaches to treatment
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Affiliation(s)
| | | | - Jeong S Hong
- Emory University School of Medicine, Atlanta, GA, USA
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Affiliation(s)
- Lisa M. LaVange
- Department of Biostatistics, University of North Carolina at Chapel Hill, NC
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10
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Isoherranen N, Madabushi R, Huang S. Emerging Role of Organ-on-a-Chip Technologies in Quantitative Clinical Pharmacology Evaluation. Clin Transl Sci 2019; 12:113-121. [PMID: 30740886 PMCID: PMC6440571 DOI: 10.1111/cts.12627] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/26/2019] [Indexed: 12/28/2022] Open
Abstract
The recently enacted Prescription Drug User Fee Act (PDUFA) VI includes in its performance goals "enhancing regulatory science and expediting drug development." The key elements in "enhancing regulatory decision tools to support drug development and review" include "advancing model-informed drug development (MIDD)." This paper describes (i) the US Food and Drug Administration (FDA) Office of Clinical Pharmacology's continuing efforts in developing quantitative clinical pharmacology models (disease, drug, and clinical trial models) to advance MIDD, (ii) how emerging novel tools, such as organ-on-a-chip technologies or microphysiological systems, can provide new insights into physiology and disease mechanisms, biomarker identification and evaluation, and elucidation of mechanisms of adverse drug reactions, and (iii) how the single organ or linked organ microphysiological systems can provide critical system parameters for improved physiologically-based pharmacokinetic and pharmacodynamic evaluations. Continuous public-private partnerships are critical to advance this field and in the application of these new technologies in drug development and regulatory review.
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Affiliation(s)
- Nina Isoherranen
- Office of Clinical Pharmacology (OCP)Office of Translational SciencesCenter for Drug Evaluation and ResearchUS Food and Drug Administration (FDA)Silver SpringMarylandUSA
- Department of PharmaceuticsSchool of PharmacyUniversity of WashingtonSeattleWashingtonUSA
| | - Rajanikanth Madabushi
- Office of Clinical Pharmacology (OCP)Office of Translational SciencesCenter for Drug Evaluation and ResearchUS Food and Drug Administration (FDA)Silver SpringMarylandUSA
| | - Shiew‐Mei Huang
- Office of Clinical Pharmacology (OCP)Office of Translational SciencesCenter for Drug Evaluation and ResearchUS Food and Drug Administration (FDA)Silver SpringMarylandUSA
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