1
|
Pearson AD, DuBois SG, Macy ME, de Rojas T, Donoghue M, Weiner S, Knoderer H, Bernardi R, Buenger V, Canaud G, Cantley L, Chung J, Fox E, Friend J, Glade-Bender J, Gorbatchevsky I, Gore L, Gupta A, Hawkins DS, Juric D, Lang LA, Leach D, Liaw D, Lesa G, Ligas F, Lindberg G, Lindberg W, Ludwinski D, Marshall L, Mazar A, McDonough J, Nysom K, Ours C, Pappo A, Parsons DW, Rosenfeld A, Scobie N, Smith M, Taylor D, Weigel B, Weinstein A, Karres D, Vassal G. Paediatric strategy forum for medicinal product development of PI3-K, mTOR, AKT and GSK3β inhibitors in children and adolescents with cancer. Eur J Cancer 2024; 207:114145. [PMID: 38936103 DOI: 10.1016/j.ejca.2024.114145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 05/16/2024] [Accepted: 05/27/2024] [Indexed: 06/29/2024]
Abstract
Phosphatidylinositol 3-kinase (PI3-K) signalling pathway is a crucial path in cancer for cell survival and thus represents an intriguing target for new paediatric anti-cancer drugs. However, the unique clinical toxicities of targeting this pathway (resulting in hyperglycaemia) difficulties combining with chemotherapy, rarity of mutations in childhood tumours and concomitant mutations have resulted in major barriers to clinical translation of these inhibitors in treating both adults and children. Mutations in PIK3CA predict response to PI3-K inhibitors in adult cancers. The same mutations occur in children as in adults, but they are significantly less frequent in paediatrics. In children, high-grade gliomas, especially diffuse midline gliomas (DMG), have the highest incidence of PIK3CA mutations. New mutation-specific PI3-K inhibitors reduce toxicity from on-target PI3-Kα wild-type activity. The mTOR inhibitor everolimus is approved for subependymal giant cell astrocytomas. In paediatric cancers, mTOR inhibitors have been predominantly evaluated by academia, without an overall strategy, in empiric, mutation-agnostic clinical trials with very low response rates to monotherapy. Therefore, future trials of single agent or combination strategies of mTOR inhibitors in childhood cancer should be supported by very strong biological rationale and preclinical data. Further preclinical evaluation of glycogen synthase kinase-3 beta inhibitors is required. Similarly, even where there is an AKT mutation (∼0.1 %), the role of AKT inhibitors in paediatric cancers remains unclear. Patient advocates strongly urged analysing and conserving data from every child participating in a clinical trial. A priority is to evaluate mutation-specific, central nervous system-penetrant PI3-K inhibitors in children with DMG in a rational biological combination. The choice of combination, should be based on the genomic landscape e.g. PTEN loss and resistance mechanisms supported by preclinical data. However, in view of the very rare populations involved, innovative regulatory approaches are needed to generate data for an indication.
Collapse
Affiliation(s)
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, USA
| | | | | | | | | | | | - Ronald Bernardi
- Genentech, A Member of the Roche Group, South San Francisco, CA USA
| | - Vickie Buenger
- Coalition Against Childhood Cancer (CAC2), Philadelphia, USA
| | | | | | - John Chung
- Bayer Healthcare Pharmaceuticals, Whippany, NJ, USA
| | | | | | | | | | | | - Abha Gupta
- The Hospital for Sick Children (SickKids), Princess Margaret Hospital Toronto, Canada
| | | | | | - Leigh Anna Lang
- Rally Foundation for Childhood Cancer Research, Atlanta, GA, USA
| | | | | | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), the Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), the Netherlands
| | | | | | | | - Lynley Marshall
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | | | - Joe McDonough
- The Andrew McDonough B+ Foundation, Wilmington, DE, USA
| | | | - Christopher Ours
- National Human Genome Research Institute/National Institutes of Health, MD, USA
| | | | | | | | | | | | | | | | - Amy Weinstein
- Pediatric Brain Tumor Foundation of the US, Atlanta, USA
| | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), the Netherlands
| | - Gilles Vassal
- ACCELERATE, Europe, Belgium; Gustave Roussy Cancer Centre, Paris, France
| |
Collapse
|
2
|
Brivio E, Bautista F, Zwaan CM. Naked antibodies and antibody-drug conjugates: targeted therapy for childhood acute lymphoblastic leukemia. Haematologica 2024; 109:1700-1712. [PMID: 38832425 PMCID: PMC11141655 DOI: 10.3324/haematol.2023.283815] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 03/15/2024] [Indexed: 06/05/2024] Open
Abstract
The treatment of childhood acute lymphoblastic leukemia (ALL) has reached overall survival rates exceeding 90%. The present and future challenges are to cure the remainder of patients still dying from disease, and to reduce morbidity and mortality in those who can be cured with standard-of-care chemotherapy by replacing toxic chemotherapy elements while retaining cure rates. With the novel therapeutic options introduced in the last years, including immunotherapies and targeted antibodies, the treatment of ALL is undergoing major changes. For B-cell precursor ALL, blinatumomab, an anti-CD19 bispecific antibody, has established its role in the consolidation treatment for both high- and standard-risk first relapse of ALL, in the presence of bone marrow involvement, and may also have an impact on the outcome of high-risk subsets such as infant ALL and Philadelphia chromosome-positive ALL. Inotuzumab ozogamicin, an anti-CD22 drug conjugated antibody, has demonstrated high efficacy in inducing complete remission in relapsed ALL, even in the presence of high tumor burden, but randomized phase III trials are still ongoing. For T-ALL the role of CD38-directed treatment, such as daratumumab, is gaining interest, but randomized data are needed to assess its specific benefit. These antibodies are currently being tested in patients with newly diagnosed ALL and may lead to major changes in the present paradigm of treatment of pediatric ALL. Unlike the past, lessons may be learned from innovations in adult ALL, in which more drastic changes are piloted that may need to be translated to pediatrics.
Collapse
Affiliation(s)
- Erica Brivio
- Princess Máxima Center for Pediatric Oncology, Utrecht
| | | | - C. Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Utrecht
- Pediatric Oncology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| |
Collapse
|
3
|
Bautista F, Verdú-Amorós J, Geoerger B, Rubio-San-Simón A, Paoletti X, Zwaan CM, Casanova M, Marshall LV, Carceller F, Doz F, Lecinse C, Vassal G, Pearson ADJ, Kearns P, Moreno L. Evolution of the Innovative Therapies for Children With Cancer Consortium Trial Portfolio for Drug Development for Children With Cancer. J Clin Oncol 2024:JCO2301237. [PMID: 38743911 DOI: 10.1200/jco.23.01237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 02/09/2024] [Accepted: 02/29/2024] [Indexed: 05/16/2024] Open
Abstract
PURPOSE The aim of the Innovative Therapies for Children with Cancer (ITCC) consortium is to improve access to novel therapies for children and adolescents with cancer. The evolution of the ITCC clinical trial portfolio since 2003 was reviewed. METHODS All ITCC-labeled phase I/II trials opened between January 1, 2003 and February 3, 2018 were analyzed in two periods (2003-2010 and 2011-2018), and data were extracted from the ITCC database, regulatory agencies' registries, and publications. RESULTS Sixty-one trials (62% industry-sponsored) enrolled 3,198 patients. The number of trials in the second period increased by almost 300% (16 v 45). All biomarker-driven trials (n = 14) were conducted in the second period. The use of rolling six and model-based designs increased (1 of 9, 11% v 21 of 31, 68%), and that of 3 + 3 designs decreased (5 of 9, 55% v 5 of 31, 16%; P = .014). The proportion of studies evaluating chemotherapeutics only decreased (5 of 16, 31% v 4 of 45, 9%), the proportion of single-agent targeted therapies did not change (9 of 16, 56.2% v 24 of 45, 53.3%), the proportion of combination targeted therapies trials increased (2 of 16, 12%, v 17 of 45, 38%), the proportion of randomized phase II trials increased (1 of 7, 14% v 8 of 14, 57%). More trials were part of a pediatric investigation plan in the second period (4 of 16, 25% v 21 of 45, 46%). The median time for Ethics Committees' approvals was 1.7 times longer for academic compared with industry-sponsored trials. CONCLUSION This study reports a shift in the paradigm of early drug development for childhood cancers, with more biologically relevant targets evaluated in biomarker-driven trials or in combination with other therapies and with more model-based or randomized designs and a greater focus on fulfilling regulatory requirements. Improvement of trial setup and recruitment could increase the number of patients benefiting from novel agents.
Collapse
Affiliation(s)
- Francisco Bautista
- Division of Pediatric Hematology and Oncology, Hospital Universitario Niño Jesús, Madrid, Spain
- Princess Máxima Center, Utrecht, the Netherlands
| | - Jaime Verdú-Amorós
- Division of Pediatric Hematology and Oncology, Hospital Universitario Niño Jesús, Madrid, Spain
- Division of Pediatric Hematology and Oncology, Hospital Clínico Universitario de Valencia, Biomedical Research Institute, INCLIVA, Valencia, Spain
| | - Birgit Geoerger
- Pediatric and Adolescent Oncology Department, Gustave Roussy Cancer Campus, INSERM U1015, Université Paris-Saclay, Villejuif, France
| | - Alba Rubio-San-Simón
- Division of Pediatric Hematology and Oncology, Hospital Universitario Niño Jesús, Madrid, Spain
| | - Xavier Paoletti
- Institut Curie & Université Versailles St Quentin & INSERM U900 STAMPM, Paris, France
| | - C Michel Zwaan
- Princess Máxima Center, Utrecht, the Netherlands
- Department of Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Michela Casanova
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Lynley V Marshall
- Pediatric and Adolescent Oncology Drug Development, Children & Young People's Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom
- Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research, London, United Kingdom
| | - Fernando Carceller
- Pediatric and Adolescent Oncology Drug Development, Children & Young People's Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom
- Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research, London, United Kingdom
| | - Francois Doz
- SIREDO Cancer Center (Care, Innovation and Research in Pediatric, Adolescents, and Young Adults Oncology), Curie Institute Paris, and University Paris Cité, Paris, France
| | - Carole Lecinse
- Innovative Therapies for Children with Cancer, Gustave Roussy Cancer Campus, Villejuif, France
| | - Gilles Vassal
- Innovative Therapies for Children with Cancer, Gustave Roussy Cancer Campus, Villejuif, France
| | - Andrew D J Pearson
- Pediatric and Adolescent Oncology Drug Development, Children & Young People's Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Pamela Kearns
- Institute of Cancer and Genomic Sciences, NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, United Kingdom
| | - Lucas Moreno
- Division of Pediatric Hematology and Oncology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| |
Collapse
|
4
|
Haroutounian S, Holzer KJ, Kerns RD, Veasley C, Dworkin RH, Turk DC, Carman KL, Chambers CT, Cowan P, Edwards RR, Eisenach JC, Farrar JT, Ferguson M, Forsythe LP, Freeman R, Gewandter JS, Gilron I, Goertz C, Grol-Prokopczyk H, Iyengar S, Jordan I, Kamp C, Kleykamp BA, Knowles RL, Langford DJ, Mackey S, Malamut R, Markman J, Martin KR, McNicol E, Patel KV, Rice AS, Rowbotham M, Sandbrink F, Simon LS, Steiner DJ, Vollert J. Patient engagement in designing, conducting, and disseminating clinical pain research: IMMPACT recommended considerations. Pain 2024; 165:1013-1028. [PMID: 38198239 PMCID: PMC11017749 DOI: 10.1097/j.pain.0000000000003121] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/31/2023] [Accepted: 09/08/2023] [Indexed: 01/12/2024]
Abstract
ABSTRACT In the traditional clinical research model, patients are typically involved only as participants. However, there has been a shift in recent years highlighting the value and contributions that patients bring as members of the research team, across the clinical research lifecycle. It is becoming increasingly evident that to develop research that is both meaningful to people who have the targeted condition and is feasible, there are important benefits of involving patients in the planning, conduct, and dissemination of research from its earliest stages. In fact, research funders and regulatory agencies are now explicitly encouraging, and sometimes requiring, that patients are engaged as partners in research. Although this approach has become commonplace in some fields of clinical research, it remains the exception in clinical pain research. As such, the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials convened a meeting with patient partners and international representatives from academia, patient advocacy groups, government regulatory agencies, research funding organizations, academic journals, and the biopharmaceutical industry to develop consensus recommendations for advancing patient engagement in all stages of clinical pain research in an effective and purposeful manner. This article summarizes the results of this meeting and offers considerations for meaningful and authentic engagement of patient partners in clinical pain research, including recommendations for representation, timing, continuous engagement, measurement, reporting, and research dissemination.
Collapse
Affiliation(s)
- Simon Haroutounian
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, United States
| | - Katherine J. Holzer
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, United States
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology, and Psychology, Yale University, New Haven, CT, United States
| | - Christin Veasley
- Chronic Pain Research Alliance, North Kingstown, RI, United States
| | - Robert H. Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Dennis C. Turk
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, United States
| | - Kristin L. Carman
- Patient-Centered Outcomes Research Institute (PCORI), Washington, DC, United States
| | - Christine T. Chambers
- Departments of Psychology & Neuroscience and Pediatrics, Dalhousie University, and Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS, Canada
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | - Robert R. Edwards
- Department of Anesthesiology, Harvard Medical School, Brigham & Women's Hospital, Boston, MA, United States
| | - James C. Eisenach
- Departments of Anesthesiology, Physiology and Pharmacology, Wake Forest University School of Medicine, Winston Salem, NC, United States
| | - John T. Farrar
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - McKenzie Ferguson
- Southern Illinois University Edwardsville, School of Pharmacy, Edwardsville, IL, United States
| | - Laura P. Forsythe
- Patient-Centered Outcomes Research Institute (PCORI), Washington, DC, United States
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Jennifer S. Gewandter
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Ian Gilron
- Departments of Anesthesiology & Perioperative Medicine and Biomedical & Molecular Sciences, Queen's University, Kingston, ON, Canada
| | - Christine Goertz
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, United States
| | | | - Smriti Iyengar
- Division of Translational Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Isabel Jordan
- Departments of Psychology & Neuroscience and Pediatrics, Dalhousie University, and Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS, Canada
| | - Cornelia Kamp
- Center for Health and Technology/Clinical Materials Services Unit, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Bethea A. Kleykamp
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Rachel L. Knowles
- Medical Research Council (part of UK Research and Innovation), London, United Kingdom
| | - Dale J. Langford
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, United States
| | - Sean Mackey
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University Medical Center, Stanford, CA, United States
| | | | - John Markman
- Department of Neurosurgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Kathryn R. Martin
- Aberdeen Centre for Arthritis and Musculoskeletal Health, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland, United Kingdom
| | - Ewan McNicol
- Massachusetts College of Pharmacy and Health Sciences, Boston, MA, United States
| | - Kushang V. Patel
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, United States
| | - Andrew S.C. Rice
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Michael Rowbotham
- Departments of Anesthesia and Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Friedhelm Sandbrink
- National Pain Management, Opioid Safety, and Prescription Drug Monitoring Program, Specialty Care Program Office, Veterans Health Administration, Washington, DC, United States
| | | | - Deborah J. Steiner
- Global Pain, Pain & Neurodegeneration, Eli Lilly and Company, Indianapolis, IN, United States
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Münster, Germany
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience MCTN, Medical Faculty Mannheim, Ruprecht Karls University, Heidelberg, Germany
| |
Collapse
|
5
|
Papadakis V, Astigarraga I, van den Bos C, Donadieu J, Henter JI, Jacobs S, Lehrnbecher T, Munthe-Kaas MC, Naeije L, Nanduri V, Nguyen T, Nysom K, Pears J, Raciborska A, Sieni E, Svojgr K, Tzotzola V, Minkov M. The ECHO recommendations for dealing with vinblastine shortage affecting standard treatment of systemic Langerhans cell histiocytosis. Pediatr Blood Cancer 2024; 71:e30850. [PMID: 38185727 DOI: 10.1002/pbc.30850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/09/2024]
Affiliation(s)
- Vassilios Papadakis
- Department of Pediatric Hematology-Oncology (TAO), Marianna V Vardinoyannis-ELPIDA Oncology Unit, Agia Sofia Children's Hospital, Athens, Greece
| | - Itziar Astigarraga
- Pediatric Oncology Group, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Pediatric Department, Hospital Universitario Cruces, Osakidetza, Barakaldo, Biscay, Spain
- Pediatric Department, Faculty of Medicine and Nursing, University of the Basque Country, UPV/EHU, Leioa, Spain
| | - Cor van den Bos
- Department of Hemato-oncology, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Jean Donadieu
- Centre de Référence des Histiocytoses Registre des histiocytoses, Service d'Hémato-Oncologie Pédiatrique Hopital Trousseau APHP Paris Sorbonne, Paris, France
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
- Department of Pediatrics, Astrid Lindgrens Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Sandra Jacobs
- Pediatric Hematology Oncology, University Hospital Leuven, Leuven, Belgium
| | - Thomas Lehrnbecher
- Department of Pediatrics, Division of Hematology, Oncology and Hemostaseology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | | | - Leonie Naeije
- Department of Hemato-oncology, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Vasanta Nanduri
- Department of Paediatrics, Watford General Hospital, Watford, UK
| | - Trung Nguyen
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Karsten Nysom
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jane Pears
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Anna Raciborska
- Department of Oncology and Surgical Oncology for Children and Youth, Institute of Mother and Child, Warsaw, Poland
| | - Elena Sieni
- Pediatric Hematology/Oncology Department, Meyer Children's University Hospital, Florence, Italy
| | - Karel Svojgr
- Department of Pediatric Hematology and Oncology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
| | - Vasiliki Tzotzola
- Department of Pediatric Hematology-Oncology (TAO), Marianna V Vardinoyannis-ELPIDA Oncology Unit, Agia Sofia Children's Hospital, Athens, Greece
| | - Milen Minkov
- CCRI, St. Anna Kinderkrebsforschung, Vienna, Austria
- Faculty of Medicine, Sigmund Freud Private University, Vienna, Austria
| |
Collapse
|
6
|
Pearson ADJ, de Rojas T, Karres D, Reaman G, Scobie N, Fox E, Lesa G, Ligas F, Norga K, Nysom K, Pappo A, Weigel B, Weiner SL, Vassal G. Impact of ACCELERATE Paediatric Strategy Forums: a review of the value of multi-stakeholder meetings in oncology drug development. J Natl Cancer Inst 2024; 116:200-207. [PMID: 37975877 PMCID: PMC10852613 DOI: 10.1093/jnci/djad239] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/23/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023] Open
Abstract
In a landscape of an increasing number of products and histology and age agnostic trials for rare patient cancer, prioritization of products is required. Paediatric Strategy Forums, organized by ACCELERATE and the European Medicines Agency with participation of the US Food and Drug Administration, are multi-stakeholder meetings that share information to best inform pediatric drug development strategies and subsequent clinical trial decisions. Academia, industry, regulators, and patient advocates are equal members, with patient advocates highlighting unmet needs of children and adolescents with cancer. The 11 Paediatric Strategy Forums since 2017 have made specific and general conclusions to accelerate drug development. Conclusions on product prioritization meetings, as well as global master protocols, have been outputs of these meetings. Forums have provided information for regulatory discussions and decisions by industry to facilitate development of high-priority products; for example, 62% of high-priority assets (agreed at a Forum) in contrast to 5% of those assets not considered high priority have been the subject of a Paediatric Investigational Plan or Written Request. Where there are multiple products of the same class, Forums have recommended a focused and sequential approach. Class prioritization resulted in an increase in waivers for non-prioritized B-cell products (44% to 75%) and a decrease in monotherapy trials, proposed in Paediatric Investigation Plans (PIP) submissions of checkpoint inhibitors from 53% to 19%. Strategy Forums could play a role in defining unmet medical needs. Multi-stakeholder forums, such as the Paediatric Strategy Forum, serve as a model to improve collaboration in the oncology drug development paradigm.
Collapse
Affiliation(s)
| | | | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Gregory Reaman
- US Food and Drug Administration (FDA), Silver Spring, MD, USA
| | | | - Elizabeth Fox
- St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Koen Norga
- Antwerp University Hospital, Antwerp, Belgium
- Paediatric Committee of the European Medicines Agency, (EMA), Amsterdam, The Netherlands
- Federal Agency for Medicines and Health Products, Brussels, Belgium
| | | | - Alberto Pappo
- St Jude Children’s Research Hospital, Memphis, TN, USA
| | | | | | - Gilles Vassal
- ACCELERATE, Brussels, Belgium, Europe
- Gustave Roussy Cancer Centre, Paris, France
| |
Collapse
|
7
|
Judd S, Revon‐Riviere G, Grover SA, Deyell RJ, Vanan MI, Lewis VA, Pecheux L, Zorzi AP, Goudie C, Santiago R, Tran TH, Abbott LS, Brossard J, Moorehead P, Alvi S, Portwine C, Denburg A, Whitlock JA, Cohen‐Gogo S, Morgenstern DA. Access to innovative therapies in pediatric oncology: Report of the nationwide experience in Canada. Cancer Med 2024; 13:e7033. [PMID: 38400668 PMCID: PMC10891445 DOI: 10.1002/cam4.7033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/31/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The need for new therapies to improve survival and outcomes in pediatric oncology along with the lack of approval and accessible clinical trials has led to "out-of-trial" use of innovative therapies. We conducted a retrospective analysis of requests for innovative anticancer therapy in Canadian pediatric oncology tertiary centers for patients less than 30 years old between 2013 and 2020. METHODS Innovative therapies were defined as cancer-directed drugs used (a) off-label, (b) unlicensed drugs being used outside the context of a clinical trial, or (c) approved drugs with limited evidence in pediatrics. We excluded cytotoxic chemotherapy, cellular products, and cytokines. RESULTS We retrieved data on 352 innovative therapy drug requests. Underlying diagnosis was primary CNS tumor 31%; extracranial solid tumor 37%, leukemia/lymphoma 22%, LCH 2%, and plexiform neurofibroma 6%. RAS/MAP kinase pathway inhibitors were the most frequently requested innovative therapies in 28% of all requests followed by multi-targeted tyrosine kinase inhibitors (17%), inhibitors of the PIK3CA-mTOR-AKT pathway (8%), immune checkpoints inhibitors (8%), and antibody drug conjugates (8%). In 112 out of 352 requests, innovative therapies were used in combination with another anticancer agent. 48% of requests were motivated by the presence of an actionable molecular target. Compassionate access accounted for 52% of all requests while public insurance was used in 27%. Mechanisms of funding varied between provinces. CONCLUSION This real-world data collection illustrates an increasing use of "out-of-trial" innovative therapies in pediatric oncology. This new field of practice warrants further studies to understand the impact on patient trajectory and equity in access to innovative therapies.
Collapse
Affiliation(s)
- Sandra Judd
- Department of PharmacyHospital for Sick ChildrenTorontoOntarioCanada
| | - Gabriel Revon‐Riviere
- Division of Haematology/Oncology, Hospital for Sick Children, Department of PediatricsUniversity of TorontoTorontoOntarioCanada
| | | | - Rebecca J. Deyell
- Division of Pediatric Hematology Oncology BMTBC Children's Hospital and Research InstituteVancouverBritish ColumbiaCanada
| | - Magimairajan Issai Vanan
- Pediatric Neuro‐Oncology, Division of Pediatric Hematology‐Oncology, Cancer Care ManitobaUniversity of ManitobaWinnipegManitobaCanada
| | | | - Lucie Pecheux
- Stollery Children's HospitalUniversity of AlbertaEdmontonAlbertaCanada
| | - Alexandra P. Zorzi
- Department of Pediatrics, Children's Hospital London Health Sciences CentreWestern UniversityLondonOntarioCanada
| | - Catherine Goudie
- Department of Pediatrics, Division of Hematology‐Oncology, Montreal Children's HospitalMcGill University Health CentreQuébecCanada
| | - Raoul Santiago
- Department of Pediatrics, CHU de QuébecLaval UniversityQuébecCanada
| | - Thai Hoa Tran
- Division of Pediatric Hematology‐OncologyCharles‐Bruneau Cancer Center, CHU Sainte‐JustineMontrealQuébecCanada
| | - Lesleigh S. Abbott
- Division of Hematology/OncologyChildren's Hospital of Eastern OntarioOttawaOntarioCanada
| | - Josee Brossard
- Department of PediatricsCHU de Sherbrooke, Univesité de SherbrookeSherbrookeQuébecCanada
| | - Paul Moorehead
- Department of Pediatrics, Janeway Children's Health and Rehabilitation CentreMemorial University of NewfoundlandSt. John'sNewfoundland and LabradorCanada
| | - Saima Alvi
- Pediatric Hematology/Oncology, Jim Pattison Children's HospitalSaskatoonSaskatchewanCanada
| | - Carol Portwine
- McMaster Children's HospitalMcMaster UniversityHamiltonOntarioCanada
| | - Avram Denburg
- Division of Haematology/Oncology, Hospital for Sick Children, Department of PediatricsUniversity of TorontoTorontoOntarioCanada
| | - James A. Whitlock
- Division of Haematology/Oncology, Hospital for Sick Children, Department of PediatricsUniversity of TorontoTorontoOntarioCanada
| | - Sarah Cohen‐Gogo
- Division of Haematology/Oncology, Hospital for Sick Children, Department of PediatricsUniversity of TorontoTorontoOntarioCanada
| | - Daniel A. Morgenstern
- Division of Haematology/Oncology, Hospital for Sick Children, Department of PediatricsUniversity of TorontoTorontoOntarioCanada
| |
Collapse
|
8
|
Janssens GO, Timmermann B, Laprie A, Mandeville H, Padovani L, Chargari C, Kearns P, Kozhaeva O, Kameric L, Kienesberger A, van Rossum PSN, Boterberg T, Lievens Y, Vassal G. The organization of care in pediatric radiotherapy across SIOP Europe affiliated centers: A multicenter survey in the framework of the 'Joint Action on Rare Cancers' project. Radiother Oncol 2024; 191:110075. [PMID: 38159681 DOI: 10.1016/j.radonc.2023.110075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/21/2023] [Accepted: 12/23/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND/PURPOSE To reduce inequalities among SIOPE-affiliated countries, standard and optional levels to deliver 'Good Clinical Practice' compliant treatment in pediatric radiation oncology have been published. The aim of this project was to map the availability of pediatric radiotherapy resources across SIOPE-affiliated radiotherapy departments. MATERIALS/METHODS An online survey with 34 questions was distributed to 246 radiotherapy departments across 35 SIOPE-affiliated countries. In addition to demographic data, 15 general items related to the organization of the radiotherapy process, and 10 radiotherapy-specific items were defined. For each of the 25 items, sum scores were calculated per center and country. Mann-Whitney U tests were used to analyze associations. RESULTS Between March-June 2019, 121 departments (49 %) out of 31 countries (89 %) completed the survey. At center level, involvement of core disciplines in tumor boards (28 %), and integration of dedicated pediatric radiation therapy technologists (24 %) are limited, while rare & complex brachytherapy procedures are performed in many centers (23 %). For general and radiotherapy-specific items respectively, a relevant variation of sum scores was observed across countries (Δgeneral: ≤10 points; ΔRT_specific: ≤5 points) and among centers within a country (Δgeneral: ≤9 points; ΔRT_specific: ≤6 points). Sum scores for general and radiotherapy-specific items were higher in countries with a high-income (p < 0.01) and higher health development index (p < 0.01). A larger annual number of irradiated pediatric patients was associated with higher sum scores for general items (p < 0.01). CONCLUSION This survey demonstrates the disparities in organization of pediatric radiotherapy departments between SIOPE-affiliated countries and centers within the same country. Investment is needed to reduce inequalities in pediatric radiotherapy care.
Collapse
Affiliation(s)
- Geert O Janssens
- Department of Radiation Oncology, University Medical Center, Utrecht, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), German Cancer Consortium (DKTK), Germany
| | - Anne Laprie
- Department of Radiation Oncology, Oncopole Claudius Regaud at Institut Universitaire du Cancer de Toulouse IUCT-Oncopole, Toulouse, France
| | - Henry Mandeville
- The Royal Marsden Hospital and Institute of Cancer Research, Sutton, United Kingdom
| | - Laetitia Padovani
- Aix-Marseille University, Oncology-Radiotherapy-Department, CRCM Inserm UMR1068, CNRSUMR7258 AMUUM105, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Pamela Kearns
- Cancer Research UK Clinical Trials Unit, National Institute for Health Research Birmingham Biomedical Research Centre, Institute of Cancer and Genomic Sciences, University of Birmingham, B15 2TT, Birmingham, United Kingdom
| | - Olga Kozhaeva
- Policy Department, European Society for Pediatric Oncology, SIOP Europe, Brussels, Belgium
| | - Leila Kameric
- Childhood Cancer International - Europe, Vienna, Austria
| | | | - Peter S N van Rossum
- Department of Radiation Oncology, University Medical Center, Utrecht, the Netherlands
| | - Tom Boterberg
- Department of Radiation Oncology, Ghent University Hospital and Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Particle Therapy Interuniversity Center Leuven (PARTICLE), Leuven, Belgium
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital and Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Gilles Vassal
- Department of Children and Adolescent Oncology, Gustave Roussy Comprehensive Cancer Center, Paris-Saclay University, Villejuif, France
| |
Collapse
|
9
|
Cheung SYA, Hay JL, Lin YW, de Greef R, Bullock J. Pediatric oncology drug development and dosage optimization. Front Oncol 2024; 13:1235947. [PMID: 38348118 PMCID: PMC10860405 DOI: 10.3389/fonc.2023.1235947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 12/29/2023] [Indexed: 02/15/2024] Open
Abstract
Oncology drug discovery and development has always been an area facing many challenges. Phase 1 oncology studies are typically small, open-label, sequential studies enrolling a small sample of adult patients (i.e., 3-6 patients/cohort) in dose escalation. Pediatric evaluations typically lag behind the adult development program. The pediatric starting dose is traditionally referenced on the recommended phase 2 dose in adults with the incorporation of body size scaling. The size of the study is also small and dependent upon the prevalence of the disease in the pediatric population. Similar to adult development, the dose is escalated or de-escalated until reaching the maximum tolerated dose (MTD) that also provides desired biological activities or efficacy. The escalation steps and identification of MTD are often rule-based and do not incorporate all the available information, such as pharmacokinetic (PK), pharmacodynamic (PD), tolerability and efficacy data. Therefore, it is doubtful if the MTD approach is optimal to determine the dosage. Hence, it is important to evaluate whether there is an optimal dosage below the MTD, especially considering the emerging complexity of combination therapies and the long-term tolerability and safety of the treatments. Identification of an optimal dosage is also vital not only for adult patients but for pediatric populations as well. Dosage-finding is much more challenging for pediatric populations due to the limited patient population and differences among the pediatric age range in terms of maturation and ontogeny that could impact PK. Many sponsors defer the pediatric strategy as they are often perplexed by the challenges presented by pediatric oncology drug development (model of action relevancy to pediatric population, budget, timeline and regulatory requirements). This leads to a limited number of approved drugs for pediatric oncology patients. This review article provides the current regulatory landscape, incentives and how they impact pediatric drug discovery and development. We also consider different pediatric cancers and potential clinical trial challenges/opportunities when designing pediatric clinical trials. An outline of how quantitative methods such as pharmacometrics/modelling & simulation can support the dosage-finding and justification is also included. Finally, we provide some reflections that we consider helpful to accelerate pediatric drug discovery and development.
Collapse
|
10
|
de Rojas T, Chiodin D, Pearson ADJ, Heenen D, Adamson P, Caron H, Vassal G. Rescuing Drugs That are Discontinued in Adult Oncology Development for the Benefit of Children and Adolescents With Cancer - An ACCELERATE Multistakeholder Consensus. Clin Pharmacol Ther 2024; 115:36-41. [PMID: 37885401 DOI: 10.1002/cpt.3088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023]
Abstract
Better therapies for childhood cancer remain an unmet need to improve the dismal prognosis of certain malignancies and to reduce the burden of toxicity. Rescuing discontinued or shelved drugs for children, adolescents, and young adults is a strategy to identify new uses for approved or investigational medicines outside the scope of their original medical indication. Our proposed multistakeholder consensus focuses on the development of innovative, patent-protected targeted agents, sourced from previously shelved or discontinued programs that have the potential to provide significant benefit to underserved patient populations, with unmet medical needs. There are several challenges to continuing/rescuing drugs for pediatric oncology development, which include the lack of information for decision making, corporate strategy considerations underlying the decision to invest in pediatric development, and the contracting and technology transfer complexities required to enable divestment and subsequent development. The multistakeholder approach for drug development has the advantage of conveying a consensus among academia, patient advocates, and importantly industry itself. We propose three areas of action to facilitate rescuing potentially beneficial drugs for children and adolescents with cancer: (i) initiatives to provide information to companies considering developing these drugs and a standards framework; (ii) incentives both in Europe and in the United States to encourage companies to develop pediatric-only drugs, with the reform of the EU Pharmaceutical Legislation posing an important opportunity; and (iii) communication of the issues to all stakeholders. Ultimately, this will benefit children and adolescents with cancer.
Collapse
Affiliation(s)
| | - Davy Chiodin
- Day One Biopharmaceuticals, Brisbane, California, USA
| | | | | | | | | | - Gilles Vassal
- ACCELERATE, Brussels, Belgium
- Gustave Roussy Cancer Centre, Villejuif, France
| |
Collapse
|
11
|
Aggarwal A, Choudhury A, Fearnhead N, Kearns P, Kirby A, Lawler M, Quinlan S, Palmieri C, Roques T, Simcock R, Walter FM, Price P, Sullivan R. The future of cancer care in the UK-time for a radical and sustainable National Cancer Plan. Lancet Oncol 2024; 25:e6-e17. [PMID: 37977167 DOI: 10.1016/s1470-2045(23)00511-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 11/19/2023]
Abstract
Cancer affects one in two people in the UK and the incidence is set to increase. The UK National Health Service is facing major workforce deficits and cancer services have struggled to recover after the COVID-19 pandemic, with waiting times for cancer care becoming the worst on record. There are severe and widening disparities across the country and survival rates remain unacceptably poor for many cancers. This is at a time when cancer care has become increasingly complex, specialised, and expensive. The current crisis has deep historic roots, and to be reversed, the scale of the challenge must be acknowledged and a fundamental reset is required. The loss of a dedicated National Cancer Control Plan in England and Wales, poor operationalisation of plans elsewhere in the UK, and the closure of the National Cancer Research Institute have all added to a sense of strategic misdirection. The UK finds itself at a crossroads, where the political decisions of governments, the cancer community, and research funders will determine whether we can, together, achieve equitable, affordable, and high-quality cancer care for patients that is commensurate with our wealth, and position our outcomes among the best in the world. In this Policy Review, we describe the challenges and opportunities that are needed to develop radical, yet sustainable plans, which are comprehensive, evidence-based, integrated, patient-outcome focused, and deliver value for money.
Collapse
Affiliation(s)
- Ajay Aggarwal
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Ananya Choudhury
- Department of Clinical Oncology and Division of Cancer Sciences, The Christie NHS Foundation Trust, Manchester, UK
| | - Nicola Fearnhead
- Department of Colorectal Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Pam Kearns
- Institute of Cancer and Genomic Sciences NIHR Birmingham Biomedical Research Centre, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Anna Kirby
- Department of Radiotherapy, Royal Marsden Hospital, London, UK
| | - Mark Lawler
- Patrick G Johnston Centre for Cancer Research, Queens University Belfast Belfast, UK
| | | | - Carlo Palmieri
- The Clatterbridge Cancer Centre NHS Foundation Trust, & Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Tom Roques
- Royal College of Radiologists & Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Richard Simcock
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Fiona M Walter
- Wolfson Institute of Population Health, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Pat Price
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Richard Sullivan
- Institute of Cancer Policy, Centre for Cancer, Society & Public Health, King's College London, London, UK
| |
Collapse
|
12
|
Tesileanu CMS, Pignatti F, Tognana E, Humphreys A. Queries Raised During Oncology Business Pipeline Meetings at the European Medicines Agency: A 5-Year Retrospective Analysis. Clin Pharmacol Ther 2023; 114:1043-1049. [PMID: 37539657 DOI: 10.1002/cpt.3015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023]
Abstract
The European Medicines Agency (EMA) offers guidance and support to pharmaceutical companies through bilateral discussions called business pipeline meetings (BPMs). An analysis of BPMs in oncology over a 5-year period was conducted to identify common topics and recurring queries. The documents of all BPMs available at the EMA regarding the field of oncology from January 1, 2018, to Decemer 31, 2022, were reviewed. For every query, a main category was assigned, and in case of multiple relevant topics, a secondary category was appointed too. For all queries, the follow-up offered by the EMA was documented, and whether the requested information was available. Subsequently, all queries were scanned for overlapping topics between meetings. From 2018 to 2022, 31 BPMs were held between the EMA and pharmaceutical companies to discuss oncology-related questions, for a total of 397 queries raised. They were classified into 24 topics, of which 15 were common topics (n ≥ 10 queries) with regulatory pathways/guidelines and trial design having the most queries. Post-BPM actions were taken or recommended by the EMA for 41.3% of queries, such as referrals to scientific advice or published guidelines. Forty-three queries were raised at more than one BPM. Targeted therapy, companion diagnostics, institutional collaboration, trial design, and regulatory pathways/guidelines were the most discussed topics in oncology BPMs, with molecular developments being the common denominator. Creating Q&A documents, publishing new guidelines, providing a framework for discussions, and questionnaire-based follow-up research can improve the quality of BPMs, and the accessibility of the information requested during the BPMs.
Collapse
Affiliation(s)
- C Mircea S Tesileanu
- Oncology and Hematology Office, European Medicines Agency, Amsterdam, The Netherlands
- Department of Neurology, The Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Francesco Pignatti
- Oncology and Hematology Office, European Medicines Agency, Amsterdam, The Netherlands
| | - Enrico Tognana
- Regulatory Science and Innovation Task Force, European Medicines Agency, Amsterdam, The Netherlands
| | - Anthony Humphreys
- Regulatory Science and Innovation Task Force, European Medicines Agency, Amsterdam, The Netherlands
| |
Collapse
|
13
|
van Ewijk R, Cleirec M, Herold N, le Deley MC, van Eijkelenburg N, Boudou-Rouquette P, Risbourg S, Strauss SJ, Palmerini E, Boye K, Kager L, Hecker-Nolting S, Marchais A, Gaspar N. A systematic review of recent phase-II trials in refractory or recurrent osteosarcoma: Can we inform future trial design? Cancer Treat Rev 2023; 120:102625. [PMID: 37738712 DOI: 10.1016/j.ctrv.2023.102625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND/OBJECTIVE To analyze changes in recurrent/refractory osteosarcoma phase II trials over time to inform future trials in this population with poor prognosis. METHODS A systematic review of trials registered on trial registries between 01/01/2017-14/02/2022. Comparison of 98 trials identified between 2003 and 2016. Publication search/analysis for both periods, last update on 01/12/2022. RESULTS Between 2017 and 2022, 71 phase-II trials met our selection criteria (19 osteosarcoma-specific trials, 14 solid tumor trials with and 38 trials without an osteosarcoma-specific stratum). The trial number increased over time: 13.9 versus 7 trials/year (p = 0.06). Monotherapy remained the predominant treatment (62% vs. 62%, p = 1). Targeted therapies were increasingly evaluated (66% vs. 41%, P = 0.001). Heterogeneity persisted in the trial characteristics. The inclusion criteria were measurable disease (75%), evaluable disease (14%), and surgical remission (11%). 82% of the trials included pediatric or adolescent patients. Biomarker-driven trials accounted for 25% of the total trials. The survival endpoint use (rather than response) slightly increased (40% versus 31%), but the study H1/H0 hypotheses remained heterogeneous. Single-arm designs predominated over multiarm trials (n = 7). Available efficacy data on 1361 osteosarcoma patients in 58 trials remained disappointing, even though 21% of these trials were considered positive, predominantly those evaluating multi-targeted kinase inhibitors. CONCLUSION Despite observed changes in trial design and an increased number of trials investigating new therapies, high heterogeneity remained with respect to patient selection, study design, primary endpoints, and statistical hypotheses in recently registered phase II trials for osteosarcoma. Continued optimization of trial design informed by a deeper biological understanding should strengthen the development of new therapies.
Collapse
Affiliation(s)
- Roelof van Ewijk
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Morgane Cleirec
- Department of Pediatric Oncology, CHU Nantes, Nantes, France
| | - Nikolas Herold
- Paediatric Oncology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden, and Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Marie-Cécile le Deley
- Unité de Méthodologie et Biostatistiques, Centre Oscar Lambret, Lille, France; Université Paris-Saclay, Université Paris-Sud, UVSQ, CESP, INSERM, U1018 ONCOSTAT, F-94085 Villejuif, France
| | | | - Pascaline Boudou-Rouquette
- Department of Medical Oncology, Cochin Hospital, Cochin Institute, INSERMU1016, Paris Cancer Institute, CARPEM, AP-HP, Paris, France
| | - Séverine Risbourg
- Unité de Méthodologie et Biostatistiques, Centre Oscar Lambret, Lille, France
| | - Sandra J Strauss
- Department of Oncology, University College London Cancer Institute, London, UK
| | - Emanuela Palmerini
- Osteoncology, Bone and Soft Tissue Sarcomas and Innovative Therapies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Kjetil Boye
- Department of Oncology, Oslo University Hospital, Norway
| | - Leo Kager
- St. Anna Children's Hospital, Department of Pediatrics, Medical University Vienna, Vienna, Austria; St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
| | | | - Antonin Marchais
- Department of Oncology for Child and Adolescents, Gustave Roussy Cancer Center, Paris-Saclay University, Villejuif, France; National Institute for Health and Medical Research (INSERM) U1015, BiiOSTeam, Gustave Roussy Institute, Villejuif, France
| | - Nathalie Gaspar
- Department of Oncology for Child and Adolescents, Gustave Roussy Cancer Center, Paris-Saclay University, Villejuif, France; National Institute for Health and Medical Research (INSERM) U1015, BiiOSTeam, Gustave Roussy Institute, Villejuif, France.
| |
Collapse
|
14
|
Argotti U, Leyens L, Lisbona C, López P, Alonso-Orgaz S, Nevado A, Cozzi V. Comparison of the Latin America Regulation Landscape and International Reference Health Authorities to Hasten Drug Registration and Clinical Research Applications. Ther Innov Regul Sci 2023; 57:1287-1297. [PMID: 37682461 PMCID: PMC10579156 DOI: 10.1007/s43441-023-00565-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 07/28/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Promptly providing new drugs to fulfill unmet medical needs requires changes in drug development and registration processes. Health Authorities (HAs) considered as reference due to their experience and acknowledgement (Food and Drug Administration [FDA] among others) already consider innovative clinical trial (CT) designs and flexible approval procedures, but Latin America (LATAM) regulations are still far. A comparison was performed to identify gaps. MATERIALS AND METHODS CT requirements for drug Marketing Authorization Application (MAA) and CT approval regulations were compared between LATAM and reference HAs (FDA/European Medicines Agency [EMA]/Health-Canada/Swissmedic/Therapeutic Goods Administration [TGA]/Pharmaceuticals and Medical Devices Agency [PMDA]), as of August 2022. Procedure included reference HAs regulations review, item selection, identification in LATAM regulations, and International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines (ICH-E6[R2]/ICH-E8[R1]) implementation revision. RESULTS For MAA, specific application requirements or ICH guideline M4(R4) on common technical document (CTD) adoption are generally stated, and phase-I/III performance is mandatory (explicitly/implicitly). Faster patient access procedures are infrequent: Priority-drug programs, conditional authorizations, or expedited procedures are scarce or non-existent. Regulatory reliance procedures are adopted through different pathways. Regarding CT approval, innovative/complex CT designs are not prohibited but usually omitted. Some countries implemented adapted CT conducting during the COVID-19 pandemic. Early scientific advice meetings (HA-sponsor) are occasionally considered. Most countries are not formally ICH-joined. CONCLUSIONS LATAM regulations must adapt to new regulatory standards (FDA/EMA/ICH) through implementation of frequent updates, reliance/expedited procedures, early HA-sponsor interactions, innovative/complex CTs, mandatory phase-III reaching elimination, and decentralized elements for CT conducting.
Collapse
Affiliation(s)
- Urimara Argotti
- International Regulatory Policy Department, Latin America Productos Roche, S.A. de C.V., Mexico City, Mexico
| | - Lada Leyens
- Product Development Regulatory, F. Hoffmann-La Roche AG, Basel, Switzerland
| | | | - Pilar López
- Medical Writing Department, LIDESEC S.L, Madrid, Spain
| | | | - Angel Nevado
- Medical Writing Department, LIDESEC S.L, Madrid, Spain
| | - Virginia Cozzi
- Medical Affairs Department, Roche Central America, Venezuela, and the Caribbean, Heredia, Costa Rica.
| |
Collapse
|
15
|
Domingues C, Jarak I, Veiga F, Dourado M, Figueiras A. Pediatric Drug Development: Reviewing Challenges and Opportunities by Tracking Innovative Therapies. Pharmaceutics 2023; 15:2431. [PMID: 37896191 PMCID: PMC10610377 DOI: 10.3390/pharmaceutics15102431] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/16/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023] Open
Abstract
The paradigm of pediatric drug development has been evolving in a "carrot-and-stick"-based tactic to address population-specific issues. However, the off-label prescription of adult medicines to pediatric patients remains a feature of clinical practice, which may compromise the age-appropriate evaluation of treatments. Therefore, the United States and the European Pediatric Formulation Initiative have recommended applying nanotechnology-based delivery systems to tackle some of these challenges, particularly applying inorganic, polymeric, and lipid-based nanoparticles. Connected with these, advanced therapy medicinal products (ATMPs) have also been highlighted, with optimistic perspectives for the pediatric population. Despite the results achieved using these innovative therapies, a workforce that congregates pediatric patients and/or caregivers, healthcare stakeholders, drug developers, and physicians continues to be of utmost relevance to promote standardized guidelines for pediatric drug development, enabling a fast lab-to-clinical translation. Therefore, taking into consideration the significance of this topic, this work aims to compile the current landscape of pediatric drug development by (1) outlining the historic regulatory panorama, (2) summarizing the challenges in the development of pediatric drug formulation, and (3) delineating the advantages/disadvantages of using innovative approaches, such as nanomedicines and ATMPs in pediatrics. Moreover, some attention will be given to the role of pharmaceutical technologists and developers in conceiving pediatric medicines.
Collapse
Affiliation(s)
- Cátia Domingues
- Univ Coimbra, Laboratory of Drug Development and Technologies, Faculty of Pharmacy, 3000-548 Coimbra, Portugal; (C.D.); (I.J.); (F.V.)
- LAQV-REQUIMTE, Laboratory of Drug Development and Technologies, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- Univ Coimbra, Institute for Clinical and Biomedical Research (iCBR) Area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, 3000-548 Coimbra, Portugal;
| | - Ivana Jarak
- Univ Coimbra, Laboratory of Drug Development and Technologies, Faculty of Pharmacy, 3000-548 Coimbra, Portugal; (C.D.); (I.J.); (F.V.)
- Institute for Health Research and Innovation (i3s), University of Porto, 4200-135 Porto, Portugal
| | - Francisco Veiga
- Univ Coimbra, Laboratory of Drug Development and Technologies, Faculty of Pharmacy, 3000-548 Coimbra, Portugal; (C.D.); (I.J.); (F.V.)
- LAQV-REQUIMTE, Laboratory of Drug Development and Technologies, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Marília Dourado
- Univ Coimbra, Institute for Clinical and Biomedical Research (iCBR) Area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, 3000-548 Coimbra, Portugal;
- Univ Coimbra, Center for Health Studies and Research of the University of Coimbra (CEISUC), Faculty of Medicine, 3000-548 Coimbra, Portugal
- Univ Coimbra, Center for Studies and Development of Continuous and Palliative Care (CEDCCP), Faculty of Medicine, 3000-548 Coimbra, Portugal
| | - Ana Figueiras
- Univ Coimbra, Laboratory of Drug Development and Technologies, Faculty of Pharmacy, 3000-548 Coimbra, Portugal; (C.D.); (I.J.); (F.V.)
- LAQV-REQUIMTE, Laboratory of Drug Development and Technologies, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
| |
Collapse
|
16
|
Lacerda A, Martínez MA, Dumont B, Leiss U, Kokkinou G, Scheinemann K, Craig F. Embracing paediatric palliative care in paediatric oncology from diagnosis onwards. Pediatr Blood Cancer 2023; 70:e30561. [PMID: 37430425 DOI: 10.1002/pbc.30561] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 06/13/2023] [Accepted: 06/30/2023] [Indexed: 07/12/2023]
Abstract
Paediatric palliative care aims to support children and young people with life-limiting or life-threatening conditions, and their families, from the time of diagnosis. Early integration within oncology has been recognised as having benefits for all involved, whatever the outcome may be. Through improved communication and advance care planning, it enables user-centred care, where concerns about quality of life, preferences and values are given the same relevance as cutting-edge therapy. Challenges to the integration of palliative care within paediatric oncology include raising awareness and providing education, whilst searching for the best care model and adapting to an ever-changing therapeutic scenario.
Collapse
Affiliation(s)
- Ana Lacerda
- SIOP Europe Palliative Care Working Group Steering Committee, Brussels, Belgium
- European Association for Palliative Care Children and Young People Reference Group, Vilvoorde, Belgium
- Department of Paediatrics, Portuguese Institute of Oncology, Lisbon, Portugal
| | - María Avilés Martínez
- SIOP Europe Palliative Care Working Group Steering Committee, Brussels, Belgium
- Paediatric Palliative Care Unit, Niño Jesús Children's University Hospital, Madrid, Spain
- Department of Nursing, Autonomous University of Madrid, Madrid, Spain
| | - Benoît Dumont
- SIOP Europe Palliative Care Working Group Steering Committee, Brussels, Belgium
- Paediatric Hematology and Oncology Institute, Léon Bérard Cancer Center, Lyon, France
| | - Ulrike Leiss
- SIOP Europe Palliative Care Working Group Steering Committee, Brussels, Belgium
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Georgia Kokkinou
- SIOP Europe Palliative Care Working Group Steering Committee, Brussels, Belgium
- Floga - Parents Association of Children with Cancer, Athens, Greece
- Childhood Cancer International Europe, Vienna, Austria
| | - Katrin Scheinemann
- SIOP Europe Palliative Care Working Group Steering Committee, Brussels, Belgium
- Division of Oncology-Haematology, Department of Paediatrics, Kantonsspital Aarau, Aarau, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
- Department of Paediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
| | - Finella Craig
- SIOP Europe Palliative Care Working Group Steering Committee, Brussels, Belgium
- European Association for Palliative Care Children and Young People Reference Group, Vilvoorde, Belgium
- Louis Dundas Paediatric Palliative Care Centre, Great Ormond Street Hospital, London, UK
| |
Collapse
|
17
|
Valle-Simón P, Borobia AM, Pérez-Martínez A. Clinical research with targeted drugs in paediatric oncology. Drug Discov Today 2023; 28:103672. [PMID: 37330039 DOI: 10.1016/j.drudis.2023.103672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/31/2023] [Accepted: 06/12/2023] [Indexed: 06/19/2023]
Abstract
The development of targeted drugs in paediatric oncology has been notoriously slow, in part due to the peculiarities of this rare and highly heterogeneous population. To provide therapeutic breakthroughs for the highest risk subgroups of childhood cancer, innovative research solutions have been implemented in the last several years by different international collaborative groups and regulators. Here, we discuss and summarise some of these approaches, as well as challenges and unmet needs that are still being addressed. A wide range of topics were covered in this review including molecular diagnosis optimisation, innovative research methodologies, big data approaches, trial enrolment strategies, and improvements in regulation and preclinical research platforms.
Collapse
Affiliation(s)
- Paula Valle-Simón
- Clinical Pharmacology Department, La Paz University Hospital, Idipaz, Paseo de la Castellana 261, 28046 Madrid, Spain.
| | - Alberto M Borobia
- Clinical Pharmacology Department, La Paz University Hospital, School of Medicine, Universidad Autónoma de Madrid (UAM) IdiPAZ, Paseo de la Castellana 261, 28046 Madrid, Spain
| | - Antonio Pérez-Martínez
- Paediatric Haemato-Oncology Department, La Paz University Hospital, School of Medicine, Universidad Autónoma de Madrid (UAM), IdiPAZ, Paseo de la Castellana 261, 28046 Madrid, Spain
| |
Collapse
|
18
|
Leys K, Stroe MS, Annaert P, Van Cruchten S, Carpentier S, Allegaert K, Smits A. Pharmacokinetics during therapeutic hypothermia in neonates: from pathophysiology to translational knowledge and physiologically-based pharmacokinetic (PBPK) modeling. Expert Opin Drug Metab Toxicol 2023; 19:461-477. [PMID: 37470686 DOI: 10.1080/17425255.2023.2237412] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/13/2023] [Accepted: 07/13/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Perinatal asphyxia (PA) still causes significant morbidity and mortality. Therapeutic hypothermia (TH) is the only effective therapy for neonates with moderate to severe hypoxic-ischemic encephalopathy after PA. These neonates need additional pharmacotherapy, and both PA and TH may impact physiology and, consequently, pharmacokinetics (PK) and pharmacodynamics (PD). AREAS COVERED This review provides an overview of the available knowledge in PubMed (until November 2022) on the pathophysiology of neonates with PA/TH. In vivo pig models for this setting enable distinguishing the effect of PA versus TH on PK and translating this effect to human neonates. Available asphyxia pig models and methodological considerations are described. A summary of human neonatal PK of supportive pharmacotherapy to improve neurodevelopmental outcomes is provided. EXPERT OPINION To support drug development for this population, knowledge from clinical observations (PK data, real-world data on physiology), preclinical (in vitro and in vivo (minipig)) data, and molecular and cellular biology insights can be integrated into a predictive physiologically-based PK (PBPK) framework, as illustrated by the I-PREDICT project (Innovative physiology-based pharmacokinetic model to predict drug exposure in neonates undergoing cooling therapy). Current knowledge, challenges, and expert opinion on the future directions of this research topic are provided.
Collapse
Affiliation(s)
- Karen Leys
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences KU Leuven, Leuven, Belgium
| | - Marina-Stefania Stroe
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, Antwerp, Belgium
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences KU Leuven, Leuven, Belgium
- BioNotus GCV, Niel, Belgium
| | - Steven Van Cruchten
- Comparative Perinatal Development, Department of Veterinary Sciences, University of Antwerp, Antwerp, Belgium
| | | | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC, GA, Rotterdam, The Netherlands
- Child and Youth Institute, KU Leuven, Leuven, Belgium
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Child and Youth Institute, KU Leuven, Leuven, Belgium
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
19
|
Pearson ADJ, Federico S, Gatz SA, Ortiz M, Lesa G, Scobie N, Gounaris I, Weiner SL, Weigel B, Unger TJ, Stewart E, Smith M, Slotkin EK, Reaman G, Pappo A, Nysom K, Norga K, McDonough J, Marshall LV, Ludwinski D, Ligas F, Karres D, Kool M, Horner TJ, Henssen A, Heenen D, Hawkins DS, Gore L, Bender JG, Galluzzo S, Fox E, de Rojas T, Davies BR, Chakrabarti J, Carmichael J, Bradford D, Blanc P, Bernardi R, Benchetrit S, Akindele K, Vassal G. Paediatric Strategy Forum for medicinal product development of DNA damage response pathway inhibitors in children and adolescents with cancer: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2023; 190:112950. [PMID: 37441939 DOI: 10.1016/j.ejca.2023.112950] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/09/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023]
Abstract
DNA damage response inhibitors have a potentially important therapeutic role in paediatric cancers; however, their optimal use, including patient selection and combination strategy, remains unknown. Moreover, there is an imbalance between the number of drugs with diverse mechanisms of action and the limited number of paediatric patients available to be enrolled in early-phase trials, so prioritisation and a strategy are essential. While PARP inhibitors targeting homologous recombination-deficient tumours have been used primarily in the treatment of adult cancers with BRCA1/2 mutations, BRCA1/2 mutations occur infrequently in childhood tumours, and therefore, a specific response hypothesis is required. Combinations with targeted radiotherapy, ATR inhibitors, or antibody drug conjugates with DNA topoisomerase I inhibitor-related warheads warrant evaluation. Additional monotherapy trials of PARP inhibitors with the same mechanism of action are not recommended. PARP1-specific inhibitors and PARP inhibitors with very good central nervous system penetration also deserve evaluation. ATR, ATM, DNA-PK, CHK1, WEE1, DNA polymerase theta and PKMYT1 inhibitors are early in paediatric development. There should be an overall coordinated strategy for their development. Therefore, an academia/industry consensus of the relevant biomarkers will be established and a focused meeting on ATR inhibitors (as proof of principle) held. CHK1 inhibitors have demonstrated activity in desmoplastic small round cell tumours and have a potential role in the treatment of other paediatric malignancies, such as neuroblastoma and Ewing sarcoma. Access to CHK1 inhibitors for paediatric clinical trials is a high priority. The three key elements in evaluating these inhibitors in children are (1) innovative trial design (design driven by a clear hypothesis with the intent to further investigate responders and non-responders with detailed retrospective molecular analyses to generate a revised or new hypothesis); (2) biomarker selection and (3) rational combination therapy, which is limited by overlapping toxicity. To maximally benefit children with cancer, investigators should work collaboratively to learn the lessons from the past and apply them to future studies. Plans should be based on the relevant biology, with a focus on simultaneous and parallel research in preclinical and clinical settings, and an overall integrated and collaborative strategy.
Collapse
Affiliation(s)
- Andrew D J Pearson
- ACCELERATE, c/o BLSI, Clos Chapelle-aux-Champs 30, Bte 1.30.30 BE-1200 Brussels, Belgium.
| | - Sara Federico
- St Jude Children's Research Hospital, Memphis, TN, USA
| | - Susanne A Gatz
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Michael Ortiz
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, the Netherlands
| | | | - Ioannis Gounaris
- Merck Serono Ltd (an affiliate of Merck KGaA, Darmstadt, Germany), Feltham, UK
| | | | | | - T J Unger
- Repare Therapeutics, Cambridge, MA, USA
| | | | | | | | - Gregory Reaman
- US Food and Drug Administration, Silver Springs, MD, USA
| | - Alberto Pappo
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Koen Norga
- Antwerp University Hospital, Antwerp, Belgium; Paediatric Committee of the European Medicines Agency (EMA), Amsterdam, the Netherlands; Federal Agency for Medicines and Health Products, Brussels, Belgium
| | - Joe McDonough
- The Andrew McDonough B+ Foundation, Wilmington, DE, USA
| | - Lynley V Marshall
- The Royal Marsden NHS Foundation Hospital, The Institute of Cancer Research, Sutton, Surrey, UK
| | | | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, the Netherlands
| | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, the Netherlands
| | - Marcel Kool
- Hopp Children's Cancer Center, Heidelberg, Germany
| | | | | | | | - Douglas S Hawkins
- Seattle Children's Hospital, Seattle, WA, USA; Children's Oncology Group, Seattle, WA, USA
| | - Lia Gore
- Children's Hospital Colorado, Aurora, CO, USA; University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Elizabeth Fox
- St Jude Children's Research Hospital, Memphis, TN, USA
| | - Teresa de Rojas
- ACCELERATE, c/o BLSI, Clos Chapelle-aux-Champs 30, Bte 1.30.30 BE-1200 Brussels, Belgium
| | | | | | - Juliet Carmichael
- The Royal Marsden NHS Foundation Hospital, The Institute of Cancer Research, Sutton, Surrey, UK
| | - Diana Bradford
- US Food and Drug Administration, Silver Springs, MD, USA
| | | | - Ronald Bernardi
- Genentech, a Member of the Roche Group, South San Francisco, CA, USA
| | - Sylvie Benchetrit
- National Agency for the Safety of Medicine and Health Products, Paris, France
| | | | - Gilles Vassal
- ACCELERATE, c/o BLSI, Clos Chapelle-aux-Champs 30, Bte 1.30.30 BE-1200 Brussels, Belgium; Gustave Roussy Cancer Centre, Paris, France
| |
Collapse
|
20
|
Moreno L, DuBois SG, Glade Bender J, Mauguen A, Bird N, Buenger V, Casanova M, Doz F, Fox E, Gore L, Hawkins DS, Izraeli S, Jones DT, Kearns PR, Molenaar JJ, Nysom K, Pfister S, Reaman G, Smith M, Weigel B, Vassal G, Zwaan CM, Paoletti X, Iasonos A, Pearson AD. Combination Early-Phase Trials of Anticancer Agents in Children and Adolescents. J Clin Oncol 2023; 41:3408-3422. [PMID: 37015036 PMCID: PMC10414747 DOI: 10.1200/jco.22.02430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 02/07/2023] [Indexed: 04/06/2023] Open
Abstract
PURPOSE There is an increasing need to evaluate innovative drugs for childhood cancer using combination strategies. Strong biological rationale and clinical experience suggest that multiple agents will be more efficacious than monotherapy for most diseases and may overcome resistance mechanisms and increase synergy. The process to evaluate these combination trials needs to maximize efficiency and should be agreed by all stakeholders. METHODS After a review of existing combination trial methodologies, regulatory requirements, and current results, a consensus among stakeholders was achieved. RESULTS Combinations of anticancer therapies should be developed on the basis of mechanism of action and robust preclinical evaluation, and may include data from adult clinical trials. The general principle for combination early-phase studies is that, when possible, clinical trials should be dose- and schedule-confirmatory rather than dose-exploratory, and every effort should be made to optimize doses early. Efficient early-phase combination trials should be seamless, including dose confirmation and randomized expansion. Dose evaluation designs for combinations depend on the extent of previous knowledge. If not previously evaluated, limited evaluation of monotherapy should be included in the same clinical trial as the combination. Randomized evaluation of a new agent plus standard therapy versus standard therapy is the most effective approach to isolate the effect and toxicity of the novel agent. Platform trials may be valuable in the evaluation of combination studies. Patient advocates and regulators should be engaged with investigators early in a proposed clinical development pathway and trial design must consider regulatory requirements. CONCLUSION An optimized, agreed approach to the design and evaluation of early-phase pediatric combination trials will accelerate drug development and benefit all stakeholders, most importantly children and adolescents with cancer.
Collapse
Affiliation(s)
- Lucas Moreno
- Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Steven G. DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA
| | | | | | - Nick Bird
- Solving Kids' Cancer UK, London, United Kingdom
| | - Vickie Buenger
- Coalition Against Childhood Cancer (CAC2), Philadelphia, PA
| | | | - François Doz
- Université Paris Cité, Paris, France
- SIREDO Centre (Care, Innovation Research in Pediatric, Adolescent and Young Adults Oncology), Institut Curie, Paris, France
| | | | - Lia Gore
- Children's Hospital Colorado, Aurora, CO
- University of Colorado, Aurora, CO
| | | | - Shai Izraeli
- Rina Zaizov Pediatric Hematology Oncology Division, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Hematological Malignancies Centre of Human Molecular Genetics and Biochemistry, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David T.W. Jones
- Hopp Children’s Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, United Kingdom
| | - Pamela R. Kearns
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pharmaceutical Sciences Utrecht University, Utrecht, the Netherlands
| | - Jan J. Molenaar
- Division of Pediatric Neurooncology, DKFZ, KiTZ
- Righospitalet, Copenhagen, Denmark
| | - Karsten Nysom
- Clinical Trial Unit and Childhood Brain Tumors, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Pfister
- Hopp Children’s Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Glioma Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Gilles Vassal
- Innovative Therapies for Children with Cancer, Paris, France
- ACCELERATE, Brussels, Belgium
- Gustave Roussy Cancer Centre, Paris, France
| | - Christian Michel Zwaan
- Righospitalet, Copenhagen, Denmark
- Department of Pediatric Oncology, Hematology, Erasmus MC, Sophia Children’s Hospital, the Netherlands
| | | | | | - Andrew D.J. Pearson
- Innovative Therapies for Children with Cancer, Paris, France
- ACCELERATE, Brussels, Belgium
| |
Collapse
|
21
|
Van Haesendonck L, Ruof J, Desmet T, Van Dyck W, Simoens S, Huys I, Giuliani R, Toumi M, Dierks C, Dierks J, Cardone A, Houÿez F, Pavlovic M, Berntgen M, Mol PG, Schiel A, Goettsch W, Gianfrate F, Capri S, Ryan J, Ducournau P, Solà-Morales O, Julian E. The role of stakeholder involvement in the evolving EU HTA process: Insights generated through the European Access Academy's multi-stakeholder pre-convention questionnaire. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2023; 11:2217543. [PMID: 37284060 PMCID: PMC10240997 DOI: 10.1080/20016689.2023.2217543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 06/08/2023]
Abstract
Involvement of all relevant stakeholders will be of utmost importance for the success of the developing EU HTA harmonization process. A multi-step procedure was applied to develop a survey across stakeholders/collaborators within the EU HTA framework to assess their current level of involvement, determine their suggested future role, identify challenges to contribution, and highlight efficient ways to fulfilling their role. The 'key' stakeholder groups identified and covered by this research included: patients', clinicians', regulatory, and Health Technology Developer representatives. The survey was circulated to a wide expert audience including all relevant stakeholder groups in order to determine self-perception by the 'key' stakeholders regarding involvement in the HTA process (self-rating), and in a second, slightly modified version of the questionnaire, to determine the perception of 'key' stakeholder involvement by HTA bodies, payers, and policymakers (external rating). Predefined analyses were conducted on the submitted responses. Fifty-four responses were received (patients 9; clinicians: 8; regulators: 4; HTDs 14; HTA bodies: 7; Payers: 5; policymakers 3; others 4). The mean self-perceived involvement score was consistently lower for each of the 'key' stakeholder groups than the respective external ratings. Based on the qualitative insights generated in the survey, a RACI Chart (Responsible/Accountable/Consulted/Informed) was developed for each of the stakeholder groups to determine their roles and involvement in the current EU HTA process. Our findings suggest extensive effort and a distinct research agenda are required to ensure adequate involvement of the key stakeholder groups in the evolving EU HTA process.
Collapse
Affiliation(s)
| | - Jörg Ruof
- r-connect Ltd, Basel, Switzerland
- Medical School of Hanover, Hanover, Germany
| | - Thomas Desmet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Healthcare Management Centre, Vlerick Business School, Brussels, Belgium
| | - Walter Van Dyck
- Healthcare Management Centre, Vlerick Business School, Brussels, Belgium
| | - Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Isabelle Huys
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Rosa Giuliani
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Mondher Toumi
- Faculty of Medicine, Public Health Department, Aix-Marseille University, Marseille, France
| | | | | | | | - Francois Houÿez
- European Organisation for Rare Diseases (EURORDIS), Paris, France
| | - Mira Pavlovic
- Medicines Development and Training (MDT) Services, Paris, France
| | - Michael Berntgen
- Scientific Evidence Generation department, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Peter G.M. Mol
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Anja Schiel
- Norwegian Medicines Agency (NOMA), Oslo, Norway
| | - Wim Goettsch
- National Health Care Institute, Diemen, The Netherlands
| | - Fabrizio Gianfrate
- University of Ferrara, Ferrara, Italy
- School of Economics and Management, Cattaneo-LIUC University, Castellanza, Italy
| | - Stefano Capri
- Health Economics and Payer Evidence, Astra Zeneca, Cambridge, UK
| | - James Ryan
- Global Market Access & Pricing, Abbvie AG, Cham, Switzerland
| | - Pierre Ducournau
- HiTT Foundation, International University of Catalonia-UIC, Barcelona, Spain
| | - Oriol Solà-Morales
- Utrecht Centre for Pharmaceutical Policy, Division of Pharmacoepidemiology and Clinical Pharmacology, University of Utrecht, Utrecht, The Netherlands
| | | |
Collapse
|
22
|
de Rojas T, Kearns P, Blanc P, Skolnik J, Fox E, Knox L, Rousseau R, Doz F, Bird N, Pearson AJ, Vassal G. Changing incentives to ACCELERATE drug development for paediatric cancer. Cancer Med 2023; 12:8825-8837. [PMID: 36645217 PMCID: PMC10134303 DOI: 10.1002/cam4.5627] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/03/2023] [Accepted: 01/04/2023] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND More effective incentives are needed to motivate paediatric oncology drug development, uncoupling it from dependency on adult drug development. Although the current European and North-American legislations aim to promote drug development for paediatrics and rare diseases, children and adolescents with cancer have not benefited as expected from these initiatives and cancer remains the first cause of death by disease in children older than one. Drug development for childhood cancer remains dependent on adult cancer indications and their potential market. The balance between the investment needed to execute a Paediatric Investigation Plan (PIP) in Europe and an initial Paediatric Study Plan (iPSP) in the US, coupled with the potential financial reward has not been sufficiently attractive to incite the pharmaceutical industry to develop drugs for rare indications such as childhood cancer. METHODS We propose changes in the timing and nature of the rewards within the European Paediatric Medicine Regulation (PMR) and Regulation on Orphan Medicinal Products (both currently under review), which would drive earlier initiation of paediatric oncology studies and provide incentives for drug development specifically for childhood indications. RESULTS We suggest modifying the PMR to ensure mechanism-of-action driven mandatory PIP and reorganization of incentives to a stepwise and incremental approach. Interim and final deliverables should be defined within a PIP or iPSP, each attracting a reward on completion. A crucial change would be the introduction of the interim deliverable requiring production of paediatric data that inform the go/no-go decisions on whether to take a drug forward to paediatric efficacy trials. CONCLUSION Additionally, to address the critical gap in the current framework where there is a complete lack of incentives to promote paediatric-specific cancer drug development, we propose the introduction of early rewards in the Orphan Regulation, with a variant on the US-Creating Hope Act and its priority review vouchers.
Collapse
Affiliation(s)
| | - Pamela Kearns
- Cancer Research UK Clinical Trials Unit, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Cancer and Genomic Sciences, Birmingham, UK
| | - Patricia Blanc
- Imagine for Margo - Children Without Cancer, Saint-Germain-en-Laye, France
| | - Jeffrey Skolnik
- INOVIO Pharmaceuticals, Inc., Plymouth Meeting, Pennsylvania, USA
| | - Elizabeth Fox
- St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | | | - François Doz
- SIREDO Centre (Care, Innovation Research in Paediatric, Adolescent and Young Adult Oncology), Institut Curie, Paris, France.,Université Paris Cité, Paris, France
| | | | | | - Gilles Vassal
- ACCELERATE, Brussels, Belgium.,Paediatric and Adolescent Oncology Department, Gustave Roussy Cancer Campus, INSERM U1015, Université Paris-Saclay, Villejuif, France
| |
Collapse
|
23
|
Kaguelidou F, Ouèdraogo M, Treluyer JM, Le Jeunne C, Annereau M, Blanc P, Bureau S, Ducassou S, Fiquet B, Flamein F, Gaillard S, Hankard R, Laugel V, Laurent C, Levy C, Marquet T, Polak M, Portefaix A, Vassal G. Paediatric drug development and evaluation: Existing challenges and recommendations. Therapie 2023; 78:105-114. [PMID: 36528416 DOI: 10.1016/j.therap.2022.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/07/2022] [Indexed: 12/11/2022]
Abstract
Despite various international regulatory initiatives over the last 20 years, many challenges remain in the field of paediatric drug development and evaluation. Indeed, drug research and development is still focused essentially on adult indications, thereby excluding many paediatric patients, limiting the feasibility of trials and favouring competing developments. Off-label prescribing persists and the development of age-appropriate dosage forms for children remains limited. Against this background, the members of this panel (TR) recommend the launch of multi-partner exchange forums on specific topics in order to focus new drug research and development on the real, unmet medical needs of children and adolescents, and in keeping with the underlying mechanisms of action. Scientific information sharing and cooperation between stakeholders are also essential for defining reference evaluation methods in each medical field. These forums can be organised through existing paediatric facilities and research networks at the French and European level. The latter are specifically dedicated to paediatric research and can facilitate clinical trial implementation and patient enrolment. Moreover, specific grants and public/private partnerships are still needed to support studies on the repositioning of drugs in paediatric indications, and pharmacokinetic studies aimed at defining appropriate dosages. The development of new pharmaceutical forms, better suited for paediatric use, and the promotion of resulting innovations will stimulate future investments. Initiatives to gather observational safety and efficacy data following off-label and/or derogatory early access should also be encouraged to compensate for the lack of information available in these situations. Finally, the creation of Ethics Committees (EC) with a specific "mother-child" advisory expertise should be promoted to ensure that the current regulation (Jardé law in France) is implemented whilst also taking into account the paediatric specificities in medical trials.
Collapse
Affiliation(s)
- Florentia Kaguelidou
- Center of Clinical Investigations and Pediatric Pharmacology, Inserm CIC1426, Robert-Debré hospital, AP-HP.Nord, 75000 Paris, France; Paris Cité University, EA7323 « Therapeutic assessment, and perinatal and pediatric pharmacology », 75000 Paris, France.
| | - Maria Ouèdraogo
- Lead « partenaires parcours de soins référents médicaux », laboratoire Roche, 92100 Boulogne, France
| | - Jean-Marc Treluyer
- Paris Cité University, EA7323 « Therapeutic assessment, and perinatal and pediatric pharmacology », 75000 Paris, France; Département de pharmacologie, CRPV, hôpital Cochin, AP-HP.Centre, 75014 Paris, France
| | - Claire Le Jeunne
- Paris Cité University, EA7323 « Therapeutic assessment, and perinatal and pediatric pharmacology », 75000 Paris, France; Service de médecine interne, hôpital Cochin, AP-HP Centre, 75014 Paris, France
| | - Maxime Annereau
- Département de pharmacie clinique, Gustave Roussy Cancer Campus, 94800 Villejuif, France
| | - Patricia Blanc
- Association de patients («) Imagine for Margo - Enfants sans Cancer », 78100 Saint-Germain-en-Laye, France
| | - Serge Bureau
- Direction de la recherche clinique, de l'innovation, des relations avec les universités et organismes de recherche (DRCI), Assistance publique-Hôpitaux de Paris, 75000 Paris, France
| | - Stéphane Ducassou
- Unité hématologie oncologie pédiatrique, CHU Bordeaux, 33000 Bordeaux, France
| | - Béatrice Fiquet
- Département médical, Amgen, 92100 Boulogne-Billancourt, France
| | - Florence Flamein
- University Lille, Inserm, CHU Lille, CIC-1403 Inserm-CHU, 59000 Lille, France; French Clinical Research Infrastructure Network (F-CRIN) - PEDSTART, 94000 Créteil, France
| | - Ségolène Gaillard
- Hospices civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, CHU-Lyon, 69677 Bron, France; Université Lyon 1, CNRS UMR 5558, laboratoire de biométrie et biologie évolutive, 69622 Villeurbanne, France
| | | | - Vincent Laugel
- Pôle médico-chirurgical de pédiatrie, centre d'investigation clinique, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France
| | | | - Corinne Levy
- Clinical Research Center (CRC), centre hospitalier intercommunal de Créteil, 94000 Créteil, France
| | - Thierry Marquet
- Accès des patients à l'innovation, Takeda, 75116 Paris, France
| | - Michel Polak
- Unité d'endocrinologie, gynécologie, diabétologie pédiatriques, Inserm U1016, Institut Imagine, centre de référence des maladies endocriniennes rares de la croissance et du développement, hôpital universitaire Necker-Enfants-Malades, AP-HP Centre, université Paris-Descartes, 75743 Paris, France
| | - Aurélie Portefaix
- Hospices civils de Lyon, Pediatric Clinic Investigation Center, Inserm P-1407, 69500 Bron, France
| | - Gilles Vassal
- Département de cancérologie de l'enfant et de l'adolescent, Gustave Roussy Comprehensive Cancer Center et université Paris-Saclay, 94805 Villejuif, France
| |
Collapse
|
24
|
Kaguelidou F, Ouèdraogo M, Treluyer JM, Le Jeunne C, Annereau M, Blanc P, Bureau S, Ducassou S, Fiquet B, Flamein F, Gaillard S, Hankard R, Laugel V, Laurent C, Levy C, Marquet T, Polak M, Portefaix A, Vassal G. Développement des médicaments en pédiatrie : défis existants et recommandations. Therapie 2023; 78:95-104. [PMID: 36543724 DOI: 10.1016/j.therap.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Florentia Kaguelidou
- Center of Clinical Investigations and Pediatric Pharmacology, Inserm CIC1426, Robert-Debré Hospital, AP-HP Nord, 75000 Paris, France; Paris Cité University, EA7323 « Therapeutic assessment, and perinatal and pediatric pharmacology », 75000 Paris, France.
| | - Maria Ouèdraogo
- Lead « partenaires parcours de soins référents médicaux », laboratoire Roche, 92100 Boulogne, France
| | - Jean-Marc Treluyer
- Paris Cité University, EA7323 « Therapeutic assessment, and perinatal and pediatric pharmacology », 75000 Paris, France; Département de pharmacologie, CRPV, hôpital Cochin, AP-HP Centre, 75014 Paris, France
| | - Claire Le Jeunne
- Paris Cité University, EA7323 « Therapeutic assessment, and perinatal and pediatric pharmacology », 75000 Paris, France; Service de médecine interne, hôpital Cochin, AP-HP Centre, 75014 Paris, France
| | - Maxime Annereau
- Département de pharmacie clinique, Gustave-Roussy Cancer Campus, 94800 Villejuif, France
| | - Patricia Blanc
- Association de patients « Imagine for Margo - Enfants sans Cancer », 78100 Saint-Germain-en-Laye, France
| | - Serge Bureau
- Direction de la recherche clinique, de l'innovation, des relations avec les universités et organismes de recherche (DRCI), Assistance publique-Hôpitaux de Paris, 75000 Paris, France
| | - Stéphane Ducassou
- Unité hématologie oncologie pédiatrique, CHU Bordeaux, 33000 Bordeaux, France
| | - Béatrice Fiquet
- Département médical, Amgen, 92100 Boulogne-Billancourt, France
| | - Florence Flamein
- Université Lille, Inserm, CHU Lille, CIC-1403 Inserm-CHU, 59000 Lille, France; French Clinical Research Infrastructure Network (F-CRIN) - PEDSTART, 94000 Créteil, France
| | - Ségolène Gaillard
- Hospices civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, CHU-Lyon, 69677 Bron, France; Université Lyon 1, CNRS UMR 5558, laboratoire de biométrie et biologie évolutive, 69622 Villeurbanne, France
| | | | - Vincent Laugel
- Pôle médicochirurgical de pédiatrie, centre d'investigation clinique, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France
| | | | - Corinne Levy
- Clinical Research Center (CRC), centre hospitalier intercommunal de Créteil, 94000 Créteil, France
| | - Thierry Marquet
- Directeur de l'accès des patients à l'innovation, Takeda, 75116 Paris, France
| | - Michel Polak
- Unité d'endocrinologie, gynécologie, diabétologie pédiatriques, Inserm U1016, Institut Imagine, centre de référence des maladies endocriniennes rares de la croissance et du développement, hôpital universitaire Necker-Enfants-Malades, AP-HP Centre, université Paris Descartes, 75743 Paris, France
| | - Aurélie Portefaix
- Hospices civils de Lyon, Pediatric Clinic Investigation Center, Inserm P-1407, 69500 Bron, France
| | - Gilles Vassal
- Département de cancérologie de l'enfant et de l'adolescent, Gustave-Roussy Comprehensive Cancer Center, université Paris-Saclay, 94805 Villejuif, France
| |
Collapse
|
25
|
Phillips RS, Vaarwerk B, Morgan JE. Using Evidence-Based Medicine to Support Clinical Decision-Making in RMS. Cancers (Basel) 2022; 15:cancers15010066. [PMID: 36612064 PMCID: PMC9817945 DOI: 10.3390/cancers15010066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
The foundations of evidence-based practice are the triad of patient values and preferences, healthcare professional experience, and best available evidence, used together to inform clinical decision-making. Within the field of rhabdomyosarcoma, collaborative groups such as the European Paediatric Soft Tissue Sarcoma Group (EpSSG) have worked to develop evidence to support this process. We have explored many of the key research developments within this review, including patient and public involvement, decision-making research, research into areas other than drug development, core outcome sets, reporting and dissemination of research, evidence synthesis, guideline development and clinical decision rules, research of research methodologies, and supporting research in RMS.
Collapse
Affiliation(s)
- Robert S. Phillips
- Centre for Reviews and Dissemination, University of York, York YO10 5DD, UK
- Department of Paediatric Haematology and Oncology, Leeds Children’s Hospital, Leeds LS1 3EX, UK
| | - Bas Vaarwerk
- Department of Paediatrics, Amsterdam UMC—Emma Children’s Hospital, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jessica E. Morgan
- Centre for Reviews and Dissemination, University of York, York YO10 5DD, UK
- Department of Paediatric Haematology and Oncology, Leeds Children’s Hospital, Leeds LS1 3EX, UK
- Correspondence:
| |
Collapse
|
26
|
Pearson AD, Allen C, Fangusaro J, Hutter C, Witt O, Weiner S, Reaman G, Russo M, Bandopadhayay P, Ahsan S, Barone A, Barry E, de Rojas T, Fisher M, Fox E, Bender JG, Gore L, Hargrave D, Hawkins D, Kreider B, Langseth AJ, Lesa G, Ligas F, Marotti M, Marshall LV, Nasri K, Norga K, Nysom K, Pappo A, Rossato G, Scobie N, Smith M, Stieglitz E, Weigel B, Weinstein A, Viana R, Karres D, Vassal G. Paediatric Strategy Forum for medicinal product development in mitogen-activated protein kinase pathway inhibitors: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2022; 177:120-142. [PMID: 36335782 DOI: 10.1016/j.ejca.2022.09.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/08/2022] [Accepted: 09/26/2022] [Indexed: 01/06/2023]
Abstract
As the mitogen-activated protein kinase (MAPK) signalling pathway is activated in many paediatric cancers, it is an important therapeutic target. Currently, a range of targeted MAPK pathway inhibitors are being developed in adults. However, MAPK signals through many cascades and feedback loops and perturbing the MAPK pathway may have substantial influence on other pathways as well as normal development. In view of these issues, the ninth Paediatric Strategy Forum focused on MAPK inhibitors. Development of MAPK pathway inhibitors to date has been predominantly driven by adult indications such as malignant melanoma. However, these inhibitors may also target unmet needs in paediatric low-grade gliomas, high-grade gliomas, Langerhans cell histiocytosis, juvenile myelomonocytic leukaemia and several other paediatric conditions. Although MAPK inhibitors have demonstrated activity in paediatric cancer, the response rates and duration of responses needs improvement and better documentation. The rapid development and evaluation of combination approaches, based on a deep understanding of biology, is required to optimise responses and to avoid paradoxical tumour growth and other unintended consequences including severe toxicity. Better inhibitors with higher central nervous systempenetration for primary brain tumours and cancers with a propensity for central nervous system metastases need to be studied to determine if they are more effective than agents currently being used, and the optimum duration of therapy with MAPK inhibition needs to be determined. Systematic and coordinated clinical investigations to inform future treatment strategies with MAPK inhibitors, rather than use outside of clinical trials, are needed to fully assess the risks and benefits of these single agents and combination strategies in both front-line and in the refractory/relapse settings. Platform trials could address the investigation of multiple similar products and combinations. Accelerating the introduction of MAPK inhibitors into front-line paediatric studies is a priority, as is ensuring that these studies generate data appropriate for scientific and regulatory purposes. Early discussions with regulators are crucial, particularly if external controls are considered as randomised control trials in small patient populations can be challenging. Functional end-points specific to the populations in which they are studied, such as visual acuity, motor and neuro psychological function are important, as these outcomes are often more reflective of benefit for lower grade tumours (such as paediatric low-grade glioma and plexiform neurofibroma) and should be included in initial study designs for paediatric low-grade glioma. Early prospective discussions and agreements with regulators are necessary. Long-term follow-up of patients receiving MAPK inhibitors is crucial in view of their prolonged administration and the important involvement of this pathway in normal development. Further rational development, with a detailed understanding of biology of this class of products, is crucial to ensure they provide optimal benefit while minimising toxicity to children and adolescents with cancer.
Collapse
Affiliation(s)
| | - Carl Allen
- Texas Children Hospital, Houston, TX, USA; Baylor College of Medicine, Houston, TX, USA
| | - Jason Fangusaro
- Children's Healthcare of Atlanta, USA; Emory University School of Medicine, Atlanta, USA
| | - Caroline Hutter
- St. Anna Children's Hospital, Vienna, Austria; Children's Cancer Research Institute, Vienna, Austria
| | - Olaf Witt
- Hopp Children's Cancer Center (KiTZ), Heidelberg, Germany; Heidelberg University Hospital, Heidelberg, Germany; German Cancer Research Center, Heidelberg, Germany
| | | | | | | | - Pratiti Bandopadhayay
- Department of Pediatrics, Harvard Medical School, Broad Institute, USA; Dana-Farber/Boston Children's Cancer and Blood Disorders Center, USA
| | | | - Amy Barone
- US Food and Drug Administration, Silver Springs, USA
| | - Elly Barry
- Day One Biopharmaceuticals, San Francisco, USA
| | | | - Michael Fisher
- The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Elizabeth Fox
- St Jude Children's Research Hospital, Tennessee, USA
| | | | - Lia Gore
- Children's Hospital Colorado, USA; University of Colorado, USA
| | - Darren Hargrave
- UCL Great Ormond Street Institute of Child Health, London UK
| | - Doug Hawkins
- Seattle Children's Hospital, USA; Children's Oncology Group, Seattle, USA
| | | | | | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Netherlands
| | | | - Lynley V Marshall
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | | | - Koen Norga
- Antwerp University Hospital, Antwerp, Belgium; Paediatric Committee of the European Medicines Agency, (EMA), Netherlands; Federal Agency for Medicines and Health Products, Brussels, Belgium
| | | | - Alberto Pappo
- St Jude Children's Research Hospital, Tennessee, USA
| | | | | | | | | | | | | | - Ruth Viana
- Alexion Pharmaceuticals, Zurich, Switzerland
| | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Netherlands
| | - Gilles Vassal
- ACCELERATE, Europe; Gustave Roussy Cancer Centre, Paris, France
| |
Collapse
|
27
|
Julian E, Pavlovic M, Sola-Morales O, Gianfrate F, Toumi M, Bucher HC, Dierks C, Greiner W, Mol P, Bergmann JF, Salmonson T, Hebborn A, Grande M, Cardone A, Ruof J. Shaping a research agenda to ensure a successful European health technology assessment: insights generated during the inaugural convention of the European access academy. HEALTH ECONOMICS REVIEW 2022; 12:54. [PMID: 36333433 PMCID: PMC9636785 DOI: 10.1186/s13561-022-00402-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/18/2022] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Key challenges for a joint European Health Technology Assessment (HTA) include consolidated approaches towards the choice of adequate comparator(s), selection of endpoints that are relevant to patients with a given disease, dealing with remaining uncertainties as well as transparent and consistent management of related processes. We aimed to further crystallize related core domains within these four areas that warrant further research and scrutiny. METHODS Building on the outcomes of a previously conducted questionnaire survey, four key areas, processes, uncertainty, comparator choice and endpoint selection, were identified. At the inaugural convention of the European Access Academy dedicated working groups were established defining and prioritizing core domains for each of the four areas. The working groups consisted of ~ 10 participants each, representing all relevant stakeholder groups (patients/ clinicians/ regulators/ HTA & payers/ academia/ industry). Story books identifying the work assignments were shared in advance. Two leads and one note taker per working group facilitated the process. All rankings were conducted on an ordinal Likert Response Scale scoring from 1 (low priority) to 7 (high priority). RESULTS Identified key domains include for processes: i) address (resource-) challenge of multiple PICOs (Patient/ Intervention/ Comparator/ Outcomes), ii) time and capacity challenges, iii) integrating all involved stakeholders, iv) conflicts and aligning between different multi-national stakeholders, v) interaction with health technology developer; for uncertainty: i) early and inclusive collaboration, ii) agreement on feasibility of RCT and acceptance of uncertainty, iii) alignment on closing evidence gaps, iv) capacity gaps; for comparator choice: i) criteria for the choice of comparator in an increasingly fragmented treatment landscape, ii) reasonable number of comparators in PICOs, iii) shape Early Advice so that comparator fulfils both regulatory and HTA needs, iv) acceptability of Indirect Treatment Comparisons (ITC), v) ensure broad stakeholder involvement in comparator selection; for endpoint selection: i) approaching new endpoints; ii) patient preferences on endpoints; iii) position of HTA and other stakeholders; iv) long-term generation and secondary use of data; v) endpoint challenges in RCTs. CONCLUSIONS The implementation of a joint European HTA assessment is a unique opportunity for a stronger European Health Union. We identified 19 domains related to the four key areas, processes, uncertainty, comparator choice and endpoint selection that urgently need to be addressed for this regulation to become a success.
Collapse
Affiliation(s)
| | - Mira Pavlovic
- Medicines Development and Training (MDT) Services, Paris, France
| | | | | | - Mondher Toumi
- Faculty of Medicine, Public Health Department, Aix-Marseille University, Marseille, France
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics (CEB), University Hospital Basel and University of Basel, Basel, Switzerland
| | | | - Wolfgang Greiner
- School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Peter Mol
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | | | | | | | - Jörg Ruof
- R-Connect Ltd, Basel, Switzerland.
- Medical School of Hanover, Hanover, Germany.
| |
Collapse
|
28
|
Towards Better Pharmaceutical Provision in Europe—Who Decides the Future? Healthcare (Basel) 2022; 10:healthcare10081594. [PMID: 36011250 PMCID: PMC9408332 DOI: 10.3390/healthcare10081594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/15/2022] [Accepted: 08/19/2022] [Indexed: 11/25/2022] Open
Abstract
Significant progress has been achieved in human health in the European Union in recent years. New medicines, vaccines, and treatments have been developed to tackle some of the leading causes of disease and life-threatening illnesses. It is clear that investment in research and development (R&D) for innovative medicines and treatments is essential for making progress in preventing and treating diseases. Ahead of the legislative process, which should begin by the end of 2022, discussions focus on how Europe can best promote the huge potential benefits of new science and technology within the regulatory framework. The challenges in European healthcare were spelled out by the panellists at the roundtable organised by European Alliance for Personalised Medicine (EAPM). Outcomes from panellists’ discussions have been summarized and re-arranged in this paper under five headings: innovation, unmet medical need, access, security of supply, adapting to progress, and efficiency. Some of the conclusions that emerged from the panel are a call for a better overall holistic vision of the future of pharmaceuticals and health in Europe and a collaborative effort among all stakeholders, seeing the delivery of medicines as part of a broader picture of healthcare.
Collapse
|
29
|
Paediatric Strategy Forum for medicinal product development of multi-targeted kinase inhibitors in bone sarcomas: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2022; 173:71-90. [PMID: 35863108 DOI: 10.1016/j.ejca.2022.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/26/2022] [Accepted: 06/12/2022] [Indexed: 12/27/2022]
Abstract
The eighth Paediatric Strategy Forum focused on multi-targeted kinase inhibitors (mTKIs) in osteosarcoma and Ewing sarcoma. The development of curative, innovative products in these tumours is a high priority and addresses unmet needs in children, adolescents and adults. Despite clinical and investigational use of mTKIs, efficacy in patients with bone tumours has not been definitively demonstrated. Randomised studies, currently being planned or in progress, in front-line and relapse settings will inform the further development of this class of product. It is crucial that these are rapidly initiated to generate robust data to support international collaborative efforts. The experience to date has generally indicated that the safety profile of mTKIs as monotherapy, and in combination with chemotherapy or other targeted therapy, is consistent with that of adults and that toxicity is manageable. Increasing understanding of relevant predictive biomarkers and tumour biology is absolutely critical to further develop this class of products. Biospecimen samples for correlative studies and biomarker development should be shared, and a joint academic-industry consortium created. This would result in an integrated collection of serial tumour tissues and a systematic retrospective and prospective analyses of these samples to ensure robust assessment of biologic effect of mTKIs. To support access for children to benefit from these novel therapies, clinical trials should be designed with sufficient scientific rationale to support regulatory and payer requirements. To achieve this, early dialogue between academia, industry, regulators, and patient advocates is essential. Evaluating feasibility of combination strategies and then undertaking a randomised trial in the same protocol accelerates drug development. Where possible, clinical trials and development should include children, adolescents, and adults less than 40 years. To respond to emerging science, in approximately 12 months, a multi-stakeholder group will meet and review available data to determine future directions and priorities.
Collapse
|