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Beck L, Witt R, Nesper-Brock M, Milde T, Hettmer S, Frühwald MC, Rössig C, Fischer M, Reinhardt D, Taylor LA, Riedel C, Witt O, van Tilburg CM. A Study of Regulatory Challenges of Pediatric Oncology Phase I/II Trial Submissions and Guidance on Protocol Development. Clin Pharmacol Ther 2021; 110:1025-1037. [PMID: 34050933 DOI: 10.1002/cpt.2319] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/20/2021] [Indexed: 01/14/2023]
Abstract
The purpose of this study was to identify key deficiencies in pediatric oncology early phase clinical trial protocols in Germany and to provide guidance for efficient trial protocol development. A systematic review of the response letters of German competent authorities (CAs) and Ethics Committees to phase I/II pediatric oncology trial submissions in the period from 2014 to 2019 was performed. Documents were requested from all five Society for Paediatric Oncology and Haematology in Germany (GPOH) phase I/II trial networks plus all nine German Innovative Therapies for Children with Consortium Cancer (ITCC) centers. A blinded dataset containing aggregated data from 33 studies was analyzed for validation. All deficiencies were reviewed, listed, and weighted using a structured matrix according to frequency, category, significance, and feasibility. In total, documents of 17 trials from 6 different sites were collected. Two hundred fifty deficiencies identified by the CAs were identified and categorized into eight categories. "Toxicity and safety" was the most prominent category (27.6%), followed by "Manufacturing and Import" (18%). The majority of deficiencies were categorized as minor and potential measures as easy to address, but an important group of major and difficult to implement deficiencies was also identified. The blinded validation dataset confirmed these findings. The majority of the EC deficiencies could be resolved by changing the wording in the patient-facing documents. In conclusion, this study was able to detect a pattern of key deficiencies. Most of the shortcomings can be anticipated by minor changes in the protocol and increased awareness can prevent time-consuming revisions, withdrawals, or even rejections. A corresponding guideline describing key regulatory aspects is provided.
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Affiliation(s)
- Lydia Beck
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany.,Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Heidelberg Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Ruth Witt
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany.,Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany.,National Center for Tumor Diseases (NCT) Network, Heidelberg, Germany
| | - Martina Nesper-Brock
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany.,Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany.,National Center for Tumor Diseases (NCT) Network, Heidelberg, Germany
| | - Till Milde
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany.,Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany.,National Center for Tumor Diseases (NCT) Network, Heidelberg, Germany.,Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simone Hettmer
- German Cancer Consortium (DKTK), Heidelberg, Germany.,Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Michael C Frühwald
- National Center for Tumor Diseases (NCT) Network, Heidelberg, Germany.,Swabian Children's Cancer Center, Paediatric and Adolescent Medicine, University Medical Center Augsburg, Augsburg, Germany
| | - Claudia Rössig
- Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Matthias Fischer
- National Center for Tumor Diseases (NCT) Network, Heidelberg, Germany.,Department of Experimental Pediatric Oncology, Center for Molecular Medicine (CMMC), Medical Faculty, University Hospital Köln, Cologne, Germany
| | - Dirk Reinhardt
- German Cancer Consortium (DKTK), Heidelberg, Germany.,National Center for Tumor Diseases (NCT) Network, Heidelberg, Germany.,West German Cancer Center, Pediatrics III, University Hospital Essen, Essen, Germany
| | - Lenka A Taylor
- Pharmacy Heidelberg University Hospital, Heidelberg, Germany
| | - Claudia Riedel
- The Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | - Olaf Witt
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany.,Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany.,National Center for Tumor Diseases (NCT) Network, Heidelberg, Germany.,Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Cornelis M van Tilburg
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany.,Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany.,National Center for Tumor Diseases (NCT) Network, Heidelberg, Germany.,Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
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Abstract
Off-label use of drugs is relatively common in medical practice, even if it's often not supported by strong scientific evidence. Off-label use of medicine not only involves physicians and pharmaceutical companies, but regulatory agencies and patients as well. Therapeutic options might get restricted without off-label prescribing in some patient population. Off-label uses can be useful to patients with an orphan disease where sometimes it can be the only available treatment. Permitting the promotion of drugs for off-label uses may be appropriate in instances in which a drug can improve the quality (e.g., same or better outcomes at lower cost). Although many controversies exist, experts generally agree that further efforts are needed to increase access to suitable off-label drugs for patients with rare and other diseases. However, they also concur that potential inappropriate promotion, as well as possibly dangerous prescribing practices for these drugs, should be prevented. Proponents argue that the key benefit of allowing manufacturers to distribute off-label information is that it allows more data to be readily available to physicians, enabling them to make better treatment decisions.
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Affiliation(s)
- Sukhvinder Singh Oberoi
- Department of Public Health Dentistry, Sudha College of Dental Sciences and Research, Faridabad, Haryana, India
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Calaminus G, Birch JR, Hollis R, Pau B, Kruger M. The role of SIOP as a platform for communication in the global response to childhood cancer. Pediatr Blood Cancer 2013; 60:2080-6. [PMID: 23940113 DOI: 10.1002/pbc.24728] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 07/16/2013] [Indexed: 11/07/2022]
Abstract
Since the year 2000, there has been a 35% annual decrease in mortality among children under the age of five worldwide. The decrease is mainly attributed to the decrease in childhood epidemic infections, for example, due to vaccination programs. In the near future, this decrease will draw attention to paediatric non-communicable diseases (NCDs), and cancer is one of the most common. Access to care for children with cancer and survival rates have improved dramatically in high-income countries. However, it is important that a global perspective addresses problems in developing countries in particular. To meet this challenge, it is critical that emphasis is placed on demands such as access to care and drugs that are known to be effective, and which can be safely administered in resource-limited settings. Additionally, cancer registries and improved health care structures that include care for children with cancer, are paramount for further progress to increase awareness and the survival of children with cancer. The purpose of this paper is to describe current worldwide interventions to improve childhood cancer from the perspective of the International Society of Paediatric Oncology (SIOP). This global perspective will serve as an introduction to a series of papers from six SIOP continental branches, which will highlight the specific and/or common issues related to children with cancer worldwide. To strengthen the communication among and synergistic effects of various paediatric cancer stakeholders, SIOP could serve as a global platform for a proposed Global Paediatric Cancer Network through the interaction of its continental branches and partner collaborations.
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Affiliation(s)
- Gabriele Calaminus
- University of Muenster, Paediatric Haematology and Oncology, Muenster, Germany
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Scarpa M, Ceci A, Tomanin R, Mincarone P, Begley D. Personalised medicine in paediatrics: individualising treatment in children with rare neurological diseases. EPMA J 2011. [PMID: 23199151 PMCID: PMC3405387 DOI: 10.1007/s13167-011-0081-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
The development of personalised medicine is of considerable importance for paediatric patient populations, and represents a move away from the use of treatment dosages based on experience with the same compounds in adults. Currently, however, we know little about developmental pharmacogenomics and, although many biomarkers are available for clinical research use, there have been few applications in the management of paediatric diseases. This paper reviews where we are in the journey towards achieving paediatric personalised medicine and describes a group of diseases requiring such an approach. The personalised medicine approach is particularly relevant for the treatment of rare childhood diseases, and the group of life-threatening neurological disorders known as lysosomal storage diseases represents a potential study population. The genetic bases of these disorders are generally well defined, there is the potential for diagnosis at birth or prenatally, and there are a range of therapeutic options available or under development.
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Affiliation(s)
- Maurizio Scarpa
- Department of Pediatrics, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
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Rocchi F, Tomasi P. The development of medicines for children. Part of a series on Pediatric Pharmacology, guest edited by Gianvincenzo Zuccotti, Emilio Clementi, and Massimo Molteni. Pharmacol Res 2011; 64:169-75. [PMID: 21376810 DOI: 10.1016/j.phrs.2011.01.016] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 01/27/2011] [Indexed: 10/18/2022]
Abstract
The lack of availability of appropriate medicines for children is an extensive and well known problem. As a consequence off label or unlicensed administration of medicinal products in every day paediatric practice is frequent. A variety of obstacles hinder the development of paediatric indications for drugs primarily intended for the adult market. The barriers to proper research on children's drug development include several complex factors, such as the limited commercial interest, lack of suitable infrastructure and competence for conducting paediatric clinical trials, difficulties in trial design, ethical worries and many others. Medicinal products used to treat children should be subjected to ethical research of high quality and be explicitly authorised for use in children as it happens in adults. Conducting adequate clinical trials in children is challenging and demanding. Identification of paediatric medical needs, extrapolation from adult data, modelling and simulation, specific clinical trial methodology are important features in the development of drugs intended for children. Market forces alone have proven insufficient to stimulate adequate research aimed at specific authorisation of medicinal products for the paediatric population, and for that reason, following the US experience, the European Paediatric Regulation has been amended in January 2007 by the European Commission. The objective of the Paediatric Regulation is to improve the development of high quality and ethically researched medicines for children aged 0 to 17 years, to facilitate the availability of information on the use of medicines for children, without subjecting children to unnecessary trials, or delaying the authorisation of medicines for use in adults. The impact of the Paediatric Regulation reflects in an increase in the number of paediatric studies to be performed, even if a significant number of these studies have not started yet. The objective of this review is to describe the main regulatory and scientific features which play a role in the complex issue of paediatric drug development.
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Affiliation(s)
- Francesca Rocchi
- European Assessment Unit - Agenzia Italiana del Farmaco (AIFA), via del Tritone 181, 00187 Rome, Italy.
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Jackson C, Dixon-Woods M, Tobin M, Young B, Heney D, Pritchard-Jones K. Seeking consent to tissue banking: a survey of health professionals in childhood cancer. Eur J Cancer Care (Engl) 2011; 18:391-400. [PMID: 19594610 DOI: 10.1111/j.1365-2354.2008.01033.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To identify the views of health professionals working in childhood cancer on seeking consent to tissue banking from potential donors. Self-completion questionnaires sent to 553 UK paediatric oncology health professionals. The response rate was 60%. Respondents (100%) were in favour of using tissue samples from children with cancer for research. A substantial minority (30%) had concerns about the impact of the law on their professional role in relation to tissue banking. Almost all (90%) reported that both the parent(s) and the child, if able, should be asked for consent, though the UK Human Tissue Act provides that a competent child's consent is sufficient. Most (94%) supported 'generic' rather than 'specific' consent. Barriers to obtaining consent included: (1) timing of the approach to families; (2) availability of suitable staff; (3) sensitivity of the issues; (4) difficulties of managing the process; and (5) problems of maintaining a paper trail. Many would welcome training on seeking consent. Personal knowledge and relationships with families are often seen as important in guiding the proper approach to consent rather than formalized rules. There is widespread support among health professionals for tissue banking in childhood cancer. In sensitive situations, disciplined exercise of professional discretion might better deliver on aspirations for regulation than rigid procedures.
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Affiliation(s)
- C Jackson
- Department of Health Sciences, University of Leicester, Leicester, UK
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Rocchi F, Paolucci P, Ceci A, Rossi P. The European paediatric legislation: benefits and perspectives. Ital J Pediatr 2010; 36:56. [PMID: 20716337 PMCID: PMC2933611 DOI: 10.1186/1824-7288-36-56] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 08/17/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The lack of availability of appropriate medicines for children is an extensive and well known problem. Paediatricians and Physicians who take care of the paediatric population are primarily exposed to cope with this negative situation very often as more than half of the children are prescribed off-label or unlicensed medicines. DISCUSSION Medicinal products used to treat this population should be subjected to ethical research of high quality and be explicitly authorized for use in children as it happens in adults. For that reason, and following the US experience, the European Paediatric Regulation has been amended in January 2007 by the European Commission. The objective of the Paediatric Regulation is to improve the development of high quality and ethically researched medicines for children aged 0 to 17 years, to facilitate the availability of information on the use of medicines for children, without subjecting children to unnecessary trials, or delaying the authorization of medicines for use in adults. SUMMARY The Paediatric Regulation is dramatically changing the regulatory environment for paediatric medicines in Europe and is fuelling an increased number of clinical trials in the paediatric population. Nevertheless, there are some risks and pitfalls that need to be anticipated and controlled in order to ensure that children will ultimately benefit from this European initiative.
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Affiliation(s)
- Francesca Rocchi
- Ufficio Informazione e Comunicazione - Agenzia Italiana del Farmaco (AIFA), Via del Tritone, 181 - 00187 Roma, Italy.
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