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Ortiz MV, Glade Bender JL. Delays in Pediatric Evaluation of New and Relevant Cancer Therapies. J Pediatr 2024; 265:113826. [PMID: 37977329 DOI: 10.1016/j.jpeds.2023.113826] [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: 10/25/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Michael V Ortiz
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
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2
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Jamaladdin N, Sigaud R, Kocher D, Kolodziejczak AS, Nonnenbroich LF, Ecker J, Usta D, Benzel J, Peterziel H, Pajtler KW, van Tilburg CM, Oehme I, Witt O, Milde T. Key Pharmacokinetic Parameters of 74 Pediatric Anticancer Drugs Providing Assistance in Preclinical Studies. Clin Pharmacol Ther 2023; 114:904-913. [PMID: 37441736 DOI: 10.1002/cpt.3002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/01/2023] [Indexed: 07/15/2023]
Abstract
Novel drug treatments for pediatric patients with cancer are urgently needed. Success of drug development in pediatric oncology has been promising, but many drugs still fail in translation from preclinical to clinical phases. To increase the translational potential, several improvements have been implemented, including the use of clinically achievable concentrations in the drug testing phase. Although pharmacokinetic (PK) parameters of numerous investigated drugs are published, a comprehensive PK overview of the most common drugs in pediatric oncology could guide preclinical trial design and improve the translatability into clinical trials. A review of the literature was conducted for PK parameters of 74 anticancer drugs, from the drug sensitivity profiling library of the INdividualized Therapy FOr Relapsed Malignancies in Childhood (INFORM) registry. PK data in the pediatric population were reported and complemented by adult parameters when no pediatric data were available. In addition, blood-brain barrier (BBB)-penetration assessment of drugs was provided by using the BBB score. Maximum plasma concentration was available for 73 (97%), area under the plasma concentration-time curve for 69 (92%), plasma protein binding for 66 (88%), plasma half-life for 57 (76%), time to maximum concentration for 54 (72%), clearance for 52 (69%), volume of distribution for 37 (49%), lowest plasma concentration reached by the drug before the next dose administration for 21 (28%), and steady-state concentration for 4 (5%) of drugs. Pediatric PK data were available for 48 (65%) drugs. We provide a comprehensive review of PK data for 74 drugs studied in pediatric oncology. This data set can serve as a reference to design experiments more closely mimicking drug PK conditions in patients, and may thereby increase the probability of successful clinical translation.
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Affiliation(s)
- Nora Jamaladdin
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
- Faculty of Biosciences, Heidelberg University, Heidelberg, Germany
| | - Romain Sigaud
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
| | - Daniela Kocher
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
- Faculty of Biosciences, Heidelberg University, Heidelberg, Germany
| | - Anna S Kolodziejczak
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
| | - Leo F Nonnenbroich
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
- Faculty of Medicine, Heidelberg University, Heidelberg, Germany
| | - Jonas Ecker
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
- KiTZ Clinical Trial Unit (ZIPO), Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Diren Usta
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
- KiTZ Clinical Trial Unit (ZIPO), Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Julia Benzel
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
| | - Heike Peterziel
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Kristian W Pajtler
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- KiTZ Clinical Trial Unit (ZIPO), Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 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) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
- KiTZ Clinical Trial Unit (ZIPO), Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Ina Oehme
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
| | - Olaf Witt
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
- KiTZ Clinical Trial Unit (ZIPO), Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Till Milde
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
- KiTZ Clinical Trial Unit (ZIPO), Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
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3
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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: 0] [Impact Index Per Article: 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.
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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
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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.
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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
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Hovsepyan S, Giani C, Pasquali S, Di Giannatale A, Chiaravalli S, Colombo C, Orbach D, Bergamaschi L, Vennarini S, Gatz SA, Gasparini P, Berlanga P, Casanova M, Ferrari A. Desmoplastic small round cell tumor: from state of the art to future clinical prospects. Expert Rev Anticancer Ther 2023; 23:471-484. [PMID: 37017324 DOI: 10.1080/14737140.2023.2200171] [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: 02/17/2023] [Accepted: 04/04/2023] [Indexed: 04/06/2023]
Abstract
INTRODUCTION Desmoplastic small round cell tumor (DSRCT) is an extremely rare and highly aggressive soft tissue sarcoma, presenting mainly in male adolescents and young adults with multiple nodules disseminated within the abdominopelvic cavity. Despite a multimodal approach including aggressive cytoreductive surgery, intensive multi-agent chemotherapy, and postoperative whole abdominopelvic radiotherapy, the prognosis for DSRCT remains dismal. Median progression-free survival ranges between 4 and 21 months, and overall survival between 17 and 60 months, with the 5-year overall survival rate in the range of 10-20%. AREA COVERED This review discusses the treatment strategies used for DSRCT over the years, the state of the art of current treatments, and future clinical prospects. EXPERT OPINION The unsatisfactory outcomes for patients with DSRCT warrant investigations into innovative treatment combinations. An international multidisciplinary and multi-stakeholder collaboration, involving both pediatric and adult sarcoma communities, is needed to propel preclinical model generation and drug development, and innovative clinical trial designs to enable the timely testing of treatments involving novel agents guided by biology to boost the chances of survival for patients with this devastating disease.
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Affiliation(s)
- Shushan Hovsepyan
- Department of Pediatric Oncology, Pediatric Cancer and Blood Disorders Center of Armenia, Yerevan, Armenia
| | - Claudia Giani
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sandro Pasquali
- Molecular Pharmacology Unit, Department of Applied Research and Technological Development, Molecular Pharmacology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- Sarcoma Service, Department of Surgery, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Angela Di Giannatale
- Department of Hematology/Oncology, Hematology/Oncology, Ospedale Pediatrico Bambino Gesù IRCCS, Roma, Italy
| | - Stefano Chiaravalli
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Chiara Colombo
- Sarcoma Service, Department of Surgery, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Daniel Orbach
- SIREDO Oncology Center, Institut Curie, PSL University, Paris, France
| | - Luca Bergamaschi
- Molecular Pharmacology Unit, Department of Applied Research and Technological Development, Molecular Pharmacology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sabina Vennarini
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Susanne Andrea Gatz
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Patrizia Gasparini
- Tumor Genomics Unit, Department of Research, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Pablo Berlanga
- Department of Pediatric and Adolescent Oncology, Gustave-Roussy, Villejuif, France
| | - Michela Casanova
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Andrea Ferrari
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Vassal G, de Rojas T, Pearson ADJ. Impact of the EU Paediatric Medicine Regulation on new anti-cancer medicines for the treatment of children and adolescents. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:214-222. [PMID: 36682367 DOI: 10.1016/s2352-4642(22)00344-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/13/2022] [Accepted: 11/16/2022] [Indexed: 01/21/2023]
Abstract
The European Paediatric Medicine Regulation was launched in 2007, aiming to provide better medicines for children. However, its benefit for paediatric patients with cancer has been questioned and the European Paediatric and Orphan Regulations have been under review since November, 2020. To ascertain the effect of the European Paediatric Medicine Regulation, all paediatric anti-cancer medicines assessed by the European Medicines Agency from 1995 to 2022 were identified and reviewed using the agency's public assessment reports, and all Paediatric Investigation Plans granted since 2007 were analysed. 16 new molecular entities (NMEs; ie, a drug that contains an active moiety that had never been approved before) have been approved since the regulation was launched in 2007. The number of paediatric marketing authorisations increased from 2007 but represented the same 17% of all anti-cancer drug marketing authorisations before and after 2007. After 2007, nine (56%) of 16 NMEs were first authorised both in adults and children. For seven NMEs, a first paediatric indication was approved with a median lag time of 6·4 years (range 1·2-21·5 years) after the first authorisation in adults. Half of NMEs were authorised for the treatment of malignancies responsible for only 5·4% of all European childhood cancer deaths, including three medicines for melanoma and thyroid cancer-adult cancers occurring very rarely in children. The increased number of paediatric anti-cancer NMEs after 2007 is a result of the major increase in new medicines authorised for adult cancers since 2005 rather than a direct effect of the Paediatric Regulation. Paediatric development of these NMEs was driven by their adult market and did not address major unmet medical needs of children and adolescents with cancer. An improved, fit-for-purpose regulatory environment that incentivises paediatric drug development based on mechanism of action, better incentives, and a systematic multi-stakeholder engagement, with greater investment from industry, public funding, and non-governmental organisations, will increase the number of new medicines approved in the future to cure more children and adolescents with cancer.
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Affiliation(s)
- Gilles Vassal
- ACCELERATE, Brussels, Belgium; Department of Paediatric and Adolescent Oncology, Institut Gustave Roussy and Paris-Saclay University, Villejuif, France.
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Lasala R, Santoleri F, Zanon D, Romagnoli A, Abrate P, Costantini A, Musicco F. Available information about paediatric use of onco-haematological drugs authorized by EMA since 2016. J Oncol Pharm Pract 2023; 29:83-87. [PMID: 34693799 DOI: 10.1177/10781552211053251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The treatment options available to children with cancer are limited. This is why for more than 10 years, the European Medicine Agency (EMA) has stated that all drugs to be marketed must be tested on the paediatric population in accordance with the Paediatric Investigation Plan (PIP). The objective of this study is to make a cross sectional analysis of the information related to the use of cancer drugs authorised on the European market in the paediatric population. METHOD The European Public Assessment Reports and PIPs have been considered. The following data were extracted for onco-haematological drugs approved since 2016: paediatric indications, information about the paediatric population in the Summary of Product Characteristics (SmPC) and presence and characteristics of PIPs. A descriptive analysis of the characteristics of the drugs was made from the point of view of the paediatric population. RESULTS Forty-eight drugs with onco-haematological indications have been authorised for marketing since 2016, 7 (15%) of these have paediatric indications. Two (4%) drugs have no paediatric indication but have information related to the paediatric population within SmPC. Forty-one (85%) drugs have no reference to the paediatric population in SmPC. Seventeen (35%) drugs out of 48 do not have PIPs and 11 have been granted a waiver to present the results of paediatric studies. The other 19 active ingredients have a total of 28 PIPs. CONCLUSION AND RELEVANCE Most of the onco-haematological drugs approved by EMA since 2016 have neither paediatric indications nor mentions about paediatric use in SmPC. PIPs represent an opportunity, but demand for the paediatric population is still huge.
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Affiliation(s)
| | | | - Davide Zanon
- Pharmacy and Clinical Pharmacology Department, Institute for Maternal and Child Health - IRCCS 18705"Burlo Garofolo", Trieste, Italy
| | - Alessia Romagnoli
- Hospital Pharmacy of "Santo Spirito" General Hospital, Pescara, Italy
| | | | | | - Felice Musicco
- Hospital Pharmacy, 18659IFO Regina Elena San Gallicano, Rome, Italy
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Niessen VJA, Wenker STM, Lam MGEH, van Noesel MM, Poot AJ. Biologicals as theranostic vehicles in paediatric oncology. Nucl Med Biol 2022; 114-115:58-64. [PMID: 36126433 DOI: 10.1016/j.nucmedbio.2022.09.001] [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: 07/01/2021] [Revised: 09/05/2022] [Accepted: 09/08/2022] [Indexed: 12/27/2022]
Abstract
Biologicals, such as antibodies or antibody-fragments e.g. nanobodies, have changed the landscape of cancer therapy and can be used in combination with traditional cancer treatments. They have been demonstrated to be excellent vehicles for molecular imaging. Several biologicals for nuclear imaging of adult cancer may be used in combination with (nuclear) therapy. Though it's great potential, molecular imaging using biologicals is rarely applied in paediatric oncology. This paper describes the current status of biologicals as radiopharmaceuticals for childhood cancer. Furthermore, the importance and potential for developing additional biological theranostics as opportunity to image and treat childhood cancer is discussed.
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Affiliation(s)
- Veerle J A Niessen
- Princess Máxima Center for Paediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands.
| | - Sylvia T M Wenker
- Princess Máxima Center for Paediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands.
| | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands.
| | - Max M van Noesel
- Princess Máxima Center for Paediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands.
| | - Alex J Poot
- Princess Máxima Center for Paediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands.
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Christiansen H, De Bruin ML, Hallgreen CE. Mandatory requirements for pediatric drug development in the EU and the US for novel drugs—A comparative study. Front Med (Lausanne) 2022; 9:1009432. [DOI: 10.3389/fmed.2022.1009432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022] Open
Abstract
Mandatory pediatric legislation has been implemented in the European Union (EU) and the United States (US) to increase research and the availability of drugs for the pediatric population. Differences in the legislative framework can cause different pediatric requirements for similar indications granted for similar drugs across jurisdictions. This cross-sectional study compares the pediatric requirements for therapeutic indications granted at the time of initial approval for novel drugs approved in the two regions from 2010 to 2018. We collected the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA) decisions to grant a waiver and/or to agree on a pediatric development plan and deferrals hereof at marketing authorization (MA) from publicly available documents. An agreed pediatric development plan was required for 66% (N = 188/285) and 63% (N = 134/212) of the indications granted in the EU and the US at the time of approval, respectively. Almost all (EU; 98%, US; 89%) were deferred until after MA. Based on the broad scope of the EU Pediatric Regulation, an additional 36 PIPs originated from the indications granted at MA. In the subset of indications granted for drugs approved in both the EU and the US (N = 232), significantly more indications resulted in an agreed pediatric development plan for one or more subsets of the pediatric population in the EU (N = 185) as compared to the US (N = 82). This was based on the exemption of orphan designated drugs in the US and the broader scope of the EU Pediatric Regulation. However, indications subject to the mandatory pediatric legislation in both regions (N = 131) most often had similar regulatory requirements for the inclusion of the pediatric population from the EMA and the US FDA (83%, N = 109). In conclusion, when comparing mandatory pediatric requirements, more pediatric development plans were agreed upon in the EU than in the US, in line with the broader mandates of the EU Pediatric Regulation. However, authorities most often had similar regulatory requirements when an indication was subject to pediatric legislation in both regions.
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10
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Outcomes and endpoints in clinical trials supporting the marketing authorisation of treatments in paediatric acute lymphoblastic leukaemia. Drug Discov Today 2022; 27:2440-2466. [PMID: 35597514 DOI: 10.1016/j.drudis.2022.05.015] [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: 12/09/2021] [Revised: 04/04/2022] [Accepted: 05/16/2022] [Indexed: 11/23/2022]
Abstract
The improvement in acute lymphoblastic leukaemia (ALL) treatment has led research efforts to focus on the unmet medical needs of an increasingly smaller patient cohort with resistant leukaemia and to develop more-targeted agents. Survival and response rates remain the most-prevalent endpoints in paediatric ALL research, but other intermediate clinical endpoints and molecular biomarkers for efficacy and mid- and long-term safety endpoints are also being investigated. The success of current ALL treatment appears to be driving new paradigms to optimise clinical drug development, while at the same time, regulatory tools in place are supporting meaningful drug development in the area.
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ACCELERATE – Five years accelerating cancer drug development for children and adolescents. Eur J Cancer 2022; 166:145-164. [DOI: 10.1016/j.ejca.2022.01.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/06/2022] [Accepted: 01/17/2022] [Indexed: 02/06/2023]
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12
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Guidance for pediatric use in prescription information for novel medicinal products in the EU and the US. PLoS One 2022; 17:e0266353. [PMID: 35377911 PMCID: PMC8979467 DOI: 10.1371/journal.pone.0266353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/18/2022] [Indexed: 11/29/2022] Open
Abstract
Pediatric legislations in the European Union (EU) and the United States (US) have increased medicines approved for use in the pediatric population. Despite many similarities between these frameworks, the EU Paediatric Regulation more often provides regulators with a mandate to require pediatric drug development for novel medicinal products compared to US regulators. If used, this could give rise to differences in the guidance for pediatric use provided for clinicians in the two regions. However, the level of discordance in the guidance for pediatric use between the two regions is unknown. This cross-sectional study compares guidance for pediatric use in the EU Summary of Product Characteristics (SmPC) and the US Prescription Information (USPI) on the level of indications granted for novel medicinal products approved after the pediatric legislations came in to force in both regions. For all indications granted as of March 2020 for novel medicinal products approved in both regions between 2010 and 2018, we compared the guidance for pediatric use in the EU SmPC and the USPI. The guidance for pediatric use differed for 18% (61/348) of the listed indications covering 21% (45/217) of the products, but without the guidance being contradictory. Where guidance differed, an equal share was observed for indications with a higher level of information for pediatric use in one region over the other (49% (30/61) in the US; 51% (31/61) in the EU). The discrepancies in pediatric information could be explained by differences in regulations for 21% (13/61) of the indications. Only a few conditions and diseases (EU n = 4; US n = 1) were observed to cover potential pediatric use outside the approved adult indication. Although the EU Paediatric Regulation more often provides regulators a mandate for requiring pediatric drug development as compared to the US PREA, this was not reflected in the prescription information approved by the two regulatory authorities.
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13
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Vanheeswijck L, Verlooy J, Van de Vijver E, Bervoets A, Balliauw K, Schepens T, Norga K, van Heerden J. The Challenges of Crizotinib Treatment in a Child With Anaplastic Large Cell Lymphoma. J Pediatr Pharmacol Ther 2021; 26:647-654. [PMID: 34421417 PMCID: PMC8372857 DOI: 10.5863/1551-6776-26.6.647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/19/2020] [Indexed: 11/11/2022]
Abstract
Survival in cases involving childhood malignancy is reaching nearly 80% in high-income countries, yet cancer remains one of the leading disease-related causes of death in children. In adult oncology the role of targeted therapies is established, but information regarding the use of these therapies in children is limited, largely because targeted therapies were developed in the context of adult pathologies. The few pediatric reports regarding crizotinib, an anaplastic lymphoma kinase (ALK) inhibitor, seem promising. This case of an 8-year-old male with an ALK-positive anaplastic large cell lymphoma highlights the challenges of treating children with crizotinib. Our experience with crizotinib was more challenging than described in the limited pediatric reports. Not only was the tumor response poorer than described in the reports, but a substantial amount of side-effects and practical difficulties, such as the method of administration and dosing, made management challenging. Many challenges for the use of targeted therapy in pediatric care currently persist. The limited research in pediatric populations leaves uncertainty regarding efficacy and short- and long-term side effects as well as practical difficulties. Despite a clear underlying biological rationale for certain targeted therapies, their contribution toward improving the outcome of childhood cancer remains largely unclear.
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14
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Barry E, Walsh JA, Weinrich SL, Beaupre D, Blasi E, Arenson DR, Jacobs IA. Navigating the Regulatory Landscape to Develop Pediatric Oncology Drugs: Expert Opinion Recommendations. Paediatr Drugs 2021; 23:381-394. [PMID: 34173206 PMCID: PMC8275539 DOI: 10.1007/s40272-021-00455-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/30/2022]
Abstract
Regulatory changes have been enacted in the United States (US) and European Union (EU) to encourage the development of new treatments for pediatric cancer. Here, we review some of the factors that have hampered the development of pediatric cancer treatments and provide a comparison of the US and EU regulations implemented to address this clinical need. We then provide some recommendations for each stage of the oncology drug development pathway to help researchers maximize their chance of successful drug development while complying with regulations. A key recommendation is the engagement of key stakeholders such as regulatory authorities, pediatric oncologists, academic researchers, patient advocacy groups, and a Pediatric Expert Group early in the drug development process. During drug target selection, sponsors are encouraged to consult the Food and Drug Administration (FDA), European Medicines Agency (EMA), and the FDA target list, in addition to relevant US and European consortia that have been established to characterize and prioritize oncology drug targets. Sponsors also need to carefully consider the resourcing requirements for preclinical testing, which include ensuring appropriate access to the most relevant databases, clinical samples, and preclinical models (cell lines and animal models). During clinical development, sponsors can account for the pharmacodynamic (PD)/pharmacokinetic (PK) considerations specific to a pediatric population by developing pediatric formulations, selecting suitable PD endpoints, and employing sparse PK sampling or modeling/simulation of drug exposures where appropriate. Additional clinical considerations include the specific design of the clinical trial, the potential inclusion of children in adult trials, and the value of cooperative group trials.
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15
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Vassal G, Houghton PJ, Pfister SM, Smith MA, Caron HN, Li XN, Shields DJ, Witt O, Molenaar JJ, Colombetti S, Schüler J, Stancato LF. International Consensus on Minimum Preclinical Testing Requirements for the Development of Innovative Therapies For Children and Adolescents with Cancer. Mol Cancer Ther 2021; 20:1462-1468. [PMID: 34108262 DOI: 10.1158/1535-7163.mct-20-0394] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 11/11/2020] [Accepted: 06/04/2021] [Indexed: 11/16/2022]
Abstract
Cancer remains the leading cause of disease-related death in children. For the many children who experience relapses of their malignant solid tumors, usually after very intensive first-line therapy, curative treatment options are scarce. Preclinical drug testing to identify promising treatment elements that match the molecular make-up of the tumor is hampered by the fact that (i) molecular genetic data on pediatric solid tumors from relapsed patients and thus our understanding of tumor evolution and therapy resistance are very limited to date and (ii) for many of the high-risk entities, no appropriate and molecularly well-characterized patient-derived models and/or genetic mouse models are currently available. However, recent regulatory changes enacted by the European Medicines Agency (class waiver changes) and the maturation of the RACE for Children act with the FDA, will require a significant increase in preclinical pediatric cancer research and clinical development must occur. We detail the outcome of a pediatric cancer international multistakeholder meeting whose output aims at defining an international consensus on minimum preclinical testing requirements for the development of innovative therapies for children and adolescents with cancer. Recommendations based on the experience of the NCI funded PPTP/C (www.ncipptc.org) and the EU funded ITCC-P4 public private partnership (www.itccp4.eu) are provided for the use of cell-based and mouse models for pediatric solid malignancies, as well as guidance on the scope and content of preclinical proof-of-concept data packages to inform clinical development dependent on clinical urgency. These recommendations can serve as a minimal guidance necessary to jumpstart preclinical pediatric research globally.
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Affiliation(s)
- Gilles Vassal
- Institute Gustave Roussy, Université Paris Saclay, Villejuif, France.
| | - Peter J Houghton
- Greehey Children's Cancer Research Institute, UT Health, San Antonio, Texas
| | - Stefan M Pfister
- Hopp Children's Cancer Center Heidelberg (KiTZ), German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK) and University Hospital, Heidelberg, Germany
| | - Malcolm A Smith
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland
| | | | - Xiao-Nan Li
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - David J Shields
- Pfizer Centers for Therapeutic Innovation, Pfizer Inc., New York, New York
| | - Olaf Witt
- Hopp Children's Cancer Center Heidelberg (KiTZ), German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK) and University Hospital, Heidelberg, Germany
| | - Jan J Molenaar
- Princess Máxima Centrum for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Julia Schüler
- Charles River Discovery Research Services Germany, Freiburg, Germany
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16
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Thioridazine requires calcium influx to induce MLL-AF6-rearranged AML cell death. Blood Adv 2021; 4:4417-4429. [PMID: 32931582 DOI: 10.1182/bloodadvances.2020002001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/12/2020] [Indexed: 01/25/2023] Open
Abstract
In pediatric acute myeloid leukemia (AML), intensive chemotherapy and allogeneic hematopoietic stem cell transplantation are the cornerstones of treatment in high-risk cases, with severe late effects and a still high risk of disease recurrence as the main drawbacks. The identification of targeted, more effective, safer drugs is thus desirable. We performed a high-throughput drug-screening assay of 1280 compounds and identified thioridazine (TDZ), a drug that was highly selective for the t(6;11)(q27;q23) MLL-AF6 (6;11)AML rearrangement, which mediates a dramatically poor (below 20%) survival rate. TDZ induced cell death and irreversible progress toward the loss of leukemia cell clonogenic capacity in vitro. Thus, we explored its mechanism of action and found a profound cytoskeletal remodeling of blast cells that led to Ca2+ influx, triggering apoptosis through mitochondrial depolarization, confirming that this latter phenomenon occurs selectively in t(6;11)AML, for which AF6 does not work as a cytoskeletal regulator, because it is sequestered into the nucleus by the fusion gene. We confirmed TDZ-mediated t(6;11)AML toxicity in vivo and enhanced the drug's safety by developing novel TDZ analogues that exerted the same effect on leukemia reduction, but with lowered neuroleptic effects in vivo. Overall, these results refine the MLL-AF6 AML leukemogenic mechanism and suggest that the benefits of targeting it be corroborated in further clinical trials.
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Pearson AD, DuBois SG, Buenger V, Kieran M, Stegmaier K, Bandopadhayay P, Bennett K, Bourdeaut F, Brown PA, Chesler L, Clymer J, Fox E, French CA, Germovsek E, Giles FJ, Bender JG, Hattersley MM, Ludwinski D, Luptakova K, Maris J, McDonough J, Nikolova Z, Smith M, Tsiatis AC, Vibhakar R, Weiner S, Yi JS, Zheng F, Vassal G. Bromodomain and extra-terminal inhibitors-A consensus prioritisation after the Paediatric Strategy Forum for medicinal product development of epigenetic modifiers in children-ACCELERATE. Eur J Cancer 2021; 146:115-124. [PMID: 33601323 DOI: 10.1016/j.ejca.2021.01.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/05/2021] [Indexed: 01/28/2023]
Abstract
Based on biology and pre-clinical data, bromodomain and extra-terminal (BET) inhibitors have at least three potential roles in paediatric malignancies: NUT (nuclear protein in testis) carcinomas, MYC/MYCN-driven cancers and fusion-driven malignancies. However, there are now at least 10 BET inhibitors in development, with a limited relevant paediatric population in which to evaluate these medicinal products. Therefore, a meeting was convened with the specific aim to develop a consensus among relevant biopharmaceutical companies, academic researchers, as well as patient and family advocates, about the development of BET inhibitors, including prioritisation and their specific roles in children. Although BET inhibitors have been in clinical trials in adults since 2012, the first-in-child study (BMS-986158) only opened in 2019. In the future, when there is strong mechanistic rationale or pre-clinical activity of a class of medicinal product in paediatrics, early clinical evaluation with embedded correlative studies of a member of the class should be prioritised and rapidly executed in paediatric populations. There is a strong mechanistic and biological rationale to evaluate BET inhibitors in paediatrics, underpinned by substantial, but not universal, pre-clinical data. However, most pan-BET inhibitors have been challenging to administer in adults, since monotherapy results in only modest anti-tumour activity and provides a narrow therapeutic index due to thrombocytopenia. It was concluded that it is neither scientifically justified nor feasible to undertake simultaneously early clinical trials in paediatrics of all pan-BET inhibitors. However, there is a clinical need for global access to BET inhibitors for patients with NUT carcinoma, a very rare malignancy driven by bromodomain fusions, with proof of concept of clinical benefit in a subset of patients treated with BET inhibitors. Development and regulatory pathway in this indication should include children and adolescents as well as adults. Beyond NUT carcinoma, it was proposed that further clinical development of other pan-BET inhibitors in children should await the results of the first paediatric clinical trial of BMS-986158, unless there is compelling rationale based on the specific agent of interest. BDII-selective inhibitors, central nervous system-penetrant BET inhibitors (e.g. CC-90010), and those dual-targeting BET/p300 bromodomain are of particular interest and warrant further pre-clinical investigation. This meeting emphasised the value of a coordinated and integrated strategy to drug development in paediatric oncology. A multi-stakeholder approach with multiple companies developing a consensus with academic investigators early in the development of a class of compounds, and then engaging regulatory agencies would improve efficiency, productivity, conserve resources and maximise potential benefit for children with cancer.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Jessica Clymer
- Dana-Farber Cancer Institute/Harvard Medical School, USA
| | | | | | | | | | | | | | | | | | - John Maris
- Children's Hospital of Philadelphia, USA
| | | | - Zariana Nikolova
- Celgene International, a Bristol Myers Squibb Company, Switzerland
| | | | | | - Rajeev Vibhakar
- University of Colorado and Children's Hospital Colorado, USA
| | | | - Joanna S Yi
- Texas Children's Hospital/Baylor College of Medicine, USA
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18
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Laetsch TW, DuBois SG, Bender JG, Macy ME, Moreno L. Opportunities and Challenges in Drug Development for Pediatric Cancers. Cancer Discov 2021; 11:545-559. [PMID: 33277309 PMCID: PMC7933059 DOI: 10.1158/2159-8290.cd-20-0779] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/08/2020] [Accepted: 09/08/2020] [Indexed: 11/16/2022]
Abstract
The use of targeted small-molecule therapeutics and immunotherapeutics has been limited to date in pediatric oncology. Recently, the number of pediatric approvals has risen, and regulatory initiatives in the United States and Europe have aimed to increase the study of novel anticancer therapies in children. Challenges of drug development in children include the rarity of individual cancer diagnoses and the high prevalence of difficult-to-drug targets, including transcription factors and epigenetic regulators. Ongoing pediatric adaptation of biomarker-driven trial designs and further exploration of agents targeting non-kinase drivers constitute high-priority objectives for future pediatric oncology drug development. SIGNIFICANCE: Increasing attention to drug development for children with cancer by regulators and pharmaceutical companies holds the promise of accelerating the availability of new therapies for children with cancer, potentially improving survival and decreasing the acute and chronic toxicities of therapy. However, unique approaches are necessary to study novel therapies in children that take into account low patient numbers, the pediatric cancer genomic landscape and tumor microenvironment, and the need for pediatric formulations. It is also critical to evaluate the potential for unique toxicities in growing hosts without affecting the pace of discovery for children with these life-threatening diseases.
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Affiliation(s)
- Theodore W Laetsch
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, and Abramson Cancer Center and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts
| | | | - Margaret E Macy
- Children's Hospital Colorado and University of Colorado, Denver, Colorado
| | - Lucas Moreno
- Division of Pediatric Hematology and Oncology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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19
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Felix A, Berlanga P, Toulmonde M, Landman‐Parker J, Dumont S, Vassal G, Le Deley M, Gaspar N. Systematic review of phase-I/II trials enrolling refractory and recurrent Ewing sarcoma: Actual knowledge and future directions to optimize the research. Cancer Med 2021; 10:1589-1604. [PMID: 33452711 PMCID: PMC7940237 DOI: 10.1002/cam4.3712] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Optimal Phase-II design to evaluate new therapies in refractory/relapsed Ewing sarcomas (ES) remains imperfectly defined. OBJECTIVES Recurrent/refractory ES phase-I/II trials analysis to improve trials design. METHODS Comprehensive review of therapeutic trials registered on five databases (who.int/trialsearch, clinicaltrials.gov, clinicaltrialsregister.eu, e-cancer.fr, and umin.ac.jp) and/or published in PubMed/ASCO/ESMO websites, between 2005 and 2018, using the criterion: (Ewing sarcoma OR bone sarcoma OR sarcoma) AND (Phase-I or Phase-II). RESULTS The 146 trials identified (77 phase-I/II, 67 phase-II, and 2 phase-II/III) tested targeted (34%), chemo- (23%), immune therapies (19%), or combined therapies (24%). Twenty-three trials were ES specific and 48 had a specific ES stratum. Usually multicentric (88%), few trials were international (30%). Inclusion criteria cover the recurrent ES age range for only 12% of trials and allowed only accrual of measurable diseases (RECIST criteria). Single-arm design was the most frequent (88%) testing mainly single drugs (61%), only 5% were randomized. Primary efficacy outcome was response rate (RR=CR+PR; Complete+Partial response) (n = 116/146; 79%), rarely progression-free or overall survival (16% PFS and 3% OS). H0 and H1 hypotheses were variable (3%-25% and 20%-50%, respectively). The 62 published trials enrolled 827 ES patients. RR was poor (10%; 15 CR=1.7%, 68 PR=8.3%). Stable disease was the best response for 186 patients (25%). Median PFS/OS was of 1.9 (range 1.3-14.7) and 7.6 months (5-30), respectively. Eleven (18%) published trials were considered positive, with median RR/PFS/OS of 15% (7%-30%), 4.5 (1.3-10), and 16.6 months (6.9-30), respectively. CONCLUSION This review supports the need to develop the international randomized phase-II trials across all age ranges with PFS as primary endpoint.
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Affiliation(s)
- Arthur Felix
- Department of Oncology for Child and AdolescentGustave Roussy Cancer CampusVillejuif cedexFrance
| | - Pablo Berlanga
- Department of Oncology for Child and AdolescentGustave Roussy Cancer CampusVillejuif cedexFrance
| | - Maud Toulmonde
- Medical Oncology DepartmentInstitut BergoniéBordeauxFrance
| | | | - Sarah Dumont
- Department of Medical OncologyGustave Roussy Cancer CampusVillejuifFrance
| | - Gilles Vassal
- Department of Oncology for Child and AdolescentGustave Roussy Cancer CampusVillejuif cedexFrance
| | - Marie‐Cécile Le Deley
- Direction de la Recherche Clinique et de l'InnovationCentre Oscar LambretLilleFrance
| | - Nathalie Gaspar
- Department of Oncology for Child and AdolescentGustave Roussy Cancer CampusVillejuif cedexFrance
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20
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Gap between pediatric and adult approvals of molecular targeted drugs. Sci Rep 2020; 10:17145. [PMID: 33051474 PMCID: PMC7555892 DOI: 10.1038/s41598-020-73028-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/04/2020] [Indexed: 12/24/2022] Open
Abstract
To clarify the approval status of molecular targeted antineoplastic drugs in the United States (U.S.), the European Union (E.U.), and Japan (JP), we checked the status of pediatric indications according to the package insert of each drug. A total of 103 drugs were approved for adult patients in at least one of the three regions whereas only 19 drugs were approved for pediatric patients. Sixty-six of 103 drugs (64.1%) had adult indications in the U.S., the E.U., and JP, whereas only three drugs had pediatric indications in all three regions. Abnormalities in six genes (NRAS, ABL1, JAK2, KIT, ALK and BRAF) were common in childhood cancers as well as adult cancers, for which at least one approved drug could be a potentially actionable drug. Although there were 16 candidate drugs that had adult indications for these abnormalities, only three drugs (18.8%) had pediatric indications. We confirmed that there were few molecular targeted antineoplastic drugs with pediatric indications in the U.S., the E.U., and JP compared with the number of approved drugs for adults. Drugs targeting genomic abnormalities which were common in both adult and pediatric cancers were considered to be good candidates for expansion of their indication for pediatric patients.
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21
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Pearson ADJ, Karres D, Reaman G, DuBois SG, Knox L, Scobie N, Vassal G. The RACE to accelerate drug development for children with cancer. THE LANCET. CHILD & ADOLESCENT HEALTH 2020; 4:714-716. [PMID: 32822672 DOI: 10.1016/s2352-4642(20)30247-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 06/11/2023]
Affiliation(s)
| | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency, Amsterdam, Netherlands
| | | | - Steven G DuBois
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Nicole Scobie
- Zoé4life, Sullens, Switzerland; Childhood Cancer International, Europe
| | - Gilles Vassal
- ACCELERATE, Europe; Gustave Roussy Cancer Centre, Villejuif, France
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22
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Hwang TJ, Orenstein L, DuBois SG, Janeway KA, Bourgeois FT. Pediatric Trials for Cancer Therapies With Targets Potentially Relevant to Pediatric Cancers. J Natl Cancer Inst 2020; 112:224-228. [PMID: 31665394 DOI: 10.1093/jnci/djz207] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 09/30/2019] [Accepted: 10/16/2019] [Indexed: 01/23/2023] Open
Abstract
The Research to Accelerate Cures and Equity (RACE) for Children Act was enacted in 2017 to authorize the US Food and Drug Administration (FDA) to require pediatric studies for new cancer drugs that have a molecular target relevant to the growth or progression of a pediatric cancer. To assess the possible scope of this new policy, we examined all 78 adult cancer drugs approved by the FDA from 2007 to 2017. Only 17 (21.8%) drugs received any pediatric labeling information. Based on the FDA's Pediatric Molecular Target List, we found that the RACE Act could have increased the proportion of cancer drugs potentially subject to pediatric study requirements from 0% to 78.2%. However, the actual effect of the legislation will depend on how often regulators require pediatric trials and on timely completion of such trials.
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Affiliation(s)
- Thomas J Hwang
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Liat Orenstein
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Katherine A Janeway
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Florence T Bourgeois
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
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Reaman G, Karres D, Ligas F, Lesa G, Casey D, Ehrlich L, Norga K, Pazdur R. Accelerating the Global Development of Pediatric Cancer Drugs: A Call to Coordinate the Submissions of Pediatric Investigation Plans and Pediatric Study Plans to the European Medicines Agency and US Food and Drug Administration. J Clin Oncol 2020; 38:4227-4230. [PMID: 32946356 DOI: 10.1200/jco.20.02152] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- Gregory Reaman
- Oncology Center of Excellence, Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD.,Office of Oncologic Diseases, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency, Amsterdam, the Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency, Amsterdam, the Netherlands
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency, Amsterdam, the Netherlands
| | - Denise Casey
- Office of Oncologic Diseases, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Lori Ehrlich
- Office of Oncologic Diseases, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Koen Norga
- Federal Agency for Medicines and Health Products and Paediatric Oncology, Antwerp University Hospital, Edegem, Belgium.,European Medicines Agency's Paediatric Committee, European Medicines Agency, Amsterdam, the Netherlands
| | - Richard Pazdur
- Oncology Center of Excellence, Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD.,Office of Oncologic Diseases, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
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24
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Sharpe E, Hoey R, Yap C, Workman P. From patent to patient: analysing access to innovative cancer drugs. Drug Discov Today 2020; 25:1561-1568. [PMID: 32006467 DOI: 10.1016/j.drudis.2020.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/08/2020] [Accepted: 01/15/2020] [Indexed: 12/29/2022]
Abstract
Analysis of cancer drugs licensed through the European Medicines Agency (EMA) in 2000-2016 shows that the number of authorisations increased over that timeframe. The median number of licensed drugs each year rose from six for 2000-2008 to 13.5 for 2009-2016. Over 2000-2016, there were 64 drug authorisations for haematological, 15 for breast, and 12 for skin cancer, but none for oesophageal, brain, bladder, or uterine cancer. Only 6% of authorisations included a paediatric indication. The average time for a drug to progress from patent priority date to availability on the National Health Service (NHS) increased from 12.8 years for drugs first licensed in 2000-2008 to 14.0 years for those licensed in 2009-2016. There was evidence that the most innovative drugs were not being prioritised for EMA licensing and NICE approval.
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Affiliation(s)
- Eva Sharpe
- The Institute of Cancer Research, Old Brompton Road, London, SW7 3RP, UK
| | - Richard Hoey
- The Institute of Cancer Research, Old Brompton Road, London, SW7 3RP, UK
| | - Christina Yap
- The Institute of Cancer Research, Old Brompton Road, London, SW7 3RP, UK
| | - Paul Workman
- The Institute of Cancer Research, Old Brompton Road, London, SW7 3RP, UK.
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25
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Pearson H, Marshall LV, Carceller F. Sorafenib in pediatric hepatocellular carcinoma from a clinician perspective. Pediatr Hematol Oncol 2020; 37:412-423. [PMID: 32183592 DOI: 10.1080/08880018.2020.1740844] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Hepatocellular Carcinoma (HCC) is a rare tumor in children and normally carries poor outcomes. The most frequently employed chemotherapy regimen includes cisplatin and doxorubicin (PLADO), but this combination offers limited efficacy. Sorafenib is a multi-tyrosine kinase inhibitor which, following positive studies in adults with HCC, has begun to be introduced in conjunction with PLADO in pediatric oncology with some encouraging results. Based on these findings, the use of sorafenib is become more common in children with unresectable and/or metastatic HCC. The care of patients receiving sorafenib requires appropriate expertise and standardized pediatric guidelines are lacking. An increasing number of children with HCC are expected to receive sorafenib in the years to come. Pediatric oncology clinicians have a key role in identifying side effects early and clinicians caring for children receiving sorafenib need to be familiar with these. This review article provides suitable and practical information on sorafenib for educational development to optimize clinical care and facilitate enhanced patient/parent education. The article addresses specific areas including mechanisms of action, pre-clinical and clinical evidence, dosing and drug administration and toxicities of sorafenib. Clinical research and recommendations for managing sorafenib-related side effects are discussed. Underpinned by research, this article provides pediatric oncology clinicians with the knowledge required to deliver optimal care to children receiving sorafenib.
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Affiliation(s)
- Helen Pearson
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey, United Kingdom
| | - Lynley V Marshall
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey, United Kingdom.,The Institute of Cancer Research, Division of Clinical Studies and Cancer Therapeutics, Sutton, Surrey, United Kingdom
| | - Fernando Carceller
- The Royal Marsden NHS Foundation Trust, Sutton, Surrey, United Kingdom.,The Institute of Cancer Research, Division of Clinical Studies and Cancer Therapeutics, Sutton, Surrey, United Kingdom
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26
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Crestan D, Trojniak MP, Francescon S, Fornasier G, Baldo P. Pharmacovigilance of anti-cancer medicines: opportunities and challenges. Expert Opin Drug Saf 2020; 19:849-860. [PMID: 32552095 DOI: 10.1080/14740338.2020.1772751] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The foundations of pharmacovigilance are the monitoring of drug safety in real-world medicine, and identification of new adverse effects, unknown at the time of market approval. Cancer patients are prone to adverse drug reactions due to the complexity of the neoplastic disease and its treatment. Pharmacovigilance of anti-cancer medicines is further complicated because patients have comorbidities, as for elderly patients. It is even more challenging when complete safety and risk data for a drug are lacking, as may occur for new molecules or when it comes to drugs for children. AREAS COVERED This article introduces the field of pharmacovigilance of anti-cancer drugs, describing the various layers of complexity that make the recognition of adverse drug events in oncology particularly problematic, including the type of medicines, the phenomenon of underreporting and polypharmacy. Finally, it reviews new digital tools to help pharmacovigilance activities in oncology. EXPERT OPINION The authors outline some crucial challenges and opportunities that can be useful for pharmacovigilance to keep up with the times and follow the current technological and scientific progress. In addition to the evaluations made by researchers, it will, of course, be necessary to have an equality important concrete response from the institutions and regulatory bodies.
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Affiliation(s)
- Diana Crestan
- Pharmacy Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS , Aviano, Italy
| | - Marta Paulina Trojniak
- Hospital Pharmacy Unit, Institute for Maternal and Child Health "IRCCS Burlo Garofolo" , Trieste, Italy
| | - Sara Francescon
- Pharmacy Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS , Aviano, Italy.,Department of Hospital Pharmacy, Azienda Sanitaria Universitaria Friuli Centrale, ASUFC , Udine, Italy
| | - Giulia Fornasier
- Hospital Pharmacy Unit, Institute for Maternal and Child Health "IRCCS Burlo Garofolo" , Trieste, Italy
| | - Paolo Baldo
- Pharmacy Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS , Aviano, Italy
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27
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Moreno L, DuBois SG, Marshall LV, Fox E, Carceller F, Pearson AD. How to address challenges and opportunities in pediatric cancer drug development? Expert Opin Drug Discov 2020; 15:869-872. [PMID: 32421361 DOI: 10.1080/17460441.2020.1767064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Lucas Moreno
- Division of Pediatric Hematology and Oncology. Hospital Universitari Vall d'Hebron , Barcelona, Spain
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School , Boston, MA, USA
| | - Lynley V Marshall
- Pediatric and Adolescent Oncology Drug Development, Children & Young People's Unit, The Royal Marsden NHS Foundation Trust , London, UK.,Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research , London, UK
| | - Elizabeth Fox
- Department of Oncology, St. Jude Children's Research Hospital , Memphis, TN, USA
| | - Fernando Carceller
- Pediatric and Adolescent Oncology Drug Development, Children & Young People's Unit, The Royal Marsden NHS Foundation Trust , London, UK.,Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research , London, UK
| | - Andrew Dj Pearson
- Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research , London, UK
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28
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Tumour-agnostic drugs in paediatric cancers. Br J Cancer 2020; 122:1425-1427. [PMID: 32161367 PMCID: PMC7217925 DOI: 10.1038/s41416-020-0770-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/03/2020] [Accepted: 02/13/2020] [Indexed: 02/06/2023] Open
Abstract
The recognition that new cancer drugs can be truly tumour-agnostic based on mechanism-of-action is important for paediatric cancers, where access to novel targeted therapies developed for adult indications has sometimes been problematic. The recently approved drug larotrectinib is an excellent case study of the development of a tumour-agnostic drug relevant to children.
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29
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Janssen JM, Dorlo TPC, Steeghs N, Beijnen JH, Hanff LM, van Eijkelenburg NKA, van der Lugt J, Zwaan CM, Huitema ADR. Pharmacokinetic Targets for Therapeutic Drug Monitoring of Small Molecule Kinase Inhibitors in Pediatric Oncology. Clin Pharmacol Ther 2020; 108:494-505. [PMID: 32022898 DOI: 10.1002/cpt.1808] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/14/2020] [Indexed: 12/11/2022]
Abstract
In recent years new targeted small molecule kinase inhibitors have become available for pediatric patients with cancer. Relationships between drug exposure and treatment response have been established for several of these drugs in adults. Following these exposure-response relationships, pharmacokinetic (PK) target minimum plasma rug concentration at the end of a dosing interval (Cmin ) values to guide therapeutic drug monitoring (TDM) in adults have been proposed. Despite the fact that variability in PK may be even larger in pediatric patients, TDM is only sparsely applied in pediatric oncology. Based on knowledge of the PK, mechanism of action, molecular driver, and pathophysiology of the disease, we bridge available data on the exposure-efficacy relationship from adults to children and propose target Cmin values to guide TDM for the pediatric population. Dose adjustments in individual pediatric patients can be based on these targets. Nevertheless, further research should be performed to validate these targets.
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Affiliation(s)
- Julie M Janssen
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas P C Dorlo
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Neeltje Steeghs
- Department of Clinical Pharmacology, Division of Medical Oncology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, Amsterdam, The Netherlands.,Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Lidwien M Hanff
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | | | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Department of Pediatric Hematology and Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Abstract
PURPOSE OF REVIEW We provide an overview of the current landscape of drug development relevant to childhood cancers. We present recent and ongoing efforts to identify therapeutic targets in pediatric cancers. We describe efforts to improve the approach to clinical trials and highlight the role regulatory changes and multistakeholder platforms play in advancing pediatric cancer drug development. RECENT FINDINGS Expanding knowledge of the genetic landscape of pediatric malignancies through clinical genomics studies has yielded an increasing number of potential targets for intervention. In parallel, new therapies for children with cancer have shifted from cytotoxic agents to targeted therapy, with examples of striking activity in patients with tumors driven by oncogenic kinase fusions. Innovative trial designs and recent governmental policies provide opportunities for accelerating development of targeted therapies in pediatric oncology. SUMMARY Novel treatment strategies in pediatric oncology increasingly utilize molecularly targeted agents either as monotherapy or in combination with conventional cytotoxic agents. The interplay between new target identification, efforts to improve clinical trial design and new government regulations relevant to pediatric cancer drug development has the potential to advance novel agents into frontline care of children with cancer.
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31
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Jones DTW, Banito A, Grünewald TGP, Haber M, Jäger N, Kool M, Milde T, Molenaar JJ, Nabbi A, Pugh TJ, Schleiermacher G, Smith MA, Westermann F, Pfister SM. Molecular characteristics and therapeutic vulnerabilities across paediatric solid tumours. Nat Rev Cancer 2019; 19:420-438. [PMID: 31300807 DOI: 10.1038/s41568-019-0169-x] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2019] [Indexed: 02/06/2023]
Abstract
The spectrum of tumours arising in childhood is fundamentally different from that seen in adults, and they are known to be divergent from adult malignancies in terms of cellular origins, epidemiology, genetic complexity, driver mutations and underlying mutational processes. Despite the immense knowledge generated through sequencing efforts and functional characterization of identified (epi-)genetic alterations over the past decade, the clinical implications of this knowledge have so far been limited. Novel preclinical platforms such as the European Innovative Therapies for Children with Cancer-Paediatric Preclinical Proof-of-Concept Platform and the US-based Pediatric Preclinical Testing Consortium are being developed to try to change this by aiming to recapitulate the extensive heterogeneity of paediatric tumours and thereby, hopefully, improve the ability to predict clinical benefit. Numerous studies have also been established worldwide to provide patients with access to real-time molecular profiling and the possibility of more precise mechanism-of-action-based treatments. In addition to tumour-intrinsic findings and mechanisms, ongoing studies are investigating features such as the immune microenvironment of paediatric tumours in comparison with adult cancers - currently of very timely clinical relevance. However, there is an ongoing need for rigorous preclinical biomarker and target validation to feed into the next generation of molecularly stratified clinical trials. This Review aims to provide a comprehensive state-of-the-art overview of the molecular landscape of paediatric solid tumours, including their underlying genomic alterations and interactions with the microenvironment, complemented with our current understanding of potential therapeutic vulnerabilities and how these can be preclinically tested using more accurate predictive methods. Finally, we provide an outlook on the challenges and opportunities associated with translating this overwhelming scientific progress into real clinical benefit.
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Affiliation(s)
- David T W Jones
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Pediatric Glioma Research Group, German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ana Banito
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Pediatric Soft Tissue Sarcoma Research Group, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Thomas G P Grünewald
- Max-Eder Research Group for Pediatric Sarcoma Biology, Institute of Pathology, Faculty of Medicine, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Michelle Haber
- Children's Cancer Institute, Lowy Cancer Research Centre, UNSW Australia, Randwick, NSW, Australia
- School of Women's & Children's Health, UNSW Australia, Randwick, NSW, Australia
| | - Natalie Jäger
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Marcel Kool
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Neurooncology, German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Till Milde
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
- KiTZ Clinical Trial Unit (ZIPO), Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan J Molenaar
- Princess Maxima Center for Pediatric Cancer, Utrecht, The Netherlands
| | - Arash Nabbi
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Trevor J Pugh
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Gudrun Schleiermacher
- SIREDO Oncology Center (Care, Innovation and Research for Children and AYA with Cancer), Institut Curie, Paris, France
- INSERM U830, Laboratoire de Génétique et Biologie des Cancers, Research Center, Institut Curie, Paris, France
| | - Malcolm A Smith
- Cancer Therapy Evaluation Program, National Cancer Institute, Rockville, MD, USA
| | - Frank Westermann
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Neuroblastoma Genomics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan M Pfister
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany.
- Division of Pediatric Neurooncology, German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany.
- KiTZ Clinical Trial Unit (ZIPO), Department of Pediatric Hematology and Oncology, Heidelberg University Hospital, Heidelberg, Germany.
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Rose K, Neubauer D, Grant-Kels JM. Rational Use of Medicine in Children-The Conflict of Interests Story. A Review. Rambam Maimonides Med J 2019; 10:RMMJ.10371. [PMID: 31335307 PMCID: PMC6649781 DOI: 10.5041/rmmj.10371] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND United States (US) and European Union (EU) legislation attempts to counterbalance the presumed discrimination in pediatric drug treatment and development. METHODS We analyzed the history of drug development, US/EU pediatric laws, and pediatric studies required by US/EU regulatory authorities and reviewed relevant literature. RESULTS The US and EU definitions of a child are defined administratively (rather than physiologically) as being aged <17 years and <18 years, respectively. However, children mature physiologically well before their seventeenth or eighteenth birthdays. The semantic blur for these differing definitions may indicate certain conflicts of interest. CONCLUSIONS Pediatric healthcare today is better than ever. Regulatory-related requirements for "pediatric" studies focus on labeling. Most of these studies lack medical usefulness and may even harm "pediatric" patients through administration of placebo and/or substandard treatment, despite the resultant publications, networking, patent extensions, and strengthened regulatory standing. Clinicians, parents, and ethics committees should be aware of these issues. New rules are needed to determine new pharmaceutical dose estimates in prepubescent patients, and when/how to clinically confirm them. Internet-based structures to divulge this information should be established between drug developers, clinicians, and regulatory authorities. A prerequisite for the rational use of pharmaceuticals in children would be to correct the flawed concept that children are discriminated against in drug treatment and development, and to abandon separate "pediatric" drug approval processes.
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Affiliation(s)
- Klaus Rose
- klausrose Consulting, Pediatric Drug Development & More, Riehen, Switzerland
| | - David Neubauer
- Department of Child, Adolescent and Developmental Neurology, University Children’s Hospital, Ljubljana, Slovenia
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33
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Rose K, Grant-Kels JM. Pediatric melanoma-The whole (conflicts of interest) story. Int J Womens Dermatol 2019; 5:110-115. [PMID: 30997384 PMCID: PMC6451736 DOI: 10.1016/j.ijwd.2018.10.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 09/25/2018] [Accepted: 10/09/2018] [Indexed: 01/13/2023] Open
Affiliation(s)
- Klaus Rose
- klausrose Consulting, Riehen, Switzerland
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34
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Neel DV, Shulman DS, DuBois SG. Timing of first-in-child trials of FDA-approved oncology drugs. Eur J Cancer 2019; 112:49-56. [PMID: 30928805 DOI: 10.1016/j.ejca.2019.02.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/17/2019] [Accepted: 02/17/2019] [Indexed: 12/21/2022]
Abstract
AIM The lag time between initial human studies of oncology agents and the first-in-child clinical trials of these agents has not been defined. METHODS We conducted a systematic analysis of time from first-in-human trials to first-in-child trials (age of eligibility <18 years) of agents first approved by the US Food and Drug Administration (FDA) for any oncology indication from 1997 to 2017. We used clinical trial registry data, published literature and oncology abstracts to identify relevant trials and start dates. RESULTS From 1997 to 2017, 126 drugs received initial FDA approval for an oncology indication. Of these, 117 were non-hormonal agents used in subsequent analyses. Fifteen of 117 drugs (12.8%) did not yet have a paediatric trial, and six of 117 drugs (5.1%) had an initial approval that included children. The median time between the first-in-human trial and first-in-child trial was 6.5 years (range 0-27.7 years). The median time from initial FDA approval to the first-in-child clinical trial was -0.66 years (range -43 to +19 years). These values were stable regardless of year of initial FDA approval, drug class and initial approved disease indication. CONCLUSION The median lag time from first-in-human to first-in-child trials of oncology agents that were ultimately approved by FDA was 6.5 years. These results provide a benchmark against which to evaluate recent initiatives designed to hasten drug development relevant to children with cancer.
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Affiliation(s)
| | - David S Shulman
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA.
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35
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DuBois SG, Corson LB, Stegmaier K, Janeway KA. Ushering in the next generation of precision trials for pediatric cancer. Science 2019; 363:1175-1181. [DOI: 10.1126/science.aaw4153] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cancer treatment decisions are increasingly based on the genomic profile of the patient’s tumor, a strategy called “precision oncology.” Over the past few years, a growing number of clinical trials and case reports have provided evidence that precision oncology is an effective approach for at least some children with cancer. Here, we review key factors influencing pediatric drug development in the era of precision oncology. We describe an emerging regulatory framework that is accelerating the pace of clinical trials in children as well as design challenges that are specific to trials that involve young cancer patients. Last, we discuss new drug development approaches for pediatric cancers whose growth relies on proteins that are difficult to target therapeutically, such as transcription factors.
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36
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Bassan R, Bourquin JP, DeAngelo DJ, Chiaretti S. New Approaches to the Management of Adult Acute Lymphoblastic Leukemia. J Clin Oncol 2018; 36:JCO2017773648. [PMID: 30240326 DOI: 10.1200/jco.2017.77.3648] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Traditional treatment regimens for adult acute lymphoblastic leukemia, including allogeneic hematopoietic cell transplantation, result in an overall survival of approximately 40%, a figure hardly comparable with the extraordinary 80% to 90% cure rate currently reported in children. When translated to the adult setting, modern pediatric-type regimens improve the survival to approximately 60% in young adults. The addition of tyrosine kinase inhibitors for patients with Philadelphia chromosome-positive disease and the measurement of minimal residual disease to guide risk stratification and postremission approaches has led to additional improvements in outcomes. Relapsed disease and treatment toxicity-sparing no patient but representing a major concern especially in the elderly-are the most critical current issues awaiting further therapeutic advancement. Recently, there has been considerable progress in understanding the disease biology, specifically the Philadelphia-like signature, as well as other high-risk subgroups. In addition, there are several new agents that will undoubtedly contribute to additional improvement in the current outcomes. The most promising agents are monoclonal antibodies, immunomodulators, and chimeric antigen receptor T cells, and, to a lesser extent, several new drugs targeting key molecular pathways involved in leukemic cell growth and proliferation. This review examines the evidence supporting the increasing role of the new therapeutic tools and treatment options in different disease subgroups, including frontline and relapsed or refractory disease. It is now possible to define the best individual approach on the basis of the emerging concepts of precision medicine.
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Affiliation(s)
- Renato Bassan
- Renato Bassan, Ospedale dell'Angelo, Mestre-Venezia; Sabina Chiaretti, "Sapienza" University, Rome, Italy; Jean-Pierre Bourquin, University Children's Hospital, Zurich, Switzerland; and Daniel J. DeAngelo, Dana-Farber Cancer Institute, Boston, MA
| | - Jean-Pierre Bourquin
- Renato Bassan, Ospedale dell'Angelo, Mestre-Venezia; Sabina Chiaretti, "Sapienza" University, Rome, Italy; Jean-Pierre Bourquin, University Children's Hospital, Zurich, Switzerland; and Daniel J. DeAngelo, Dana-Farber Cancer Institute, Boston, MA
| | - Daniel J DeAngelo
- Renato Bassan, Ospedale dell'Angelo, Mestre-Venezia; Sabina Chiaretti, "Sapienza" University, Rome, Italy; Jean-Pierre Bourquin, University Children's Hospital, Zurich, Switzerland; and Daniel J. DeAngelo, Dana-Farber Cancer Institute, Boston, MA
| | - Sabina Chiaretti
- Renato Bassan, Ospedale dell'Angelo, Mestre-Venezia; Sabina Chiaretti, "Sapienza" University, Rome, Italy; Jean-Pierre Bourquin, University Children's Hospital, Zurich, Switzerland; and Daniel J. DeAngelo, Dana-Farber Cancer Institute, Boston, MA
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37
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Fletcher JI, Ziegler DS, Trahair TN, Marshall GM, Haber M, Norris MD. Too many targets, not enough patients: rethinking neuroblastoma clinical trials. Nat Rev Cancer 2018; 18:389-400. [PMID: 29632319 DOI: 10.1038/s41568-018-0003-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Neuroblastoma is a rare solid tumour of infancy and early childhood with a disproportionate contribution to paediatric cancer mortality and morbidity. Combination chemotherapy, radiation therapy and immunotherapy remains the standard approach to treat high-risk disease, with few recurrent, actionable genetic aberrations identified at diagnosis. However, recent studies indicate that actionable aberrations are far more common in relapsed neuroblastoma, possibly as a result of clonal expansion. In addition, although the major validated disease driver, MYCN, is not currently directly targetable, multiple promising approaches to target MYCN indirectly are in development. We propose that clinical trial design needs to be rethought in order to meet the challenge of providing rigorous, evidence-based assessment of these new approaches within a fairly small patient population and that experimental therapies need to be assessed at diagnosis in very-high-risk patients rather than in relapsed and refractory patients.
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Affiliation(s)
- Jamie I Fletcher
- Children's Cancer Institute Australia, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW, Australia
- School of Women's and Children's Health, UNSW Sydney, Kensington, NSW, Australia
| | - David S Ziegler
- Children's Cancer Institute Australia, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW, Australia
- School of Women's and Children's Health, UNSW Sydney, Kensington, NSW, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Toby N Trahair
- Children's Cancer Institute Australia, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW, Australia
- School of Women's and Children's Health, UNSW Sydney, Kensington, NSW, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Glenn M Marshall
- Children's Cancer Institute Australia, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Michelle Haber
- Children's Cancer Institute Australia, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW, Australia
- School of Women's and Children's Health, UNSW Sydney, Kensington, NSW, Australia
| | - Murray D Norris
- Children's Cancer Institute Australia, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW, Australia.
- University of New South Wales Centre for Childhood Cancer Research, UNSW Sydney, Kensington, NSW, Australia.
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39
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Pearson AD, Heenen D, Kearns PR, Goeres A, Marshall LV, Blanc P, Vassal G. 10-year report on the European Paediatric Regulation and its impact on new drugs for children's cancers. Lancet Oncol 2018; 19:285-287. [PMID: 29508745 DOI: 10.1016/s1470-2045(18)30105-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 01/08/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Andrew Dj Pearson
- Paediatric and Adolescent Oncology Drug Development, The Royal Marsden NHS Foundation Trust, Sutton, SM2 5PT, UK; Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research, Sutton, UK; Innovative Therapy for Children with Cancer, Europe.
| | | | - Pamela R Kearns
- Innovative Therapy for Children with Cancer, Europe; Cancer Research UK Clinical Trials Unit Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK; SIOPE Brussels, Belgium
| | - Anne Goeres
- Unite 2 Cure, Europe; Fondatioun Kriibskrank Kanner, Strassen, Luxembourg
| | - Lynley V Marshall
- Paediatric and Adolescent Oncology Drug Development, The Royal Marsden NHS Foundation Trust, Sutton, SM2 5PT, UK; Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research, Sutton, UK
| | | | - Gilles Vassal
- Innovative Therapy for Children with Cancer, Europe; SIOPE Brussels, Belgium; Department of Clinical Research, Gustave Roussy, Paris-Saclay University, Villejuif, France
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40
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Patel SK, Leong R, Zhao H, Barone A, Casey D, Liu Q, Burckart GJ, Reaman G. Pediatric Development of Molecularly Targeted Oncology Drugs. Clin Pharmacol Ther 2017; 104:384-389. [DOI: 10.1002/cpt.942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Shivam Kamlesh Patel
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
- University of North Carolina at Chapel Hill; Chapel Hill North Carolina USA
| | - Ruby Leong
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Hong Zhao
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Amy Barone
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Denise Casey
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Qi Liu
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Gilbert J. Burckart
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Gregory Reaman
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
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Vassal G, Kearns P, Blanc P, Scobie N, Heenen D, Pearson A. Orphan Drug Regulation: A missed opportunity for children and adolescents with cancer. Eur J Cancer 2017; 84:149-158. [PMID: 28818704 DOI: 10.1016/j.ejca.2017.07.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 07/14/2017] [Accepted: 07/18/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Oncology represents a major sector in the field of orphan drug development in Europe. The objective was to evaluate whether children and adolescents with cancer benefited from the Orphan Drug Regulation. METHODS Data on orphan drug designations (ODDs) and registered orphan drugs from 8th August 2000 to 10th September 2016 were collected from the Community Register of medicinal products for human use. Assessment history, product information and existence of paediatric investigation plans were searched and retrieved from the European Medicine Agency website. RESULTS Over 16 years, 272 of 657 oncology ODDs (41%) concerned a malignant condition occurring both in adults and children. The five most common were acute myeloid leukaemia, high-grade glioma, acute lymphoblastic leukaemia, graft-versus-host disease and soft-tissue sarcomas. 74% of 31 marketing authorisations (MAs) for an indication both in adults and children (26 medicines) had no information for paediatric use in their Summary of Product Characteristics (SmPC) at the time of the first MA. Furthermore, 68% still have no paediatric information in their most recently updated SmPC, at a median of 7 years after. Only 15 ODDs (2%) pertained to a malignancy occurring specifically in children and only two drugs received an MA: Unituxin for high-risk neuroblastoma and Votubia for sub-ependymal giant-cell astrocytoma. CONCLUSION The Orphan Drug Regulation failed to promote the development of innovative therapies for malignancies occurring in children. Major delays and waivers occurred through the application of the Paediatric Medicines Regulation. The European regulatory environment needs to be improved to accelerate innovation for children and adolescents dying of cancer.
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Affiliation(s)
- Gilles Vassal
- Department of Clinical Research, Gustave Roussy, Paris-Sud University, Paris, France; Innovative Therapy for Children with Cancer, Villejuif, France.
| | - Pam Kearns
- Innovative Therapy for Children with Cancer, Villejuif, France; Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Patricia Blanc
- Imagine for Margo, 9 Avenue Eric Tabarly, 78112 Fourqueux, France
| | | | | | - Andy Pearson
- Innovative Therapy for Children with Cancer, Villejuif, France; Paediatric Drug Development, Children and Young People's Unit, The Royal Marsden NHS Foundation Trust, Sutton, SM2 5PT, UK; Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research, Sutton, SM2 5NG, UK
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