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Michaeli DT, Michaeli T, Albers S, Boch T, Michaeli JC. Special FDA designations for drug development: orphan, fast track, accelerated approval, priority review, and breakthrough therapy. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024; 25:979-997. [PMID: 37962724 PMCID: PMC11283430 DOI: 10.1007/s10198-023-01639-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/02/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Over the past decades, US Congress enabled the US Food and Drug Administration (FDA) to facilitate and expedite drug development for serious conditions filling unmet medical needs with five special designations and review pathways: orphan, fast track, accelerated approval, priority review, and breakthrough therapy. OBJECTIVES This study reviews the FDA's five special designations for drug development regarding their safety, efficacy/clinical benefit, clinical trials, innovation, economic incentives, development timelines, and price. METHODS We conducted a keyword search to identify studies analyzing the impact of the FDA's special designations (orphan, fast track, accelerated approval, priority review, and breakthrough therapy) on the safety, efficacy/clinical benefit, trials, innovativeness, economic incentives, development times, and pricing of new drugs. Results were summarized in a narrative overview. RESULTS Expedited approval reduces new drugs' time to market. However, faster drug development and regulatory review are associated with more unrecognized adverse events and post-marketing safety revisions. Clinical trials supporting special FDA approvals frequently use small, non-randomized, open-label designs. Required post-approval trials to monitor unknown adverse events are often delayed or not even initiated. Evidence suggests that drugs approved under special review pathways, marketed as "breakthroughs", are more innovative and deliver a higher clinical benefit than those receiving standard FDA approval. Special designations are an economically viable strategy for investors and pharmaceutical companies to develop drugs for rare diseases with unmet medical needs, due to financial incentives, expedited development timelines, higher clinical trial success rates, alongside greater prices. Nonetheless, patients, physicians, and insurers are concerned about spending money on drugs without a proven benefit or even on drugs that turn out to be ineffective. While European countries established performance- and financial-based managed entry agreements to account for this uncertainty in clinical trial evidence and cost-effectiveness, the pricing and reimbursement of these drugs remain largely unregulated in the US. CONCLUSION Special FDA designations shorten clinical development and FDA approval times for new drugs treating rare and severe diseases with unmet medical needs. Special-designated drugs offer a greater clinical benefit to patients. However, physicians, patients, and insurers must be aware that special-designated drugs are often approved based on non-robust trials, associated with more unrecognized side effects, and sold for higher prices.
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Affiliation(s)
- Daniel Tobias Michaeli
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany.
- TUM School of Management, Technical University of Munich, Munich, Germany.
| | - Thomas Michaeli
- Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- DKFZ-Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
- Division of Personalized Medical Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sebastian Albers
- Department of Orthopaedics and Sport Orthopaedics, School of Medicine, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Tobias Boch
- Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- DKFZ-Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
- Division of Personalized Medical Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
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Dong F. Pan-Cancer Molecular Biomarkers: A Paradigm Shift in Diagnostic Pathology. Clin Lab Med 2024; 44:325-337. [PMID: 38821647 DOI: 10.1016/j.cll.2023.08.013] [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] [Indexed: 06/02/2024]
Abstract
The rapid adoption of next-generation sequencing in clinical oncology has enabled the detection of molecular biomarkers shared between multiple tumor types. These pan-cancer biomarkers include sequence-altering mutations, copy number changes, gene rearrangements, and mutational signatures and have been demonstrated to predict response to targeted therapy. This article reviews issues surrounding current and emerging pan-cancer molecular biomarkers in clinical oncology: technological advances that enable the broad detection of cancer mutations across hundreds of genes, the spectrum of driver and passenger mutations derived from human cancer genomes, and implications for patient care now and in the near future.
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Affiliation(s)
- Fei Dong
- Department of Pathology, Stanford University School of Medicine, 3375 Hillview Ave, Palo Alto, CA 94304, USA.
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Michaeli DT, Michaeli T, Albers S, Michaeli JC. Clinical trial design and treatment effects: a meta-analysis of randomised controlled and single-arm trials supporting 437 FDA approvals of cancer drugs and indications. BMJ Evid Based Med 2024:bmjebm-2023-112544. [PMID: 38760158 DOI: 10.1136/bmjebm-2023-112544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVES This study aims to analyse the association between clinical trial design and treatment effects for cancer drugs with US Food and Drug Administration (FDA) approval. DESIGN Cross-sectional study and meta-analysis. SETTING Data from Drugs@FDA, FDA labels, ClincialTrials.gov and the Global Burden of Disease study. PARTICIPANTS Pivotal trials for 170 drugs with FDA approval across 437 cancer indications between 2000 and 2022. MAIN OUTCOME MEASURES Treatment effects were measured in HRs for overall survival (OS) and progression-free survival (PFS), and in relative risk for tumour response. Random-effects meta-analyses and meta-regressions explored the association between treatment effect estimates and clinical trial design for randomised controlled trials (RCTs) and single-arm trials. RESULTS Across RCTs, greater effect estimates were observed in smaller trials for OS (ß=0.06, p<0.001), PFS (ß=0.15, p<0.001) and tumour response (ß=-3.61, p<0.001). Effect estimates were larger in shorter trials for OS (ß=0.08, p<0.001) and PFS (ß=0.09, p=0.002). OS (ß=0.04, p=0.006), PFS (ß=0.10, p<0.001) and tumour response (ß=-2.91, p=0.004) outcomes were greater in trials with fewer centres. HRs for PFS (0.54 vs 0.62, p=0.011) were lower in trials testing the new drug to an inactive (placebo/no treatment) rather than an active comparator. The analysed efficacy population (intention-to-treat, per-protocol, or as-treated) was not consistently associated with treatment effects. Results were consistent for single-arm trials and in multivariable analyses. CONCLUSIONS Pivotal trial design is significantly associated with measured treatment effects. Particularly small, short, single-centre trials testing a new drug compared with an inactive rather than an active comparator could overstate treatment outcomes. Future studies should verify results in unsuccessful trials, adjust for further confounders and examine other therapeutic areas. The FDA, manufacturers and trialists must strive to conduct robust clinical trials with a low risk of bias.
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Affiliation(s)
- Daniel Tobias Michaeli
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Michaeli
- Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- German Cancer Research Center-Hector Cancer Institute, University Medical Center Mannheim, Mannheim, Germany
- Division of Personalized Medical Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Sebastian Albers
- Department of Trauma Surgery, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Julia Caroline Michaeli
- Department of Obstetrics and Gynaecology, LMU University Hospital, LMU Munich, Munich, Germany
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Stewart DJ, Bradford JP, Sehdev S, Ramsay T, Navani V, Rawson NSB, Jiang DM, Gotfrit J, Wheatley-Price P, Liu G, Kaplan A, Spadafora S, Goodman SG, Auer RAC, Batist G. New Anticancer Drugs: Reliably Assessing "Value" While Addressing High Prices. Curr Oncol 2024; 31:2453-2480. [PMID: 38785465 PMCID: PMC11119944 DOI: 10.3390/curroncol31050184] [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: 02/27/2024] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/25/2024] Open
Abstract
Countries face challenges in paying for new drugs. High prices are driven in part by exploding drug development costs, which, in turn, are driven by essential but excessive regulation. Burdensome regulation also delays drug development, and this can translate into thousands of life-years lost. We need system-wide reform that will enable less expensive, faster drug development. The speed with which COVID-19 vaccines and AIDS therapies were developed indicates this is possible if governments prioritize it. Countries also differ in how they value drugs, and generally, those willing to pay more have better, faster access. Canada is used as an example to illustrate how "incremental cost-effectiveness ratios" (ICERs) based on measures such as gains in "quality-adjusted life-years" (QALYs) may be used to determine a drug's value but are often problematic, imprecise assessments. Generally, ICER/QALY estimates inadequately consider the impact of patient crossover or long post-progression survival, therapy benefits in distinct subpopulations, positive impacts of the therapy on other healthcare or societal costs, how much governments willingly might pay for other things, etc. Furthermore, a QALY value should be higher for a lethal or uncommon disease than for a common, nonlethal disease. Compared to international comparators, Canada is particularly ineffective in initiating public funding for essential new medications. Addressing these disparities demands urgent reform.
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Affiliation(s)
- David J. Stewart
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - John-Peter Bradford
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Sandeep Sehdev
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
| | - Vishal Navani
- Division of Medical Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Nigel S. B. Rawson
- Canadian Health Policy Institute, Toronto, ON M5V 0A4, Canada;
- Macdonald-Laurier Institute, Ottawa, ON K1N 7Z2, Canada
| | - Di Maria Jiang
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Princess Margaret Cancer Center, Toronto, ON M5G 2M9, Canada
| | - Joanna Gotfrit
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
| | - Paul Wheatley-Price
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Geoffrey Liu
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Princess Margaret Cancer Center, Toronto, ON M5G 2M9, Canada
| | - Alan Kaplan
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Family Physicians Airway Group of Canada, Markham, ON L3R 9X9, Canada
| | - Silvana Spadafora
- Algoma District Cancer Program, Sault Ste Marie, ON P6B 0A8, Canada;
| | - Shaun G. Goodman
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- St. Michael’s Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, Toronto, ON M5B 1W8, Canada
| | - Rebecca A. C. Auer
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Department of Surgery, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada
| | - Gerald Batist
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
- Centre for Translational Research, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
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Maeda H, Shingai R, Takeda K, Hara A, Murai Y, Ofuchi M. Assessment of Surrogate End Point Trends in Clinical Trials to Approve Oncology Drugs From 2001 to 2020 in Japan. JAMA Netw Open 2023; 6:e238875. [PMID: 37115550 PMCID: PMC10148198 DOI: 10.1001/jamanetworkopen.2023.8875] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
Importance A surrogate end point (SEP) is an end point used in clinical trials as an alternative for measuring the true clinical benefit. The use of SEPs in trials shortens their duration. Objectives To investigate the use of SEPs in clinical trials to support the approval of anticancer drugs and to determine whether confirmatory studies that use overall survival (OS) as an end point are being conducted in Japan. Design, Setting, and Participants In this cross-sectional study, drug approvals and background information were obtained from publicly available information, such as the Pharmaceuticals and Medical Devices Agency website, for anticancer drugs approved in Japan from January 2001 to December 2020. Data analysis was performed from September 2021 to March 2022. Main Outcomes and Measures Characteristics of approved oncology drugs in Japan, end points for pivotal clinical trials, and outcomes of confirmatory trials using OS as an end point following drug approval. Results There were 299 anticancer drugs approved in Japan during the study period. Of these, 142 (47.5%) were molecular-targeted drugs, the most common of which targeted non-small cell lung cancer. There were 111 (37.1%) anticancer drugs with orphan designation. From 2001 to 2005, OS was used as an end point in 1 approval (3.6%); however, from 2006 to 2020, OS was used in 86 approvals (31.7%). Of the 212 anticancer drugs approved on the basis of SEPs, confirmatory studies with OS as the end point were conducted for only 37 approvals (17.5%); for the remaining 175 approvals, studies are under way for 35 approvals (16.5%), were waivered for 75 approvals (35.4%), and were not conducted for 65 approvals (30.7%). Furthermore, in 20 drug approvals (9.4%), the conducted confirmatory studies were not effective in determining the OS, but the drugs were approved following re-examination. Conclusions and Relevance The findings of this study suggest that starting from 2005, the use of OS as an end point has increased in studies supporting the approval of anticancer drugs in Japan. However, even after 2005, approximately two-thirds of these approvals were SEP based. Postmarketing surveillance studies of the true end points are necessary to validate the use of SEPs.
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Affiliation(s)
- Hideki Maeda
- Department of Regulatory Science, Faculty of Pharmacy, Meiji Pharmaceutical University, Noshio, Kiyose-city, Tokyo, Japan
| | - Riko Shingai
- Department of Regulatory Science, Faculty of Pharmacy, Meiji Pharmaceutical University, Noshio, Kiyose-city, Tokyo, Japan
| | - Kentaro Takeda
- Data Science, Astellas Pharma Global Development, Inc, Northbrook, Illinois
| | - Asuka Hara
- Department of Regulatory Science, Faculty of Pharmacy, Meiji Pharmaceutical University, Noshio, Kiyose-city, Tokyo, Japan
| | - Yuna Murai
- Department of Regulatory Science, Faculty of Pharmacy, Meiji Pharmaceutical University, Noshio, Kiyose-city, Tokyo, Japan
| | - Momoka Ofuchi
- Department of Regulatory Science, Faculty of Pharmacy, Meiji Pharmaceutical University, Noshio, Kiyose-city, Tokyo, Japan
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Dhruva SS, Darrow JJ, Kesselheim AS, Redberg RF. Experts' Views on FDA Regulatory Standards for Drug and High-Risk Medical Devices: Implications for Patient Care. J Gen Intern Med 2022; 37:4176-4182. [PMID: 35138547 PMCID: PMC9708961 DOI: 10.1007/s11606-021-07316-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/07/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Drugs and high-risk medical devices are increasingly likely to receive Food and Drug Administration (FDA) approval through expedited pathways, which has implications for informed treatment consent (i.e., consent in clinical practice). OBJECTIVE To obtain expert opinion about the clinical and ethical implications of the increasing availability of new drugs and devices approved through expedited development and regulatory review pathways. DESIGN Qualitative study using individual semi-structured videoconference interviews. PARTICIPANTS National leaders in medicine, ethics, and law (n=12) with expertise in medical product regulation, payor policymaking, bioethics, physician practice, patient advocacy, public health expertise/advocacy, clinical trials, the pharmaceutical and device industry, institutional review board oversight, and real-world evidence. MAIN MEASURES Principal themes in 3 domains: expedited regulatory pathways, physician and patient understanding of and reliance on FDA approval, and informed treatment consent. KEY RESULTS Respondents pointed out that more common use of expedited pathways translates to increased reliance on surrogate measures, some with uncertain clinical significance. While expedited development and review can have advantages, participants expressed worry that physicians were unaware when medical products were expedited and did not communicate about uncertainties in knowledge about new drug or device approvals effectively with patients. Many participants felt that informed treatment consent discussions about new drugs or devices should include some explanations of expedited pathways and use of surrogate measures. CONCLUSIONS Experts identified advantages of expediting development and of FDA flexibility in applying its standards to new drugs and medical devices, but highlighted concerns that patients may not be adequately informed about the risks of shorter review times or about uncertainties in the evidence that result. There is a need to identify approaches to ensure effective clinical use of drugs and devices when approved through expedited pathways.
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Affiliation(s)
- Sanket S. Dhruva
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA USA
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA USA
| | - Jonathan J. Darrow
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA USA
- Department of Law and Taxation, Bentley University, Waltham, MA USA
| | - Aaron S. Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA USA
| | - Rita F. Redberg
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA USA
- Division of Cardiology, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA USA
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Watanabe Y, Narukawa M. [Association between Post-marketing Safety-related Regulatory Actions and Characteristics of New Drugs Approved in Japan between 2005 and 2016]. YAKUGAKU ZASSHI 2022; 142:761-770. [PMID: 35781506 DOI: 10.1248/yakushi.22-00055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The pharmacovigilance activities of new drugs are usually planned and conducted based on the clinical safety information obtained at approval. Revealing pre- and post-marketing drug characteristics associated with post-marketing safety-related regulatory actions (PSRAs) would help facilitate pharmacovigilance activities as these activities are not sufficient for early detection of safety signals that require warning. Therefore, we investigated the association between PSRAs and characteristics of new drugs in Japan. New active substances approved in Japan between fiscal year 2005 and 2015 were analyzed. PSRAs were defined as "revisions of precautions in drug package insert" instructed by the regulatory authority within the first 5 years after the initial approval (up to 2021). Drug characteristics included therapeutic area, number of Japanese subjects in clinical trials, dose-response study in Japanese subjects, approval lag between Japan and the United States or Europe (US/EU), novelty of the drug, estimated number of target patients, and number of supplemental approvals. Negative binomial regression and path analyses were performed to investigate the association between PSRAs and drug characteristics. PSRAs were more common among antineoplastic agents and drugs with a larger estimated number of target patients and were less common among drugs with a longer approval lag between Japan and the US/EU. Supplemental approval was more common among antineoplastic agents, and there were fewer target patients for novel drugs. For new drugs with the characteristics identified in the present study, it is important to proactively collect post-market safety information by intensifying patient monitoring.
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Affiliation(s)
- Yuta Watanabe
- Kitasato University Graduate School of Pharmaceutical Sciences
| | - Mamoru Narukawa
- Kitasato University Graduate School of Pharmaceutical Sciences
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Dhruva SS, Darrow JJ, Kesselheim AS, Redberg RF. Strategies to Manage Drugs and Devices Approved Based on Limited Evidence: Results of a Modified Delphi Panel. Clin Pharmacol Ther 2022; 111:1307-1314. [PMID: 35292958 DOI: 10.1002/cpt.2583] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/09/2022] [Indexed: 11/08/2022]
Abstract
Prescription drugs and medical devices are increasingly coming to market through expedited US Food and Drug Administration (FDA) pathways that require only limited evidence of safety and efficacy, such as nonrandomized, unblinded trial data in small numbers of patients, or the use of surrogate end points. Reliance on more limited evidence means that there is often greater uncertainty about risks and benefits. Using a modified Delphi process, we sought to identify promising policy approaches that address physician-patient decision-making needs about the use of such drugs and medical devices. We convened 13 national leaders from academia, government, nonprofits, payors, and industry who had expertise in medical product regulation, payor policymaking, bioethics, physician practice, patient advocacy, public health expertise/advocacy, clinical trials, the pharmaceutical and device industry, institutional review board oversight, and real-world evidence. Through multiple rounds of voting and meetings focused on evaluating the feasibility and impact of various interventions, the 13 participants reached the broadest consensus on 4 interventions: strengthening FDA post-approval study requirements to ensure postmarket evidence is generated in a timely manner, better informing patients about the risks and benefits and level of evidence supporting therapies via simplified and patient-centered product information "boxes" modeled on nutrition labels, limiting prices for drugs and medical devices approved based on surrogate end point data until confirmatory clinical evidence is generated, and improving health professional education about FDA regulation to better support clinician use of drugs and devices as well as communication with patients.
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Affiliation(s)
- Sanket S Dhruva
- University of California, San Francisco School of Medicine, San Francisco, California, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA.,Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Jonathan J Darrow
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Law and Taxation, Bentley University, Waltham, Massachusetts, USA
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rita F Redberg
- University of California, San Francisco School of Medicine, San Francisco, California, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA.,Division of Cardiology, Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, California, USA
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Veselinović T, Neuner I. Progress and Pitfalls in Developing Agents to Treat Neurocognitive Deficits Associated with Schizophrenia. CNS Drugs 2022; 36:819-858. [PMID: 35831706 PMCID: PMC9345797 DOI: 10.1007/s40263-022-00935-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 12/11/2022]
Abstract
Cognitive impairments associated with schizophrenia (CIAS) represent a central element of the symptomatology of this severe mental disorder. CIAS substantially determine the disease prognosis and hardly, if at all, respond to treatment with currently available antipsychotics. Remarkably, all drugs presently approved for the treatment of schizophrenia are, to varying degrees, dopamine D2/D3 receptor blockers. In turn, rapidly growing evidence suggests the immense significance of systems other than the dopaminergic system in the genesis of CIAS. Accordingly, current efforts addressing the unmet needs of patients with schizophrenia are primarily based on interventions in other non-dopaminergic systems. In this review article, we provide a brief overview of the available evidence on the importance of specific systems in the development of CIAS. In addition, we describe the promising targets for the development of new drugs that have been used so far. In doing so, we present the most important candidates that have been investigated in the field of the specific systems in recent years and present a summary of the results available at the time of drafting this review (May 2022), as well as the currently ongoing studies.
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Affiliation(s)
- Tanja Veselinović
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.
- Institute of Neuroscience and Medicine 4, INM-4, Forschungszentrum Jülich, Jülich, Germany.
| | - Irene Neuner
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
- Institute of Neuroscience and Medicine 4, INM-4, Forschungszentrum Jülich, Jülich, Germany
- JARA-BRAIN, Aachen, Germany
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Abstract
The rapid adoption of next-generation sequencing in clinical oncology has enabled the detection of molecular biomarkers shared between multiple tumor types. These pan-cancer biomarkers include sequence-altering mutations, copy number changes, gene rearrangements, and mutational signatures and have been demonstrated to predict response to targeted therapy. This article reviews issues surrounding current and emerging pan-cancer molecular biomarkers in clinical oncology: technological advances that enable the broad detection of cancer mutations across hundreds of genes, the spectrum of driver and passenger mutations derived from human cancer genomes, and implications for patient care now and in the near future.
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Affiliation(s)
- Fei Dong
- Department of Pathology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Jibiki T, Nishimura H, Sengoku S, Kodama K. Regulations, Open Data and Healthcare Innovation: A Case of MSK-IMPACT and Its Implications for Better Cancer Care. Cancers (Basel) 2021; 13:cancers13143448. [PMID: 34298662 PMCID: PMC8304506 DOI: 10.3390/cancers13143448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 01/16/2023] Open
Abstract
Simple Summary The advancement in both science and technology has contributed to the development of novel diagnostic technologies; such technologies enable medical practitioners to diagnose diseases that could not be previously detected. However, in order to translate new technologies into practical applications, various types of challenges need to be overcome. To address these challenges, including those in clinical management and regulatory science, healthcare policies have been constantly implemented to promote the practical application of outcomes generated by healthcare innovation. This study conducted comparative analyses of three tumor profiling tests approved by the U.S. Food and Drug Administration (FDA) in 2017, hypothesizing that the FDA’s regulatory reforms, early application of new technologies to both research and clinical settings, and open data accumulated as a result of large-scale research programs have promoted new drug development in oncology. The study then discussed the implications potentially suggested by the outcomes and challenges of the three tests. Abstract This study investigated a case of Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets (MSK-IMPACT), a tumor profiling test approved by the U.S. Food and Drug Administration (FDA) in 2017, to examine what factors would contribute to healthcare innovation. First, we set the following three parameters to observe cases: (i) the FDA regulatory reforms, (ii) early application of new technologies, such as next-generation sequencing (NGS), to both research and clinical settings, and (iii) accumulation of open data. Then, we performed a comparative analysis of MSK-IMPACT with FoundationOne CDx and Oncomine Dx Target Test, both of which were FDA-approved tumor profiling tests launched in 2017. As a result, we found that MSK-IMPACT secures neutrality as a non-profit organization, achieves the active incorporation of basic research results, and performs superiorly in clinical operations, such as patient enrollment. On the contrary, we confirmed that FoundationOne CDx was the most prominent case in terms of the number of new drugs and expanded indications approved in which the FDA’s expedited approval programs were considerably utilized. Consequently, to uncover the full potential of MSK-IMPACT, it is suggested that more intersectoral collaborative activities between various healthcare stakeholders, in particular, pharmaceutical companies, for driving clinical development must be carried out based on an organizational framework that facilitates collaboration.
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Affiliation(s)
- Takaharu Jibiki
- Department of Innovation Science, School of Environment and Society, Tokyo Institute of Technology, Tokyo 108-0023, Japan; (T.J.); (H.N.)
| | - Hayato Nishimura
- Department of Innovation Science, School of Environment and Society, Tokyo Institute of Technology, Tokyo 108-0023, Japan; (T.J.); (H.N.)
- Policy Planning Division, RIKEN, Saitama 351-0198, Japan
| | - Shintaro Sengoku
- Department of Innovation Science, School of Environment and Society, Tokyo Institute of Technology, Tokyo 108-0023, Japan; (T.J.); (H.N.)
- Life Style by Design Research Unit, Institute for Future Initiatives, University of Tokyo, Tokyo 113-0033, Japan
- Correspondence: ; Tel.: +81-3-3454-8907
| | - Kota Kodama
- Graduate School of Technology Management, Ritsumeikan University, Osaka 567-8570, Japan;
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12
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Petrou P. Assessing the pricing and benefits of oncology products: an update. Expert Rev Pharmacoecon Outcomes Res 2021; 21:335-342. [PMID: 33950772 DOI: 10.1080/14737167.2021.1926987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Oncology expenditure is outperforming all other health care sectors. In particular, the cost of oncology pharmaceuticals is soaring as it is fueled both by incremental costs and the introduction rate of new products. Due to the particularities of cancer as a disease, a significant multilayer of pressure is exerted toward the reimbursement of new treatments. Nevertheless, if the expenditure increase is left unattended, it may hamper the viability of any health care system worldwide.Areas covered: A literature review of the expenditure on oncology pharmaceuticals and the exploration of the root causes for the increase in expenditure was performed.Expert commentary: The surging oncology expenditure demonstrates a multi-layer causality that encompasses prices, the uncertainty of clinical trials, the specificities of cancer as a disease, and the artificial monopoly of oncology modalities. Moreover, laxity in the regulatory approval of new products was noted. In addition, the study design should be adequately justified. Finally, new reimbursement schemes, that explicitly reward and promote clinically meaningful and measurable outcomes, are also imperative.
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Affiliation(s)
- Panagiotis Petrou
- Pharmacoepidemiology-Pharmacovigilance, Pharmacy Programme, Department of Life and Health Sciences, School of Sciences and Engineering, University of Nicosia, Nicosia, Cyprus
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13
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Boyd NK, Teng C, Frei CR. Brief Overview of Approaches and Challenges in New Antibiotic Development: A Focus On Drug Repurposing. Front Cell Infect Microbiol 2021; 11:684515. [PMID: 34079770 PMCID: PMC8165386 DOI: 10.3389/fcimb.2021.684515] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/04/2021] [Indexed: 12/19/2022] Open
Abstract
Drug repurposing, or identifying new uses for existing drugs, has emerged as an alternative to traditional drug discovery processes involving de novo synthesis. Drugs that are currently approved or under development for non-antibiotic indications may possess antibiotic properties, and therefore may have repurposing potential, either alone or in combination with an antibiotic. They might also serve as "antibiotic adjuvants" to enhance the activity of certain antibiotics.
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Affiliation(s)
- Natalie K Boyd
- College of Pharmacy, The University of Texas at Austin, San Antonio, TX, United States.,Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Chengwen Teng
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, The University of South Carolina, Columbia, SC, United States
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, San Antonio, TX, United States.,Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States.,Research Department, South Texas Veterans Health Care System, San Antonio, TX, United States.,Pharmacy Department, University Health System, San Antonio, TX, United States
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14
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Abstract
DISCLOSURES: This commentary is based on work by the author that was supported by Arnold Ventures and the Harvard-MIT Center for Regulatory Science. The funders had no role in the writing of this commentary, or the decision to submit for publication. The author has nothing else to disclose.
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Affiliation(s)
- Jonathan J Darrow
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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15
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The Potential Benefit of Expedited Development and Approval Programs in Precision Medicine. J Pers Med 2021; 11:jpm11010045. [PMID: 33466644 PMCID: PMC7828670 DOI: 10.3390/jpm11010045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Increased understanding of the molecular causes of disease has begun to fulfill the promise of precision medicine with the development of targeted drugs, particularly for serious diseases with unmet needs. The drug approval regulatory process is a critical component to the continued growth of precision medicine drugs and devices. To facilitate the development and approval process of drugs for serious unmet needs, four expedited approval programs have been developed in the US: priority review, accelerated approval, fast track, and breakthrough therapy programs. METHODS To determine if expedited approval programs are fulfilling the intended goals, we reviewed drug approvals by the US Food and Drug Administration (FDA) between 2011 and 2017 for new molecular entities (NMEs). RESULTS From 2011 through 2017, the FDA approved 250 NMEs, ranging from 27 approvals in 2013 to 46 in 2017. The NME approvals spanned 22 different disease classes; almost one-third of all NMEs were for oncology treatments. CONCLUSIONS As these pathways are utilized more, additional legislative changes may be needed to re-align incentives to promote continued development of innovative drugs for serious unmet needs in a safe, efficacious, and affordable manner.
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16
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Kesselheim AS, Darrow JJ, Kulldorff M, Brown BL, Mitra-Majumdar M, Lee CC, Moneer O, Avorn J. An Overview Of Vaccine Development, Approval, And Regulation, With Implications For COVID-19. Health Aff (Millwood) 2021; 40:25-32. [DOI: 10.1377/hlthaff.2020.01620] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Aaron S. Kesselheim
- Aaron S. Kesselheim is a professor of medicine and the director of the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, in Boston, Massachusetts
| | - Jonathan J. Darrow
- Jonathan J. Darrow is an assistant professor of medicine in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School
| | - Martin Kulldorff
- Martin Kulldorff is a professor of medicine in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School
| | - Beatrice L. Brown
- Beatrice L. Brown is a research assistant in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School
| | - Mayookha Mitra-Majumdar
- Mayookha Mitra-Majumdar is a research scientist in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School
| | - ChangWon C. Lee
- ChangWon C. Lee is a research assistant in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School
| | - Osman Moneer
- Osman Moneer is a medical student at the Yale School of Medicine, in New Haven, Connecticut
| | - Jerry Avorn
- Jerry Avorn is a professor of medicine in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School
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17
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Chorniy A, Bailey J, Civan A, Maloney M. Regulatory review time and pharmaceutical research and development. HEALTH ECONOMICS 2021; 30:113-128. [PMID: 33078483 DOI: 10.1002/hec.4180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 03/31/2020] [Accepted: 05/29/2020] [Indexed: 06/11/2023]
Abstract
In the United States, all newly developed drugs undergo a lengthy review process conducted by the US Food and Drug Administration (FDA). These regulatory delays have direct immediate costs for drug manufacturers and patients waiting for treatment. Under certain market conditions, regulatory delays may also affect future research and development (R&D) strategies of pharmaceutical companies. To estimate the magnitude of this effect, we match data on drugs in the development pipeline in 2006 to data that we collect on FDA review times for all drugs approved between 1999 and 2005. Employing a rich and novel set of controls that affect drug R&D decisions and, potentially, regulatory review lags, we find that on average, three additional months of delay result in one fewer drug in development in that drug category. Our results suggest that the length of the regulatory delay matters for pharmaceutical firms' R&D decisions and that the firms are likely unable to pass on these costs onto consumers.
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Affiliation(s)
- Anna Chorniy
- Department of Medical Social Sciences, Buehler Center for Health Policy & Economics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - James Bailey
- Department of Economics, Providence College, Providence, Rhode Island, USA
| | | | - Michael Maloney
- John E. Walker Department of Economics, Clemson University, Clemson, South Carolina, USA
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18
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McNamee LM, Cleary EG, Zhang S, Salim U, Ledley FD. Late-stage Product Development and Approvals by Biotechnology Companies After Initial Public Offering, 1997-2016. Clin Ther 2020; 43:156-171.e15. [PMID: 33380363 DOI: 10.1016/j.clinthera.2020.11.012] [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: 09/26/2020] [Revised: 11/20/2020] [Accepted: 11/22/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE This work describes the late-stage product portfolios of the biotechnology companies that completed initial public offerings (IPOs) from 1997 to 2016. We asked whether these emerging companies continue to develop innovative, biologic products and produce the innovation promised by the early biotechnology industry. METHODS We identified therapeutic products that reached Phase III development from 1997 to 2016, the characteristics of the products, the dates of the initiation of Phase III and product approval, proxy indicators of the innovativeness of each product, and the contribution of each biotechnology company. Companies were characterized by IPO window and clinical status of the most advanced product at IPO. Time from IPO to Phase III or approval, and the estimated probability of a company having a product advance to these milestones, were examined using Kaplan-Meier analysis. FINDINGS A total of 319 biotechnology companies completed IPOs from 1997 to 2016. These companies contributed to the development of 367 products that progressed to Phase III, and of 144 new drug approvals, through 2016. The estimated probability of a company having a product reach Phase III was 78%, and the estimated probability of a company receiving at least 1 product approval was 52%, with most approvals occurring >5 years after IPO. Small-molecule drugs represented 74% of products reaching Phase III and 78% of approvals. Reformulations represented 36% of Phase III products and 46% of approvals. The estimated probability of product approval was significantly higher for reformulations than new molecular entities (NMEs) and slightly higher for small molecules than biologics. The estimated probability of a company receiving product approval varied significantly by IPO window and was greater for companies with Phase III products at IPO (74%). These companies contributed to the development of 78 NMEs, 44% of which were classified as first in class, initiating development of 69% and contributing to the clinical development of 96%. These products represented 16% of all NMEs and 28% of biologics approved between 1997 and 2016. Seven products achieved per-annum sales of >$1 billion during the study period. IMPLICATIONS The majority of emerging publicly owned biotechnology companies contribute to products that advance to Phase III development and approval, although these companies are no longer distinctively focused on biologic products.
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Affiliation(s)
- Laura M McNamee
- Center for Integration of Science and Industry, Bentley University, Waltham, MA, USA; Department of Natural & Applied Science, Bentley University, Waltham, MA, USA
| | - Ekaterina Galkina Cleary
- Center for Integration of Science and Industry, Bentley University, Waltham, MA, USA; Department of Mathematical Science, Bentley University, Waltham, MA, USA
| | - Sunyi Zhang
- Center for Integration of Science and Industry, Bentley University, Waltham, MA, USA
| | - Usama Salim
- Center for Integration of Science and Industry, Bentley University, Waltham, MA, USA
| | - Fred D Ledley
- Center for Integration of Science and Industry, Bentley University, Waltham, MA, USA; Department of Natural & Applied Science, Bentley University, Waltham, MA, USA; Department of Management, Bentley University, Waltham, MA, USA.
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19
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Sarpatwari A, Avorn J, Kesselheim AS. Accounting for US public funding in drug development: how can we better balance access, affordability, and innovation? BMJ 2020; 371:m3841. [PMID: 33032982 DOI: 10.1136/bmj.m3841] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Ameet Sarpatwari
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA 02120, USA
| | - Jerry Avorn
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA 02120, USA
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA 02120, USA
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20
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Leopold C, Haffajee RL, Lu CY, Wagner AK. The Complex Cancer Care Coverage Environment - What is the Role of Legislation? A Case Study from Massachusetts. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2020; 48:538-551. [PMID: 33021165 DOI: 10.1177/1073110520958879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Over the past decades, anti-cancer treatments have evolved rapidly from cytotoxic chemotherapies to targeted therapies including oral targeted medications and injectable immuno-oncology and cell therapies. New anti-cancer medications come to markets at increasingly high prices, and health insurance coverage is crucial for patient access to these therapies. State laws are intended to facilitate insurance coverage of anti-cancer therapies.Using Massachusetts as a case study, we identified five current cancer coverage state laws and interviewed experts on their perceptions of the relevance of the laws and how well they meet the current needs of cancer care given rapid changes in therapies. Interviewees emphasized that cancer therapies, as compared to many other therapeutic areas, are unique because insurance legislation targets their coverage. They identified the oral chemotherapy parity law as contributing to increasing treatment costs in commercial insurance. For commercial insurers, coverage mandates combined with the realities of new cancer medications - including high prices and often limited evidence of efficacy at approval - compound a difficult situation. Respondents recommended policy approaches to address this challenging coverage environment, including the implementation of closed formularies, the use of cost-effectiveness studies to guide coverage decisions, and the application of value-based pricing concepts. Given the evolution of cancer therapeutics, it may be time to evaluate the benefits and challenges of cancer coverage mandates.
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Affiliation(s)
- Christine Leopold
- Christine Leopold, Ph.D., M.Sc., conducted this research while she was a senior research fellow in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She received her Ph.D. from Utrecht University and her Master of Science degree in international healthcare management, economics and policy from Bocconi University. Rebecca L. Haffajee, J.D., Ph.D., M.P.H., is a Policy Researcher at RAND Corporation and an Adjunct Assistant Professor of Health Management and Policy at the University of Michigan School of Public Health. She received her law degree from Harvard Law School and a Master in Public Health degree from Harvard T.H. Chan School of Public Health. She completed her Ph.D. in health policy with a concentration in evaluative science and statistics at Harvard University in 2016. Christine Y. Lu, M.Sc, Ph.D., is an Associate Professor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute and she co-directs the PRecisiOn Medicine Translational Research Center. She received her M.Sc. in biopharmaceuticals and a Ph.D. from the University of New South Wales. Anita K. Wagner, Pharm.D., M.P.H, Dr.P.H., is Associate Professor at the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She serves as the Director of the Harvard Pilgrim Health Care Ethics Program. She received her Master of Public Health degree in international health and Doctor of Public Health degree in epidemiology from the Harvard School of Public Health
| | - Rebecca L Haffajee
- Christine Leopold, Ph.D., M.Sc., conducted this research while she was a senior research fellow in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She received her Ph.D. from Utrecht University and her Master of Science degree in international healthcare management, economics and policy from Bocconi University. Rebecca L. Haffajee, J.D., Ph.D., M.P.H., is a Policy Researcher at RAND Corporation and an Adjunct Assistant Professor of Health Management and Policy at the University of Michigan School of Public Health. She received her law degree from Harvard Law School and a Master in Public Health degree from Harvard T.H. Chan School of Public Health. She completed her Ph.D. in health policy with a concentration in evaluative science and statistics at Harvard University in 2016. Christine Y. Lu, M.Sc, Ph.D., is an Associate Professor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute and she co-directs the PRecisiOn Medicine Translational Research Center. She received her M.Sc. in biopharmaceuticals and a Ph.D. from the University of New South Wales. Anita K. Wagner, Pharm.D., M.P.H, Dr.P.H., is Associate Professor at the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She serves as the Director of the Harvard Pilgrim Health Care Ethics Program. She received her Master of Public Health degree in international health and Doctor of Public Health degree in epidemiology from the Harvard School of Public Health
| | - Christine Y Lu
- Christine Leopold, Ph.D., M.Sc., conducted this research while she was a senior research fellow in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She received her Ph.D. from Utrecht University and her Master of Science degree in international healthcare management, economics and policy from Bocconi University. Rebecca L. Haffajee, J.D., Ph.D., M.P.H., is a Policy Researcher at RAND Corporation and an Adjunct Assistant Professor of Health Management and Policy at the University of Michigan School of Public Health. She received her law degree from Harvard Law School and a Master in Public Health degree from Harvard T.H. Chan School of Public Health. She completed her Ph.D. in health policy with a concentration in evaluative science and statistics at Harvard University in 2016. Christine Y. Lu, M.Sc, Ph.D., is an Associate Professor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute and she co-directs the PRecisiOn Medicine Translational Research Center. She received her M.Sc. in biopharmaceuticals and a Ph.D. from the University of New South Wales. Anita K. Wagner, Pharm.D., M.P.H, Dr.P.H., is Associate Professor at the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She serves as the Director of the Harvard Pilgrim Health Care Ethics Program. She received her Master of Public Health degree in international health and Doctor of Public Health degree in epidemiology from the Harvard School of Public Health
| | - Anita K Wagner
- Christine Leopold, Ph.D., M.Sc., conducted this research while she was a senior research fellow in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She received her Ph.D. from Utrecht University and her Master of Science degree in international healthcare management, economics and policy from Bocconi University. Rebecca L. Haffajee, J.D., Ph.D., M.P.H., is a Policy Researcher at RAND Corporation and an Adjunct Assistant Professor of Health Management and Policy at the University of Michigan School of Public Health. She received her law degree from Harvard Law School and a Master in Public Health degree from Harvard T.H. Chan School of Public Health. She completed her Ph.D. in health policy with a concentration in evaluative science and statistics at Harvard University in 2016. Christine Y. Lu, M.Sc, Ph.D., is an Associate Professor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute and she co-directs the PRecisiOn Medicine Translational Research Center. She received her M.Sc. in biopharmaceuticals and a Ph.D. from the University of New South Wales. Anita K. Wagner, Pharm.D., M.P.H, Dr.P.H., is Associate Professor at the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. She serves as the Director of the Harvard Pilgrim Health Care Ethics Program. She received her Master of Public Health degree in international health and Doctor of Public Health degree in epidemiology from the Harvard School of Public Health
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21
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Regulatory approval characteristics of antimicrobial versus non-antimicrobial products, 1984–2018: an evaluation of Food and Drug Administration flexibilities. THE LANCET. INFECTIOUS DISEASES 2020; 20:e159-e164. [DOI: 10.1016/s1473-3099(20)30197-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/07/2020] [Accepted: 03/12/2020] [Indexed: 12/31/2022]
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22
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Darrow JJ, Beall RF. Commentary: Expedited Regulatory Review of Low-Value Drugs. Healthc Policy 2020; 15:35-40. [PMID: 32538347 PMCID: PMC7294442 DOI: 10.12927/hcpol.2020.26226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Lexchin has criticized Health Canada's recently published draft guidance on accelerated drug review, expressing concern over agency conflicts of interest and observing that priority review and notice of compliance with conditions correlate poorly with therapeutic benefit. Although agency operations may be imperfect, perhaps the most important finding of Lexchin's research is that only 11% of newly approved drugs provide meaningful benefit over standard treatments. To improve the expedited review process in light of these findings, we suggest eliminating user fees and fully funding the review process with public monies, reserving the use of expedited approval pathways for when preliminary measures of benefit are so large that traditional approval thresholds can be met earlier in the clinical trial process, improving labelling to quantitatively communicate drug benefits and risks, and avoiding the use of titles such as “priority” review, which could imply a magnitude of clinical superiority that has not been established.
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Affiliation(s)
- Jonathan J Darrow
- Assistant Professor, Program on Regulation, Therapeutics and Law (PORTAL), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Reed F Beall
- Assistant Professor, Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB
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23
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Vreman RA, Naci H, Goettsch WG, Mantel-Teeuwisse AK, Schneeweiss SG, Leufkens HGM, Kesselheim AS. Decision Making Under Uncertainty: Comparing Regulatory and Health Technology Assessment Reviews of Medicines in the United States and Europe. Clin Pharmacol Ther 2020; 108:350-357. [PMID: 32236959 PMCID: PMC7484915 DOI: 10.1002/cpt.1835] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/03/2020] [Indexed: 12/25/2022]
Abstract
Assessments of clinical evidence vary between regulators and health technology assessment bodies, but precise differences remain unclear. To compare uncertainties raised on the clinical evidence of approved drugs, we analyzed assessments of regulators and health technology assessment (HTA) bodies in the United States and Europe. We found that US and European regulators report uncertainties related to safety for almost all drugs (85–94%), whereas HTA bodies reported these less (53–59%). By contrast, HTA bodies raised uncertainties related to effects against relevant comparators for almost all drugs (88–100%), whereas this was infrequently addressed by regulators (12–32%). Regulators as well as HTA bodies reported uncertainties related to the patient population for 60–95% of drugs. The patterns of regulator‐HTA misalignment were comparable between the United States and Europe. Our results indicate that increased coordination between these complementary organizations is necessary to facilitate the collection of necessary evidence in an efficient and timely manner.
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Affiliation(s)
- Rick A Vreman
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,National Health Care Institute, Diemen, The Netherlands
| | - Huseyin Naci
- Department of Health Policy, LSE Health, London School of Economics and Political Science, London, UK.,Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wim G Goettsch
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,National Health Care Institute, Diemen, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Sebastian G Schneeweiss
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hubert G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Gyawali B, Hey SP, Kesselheim AS. Evaluating the evidence behind the surrogate measures included in the FDA's table of surrogate endpoints as supporting approval of cancer drugs. EClinicalMedicine 2020; 21:100332. [PMID: 32382717 PMCID: PMC7201012 DOI: 10.1016/j.eclinm.2020.100332] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In July 2018, the FDA first published a table listing all surrogate measures that it has used, and may accept for future use, in regulatory approval. However, the strength of surrogacy for those measures was not formally assessed. Using the case example of breast cancer, we aimed to evaluate the strength of correlation of surrogate measures listed in the FDA's Table with overall survival. METHODS This cross-sectional study of the FDA's Table of Surrogate Endpoints was conducted in May 2019. All surrogate measures listed in the FDA table as appropriate for accelerated or regular approval for breast cancer were extracted. We identified studies evaluating the correlation of treatment benefit in the surrogate with treatment benefit in overall survival and extracted results from the correlation analysis. FINDINGS Five surrogate endpoints were listed for breast cancer in the FDA website: pathological complete response rates (pCR), event-free survival (EFS), disease-free survival (DFS), objective response rates (ORR), and progression-free survival (PFS), of which pCR was listed as appropriate only for accelerated approval, while the rest were considered appropriate for accelerated or regular approval. No correlation study evaluated the correlation of treatment effects on EFS with that on OS. The results from correlation studies evaluating pCR, DFS, ORR, and PFS suggest that the treatment effects on none of these surrogate measures were strongly correlated with treatment effects on OS (r<0.85 or R2 < 0.7, except for DFS in HER2 positive early breast cancer (R2 = 0.75). INTERPRETATION Using breast cancer as an example, we evaluated the underlying evidence for the surrogate endpoints for solid tumors listed in the FDA's Table of Surrogate Endpoints and found weak or missing correlations of treatment effects on these surrogates with treatment effects on OS . Surrogate measures should be predictive of clinical benefit to be useful in supporting regular FDA approval. FUNDING Work on this project was funded by the Arnold Ventures. Dr. Kesselheim is also supported by the Harvard-MIT Center for Regulatory Science. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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Affiliation(s)
- Bishal Gyawali
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, US
- Department of Oncology, Department of Public Health Sciences and Division of Cancer Care and Epidemiology, Queen's University, Kingston, Canada
- Corresponding author.
| | - Spencer P. Hey
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, US
- Harvard Center for Bioethics, Harvard Medical School, Boston, MA, US
| | - Aaron S. Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, US
- Harvard Center for Bioethics, Harvard Medical School, Boston, MA, US
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Vreman RA, Belitser SV, Mota ATM, Hövels AM, Goettsch WG, Roes KCB, Leufkens HGM, Mantel-Teeuwisse AK. Efficacy gap between phase II and subsequent phase III studies in oncology. Br J Clin Pharmacol 2020; 86:1306-1313. [PMID: 32034790 PMCID: PMC7318994 DOI: 10.1111/bcp.14237] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/08/2020] [Accepted: 01/22/2020] [Indexed: 12/13/2022] Open
Abstract
Aims There is a trend for more flexibility in timing of evidence generation in relation to marketing authorization, including the option to complete phase III trials after authorization or not at all. This paper investigated the relation between phase II and III clinical trial efficacy in oncology. Methods All oncology drugs approved by the European Medicines Agency (2007–2016) were included. Phase II and phase III trials were matched based on indication and treatment and patient characteristics. Reported objective response rates (ORR), median progression‐free survival (PFS) and median overall survival (OS) were analysed through weighted mixed‐effects regression with previous treatment, treatment regimen, blinding, randomization, marketing authorization type and cancer type as covariates. Results A total of 81 phase II‐III matches were identified including 252 trials. Mean (standard deviation) weighted difference (phase III minus II) was −4.2% (17.4) for ORR, 2.1 (6.7) months for PFS and −0.3 (5.1) months for OS, indicating very small average differences between phases. Differences varied substantially between individual indications: from −46.6% to 47.3% for ORR, from −5.3 to 35.9 months for PFS and from −13.3 to 10.8 months for OS. All covariates except blinding were associated with differences in effect sizes for at least 1 outcome. Conclusions The lack of marked average differences between phases may encourage decision‐makers to regard the quality of design and total body of evidence instead of differentiating between phases of clinical development. The large variability emphasizes that replication of study findings remains essential to confirm efficacy of oncology drugs and discern variables associated with demonstrated effects.
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Affiliation(s)
- Rick A Vreman
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, The Netherlands.,The National Health Care Institute (ZIN), Diemen, The Netherlands
| | - Svetlana V Belitser
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, The Netherlands
| | - Ana T M Mota
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, The Netherlands
| | - Anke M Hövels
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, The Netherlands
| | - Wim G Goettsch
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, The Netherlands.,The National Health Care Institute (ZIN), Diemen, The Netherlands
| | - Kit C B Roes
- Department of Health Evidence, Biostatistics, Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Hubert G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, The Netherlands
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Abstract
IMPORTANCE US law requires testing of new drugs before approval to ensure that they provide a well-defined benefit that is commensurate with their risks. A major challenge for the US Food and Drug Administration (FDA) is to achieve an appropriate balance between rigorous testing and the need for timely approval of drugs that have benefits that outweigh their risks. OBJECTIVE To describe the evolution of laws and standards affecting drug testing, the use of new approval programs and standards, expansions of the role and authority of the FDA, and changes in the number of drugs approved from the 1980s to 2018. EVIDENCE Sources of evidence included principal federal laws and FDA regulations (1962-2018) and FDA databases of approved new drugs (1984-2018), generic drugs (1970-2018), biologics (1984-2018), and vaccines (1998-2018); special development and approval programs (Orphan drug [1984-2018], Fast-Track [1988-2018], Priority Review and its predecessors [1984-2018], Accelerated Approval [1992-2018], and Breakthrough Therapy [2012-2018]); expanded access (2010-2017) and Risk Evaluation and Mitigation Strategies (2008-2018); and user fees paid to the FDA by industry (1993-2018). FINDINGS From 1983 to 2018, legislation and regulatory initiatives have substantially changed drug approval at the FDA. The mean annual number of new drug approvals, including biologics, was 34 from 1990-1999, 25 from 2000-2009, and 41 from 2010-2018. New biologic product approvals increased from a median of 2.5 from 1990-1999, to 5 from 2000-2013, to 12 from 2014-2018. The median annual number of generic drugs approved was 136 from 1970 to the enactment of the Hatch-Waxman Act in 1984; 284 from 1985 to the enactment of the Generic Drug User Fee Act in 2012; and 588 from 2013-2018. Prescription drug user fee funding expanded from new drugs and biologics in 1992 to generic and biosimilar drugs in 2012. The amount of Prescription Drug User Fee Act fees collected from industry increased from an annual mean of $66 million in 1993-1997 to $820 million in 2013-2017, and in 2018, user fees accounted for approximately 80% of the salaries of review personnel responsible for the approval of new drugs. The proportion of drugs approved with an Orphan Drug Act designation increased from 18% (55/304) in 1984-1995, to 22% (82/379) in 1996-2007, to 41% (154/380) in 2008-2018. Use of Accelerated Approval, Fast-Track, and Priority Review for new drugs has increased over time, with 81% (48/59) of new drugs benefiting from at least 1 such expedited program in 2018. The proportion of new approvals supported by at least 2 pivotal trials decreased from 80.6% in 1995-1997 to 52.8% in 2015-2017, based on 124 and 106 approvals, respectively, while the median number of patients studied did not change significantly (774 vs 816). FDA drug review times declined from more than 3 years in 1983 to less than 1 year in 2017, but total time from the authorization of clinical testing to approval has remained at approximately 8 years over that period. CONCLUSIONS AND RELEVANCE Over the last 4 decades, the approval and regulation processes for pharmaceutical agents have evolved and increased in complexity as special programs have been added and as the use of surrogate measures has been encouraged. The FDA funding needed to implement and manage these programs has been addressed by expanding industry-paid user fees. The FDA has increasingly accepted less data and more surrogate measures, and has shortened its review times.
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Affiliation(s)
- Jonathan J Darrow
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jerry Avorn
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Huntington SF, Davidoff AJ, Gross CP. Precision Medicine in Oncology II: Economics of Targeted Agents and Immuno-Oncology Drugs. J Clin Oncol 2019; 38:351-358. [PMID: 31804866 DOI: 10.1200/jco.19.01573] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Chen AJ, Hu X, Conti RM, Jena AB, Goldman DP. Trends in the Price per Median and Mean Life-Year Gained Among Newly Approved Cancer Therapies 1995 to 2017. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1387-1395. [PMID: 31806195 PMCID: PMC7589784 DOI: 10.1016/j.jval.2019.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 07/22/2019] [Accepted: 08/19/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND The prices of newly approved cancer drugs have risen over the past decades. A key policy question is whether the clinical gains offered by these drugs in treating specific cancer indications justify the price increases. OBJECTIVES To evaluate the price per median and mean life year gained among newly approved cancer therapies from 1995 to 2017. METHODS We collected data on the price (in 2017 USD) per life-year gained among cancer drug-indication pairs approved by the US Food and Drug Administration (FDA) between 1995 and 2017. We modeled trends using fractional polynomial and linear spline regression models that controlled for route of administration and cancer type fixed effects. RESULTS We found that between 1995 and 2012, price increases outstripped median survival gains, a finding consistent with previous literature. Nevertheless, price per mean life-year gained increased at a considerably slower rate, suggesting that new drugs have been more effective in achieving longer-term survival. Between 2013 and 2017, price increases reflected equally large gains in median and mean survival, resulting in a flat profile for benefit-adjusted launch prices in recent years. CONCLUSIONS Although drug costs have been rising more rapidly than median survival gains, they have been rising at about the same rate as mean survival gains. This suggests that when accounting for longer-term survival gains, the benefits of new drugs are roughly keeping pace with their costs, despite rapid cost growth.
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Affiliation(s)
- Alice J Chen
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA.
| | - Xiaohan Hu
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - Rena M Conti
- Questrom School of Business, Boston University, Boston, MA, USA
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA; National Bureau of Economic Research, Cambridge, MA, USA
| | - Dana P Goldman
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA; National Bureau of Economic Research, Cambridge, MA, USA
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29
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Price WN. Big data and black-box medical algorithms. Sci Transl Med 2019; 10:10/471/eaao5333. [PMID: 30541791 DOI: 10.1126/scitranslmed.aao5333] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 01/04/2018] [Accepted: 08/20/2018] [Indexed: 11/02/2022]
Abstract
New machine-learning techniques entering medicine present challenges in validation, regulation, and integration into practice.
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Affiliation(s)
- W Nicholson Price
- University of Michigan Law School, 921 Legal Research, 801 Monroe St., Ann Arbor, MI 48109, USA.,Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard Law School, 23 Everett St., Cambridge, MA 02138, USA.,Collaborative Research Program for Biomedical Innovation Law, University of Copenhagen Faculty of Law, Copenhagen, Denmark
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Abstract
IMPORTANCE Although randomized clinical trials are considered to be the criterion standard for generating clinical evidence, the use of real-world evidence to evaluate the efficacy and safety of medical interventions is gaining interest. Whether observational data can be used to address the same clinical questions being answered by traditional clinical trials is still unclear. OBJECTIVE To identify the number of clinical trials published in high-impact journals in 2017 that could be feasibly replicated using observational data from insurance claims and/or electronic health records (EHRs). DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional analysis, PubMed was searched to identify all US-based clinical trials, regardless of randomization, published between January 1, 2017, and December 31, 2017, in the top 7 highest-impact general medical journals of 2017. Trials were excluded if they did not involve human participants, did not use end points that represented clinical outcomes among patients, were not characterized as clinical trials, and had no recruitment sites in the United States. MAIN OUTCOMES AND MEASURES The primary outcomes were the number and percentage of trials for which the intervention, indication, trial inclusion and exclusion criteria, and primary end points could be ascertained from insurance claims and/or EHR data. RESULTS Of the 220 US-based trials analyzed, 33 (15.0%) could be replicated using observational data because their intervention, indication, inclusion and exclusion criteria, and primary end points could be routinely ascertained from insurance claims and/or EHR data. Of the 220 trials, 86 (39.1%) had an intervention that could be ascertained from insurance claims and/or EHR data. Among the 86 trials, 62 (72.1%) had an indication that could be ascertained. Forty-five (72.6%) of 62 trials had at least 80% of inclusion and exclusion criteria data that could be ascertained. Of these 45 studies, 33 (73.3%) had at least 1 primary end point that could be ascertained. CONCLUSIONS AND RELEVANCE This study found that only 15% of the US-based clinical trials published in high-impact journals in 2017 could be feasibly replicated through analysis of administrative claims or EHR data. This finding suggests the potential for real-world evidence to complement clinical trials, both by examining the concordance between randomized experiments and observational studies and by comparing the generalizability of the trial population with the real-world population of interest.
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Affiliation(s)
| | - Sanket S. Dhruva
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco
- Section of Cardiology, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Nilay D. Shah
- Division of Health Care Policy & Research, Mayo Clinic, Rochester, Minnesota
| | - Patrick Ryan
- Epidemiology Analytics, Janssen Research and Development, Titusville, New Jersey
- Observational Health Data Sciences and Informatics (OHDSI), Department of Biomedical Informatics, Columbia University Medical Center, New York, New York
| | - Joseph S. Ross
- Section of General Internal Medicine and the National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
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31
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Vokinger KN, Kesselheim AS. Characteristics of trials and regulatory pathways leading to US approval of innovative vs. non-innovative oncology drugs. Health Policy 2019; 123:721-727. [DOI: 10.1016/j.healthpol.2019.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/22/2019] [Accepted: 06/04/2019] [Indexed: 12/22/2022]
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32
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Vera-Badillo FE, Tannock IF, Booth CM. Immunotherapy for Urothelial Cancer: Where Are the Randomized Trials? J Clin Oncol 2019; 37:2587-2591. [PMID: 31260641 DOI: 10.1200/jco.18.02257] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
| | - Ian F Tannock
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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33
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Vreman RA, Bouvy JC, Bloem LT, Hövels AM, Mantel‐Teeuwisse AK, Leufkens HG, Goettsch WG. Weighing of Evidence by Health Technology Assessment Bodies: Retrospective Study of Reimbursement Recommendations for Conditionally Approved Drugs. Clin Pharmacol Ther 2018; 105:684-691. [PMID: 30300938 PMCID: PMC6587700 DOI: 10.1002/cpt.1251] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/21/2018] [Indexed: 11/07/2022]
Abstract
This study assessed whether five Health Technology Assessment (HTA) bodies in Europe were more negative about drugs with a Conditional Marketing Authorization (CMA) that are approved without controlled studies compared to CMA drugs that are approved based on controlled studies. The HTA recommendations were categorized into positive, restricted, and negative. A total of 92 HTA recommendations were available for 27 drugs. Thirty of 62 (48%) and 17 of 30 (57%) of the recommendations were negative for drugs with and without controlled studies, respectively. Overall, only 12 (13%) recommendations were positive. In all jurisdictions, recommendations between drugs with and drugs without controlled data were comparable, which suggests that the presence of controlled data is not decisive in HTA evaluations. The small proportion of unrestricted positive recommendations highlights difficulties with recommending the drugs in this cohort, which may be caused by scientific uncertainty or other factors. Earlier collaboration between stakeholders is advised in order to improve patient access.
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Affiliation(s)
- Rick A. Vreman
- Division of Pharmacoepidemiology and Clinical PharmacologyUtrecht Institute for Pharmaceutical Sciences (UIPS)Utrecht UniversityUtrechtThe Netherlands
- The National Healthcare Institute (ZIN)DiemenThe Netherlands
| | | | - Lourens T. Bloem
- Division of Pharmacoepidemiology and Clinical PharmacologyUtrecht Institute for Pharmaceutical Sciences (UIPS)Utrecht UniversityUtrechtThe Netherlands
- Dutch Medicines Evaluation Board (MEB)UtrechtThe Netherlands
| | - Anke M. Hövels
- Division of Pharmacoepidemiology and Clinical PharmacologyUtrecht Institute for Pharmaceutical Sciences (UIPS)Utrecht UniversityUtrechtThe Netherlands
| | - Aukje K. Mantel‐Teeuwisse
- Division of Pharmacoepidemiology and Clinical PharmacologyUtrecht Institute for Pharmaceutical Sciences (UIPS)Utrecht UniversityUtrechtThe Netherlands
| | - Hubert G.M. Leufkens
- Division of Pharmacoepidemiology and Clinical PharmacologyUtrecht Institute for Pharmaceutical Sciences (UIPS)Utrecht UniversityUtrechtThe Netherlands
| | - Wim G. Goettsch
- Division of Pharmacoepidemiology and Clinical PharmacologyUtrecht Institute for Pharmaceutical Sciences (UIPS)Utrecht UniversityUtrechtThe Netherlands
- The National Healthcare Institute (ZIN)DiemenThe Netherlands
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Abstract
Patients with life-threatening disorders such as amyotrophic lateral sclerosis, for which only minimally effective medical therapies currently exist, often seek treatments not proven to be effective and not approved by regulatory agencies for use outside of experimental treatment trials. The expanded access (compassionate use) provisions of the US Food and Drug Administration (FDA) for access to such therapies are often perceived as being inadequate. In response, states have passed right-to-try laws designed to improve access to experimental therapies for patients willing to assume the risks associated with such treatments. This situation has resulted in conflicts between those who perceive access to such treatments as their right as autonomous individuals and those who believe that the principles of beneficence and nonmaleficence justify actions of physicians and regulators in controlling access to such treatments. A variety of factors also contribute to the inequitable distribution of such treatments. Better systems are needed to improve access to promising new treatments while protecting these vulnerable patients from the abuses associated with human research in the preregulatory era.
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Shepshelovich D, Tibau A, Goldvaser H, Molto C, Ocana A, Seruga B, Amir E. Postmarketing Modifications of Drug Labels for Cancer Drugs Approved by the US Food and Drug Administration Between 2006 and 2016 With and Without Supporting Randomized Controlled Trials. J Clin Oncol 2018; 36:1798-1804. [DOI: 10.1200/jco.2017.77.5593] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PurposeModifications in cancer drug indications, dosing, and related toxicities after Food and Drug Administration approval are common. It is unclear whether drug approval without a supporting randomized controlled trial (RCT) influences the probability of such modifications.MethodsWe searched the Drugs@FDA Web site for new drug indications for solid tumors approved between January 2006 and December 2016. Study characteristics, regulatory pathways, and label modifications from approval to October 2017 were collected from drug labels. Label modifications were considered to be major if defined as such in the drug label. Indications approved with and without supporting RCTs were compared using logistic regression. The Benjamini-Hochberg false discovery rate method was used to adjust for multiplicity.ResultsWe identified 59 individual drugs for 109 solid tumor indications. Of these, 17 indications (15.6%) were not supported by an RCT, with no change over time. Indications not supported by RCTs were more likely to require companion diagnostic tests (odds ratio [OR], 3.90; P = .02), to include surrogate end points as primary outcomes (OR, 7.88; P < .001), and to receive breakthrough therapy designation (OR, 7.62; P = .006) or accelerated approval (OR, 17.67; P < .001). Indications not supported by RCTs were associated with significantly higher odds of postapproval modifications in common adverse events (71% v 29%; OR, 5.78; P = .002). A nonsignificantly higher odds of postapproval major modifications in warnings and precautions was also observed (88% v 62%; OR, 4.61; P = .051). Postapproval major modifications in indication and usage, dosing and administration, boxed warnings, and contraindications were comparable in the two groups.ConclusionCancer drug indications not supported initially by RCTs are associated with more postmarketing safety-related label modifications. Health care professionals should be vigilant for unrecognized adverse effects when prescribing drugs approved without a supporting RCT.
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Affiliation(s)
- Daniel Shepshelovich
- Daniel Shepshelovich, Hadar Goldvaser, and Eitan Amir, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada; Daniel Shepshelovich and Hadar Goldvaser, Tel-Aviv University, Tel Aviv, Israel; Ariadna Tibau and Consolación Molto, Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona, Barcelona; Alberto Ocana, Castilla La Mancha University, Albacete, Spain; and Bostjan Seruga, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Ariadna Tibau
- Daniel Shepshelovich, Hadar Goldvaser, and Eitan Amir, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada; Daniel Shepshelovich and Hadar Goldvaser, Tel-Aviv University, Tel Aviv, Israel; Ariadna Tibau and Consolación Molto, Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona, Barcelona; Alberto Ocana, Castilla La Mancha University, Albacete, Spain; and Bostjan Seruga, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Hadar Goldvaser
- Daniel Shepshelovich, Hadar Goldvaser, and Eitan Amir, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada; Daniel Shepshelovich and Hadar Goldvaser, Tel-Aviv University, Tel Aviv, Israel; Ariadna Tibau and Consolación Molto, Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona, Barcelona; Alberto Ocana, Castilla La Mancha University, Albacete, Spain; and Bostjan Seruga, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Consolación Molto
- Daniel Shepshelovich, Hadar Goldvaser, and Eitan Amir, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada; Daniel Shepshelovich and Hadar Goldvaser, Tel-Aviv University, Tel Aviv, Israel; Ariadna Tibau and Consolación Molto, Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona, Barcelona; Alberto Ocana, Castilla La Mancha University, Albacete, Spain; and Bostjan Seruga, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Alberto Ocana
- Daniel Shepshelovich, Hadar Goldvaser, and Eitan Amir, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada; Daniel Shepshelovich and Hadar Goldvaser, Tel-Aviv University, Tel Aviv, Israel; Ariadna Tibau and Consolación Molto, Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona, Barcelona; Alberto Ocana, Castilla La Mancha University, Albacete, Spain; and Bostjan Seruga, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Bostjan Seruga
- Daniel Shepshelovich, Hadar Goldvaser, and Eitan Amir, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada; Daniel Shepshelovich and Hadar Goldvaser, Tel-Aviv University, Tel Aviv, Israel; Ariadna Tibau and Consolación Molto, Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona, Barcelona; Alberto Ocana, Castilla La Mancha University, Albacete, Spain; and Bostjan Seruga, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Eitan Amir
- Daniel Shepshelovich, Hadar Goldvaser, and Eitan Amir, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada; Daniel Shepshelovich and Hadar Goldvaser, Tel-Aviv University, Tel Aviv, Israel; Ariadna Tibau and Consolación Molto, Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona, Barcelona; Alberto Ocana, Castilla La Mancha University, Albacete, Spain; and Bostjan Seruga, Institute of Oncology Ljubljana, Ljubljana, Slovenia
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36
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Pregelj L, Hwang TJ, Hine DC, Siegel EB, Barnard RT, Darrow JJ, Kesselheim AS. Precision Medicines Have Faster Approvals Based On Fewer And Smaller Trials Than Other Medicines. Health Aff (Millwood) 2018; 37:724-731. [DOI: 10.1377/hlthaff.2017.1580] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lisette Pregelj
- Lisette Pregelj is a postdoctoral research fellow in the Business School, University of Queensland, in Brisbane, Australia
| | - Thomas J. Hwang
- Thomas J. Hwang is a researcher in the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, in Boston, Massachusetts
| | - Damian C. Hine
- Damian C. Hine is an associate professor of innovation and director of the Asia Pacific Enterprise Initiative in the Business Economics and Law Faculty, University of Queensland
| | - Evan B. Siegel
- Evan B. Siegel is CEO of Ground Zero Pharmaceuticals, Inc., in Irvine, California, and an adjunct professor in the School of Chemistry and Molecular Biosciences, University of Queensland
| | - Ross T. Barnard
- Ross T. Barnard is a professor of biotechnology and director of the Biotechnology Program, School of Chemistry and Molecular Biosciences, and ARC Training Centre for Biopharmaceutical Innovation, University of Queensland
| | - Jonathan J. Darrow
- Jonathan J. Darrow is a faculty member in the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School
| | - Aaron S. Kesselheim
- Aaron S. Kesselheim is an associate professor of medicine at Harvard Medical School and director of the Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School
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Lexchin J. Quality of evidence considered by Health Canada in granting full market authorisation to new drugs with a conditional approval: a retrospective cohort study. BMJ Open 2018; 8:e020377. [PMID: 29705760 PMCID: PMC5931291 DOI: 10.1136/bmjopen-2017-020377] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES This study examines the characteristics of studies that Health Canada uses to grant full marketing authorisation for products given a conditional approval between 1 January 1998 and 30 June 2017. DESIGN Cohort study. DATA SOURCES Journal articles listing drugs that fulfilled their conditions and received full marketing authorisation, Notice of Compliance database, Notice of Compliance with conditions website, Qualifying Notices listing required confirmatory studies, clinicaltrials.gov, PubMed, Embase, companies making products being analysed, journal articles resulting from confirmatory studies. INTERVENTIONS None. PRIMARY AND SECONDARY OUTCOME MEASURES Characteristics of studies-study design (randomised controlled trials, observational), primary outcome used (clinical, surrogate), blinding, number of patients in studies, patient median age, number of men and women. RESULTS Eleven companies confirmed 36 publications for 19 products (21 indications). Twenty-nine out of the 36 studies were randomised controlled trials (RCTs) but only 10 stated if they were blinded. Twenty used surrogate outcomes. The median age of patients was 56 (IQR 44-61). The median number of men per study/trial was 184 (IQR 58-514) versus women 141 (IQR 46-263). CONCLUSIONS Postmarket studies required by Health Canada had more rigorous methodology than those required by either the Food and Drug Administration or the European Medicines Agency. There were still deficiencies in these studies. The absence of blinding in the majority of RCTs may introduce bias in their results. The use of surrogate outcomes especially in oncology trials means that improvements in survival are not available. The relatively young age of patients, even for products for cancer, means that predicting how the elderly will respond is often unknown. The almost universal finding that men outnumbered women may make it hard to differentiate responses by sex. These results raise potential concerns about the quality of evidence that Health Canada accepts.
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Affiliation(s)
- Joel Lexchin
- School of Health Policy and Management, York University, Toronto, Ontario, Canada
- Emergency Department, University Health Network, Toronto, Ontario, Canada
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Affiliation(s)
- Jonathan J Darrow
- From the Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston
| | - Jerry Avorn
- From the Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston
| | - Aaron S Kesselheim
- From the Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston
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The ethical plausibility of the 'Right To Try' laws. Crit Rev Oncol Hematol 2018; 122:64-71. [PMID: 29458791 DOI: 10.1016/j.critrevonc.2017.12.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/27/2017] [Accepted: 12/19/2017] [Indexed: 11/23/2022] Open
Abstract
'Right To Try' (RTT) laws originated in the USA to allow terminally ill patients to request access to early stage experimental medical products directly from the producer, removing the oversight and approval of the Food and Drug Administration. These laws have received significant media attention and almost equally unanimous criticism by the bioethics, clinical and scientific communities. They touch indeed on complex issues such as the conflict between individual and public interest, and the public understanding of medical research and its regulation. The increased awareness around RTT laws means that healthcare providers directly involved in the management of patients with life-threatening conditions such as cancer, infective, or neurologic conditions will deal more frequently with patients' requests of access to experimental medical products. This paper aims to assess the ethical plausibility of the RTT laws, and to suggest some possible ethical tools and considerations to address the main issues they touch.
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Jokura Y, Yano K, Yamato M. Comparison of the new Japanese legislation for expedited approval of regenerative medicine products with the existing systems in the USA and European Union. J Tissue Eng Regen Med 2018; 12:e1056-e1062. [PMID: 28211195 PMCID: PMC5836905 DOI: 10.1002/term.2428] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/13/2017] [Indexed: 11/23/2022]
Abstract
Legislation for expedited-approval pathways and programmes for drugs, biologics or medical devices has been enacted for rapid commercialization of innovative products in the United States of America (USA) and the European Union (EU). However, less innovative products are increasingly benefitting from these expedited-approval pathways, and obligations to collect and report post-marketing data on approved products are being bypassed frequently. The Japanese government recently enacted legislation for a new conditional and time-limited approval pathway dedicated to regenerative medicine products. The current study examines this new legislation and compares it with existing US and EU regulatory frameworks, with a particular focus on how it addresses the limitations of existing systems. Regulations, guidance documents and approval information were gathered from the websites of the respective authorities in the USA, the EU and Japan, and the systems were categorized through qualitative analysis. The pathways and programmes from each region were categorized into four groups, based on the requirement of pre- or post-marketing clinical data. Expedited-approval pathways in the USA and the EU provide similar qualification criteria, such as severity of target disease; however, such criteria are not specified for the new pathway in Japan. Only the Japanese pathway stipulates a time limitation on exceptional approval, requiring post-marketing study for conditional and time-limited products. Continuous improvement is necessary to solve previously addressed issues within the expedited-approval pathways and programmes and to ensure that innovative medical products are rigourously screened, but also readily available to patients in need. The time limitation of conditional approval could be a potential solution to some of these problems. Copyright © 2017 The Authors. Tissue Engineering Regenerative Medicine published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Yoji Jokura
- Joint Graduate School of Tokyo Women's Medical University and Waseda UniversityTokyoJapan
| | - Kazuo Yano
- Joint Graduate School of Tokyo Women's Medical University and Waseda UniversityTokyoJapan
- Institute of Advanced Biomedical Engineering and ScienceTokyo Women's Medical UniversityTokyoJapan
- Research Institute for Science and EngineeringWaseda UniversityTokyoJapan
| | - Masayuki Yamato
- Joint Graduate School of Tokyo Women's Medical University and Waseda UniversityTokyoJapan
- Institute of Advanced Biomedical Engineering and ScienceTokyo Women's Medical UniversityTokyoJapan
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Kimberly LL, Beuttler MM, Shen M, Caplan AL, Bateman-House A. Pre-approval Access Terminology: A Cause for Confusion and a Danger to Patients. Ther Innov Regul Sci 2017; 51:494-500. [DOI: 10.1177/2168479017696267] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Yeh JS, Sarpatwari A, Kesselheim AS. Ethical and Practical Considerations in Removing Black Box Warnings from Drug Labels. Drug Saf 2017; 39:709-14. [PMID: 27000800 DOI: 10.1007/s40264-016-0419-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Boxed warnings-also known as "black box" warnings-can be a powerful tool in communicating drug risks to physicians and patients. The overall number of boxed warnings has grown in recent years as the US Food and Drug Administration (FDA) has approved more drugs on the basis of limited pre-marketing information and as new safety issues for marketed drugs have been identified. Two recent manufacturers' petitions to remove boxed warnings on the drugs rosiglitazone (Avandia) and varenicline (Chantix) have led to divergent FDA decisions and revealed different considerations involved in boxed warning imposition and removal. For ethical and practical reasons, the FDA is justified in applying a higher standard for boxed warning removal than for imposition, as removal of a boxed warning may have unintended effects on physician and patient behavior. However, no guidelines on boxed warning removal currently exist. To promote safe use of approved prescription drugs, the FDA should adopt a uniform and transparent process governing decisions to impose or remove boxed warnings.
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Affiliation(s)
- James S Yeh
- Program on Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA.
| | - Ameet Sarpatwari
- Program on Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
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Tibau A, Molto C, Ocana A, Templeton AJ, Del Carpio LP, Del Paggio JC, Barnadas A, Booth CM, Amir E. Magnitude of Clinical Benefit of Cancer Drugs Approved by the US Food and Drug Administration. J Natl Cancer Inst 2017; 110:486-492. [DOI: 10.1093/jnci/djx232] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/06/2017] [Indexed: 12/31/2022] Open
Affiliation(s)
- Ariadna Tibau
- Oncology Department, Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Consolación Molto
- Oncology Department, Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alberto Ocana
- Centro de Investigación Biomédica en Red Cáncer, Madrid, Spain
| | - Arnoud J Templeton
- Department of Medical Oncology, St Claraspital and Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Luis P Del Carpio
- Oncology Department, Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joseph C Del Paggio
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Agustí Barnadas
- Oncology Department, Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, Canada
- Departments of Oncology and Public Health Sciences, Queen’s University, Kingston, Canada
| | - Eitan Amir
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada
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Affiliation(s)
- Feras Ali Mustafa
- Northamptonshire Healthcare NHS Foundation Trust, Northampton NN1 3EB, UK.
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Lexchin J. The Pharmaceutical Industry and the Canadian Government: Folie à Deux. ACTA ACUST UNITED AC 2017; 13:10-16. [PMID: 28906232 PMCID: PMC5595210 DOI: 10.12927/hcpol.2017.25195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The interest of the pharmaceutical industry is in achieving a profit for its shareholders while the interest of the Canadian government should be in protecting public health. However, over the course of the past few decades the actions of the Canadian government have been tilted in favour of industry in two areas. The first is in the relationship between industry and Health Canada and is manifested in the regulation of clinical trials, the drug approval system, drug safety and promotion. The second is in economic policy as it applies to policies about patent protection, the price of medications and measures taken to incentivize research and development. The problems in the relationship are structural and will only be solved through systemic changes.
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Affiliation(s)
- Joel Lexchin
- Professor Emeritus, School of Health Policy and Management, York University; Emergency Physician, University Health Network; Associate Professor, Department of Family and Community Medicine, University of Toronto, Toronto, ON
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Lysaght T. Accelerating regenerative medicine: the Japanese experiment in ethics and regulation. Regen Med 2017; 12:657-668. [DOI: 10.2217/rme-2017-0038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
In 2014, the Japanese National Diet introduced new laws aimed at promoting the clinical translation of stem cells and regenerative medicine. The basic action of these laws is to allow the early introduction of regenerative medicine products into the Japanese market through an accelerated approval process, while providing patients with access to certain types of stem cell and cell-based therapies in the context of private clinical practice. While this framework appears to offer enormous opportunities for the translation of stem cell science, it raises ethical challenges that have not yet been fully explored. This paper critically analyzes this framework with respect to the prioritization of safety over clinical benefit, distributive justice and public trust in science and medicine. It is argued that the framework unfairly burdens patients and strained healthcare systems without any clear benefits, and may undermine the credibility of the regenerative medicine field as it emerges.
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Affiliation(s)
- Tamra Lysaght
- Centre for Biomedical Ethics, Yong LooLin School of Medicine, National University of Singapore, 119228, Singapore
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Variability in state Medicaid medication management initiatives. Res Social Adm Pharm 2017; 13:214-223. [DOI: 10.1016/j.sapharm.2016.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 01/23/2016] [Indexed: 11/23/2022]
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Kesselheim AS, Tan YT, Darrow JJ, Avorn J. Existing FDA pathways have potential to ensure early access to, and appropriate use of, specialty drugs. Health Aff (Millwood) 2016; 33:1770-8. [PMID: 25288421 DOI: 10.1377/hlthaff.2014.0529] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Specialty drugs are notable among prescription drugs in that they offer the possibility of substantial clinical improvement, come with important risks of adverse events and mortality, can be complex to manufacture or administer, and are usually extremely costly. The Food and Drug Administration (FDA) plays a critical role in ensuring that patients who could benefit from specialty drugs have access to them in a timely fashion. In this article we review the different strategies that the FDA can use to approve and influence the post-approval prescribing of specialty drugs. When specialty drugs show promise in early clinical trials, the FDA can expedite the drugs' availability to patients through expanded access programs and expedited approval pathways that speed regulatory authorization. After approval, to ensure that specialty drugs are directed to the patients who are most likely to benefit from them, the FDA can limit the scope of the drugs' indications, encourage the development of companion diagnostic tests to indicate which patients should receive the drugs, or require that manufacturers subject them to Risk Evaluation and Mitigation Strategies to ensure that their use is appropriately limited to a restricted population that is aware of the drugs' risks and benefits. Implementing these existing regulatory approaches can promote timely patient access to specialty drugs while preventing expensive and potentially inappropriate overuse.
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Affiliation(s)
- Aaron S Kesselheim
- Aaron S. Kesselheim is an associate professor of medicine at Harvard Medical School/Brigham and Women's Hospital, in Boston, Massachusetts
| | - Yongtian Tina Tan
- Yongtian Tina Tan is a medical student at Harvard Medical School, in Boston
| | - Jonathan J Darrow
- Jonathan J. Darrow was a postdoctoral research fellow at Brigham and Women's Hospital at the time of this research
| | - Jerry Avorn
- Jerry Avorn is a professor of medicine at Harvard Medical School/Brigham and Women's Hospital
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Boucaud-Maitre D, Altman JJ. Do the EMA accelerated assessment procedure and the FDA priority review ensure a therapeutic added value? 2006–2015: a cohort study. Eur J Clin Pharmacol 2016; 72:1275-1281. [DOI: 10.1007/s00228-016-2104-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 07/13/2016] [Indexed: 11/30/2022]
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