Standards for gene therapy clinical trials based on pro-active risk assessment in a London NHS Teaching Hospital Trust

A review of the evidence for occupational exposure risks to novel anticancer agents – A focus on monoclonal antibodies

Introduction

Evidence of occupational exposure risks to novel anticancer agents is limited and yet to be formally evaluated from the Australian healthcare perspective.

Methods

From March to September 2013 medical databases, organizational policies, drug monographs, and the World Wide Web were searched for evidence relating to occupational exposure to monoclonal antibodies, fusion proteins, gene therapies, and other unclassified novel anticancer agents.

Results

Australian legislation, national and international guidelines, and drug company information excluded novel agents or provided inconsistent risk assessments and safe handling recommendations. Monoclonal antibody guidelines reported conflicting information and were often divergent with available evidence and pharmacologic rationale demonstrating minimal internalisation ability and occupational exposure risk. Despite similar physiochemical, pharmacologic, and internalisation properties to monoclonal antibodies, fusion proteins were included in only a minority of guidelines. Clinical directives for the safe handling of gene therapies and live vaccines were limited, where available focusing on prevention against exposure and cross-contamination. Although mechanistically different, novel small molecule agents (proteasome inhibitors), possess similar physiochemical and internalisation properties to traditional cytotoxic agents warranting cytotoxic classification and handling.

Conclusion

Novel agents are rapidly emerging into clinical practice, and healthcare personnel have few resources to evaluate risk and provide safety recommendations. Novel agents possess differing physical, molecular and pharmacological profiles compared to traditional cytotoxic anticancer agents. Evaluation of occupational exposure risk should consider both toxicity and internalisation. Evidence-based guidance able to direct safe handling practices for novel anticancer agents across a variety of clinical settings is urgently required.

Overseeing innovative therapy without mistaking it for research: a function-based model based on old truths, new capacities, and lessons from stem cells

Should innovative therapy occur only within a research paradigm and under institutional review board oversight? The health risks from current human embryonic stem cell clinical applications have raised again a fundamental question addressed first in papers submitted to inform the writing of the Belmont Report. Revisiting the thinking underlying the Belmont Report, together with examining changed circumstances since then, leads to a new model for overseeing innovative therapy based on its unique risks and context, important changes since the Belmont Report, and new opportunities for addressing risks through safety and quality systems in health care.

Hypothesis: upregulation of a muscle-specific isoform of insulin-like growth factor-1 (IGF-1) by spinal manipulation

Spinal manipulation is a manual therapy approach commonly employed by chiropractors, osteopaths and manipulative physiotherapists in the treatment of back pain. It is characterised by a rapid high velocity, low amplitude thrust which commonly causes an audible 'pop' or 'cavitation' in the joint. Any beneficial effects are generally explained with reference to changes in vertebral joint movement. This paper looks at the process of spinal manipulation to see if there is reason to expect effects beyond simple changes in the biomechanics of the spine. It shows that during the process of spinal manipulation, rapid stretching of spinal muscles is inevitable. It goes on to review recent evidence that muscle stretch is a potent stimulus for the upregulation of a splice product of the insulin-like growth factor gene by the stretched muscle. Evidence that the product of this gene (mechano-growth factor; MGF) promotes muscle growth and repair (myotrophism) is presented, together with evidence that MGF promotes the growth and repair of neurones (neurotrophism). Against this background the hypothesis is proposed that one of the effects of spinal manipulation is to stretch spinal muscles which will upregulate MGF and result in local myotrophic and neurotrophic effects. This growth factor hypothesis represents a major departure from the biomechanical and biopsychosocial models currently used to explain the effects of spinal manipulation, and could provide the basis for further studies aimed at defining the molecular correlates of this type of manual therapy.