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Gale RP, Zhang MJ, Lazarus HM. The role of randomized controlled trials, registries, observational databases in evaluating new interventions. Best Pract Res Clin Haematol 2023; 36:101523. [PMID: 38092482 DOI: 10.1016/j.beha.2023.101523] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/17/2023] [Indexed: 12/18/2023]
Abstract
Approaches to comparing safety and efficacy of interventions include analyzing data from randomized controlled trials (RCTs), registries and observational databases (ODBs). RCTs are regarded as the gold standard but data from such trials are sometimes unavailable because a disease is uncommon, because the intervention is uncommon, because of structural limitations or because randomization cannot be done for practical or (seemingly) ethical reasons. There are many examples of an unproved intervention being so widely-believed to be effective that clinical trialists and potential subjects decline randomization. Often, when a RCT is finally done the intervention is proved ineffective or even harmful. These situations are termed medical reversals and are not uncommon [1,2]. There is also the dilemma of when seemingly similar RCTs report discordant conclisions Data from high-quality registries, especially ODBs can be used when data from RCTs are unavailable but also have limitations. Biases and confounding co-variates may be unknown, difficult or impossible to identify and/or difficult to adjust for adequately. However, ODBs sometimes have large numbers of diverse subjects and often give answers more useful to clinicians than RCTs. Side-by-side comparisons suggest analyses from high-quality ODBs often give similar conclusions from high quality RCTs. Meta-analyses combining data from RCTs, registries and ODBs are sometimes appropriate. We suggest increased use of registries and ODBs to compare efficacy of interventions.
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Affiliation(s)
- Robert Peter Gale
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College of Science, Technology and Medicine, London, UK.
| | - Mei-Jie Zhang
- Center for International Blood and Marrow Research (CIBMTR), Medical College of Wisconsin, Milwaukee, WI, USA
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2
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Franzoi MA, Gillanders E, Vaz-Luis I. Unlocking digitally enabled research in oncology: the time is now. ESMO Open 2023; 8:101633. [PMID: 37660408 PMCID: PMC10482746 DOI: 10.1016/j.esmoop.2023.101633] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023] Open
Affiliation(s)
- M A Franzoi
- Cancer Survivorship Group, Inserm Unit 981, Gustave Roussy, Villejuif
| | - E Gillanders
- Cancer Survivorship Group, Inserm Unit 981, Gustave Roussy, Villejuif
| | - I Vaz-Luis
- Cancer Survivorship Group, Inserm Unit 981, Gustave Roussy, Villejuif; Department for the Organization of Patient Pathways, DIOPP, Gustave Roussy, Villejuif, France.
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3
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Brown BL, Mitra-Majumdar M, Joyce K, Ross M, Pham C, Darrow JJ, Avorn J, Kesselheim AS. Trends in the Quality of Evidence Supporting FDA Drug Approvals: Results from a Literature Review. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2022; 47:649-672. [PMID: 35867548 DOI: 10.1215/03616878-10041093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
CONTEXT New drug approvals in the United States must be supported by substantial evidence from "adequate and well-controlled" trials. The Food and Drug Administration (FDA) has flexibility in how it applies this standard. METHODS The authors conducted a systematic literature review of studies evaluating the design and outcomes of the key trials supporting new drug approvals in the United States. They extracted data on the trial characteristics, endpoint types, and expedited regulatory pathways. FINDINGS Among 48 publications eligible for inclusion, 30 covered trial characteristics, 23 covered surrogate measures, and 30 covered regulatory pathways. Trends point toward less frequent randomization, double-blinding, and active controls, with variation by drug type and indication. Surrogate measures are becoming more common but are not consistently well correlated with clinical outcomes. Drugs approved through expedited regulatory pathways often have less rigorous trial design characteristics. CONCLUSIONS The characteristics of trials used to approve new drugs have evolved over the past two decades along with greater use of expedited regulatory pathways and changes in the nature of drugs being evaluated. While flexibility in regulatory standards is important, policy changes can emphasize high-quality data collection before or after FDA approval.
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Affiliation(s)
| | | | | | | | | | | | - Jerry Avorn
- Brigham and Women's Hospital / Harvard Medical School
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4
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Paul V, Ferranti LB, Dilts DM. Redesigning the Clinical Trial Development Process as a Global Pharmaceutical Firm: Gaining Velocity via Lean-Sprint. J Pharm Innov 2022. [DOI: 10.1007/s12247-022-09669-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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N Chin C, Subhawong T, Grosso J, Wortman JR, McIntosh LJ, Tai R, Braschi-Amirfarzan M, Castillo P, Alessandrino F. Teaching cancer imaging in the era of precision medicine: Looking at the big picture. Eur J Radiol Open 2022; 9:100414. [PMID: 35309874 PMCID: PMC8927915 DOI: 10.1016/j.ejro.2022.100414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The role of imaging in cancer diagnosis and treatment has evolved at the same rapid pace as cancer management. Over the last twenty years, with the advancement of technology, oncology has become a multidisciplinary field that allows for researchers and clinicians not only to create individualized treatment options for cancer patients, but also to evaluate patients’ response to therapy with increasing precision. Familiarity with these concepts is a requisite for current and future radiologists, as cancer imaging studies represent a significant and growing component of any radiology practice, from tertiary cancer centers to community hospitals. In this review we provide the framework to teach cancer imaging in the era of genomic oncology. After reading this article, readers should be able to illustrate the basics cancer genomics, modern cancer genomics, to summarize the types of systemic oncologic therapies available, their patterns of response and their adverse events, to discuss the role of imaging in oncologic clinical trials and the role of tumor response criteria and to display the future directions of oncologic imaging.
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Affiliation(s)
- Christopher N Chin
- Department of Surgery, Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Ty Subhawong
- Department of Radiology, Leonard M. Miller School of Medicine, Miami, FL, USA
| | - James Grosso
- Department of Radiology, Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Jeremy R Wortman
- Department of Radiology, Lahey Health Medical Center, Beth Israel Lahey Health, Tufts University school of Medicine, Boston, MA, USA
| | - Lacey J McIntosh
- Department of Radiology, University of Massachusetts Chan Medical School, Memorial Health Care, Worcester, MA, USA
| | - Ryan Tai
- Department of Radiology, University of Massachusetts Chan Medical School, Memorial Health Care, Worcester, MA, USA
| | - Marta Braschi-Amirfarzan
- Department of Radiology, Lahey Health Medical Center, Beth Israel Lahey Health, Tufts University school of Medicine, Boston, MA, USA
| | - Patricia Castillo
- Department of Radiology, Leonard M. Miller School of Medicine, Miami, FL, USA
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Hauck CL, Kelechi TJ, Cartmell KB, Mueller M. Trial-level factors affecting accrual and completion of oncology clinical trials: A systematic review. Contemp Clin Trials Commun 2021; 24:100843. [PMID: 34765799 PMCID: PMC8573122 DOI: 10.1016/j.conctc.2021.100843] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 08/05/2021] [Accepted: 09/02/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Cancer is the second-leading cause of death in the United States. Clinical trials translate basic science discoveries into treatments needed by cancer patients. Inadequate accrual of trial participants is one of the most significant barriers to the completion of oncology clinical trials. OBJECTIVE The purpose of this study was to investigate trial-level factors that affect accrual and/or completion of oncology clinical trials, identify gaps in the literature, and indicate opportunities for future research. DESIGN A systematic review of the literature on trial-level factors that affect accrual and/or completion of oncology clinical trials was performed. Searches in PubMed and Scopus identified 6582 studies. Based on eligibility criteria, 16 studies were selected for the review. Results were analyzed according to the following: a) background factors, b) disease-related, c) treatment-related, and d) trial design. RESULTS Background factors that were investigated in relation to oncology clinical trial accrual and/or completion included sponsor, number and location of participating institutions, competing trials, time of trial opening, and fast-track status. Disease-related factors included the annual incidence and type(s) of targeted cancer. Several types of treatment such as drugs, radiation and surgery were examined in the studies. Trial design factors included trial development time, eligibility criteria, randomization, sample size, trial phase, placebo use, and required protocol procedures and their timing. CONCLUSION With low patient participation rates in oncology clinical trials that hold promise for future treatments, it is imperative that trial-level factors affecting accrual be identified and addressed to facilitate the completion of trials.
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Affiliation(s)
- Cherie L. Hauck
- Medical University of South Carolina, College of Nursing, 99 Jonathan Lucas St., Charleston, SC, 29425, USA
| | - Teresa J. Kelechi
- Medical University of South Carolina, College of Nursing, 99 Jonathan Lucas St., Charleston, SC, 29425, USA
| | - Kathleen B. Cartmell
- Clemson University, Department of Public Health Sciences, 503 Edwards Hall, Clemson, SC, 29634, USA
| | - Martina Mueller
- Medical University of South Carolina, College of Nursing, 99 Jonathan Lucas St., Charleston, SC, 29425, USA
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Ruchalski K, Braschi-Amirfarzan M, Douek M, Sai V, Gutierrez A, Dewan R, Goldin J. A Primer on RECIST 1.1 for Oncologic Imaging in Clinical Drug Trials. Radiol Imaging Cancer 2021; 3:e210008. [PMID: 33988475 DOI: 10.1148/rycan.2021210008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Drug discovery and approval in oncology is mediated by the use of imaging to evaluate drug efficacy in clinical trials. Imaging is performed while patients receive therapy to evaluate their response to treatment. Response criteria, specifically Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1), are standardized and can be used at different time points to classify response into the categories of complete response, partial response, stable disease, or disease progression. At the trial level, categorical responses for all patients are summated into image-based trial endpoints. These outcome measures, including objective response rate (ORR) and progression-free survival (PFS), are characteristics that can be derived from imaging and can be used as surrogates for overall survival (OS). Similar to OS, ORR and PFS describe the efficacy of a drug. U.S. Food and Drug Administration (FDA) regulatory approval requires therapies to demonstrate direct evidence of clinical benefit, such as improved OS. However, multiple programs have been created to expedite drug approval for life-threatening illnesses, including advanced cancer. ORR and PFS have been accepted by the FDA as adequate predictors of OS on which to base drug approval decisions, thus substantially shortening the time and cost of drug development (1). Use of imaging surrogate markers for drug approval has become increasingly common, accounting for more than 90% of approvals through the Accelerated Approval Program and allowing for use of many therapies which have altered the course of cancer. Keywords: Oncology, Tumor Response RSNA, 2021.
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Affiliation(s)
- Kathleen Ruchalski
- From the Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 1621, Los Angeles, CA 90095-1721 (K.R., M.D., V.S., A.G., R.D., J.G.); and Department of Radiology, Beth Israel Lahey Health, Burlington, Mass (M.B.A.)
| | - Marta Braschi-Amirfarzan
- From the Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 1621, Los Angeles, CA 90095-1721 (K.R., M.D., V.S., A.G., R.D., J.G.); and Department of Radiology, Beth Israel Lahey Health, Burlington, Mass (M.B.A.)
| | - Michael Douek
- From the Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 1621, Los Angeles, CA 90095-1721 (K.R., M.D., V.S., A.G., R.D., J.G.); and Department of Radiology, Beth Israel Lahey Health, Burlington, Mass (M.B.A.)
| | - Victor Sai
- From the Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 1621, Los Angeles, CA 90095-1721 (K.R., M.D., V.S., A.G., R.D., J.G.); and Department of Radiology, Beth Israel Lahey Health, Burlington, Mass (M.B.A.)
| | - Antonio Gutierrez
- From the Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 1621, Los Angeles, CA 90095-1721 (K.R., M.D., V.S., A.G., R.D., J.G.); and Department of Radiology, Beth Israel Lahey Health, Burlington, Mass (M.B.A.)
| | - Rohit Dewan
- From the Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 1621, Los Angeles, CA 90095-1721 (K.R., M.D., V.S., A.G., R.D., J.G.); and Department of Radiology, Beth Israel Lahey Health, Burlington, Mass (M.B.A.)
| | - Jonathan Goldin
- From the Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 1621, Los Angeles, CA 90095-1721 (K.R., M.D., V.S., A.G., R.D., J.G.); and Department of Radiology, Beth Israel Lahey Health, Burlington, Mass (M.B.A.)
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8
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Moore TJ, Mouslim MC, Blunt JL, Alexander GC, Shermock KM. Assessment of Availability, Clinical Testing, and US Food and Drug Administration Review of Biosimilar Biologic Products. JAMA Intern Med 2021; 181:52-60. [PMID: 33031559 PMCID: PMC7536628 DOI: 10.1001/jamainternmed.2020.3997] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Biosimilar biologic products were authorized in 2010, after the US Congress established an expedited pathway for approval of clinically similar versions of approved biologic products. Unlike for most small-molecule generic drugs, approval requirements for a biosimilar included animal studies and a comparative efficacy clinical trial. OBJECTIVE To analyze the evidence required to support a biosimilarity license application, examine the US Food and Drug Administration (FDA) evaluation process, and estimate the costs of the key clinical trial evidence. DESIGN This study evaluated all biosimilar biologic products approved from January 2010 through October 2019, using the publicly available FDA review documents, disclosures from ClinicalTrials.gov, and the published peer-reviewed literature. The costs of efficacy clinical trials were estimated using licensed proprietary software. MAIN OUTCOMES AND MEASURES The following elements of each approved biosimilar were evaluated: the extent of human clinical testing to establish that the biosimilar had no clinically meaningful differences with the reference product, results of comparative animal studies, and FDA-cited application deficiencies. The cited deficiencies included the following categories: (1) facility inspection, (2) manufacturing or product quality, (3) animal studies, (4) laboratory analytical studies, (5) phase 1 and/or immunogenicity studies, and (6) phase 3 comparative efficacy trials. RESULTS As of October 2019, the FDA had approved 23 biosimilar biologics for 9 reference products. The 29 clinical trials that established that the efficacy of the biosimilar products was comparable to that of the reference products enrolled a median (interquartile range [IQR]) of 504 (258-612) patients, had a median (IQR) estimated cost of $20.8 ($13.8-$35.3) million, and had a median (IQR) treatment duration of 52 (28-68) weeks. Substantial deficiencies temporarily halted the review of 9 applications, and the most frequent deficits were failed facilities inspections (n = 5) and manufacturing process quality problems (n = 6). The approved biosimilar submissions included 51 animal studies on species that included mice, rats, rabbits, dogs, and cynomolgus monkeys. Negative outcomes in 2 animal studies were attributed to differences between human and test species. The FDA generally met the standard 12-month review deadlines or stopped the review clock when serious deficiencies were identified. CONCLUSIONS AND RELEVANCE This study found that most comparative efficacy trials supporting the FDA approval of biosimilars appeared to be as rigorous as and often larger, longer, and more costly than pivotal trials for new molecular entities. Further research is needed into whether less costly comparative efficacy trials could provide adequate evidence of biosimilarity and whether animal studies contribute useful scientific evidence.
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Affiliation(s)
- Thomas J Moore
- Institute for Safe Medication Practices, Alexandria, Virginia.,Milken Institute School of Public Health, Department of Epidemiology, The George Washington University, Washington, DC
| | - Morgane C Mouslim
- The Center for Drug Safety and Effectiveness and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jenna L Blunt
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - G Caleb Alexander
- The Center for Drug Safety and Effectiveness and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | - Kenneth M Shermock
- The Center for Drug Safety and Effectiveness and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland.,Department of Pharmacy, Johns Hopkins Health System, Baltimore, Maryland
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Navigating Ethical Practices in the Era of High Cost Hematology. Curr Hematol Malig Rep 2020; 15:401-407. [PMID: 33025550 DOI: 10.1007/s11899-020-00599-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW In this review article, we will highlight ethical issues faced by hematologists due to a growing constellation of expensive diagnostics and therapeutics in hematology. We outline the important issues surrounding this topic including stakeholders, cost considerations, and various ethical challenges surrounding access to care, communication about costs, and individual vs. societal responsibilities. We review available tools to navigate these ethical themes and offer potential solutions. RECENT FINDINGS We identified several gaps in the literature on the topic of ethical issues in hematology treatment and supplement by non-hematological cancer and general medical literature. We propose proactive solutions to address these problems to include cost transparency, utilization of evidence-based decision making tools, application of the four quadrant approach to ethical care, and advanced systems-based practice curriculum for physician trainees.
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Increasing operational and scientific efficiency in clinical trials. Br J Cancer 2020; 123:1207-1208. [PMID: 32690866 PMCID: PMC7555462 DOI: 10.1038/s41416-020-0990-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/23/2020] [Accepted: 06/29/2020] [Indexed: 11/09/2022] Open
Abstract
Operational and scientific inefficiencies in clinical trials represent roadblocks that need to be identified and circumvented to advance drug development in oncology. The collaboration of key stakeholders to advance this agenda is crucial to accelerate clinical research and ultimately benefit patient care through the optimal allocation of time and resources.
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11
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Bach PB. Commentary on Hsiue et al: Cost savings and data limitations of new cancer drug studies. Clin Trials 2020; 17:126-128. [DOI: 10.1177/1740774520907668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Peter B Bach
- Center for Health Policy & Outcomes, Memorial Sloan Kettering Cancer Center, New York, USA
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