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Kokkotou E, Anagnostakis M, Evangelou G, Syrigos NK, Gkiozos I. Real-World Data and Evidence in Lung Cancer: A Review of Recent Developments. Cancers (Basel) 2024; 16:1414. [PMID: 38611092 PMCID: PMC11010882 DOI: 10.3390/cancers16071414] [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: 02/23/2024] [Revised: 03/31/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
Conventional cancer clinical trials can be time-consuming and expensive, often yielding results with limited applicability to real-world scenarios and presenting challenges for patient participation. Real-world data (RWD) studies offer a promising solution to address evidence gaps and provide essential information about the effects of cancer treatments in real-world settings. The distinction between RWD and data derived from randomized clinical trials lies in the method of data collection, as RWD by definition are obtained at the point of care. Experimental designs resembling those used in traditional clinical trials can be utilized to generate RWD, thus offering multiple benefits including increased efficiency and a more equitable balance between internal and external validity. Real-world data can be utilized in the field of pharmacovigilance to facilitate the understanding of disease progression and to formulate external control groups. By utilizing prospectively collected RWD, it is feasible to conduct pragmatic clinical trials (PCTs) that can provide evidence to support randomized study designs and extend clinical research to the patient's point of care. To ensure the quality of real-world studies, it is crucial to implement auditable data abstraction methods and develop new incentives to capture clinically relevant data electronically at the point of care. The treatment landscape is constantly evolving, with the integration of front-line immune checkpoint inhibitors (ICIs), either alone or in combination with chemotherapy, affecting subsequent treatment lines. Real-world effectiveness and safety in underrepresented populations, such as the elderly and patients with poor performance status (PS), hepatitis, or human immunodeficiency virus, are still largely unexplored. Similarly, the cost-effectiveness and sustainability of these innovative agents are important considerations in the real world.
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Affiliation(s)
- Eleni Kokkotou
- Oncology Unit, Third Department of Medicine, “Sotiria” General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.A.); (G.E.); (N.K.S.); (I.G.)
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Koole SN, Huisman AH, Timmers L, Westgeest HM, van Breugel E, Sonke GS, van Waalwijk van Doorn-Khosrovani SB. Lessons learned from postmarketing withdrawals of expedited approvals for oncology drug indications. Lancet Oncol 2024; 25:e126-e135. [PMID: 38423058 DOI: 10.1016/s1470-2045(23)00592-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 03/02/2024]
Abstract
In the past decade, there have been a record number of oncology therapy approvals by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA). Besides the EMA's conditional marketing authorisation programme and the FDA's Accelerated Approval Program, we observe a tendency towards fast approval for exploratory studies with non-randomised, uncontrolled designs and surrogate endpoints. This issue raises concerns about the robustness and effectiveness of accepted treatments, leaving patients and health-care professionals in a state of uncertainty. A substantial number of accelerated approvals have recently been withdrawn in the USA, with some still authorised in Europe, emphasising discrepancies in regulatory standards that affect both patients and society as a whole. We highlight examples of drugs, authorised on the basis of surrogate endpoints, that were later withdrawn due to an absence of overall survival benefit. Our findings address the challenges and consequences of accelerated approval pathways in oncology. In conclusion, this Policy Review calls for regulatory bodies to better align their procedures and insist on robust evidence, preferably through unbiased randomised controlled trials. Drug approval processes should prioritise patient benefit, overall survival, and quality of life to minimise risks and uncertainties for patients.
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Affiliation(s)
- Simone N Koole
- Medical Advisory Department, ONVZ Health Insurance, Houten, Netherlands.
| | | | - Lonneke Timmers
- Care Department, National Health Care Institute, Diemen, Netherlands
| | - Hans M Westgeest
- Department of Internal Medicine, Amphia Hospital, Breda, Netherlands
| | - Edwin van Breugel
- Medical Advisory Department, VGZ Health Insurance, Arnhem, Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
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Hermosilla M. Regulating ethical experimentation: Impacts of the breakthrough therapy designation on drug R&D. JOURNAL OF HEALTH ECONOMICS 2024; 94:102855. [PMID: 38241795 DOI: 10.1016/j.jhealeco.2023.102855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 12/16/2023] [Accepted: 12/28/2023] [Indexed: 01/21/2024]
Abstract
This article investigates patterns of pharmaceutical development activity around the 2012 creation of the FDA's Breakthrough Therapy Designation (BTD). The BTD introduced regulatory flexibility and support to avoid ethical challenges created by experimental therapies of exceptional performance in early stage clinical trials. We argue that the program's design indirectly created substantial incentives for the industry to pursue the designation. Consistent with this hypothesis, our evidence links the creation of the program with a substantial increase in the number of new drug indications entering the clinical trial process. This surge in introductions has resulted in a discernible increase in approvals, which has manifested with a lag and may strengthen in the future. Countering theoretical predictions, BTD incentives have not led to increased risk taking in project selection.
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Affiliation(s)
- Manuel Hermosilla
- University of Illinois at Chicago, College of Business Administration, United States of America; Johns Hopkins University, Carey Business School, United States of America.
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Henderson RH, French D, Stewart E, Smart D, Idica A, Redmond S, Eckstein M, Clark J, Sullivan R, Keeling P, Lawler M. Delivering the precision oncology paradigm: reduced R&D costs and greater return on investment through a companion diagnostic informed precision oncology medicines approach. J Pharm Policy Pract 2023; 16:84. [PMID: 37408046 DOI: 10.1186/s40545-023-00590-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 06/26/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Precision oncology medicines represent a paradigm shift compared to non-precision oncology medicines in cancer therapy, in some situations delivering more clinical benefit, and potentially lowering healthcare costs. We determined whether employing a companion diagnostic (CDx) approach during oncology medicines development delivers effective therapies that are within the cost constraints of current health systems. R&D costs of developing a medicine are subject to debate, with average estimates ranging from $765 million (m) to $4.6 billion (b). Our aim was to determine whether precision oncology medicines are cheaper to bring from R&D to market; a secondary goal was to determine whether precision oncology medicines have a greater return on investment (ROI). METHOD Data on oncology medicines approved between 1997 and 2020 by the US Food and Drug Administration (FDA) were analysed from the Securities and Exchange Commission (SEC) filings. Data were compiled from 10-K, 10-Q, and 20-F financial performance filings on medicines' development costs through their R&D lifetime. Clinical trial data were split into clinical trial phases 1-3 and probability of success (POS) of trials was calculated, along with preclinical costs. Cost-of-capital (CoC) approach was applied and, if appropriate, a tax rebate was subtracted from the total. RESULTS Data on 42 precision and 29 non-precision oncology medicines from 56 companies listed by the National Cancer Institute which had complete data available were analysed. Estimated mean cost to deliver a new oncology medicine was $4.4b (95% CI, $3.6-5.2b). Costs to bring a precision oncology medicine to market were $1.1b less ($3.5b; 95% CI, $2.7-4.5b) compared to non-precision oncology medicines ($4.6b; 95% CI, $3.5-6.1b). The key driver of costs was POS of clinical trials, accounting for a difference of $591.3 m. Additional data analysis illustrated that there was a 27% increase in return on investment (ROI) of precision oncology medicines over non-precision oncology medicines. CONCLUSION Our results provide an accurate estimate of the R&D spend required to bring an oncology medicine to market. Deployment of a CDx at the earliest stage substantially lowers the cost associated with oncology medicines development, potentially making them available to more patients, while staying within the cost constraints of cancer health systems.
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Affiliation(s)
- Raymond H Henderson
- Patrick G. Johnston Centre for Cancer Research, Queen's University, Belfast, UK.
- Queen's Management School, Queen's University Belfast, Belfast, UK.
- Diaceutics PLC, Dataworks at Kings Hall Health and Wellbeing Park, Co Antrim, Belfast, BT9 6GW, UK.
- Salutem Insights Ltd, Clough, Portlaoise, Garryduff, R32 V653, Ireland.
| | - Declan French
- Queen's Management School, Queen's University Belfast, Belfast, UK
| | - Elaine Stewart
- Queen's Management School, Queen's University Belfast, Belfast, UK
| | - Dave Smart
- Diaceutics PLC, Dataworks at Kings Hall Health and Wellbeing Park, Co Antrim, Belfast, BT9 6GW, UK
| | - Adam Idica
- Inovalon Inc., 4321 Collington Road, Bowie, MD, 20716, USA
| | - Sandra Redmond
- Salutem Insights Ltd, Clough, Portlaoise, Garryduff, R32 V653, Ireland
| | - Markus Eckstein
- Institute of Pathology, University Hospital Erlangen, Erlangen, Germany
| | - Jordan Clark
- Diaceutics PLC, Dataworks at Kings Hall Health and Wellbeing Park, Co Antrim, Belfast, BT9 6GW, UK
| | - Richard Sullivan
- Institute of Cancer Policy, School of Cancer Sciences, King's College London, London, UK
| | - Peter Keeling
- Diaceutics PLC, Dataworks at Kings Hall Health and Wellbeing Park, Co Antrim, Belfast, BT9 6GW, UK
| | - Mark Lawler
- Patrick G. Johnston Centre for Cancer Research, Queen's University, Belfast, UK
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Saesen R, Van Hemelrijck M, Bogaerts J, Booth CM, Cornelissen JJ, Dekker A, Eisenhauer EA, Freitas A, Gronchi A, Hernán MA, Hulstaert F, Ost P, Szturz P, Verkooijen HM, Weller M, Wilson R, Lacombe D, van der Graaf WT. Defining the role of real-world data in cancer clinical research: The position of the European Organisation for Research and Treatment of Cancer. Eur J Cancer 2023; 186:52-61. [PMID: 37030077 DOI: 10.1016/j.ejca.2023.03.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 04/07/2023]
Abstract
The emergence of the precision medicine paradigm in oncology has led to increasing interest in the integration of real-world data (RWD) into cancer clinical research. As sources of real-world evidence (RWE), such data could potentially help address the uncertainties that surround the adoption of novel anticancer therapies into the clinic following their investigation in clinical trials. At present, RWE-generating studies which investigate antitumour interventions seem to primarily focus on collecting and analysing observational RWD, typically forgoing the use of randomisation despite its methodological benefits. This is appropriate in situations where randomised controlled trials (RCTs) are not feasible and non-randomised RWD analyses can offer valuable insights. Nevertheless, depending on how they are designed, RCTs have the potential to produce strong and actionable RWE themselves. The choice of which methodology to employ for RWD studies should be guided by the nature of the research question they are intended to answer. Here, we attempt to define some of the questions that do not necessarily require the conduct of RCTs. Moreover, we outline the strategy of the European Organisation for Research and Treatment of Cancer (EORTC) to contribute to the generation of robust and high-quality RWE by prioritising the execution of pragmatic trials and studies set up according to the trials-within-cohorts approach. If treatment allocation cannot be left up to random chance due to practical or ethical concerns, the EORTC will consider undertaking observational RWD research based on the target trial principle. New EORTC-sponsored RCTs may also feature concurrent prospective cohorts composed of off-trial patients.
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Saesen R, Lacombe D, Huys I. Real-world data in oncology: a questionnaire-based analysis of the academic research landscape examining the policies and experiences of the cancer cooperative groups. ESMO Open 2023; 8:100878. [PMID: 36822113 PMCID: PMC10163156 DOI: 10.1016/j.esmoop.2023.100878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/07/2023] [Accepted: 01/13/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Real-world data (RWD) have quickly emerged as an important source of information to address uncertainties about new treatments, including novel anticancer therapies. Many stakeholders are using such data and the evidence derived therefrom to answer the questions that remain about the safety and effectiveness of antitumor medicines after their approval by regulators. Our objective was to investigate the academic RWD study landscape and explore to what extent RWD are being integrated into investigator-initiated clinical research. MATERIALS AND METHODS We designed an online survey that was distributed between May and August 2022 to representatives of cancer cooperative groups active in Europe, North America, South America, Asia, and/or Oceania. RESULTS In total, 125 cooperative groups operating in 58 different countries and conducting research across 13 distinct cancer domains participated in the survey. While most of the responders (67.2%) did not have a formal policy in place to gather and utilize RWD, a majority (68.0%) had carried out studies involving the analysis of such data before, both for exploratory and confirmatory purposes. The groups that were experienced in capturing and interpreting RWD had mainly worked with observational RWD that were not predominantly prospective or retrospective in nature and which originated from disease registries, electronic health records, and patient questionnaires. They perceived the low costs and the large scale of RWD research to be its most significant benefits, and viewed the accompanying methodological and operational challenges as its biggest constraints. However, they did not have a common understanding of what RWD were. Despite their experience with analyzing RWD, their research portfolio still primarily comprised traditional clinical trials; 62.5% of the groups that had never undertaken any RWD studies were nonetheless planning to initiate them in the future. CONCLUSIONS Cancer cooperative groups are already incorporating RWD studies into their research agendas, but still lack knowledge and expertise in this regard, and do not agree on what RWD are. The conduct of conventional clinical trials continues to be their priority.
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Affiliation(s)
- R Saesen
- European Organisation for Research and Treatment of Cancer (EORTC), Brussels, Belgium; Clinical Pharmacology and Pharmacotherapy Research Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| | - D Lacombe
- European Organisation for Research and Treatment of Cancer (EORTC), Brussels, Belgium
| | - I Huys
- Clinical Pharmacology and Pharmacotherapy Research Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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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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8
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Sahu M, Gupta R, Ambasta RK, Kumar P. Artificial intelligence and machine learning in precision medicine: A paradigm shift in big data analysis. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2022; 190:57-100. [PMID: 36008002 DOI: 10.1016/bs.pmbts.2022.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The integration of artificial intelligence in precision medicine has revolutionized healthcare delivery. Precision medicine identifies the phenotype of particular patients with less-common responses to treatment. Recent studies have demonstrated that translational research exploring the convergence between artificial intelligence and precision medicine will help solve the most difficult challenges facing precision medicine. Here, we discuss different aspects of artificial intelligence in precision medicine that improve healthcare delivery. First, we discuss how artificial intelligence changes the landscape of precision medicine and the evolution of artificial intelligence in precision medicine. Second, we highlight the synergies between artificial intelligence and precision medicine and promises of artificial intelligence and precision medicine in healthcare delivery. Third, we briefly explain the promise of big data analytics and the integration of nanomaterials in precision medicine. Last, we highlight the challenges and opportunities of artificial intelligence in precision medicine.
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Affiliation(s)
- Mehar Sahu
- Molecular Neuroscience and Functional Genomics Laboratory, Delhi Technological University (Formerly Delhi College of Engineering), Shahbad Daulatpur, Delhi, India
| | - Rohan Gupta
- Molecular Neuroscience and Functional Genomics Laboratory, Delhi Technological University (Formerly Delhi College of Engineering), Shahbad Daulatpur, Delhi, India
| | - Rashmi K Ambasta
- Molecular Neuroscience and Functional Genomics Laboratory, Delhi Technological University (Formerly Delhi College of Engineering), Shahbad Daulatpur, Delhi, India
| | - Pravir Kumar
- Molecular Neuroscience and Functional Genomics Laboratory, Delhi Technological University (Formerly Delhi College of Engineering), Shahbad Daulatpur, Delhi, India.
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Saesen R, Kantidakis G, Marinus A, Lacombe D, Huys I. How do cancer clinicians perceive real-world data and the evidence derived therefrom? Findings from an international survey of the European Organisation for Research and Treatment of Cancer. Front Pharmacol 2022; 13:969778. [PMID: 36091761 PMCID: PMC9449152 DOI: 10.3389/fphar.2022.969778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
Background: The role of real-world evidence (RWE) in the development of anticancer therapies has been gradually growing over time. Regulators, payers and health technology assessment agencies, spurred by the rise of the precision medicine model, are increasingly incorporating RWE into their decision-making regarding the authorization and reimbursement of novel antineoplastic treatments. However, it remains unclear how this trend is viewed by clinicians in the field. This study aimed to investigate the opinions of these stakeholders with respect to RWE and its suitability for informing regulatory, reimbursement-related and clinical decisions in oncology.Methods: An online survey was disseminated to clinicians belonging to the network of the European Organisation for Research and Treatment of Cancer between May and July 2021.Results: In total, 557 clinicians across 30 different countries participated in the survey, representing 13 distinct cancer domains. Despite seeing the methodological challenges associated with its interpretation as difficult to overcome, the respondents mostly (75.0%) perceived RWE positively, and believed such evidence could be relatively strong, depending on the designs and data sources of the studies from which it is produced. Few (4.6%) saw a future expansion of its influence on decision-makers as a negative evolution. Furthermore, nearly all (94.0%) participants were open to the idea of sharing anonymized or pseudonymized electronic health data of their patients with external parties for research purposes. Nevertheless, most clinicians (77.0%) still considered randomized controlled trials (RCTs) to be the gold standard for generating clinical evidence in oncology, and a plurality (49.2%) thought that RWE cannot fully address the knowledge gaps that remain after a new antitumor intervention has entered the market. Moreover, a majority of respondents (50.7%) expressed that they relied more heavily on RCT-derived evidence than on RWE for their own decision-making.Conclusion: While cancer clinicians have positive opinions about RWE and want to contribute to its generation, they also continue to hold RCTs in high regard as sources of actionable evidence.
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Affiliation(s)
- Robbe Saesen
- European Organisation for Research and Treatment of Cancer (EORTC), Brussels, Belgium
- Clinical Pharmacology and Pharmacotherapy Research Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- *Correspondence: Robbe Saesen,
| | - Georgios Kantidakis
- European Organisation for Research and Treatment of Cancer (EORTC), Brussels, Belgium
| | - Ann Marinus
- European Organisation for Research and Treatment of Cancer (EORTC), Brussels, Belgium
| | - Denis Lacombe
- European Organisation for Research and Treatment of Cancer (EORTC), Brussels, Belgium
| | - Isabelle Huys
- Clinical Pharmacology and Pharmacotherapy Research Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Janiaud P, Irony T, Russek-Cohen E, Goodman SN. U.S. Food and Drug Administration Reasoning in Approval Decisions When Efficacy Evidence Is Borderline, 2013-2018. Ann Intern Med 2021; 174:1603-1611. [PMID: 34543584 DOI: 10.7326/m21-2918] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The U.S. Food and Drug Administration (FDA) has substantial flexibility in its approval criteria in the context of life-threatening disease and unmet therapeutic need. OBJECTIVE To understand the FDA's evidentiary standards when flexible criteria are employed. DESIGN Case series. SETTING Applications submitted between 2013 and 2018 that went through multiple review cycles because the evidence for clinical efficacy was initially deemed insufficient. MEASUREMENTS Information was obtained from the approval package (available on Drugs@FDA), including advisory committee minutes, FDA reviews, and complete response letters. RESULTS Of 912 applications reviewed, 117 went through multiple review cycles; only 22 of these faced additional review primarily because of issues related to clinical efficacy. Concerns about the end point, the clinical meaningfulness of the observed effect, and inconsistent results were common bases for initial rejection. In 7 of the 22 cases, the approval did not require new evidence but rather new interpretations of the original evidence. No FDA decisions cited reasoning used in previous decisions. LIMITATION The conclusions rely on the authors' interpretation of the FDA statements and on a series of "close calls." CONCLUSION The FDA has no mechanism to find or tradition to cite similar cases when weighing evidence for approvals, resulting in standalone, bespoke decisions. These decisions show highly variable criteria for "substantial evidence" when flexible evidential criteria are used, highlighted by the recent approval of aducanumab. A precedential tradition and suitable information system are required for the FDA to improve institutional memory and build upon past decisions. These would increase the FDA's decisional transparency, consistency, and predictability, which are critical to preserving the FDA's most valuable asset, the public's trust. PRIMARY FUNDING SOURCE U.S. Food and Drug Administration.
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Affiliation(s)
- Perrine Janiaud
- Meta-research Innovation Center at Stanford, Stanford University School of Medicine, Stanford, California (P.J.)
| | - Telba Irony
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland (T.I.)
| | - Estelle Russek-Cohen
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland (E.R.-C.)
| | - Steven N Goodman
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California (S.N.G.)
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Pregelj L, Hine DC, Kesselheim AS, Darrow JJ. Assessing the Impact of US Food and Drug Administration Breakthrough Therapy Designation Timing on Trial Characteristics and Development Speed. Clin Pharmacol Ther 2021; 110:1018-1024. [PMID: 34048058 DOI: 10.1002/cpt.2318] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/23/2021] [Indexed: 11/10/2022]
Abstract
The US Congress created the Breakthrough Therapy designation in 2012 to expedite drug development and review through efficient clinical trial design and intensive interaction with US Food and Drug Administration (FDA) reviewers. Yet, of the 116 pivotal trials supporting Breakthrough-designated drugs approved 2013-2018, 96 (83%) were already underway or completed when the designation was granted, limiting the potential of the designation to influence trial design. We found no difference between these trials and the 20 (17%) that had not yet begun when the designation was granted (which had greater potential to be impacted by the designation) with respect to phase, size, intervention model (single-arm vs. multi-arm), or use of surrogate end points under the Accelerated Approval (AA) pathway. This finding suggests that, in contrast to previous studies, observed trial characteristics were not likely attributable to the designation, and instead other factors such as disease category (e.g., oncology) may be driving both trial design and Breakthrough designation. The 20 trials in our sample that began after designation was granted were, however, over 8 months shorter than trials of nondesignated drugs. This suggests that designations granted early in clinical development may reduce trial time by influencing aspects of clinical programs other than design characteristics, such as timelines for FDA responses. Alternately, certain drugs may be more likely to both receive an early designation and have a shorter trial duration, for example, because of therapeutic category or large effect size.
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Affiliation(s)
- Lisette Pregelj
- School of Chemistry and Molecular Biosciences, University of Queensland Business School, The University of Queensland, St Lucia, Queensland, Australia
| | - Damian C Hine
- Kemmy Business School, University of Limerick, Limerick, Ireland
| | - 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
| | - 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
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Lee SJC, Murphy CC, Gerber DE, Geiger AM, Halm E, Nair RG, Cox JV, Tiro JA, Skinner CS. Reimbursement Matters: Overcoming Barriers to Clinical Trial Accrual. Med Care 2021; 59:461-466. [PMID: 33492049 PMCID: PMC8026490 DOI: 10.1097/mlr.0000000000001509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Accrual to cancer clinical trials is suboptimal. Few data exist regarding whether financial reimbursement might increase accruals. OBJECTIVE The objective of this study was to assess perceptions about reimbursement to overcome barriers to trial accrual. RESEARCH DESIGN This was a cross-sectional survey. SUBJECTS Oncologists identified from the American Medical Association Physician Masterfile. MEASURES We report descriptive statistics, associations of physician characteristics with perceptions of reimbursement, domains, and subthemes of free-text comments. RESULTS Respondents (n=1030) were mostly medical oncologists (59.4%), ages 35-54 (67%), and male (75%). Overall, 30% reported discussing trials with >25% of patients. Barriers perceived were administrative/regulatory, physician/staff time, and eligibility criteria. National Cancer Institute cooperative group participants and practice owners were more likely to endorse higher reimbursement. Respondents indicated targeted reimbursement would help improve infrastructure, but also noted potential ethical problems with reimbursement for discussion (40.7%) and accrual (85.9%). Free-text comments addressed reimbursement sources, recipients, and concerns about the real and apparent conflict of interest. CONCLUSIONS Though concerns about a potential conflict of interest remain paramount and must be addressed in any new system of reimbursement, oncologists believe reimbursement to enhance infrastructure could help overcome barriers to trial accrual.
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Affiliation(s)
- Simon J. Craddock Lee
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
- Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
| | - Caitlin C. Murphy
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
- Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
| | - David E. Gerber
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
- Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
| | - Ann M. Geiger
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - Ethan Halm
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
- Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
| | - Rasmi G. Nair
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center
| | - John V. Cox
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jasmin A. Tiro
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
- Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
| | - Celette Sugg Skinner
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
- Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
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Issa AM, Carleton B, Gerhard T, Filipski KK, Freedman AN, Kimmel S, Liu G, Longo C, Maitland-van der Zee AH, Sansbury L, Zhou W, Bartlett G. Pharmacoepidemiology: A time for a new multidisciplinary approach to precision medicine. Pharmacoepidemiol Drug Saf 2021; 30:985-992. [PMID: 33715268 DOI: 10.1002/pds.5226] [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: 08/16/2020] [Accepted: 03/09/2021] [Indexed: 11/06/2022]
Abstract
The advent of the genomic age has created a rapid increase in complexity for the development and selection of drug treatments. A key component of precision medicine is the use of genetic information to improve therapeutic effectiveness of drugs and prevent potential adverse drug reactions. Pharmacoepidemiology, as a field, uses observational methods to evaluate the safety and effectiveness of drug treatments in populations. Pharmacoepidemiology by virtue of its focus, tradition, and research orientation can provide appropriate study designs and analysis methods for precision medicine. The objective of this manuscript is to demonstrate how pharmacoepidemiology can impact and shape precision medicine and serve as a reference for pharmacoepidemiologists interested in contributing to the science of precision medicine. This paper depicts the state of the science with respect to the need for pharmacoepidemiology and pharmacoepidemiological methods, tools and approaches for precision medicine; the need for and how pharmacoepidemiologists use their skills to engage with the precision medicine community; and recommendations for moving the science of precision medicine pharmacoepidemiology forward. We propose a new integrated multidisciplinary approach dedicated to the emerging science of precision medicine pharmacoepidemiology.
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Affiliation(s)
- Amalia M Issa
- Personalized Precision Medicine & Targeted Therapeutics, Springfield, Pennsylvania, USA.,'Pharmaceutical Sciences' and 'Health Policy', University of the Sciences in Philadelphia, Philadelphia, Pennsylvania, USA.,'Family Medicine' and `Centre of Genomics & Policy'; Faculty of Medicine & Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Bruce Carleton
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia, and BC Children's Hospital and Research Institute, Vancouver, British Columbia, Canada
| | - Tobias Gerhard
- Center for Pharmacoepidemiology and Treatment Science, Rutgers University, New Brunswick, New Jersey, USA
| | - Kelly K Filipski
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Andrew N Freedman
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Stephen Kimmel
- 'College of Public Health & Health Professions' and 'College of Medicine', University of Florida, Gainesville, Florida, USA
| | - Geoffrey Liu
- Epidemiology; Dalla Lana School of Public Health, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada
| | - Cristina Longo
- Respiratory Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Anke H Maitland-van der Zee
- Respiratory Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Leah Sansbury
- Epidemiology, Value Evidence and Outcomes, GlaxoSmithKline, Research Triangle Park, North Carolina, USA
| | - Wei Zhou
- Center for Observational and Real-world Evidence, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Gillian Bartlett
- School of Medicine, University of Missouri, Columbia, Missouri, USA
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Hwang TJ, Ross JS, Vokinger KN, Kesselheim AS. Association between FDA and EMA expedited approval programs and therapeutic value of new medicines: retrospective cohort study. BMJ 2020; 371:m3434. [PMID: 33028575 PMCID: PMC7537471 DOI: 10.1136/bmj.m3434] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To characterize the therapeutic value of new drugs approved by the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) and the association between these ratings and regulatory approval through expedited programs. DESIGN Retrospective cohort study. SETTING New drugs approved by the FDA and EMA between 2007 and 2017, with follow-up through 1 April 2020. DATA SOURCES Therapeutic value was measured using ratings of new drugs by five independent organizations (Prescrire and health authorities of Canada, France, Germany, and Italy). MAIN OUTCOME MEASURES Proportion of new drugs rated as having high therapeutic value; association between high therapeutic value rating and expedited status. RESULTS From 2007 through 2017, the FDA and EMA approved 320 and 268 new drugs, respectively, of which 181 (57%) and 39 (15%) qualified for least one expedited program. Among 267 new drugs with a therapeutic value rating, 84 (31%) were rated as having high therapeutic value by at least one organization. Compared with non-expedited drugs, a greater proportion of expedited drugs were rated as having high therapeutic value among both FDA approvals (45% (69/153) v 13% (15/114); P<0.001) and EMA approvals (67% (18/27) v 27% (65/240); P<0.001). The sensitivity and specificity of expedited program for a drug being independently rated as having high therapeutic value were 82% (95% confidence interval 72% to 90%) and 54% (47% to 62%), respectively, for the FDA, compared with 25.3% (16.4% to 36.0%) and 90.2% (85.0% to 94.1%) for the EMA. CONCLUSIONS Less than a third of new drugs approved by the FDA and EMA over the past decade were rated as having high therapeutic value by at least one of five independent organizations. Although expedited drugs were more likely than non-expedited drugs to be highly rated, most expedited drugs approved by the FDA but not the EMA were rated as having low therapeutic value.
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Affiliation(s)
- Thomas J Hwang
- 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
- Laboratory for Technology, Markets and Regulation, University of Zurich, Zurich, Switzerland
| | - Joseph S Ross
- Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Kerstin N Vokinger
- Laboratory for Technology, Markets and Regulation, University of Zurich, Zurich, Switzerland
- Institute of Law, University of Zurich, Zurich, Switzerland
| | - 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
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15
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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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Pregelj L, Hine DC, Oyola-Lozada MG, Munro TP. Working Hard or Hardly Working? Regulatory Bottlenecks in Developing a COVID-19 Vaccine. Trends Biotechnol 2020; 38:943-947. [PMID: 32600777 PMCID: PMC7293492 DOI: 10.1016/j.tibtech.2020.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 11/17/2022]
Abstract
Vaccine solutions rarely reach the public until after an outbreak abates; an Ebola vaccine was approved 5 years after peak outbreak and SARS, MERS, and Zika vaccines are still in clinical development. Despite massive leaps forward in rapid science, other regulatory bottlenecks are hamstringing the global effort for pandemic vaccines.
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Affiliation(s)
- Lisette Pregelj
- School of Chemistry and Molecular Biosciences and Australian Institute for Business and Economics, The University of Queensland, St Lucia, Queensland 4072, Australia
| | - Damian C Hine
- Kemmy Business School, University of Limerick, Limerick, V94 T9PX, Ireland
| | - Maria G Oyola-Lozada
- School of Chemistry and Molecular Biosciences and Faculty of Business, Economics and Law, The University of Queensland, St Lucia, Queensland 4072, Australia
| | - Trent P Munro
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St Lucia, Queensland 4072, Australia.
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17
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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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18
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Zhang AD, Puthumana J, Downing NS, Shah ND, Krumholz HM, Ross JS. Assessment of Clinical Trials Supporting US Food and Drug Administration Approval of Novel Therapeutic Agents, 1995-2017. JAMA Netw Open 2020; 3:e203284. [PMID: 32315070 PMCID: PMC7175081 DOI: 10.1001/jamanetworkopen.2020.3284] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
IMPORTANCE Since the introduction of the Fast Track designation in 1988, the number of special regulatory programs available for the approval of new drugs and biologics by the US Food and Drug Administration (FDA) has increased, offering the agency flexibility with respect to evidentiary requirements. OBJECTIVE To characterize pivotal efficacy trials supporting the approval of new drugs and biologics during the past 3 decades. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included 273 new drugs and biologics approved by the FDA for 339 indications from 1995 to 1997, from 2005 to 2007, and from 2015 to 2017. MAIN OUTCOMES AND MEASURES Therapeutics were classified by product type and therapeutic area as well as orphan designation and use of special regulatory programs, such as Priority Review and Accelerated Approval. Pivotal trials were characterized by use of randomization, blinding, types of comparators, primary end points, number of treated patients, and trial duration, both individually and aggregated by each indication approval. RESULTS A total of 273 new drugs and biologics were approved by the FDA in these 3 periods (107 [39.2%] in 1995-1997; 57 [20.9%] in 2005-2007; and 109 [39.9%] in 2015-2017), representing 339 indications (157 [46.3%], 64 [18.9%], and 118 [34.8%], respectively). The proportion of therapeutic approvals using at least 1 special regulatory program increased (37 [34.6%] in 1995-1997; 33 [57.9%] in 2005-2007; and 70 [64.2%] in 2015-2017), as did indication approvals receiving an orphan designation (20 [12.7%] in 1995-1997; 17 [26.6%] in 2005-2007, and 45 [38.1%] in 2015-2017). The most common therapeutic areas differed over time (infectious disease, 53 [33.8%] in 1995-1997 vs cancer, 32 [27.1%] in 2015-2017). When considering the aggregate pivotal trials supporting each indication approval, the proportion of indications supported by at least 2 pivotal trials decreased (80.6% [95% CI, 72.6%-87.2%] in 1995-1997; 60.3% [95% CI, 47.2%-72.4%] in 2005-2007; and 52.8% [95% CI, 42.9%-62.6%] in 2015-2017; P < .001). The proportion of indications supported by only single-group pivotal trials increased (4.0% [95% CI, 1.3%-9.2%] in 1995-1997; 12.7% [95% CI, 5.6%-23.5%] in 2005-2007; and 17.0% [95% CI, 10.4%-25.5%] in 2015-2017; P = .001), whereas the proportion supported by at least 1 pivotal trial of 6 months' duration increased (25.8% [95% CI, 18.4%-34.4%] in 1995-1997; 34.9% [95% CI, 23.3%-48.0%] in 2005-2007; and 46.2% [95% CI, 36.5%-56.2%] in 2015-2017; P = .001). CONCLUSIONS AND RELEVANCE In this study, more recent FDA approvals of new drugs and biologics were based on fewer pivotal trials, which, when aggregated by indication, had less rigorous designs but longer trial durations, suggesting an ongoing need for continued evaluation of therapeutic safety and efficacy after approval.
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Affiliation(s)
- Audrey D. Zhang
- New York University School of Medicine, New York
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
| | | | - Nicholas S. Downing
- Brigham and Women’s Hospital, Boston, Massachusetts
- now with Bain Capital Life Sciences, Boston Massachusetts
| | - Nilay D. Shah
- Division of Health Care Policy and Research and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- National Clinician Scholars Program, Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut
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19
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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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20
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Vokinger KN, Muehlematter UJ. Accessibility of cancer drugs in Switzerland: Time from approval to pricing decision between 2009 and 2018. Health Policy 2019; 124:261-267. [PMID: 31882156 DOI: 10.1016/j.healthpol.2019.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/25/2019] [Accepted: 12/12/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Approved drugs must be included on the so-called "special list" (SL) by the Federal Office for Public Health (FOPH) to be reimbursed by the social health insurance in Switzerland. The FOPH decides whether a drug may be included on SL and if so, negotiates the maximum price with the manufacturer. Time period between approval and inclusion on SL is important to evaluate accessibility of patients to drugs. METHODS We identified all approved cancer drugs for first indication between 2009-2018 in Switzerland and determined whether they have been included on SL, and if so, how many days passed between approval and reimbursement, i.e., inclusion on SL. Descriptive statistical analysis was performed by using R. RESULTS 70 cancer drugs have been approved between 2009 and 2018. Among this sample, 56 (80 %) are on SL. Average time from drug approval to inclusion date on SL increased from 234 days in 2009 to 463 days in 2018, with an average time of 352 days over the full analysis period. CONCLUSION Time period between approval and inclusion on SL has prolonged over the past years. This impedes patients' access to cancer drugs. Prioritizing HTA and price negotiation of cancer drugs with high clinical benefit or implement a regulation that sets a maximum time period for HTA and price negotiation are possible policy implications.
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Affiliation(s)
- Kerstin N Vokinger
- Institute of Law, and Lab for Technology, Markets and Regulation, University of Zurich, Zurich, Switzerland; Institute for Primary Care, University Hospital of Zurich and University of Zurich, Zurich, Switzerland.
| | - Urs Jakob Muehlematter
- Institute of Diagnostic and Interventional Radiology, University Hospital of Zurich / University of Zurich, Department of Nuclear Medicine, University Hospital of Zurich/University of Zurich, Zurich, Switzerland
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21
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Neez E, Hwang TJ, Sahoo SA, Naci H. European Medicines Agency's Priority Medicines Scheme at 2 Years: An Evaluation of Clinical Studies Supporting Eligible Drugs. Clin Pharmacol Ther 2019; 107:541-552. [PMID: 31591708 DOI: 10.1002/cpt.1669] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 09/20/2019] [Indexed: 11/10/2022]
Abstract
The Priority Medicines (PRIME) scheme was launched by the European Medicines Agency (EMA) in 2016 to expedite the development and approval of promising products targeting conditions with high unmet medical need. Manufacturers of PRIME drugs receive extensive regulatory advice on their trial designs. Until June 2018, the EMA granted PRIME status to 39 agents, evaluated in 138 studies (102 initiated before and 36 after PRIME eligibility). A third of the studies forming the basis of PRIME designation were randomized controlled trials, and a quarter of the studies were blinded. There was no statistically significant difference between trials initiated before and after PRIME designation in terms of randomized design and use of blinding. However, significantly more efficacy studies included a clinical end point after PRIME designation than before, and significantly fewer included surrogate measures alone. There were no statistically significant differences between the trial designs of PRIME and non-PRIME-designated products.
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Affiliation(s)
- Emilie Neez
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Thomas J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Boston, Massachusetts, USA
| | - Samali Anova Sahoo
- Department of Life Sciences and Management, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
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22
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Mueller CM, Rao GR, Miller Needleman KI. Precision Medicines' Impact on Orphan Drug Designation. Clin Transl Sci 2019; 12:633-640. [PMID: 31297924 PMCID: PMC6853264 DOI: 10.1111/cts.12667] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/12/2019] [Indexed: 11/29/2022] Open
Abstract
The incentives provided under the Orphan Drug Act (ODA) have been credited for catalyzing the marketing approval of drugs for the treatment of rare diseases by the US Food and Drug Administration. Orphan drug designation, the granting of special status to drugs or biologics ("drugs") for the treatment of rare diseases, one of the ODA's key incentive programs, has seen major increases in volume over recent years. The new era of precision medicine and the development of therapies directed toward smaller "orphan" subsets of common diseases have been suggested as being a major driver. We evaluated the basis for orphan drug designations and orphan subsets in relation to the impact of precision medicines. We found that the increasing numbers of orphan drug designation determinations were not driven by precision medicines separating common diseases into orphan subsets and that orphan subsets overall also represented a relatively small proportion of designations.
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Affiliation(s)
- Christine M Mueller
- Office of Orphan Products Development, US Food and Drug Administration, Silver Spring, Maryland, USA
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23
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Vokinger KN, Muehlematter UJ, Rosemann TJ. Access to Cancer Precision Medicines in Switzerland: A Comparative Analysis (USA and EU) and Health Policy Implications. Public Health Genomics 2019; 21:238-243. [PMID: 31319411 DOI: 10.1159/000501562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 06/15/2019] [Indexed: 11/19/2022] Open
Abstract
Social health insurance is mandatory in Switzerland and covers the costs of basic medical care. In general, with regard to medicines, the costs are only reimbursed if the drug is (1) approved by Swissmedic and (2) listed on the so-called Spezia-litätenliste (SL) by the Federal Office of Public Health (FOPH). However, the SL does not include all drugs. For non-SL drugs, cost coverage is only granted under exceptional circumstances. Absence of cost coverage by social health insurance is especially problematic for patients who need access to cancer drugs, since they are often costly. Even if such cancer drugs are approved by Swissmedic, patients may still lack access to them. Therefore, access to medicines includes two aspects: (1) the availability of a drug on the market (i.e., approval of a drug) and (2) inclusion on the SL (i.e., cost coverage by social health insurance). In this study, we aim to compare the current approval regulations for oncologic precision medicines in the USA, Europe, and Switzerland; to investigate cost coverage for these drugs in Switzerland; and to develop health policy implications about how access to these drugs could be improved in Switzerland.
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Affiliation(s)
- Kerstin Noëlle Vokinger
- Academic Chair for Public Law and Digitalization, Faculty of Law, University of Zurich, Zurich, Switzerland, .,Institute of Primary Care, University Hospital Zurich/University of Zurich, Zurich, Switzerland,
| | - Urs Jakob Muehlematter
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich/University of Zurich, Zurich, Switzerland.,Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Zurich, Switzerland
| | - Thomas J Rosemann
- Institute of Primary Care, University Hospital Zurich/University of Zurich, Zurich, Switzerland
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24
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Gyawali B, Hwang TJ, Vokinger KN, Booth CM, Amir E, Tibau A. Patient-Centered Cancer Drug Development: Clinical Trials, Regulatory Approval, and Value Assessment. Am Soc Clin Oncol Educ Book 2019; 39:374-387. [PMID: 31099613 DOI: 10.1200/edbk_242229] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Historically, patient experience, including symptomatic toxicities, physical function, and disease-related symptoms during treatment or their perspectives on clinical trials, has played a secondary role in cancer drug development. Regulatory criteria for drug approval require that drugs are safe and effective, and almost all drug approvals have been based only on efficacy endpoints rather than on quality-of-life (QoL) assessments. In contrast to Europe, information regarding the impact of drugs on patients' QoL is rarely included in oncology drug labeling in the United States. Until recently, patient input and preferences have not been incorporated into the design and conduct of clinical trials. In recent years, a more in-depth understanding of cancer biology, as well as regulatory changes focused on expediting cancer drug development and approval, has allowed earlier access to novel therapeutic agents. Understanding the implications of these expedited programs is important for oncologists and patients, given the rapid expansion of these programs. In this article, we provide an overview of the role of QoL in the regulatory drug-approval process, key issues regarding trial participation from the patient perspective, and the implications of key expedited approval programs that are increasingly being used by regulatory bodies for cancer care.
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Affiliation(s)
- Bishal Gyawali
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Thomas J Hwang
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kerstin Noelle Vokinger
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,2 Institute for Primary Care and Health Outcomes Research, University of Zürich, Zürich, Switzerland
| | - Christopher M Booth
- 3 Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,4 Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Eitan Amir
- 5 Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Ariadna Tibau
- 6 Department of Oncology, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Spain
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