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Wu W, Wang Y, Tang Z, Gao Y, Huo Y. Regulatory oversight of cell therapy in China: Government's efforts in patient access and therapeutic innovation. Pharmacol Res 2020; 158:104889. [PMID: 32428666 DOI: 10.1016/j.phrs.2020.104889] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/09/2020] [Accepted: 05/02/2020] [Indexed: 11/15/2022]
Abstract
In recent years, remarkable progress has been made in the fundamental research and on clinical development of cell therapy. Although China has launched a series of regulations to establish a proper regulatory framework that facilitates the development of cell therapy products, the regulatory framework has not been able to meet the country's regulatory requirements. This article introduced the development of regulation and current regulatory pathways for cell therapy in China and identified the main challenges in clinical studies. China has recently tightened its policy on cell therapy clinical studies after medical chaos occurred in the area of cell therapy over the past few years. Currently the regulatory jurisdiction between NMPA and NHC are not very clear, especially for clinical somatic cell research, further efforts are necessary to establish a legislative system with a clear and functional regulatory framework for cell therapy.
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Affiliation(s)
- Weijia Wu
- Department of Clinical Pharmacy and Pharmaceutical Management, School of Pharmacy, Fudan University, Shanghai, China; Sino-Danish Regulatory Science Center, Fudan University, Shanghai, China
| | - Yuanyuan Wang
- Department of Clinical Pharmacy and Pharmaceutical Management, School of Pharmacy, Fudan University, Shanghai, China; Sino-Danish Regulatory Science Center, Fudan University, Shanghai, China
| | - Zhijia Tang
- Department of Clinical Pharmacy and Pharmaceutical Management, School of Pharmacy, Fudan University, Shanghai, China
| | - Yuan Gao
- Department of Clinical Pharmacy and Pharmaceutical Management, School of Pharmacy, Fudan University, Shanghai, China; Sino-Danish Regulatory Science Center, Fudan University, Shanghai, China.
| | - Yan Huo
- National Institution of Food and Drug Control, National Medical Products Administration, Beijing, China.
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Altavilla A, Giannuzzi V, Lupo M, Bonifazi D, Ceci A. Ethical, Legal and Regulatory Issues of Paediatric Translational Research. Call for an Adequate Model of Governance. Eur J Health Law 2020; 27:213-231. [PMID: 33652400 DOI: 10.1163/15718093-bja10010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The lack of paediatric medicines, including innovative and advanced ones, is a long-lasting and well-known problem at European and international levels. Despite the existing legal frameworks and incentives, children remain deprived of many kinds of therapy because of challenges faced in appropriately study and tailoring medicinal and other products for them. In this context, the necessity to foster paediatric research addressing unsolved and uncovered issues within a 'translational approach' has appeared. This article, after having clarified the concept of translational research in the perspective of the establishment of a European paediatric research infrastructure (RI), will identify and point out ethical, legal and regulatory issues particularly relevant in a children's rights perspective. It concludes asking for the setting up of an adequate model of governance within a future RI, including adequate and independent ethical oversight and a pluridisciplinary common service dealing with ethical, legal and societal issues relevant for children.
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Affiliation(s)
- Annagrazia Altavilla
- Espace Éthique Méditerranéen/PACA-Corse, Assistance Publique Hôpitaux de Marseille/Aix-Marseille Université Marseille France TEDDYChair
- TEDDY (European Network of Excellence for Paediatric Research) Pavia Italy
| | - Viviana Giannuzzi
- Fondazione per la Ricerca Farmacologica Gianni Benzi onlus Bari Italy
- TEDDY (European Network of Excellence for Paediatric Research) Pavia Italy
| | - Mariangela Lupo
- TEDDY (European Network of Excellence for Paediatric Research) Pavia Italy
| | - Donato Bonifazi
- TEDDY (European Network of Excellence for Paediatric Research) Pavia Italy
- Consorzio per Valutazioni Biologiche e Farmacologiche Bari Italy Coordinator, European Paediatric Translational Research Infrastructure (EPTRI)
| | - Adriana Ceci
- Fondazione per la Ricerca Farmacologica Gianni Benzi onlus Bari Italy
- TEDDY (European Network of Excellence for Paediatric Research) Pavia Italy
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3
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Romanis EC. Artificial womb technology and clinical translation: Innovative treatment or medical research? Bioethics 2020; 34:392-402. [PMID: 31782820 PMCID: PMC7216961 DOI: 10.1111/bioe.12701] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 09/12/2019] [Accepted: 10/25/2019] [Indexed: 05/20/2023]
Abstract
In 2017 and 2019, two research teams claimed 'proof of principle' for artificial womb technology (AWT). AWT has long been a subject of speculation in bioethical literature, with broad consensus that it is a welcome development. Despite this, little attention is afforded to more immediate ethical problems in the development of AWT, particularly as an alternative to neonatal intensive care. To start this conversation, I consider whether experimental AWT is innovative treatment or medical research. The research-treatment distinction, pervasive in regulation worldwide, is intended to isolate research activities and subject them to a greater degree of oversight. I argue that there is a tendency in the literature to conceptualize AWT for partial ectogenesis as innovative treatment. However, there are sufficiently serious ethical concerns with experimental AWT that mean that it must not be first used on humans on the basis that it is a 'beneficial treatment'. First, I outline the prospects for translation of AWT animal studies into treatment for human preterms. Second, I challenge the conceptualizations of experimental AWT as innovative treatment. It must be considered medical research to reflect the investigatory nature of the process and guarantee sufficient protections for subjects. Identifying that AWT is research is crucial in formulating further ethico-legal questions regarding the experimental use of AWT. Third, I demonstrate that clinical trials will be a necessary part of the clinical translation of AWT because of requirements laid out by regulators. I consider the justification for clinical trials and highlight some of the crucial ethical questions about the conditions under which they should proceed.
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Affiliation(s)
- Elizabeth Chloe Romanis
- Centre for Social Ethics and PolicyDepartment of LawUniversity of ManchesterManchesterUnited Kingdom of Great Britain and Northern Ireland
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De Wachter S, Knowles CH, Elterman DS, Kennelly MJ, Lehur PA, Matzel KE, Engelberg S, Van Kerrebroeck PEV. New Technologies and Applications in Sacral Neuromodulation: An Update. Adv Ther 2020; 37:637-643. [PMID: 31875299 PMCID: PMC7004424 DOI: 10.1007/s12325-019-01205-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Indexed: 11/26/2022]
Abstract
Recently rechargeable devices have been introduced for sacral neuromodulation (SNM) with conditional safety for full-body magnetic resonance imaging (MRI). Currently a recharge-free SNM device represents the standard implant; however, it is only approved for MRI head scans. As further new technologies with broader MRI capabilities are emerging, the advantages as well as disadvantages of both rechargeable versus recharge-free devices will be briefly discussed in this commentary from the perspective of patients, healthcare professionals, and providers.
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Affiliation(s)
- Stefan De Wachter
- Department of Urology, University Hospital Antwerpen, Antwerp, Belgium.
- Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Wlrijk, Belgium.
| | - Charles H Knowles
- Blizard Institute, Barts and the London SMD, Queen Mary University of London, London, UK
| | - Dean S Elterman
- Division of Urology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada
| | - Michael J Kennelly
- Department of Urology, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Paul A Lehur
- Coloproctology Unit, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Klaus E Matzel
- Chirurgische Klinik, Universität Erlangen, Erlangen, Germany
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Henningfield JE, Ashworth JB, Gerlach KK, Simone B, Schnoll SH. The nexus of opioids, pain, and addiction: Challenges and solutions. Prev Med 2019; 128:105852. [PMID: 31634511 DOI: 10.1016/j.ypmed.2019.105852] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 09/12/2019] [Accepted: 09/19/2019] [Indexed: 11/19/2022]
Abstract
Pain and addiction are complex disorders with many commonalities. Beneficial outcomes for both disorders can be achieved through similar principles such as individualized medication selection and dosing, comprehensive multi-modal therapies, and judicious modification of treatment as indicated by the patient's status. This is implicit in the term "medication assisted treatment" (MAT) for opioid use disorders (OUD), and is equally important in pain management; however, for many OUD and pain patients, medication is central to the treatment plan and should neither be denied nor withdrawn if critical to patient well-being. Most patients prescribed opioids for pain do not develop OUD, and most people with OUD do not develop it as a result of appropriately prescribed opioids. Nonetheless, concerns about undertreatment of pain in the late 20th century likely contributed to inappropriate prescribing of opioids. This, coupled with a shortfall in OUD treatment capacity and the unfettered flood of inexpensive heroin and fentanyl, behavioral economics and other factors facilitated the 21st century opioid epidemic. Presently, injudicious reductions in opioid prescriptions for pain are contributing to increased suffering and suicides by pain patients as well as worsening disparities in pain management for ethnic minority and low-income people. Many of these people are turning to illicit opioids, and no evidence shows that the reduction in opioid prescriptions is reducing OUD or overdose deaths. Comprehensive, science-based policies that increase access to addiction treatment for all in need and better serve people with pain are vital to addressing both pain and addiction.
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Affiliation(s)
- Jack E Henningfield
- Pinney Associates, United States of America; The Johns Hopkins University School of Medicine, United States of America.
| | - Judy B Ashworth
- Pinney Associates, United States of America; Harm Reduction Therapeutics, United States of America
| | | | - Bernie Simone
- Pinney Associates, United States of America; Harm Reduction Therapeutics, United States of America
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Towse A, Fenwick E. Uncertainty and Cures: Discontinuation, Irreversibility, and Outcomes-Based Payments: What Is Different About a One-Off Treatment? Value Health 2019; 22:677-683. [PMID: 31198185 DOI: 10.1016/j.jval.2019.03.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/25/2019] [Accepted: 03/29/2019] [Indexed: 06/09/2023]
Abstract
Payers are concerned that one-off "cures" bring great uncertainty with the consequential risk of incorrect adoption decisions, and significant budget impact from large one-off payments. Innovators worry about bias against "cures" in favor of repeat treatment, which is not in patients' interests. We find that even in the absence of a difference in uncertainty of outcomes, adverse pay-offs differ. The greater financial risk associated with a cure is related to the issue of treatment discontinuation, driven by irreversibility. This paper uses a stylized example to illustrate the need to separate three different elements of the issue: (i) one-off versus repeat or ongoing treatment, (ii) duration of treatment effect, and (iii) the potential role of financial arrangements or risk sharing to mitigate the financial risk to the payer. It concludes that: (i) prevalence and discontinuation issues mean that the impact on the payer of an incorrect decision is greater with a one-off treatment than a repeat therapy; (ii) with evidence collection this risk diminishes over time (a form of CED or OWR); and (iii) financial arrangements or risk sharing can eliminate differences for the payer as between one-off and repeat therapy. The impact of (iii) also addresses payer concerns about budget impact.
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Affiliation(s)
- Adrian Towse
- Office of Health Economics, London, England, UK.
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Abstract
Innovative practice occurs when a clinician provides something new, untested, or nonstandard to a patient in the course of clinical care, rather than as part of a research study. Commentators have noted that patients engaged in innovative practice are at significant risk of suffering harm, exploitation, or autonomy violations. By creating a pathway for harmful or nonbeneficial interventions to spread within medical practice without being subjected to rigorous scientific evaluation, innovative practice poses similar risks to the wider community of patients and society as a whole. Given these concerns, how should we control and oversee innovative practice, and in particular, how should we coordinate innovative practice and clinical research? In this article, I argue that an ethical approach overseeing innovative practice must encourage the early transition to rigorous clinical research without delaying or deferring the development of beneficial innovations or violating the autonomy rights of clinicians and their patients.
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Affiliation(s)
- Jake Earl
- a National Institutes of Health Clinical Center
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8
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Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 505] [Impact Index Per Article: 84.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
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Aapro M, Beguin Y, Bokemeyer C, Dicato M, Gascón P, Glaspy J, Hofmann A, Link H, Littlewood T, Ludwig H, Österborg A, Pronzato P, Santini V, Schrijvers D, Stauder R, Jordan K, Herrstedt J. Management of anaemia and iron deficiency in patients with cancer: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv96-iv110. [PMID: 29471514 DOI: 10.1093/annonc/mdx758] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- M Aapro
- Genolier Cancer Centre, Clinique de Genolier, Genolier, Switzerland
| | - Y Beguin
- University of Liège, Liège
- CHU of Liège, Liège, Belgium
| | - C Bokemeyer
- Department of Oncology, Hematology and BMT with Section Pneumology, University of Hamburg, Hamburg, Germany
| | - M Dicato
- Hématologie-Oncologie, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - P Gascón
- Department of Haematology-Oncology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - J Glaspy
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, USA
| | - A Hofmann
- Medical Society for Blood Management, Laxenburg, Austria
| | - H Link
- Klinik für Innere Medizin I, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - T Littlewood
- Department of Haematology, John Radcliffe Hospital, Oxford, UK
| | - H Ludwig
- Wilhelminen Cancer Research Institute, Wilhelminenspital, Vienna, Austria
| | - A Österborg
- Karolinska Institute and Karolinska Hospital, Stockholm, Sweden
| | - P Pronzato
- Medica Oncology, IRCCS Asiana Pedaliter Universitaria San Martino - IST, Institutor Nazionale per la Ricercars sol Chancre, Genova
| | - V Santini
- Department of Experimental and Clinical Medicine, Haematology, University of Florence, Florence, Italy
| | - D Schrijvers
- Department of Medical Oncology, Ziekenhuisnetwerk Antwerpen, Antwerp, Belgium
| | - R Stauder
- Department of Internal Medicine V (Haematology and Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - K Jordan
- Department of Medicine V, University of Heidelberg, Heidelberg, Germany
| | - J Herrstedt
- Department of Oncology, Zealand University Hospital Roskilde, Roskilde
- University of Copenhagen, Copenhagen, Denmark
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Ackerman MH, Porter-O'Grady T, Malloch K, Melnyk BM. Innovation‐Based Practice (IBP) Versus Evidence‐Based Practice (EBP): A New Perspective That Assesses and Differentiates Evidence and Innovation. Worldviews Evid Based Nurs 2018; 15:159-160. [PMID: 29729656 DOI: 10.1111/wvn.12292] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2018] [Indexed: 11/30/2022]
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Ikonomou L, Panoskaltsis-Mortari A, Wagner DE, Freishtat RJ, Weiss DJ. Unproven Stem Cell Treatments for Lung Disease-An Emerging Public Health Problem. Am J Respir Crit Care Med 2017; 195:P13-P14. [PMID: 28362195 DOI: 10.1164/rccm.1957p13] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Tumor angiogenesis is one of the main pathways targeted to treat cancer. Bevacizumab added survival benefit when combined with platinum-based chemotherapy in NSCLC. Recently, Phase III trials showed survival benefit when anti-angiogenic drugs are added to docetaxel as second-line treatment for NSCLC. These anti-angiogenic agents include nintedanib and ramucirumab, a tyrosine-kinase inhibitor and a monoclonal antibody, respectively, which target receptors involved in angiogenesis. These studies have some similarities and differences. We propose a new algorithm for treatment sequences in performance status 0-1 patients with non-oncogene-addicted NSCLC type adenocarcinoma. Indeed clearer scientific evidences are available for this subgroup of patients.
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MESH Headings
- Angiogenesis Inhibitors/therapeutic use
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Carcinoma, Non-Small-Cell Lung/blood supply
- Carcinoma, Non-Small-Cell Lung/drug therapy
- Chemotherapy, Adjuvant/methods
- Chemotherapy, Adjuvant/trends
- Docetaxel
- Humans
- Indoles/therapeutic use
- Lung Neoplasms/blood supply
- Lung Neoplasms/drug therapy
- Neovascularization, Pathologic/drug therapy
- Practice Guidelines as Topic
- Protein Kinase Inhibitors/therapeutic use
- Taxoids/therapeutic use
- Therapies, Investigational/standards
- Therapies, Investigational/trends
- Ramucirumab
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Affiliation(s)
- Giuseppe Bronte
- a 1 Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo , Palermo, Italy
| | - Francesco Passiglia
- a 1 Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo , Palermo, Italy
| | - Antonio Galvano
- a 1 Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo , Palermo, Italy
| | - Antonio Russo
- b 2 Section of Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo , Via del Vespro 129 - 90127 Palermo, Italy +39 091 655 2500 ; +39 091 655 4529 ;
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Ethics Committee of American Society for Reproductive Medicine. Moving innovation to practice: a committee opinion. Fertil Steril 2015; 104:39-42. [PMID: 25936239 DOI: 10.1016/j.fertnstert.2015.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 04/02/2015] [Indexed: 11/18/2022]
Abstract
The introduction of new strategies, tests and procedures into clinical practice raises challenging ethical issues involving evaluation of evidence, balancing benefits and harms, supporting patient autonomy, avoiding conflict of interest, and promoting advances in health care. The purpose of this document is to assist reproductive health practitioners as they introduce new interventions into the clinical care that they provide to patients.
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Mach F, Muller O. [Keep a critical mind!]. Rev Med Suisse 2014; 10:1163-1164. [PMID: 24964522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Chazov EI. [Fundamental medicine as a basis of innovations in medical practice]. TERAPEVT ARKH 2013; 85:6-7. [PMID: 24137957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Djulbegovic B, Kumar A, Glasziou PP, Perera R, Reljic T, Dent L, Raftery J, Johansen M, Di Tanna GL, Miladinovic B, Soares HP, Vist GE, Chalmers I. New treatments compared to established treatments in randomized trials. Cochrane Database Syst Rev 2012; 10:MR000024. [PMID: 23076962 PMCID: PMC3490226 DOI: 10.1002/14651858.mr000024.pub3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The proportion of proposed new treatments that are 'successful' is of ethical, scientific, and public importance. We investigated how often new, experimental treatments evaluated in randomized controlled trials (RCTs) are superior to established treatments. OBJECTIVES Our main question was: "On average how often are new treatments more effective, equally effective or less effective than established treatments?" Additionally, we wanted to explain the observed results, i.e. whether the observed distribution of outcomes is consistent with the 'uncertainty requirement' for enrollment in RCTs. We also investigated the effect of choice of comparator (active versus no treatment/placebo) on the observed results. SEARCH METHODS We searched the Cochrane Methodology Register (CMR) 2010, Issue 1 in The Cochrane Library (searched 31 March 2010); MEDLINE Ovid 1950 to March Week 2 2010 (searched 24 March 2010); and EMBASE Ovid 1980 to 2010 Week 11 (searched 24 March 2010). SELECTION CRITERIA Cohorts of studies were eligible for the analysis if they met all of the following criteria: (i) consecutive series of RCTs, (ii) registered at or before study onset, and (iii) compared new against established treatments in humans. DATA COLLECTION AND ANALYSIS RCTs from four cohorts of RCTs met all inclusion criteria and provided data from 743 RCTs involving 297,744 patients. All four cohorts consisted of publicly funded trials. Two cohorts involved evaluations of new treatments in cancer, one in neurological disorders, and one for mixed types of diseases. We employed kernel density estimation, meta-analysis and meta-regression to assess the probability of new treatments being superior to established treatments in their effect on primary outcomes and overall survival. MAIN RESULTS The distribution of effects seen was generally symmetrical in the size of difference between new versus established treatments. Meta-analytic pooling indicated that, on average, new treatments were slightly more favorable both in terms of their effect on reducing the primary outcomes (hazard ratio (HR)/odds ratio (OR) 0.91, 99% confidence interval (CI) 0.88 to 0.95) and improving overall survival (HR 0.95, 99% CI 0.92 to 0.98). No heterogeneity was observed in the analysis based on primary outcomes or overall survival (I(2) = 0%). Kernel density analysis was consistent with the meta-analysis, but showed a fairly symmetrical distribution of new versus established treatments indicating unpredictability in the results. This was consistent with the interpretation that new treatments are only slightly superior to established treatments when tested in RCTs. Additionally, meta-regression demonstrated that results have remained stable over time and that the success rate of new treatments has not changed over the last half century of clinical trials. The results were not significantly affected by the choice of comparator (active versus placebo/no therapy). AUTHORS' CONCLUSIONS Society can expect that slightly more than half of new experimental treatments will prove to be better than established treatments when tested in RCTs, but few will be substantially better. This is an important finding for patients (as they contemplate participation in RCTs), researchers (as they plan design of the new trials), and funders (as they assess the 'return on investment'). Although we provide the current best evidence on the question of expected 'success rate' of new versus established treatments consistent with a priori theoretical predictions reflective of 'uncertainty or equipoise hypothesis', it should be noted that our sample represents less than 1% of all available randomized trials; therefore, one should exercise the appropriate caution in interpretation of our findings. In addition, our conclusion applies to publicly funded trials only, as we did not include studies funded by commercial sponsors in our analysis.
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Affiliation(s)
- Benjamin Djulbegovic
- USF Clinical Translational Science Institute, Dpts of Medicine, Hematology and Health Outcome Research, USF and H. LeeMoffitt Cancer Center, USF Health Clinical Research, University of South Florida, Tampa, Florida, USA.
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18
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Aronson JK. When I use a word ... Innovations--'The Births of Time'. QJM 2012; 105:1037-9. [PMID: 22690008 DOI: 10.1093/qjmed/hcs094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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19
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20
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Ploem MCC, Vermeulen MR. [Vigilance in experimental treatment]. Ned Tijdschr Geneeskd 2012; 156:A4603. [PMID: 23031234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
When all standard care options are exhausted, it may be justifiable to carry out an experimental treatment. In the Netherlands, experimental treatment is distinguished from medical research; the latter primarily serves the public interest (obtaining medical knowledge), while the former does not. In experimental treatment, it is a doctor's duty to explain the treatment to the patient carefully and to obtain the patient's explicit consent. In addition, the doctor needs to list all relevant aspects of the treatment in the patient's medical record. A medical practitioner who abides by these rules has acted in accordance with the Dutch law. But, given the sometimes highly risky nature of experimental treatments, is this enough? We do not think so and therefore argue for two additional conditions which are focused on transparency. First, there is a need for a service to ensure that experimental treatments are registered. Second, the effects and side effects of each experimental treatment should be reported. We envision the further elaboration of these conditions to be not only a task for the medical profession but possibly also for government-appointed institutions.
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Affiliation(s)
- M C Corrette Ploem
- Afd. Sociale Geneeskunde, Academisch Medisch Centrum, Amsterdam, the Netherlands.
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van Delden JJMH. [Experimental treatment versus scientific research: data collection is not fundamentally different]. Ned Tijdschr Geneeskd 2012; 156:A5483. [PMID: 23031245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The authors of a recent article in the Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine) suggest that experimental treatment should only be performed if the effects and side effects are monitored and described systematically, and a report is published. I believe this may intuitively be the right thing to do, but that there are nevertheless many problems. It would become impossible to differentiate experimental treatment from scientific research, resulting in problems concerning the informed consent of the patient, for example. Their approach would imply that more assessments are necessary for studying the effects of an experimental treatment than there would be in a standard treatment context. These measurements can only be performed with the informed consent of the patient. But if the patient refuses to consent, he or she will not receive the experimental treatment. This situation seriously compromises the voluntary status of informed consent. Therefore, more discussion is needed before this proposal is adopted.
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Affiliation(s)
- J J M Hans van Delden
- Universitair Medisch Centrum Utrecht, Julius Centrum voor Gezondheidswetenschappen en Eerstelijns Geneeskunde, Utrecht, the Netherlands.
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Affiliation(s)
- Kenneth De Ville
- Brody School of Medicine, Bioethics and Interdisciplinary Studies, Greenville, NC 27834, USA.
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Biffl WL, Spain DA, Reitsma AM, Minter RM, Upperman J, Wilson M, Adams R, Goldman EB, Angelos P, Krummel T, Greenfield LJ. Responsible development and application of surgical innovations: a position statement of the Society of University Surgeons. J Am Coll Surg 2008; 206:1204-9. [PMID: 18501819 DOI: 10.1016/j.jamcollsurg.2008.02.011] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2008] [Accepted: 02/08/2008] [Indexed: 10/22/2022]
Affiliation(s)
- Walter L Biffl
- Department of Surgery, Denver Health Medical Center/University of Colorado-Denver, Denver, CO, USA
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Koch A, Röhmel J. Hypothesis Testing in the “Gold Standard” Design for Proving the Efficacy of an Experimental Treatment Relative to Placebo and a Reference. J Biopharm Stat 2007; 14:315-25. [PMID: 15206529 DOI: 10.1081/bip-120037182] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This article reviews the most important reasons to include a placebo and a reference treatment group in a study to investigate the efficacy of a new experimental treatment. We argue that as a general rule the regulatory requirement is the proven superiority of the experimental treatment over placebo and the proven noninferiority of the experimental treatment as compared to the reference treatment. Whether or not the reference treatment can be shown to be superior to placebo may impact the formulation of the indication but should not, per se, question the usefulness of the experimental treatment or the credibility of the principal proof of efficacy. We argue that a mandatory requirement for the reference treatment to be superior to placebo is ill founded and especially difficult to justify in the situation where the experimental treatment can also prove its superiority over the reference treatment. For this latter situation, it is shown that no adjustment for multiple hypothesis testing is needed, if at the same time superiority of the reference over placebo and superiority of the experimental treatment over the reference are investigated.
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Affiliation(s)
- Armin Koch
- Bundesinstitut für Arzneimittel und Medizinprodukte, Kurt Georg Kiesinger Allee, Bonn, Germany.
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Lekovic GP. The high price of innovation. Surg Neurol 2005; 64:90-1; discussion 91-3. [PMID: 15993199 DOI: 10.1016/j.surneu.2004.08.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2004] [Accepted: 08/09/2004] [Indexed: 05/03/2023]
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Pons JMV. [Experimental, innovative and standard procedures. Ethics and science in the introduction of medical technology]. Gac Sanit 2003; 17:422-9. [PMID: 14599427 DOI: 10.1016/s0213-9111(03)71780-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The dividing lines between experimental, innovative and standard medical procedures are frequently blurred in current clinical practice. This is even more true in the fields of surgery and implantable devices. These differ substantially from pharmacological interventions, which are better regulated.However, the character of the various medical interventions applied in human subjects should be ethically and scientifically delimited as clearly as possible. This task cannot be abandoned to personal discretion and criteria, which are currently used, especially in the field of surgical innovation. External and independent review of the risk-benefit ratio of proposed innovations should enable specification of the particular features of a technique in the patient-doctor relationship, as well as the ethical and scientific requirements for more appropriate evaluation.
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Affiliation(s)
- J M V Pons
- Agència d'Avaluació de Tecnologia i Recerca Mèdiques. Barcelona. España
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Abstract
The media can play an important role in influencing both the demand and supply of medical treatments, regardless of evidence of effectiveness. This can be highlighted by recent experiences in Italy following publicity for a new unproven treatment in Italy, which it was claimed was highly successful in treating a wide range of cancers. The media role in influencing both health authorities to fund large scale trials of the intervention and patients awareness and expectations of therapy are discussed. The changes in Italian media over the last 20 years have seen a reduction in the numbers of specialist medical journals, with increased emphasis placed on sensationalism rather than accuracy. The media though has the potential to play in future an important strategic role in disseminating accurate information on issues pertaining to health.
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Affiliation(s)
- Eva Benelli
- ZADIG-ROMA, Agenzia di Gionalismo Scientifico, ZADIG Roma srl, Via Monte Cristallo 6, 00141 Rome, Italy.
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Rhodes R. An innovative paradigm for clinical research. Am J Bioeth 2003; 3:59-61. [PMID: 14744338 DOI: 10.1162/152651603322614643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
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