Genetic Predisposition to Hematologic Malignancies in Childhood and Adolescence

Advances in molecular biology and genetic testing have greatly improved our understanding of the genetic basis of hematologic malignancies and have enabled the identification of new cancer predisposition syndromes. Recognizing a germline mutation in a patient affected by a hematologic malignancy allows for a tailored treatment approach to minimize toxicities. It informs the donor selection, the timing, and the conditioning strategy for hematopoietic stem cell transplantation, as well as the comorbidities evaluation and surveillance strategies. This review provides an overview of germline mutations that predispose to hematologic malignancies, focusing on those most common during childhood and adolescence, based on the new International Consensus Classification of Myeloid and Lymphoid Neoplasms.

Regulatory Reform Outcomes and Accelerated Regulatory Pathways for New Prescription Medicines in Australia

National Regulatory Authorities (NRAs) globally are facing the challenge of evaluating pharmaceutical products in a speedy manner, whilst simultaneously ensuring adequate efficacy, safety and quality of approved products. Additionally, common expectations include that the evaluation process is competent, flexible, commensurate with risk, efficient and rapid. In 2014, the Australian regulatory system was out of step with global regulatory developments which led to a comprehensive regulatory review and reform process. As part of the reforms, two Facilitated Regulatory Pathways (FRP) were developed for prescription medicines: Priority Review (PR) and Provisional Approval (PA). Furthermore, regulatory reliance and recognition arrangements have been expanded with the Therapeutic Goods Administration (TGA) making increased use of evaluation reports by trusted NRAs. The new pathways have been utilised by the pharmaceutical industry in Australia since 2017, with the number of medicines going through these pathways gradually increasing. Additional facilitated pathways have been developed following the review, providing alternatives to the standard pathway for registration of prescription medicines in Australia. The reform is timely, helping to position Australia well in the current global regulatory climate.

Gilteritinib (XOSPATA®) in Turkey: Early Access Program Results

Background And Objectives

Gilteritinib (XOSPATA®, Astellas) is a type I oral FLT3 inhibitor, a tyrosine kinase AXL inhibitor, involved in both c-Kit and FMS-like tyrosine kinase 3 (FLT3) resistance. In the phase 3 ADMIRAL trial, gilteritinib was compared with the standard of care in (R/R) acute myeloid leukemia (AML) patients who harbored any FLT3 mutation and showed superior efficacy with regard to response and survival.

Objectives

This research aimed to investigate the real-life efficacy and safety of gilteritinib in FLT3-positive R/R AML patients who were treated as a part of an early access program held in Turkey in April 2020 (NCT03409081).

Results

The research included 17 R/R AML patients who had received gilteritinib from seven centers. The overall response rate was 100%. The most common adverse events were anemia and hypokalemia (7 patients, 41.2%). Grade 4 thrombocytopenia was observed in one patient only (5.9%), leading to permanent treatment discontinuation. Patients with peripheral edema had a 10.47 (95% CI: 1.64-66.82) times higher risk of death than those without peripheral edema (p<0.05).

Conclusion

This research showed that patients with febrile neutropenia and peripheral edema were at a high risk of death when compared to patients without febrile neutropenia and peripheral edema.

Regulatory oversight on the use of experimental therapies during a pandemic: The case of early access to convalescent plasma therapy in three LMICs

Clinicians, especially in low- and middle-income countries (LMICs), contend with limited economic and healthcare resources in deciding appropriate and feasible care for their patients. Some of the LMICs affected by COVID-19 implemented convalescent plasma therapy without sufficient regulatory guidance. Based on this experience, there are several requirements going forward, including: the need for an immediately accessible data gathering and processing system; the necessity of establishing regulatory pathways for early access to experimental treatment during emergency situations; and the accompanying reporting and monitoring requirements must be set. The different stakeholders must also be properly incorporated in the system that such a pathway will create, without neglecting to properly inform the public of the patient rights especially during an emergency situation.

Patterns of alternative access: Unpacking the Slovak extraordinary drug reimbursement regime 2012-2016

Many countries employ "alternative access schemes" (e.g. compassionate use, early access programs, off-label use) that seek to provide patients with access to drugs not included on a positive drug list. These schemes offer flexibility to policy-makers but often lack transparency and clear rules. This ambiguity allows for dynamic responses to weaknesses in the main drug approval and reimbursement systems, but also opportunistic use by the health professionals, industry or patients. Yet, most descriptions of these schemes focus on the de jure rather than the de facto situation, presenting a potentially misleading picture. We describe one such scheme in practice: the Slovak "extraordinary reimbursement regime" (ERR), using semi-structured interviews with 18 experts and a new dataset of ERR drugs. The ERR expanded rapidly, doubling between 2012 and 2016. It combined features of four reimbursement schemes: (1) a backdoor market access for expensive drugs; (2) a compassionate use scheme for investigational drugs combined with a "legacy drugs" scheme for older unlicensed drugs; (3) a disease-specific scheme for cancer and orphan drugs; and (4) a scheme for off-label and "off-indication" drugs. These four features reflect broader challenges facing the Slovak reimbursement system. We conclude that detailed study of the type, size and evolution over time of alternative access schemes can serve as indicators of health policy objectives neglected by standard reimbursement systems.

Examining the impact of WHO's Focused Antenatal Care policy on early access, underutilisation and quality of antenatal care services in Malawi: a retrospective study

Background

A variety of antenatal care models have been implemented in low and middle-income countries over the past decades, as proposed by the World Health Organisation (WHO). One such model is the 2001 Focused Antenatal Care (FANC) programme. FANC recommended a minimum of four visits for women with uncomplicated pregnancies and emphasised quality of care to improve both maternal and neonatal outcomes. Malawi adopted FANC in 2003, however, up to now no study has been done to analyse the model’s performance with regards to antenatal care service quality and utilisation patterns.

Methods

The paper is based on data pooled from three comparable nationally representative Malawi Demographic and Health Survey (MDHS) datasets (2000, 2004 and 2010). The DHS collects data on demographics, socio-economic indicators, antenatal care, and the fertility history of reproductive women aged between 15 and 49. We pooled a sample of 8545 women who had a live birth in the last 5 years prior to each survey. We measure the impact of FANC on early access to care, underutilisation of care and quality of care with interrupted time series analysis. This method enables us to track changes in both levels and the trends of our outcome variables.

Results

We find that FANC is associated with earlier access to care. However, it has also been associated with unintended increases in underutilisation. We see no change in the quality of ANC services.

Conclusion

In light of the WHO 2016 ANC guidelines, which recommend an increase of visits to eight, these results are important. Given that we find underutilisation when the benchmark is set at four visits, eight visits are unlikely to be feasible in low-resource settings.

Early access to health products in France: Major advances of the French "Conseil stratégique des industries de santé" (CSIS) to be implemented (modalities, regulations, funding)

In a context of perpetual evolution of treatments, access to therapeutic innovation is a major challenge for patients and the various players involved in the procedures of access to medicines. The revolutions in genomic and personalized medicine, artificial intelligence and biotechnology will transform the medicine of tomorrow and the organization of our health system. It is therefore fundamental that France prepares for these changes and supports the development of its companies in these new areas. The recent "Conseil stratégique des industries de santé" launched by Matignon makes it possible to propose a regulatory arsenal conducive to the implementation and diffusion of therapeutic innovations. In this workshop, we present a number of proposals, our approach having remained pragmatic with a permanent concern to be effective in the short term for the patients and to simplify the procedures as much as possible. This was achieved thanks to the participation in this workshop of most of the players involved (industrial companies, "Agence nationale de sécurité du médicament et des produits de santé", "Haute Autorité de santé", "Institut national du cancer", "Les entreprises du médicament", hospitals, "Observatoire du médicament, des dispositifs médicaux et de l'innovation thérapeutique"…). The main proposals tend to favor the implementation of clinical trials on our territory, especially the early phases, a wider access to innovations by favoring early access programs and setting up a process called "autorisation temporaire d'utilisation d'extension" (ATUext) that make it possible to prescribe a medicinal product even if the latter has a marketing authorisation in another indication. In addition, we propose a conditional reimbursement that will be available based on preliminary data but will require re-evaluation based on consolidated data from clinical trials and/or real-life data. Finally, in order to better carry out these assessments, with a view to access or care, we propose the establishment of partnership agreements with health agencies/hospitals in order to encourage the emergence of field experts, in order to prioritize an ascending expertise closer to patients' needs and to real life.