Clinical Benefit and Regulatory Outcomes of Cancer Drugs Receiving Accelerated Approval

Clinical Benefit, Trials, and Regulatory Approval of Oncology Indications Under Multiple Expedited Programs for Drug Marketing in China, 2018-2024

Following the implementation of drug regulatory reforms in China, expedited programs have been established to accelerate drug development, review, and approval for marketing. This study examined a sample of 302 oncology indications approved by the National Medical Products Administration (NMPA) to explore the relationship between indication characteristics, pivotal clinical trial features, clinical benefit, and the cumulative number of expedited program designations. Furthermore, the study evaluated the actual execution of these expedited programs in China by assessing the clinical development time and review time of the approvals for oncology indications. Indications that received a higher cumulative number of expedited program designations generally exhibit higher innovation, lower pivotal clinical trial quality, greater clinical benefit, and reduced clinical development time and review time. Within these expedited programs, the implementation of Conditional Approval (CA) was pivotal in shortening the clinical development time, while Priority Review (PR) contributed to a reduction in review time. However, no significant impact of Breakthrough Therapy Designation (BTD) on the drug development process was observed. The simultaneous implementation of multiple expedited programs has been shown to be more effective in decreasing both clinical development and review times. While the implementation of expedited programs in China has yielded preliminary outcomes, it is imperative for regulatory authorities to further refine the legal and regulatory frameworks associated with these programs, addressing any deficiencies arising from their implementation.

Cross-sectional Study and Comparison between Japan and the United States on Special Regulatory Pathways for Expedited Drug Development and Approval

BACKGROUND

Investigations on the relationship between the designated systems for drug development and regulatory processes in Japan and those in the United States over an extended period of time are limited.

OBJECTIVES

We aimed to comprehensively investigate the special regulatory pathways for approved drugs in Japan focusing on the types of drugs receiving SRPs, the benefits of SRP in terms of review periods, a comparison between Japan and the United States, and the investigation of mutual influences in obtaining SRPs in both countries over 20 years.

METHODS

All drugs approved in Japan between September 1999 and December 2022, and those that underwent various special regulations based on publicly available information were investigated. A comparison between Japan and the United States was conducted using publicly available information.

RESULTS

In total, 2,309 drugs were approved in Japan between September1999 and December 2022, of which 819 drugs received special regulatory pathways. The number of drugs receiving special regulatory pathways increased annually, from 10 from September to December in 1999 to 90 in 2022. Anticancer drugs accounted for one-third of all drugs. Orphan drugs (432 drugs, 52.7%), expedited reviews (257 drugs, 31.4%), and priority reviews (135 drugs, 16.5%) were the most common regulatory pathways. For drugs receiving special regulatory pathways, 315 (38.5%) were approved within 6 months and 699 (85.3%) were approved within 12 months (the mean review period in Japan). Designations of priority review, expedited review, and orphan drug in Japan mutually influence the designation of these special regulatory pathways. In addition, designation of expedited review and orphan drug in Japan was influenced by designation of breakthrough therapy in the US, and expedited review in Japan was influenced by fast track in the US. In the US, special regulatory pathways are not significantly overlapped each other in the US.

CONCLUSIONS

In the drugs approved in Japan, the Japanese specific special regulatory pathways are mutually influenced. Expedited review and orphan drug in Japan are significantly impacted by the specific special regulatory pathways of the US. Additionally, special regulatory pathways of the US did not influence each other.

Removing Ineffective Drugs From the Market: Implications for Oral Phenylephrine and Beyond

This Viewpoint examines the removal of ineffective licensed products from the market, specifically discussing the example of oral phenylephrine.

The therapeutic futility paradox: insights from oncological drug litigation in Ecuador

Background

In oncology, patients with advanced cancer are often subjected to treatments with limited therapeutic value. This phenomenon is amplified through drug litigation, where interpretations of the right to life and health can lead to decisions that fail to adequately consider evidence of real benefits.

Methods

This descriptive study analyzed discrepancies between key arguments in judicial rulings that favored access to oncological drugs and the outcomes of related clinical trials. We reviewed 5 rulings issued in Ecuador between 2012 and 2018 that represented claims from 36 patients. The analysis focused on comparing judicial decision arguments against evidence from pivotal clinical trials regarding quality of life and overall survival.

Results

The 16 litigated drugs were approved through accelerated pathways, of which 37.5% were classified by the European Medicines Agency (EMA) as requiring additional monitoring. While 97% of rulings stated that the litigated drugs improved quality of life or survival, clinical trials reported favorable benefits in less than 20% of cases for the judicially contested indications.

Conclusion

These findings reveal significant discrepancies between available scientific evidence and the arguments supporting judicial decisions in cases involving access to oncological drugs in Ecuador.

Regulatory Approval of CAR-T Cell and BsAb Products for Lymphoid Neoplasms in the US, EU, and Japan

Chimeric antigen receptor (CAR)-T cell and bispecific antibodies (BsAb) have substantially improved outcomes for lymphoid neoplasms (LN); however, a comprehensive analysis regarding the regulatory approval for these products is not available; therefore, we aimed to address this research gap. We identified all indications for CAR-T cell and BsAb products for LN approved in the United States, European Union, or Japan between January 2010 and September 2023 using public databases. The United States was the most frequent region of first approval for both CAR-T (11/12 [92%]) and BsAb groups (6/9 [67%]). Regulatory incentives, such as orphan designation and expedited reviews, were more common in the CAR-T group than in the BsAb group in the United States, the European Union, and Japan. Pivotal trials for approval were generally identical in the United States and the European Union, and all indications, excluding the two indications for CAR-T cell products, were approved based on single-arm trials. The proportion of regular approvals was higher in the CAR-T group than in the BsAb group in both the United States (75% vs. 11%) and the European Union (67% vs. 25%). Unlike in the United States and European Union, all indications were granted regular approval in Japan. In conclusion, most indications for CAR-T cell and BsAb products were approved based on single-arm studies in the United States, European Union, and Japan; however, regulatory incentives and regular approvals were more frequently granted for CAR-T cell products than for BsAb products.

Sotorasib's Accelerated Approval: Wrong Dose and Indication

This Viewpoint reviews the accelerated approval process and lack of postapproval studies to verify its benefit as it applied to sotorasib, a treatment for non–small cell lung cancer with the KRASg12c mutation, and recommends measures to ensure confirmatory follow-up studies.

Factors in Time to Full Approval or Withdrawal for Anticancer Medicines Granted Accelerated Approval by the FDA

Importance

The accelerated approval pathway was developed to expedite US Food and Drug Administration (FDA) drug approval for life-threatening conditions based on changes to unvalidated surrogate measures, with conversion to regular approval then based on a required confirmatory trial. However, confirmatory trials may not be completed in a timely fashion.

Objective

To analyze factors associated with time to conversion to regular approval.

Design, setting, and participants

This cohort study of cancer drugs FDA-approved from 1992 to 2022 extracted pivotal and confirmatory trial characteristics, outcomes, safety data, and confirmatory study status at approval from drug labels and published reports. Clinical benefit was assessed using the European Society of Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS) for pivotal and confirmatory studies. High benefit was defined as grade A or B (for trials of curative intent) and 4 or 5 (palliative intent) and low benefit as grade C and 2 or below. Data were analyzed between August 2023 and August 2024.

Main Outcome and Measure

Time to full approval or withdrawal.

Results

This cohort study analyzed 102 cancer drug indications granted accelerated approval by the FDA between 1992 and 2022 and converted to regular approval by August 31, 2024. The median (IQR) time to conversion was 3.1 (1.9-4.8) years. Of these, 83 (81%) received priority review, and 27 (26%) carried boxed warnings. On the ESMO-MCBS scale, 12 of 101 pivotal trials that were scorable showed high benefit (12%), 27 intermediate benefit (27%), and 62 low benefit (61%). Twenty-one confirmatory trials (21%) were initiated after accelerated approval. Factors at the time of accelerated approval that were associated with shorter times to full approval included priority review designation, absence of boxed warnings, initiation of confirmatory studies before approval, and pivotal trials showing intermediate or high benefit on the ESMO-MCBS framework. Among the 102 confirmatory trials, 34 (33%) demonstrated significant improvements in overall survival, and 14 of 35 trials (40%) reporting on quality of life showed significant benefits. The ESMO-MCBS scale was applicable to 98 trials, with 46 (47%) scoring high clinical benefit, 29 (30%) intermediate, and 23 (23%) low. Indications with benefits in overall survival (median [IQR], 2.15 [1.40-3.38] vs 3.70 [2.33-5.78] years), quality of life (median [IQR], 2.29 [1.85-3.53] vs 4.22 [2.52-5.72] years), and high clinical benefit in confirmatory trials (median [IQR], 2.34 [1.52-3.39] vs 3.91 [2.59-6.42] years) were associated with faster conversion to full approval.

Conclusions and Relevance

In this cohort study, drugs with low clinical benefit or safety concerns at accelerated approval were linked to delayed confirmatory studies, while high clinical benefit in confirmatory trials correlated with faster conversion. These associations can help guide patient decision-making around accelerated approval drugs.

A 5-year review of genomic medicine in breast cancer: insights from C-CAT data on 3776 Japanese patients

BACKGROUND

In Japan, despite 5 years since CGP tests were covered by insurance in 2019, low drug accessibility rates remain a critical issue. We evaluated drug accessibility in 3776 breast cancer from the C-CAT database using two criteria: the proportion first linked to PMDA-approved drugs with phase III trial evidence for breast cancer through CGP tests but not existing Companion diagnostics [CDx] (*), and the proportion first linked to PMDA-approved drugs including based on phase I and II trial evidence (**). Additionally, cases linked to investigational drugs for non-PMDA-approved drugs were counted.

METHODS

We identified the top 100 genetic alterations in Japanese breast cancer via CGP tests, listing corresponding drugs from C-CAT reports. Drug accessibility was re-evaluated through simulations with updated evidence levels by a member of the expert panel at Osaka University (EP-EL in OUH).

RESULTS

Results showed the proportion improved to 28.4% under the newest EP-EL in OUH, including 3.4% for HER2-negative cases eligible for HER2-targeted therapy due to ERBB2 amplification and 25.0% for ER-positive, HER2-negative cases eligible for capivasertib-fulvestrant therapy due to PIK3CA, AKT1, and PTEN alterations (*). However, in part, initial false negatives for HER2 status and practical difficulties in using CGP tests as a CDx for capivasertib exist. Including mutations like TMB-H, MSI-H, BRAF V600E mutation, and NTRK fusions raised the proportion to 37.9% (**), but lacking drugs with phase III trials evidence.

CONCLUSION

These findings highlight the ongoing difficulties in demonstrating clear clinical utility of CGP tests in Japan, emphasizing the need for broad discussions on its future direction.

Treatment of Multiple Myeloma in Patients Refractory to Daratumumab/Anti-CD38 Monoclonal Antibodies: A Systematic Review

BACKGROUND

There is a lack of clear guidance on the appropriate next choice of therapy for patients with relapsed/refractory multiple myeloma who become refractory to daratumumab, an anti-CD38 antibody. This review aims to identify and compare treatments with published clinical trial evidence among patients with daratumumab-refractory multiple myeloma.

METHODS

MEDLINE, Cochrane CENTRAL, and EMBASE databases were searched for clinical trials that evaluated treatments for patients with multiple myeloma who were refractory to daratumumab from November 2015 to October 2023. Eligible studies may have enrolled only patients who were refractory to daratumumab or reported findings on patients with daratumumab-refractory disease in subgroup analyses. Treatment outcomes of interest included response rates and survival outcomes. Screening and data extraction were done independently by two reviewers using covidence, and any discrepancy was resolved by a third reviewer. Qualitative synthesis was performed to describe and compare patient outcomes associated with different treatments.

RESULTS

A total of 33 papers/published studies, representing 23 clinical trials, were eligible/included. Interventions from the eligible trials include chimeric antigen receptor (CAR)-T cell therapy, B-cell maturation antigen (BCMA)-directed antibodies, other monoclonal antibodies, cereblon E3 ligase modulators, a peptide-drug conjugate, and other targeted therapies. CAR T-cell therapy demonstrated the highest overall response rates, longer median overall, and progression-free survival in addition to significantly lower risk of death and higher odds of response compared to standard of care. Similarly, high response rates and/or long-term survival was also observed for other BCMA-directed treatments, such as elranatamab and teclistamab.

CONCLUSION

Based on the results of this systematic review, BCMA-directed therapies such as CAR-T cell therapy and bispecific antibodies demonstrate promising efficacy among patients with anti-CD38 refractory disease. However, additional evidence from randomized clinical trials is necessary to establish best practice guidelines.

Inside the Mind of the DMC: A Review of Principles and Issues with Case Studies

A data monitoring committee (DMC) can have an extremely challenging job. Stop a trial too soon, and results are inconclusive and the trial fails to obtain answers to important questions that could inform future clinical practice. Stop a trial too late, and trial participants are exposed to potentially harmful or ineffective interventions longer than necessary. Securing convincing and conclusive evidence and the ethical responsibility to current and future patients are weighed carefully during DMC deliberations. The ability to interpret complex information, and appreciation of issues affecting scientific integrity, are critical for the DMC to protect trial participants and public trust. Challenges faced by and issues of prudence faced by DMCs are discussed including interim analysis issues, assessing the totality of information with statistical boundaries as guidelines, interpretation of composite and surrogate outcomes, reactions to early trends, benefit:risk assessment, landscape changes, subgroup analyses, composing information for a comprehensive understanding of patient-centric effects, and evaluating the value of additional data. Case studies illustrate how DMCs addressed the challenges.

Therapeutic value of oncology products with a conditional approval from Health Canada: a cross-sectional study

Objectives

Investigate the additional therapeutic value compared to existing medicines of new oncology drugs given a conditional approval (Notice of Compliance with conditions, NOC/c) by Health Canada using therapeutic ratings from four independent organisations.

Design

A list of all new oncology drugs with an NOC/c from the start of the programme in 1998 to the end of 2023 was constructed. First-in-class and orphan drug status was determined for all drugs. Therapeutic ratings were obtained from the Canadian Patented Medicine Prices Review Board, the French drug bulletin Prescrire International, the French agency Haute Autorité de Santé and the German Institute for Quality and Efficiency in Health Care. If more than one organisation rated the drug, the highest rating was used.

Setting

Canada.

Participants

Oncology drugs with a conditional approval.

Main outcome measures

Additional therapeutic gain compared to existing products.

Results

Fifty-four oncology drugs were approved. Conditions were fulfilled for 29, fulfilment was still pending for 22 and 3 drugs were either discontinued by the manufacturer or placed on restricted access. Eighteen drugs had both orphan drug and first-in-class status. Therapeutic evaluations were available for 50 drugs, and the distribution of additional therapeutic value was examined for the entire group of 50 drugs, for 29 drugs that had fulfilled their conditions and for 18 drugs with both orphan drug and first-in-class status. In the three groups, 8.0%, 10.3% and 11.7%, respectively, offered major therapeutic improvement.

Conclusions

Few new oncology drugs approved through the NOC/c pathway offer major therapeutic improvements over existing drugs.

Redefining Available Therapy in Oncology Accelerated Approval Decisions

When weighing rapid approval for follow-on drugs, should @FDAOncology recognize the drugs that came before?

Using Trademarks to Ensure Completion of Postapproval Trials

This Viewpoint evaluates how using trademarks can support the US Food and Drug Administration’s mission to approve safe and effective medications.

Regulatory flexibilities balancing unmet needs, benefits and risks in the approvals of imported cancer drugs in China: a cohort study from 2012 to 2021

Background

China has historically relied on importing new drugs to fulfill domestic clinical needs. However, stringent requirements for local clinical trials for these imported drugs has often delayed their market approval, restricting timely access for patients. To address this issue, China has implemented regulatory flexibility in certain contexts, allowing for expedited approval processes when appropriate. This study aimed to evaluate the characteristics of novel cancer drugs qualifying for flexible approval in China from 2012 to 2021, focusing on pivotal trials features, clinical benefits, safety profiles, and unmet medical needs.

Methods

This cohort study identified all newly imported cancer drugs and their indications approved by the China's National Medical Products Administration (NMPA) from 2012 to 2021. Indications meeting standard requirements were categorized as regular approvals, while those supported by limited clinical data from Chinese patients were classified as flexible approvals. Development strategies, pivotal trials characteristics, and clinical outcomes were extracted from publicly available review documents and drug labels. Unmet medical needs were assessed based on two dimensions: the availability of standard-of-care treatments and the novelty of medicines. We compared the pivotal trial characteristics, efficacy end points, safety (serious adverse events) and the extent of unmet clinical needs, between flexible and regular approvals using Chi-square tests. A random-effects meta-regression was conducted to examine the association between flexible status and hazard ratios (HRs) for overall survival (OS) and progression-free survival (PFS).

Findings

Among 59 novel cancer drugs approved for importation to China between 2012 and 2021, 56 products with 92 indications were included in this analysis, based on the availability of their review documents. Of these, 48 indications (52%) qualified for flexible approvals, while 44 indications (48%) received regular approvals. The median number of Chinese patients involved in the datasets for flexible approvals was significantly lower than for regular approvals (27 [IQR, 0-62] vs. 165 [IQR, 99-245], p < 0.001). Flexible approvals were more frequently supported by early-phase (18/61 vs. 1/60, p < 0.001) and single-arm (22/61 vs. 1/60, p < 0.001) pivotal trials, with response rates frequently used as the primary endpoint (24/61 vs. 1/60, p < 0.001). Meta-regression analysis revealed that flexible approvals were associated with improved OS (HR 0.61 vs. 0.72, p < 0.01), and a weaker association for PFS (HR 0.39 vs. 0.51, p = 0.03). The rate of serious adverse events was slightly higher, but not significantly, in the flexible approval group than the regular approval group (43% vs. 35%, p = 0.06). Flexible approvals were more likely to be indicated for diseases with no available existing drugs (31/48 vs. 10/44, p < 0.001) and for first-in-class drugs (21/48 vs. 9/44, p = 0.03).

Interpretation

China's regulatory flexibility in approving imported cancer drugs has enabled access to therapies with limited domestic clinical data. These decisions are largely associated with the potential for greater clinical benefits and the need to address unmet medical needs. The approach offers valuable insights into regulatory considerations for global regulatory practices. By adopting similar regulatory flexibility, other nations could enhance drug accessibility and promote more adaptive regulatory practices.

Funding

This work was funded by National Natural Science Foundation of China (72374119, 82102886) Beijing Natural Science Foundation (7242114) and Beijing Nova Program.

Financial challenges of being on long-term, high-cost medications

The isocitrate dehydrogenase (IDH) inhibitor, vorasidenib, may offer a promising new treatment option for patients with IDH-mutant gliomas. However, the indefinite nature of this targeted therapy raises significant financial concerns. High costs of targeted cancer therapies, often exceeding $150 000 annually, contribute to financial toxicity, characterized by medical debt, income loss, and psychological stress, and place stress on health systems. This review analyzes the drug approval and pricing mechanisms in various countries and their impact on healthcare costs and patient access, focusing specifically on the impacts in neuro-oncology. The United States employs a market-driven approach resulting in higher drug prices, while most countries, such as the United Kingdom, Germany, France, Italy, Japan, South Africa, and Brazil, use negotiated pricing and health technology assessment to manage costs. The financial burden of expensive medications affects patient adherence and quality of life, with many cancer patients facing substantial out-of-pocket expenses and potential treatment abandonment, and many more unable to access these drugs altogether. Vorasidenib's introduction, while potentially improving patient outcomes, may exacerbate financial toxicity unless mitigated by patient access programs and cost-management strategies. As neuro-oncology treatment paradigms evolve, understanding the economic implications of new therapies is essential to ensure equitable access and optimize patient care.

The UK's Early Access to Medicines Scheme 10 years on: an evaluation using publicly available data

Objectives

To investigate the drugs and indications that have passed through the UK's Early Access to Medicines Scheme (EAMS) to date, the type of evidence the regulator considers when accepting a drug into the EAMS, and potential risks to patients.

Design

Analysis of publicly available data: MHRA Public Assessment Reports; Electronic Medicines Compendium database; interactive Drug Analysis Profiles database; Eudravigilance database.

Setting

United Kingdom.

Participants

The 51 'scientific opinions' available on the MHRA website in June 2024.

Main Outcome Measures

Public Assessment Reports, pharmacovigilance data.

Results

After exclusions, there were 48 EAMS submissions, consisting of 48 indications and 32 drugs. 60% of indications were for cancer. Only 7% of EAMS submissions were based on double-blind, placebo-controlled randomised trials. The average sample size of studies conducted for the EAMS was 654. Most studies used surrogate (76%) and/or survival (57%) outcomes. Only 17% used subjective outcomes. For 17% of the indications, no ongoing studies were being conducted. Animal studies were conducted preclinically for all drugs and 35% also conducted in vitro studies. 47% of the drugs had elevated rates of suspected adverse reaction reports according to pharmacovigilance data.

Conclusions

We recommend that the EAMS drugs with elevated reporting rates are reviewed, that future studies of EAMS drugs use patient-centred outcomes, that preclinical studies make greater use of human biology-based approaches, that post-approval trials are conducted, and that future reviews of the EAMS centre the experience of patients.

Cancer drug applications to the EMA and the FDA: A comparison of new drugs and extension of indication in terms of approval decisions and time in review

AIMS

The aim of this study was to compare the final approval decision and time from submission to final decision for new drug applications and applications for extension of indications to the EMA and the FDA within cancer drugs.

METHODS

We performed a retrospective analysis on antineoplastic drug applications with a final decision in both the EMA and the FDA from January 1, 2018, to December 31, 2022. For each included drug application, we collected data from the EMA website and the Drugs@FDA database.

RESULTS

A total of 48 new drug applications and 94 applications for extension were included. Agreement in the final decision between the EMA and the FDA was found in 94% of new drug applications and 96% of applications for extension. For new drug applications, the time from submission to approval in the EMA and the FDA were median (interquartile range, IQR) 424 (394-481) days and 216 (169-243) days, respectively. For extensions, the median time from submission to approval in the EMA and the FDA were 295 (245-348) days and 176 (140-183) days, respectively.

CONCLUSIONS

We found a high agreement in final approval decisions for cancer drug applications between the EMA and the FDA both for new drug applications and applications for extension. The time from submission to the final decision was markedly shorter in the FDA than in the EMA, albeit the difference was smaller for extensions than for new drug applications. The results indicate that the longer time from submission to decision in the EMA than in the FDA has limited influence on the final approval decisions.

Regulatory Fate of Cancer Indications in the European Union After Accelerated Approval in the US

This cohort study investigates the regulatory fate in the European Union for drugs that received accelerated approval for cancer indications in the US.

NECTIN-4 PET FOR OPTIMIZING ENFORTUMAB VEDOTIN DOSE-RESPONSE IN UROTHELIAL CARCINOMA

The optimization of dosing strategies is critical for maximizing efficacy and minimizing toxicity in drug development, particularly for drugs with narrow therapeutic windows such as antibody-drug conjugates (ADCs). This study demonstrates the utility of Nectin-4-targeted positron emission tomography (PET) imaging using [68Ga]AJ647 as a non-invasive tool for real-time assessment of target engagement in enfortumab vedotin (EV) therapy for urothelial carcinoma (UC). By leveraging the specificity of [68Ga]AJ647 for Nectin-4, we quantified dynamic changes in target engagement across preclinical models and established its correlation with therapeutic outcomes. PET imaging revealed dose-dependent variations in Nectin-4 engagement, with suboptimal EV doses resulting in incomplete Nectin-4 engagement and reduced tumor growth. Importantly, target engagement measured by PET emerged as a more reliable predictor of therapeutic efficacy than dose or baseline Nectin-4 expression alone. Receiver operating characteristic (ROC) analysis identified a target engagement threshold that is determinant of response, providing a quantitative benchmark for dose optimization. Furthermore, PET imaging measures provide a promising framework to account for key challenges in ADC development, including tumor heterogeneity, declining drug-to-antibody ratios over time, and limitations of systemic pharmacokinetic measurements to account for tumor-drug interactions. These findings underscore the transformative potential of integrating PET pharmacodynamic measures as early biomarkers to refine dosing strategies, improve patient outcomes, and accelerate the clinical translation of next-generation targeted therapeutics.

Confirmatory Trials for Drugs Granted Conditional Approval by the Chinese National Medical Products Administration

This cross-sectional study analyzes differences in pivotal and confirmatory trial characteristics for drugs granted conditional approval in China.

Clinical Benefit and Revenues of Drugs Affected by Rare Pediatric Disease Priority Review Vouchers, 2017-2023

OBJECTIVE

To determine the clinical benefit of drugs that earned or redeemed rare pediatric disease priority review vouchers (PRVs) from 2017 through 2023, and the revenues generated by such drugs.

STUDY DESIGN

In this cohort study, Federal Register documents, publicly available health technology agency (HTA) assessments, and financial filings were used to identify drugs that were issued or redeemed using a rare pediatric disease PRV from 2017 through 2023, and to assess their added therapeutic benefit and drug-specific global revenues.

RESULTS

Among the 36 drugs whose approval resulted in issuance of a rare pediatric PRV, therapeutic benefit ratings were available for 17 (47%), with 9 (53%) rated as high by at least 1 organization. Mean annual global revenues were $363 million (year 1), $621 million (year 2), and $850 million (year 3). The median annual list price for drugs issued a voucher was $788,705. Vouchers were then redeemed for 15 different drugs; out of 13 drugs with therapeutic benefit ratings, 4 (31%) were high value.

CONCLUSIONS

Drugs that treat rare pediatric diseases generate similar revenues compared with other brand drugs, and drugs with high therapeutic benefit tend to generate more revenue than those with low therapeutic benefit. Drugs that earned the rare pediatric disease PRV for their manufacturer generate significant revenues and the voucher may not be necessary to incentivize drug development in the rare pediatric disease space.

Trastuzumab Deruxtecan in Human Epidermal Growth Factor Receptor 2-Positive Metastatic Gastric Cancer in a Real-World Setting: A Nationwide Cohort Study

INTRODUCTION

Trastuzumab deruxtecan (T-DXd) has been approved for human epidermal growth factor receptor 2-positive locally advanced or metastatic gastric and gastroesophageal junction (HER2+ mG/GEJ) cancer since July 2022 in France, through an accelerated approval. The aim of this study was to evaluate its real-world use.

METHODS

We characterized T-DXd users treated for HER2+ mG/GEJ cancer using data from the French National Health Insurance database.

RESULTS

The cohort included 196 patients, mostly men (78.1%), with a median age of 65 years. Median overall survival reached 7.7 months (95% CI: 6.2-9.0).

DISCUSSION

Patients treated with T-DXd for HER2+ mG/GEJ cancer in the real world showed lower outcomes than those in pivotal clinical trials, consistent with previous reports on accelerated approvals.

US Food and Drug Administration's Directive to Deal With Delayed Confirmatory Trials: Lessons From Pralatrexate and Belinostat for T-Cell Lymphoma

The FDA's directive to deal with delayed confirmatory trials: lessons from pralatrexate and belinostat for T-cell lymphoma.

Accelerated approvals: Early-phase success or premature authorization?

We compare the clinical trial success rates of products receiving US Food and Drug Administration (FDA) accelerated approval (AA) to those approved without using this pathway. Our findings raise important questions about how the AA pathway can best optimize early access to therapeutics that are ultimately proven safe and effective.

Drug pricing models, no 'one-size-fits-all' approach: a systematic review and critical evaluation of pricing models in an evolving pharmaceutical landscape

Access to new medicines is crucial for patients but increasingly sparks discussion due to high prices. Simultaneously, the growing emphasis on specialized products and uncertainty surrounding the long-term effectiveness of new drug classes brought to the market underscore the need for innovative pricing approaches. A systematic literature review of pharmaceutical pricing models, accompanied by a critical appraisal, was conducted to offer insights contributing to novel approaches balancing sustainable pharmaceutical innovation with affordability and accessibility for patients. Six different pricing models are identified: value based pricing, basic cost-based pricing, and four more comprehensive pricing models incorporating numerous elements: the cancer-drug-pricing model, AIM model, (Nuijtens) discounted cash flow, and the real-option rate of return method. Although there are many similarities among the models, each has unique assumptions for implementation. For instance, all models except for the standard incremental cost-effectiveness ratio and basic cost-based pricing consider the number of eligible patients and the remaining patent period. Only the AIM model and the Nuijtens discounted cash flow model use lump sums. Both the latter and the real-option rate of return method explicitly include the cost of capital as a major cost-based component. Recognizing the diverse applications of each model highlights the need for more differential and dynamic pricing tailored to the characteristics and therapeutic areas of each drug. Additionally, the study underscores the importance of cost transparency in achieving this goal. Consequently, these findings can help stakeholders develop sustainable and affordable drug pricing mechanisms that address the complexities of the ever-changing pharmaceutical landscape.

Launch and Postlaunch Price Developments of New Drugs in the US, Germany, and Switzerland

Importance

High prices of new drugs are concerning. What remains to be understood are price developments after entering the market because not only initial prices, but also postlaunch prices, contribute to drug spending.

Objective

To analyze launch and postlaunch price developments of new drugs in the US, Germany, and Switzerland.

Design, Setting, and Participants

This cohort study used the public databases of the US Food and Drug Administration, European Medicines Agency, and Swissmedic to identify all new drugs approved between January 2011 and December 2022. Data were collected and analyzed between January 2024 and September 2024. During the revision process in October 2024, SSR data were also analyzed. Drugs for which price data were available were included in the study cohort. Launch prices and postlaunch price developments in the US, Germany, and Switzerland were calculated from 2011 until 2023.

Main Outcomes and Measures

Standard statistics (mean, median, and IQR) were applied to analyze launch drug prices and postlaunch drug price developments over time in the US, Germany, and Switzerland.

Results

The cohort study included 254 drugs in the US, 298 in Germany, and 235 in Switzerland. In the US, mean (SD) launch prices increased from $31 699 ($36 439) in 2011 to $228 658 ($571 252) in 2022, with an average increase of 19.7% per year. In Germany, mean (SD) launch prices increased from $77 237 ($228 672) to $146 072 ($306 091), with an average increase of 6.0% per year. In Switzerland, mean launch prices increased from $29 211 ($41 919) to $41 399 ($39 697), with an average increase of 3.2% per year. Post launch, trimmed mean prices of included drugs in the study cohort increased -0.6% at 3 years, 2.4% at 5 years, and 4.1% at 10 years post launch in the US. A larger increase of postlaunch prices was observed for cancer drugs compared with noncancer drugs. In Germany, trimmed mean drug prices decreased -30.9% at 3 years, -33.4% at 5 years, and -45.2% at 10 years post launch. In Switzerland, trimmed mean drug prices decreased -9.3% at 3 years, -13.5% at 5 years, and -29.5% at 10 years post launch. In Switzerland and Germany, postlaunch price developments were similar for cancer and noncancer drugs, but treatment costs of cancer drugs remained substantially higher compared with noncancer drugs.

Conclusions and Relevance

The results of this cohort study suggest that, in contrast to Germany and Switzerland, prices of cancer drugs increased substantially post launch in the US. When developing solutions how drug prices can be decreased, launch as well as postlaunch prices require attention from policymakers.

Comparing supplemental indications for cancer drugs approved in the US and EU

IMPORTANCE

Cancer drugs initially granted regulatory approval for one disease may also prove useful in treating other diseases. In these cases, manufacturers may seek to add supplemental indications to their drug labels. The extent to which manufacturers seek supplemental indications for cancer drugs may differ in the US and EU.

OBJECTIVE

To investigate how manufacturers have pursued supplemental indications for cancer drugs approved in the US vs. EU.

METHODS

We performed a retrospective observational cohort study of cancer drugs first approved in the US and EU from 2005-2022 to compare the rate at which supplemental indications are added to drug labels and the times to first, second, and third supplemental indications.

RESULTS

Among 129 cancer drugs approved in both the US and EU from 2005-2022, approval occurred an average of 0.79 years earlier in the US. These drugs had a total of 145 indications at the time of approval in the US and 144 indications in the EU. Supplemental indications were granted at a rate of 0.22 per drug-year in the US, compared to 0.17 per drug-year in the EU (incidence rate ratio=1.30, 95 % confidence interval [CI]: 1.06-1.60, p = 0.01). This resulted in a total of 221 approved supplemental indications in the US and 152 approved supplemental indications in the EU through October 1, 2023. The times to the first and second supplemental indications were similar across the two jurisdictions, while the time to the third supplemental indication was shorter in the US (hazard ratio: 2.06, 95 % CI: 1.03-4.14, p = 0.04).

CONCLUSIONS AND RELEVANCE

Manufacturers obtained supplemental indications for cancer drugs in the US at a higher rate than in the EU, which could be due to variable regulatory requirements and/or different market forces.

Pharmaceutical innovativeness index: methodological approach for assessing the value of medicines - a case study of oncology drugs

BACKGROUND

We propose a framework to assess the value of pharmaceutical innovations, with explicit clinical and methodological parameters, based on the therapeutic value and health needs.

RESEARCH DESIGN AND METHODS

The study was based on the adaptation of health technology assessment methods documented in the literature, which was applied to a sample of oncological drugs. Difficulties and issues during the application of those tools were identified and addressed to develop a new framework with new and revised domains and clear classification criterion for each domain. Scores were assigned to each level and domain according to their relevance to generate the final score of innovativeness.

RESULTS

The Pharmaceutical Innovation Index (PII) includes four domains, two related to clinical and social dimensions - Therapeutic Need and Added Therapeutic Value - and other two about methodological features - Study Design and Quality (risk of bias). The scores combined after assigned to each domain results Index of the Innovativeness of the medicines represents the degree of pharmaceutical innovation.

CONCLUSION

This work proposes a transparent methodology with well-defined criteria and script; the algorithm developed with authors' weightings and criteria may be switched to best adjust to other applications, perspective or clinical indications, while keeping the transparency and objectiveness.

Clinical benefit, reimbursement outcomes, and prices of FDA-approved cancer drugs reviewed through Project Orbis in the USA, Canada, England, and Scotland: a retrospective, comparative analysis

BACKGROUND

Project Orbis is a global initiative that aims to streamline regulatory review processes across international regulators in the USA, Canada, Australia, UK, Israel, Brazil, Singapore, and Switzerland to bring promising cancer drugs to patients earlier. We explored the clinical benefit, time to regulatory approval and health technology assessment recommendations, reimbursement outcomes, and monthly treatment prices of cancer drugs reviewed through this initiative.

METHODS

For this retrospective, comparative analysis, we identified cancer drug approvals reviewed through Project Orbis in the USA, Canada, and the UK between May 1, 2019, and Nov 1, 2023. Approvals of cancer drugs reviewed Project Orbis were extracted from the Food and Drug Administration (FDA) Oncology Centre of Excellence and all other FDA approvals from the Drugs@FDA database. The co-primary outcomes were time of regulatory review, time from regulatory approval to health technology assessment recommendation (England, Scotland, and Canada), reimbursement outcomes, clinical benefit (defined as median gains in progression-free survival and overall survival) between cancer drug approvals reviewed by Project Orbis and other FDA approval processes, and monthly treatment prices. The Wilcoxon rank-sum and Fisher's Exact tests were used to examine statistical significance between approvals reviewed through Project Orbis and other FDA approvals during the same period.

FINDINGS

Between May 1, 2019 and Nov 1, 2023, 81 (33%) of 244 cancer drugs approved by the FDA were reviewed through Project Orbis. The median overall survival gains were 4·1 months (IQR 3·3-5·1) compared with 2·7 months (2·1-3·9) for other FDA approvals. Similarly, progression-free survival gains were 2·6 months (IQR 1·7-4·9) for Project Orbis compared with 2·6 months (0·6-5·1) for other FDA approvals. Neither overall survival (p=0·11) nor progression-free survival (p=0·44) gains were significantly different between the two cohorts of approvals. Of the 14 UK Medicines and Healthcare products Regulatory Agency (MHRA) approvals reviewed by the Scottish Medicines Consortium (SMC), the agency gave positive recommendations for all 14 (100%). Of the 15 MHRA approvals reviewed by the National Institute for Health and Care Excellence (NICE), the agency gave positive recommendations for six (40%). Of the 49 approvals reviewed by the Canadian Agency for Drugs and Technologies in Health (CADTH), the agency conditionally recommended 44 (90%). The time between regulatory approval to NICE recommendation increased from a median of 137 days (IQR 102-172) in 2021 to 302 days (184-483) in 2023, SMC recommendation increased from 185 days (in 2021 for one drug only) to 368 days (IQR 313-476) in 2023, and CADTH decision increased from 97 days (in 2020 for one drug only) to 202 days (IQR 153-304) in 2023. The median monthly price of approvals reviewed through Project Orbis was US$20 000 per month (IQR 13 000-37 000).

INTERPRETATION

Clinical outcomes of Project Orbis were no different than other FDA approvals during the same time, and access, after a successful health technology assessment, was considerably delayed or absent, raising questions about whether Project Orbis participation translates into faster patient access to medicines with high clinical benefit and sustainable costs. Although future challenges might benefit from regulatory harmonisation, the advantages are currently unclear.

FUNDING

None.

Bayesian Interim Analysis and Efficiency of Phase III Randomized Trials

IMPORTANCE

Improving the efficiency of interim assessments in phase III trials should reduce trial costs, hasten the approval of efficacious therapies, and mitigate patient exposure to disadvantageous randomizations.

OBJECTIVE

We hypothesized that in silico Bayesian early stopping rules improve the efficiency of phase III trials compared with the original frequentist analysis without compromising overall interpretation.

DESIGN

Cross-sectional analysis.

SETTING

230 randomized phase III oncology trials enrolling 184,752 participants.

PARTICIPANTS

Individual patient-level data were manually reconstructed from primary endpoint Kaplan-Meier curves.

INTERVENTIONS

Trial accruals were simulated 100 times per trial and leveraged published patient outcomes such that only the accrual dynamics, and not the patient outcomes, were randomly varied.

MAIN OUTCOMES AND MEASURES

Early stopping was triggered per simulation if interim analysis demonstrated ≥ 85% probability of minimum clinically important difference/3 for efficacy or futility. Trial-level early closure was defined by stopping frequencies ≥ 0.75.

RESULTS

A total of 12,451 simulations (54%) met early stopping criteria. Trial-level early stopping frequency was highly predictive of the published outcome (OR, 7.24; posterior probability of association, >99.99%; AUC, 0.91; P < 0.0001). Trial-level early closure was recommended for 82 trials (36%), including 62 trials (76%) which had performed frequentist interim analysis. Bayesian early stopping rules were 96% sensitive (95% CI, 91% to 98%) for detecting trials with a primary endpoint difference, and there was a high level of agreement in overall trial interpretation (Bayesian Cohen's κ, 0.95; 95% CrI, 0.92 to 0.99). However, Bayesian interim analysis was associated with >99.99% posterior probability of reducing patient enrollment requirements ( P < 0.0001), with an estimated cumulative enrollment reduction of 20,543 patients (11%; 89 patients averaged equally over all studied trials) and an estimated cumulative cost savings of 851 million USD (3.7 million USD averaged equally over all studied trials).

CONCLUSIONS AND RELEVANCE

Bayesian interim analyses may improve randomized trial efficiency by reducing enrollment requirements without compromising trial interpretation. Increased utilization of Bayesian interim analysis has the potential to reduce costs of late-phase trials, reduce patient exposures to ineffective therapies, and accelerate approvals of effective therapies.

KEY POINTS

Question: What are the effects of Bayesian early stopping rules on the efficiency of phase III randomized oncology trials?Findings: Individual-patient level outcomes were reconstructed for 184,752 patients from 230 trials. Compared with the original interim analysis strategy, in silico Bayesian interim analysis reduced patient enrollment requirements and preserved the original trial interpretation. Meaning: Bayesian interim analysis may improve the efficiency of conducting randomized trials, leading to reduced costs, reduced exposure of patients to disadvantageous treatments, and accelerated approval of efficacious therapies.