Accelerating the integration of China into the global development of innovative anticancer drugs

Profiles and disparities of the global cancer and subtypes burden among adults aged 65 years and older: changing patterns in incidence and mortality, 1990-2021

This study aimed to elucidate the global temporal and geographic characteristics of 29 cancers in older people aged ≥ 65 years, based on data from the Global Burden of Disease Study 2021. The average annual percentage changes (AAPCs) were calculated to estimate temporal trends of age-standardized incidence rates (ASIRs) and age-standardized mortality rates (ASMRs). Globally, there was an increase of 8.52 million cancer cases and 3.16 million cancer deaths among older people from 1990 to 2021. The ASIR of cancers combined presented an annually increased trend (AAPC: 0.49%), and regions with high sociodemographic index (SDI) experienced the highest increase (AAPC: 0.94%). Over the same period, the ASMR of cancers combined annually decreased (AAPC: -0.40%) globally, whereas regions with low SDI (AAPC: 0.32%) and low-middle SDI (AAPC: 0.48%) exhibited significantly increased ASMRs. Prostate cancer, lung cancer, and colorectal cancer were the three most common cancers for older people globally, and decreased relative inequalities were observed in higher-SDI countries from 1990 to 2021. For these three cancers, concentration index of ASMR respectively decreased from 0.26 to 0.06, from 0.20 to 0.17, and from 0.24 to 0.18. In contrast, the ASIR and ASMR of these cancers exhibited significant upward trends in lower-SDI regions. Our findings revealed that cancer burden for older people presented disparities globally, where higher-SDI countries faced a greater burden of cancer incidence and lower-SDI countries experienced an upward trend in cancer mortality. More attention should be given to prostate cancer, lung cancer, female breast cancer, and gastrointestinal cancers, especially in lower-SDI regions.

Overview of new indications for novel drugs approved in China between 2018 and 2024

Since China's regulatory reforms were initiated in 2015, the development of new indications for novel drugs has become an important trend. Between 2018 and 2024, China's National Medical Products Administration (NMPA) approved 313 new indications for 151 novel drugs. This cross-sectional study comprehensively depicts the landscape of China's new indications for novel drugs, including the characteristics of approvals, quality, and quantity of clinical trial evidence. The quality characteristics of the efficacy evidence for new indications were affected by the treatment areas and conditional approval programs. The efficacy of a novel drug for a new indication can be demonstrated by one pivotal trial or one pivotal trial plus supportive evidence in most cases.

Regulatory efforts to address the access gap for foreign new drugs in China: the priority review program and related policies

BACKGROUND

China has implemented the priority review (PR) program and flexible registration requirements for new drugs with significant clinical value since 2016 to accelerate drug access. We aim to explore the impact of the reform efforts on the drug access gap between China and the US.

METHODS

We collected data on the imported new drug approvals that were licensed in China between 2007 and 2023, and measured their launch delays as compared to the US. Difference-in-difference models were used to compare the launch delays of PR approvals and non-PR approvals before and after the implementation of the PR. Propensity score matching was used to construct the imputed PR and non-PR approvals in the pre-PR period.

RESULTS

A total of 410 imported approvals were licensed in China in 2007-2023. Most approvals (316[77.1%]) were licensed after the PR was implemented, of which 189[59.8%] received the PR designation. The difference-in-difference models found that the PR program reduced drug launch delay by 1157.0 days (robust standard error, 571.0; P<0.05) and reduced drug submission delay by 1037.3 days (robust standard error, 520.8; P<0.05). The PR identified drugs with high clinical value and informed flexible registration requirements for them, which accelerated drug submission and market entry.

CONCLUSIONS

Our findings proved the importance of value-based prioritization of new drugs and flexibility in the statutory evidentiary standard in the drug approval process. Further efforts from the drug agency are needed to leverage the regulatory flexibility to provide fast market entry of new drugs without compromising their quality.

Accelerating the Future of Oncology Drug Development: The Role of Consortia in the Delivery of Precision Oncology Early Phase Clinical Trials

PURPOSE

Over the past 15 years, the landscape of early phase clinical trials (EPCTs) has undergone a remarkable expansion in both quantity and intricacy. The proliferation of sites, trials, sponsors, and contract research organizations has surged exponentially, marking a significant shift in research conduct. However, EPCT operations suffer from numerous inefficiencies, such as cumbersome start-up processes, which are particularly critical when drug safety and the recommended phase II dose need to be established in a timely manner. Networks and consortia may overcome some of these challenges of enrolling suitable patients and streamlining start-up, particularly when distance and disease trajectory come into play.

DESIGN

In this article, we provide an overview of EPCT consortia in adult oncology across different continents assembled through systematic review of the literature and snowball sampling methodology. We illustrate their scope, structure, funding, and achievements.

RESULTS

Fifteen EPCT consortia were identified including two in the United States, three in Europe, five in Asia-Pacific, two intercontinental consortia, and three within private oncology networks. These consortia vary in their scope, funding, and structure from government-funded models such as the National Cancer Institute Experimental Therapeutics Clinical Trials Networks through charitably funded and private research organizations. EPCT consortia play a role in collaborative research, molecular tumor boards to provide patient-centric biomarker-matched treatments, and streamlining trial conduct to improve timelines and cost efficiency.

CONCLUSION

The growth in EPCT activity and complexity has resulted in expansion in the number of EPCT consortia globally. By actively engaging with regulatory bodies and pharmaceutical and contract research organization industries, consortia have an opportunity to address the evolving challenges faced in this field and to accelerate the translation of scientific discoveries into clinical practice.

Impact of HER2-targeting antibody drug conjugates in treatment strategies for patients with breast cancer

Antibody drug conjugates (ADCs) are novel drugs that exert specific cytotoxicity against breast cancer. Although ADCs such as trastuzumab emtansine and trastuzumab deruxtecan have significantly improved survival for patients with breast cancer expressing HER2, there is still controversy over options after ADCs. The radiotherapy and ablation should also be used as an effective strategy for oligoprogressions. Herein, we conducted a review of ADCs, and then discussed several strategies to maximize the potential benefit to patients with HER2 expression breast cancer.

Comparative effectiveness and safety of imported and domestic immune checkpoint inhibitors in China: A systematic review and pairwise and network meta-analyses

BACKGROUND

Multiple brands of immune checkpoint inhibitors (ICIs), including domestic and imported agents, have been approved as front-line therapy in China. However, little is known about the difference in efficacy and safety of these agents of different origins. This study aims to systematically compare the difference between National Medical Products Administration (NMPA) approved domestic and imported ICIs regarding their efficacy, safety, and price.

METHODS

We systematically searched PubMed, Embase, and Cochrane Central, from inception to July 1st, 2023, for phase III trials evaluating ICIs as first- or second-line settings that have available hazard ratio (HR) for Asians or non-Asians. Studies of domestic and imported ICIs were screened and paired by the matching clinical characteristics as mirror groups. The primary endpoint was to assess the difference in efficacy between domestic and imported ICIs regarding overall survival. An effect size was derived from each mirror group and then pooled across all groups using a random-effects model. Heterogeneity was assessed by I2 statistics. Monthly treatment costs for each drug were calculated based on dosing information on National Medical Products Administration (NMPA) label and prices extracted from INSIGHT database. The difference in monthly treatment costs was compared by unpaired T-test. The protocol is registered on PROSPERO, CRD42024580753.

RESULTS

Overall, domestic ICIs exhibited better efficacy regarding overall survival (HR, 0.87; 95 % CI, 0.79-0.97; P < 0.05; I2 = 0) compared with imported agents. No difference was observed regarding benefits in progression free survival (HR, 0.95; 95 % CI, 0.82-1.09; P > 0.05; I2 = 0). Consistent results were obtained through frequentists and Bayesian approaches. The differences in safety; measured by relative risk of treatment-related adverse events (TARE) of any grade, TARE of grade 3 or higher, immune-related adverse events(irAE) of any grade, irAE of grade 3 or higher, discontinuation due to treatment, and death due to treatment; were also similar between domestic and imported ICIs. Moreover, in current Chinese market, the monthly treatment prices of domestic ICIs was statistically lower than that of imported ICIs (P < 0.01).

CONCLUSIONS

Our research provides an essential reference of cost-effectiveness of ICIs manufactured in China for clinicians in routine practice of cancer care as well as public health authorities for decision making process.

Disparities in availability of new cancer drugs worldwide: 1990-2022

INTRODUCTION

Despite progress in the development of new cancer drugs, concerns about equity of access remain. This study aimed to examine the availability and timeliness of availability of new cancer drugs around the globe over the past three decades and their associations with country characteristics.

METHODS

From a pharmaceutical intelligence database we identified new cancer drugs launched between 1990 and 2022. We calculated the number of new drugs launched in each country and the delay in launches. Using a multivariable linear regression and a Cox regression model with shared frailty, we examined the associations of the country's Gross National Income (GNI) per capita, cancer incidence, number of physicians per population, and Gini index with the number of new cancer drug launches and launch delay in a country, respectively.

RESULTS

A total of 568 cancer drugs were launched for the first time globally between 1990 and 2022. Among these, 35% had been launched in only one country by 2022, 22% in 2-5 countries, 15% in 6-10 countries, and 28% in more than 10 countries. The number of new cancer drugs launched in a country in this period ranged from 0 to 345. The average delays from the first global launch to the second, third, fourth, and fifth launch were 18.0 months, 24.3 months, 32.5 months, and 39.4 months, respectively. Our multivariate models showed that higher GNI per capita and cancer incidence in a country were associated with more launches and shorter delays.

CONCLUSION

This research reveals significant disparities in the availability and timeliness of availability of new cancer drugs across countries. These disparities are likely to have contributed to the poor cancer outcomes observed in many countries.

Clinical advances and challenges associated with TCR-T cell therapy for cancer treatment

Background

T cell receptor (TCR)-T cell therapy is an innovative form of cancer immunotherapy that genetically modifies patients' T cells to target and destroy cancer cells. However, the current status of clinical trials of TCR-T cell therapy for the treatment of cancer remains unclear. This study aimed to comprehensively analyze the registration trials related to TCR-T cell therapy for the treatment of cancer.

Methods

A comprehensive search was conducted in the Trialtrove database for all clinical trials related to TCR-T cell therapy registered by August 1, 2024. Inclusion criteria focused on trials targeting TCR-T cell therapy for oncology, and excluded observational studies and incomplete data. Statistical analysis was performed on key trial characteristics, with between-group comparisons utilizing chi-square or Fisher's exact tests.

Results

Analysis of 174 eligible clinical trials revealed that TCR-T cell therapy exhibits significant efficacy across various tumor types, particularly in refractory hematologic malignancies and certain solid tumors. Additionally, combining TCR-T cell therapy with other immunotherapies enhanced these anti-tumor effects.

Conclusion

TCR-T cell therapy holds substantial promise for cancer treatment. Future research should focus on optimizing treatment protocols, enhancing efficacy, and minimizing prices to fully realize the potential of this therapy.

Questionnaire survey and analysis of drug clinical research implementation capabilities of breast cancer treatment departments in Chinese hospitals

BACKGROUND

Clinical research competence determines the quality of clinical research and the reliability of research findings. We aimed to explore the clinical research implementation capabilities of breast cancer treatment departments in China.

METHODS

This was a department-based cross-sectional study conducted in the form of electronic questionnaires on the Wenjuanxing platform from 7th August to 31st August 2023 among hospitals from the first batch of breast cancer standardized diagnosis and treatment quality control pilot centers in China.

RESULTS

A total of 127 questionnaires from 122 hospitals were ultimately included in the analysis. Medical personnel involved in the clinical research of 118 (92.9 %) departments received good clinical practice (GCP) training. The steps of the approval process from research initiation to completion lasted 2-4 weeks or longer. The majority of departments initiated or participated in 2 or fewer clinical research projects over the past year. Among the differences between different departments, the Department of Medical Oncology had a better qualification profile and process and greater number of initiated and participated clinical studies than did the Department of Surgical Oncology. For needs and problems, most of the departments were strongly willing to undertake clinical research and receive professional training; the most common problem in the process of conducting studies was patient recruitment.

CONCLUSIONS

Most departments generally exhibited complete capabilities for implementing clinical research. Improvements in implementation efficiency, quality of research and patient recruitment are still needed. Professional training and communication, as well as the recommendation of clinical research, are required in future development.

Efficacy and Safety of Anti-Programmed Cell Death Protein 1/Programmed Death-Ligand 1 Antibodies Plus Chemotherapy as First-Line Treatment for NSCLC in the People's Republic of China: a Systematic Review and Meta-Analysis

Introduction

The available approved anticancer drugs for Chinese patients are relatively limited because of China's low participation rate in international clinical trials. Therefore, a focus on approved anti-programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) drugs in China is needed. This study aims to assess the heterogeneity of anti-PD-1/PD-L1 antibodies manufactured in China (domestic PD-1/PD-L1) and overseas (imported PD-1/PD-L1) when combined with chemotherapy as the first-line treatment of NSCLC.

Methods

A systematic search was performed using PubMed, EMBASE, and Cochrane Library of publications up to July 13, 2023. Meta-analysis was applied to compare the efficacy and safety profile between anti-PD-1/PD-L1 antibodies plus chemotherapy (PD-1/PD-L1+Chemo) and chemotherapy alone using STATA software. Pooled hazard ratios for progression-free survival and overall survival, odds ratios for objective response rate, and incidence rate of grade greater than or equal to three treatment-related adverse events with 95% confidence intervals were calculated in the domestic group and imported group by a random-effects model, and the heterogeneity between the two estimates was assessed.

Results

There were 14 eligible clinical studies with a total of 3951 patients involved in this analysis, including eight studies of domestic PD-1/PD-L1+Chemo and six studies of imported PD-1/PD-L1+Chemo. The study revealed that there was no significant difference between domestic and imported PD-1/PD-L1+Chemo in overall survival (p = 0.80), progression-free survival (p = 0.53), and incidence rate of grade greater than or equal to three treatment-related adverse events (p = 0.10). Nevertheless, the objective response rate of imported PD-1/PD-L1+Chemo was significantly higher than that of domestic PD-1/PD-L1+Chemo (p = 0.03).

Conclusions

Domestic anti-PD-1/PD-L1 antibodies plus chemotherapy were found to have comparable efficacy and safety to those combined with imported anti-PD-1/PD-L1 antibodies based on current evidence.

Quantitative evaluation of the impact of relaxing eligibility criteria on the risk-benefit profile of drugs for lung cancer based on real-world data

INTRODUCTION

Restrictive eligibility criteria in cancer drug trials result in low enrollment rates and limited population diversity. Relaxed eligibility criteria (REC) based on solid evidence is becoming necessary for stakeholders worldwide. However, the absence of high-quality, favorable evidence remains a major challenge. This study presents a protocol to quantitatively evaluate the impact of relaxing eligibility criteria in common non-small cell lung cancer (NSCLC) protocols in China, on the risk-benefit profile. This involves a detailed explanation of the rationale, framework, and design of REC.

METHODS

To evaluate our REC in NSCLC drug trials, we will first construct a structured, cross-dimensional real-world NSCLC database using deep learning methods. We will then establish randomized virtual cohorts and perform benefit-risk assessment using Monte Carlo simulation and propensity matching. Shapley value will be utilized to quantitatively measure the effect of the change of each eligibility criterion on patient volume, clinical efficacy and safety.

DISCUSSION

This study is one of the few that focuses on the problem of overly stringent eligibility criteria cancer drug clinical trials, providing quantitative evaluation of the effect of relaxing each NSCLC eligibility criterion. This study will not only provide scientific evidence for the rational design of population inclusion in lung cancer clinical trials, but also establish a data governance system, as well as a REC evaluation framework that can be generalized to other cancer studies.

A call to rethink the necessity of and challenges facing academic research organizations in the new era of drug innovation in China

The objectives of drug R&D in China have shifted toward innovation and globalization, highlighting the ecological imperative to involve innovative partner-like academic research organizations (AROs). AROs are led by academic institutions and, when compared to contract research organizations (CROs), their strengths lie in promoting academic excellence, knowledge sharing, independence, collaborative networks and industry partnerships. Our desk-based analysis shows that although the service scope of Chinese AROs is similar to that of AROs in the US, they lack experience in broad service provision for innovative drugs, institution-institutional platforms and industry partnerships. We make several suggestions about how to achieve the synergy of academic institutions and industry-based organizations in drug innovation by using a ARO-CRO hybrid service model.

Trends in Disparities and Transitions of Treatment in Patients With Early Breast Cancer in China and the US, 2011 to 2021

Importance

Breast cancer treatment has profoundly improved in China recently. However, trends in disparities and transitions of treatment in early-stage cancer between China and the US are not well known.

Objective

To identify changes for patients with early breast cancer by using large databases from China and the US.

Design, Setting, and Participants

This multicenter cross-sectional study used the Chinese Society of Clinical Oncology Breast Cancer (CSCO BC) database from hospitals in 13 provinces in China and the Flatiron Health (hereinafter referred to as Flatiron) database from more than 280 community oncology clinics in the US. Patients with stage I to III breast cancer diagnosed from January 1, 2011, to December 31, 2021, were included. Data were analyzed from June 10 to December 1, 2022.

Main Outcomes and Measures

The distribution of age, clinical stage, and cancer subtypes at diagnosis were examined overall and by year. The mean annual percent change (MAPC) from 2011 to 2021 in systemic therapy and surgery was also analyzed.

Results

A total of 57 720 patients with early breast cancer were screened from the CSCO BC (n = 45 970) and Flatiron (n = 11 750) databases. The median age at diagnosis in China among the 41 449 patients included in the age analysis was 47 (IQR, 40-56) years; in the US, the median age was 64 (IQR, 54-73) years. Among patients with clinical stage data in the CSCO BC (n = 22 794) and Flatiron (n = 4413) databases, the proportion of stage I cancer was 7250 (31.8%) vs 2409 (54.6%); stage II cancer, 10 043 (44.1%) vs 1481 (33.6%); and stage III cancer, 5501 (24.1%) vs 523 (11.9%). The proportion of hormone receptor-positive cancer in China was 69.8%, lower than that in the US (87.5%). For patients with ERBB2 (formerly HER2 or HER2/neu)-positive cancer, the proportion in China (30.2%) was higher than that in the US (15.6%). For neoadjuvant therapy, the annual rate increased from 247 of 1553 (15.9%) to 200 of 790 (25.3%) in China, with an MAPC of -4.4% (95% CI, -50.6% to 85.0%; P = .89). For patients with ERBB2-positive cancer, the proportion treated with trastuzumab in early-stage cancer in China increased significantly, with an MAPC of 22.1% (95% CI, 17.4%-26.9%; P < .001), and overtook that in the Flatiron database since 2017 (1684 [68.5%] vs 550 [62.5%]; P < .001).

Conclusions and Relevance

The findings of this cross-sectional study suggest that disparities in treatment of early breast cancer narrowed between China and the US during the study period. The rapid growth of trastuzumab treatment in China was suggestive of differential access to targeted ERBB2 therapy.

Growing research and development of targeted anticancer drugs in China

OBJECTIVE

To deliver a comprehensive picture of the landscape and changing trend of trials and approvals on targeted anticancer drugs in China from 2012 to 2021.

METHODS

Trials, investigated products, and listed drugs were acquired from national databases. The status quo, changing trend of absolute number, and proportion of targeted trials, products, and drugs, as well as the corresponding difference between domestic and foreign companies were analyzed.

RESULTS

A total of 2,632 trials on 1,167 targeted antitumor drugs were identified, accounting for 81.5% of all registered trials. The number and proportion of trials on targeted drugs increased steadily, with an average growth rate of 36.0% and 6.2%, respectively. A similar growth trend was observed in the number (33.7%) and proportion (13.8%) of targeted drugs. Targeted drugs and trials owned by domestic companies accounted for a higher proportion than that by foreign companies (80.5% vs. 19.5%; 83.2% vs. 16.8%, respectively), and the growing trend for both targeted drugs (13.8% vs. 5.7%) and trials (13.8% vs. 33.7%) owned by domestic companies was faster. The proportion of targeted drug trials (80.5% vs. 85.6%) and multicenter trials (6.0% vs. 69.9%) initiated by domestic companies was lower than that by foreign companies, with the gap gradually narrowing. Among the identified 18 targets of the 126 immune drugs under development, only one globally new target was found.

CONCLUSIONS

Research and development of targeted antitumor drugs in China are booming and advancing rapidly, and domestic enterprises have become the pillar. Encouraging genomics activities and establishing incentives and public-private collaboration frameworks are crucial for innovation-oriented drug development in China.

Targeted protein degrader development for cancer: advances, challenges, and opportunities

Anticancer-targeted therapies inhibit various kinases implicated in cancer and have been used in clinical settings for decades. However, many cancer-related targets are proteins without catalytic activity and are difficult to target using traditional occupancy-driven inhibitors. Targeted protein degradation (TPD) is an emerging therapeutic modality that has expanded the druggable proteome for cancer treatment. With the entry of new-generation immunomodulatory drugs (IMiDs), selective estrogen receptor degraders (SERDs), and proteolysis-targeting chimera (PROTAC) drugs into clinical trials, the field of TPD has seen explosive growth in the past 10 years. Several challenges remain that need to be tackled to increase successful clinical translation of TPD drugs. We present an overview of the global landscape of clinical trials of TPD drugs over the past decade and summarize the clinical profiles of new-generation TPD drugs. In addition, we highlight the challenges and opportunities for the development of effective TPD drugs for future successful clinical translation.