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de Kanter AFJ, Jongsma KR, Verhaar MC, Bredenoord AL. The Ethical Implications of Tissue Engineering for Regenerative Purposes: A Systematic Review. TISSUE ENGINEERING PART B: REVIEWS 2022; 29:167-187. [PMID: 36112697 PMCID: PMC10122262 DOI: 10.1089/ten.teb.2022.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Tissue Engineering (TE) is a branch of Regenerative Medicine (RM) that combines stem cells and biomaterial scaffolds to create living tissue constructs to restore patients' organs after injury or disease. Over the last decade, emerging technologies such as 3D bioprinting, biofabrication, supramolecular materials, induced pluripotent stem cells, and organoids have entered the field. While this rapidly evolving field is expected to have great therapeutic potential, its development from bench to bedside presents several ethical and societal challenges. To make sure TE will reach its ultimate goal of improving patient welfare, these challenges should be mapped out and evaluated. Therefore, we performed a systematic review of the ethical implications of the development and application of TE for regenerative purposes, as mentioned in the academic literature. A search query in PubMed, Embase, Scopus, and PhilPapers yielded 2451 unique articles. After systematic screening, 237 relevant ethical and biomedical articles published between 2008 and 2021 were included in our review. We identified a broad range of ethical implications that could be categorized under 10 themes. Seven themes trace the development from bench to bedside: (1) animal experimentation, (2) handling human tissue, (3) informed consent, (4) therapeutic potential, (5) risk and safety, (6) clinical translation, and (7) societal impact. Three themes represent ethical safeguards relevant to all developmental phases: (8) scientific integrity, (9) regulation, and (10) patient and public involvement. This review reveals that since 2008 a significant body of literature has emerged on how to design clinical trials for TE in a responsible manner. However, several topics remain in need of more attention. These include the acceptability of alternative translational pathways outside clinical trials, soft impacts on society and questions of ownership over engineered tissues. Overall, this overview of the ethical and societal implications of the field will help promote responsible development of new interventions in TE and RM. It can also serve as a valuable resource and educational tool for scientists, engineers, and clinicians in the field by providing an overview of the ethical considerations relevant to their work. Impact statement To our knowledge, this is the first time that the ethical implications of Tissue Engineering (TE) have been reviewed systematically. By gathering existing scholarly work and identifying knowledge gaps, this review facilitates further research into the ethical and societal implications of TE and Regenerative Medicine (RM) and other emerging biomedical technologies. Moreover, it will serve as a valuable resource and educational tool for scientists, engineers, and clinicians in the field by providing an overview of the ethical considerations relevant to their work. As such, our review may promote successful and responsible development of new strategies in TE and RM.
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Affiliation(s)
- Anne-Floor Johanna de Kanter
- University Medical Centre Utrecht, Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, Stratenum 6.131, PO Box 85500, Utrecht, Utrecht, Netherlands, 3508 GA,
| | - Karin Rolanda Jongsma
- University Medical Centre Utrecht, Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, Utrecht, Netherlands,
| | - Marianne C Verhaar
- University Medical Centre Utrecht, Department of Nephrology and Hypertension, Utrecht, Netherlands,
| | - Annelien L Bredenoord
- University Medical Centre Utrecht, Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, Utrecht, Netherlands
- Erasmus University Rotterdam, Erasmus School of Philosophy, Rotterdam, Netherlands,
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Jovic TH, Combellack EJ, Jessop ZM, Whitaker IS. 3D Bioprinting and the Future of Surgery. Front Surg 2020; 7:609836. [PMID: 33330613 PMCID: PMC7728666 DOI: 10.3389/fsurg.2020.609836] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/06/2020] [Indexed: 12/19/2022] Open
Abstract
Introduction: The disciplines of 3D bioprinting and surgery have witnessed incremental transformations over the last century. 3D bioprinting is a convergence of biology and engineering technologies, mirroring the clinical need to produce viable biological tissue through advancements in printing, regenerative medicine and materials science. To outline the current and future challenges of 3D bioprinting technology in surgery. Methods: A comprehensive literature search was undertaken using the MEDLINE, EMBASE and Google Scholar databases between 2000 and 2019. A narrative synthesis of the resulting literature was produced to discuss 3D bioprinting, current and future challenges, the role in personalized medicine and transplantation surgery and the global 3D bioprinting market. Results: The next 20 years will see the advent of bioprinted implants for surgical use, however the path to clinical incorporation will be fraught with an array of ethical, regulatory and technical challenges of which each must be surmounted. Previous clinical cases where regulatory processes have been bypassed have led to poor outcomes and controversy. Speculated roles of 3D bioprinting in surgery include the production of de novo organs for transplantation and use of autologous cellular material for personalized medicine. The promise of these technologies has sparked an industrial revolution, leading to an exponential growth of the 3D bioprinting market worth billions of dollars. Conclusion: Effective translation requires the input of scientists, engineers, clinicians, and regulatory bodies: there is a need for a collaborative effort to translate this impactful technology into a real-world healthcare setting and potentially transform the future of surgery.
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Affiliation(s)
- Thomas H Jovic
- Reconstructive Surgery and Regenerative Medicine Research Group, Swansea University, Swansea, United Kingdom.,Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, United Kingdom
| | - Emman J Combellack
- Reconstructive Surgery and Regenerative Medicine Research Group, Swansea University, Swansea, United Kingdom.,Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, United Kingdom
| | - Zita M Jessop
- Reconstructive Surgery and Regenerative Medicine Research Group, Swansea University, Swansea, United Kingdom.,Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, United Kingdom
| | - Iain S Whitaker
- Reconstructive Surgery and Regenerative Medicine Research Group, Swansea University, Swansea, United Kingdom.,Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, United Kingdom
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Sharpe M, Barry J, Kefalas P. Clinical Adoption of Advanced Therapies: Challenges and Opportunities. J Pharm Sci 2020; 110:1877-1884. [PMID: 32918916 DOI: 10.1016/j.xphs.2020.08.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/25/2020] [Accepted: 08/28/2020] [Indexed: 12/11/2022]
Abstract
As the cell and gene therapy field matures the powerful therapeutic potential of these innovative therapies is starting to be shown, particularly in the fields of oncology and childhood immune deficiency diseases. However, as more therapies enter late stage clinical trials, advances and innovation are required in manufacturing, logistics, regulation, reimbursement and the healthcare setting to ensure that systems are in place to support wider clinical adoption of these promising treatments. A window of opportunity exists to implement new methodologies for best practice in both the ability to manufacture products reproducibly at scale, as well as ensuring healthcare systems are not overwhelmed by the variety and complexity of these new therapies and the additional burden they will place on already stretched facilities. If all interested parties work together it will be possible for the sector to develop the necessary processes, skilled staff and infrastructure needed as more treatments move from clinical trial to marketed products.
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Affiliation(s)
- Michaela Sharpe
- Moare Solutions Ltd, 99 Canterbury Road, Whitstable, Kent CT5 4HG, UK.
| | - Jacqueline Barry
- Cell and Gene Therapy Catapult, Guys Hospital, 12th Floor Tower Wing, Great Maze Pond, London SE1 9RT, UK
| | - Panos Kefalas
- Cell and Gene Therapy Catapult, Guys Hospital, 12th Floor Tower Wing, Great Maze Pond, London SE1 9RT, UK
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Lam C, Meinert E, Halioua-Haubold CL, Carter A, Yang A, Brindley D, Cui Z. Systematic review protocol: an assessment of the post-approval challenges of autologous CAR-T therapy delivery. BMJ Open 2019; 9:e026172. [PMID: 31278092 PMCID: PMC6615899 DOI: 10.1136/bmjopen-2018-026172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Following recent regulatory approvals of two chimeric antigen receptor T-cell (CAR-T) therapies, the field now faces a number of post-approval challenges. These challenges are in some respects defined and, in others, uncertain due to the nascence of the field. At present, information pertaining to such post-approval challenges are scattered in various previous reviews or raised in singular papers reporting experience in working with the therapy. This systematic review is designed to evaluate and summarise the post-approval challenges for robust delivery of CAR-T therapies to inform future work on the optimisation of CAR-T delivery to patients. METHODS AND ANALYSIS We will search Medline, EMBASE (OvidSP), BIOSIS & Web of Science, Cochrane Library, ICER database, NICE Evidence Search, CEA Registry, WHOLIS WHO Library and Scopus for studies published between 2014 and the present. In addition, a Google search for grey literature such as bioprocess blog posts, opinion pieces, press releases and listed companies involved in CAR-T development annual reports will be conducted. Two authors will independently screen the titles and abstracts identified from the search and accept or reject the studies according to the study inclusion criteria and any discrepancies will be discussed and resolved. The quality of the selected literature will be assessed using the Critical Appraisal Skills Programme(CASP) Systematic Review checklist and grey literature will be assessed using the Authority, Accuracy, Coverage, Objectivity, Date, Significance (AACODS) checklist. Data from eligible publications will be categorised using a flowchart and extracted using a data abstraction form. Qualitative and quantitative analysis of the post-approval challenges of CAR-T therapies will be conducted based on the results attained. ETHICS AND DISSEMINATION The executed study will be published in a peer-reviewed journal in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The findings from this review will be used to inform the development of an optimisation model for robust delivery of CAR-T therapies using a systems engineering approach. TRIAL REGISTRATION NUMBER CRD42018109756.
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Affiliation(s)
- Ching Lam
- Department of Engineering Sciences, University of Oxford, Oxford, UK
| | - Edward Meinert
- Healthcare Translation Research Group, Department of Paediatrics, University of Oxford, Oxford, UK
- Digital Global Health Unit, Department of Primary Care and Public Health, Imperial College London, London
| | | | - Alison Carter
- Healthcare Translation Research Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Aidong Yang
- Department of Engineering Sciences, University of Oxford, Oxford, UK
| | - David Brindley
- Healthcare Translation Research Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Zhanfeng Cui
- Department of Engineering Sciences, University of Oxford, Oxford, UK
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Roddie C, O'Reilly M, Dias Alves Pinto J, Vispute K, Lowdell M. Manufacturing chimeric antigen receptor T cells: issues and challenges. Cytotherapy 2019; 21:327-340. [PMID: 30685216 DOI: 10.1016/j.jcyt.2018.11.009] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/25/2018] [Accepted: 11/26/2018] [Indexed: 12/12/2022]
Abstract
Clinical trials of adoptively transferred CD19 chimeric antigen receptor (CAR) T cells have delivered unprecedented responses in patients with relapsed refractory B-cell malignancy. These results have prompted Food and Drug Administration (FDA) approval of two CAR T-cell products in this high-risk patient population. The widening range of indications for CAR T-cell therapy and increasing patient numbers present a significant logistical challenge to manufacturers aiming for reproducible delivery systems for high-quality clinical CAR T-cell products. This review discusses current and novel CAR T-cell processing methodologies and the quality control systems needed to meet the increasing clinical demand for these exciting new therapies.
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Affiliation(s)
- Claire Roddie
- Research Department of Haematology, University College London, London, UK; Department of Haematology, University College London Hospitals National Health Service (NHS) Foundation Trust, London.
| | - Maeve O'Reilly
- Research Department of Haematology, University College London, London, UK; Department of Haematology, University College London Hospitals National Health Service (NHS) Foundation Trust, London
| | | | - Ketki Vispute
- Research Department of Haematology, University College London, London, UK
| | - Mark Lowdell
- Research Department of Haematology, University College London, London, UK
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Gardner J, Webster A, Barry J. Anticipating the clinical adoption of regenerative medicine: building institutional readiness in the UK. Regen Med 2018; 13:29-39. [DOI: 10.2217/rme-2017-0121] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
This perspective paper examines the challenges of implementing regenerative medicine (RM) therapies within hospitals and clinics. Drawing on recent work in the social sciences, the paper highlights dynamics within existing healthcare systems that will present both hindrances and affordances for the implementation of new RM technologies within hospitals and clinics. The paper argues that identifying suitable locations for cell- and gene-therapy treatment centers requires an assessment of their institutional readiness for RM. Some provisional criteria for assessing institutional readiness are outlined, and the paper will suggest that it is necessary to begin developing a program for the phased introduction of RM in the longer term.
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Affiliation(s)
- John Gardner
- School of Social Sciences, Monash University, Clayton Campus, W414 Menzies Building, 20 Chancellors Walk, Melbourne, Australia
| | - Andrew Webster
- Department of Sociology, Science & Technology Studies Unit, Wentworth College, University of York, York YO10 5DD, UK
| | - Jacqueline Barry
- Cell & Gene Therapy Catapult, Guy's Hospital, 12th Floor Tower Wing, Great Maze Pond, London SE1 9RT, UK
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Webster A. Regenerative medicine and responsible research and innovation: proposals for a responsible acceleration to the clinic. Regen Med 2017; 12:853-864. [DOI: 10.2217/rme-2017-0028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This paper asks how regenerative medicine can be examined through the ‘responsible research and innovation’ (RRI) approach which has been developed over the past decade. It describes the drivers to the development of RRI, and then argues for the need to understand innovation itself through drawing on social science analysis rooted in science and technology studies. The paper then identifies a number of highly specific challenges faced by the regenerative medicine field and the implications these have for value creation. It offers a number of examples of how a combined RRI/science and technology studies perspective can identify priority areas for policy and concludes by arguing for a ‘responsible acceleration’, more likely to foster readiness at a time when much of the policy domain is pushing for ever-rapid access to cell therapies.
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Affiliation(s)
- Andrew Webster
- Department of Sociology, SATSU, University of York, York, YO10 5DD, UK
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Nienhuis AW, Nathwani AC, Davidoff AM. Gene Therapy for Hemophilia. Mol Ther 2017; 25:1163-1167. [PMID: 28411016 PMCID: PMC5417837 DOI: 10.1016/j.ymthe.2017.03.033] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 03/28/2017] [Accepted: 03/28/2017] [Indexed: 12/11/2022] Open
Abstract
The X-linked bleeding disorder hemophilia causes frequent and exaggerated bleeding that can be life-threatening if untreated. Conventional therapy requires frequent intravenous infusions of the missing coagulation protein (factor VIII [FVIII] for hemophilia A and factor IX [FIX] for hemophilia B). However, a lasting cure through gene therapy has long been sought. After a series of successes in small and large animal models, this goal has finally been achieved in humans by in vivo gene transfer to the liver using adeno-associated viral (AAV) vectors. In fact, multiple recent clinical trials have shown therapeutic, and in some cases curative, expression. At the same time, cellular immune responses against the virus have emerged as an obstacle in humans, potentially resulting in loss of expression. Transient immune suppression protocols have been developed to blunt these responses. Here, we provide an overview of the clinical development of AAV gene transfer for hemophilia, as well as an outlook on future directions.
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Affiliation(s)
- Arthur W Nienhuis
- Division of Experimental Hematology, Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
| | - Amit C Nathwani
- Department of Haematology, University College London Cancer Institute, 72 Huntley Street, London WC1E 6BT, UK
| | - Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
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