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Pearson ADJ, de Rojas T, Karres D, Reaman G, Scobie N, Fox E, Lesa G, Ligas F, Norga K, Nysom K, Pappo A, Weigel B, Weiner SL, Vassal G. Impact of ACCELERATE Paediatric Strategy Forums: a review of the value of multi-stakeholder meetings in oncology drug development. J Natl Cancer Inst 2024; 116:200-207. [PMID: 37975877 PMCID: PMC10852613 DOI: 10.1093/jnci/djad239] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/23/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023] Open
Abstract
In a landscape of an increasing number of products and histology and age agnostic trials for rare patient cancer, prioritization of products is required. Paediatric Strategy Forums, organized by ACCELERATE and the European Medicines Agency with participation of the US Food and Drug Administration, are multi-stakeholder meetings that share information to best inform pediatric drug development strategies and subsequent clinical trial decisions. Academia, industry, regulators, and patient advocates are equal members, with patient advocates highlighting unmet needs of children and adolescents with cancer. The 11 Paediatric Strategy Forums since 2017 have made specific and general conclusions to accelerate drug development. Conclusions on product prioritization meetings, as well as global master protocols, have been outputs of these meetings. Forums have provided information for regulatory discussions and decisions by industry to facilitate development of high-priority products; for example, 62% of high-priority assets (agreed at a Forum) in contrast to 5% of those assets not considered high priority have been the subject of a Paediatric Investigational Plan or Written Request. Where there are multiple products of the same class, Forums have recommended a focused and sequential approach. Class prioritization resulted in an increase in waivers for non-prioritized B-cell products (44% to 75%) and a decrease in monotherapy trials, proposed in Paediatric Investigation Plans (PIP) submissions of checkpoint inhibitors from 53% to 19%. Strategy Forums could play a role in defining unmet medical needs. Multi-stakeholder forums, such as the Paediatric Strategy Forum, serve as a model to improve collaboration in the oncology drug development paradigm.
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Affiliation(s)
| | | | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Gregory Reaman
- US Food and Drug Administration (FDA), Silver Spring, MD, USA
| | | | - Elizabeth Fox
- St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Koen Norga
- Antwerp University Hospital, Antwerp, Belgium
- Paediatric Committee of the European Medicines Agency, (EMA), Amsterdam, The Netherlands
- Federal Agency for Medicines and Health Products, Brussels, Belgium
| | | | - Alberto Pappo
- St Jude Children’s Research Hospital, Memphis, TN, USA
| | | | | | - Gilles Vassal
- ACCELERATE, Brussels, Belgium, Europe
- Gustave Roussy Cancer Centre, Paris, France
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Majumdar A, Rothwell R, Reaman G, Ahlberg C, Roy P. Utility of propensity score-based Bayesian borrowing of external adult data in pediatric trials: A pragmatic evaluation through a case study in acute lymphoblastic leukemia (ALL). J Biopharm Stat 2023; 33:737-751. [PMID: 36600441 DOI: 10.1080/10543406.2022.2162069] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023]
Abstract
A fully powered randomized controlled cancer trial can be challenging to conduct in children because of difficulties in enrollment of pediatric patients due to low disease incidence. One way to improve the feasibility of trials in pediatric patients, when clinically appropriate, is through borrowing information from comparable external adult trials in the same disease. Bayesian analysis of a pediatric trial provides a way of seamlessly augmenting pediatric trial efficacy data with data from external adult trials. However, not all external adult trial subjects may be equally clinically relevant with respect to the baseline disease severity, prognostic factors, co-morbidities, and prior therapy observed in the pediatric trial of interest. The propensity score matching method provides a way of matching the external adult subjects to the pediatric trial subjects on a set of clinically determined baseline covariates, such as baseline disease severity, prognostic factors and prior therapy. The matching then allows Bayesian information borrowing from only the most clinically relevant external adult subjects. Through a case study in pediatric acute lymphoblastic leukemia (ALL), we examine the utility of propensity score matched mixture and power priors in bringing appropriate external adult efficacy information into pediatric trial efficacy assessment, and present considerations for scaling fixed borrowing from external adult data.
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Affiliation(s)
- Antara Majumdar
- Oncology Biostatistics, GlaxoSmithKline, Collegeville, PA, USA
| | - Rebecca Rothwell
- Office of Biostatistics, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Gregory Reaman
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Corinne Ahlberg
- Acorn AI by Medidata, a Dassault Systèmes company, New York, NY, USA
| | - Pourab Roy
- Biostatistics, Regeneron Pharmaceuticals, Tarrytown, NY, USA
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3
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Cooner F, Ye J, Reaman G. Clinical trial considerations for pediatric cancer drug development. J Biopharm Stat 2023; 33:859-874. [PMID: 36749066 DOI: 10.1080/10543406.2023.2172424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 02/08/2023]
Abstract
Oncology has been one of the most active therapeutic areas in medicinal products development. Despite this fact, few drugs have been approved for use in pediatric cancer patients when compared to the number approved for adults with cancer. This disparity could be attributed to the fact that many oncology drugs have had orphan drug designation and were exempt from Pediatric Research Equity Act (PREA) requirements. On August 18, 2017, the RACE for Children Act, i.e. Research to Accelerate Cures and Equity Act, was signed into law as Title V of the 2017 FDA Reauthorization Act (FDARA) to amend the PREA. Pediatric investigation is now required if the drug or biological product is intended for the treatment of an adult cancer and directed at a molecular target that FDA determines to be "substantially relevant to the growth or progression of a pediatric cancer." This paper discusses the specific considerations in clinical trial designs and statistical methodologies to be implemented in oncology pediatric clinical programs.
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Affiliation(s)
- Freda Cooner
- Global Biostatistics, Amgen Inc, Thousand Oaks, CA, USA
| | - Jingjing Ye
- Global Statistics and Data Sciences (GSDS), BeiGene USA, Fulton, MD, USA
| | - Gregory Reaman
- Oncology Center of Excellence, Office of the Commissioner, U.S. FDA, Silver Spring, MD, USA
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4
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Guinn D, Gafford M, Burckart GJ, Reaman G, Charlab R. Assessing Information Gaps Associated with Initial Pediatric Study Plans for New Oncology Drug and Biological Products. Clin Pharmacol Ther 2023; 114:618-622. [PMID: 37422730 DOI: 10.1002/cpt.2995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/19/2023] [Indexed: 07/10/2023]
Abstract
The Research Acceleration for Cure and Equity (RACE) for Children Act requires sponsors to submit a Pediatric Study Plan (PSP) with a proposed pediatric investigation of new molecularly targeted drugs and biologics that are intended for treatment of adult cancers, and whose target is relevant to pediatric cancer or provide a justification for a plan to request a deferral or waiver of the required investigation. A landscape analysis was performed to identify trends in information gaps associated with a sponsor's first initial PSP (iPSP) submission for oncologic new molecular entities received in 2021. Comments sent to sponsors by the US Food and Drug Administration (FDA) during the review process of each evaluated iPSP were categorized using nine flags relating to different portions of the PSP. For iPSPs that included a plan for a full waiver request, the most common information gap was inadequate justification based on molecular target relevance. All other sponsor proposed plans (deferral and/or partial waiver or investigation) were found to have information gaps related to clinical study features, clinical pharmacology, and/or missing clinical or nonclinical data. This landscape analysis of iPSPs shows the trends in comments that often occur during initial review and may help to provide sponsors with more direction for preparing an adequate iPSP to fulfill statutory requirements aimed at ensuring pediatric patients are considered in the development of new molecularly targeted drugs.
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Affiliation(s)
- Daphne Guinn
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Marilyn Gafford
- Harding University College of Pharmacy, Searcy, Arkansas, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gregory Reaman
- Oncology Center of Excellence, Office of the Commissioner, and Office of Oncologic Diseases, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rosane Charlab
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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Arfè A, Narang C, DuBois SG, Reaman G, Bourgeois FT. Clinical development of new drugs for adults and children with cancer, 2010-2020. J Natl Cancer Inst 2023; 115:917-925. [PMID: 37171887 PMCID: PMC10407707 DOI: 10.1093/jnci/djad082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/30/2023] [Accepted: 05/09/2023] [Indexed: 05/14/2023] Open
Abstract
BACKGROUND Many new molecular entities enter clinical development to evaluate potential therapeutic benefits for oncology patients. We characterized adult and pediatric development of the set of new molecular entities that started clinical testing in 2010-2015 worldwide. METHODS We extracted data from AdisInsight, an extensive database of global pharmaceutical development, and the FDA.gov website. We followed the cohort of new molecular entities initiating first-in-human phase I clinical trials in 2010-2015 to the end of 2020. For each new molecular entity, we determined whether it was granted US Food and Drug Administration (FDA) approval, studied in a trial open to pediatric enrollment, or stalled during development. We characterized the cumulative incidence of these endpoints using statistical methods for censored data. RESULTS The 572 new molecular entities starting first-in-human studies in 2010-2015 were studied in 6142 trials by the end of 2020. Most new molecular entities were small molecules (n = 316, 55.2%), antibodies (n = 148, 25.9%), or antibody-drug conjugates (n = 44, 7.7%). After a mean follow-up of 8.0 years, 173 new molecular entities did not advance beyond first-in-human trials, and 39 were approved by the FDA. New molecular entities had a 10.4% estimated probability (95% confidence interval = 6.6% to 14.1%) of being approved by the FDA within 10 years of first-in-human trials. After a median of 4.6 years since start of first-in-human trials, 67 (11.7%) new molecular entities were tested in trials open to pediatric patients, and 5 (0.9%) were approved for pediatric indications. CONCLUSIONS More efficient clinical development strategies are needed to evaluate new cancer therapies, especially for children, and incorporate approaches to ensure knowledge gain from investigational products that stall in development.
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Affiliation(s)
- Andrea Arfè
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Claire Narang
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program (CHIP), Boston Children’s Hospital, Boston, MA, USA
| | - Steven G DuBois
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Gregory Reaman
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Florence T Bourgeois
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program (CHIP), Boston Children’s Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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6
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Pearson ADJ, Federico S, Gatz SA, Ortiz M, Lesa G, Scobie N, Gounaris I, Weiner SL, Weigel B, Unger TJ, Stewart E, Smith M, Slotkin EK, Reaman G, Pappo A, Nysom K, Norga K, McDonough J, Marshall LV, Ludwinski D, Ligas F, Karres D, Kool M, Horner TJ, Henssen A, Heenen D, Hawkins DS, Gore L, Bender JG, Galluzzo S, Fox E, de Rojas T, Davies BR, Chakrabarti J, Carmichael J, Bradford D, Blanc P, Bernardi R, Benchetrit S, Akindele K, Vassal G. Paediatric Strategy Forum for medicinal product development of DNA damage response pathway inhibitors in children and adolescents with cancer: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2023; 190:112950. [PMID: 37441939 DOI: 10.1016/j.ejca.2023.112950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/09/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023]
Abstract
DNA damage response inhibitors have a potentially important therapeutic role in paediatric cancers; however, their optimal use, including patient selection and combination strategy, remains unknown. Moreover, there is an imbalance between the number of drugs with diverse mechanisms of action and the limited number of paediatric patients available to be enrolled in early-phase trials, so prioritisation and a strategy are essential. While PARP inhibitors targeting homologous recombination-deficient tumours have been used primarily in the treatment of adult cancers with BRCA1/2 mutations, BRCA1/2 mutations occur infrequently in childhood tumours, and therefore, a specific response hypothesis is required. Combinations with targeted radiotherapy, ATR inhibitors, or antibody drug conjugates with DNA topoisomerase I inhibitor-related warheads warrant evaluation. Additional monotherapy trials of PARP inhibitors with the same mechanism of action are not recommended. PARP1-specific inhibitors and PARP inhibitors with very good central nervous system penetration also deserve evaluation. ATR, ATM, DNA-PK, CHK1, WEE1, DNA polymerase theta and PKMYT1 inhibitors are early in paediatric development. There should be an overall coordinated strategy for their development. Therefore, an academia/industry consensus of the relevant biomarkers will be established and a focused meeting on ATR inhibitors (as proof of principle) held. CHK1 inhibitors have demonstrated activity in desmoplastic small round cell tumours and have a potential role in the treatment of other paediatric malignancies, such as neuroblastoma and Ewing sarcoma. Access to CHK1 inhibitors for paediatric clinical trials is a high priority. The three key elements in evaluating these inhibitors in children are (1) innovative trial design (design driven by a clear hypothesis with the intent to further investigate responders and non-responders with detailed retrospective molecular analyses to generate a revised or new hypothesis); (2) biomarker selection and (3) rational combination therapy, which is limited by overlapping toxicity. To maximally benefit children with cancer, investigators should work collaboratively to learn the lessons from the past and apply them to future studies. Plans should be based on the relevant biology, with a focus on simultaneous and parallel research in preclinical and clinical settings, and an overall integrated and collaborative strategy.
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Affiliation(s)
- Andrew D J Pearson
- ACCELERATE, c/o BLSI, Clos Chapelle-aux-Champs 30, Bte 1.30.30 BE-1200 Brussels, Belgium.
| | - Sara Federico
- St Jude Children's Research Hospital, Memphis, TN, USA
| | - Susanne A Gatz
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Michael Ortiz
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, the Netherlands
| | | | - Ioannis Gounaris
- Merck Serono Ltd (an affiliate of Merck KGaA, Darmstadt, Germany), Feltham, UK
| | | | | | - T J Unger
- Repare Therapeutics, Cambridge, MA, USA
| | | | | | | | - Gregory Reaman
- US Food and Drug Administration, Silver Springs, MD, USA
| | - Alberto Pappo
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Koen Norga
- Antwerp University Hospital, Antwerp, Belgium; Paediatric Committee of the European Medicines Agency (EMA), Amsterdam, the Netherlands; Federal Agency for Medicines and Health Products, Brussels, Belgium
| | - Joe McDonough
- The Andrew McDonough B+ Foundation, Wilmington, DE, USA
| | - Lynley V Marshall
- The Royal Marsden NHS Foundation Hospital, The Institute of Cancer Research, Sutton, Surrey, UK
| | | | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, the Netherlands
| | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, the Netherlands
| | - Marcel Kool
- Hopp Children's Cancer Center, Heidelberg, Germany
| | | | | | | | - Douglas S Hawkins
- Seattle Children's Hospital, Seattle, WA, USA; Children's Oncology Group, Seattle, WA, USA
| | - Lia Gore
- Children's Hospital Colorado, Aurora, CO, USA; University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Elizabeth Fox
- St Jude Children's Research Hospital, Memphis, TN, USA
| | - Teresa de Rojas
- ACCELERATE, c/o BLSI, Clos Chapelle-aux-Champs 30, Bte 1.30.30 BE-1200 Brussels, Belgium
| | | | | | - Juliet Carmichael
- The Royal Marsden NHS Foundation Hospital, The Institute of Cancer Research, Sutton, Surrey, UK
| | - Diana Bradford
- US Food and Drug Administration, Silver Springs, MD, USA
| | | | - Ronald Bernardi
- Genentech, a Member of the Roche Group, South San Francisco, CA, USA
| | - Sylvie Benchetrit
- National Agency for the Safety of Medicine and Health Products, Paris, France
| | | | - Gilles Vassal
- ACCELERATE, c/o BLSI, Clos Chapelle-aux-Champs 30, Bte 1.30.30 BE-1200 Brussels, Belgium; Gustave Roussy Cancer Centre, Paris, France
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Moreno L, DuBois SG, Glade Bender J, Mauguen A, Bird N, Buenger V, Casanova M, Doz F, Fox E, Gore L, Hawkins DS, Izraeli S, Jones DT, Kearns PR, Molenaar JJ, Nysom K, Pfister S, Reaman G, Smith M, Weigel B, Vassal G, Zwaan CM, Paoletti X, Iasonos A, Pearson AD. Combination Early-Phase Trials of Anticancer Agents in Children and Adolescents. J Clin Oncol 2023; 41:3408-3422. [PMID: 37015036 PMCID: PMC10414747 DOI: 10.1200/jco.22.02430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 02/07/2023] [Indexed: 04/06/2023] Open
Abstract
PURPOSE There is an increasing need to evaluate innovative drugs for childhood cancer using combination strategies. Strong biological rationale and clinical experience suggest that multiple agents will be more efficacious than monotherapy for most diseases and may overcome resistance mechanisms and increase synergy. The process to evaluate these combination trials needs to maximize efficiency and should be agreed by all stakeholders. METHODS After a review of existing combination trial methodologies, regulatory requirements, and current results, a consensus among stakeholders was achieved. RESULTS Combinations of anticancer therapies should be developed on the basis of mechanism of action and robust preclinical evaluation, and may include data from adult clinical trials. The general principle for combination early-phase studies is that, when possible, clinical trials should be dose- and schedule-confirmatory rather than dose-exploratory, and every effort should be made to optimize doses early. Efficient early-phase combination trials should be seamless, including dose confirmation and randomized expansion. Dose evaluation designs for combinations depend on the extent of previous knowledge. If not previously evaluated, limited evaluation of monotherapy should be included in the same clinical trial as the combination. Randomized evaluation of a new agent plus standard therapy versus standard therapy is the most effective approach to isolate the effect and toxicity of the novel agent. Platform trials may be valuable in the evaluation of combination studies. Patient advocates and regulators should be engaged with investigators early in a proposed clinical development pathway and trial design must consider regulatory requirements. CONCLUSION An optimized, agreed approach to the design and evaluation of early-phase pediatric combination trials will accelerate drug development and benefit all stakeholders, most importantly children and adolescents with cancer.
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Affiliation(s)
- Lucas Moreno
- Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Steven G. DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA
| | | | | | - Nick Bird
- Solving Kids' Cancer UK, London, United Kingdom
| | - Vickie Buenger
- Coalition Against Childhood Cancer (CAC2), Philadelphia, PA
| | | | - François Doz
- Université Paris Cité, Paris, France
- SIREDO Centre (Care, Innovation Research in Pediatric, Adolescent and Young Adults Oncology), Institut Curie, Paris, France
| | | | - Lia Gore
- Children's Hospital Colorado, Aurora, CO
- University of Colorado, Aurora, CO
| | | | - Shai Izraeli
- Rina Zaizov Pediatric Hematology Oncology Division, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Hematological Malignancies Centre of Human Molecular Genetics and Biochemistry, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David T.W. Jones
- Hopp Children’s Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, United Kingdom
| | - Pamela R. Kearns
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pharmaceutical Sciences Utrecht University, Utrecht, the Netherlands
| | - Jan J. Molenaar
- Division of Pediatric Neurooncology, DKFZ, KiTZ
- Righospitalet, Copenhagen, Denmark
| | - Karsten Nysom
- Clinical Trial Unit and Childhood Brain Tumors, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Pfister
- Hopp Children’s Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- Division of Pediatric Glioma Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Gilles Vassal
- Innovative Therapies for Children with Cancer, Paris, France
- ACCELERATE, Brussels, Belgium
- Gustave Roussy Cancer Centre, Paris, France
| | - Christian Michel Zwaan
- Righospitalet, Copenhagen, Denmark
- Department of Pediatric Oncology, Hematology, Erasmus MC, Sophia Children’s Hospital, the Netherlands
| | | | | | - Andrew D.J. Pearson
- Innovative Therapies for Children with Cancer, Paris, France
- ACCELERATE, Brussels, Belgium
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8
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Pearson AD, Allen C, Fangusaro J, Hutter C, Witt O, Weiner S, Reaman G, Russo M, Bandopadhayay P, Ahsan S, Barone A, Barry E, de Rojas T, Fisher M, Fox E, Bender JG, Gore L, Hargrave D, Hawkins D, Kreider B, Langseth AJ, Lesa G, Ligas F, Marotti M, Marshall LV, Nasri K, Norga K, Nysom K, Pappo A, Rossato G, Scobie N, Smith M, Stieglitz E, Weigel B, Weinstein A, Viana R, Karres D, Vassal G. Paediatric Strategy Forum for medicinal product development in mitogen-activated protein kinase pathway inhibitors: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2022; 177:120-142. [PMID: 36335782 DOI: 10.1016/j.ejca.2022.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/08/2022] [Accepted: 09/26/2022] [Indexed: 01/06/2023]
Abstract
As the mitogen-activated protein kinase (MAPK) signalling pathway is activated in many paediatric cancers, it is an important therapeutic target. Currently, a range of targeted MAPK pathway inhibitors are being developed in adults. However, MAPK signals through many cascades and feedback loops and perturbing the MAPK pathway may have substantial influence on other pathways as well as normal development. In view of these issues, the ninth Paediatric Strategy Forum focused on MAPK inhibitors. Development of MAPK pathway inhibitors to date has been predominantly driven by adult indications such as malignant melanoma. However, these inhibitors may also target unmet needs in paediatric low-grade gliomas, high-grade gliomas, Langerhans cell histiocytosis, juvenile myelomonocytic leukaemia and several other paediatric conditions. Although MAPK inhibitors have demonstrated activity in paediatric cancer, the response rates and duration of responses needs improvement and better documentation. The rapid development and evaluation of combination approaches, based on a deep understanding of biology, is required to optimise responses and to avoid paradoxical tumour growth and other unintended consequences including severe toxicity. Better inhibitors with higher central nervous systempenetration for primary brain tumours and cancers with a propensity for central nervous system metastases need to be studied to determine if they are more effective than agents currently being used, and the optimum duration of therapy with MAPK inhibition needs to be determined. Systematic and coordinated clinical investigations to inform future treatment strategies with MAPK inhibitors, rather than use outside of clinical trials, are needed to fully assess the risks and benefits of these single agents and combination strategies in both front-line and in the refractory/relapse settings. Platform trials could address the investigation of multiple similar products and combinations. Accelerating the introduction of MAPK inhibitors into front-line paediatric studies is a priority, as is ensuring that these studies generate data appropriate for scientific and regulatory purposes. Early discussions with regulators are crucial, particularly if external controls are considered as randomised control trials in small patient populations can be challenging. Functional end-points specific to the populations in which they are studied, such as visual acuity, motor and neuro psychological function are important, as these outcomes are often more reflective of benefit for lower grade tumours (such as paediatric low-grade glioma and plexiform neurofibroma) and should be included in initial study designs for paediatric low-grade glioma. Early prospective discussions and agreements with regulators are necessary. Long-term follow-up of patients receiving MAPK inhibitors is crucial in view of their prolonged administration and the important involvement of this pathway in normal development. Further rational development, with a detailed understanding of biology of this class of products, is crucial to ensure they provide optimal benefit while minimising toxicity to children and adolescents with cancer.
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Affiliation(s)
| | - Carl Allen
- Texas Children Hospital, Houston, TX, USA; Baylor College of Medicine, Houston, TX, USA
| | - Jason Fangusaro
- Children's Healthcare of Atlanta, USA; Emory University School of Medicine, Atlanta, USA
| | - Caroline Hutter
- St. Anna Children's Hospital, Vienna, Austria; Children's Cancer Research Institute, Vienna, Austria
| | - Olaf Witt
- Hopp Children's Cancer Center (KiTZ), Heidelberg, Germany; Heidelberg University Hospital, Heidelberg, Germany; German Cancer Research Center, Heidelberg, Germany
| | | | | | | | - Pratiti Bandopadhayay
- Department of Pediatrics, Harvard Medical School, Broad Institute, USA; Dana-Farber/Boston Children's Cancer and Blood Disorders Center, USA
| | | | - Amy Barone
- US Food and Drug Administration, Silver Springs, USA
| | - Elly Barry
- Day One Biopharmaceuticals, San Francisco, USA
| | | | - Michael Fisher
- The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Elizabeth Fox
- St Jude Children's Research Hospital, Tennessee, USA
| | | | - Lia Gore
- Children's Hospital Colorado, USA; University of Colorado, USA
| | - Darren Hargrave
- UCL Great Ormond Street Institute of Child Health, London UK
| | - Doug Hawkins
- Seattle Children's Hospital, USA; Children's Oncology Group, Seattle, USA
| | | | | | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Netherlands
| | | | - Lynley V Marshall
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | | | - Koen Norga
- Antwerp University Hospital, Antwerp, Belgium; Paediatric Committee of the European Medicines Agency, (EMA), Netherlands; Federal Agency for Medicines and Health Products, Brussels, Belgium
| | | | - Alberto Pappo
- St Jude Children's Research Hospital, Tennessee, USA
| | | | | | | | | | | | | | - Ruth Viana
- Alexion Pharmaceuticals, Zurich, Switzerland
| | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Netherlands
| | - Gilles Vassal
- ACCELERATE, Europe; Gustave Roussy Cancer Centre, Paris, France
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9
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Pearson ADJ, de Rojas T, Karres D, Reaman G, Scobie N, Fox E, Lesa G, Ligas F, Norga K, Nysom K, Pappo A, Weigel B, Weiner S, Vassal G. ACCELERATE Paediatric Strategy Forums: an advance for oncological drug development? Lancet Oncol 2022; 23:1354-1357. [PMID: 36328007 DOI: 10.1016/s1470-2045(22)00619-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency, Amsterdam, Netherlands
| | | | | | - Elizabeth Fox
- St Jude Children's Research Hospital, Memphis, TN, USA
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency, Amsterdam, Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency, Amsterdam, Netherlands
| | - Koen Norga
- Antwerp University Hospital, Antwerp, Belgium; Paediatric Committee of the European Medicines Agency, Amsterdam, Netherlands; Federal Agency for Medicines and Health Products, Brussels, Belgium
| | | | - Alberto Pappo
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | - Gilles Vassal
- ACCELERATE, 1200 Brussels, Belgium; Gustave Roussy Cancer Centre, Paris, France
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10
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De Wilde B, Barry E, Fox E, Karres D, Kieran M, Manlay J, Ludwinski D, Reaman G, Kearns P. The Critical Role of Academic Clinical Trials in Pediatric Cancer Drug Approvals: Design, Conduct, and Fit for Purpose Data for Positive Regulatory Decisions. J Clin Oncol 2022; 40:3456. [PMID: 35947814 DOI: 10.1200/jco.22.00033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 05/11/2022] [Accepted: 06/24/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE For decades, academic clinical trials consortia have collaborated to optimize outcomes for childhood cancers through evaluating incremental improvements in conventional mutimodality treatment regimes. There are now increasing opportunities to partner with industry to test new medicines in academic-sponsored trials, but these collaborative studies rarely contribute to marketing authorizations. We addressed why this is the case and sought solutions to enable academic-sponsored trials to directly contribute to the licensing of new medicines. METHODS Under the auspices of the multistakeholder platform ACCELERATE, we convened a working group of representatives from clinical academia, pharmaceutical industry, European Medicines Agency, US Food and Drug Administration, and patient advocacy to define the challenges and propose recommendations to facilitate academic-sponsored trial design and conduct to be aligned to both the needs of the pharmaceutical company who own the asset and the expectations of the regulatory (licensing) authorities. RESULTS We identified that although academic consortia have long-standing expertise to conduct robust clinical trials, there were critical gaps in knowledge, standard procedures, and resources that hindered the trial data directly contributing to marketing authorization applications. We propose a suite of recommendations focused on (1) essential documents, (2) essential data, (3) data management, and (4) trial resources, specifically aimed at enabling academic-industry partnerships to deliver an academic-sponsored trial that meets the requirements for a marketing authorization submission. These recommendations pivot around transparency in academic-industry partnerships and early engagement with regulators. CONCLUSION Academic sponsors and industry partners need to prospectively recognize when the planned collaborative trial could contribute to an application to marketing authorization and plan accordingly. Transparent collaboration and knowledge sharing between the partners opens an important pathway for accelerating new treatments into clinical practice for children with cancer.
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Affiliation(s)
- Bram De Wilde
- Department of Paediatric Haematology, Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent, Belgium
- Cancer Research Institute Ghent, Ghent University, Ghent, Belgium
| | - Elly Barry
- Day One Biopharmaceuticals Inc, San Francisco, CA
| | | | - Dominik Karres
- Human Medicines Division, Scientific Evidence Generation Department, Paediatric Medicines Office, European Medicines Agency (EMA), Amsterdam, the Netherlands
| | - Mark Kieran
- Day One Biopharmaceuticals Inc, San Francisco, CA
| | | | | | - Gregory Reaman
- Oncology Center of Excellence, Office of the Commissioner, and Office of Oncologic Diseases, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Pamela Kearns
- Cancer Research UK Clinical Trials Unit, NIHR Birmingham Biomedical Research Centre, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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11
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Merino M, Kasamon Y, Li H, Ma L, Leong R, Zhou J, Reaman G, Chambers W, Richardson N, Theoret M, Pazdur R, Gormley N. FDA approval summary: Crizotinib for pediatric and young adult patients with relapsed or refractory systemic anaplastic large cell lymphoma. Pediatr Blood Cancer 2022; 69:e29602. [PMID: 35561013 DOI: 10.1002/pbc.29602] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/07/2022] [Accepted: 01/27/2022] [Indexed: 12/14/2022]
Abstract
In January 2021, the U.S. Food and Drug Administration (FDA) approved crizotinib for pediatric patients 1 year and older and young adults with relapsed or refractory systemic anaplastic large cell lymphoma (sALCL). This is the first approval for pediatric sALCL. Approval was based on a single-arm trial of crizotinib monotherapy that included 26 patients, aged 1-20 years, with previously treated sALCL. Efficacy was based on centrally assessed objective response rate (88%) and duration of response. Herein, we highlight unique aspects of the regulatory review, including extension of the indication to young adults, postmarketing safety, and dose optimization strategies.
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Affiliation(s)
- Margret Merino
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yvette Kasamon
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Hongshan Li
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lian Ma
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ruby Leong
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jiaxi Zhou
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gregory Reaman
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA.,Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Wiley Chambers
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Nicholas Richardson
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Marc Theoret
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA.,Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Richard Pazdur
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA.,Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Nicole Gormley
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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12
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Li G, Ghosh S, Park J, Shin H, Garige M, Reaman G, Sourbier C. A mouse pancreatic organoid model to compare PD-L1 blocking antibodies. MAbs 2022; 14:2139886. [PMID: 36334035 PMCID: PMC9639566 DOI: 10.1080/19420862.2022.2139886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have changed the therapeutic landscape for cancer patients, but diabetes, a rare, severe immune-related endocrinopathy, is linked to ICI therapy. It is unclear whether glycosylation of ICIs may play a role in the development of this adverse event and how the physiological effects of different ICIs on pancreatic cells should be evaluated. We used a mouse pancreatic organoid model to compare three PD-L1 blocking antibodies in the presence or absence of IFNγ using a metabolic bioanalyzer. Modulation of ICI glycosylation altered its metabolic effects on mouse pancreatic organoids, suggesting that this model could be used to monitor and compare ICIs and to study the mechanisms underlying the development of IC-mediated diabetes.
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Affiliation(s)
- Guangyuan Li
- Division of Biotechnology Review and Research 1, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Susmita Ghosh
- Division of Biotechnology Review and Research 1, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - JuMe Park
- Division of Biotechnology Review and Research 1, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Hyunsu Shin
- Division of Biotechnology Review and Research 1, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Mamatha Garige
- Division of Biotechnology Review and Research 1, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gregory Reaman
- Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Carole Sourbier
- Division of Biotechnology Review and Research 1, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA,CONTACT Carole Sourbier Division of Biotechnology Review and Research 1, Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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13
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de Rojas T, Pearson AJ, Scobie N, Knox L, Wariabharaj D, Kearns P, Vassal G, Reaman G. Intercontinental collaboration in clinical trials for children and adolescents with cancer-A systematic review by ACCELERATE. Cancer Med 2021; 10:8462-8474. [PMID: 34687165 PMCID: PMC8633236 DOI: 10.1002/cam4.4356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/21/2021] [Accepted: 09/21/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Since pediatric cancer drug development is a global enterprise, we sought to provide an overview of the landscape of intercontinental clinical trials in pediatric oncology opened over the last decade. METHODS ClinicalTrials.gov was systematically searched to identify all clinical therapeutic trials which opened between 2010 and 2020 and recruited pediatric patients (<18 years) with cancer. RESULTS Over the last 10 years, 295 (8.7%) of 3383 therapeutic pediatric cancer trials were international and 182 (5.4%) were intercontinental. Most intercontinental trials were phase-1 or 2, with 25% late-phase, 65% were sponsored by industry, and North America was involved in 92%. Industry-sponsored proportionally more phase-1 trials than academia (41% vs. 25%); conversely, academia sponsored more phase-2 and late-phase trials (39% and 31% vs. 36% and 21%, respectively) (p = 0.020). North America-Europe collaboration was predominantly industry sponsored as opposed to North America-Oceania and Europe-Oceania collaboration, more frequently academic (p < 0.0001). Most late-phase trials (18/20, 90%) focusing on pediatric malignancies were conducted by academic sponsors and 10 of these were conducted by Children's Oncology Group (COG)/National Cancer Institute in the United States and Oceania. There was no significant increase over time of intercontinental trials and a trend for a reduction in academic trials. CONCLUSIONS Despite the relative rarity of childhood malignancies, especially within molecular subtypes, only 5.4% of pediatric cancer trials were intercontinental. The number of intercontinental trials remains small, with no significant increase over the last decade. The ACCELERATE International Collaboration Working Group aims to identify existing hurdles and propose solutions to improve intercontinental collaboration in clinical research for the benefit of children and adolescents with cancer.
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Affiliation(s)
| | | | | | | | | | - Pamela Kearns
- Cancer Research UK Clinical Trials UnitNational Institute for Health Research (NIHR) Birmingham Biomedical Research CentreInstitute of Cancer and Genomic SciencesBirminghamUK
| | - Gilles Vassal
- ACCELERATEBrusselsBelgium
- Paediatric and Adolescent Oncology DepartmentGustave Roussy Cancer CampusINSERM U1015Université Paris‐SaclayVillejuifFrance
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14
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Pearson AD, Rossig C, Mackall C, Shah NN, Baruchel A, Reaman G, Ricafort R, Heenen D, Bassan A, Berntgen M, Bird N, Bleickardt E, Bouchkouj N, Bross P, Brownstein C, Cohen SB, de Rojas T, Ehrlich L, Fox E, Gottschalk S, Hanssens L, Hawkins DS, Horak ID, Taylor DH, Johnson C, Karres D, Ligas F, Ludwinski D, Mamonkin M, Marshall L, Masouleh BK, Matloub Y, Maude S, McDonough J, Minard-Colin V, Norga K, Nysom K, Pappo A, Pearce L, Pieters R, Pule M, Quintás-Cardama A, Richardson N, Schüßler-Lenz M, Scobie N, Sersch MA, Smith MA, Sterba J, Tasian SK, Weigel B, Weiner SL, Zwaan CM, Lesa G, Vassal G. Paediatric Strategy Forum for medicinal product development of chimeric antigen receptor T-cells in children and adolescents with cancer: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2021; 160:112-133. [PMID: 34840026 DOI: 10.1016/j.ejca.2021.10.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/13/2021] [Indexed: 12/30/2022]
Abstract
The seventh multi-stakeholder Paediatric Strategy Forum focused on chimeric antigen receptor (CAR) T-cells for children and adolescents with cancer. The development of CAR T-cells for patients with haematological malignancies, especially B-cell precursor acute lymphoblastic leukaemia (BCP-ALL), has been spectacular. However, currently, there are scientific, clinical and logistical challenges for use of CAR T-cells in BCP-ALL and other paediatric malignancies, particularly in acute myeloid leukaemia (AML), lymphomas and solid tumours. The aims of the Forum were to summarise the current landscape of CAR T-cell therapy development in paediatrics, too identify current challenges and future directions, with consideration of other immune effector modalities and ascertain the best strategies to accelerate their development and availability to children. Although the effect is of limited duration in about half of the patients, anti-CD19 CAR T-cells produce high response rates in relapsed/refractory BCP-ALL and this has highlighted previously unknown mechanisms of relapse. CAR T-cell treatment as first- or second-line therapy could also potentially benefit patients whose disease has high-risk features associated with relapse and failure of conventional therapies. Identifying patients with very early and early relapse in whom CAR T-cell therapy may replace haematopoietic stem cell transplantation and be definitive therapy versus those in whom it provides a more effective bridge to haematopoietic stem cell transplantation is a very high priority. Development of approaches to improve persistence, either by improving T cell fitness or using more humanised/fully humanised products and co-targeting of multiple antigens to prevent antigen escape, could potentially further optimise therapy. Many differences exist between paediatric B-cell non-Hodgkin lymphomas (B-NHL) and BCP-ALL. In view of the very small patient numbers with relapsed lymphoma, careful prioritisation is needed to evaluate CAR T-cells in children with Burkitt lymphoma, primary mediastinal B cell lymphoma and other NHL subtypes. Combination trials of alternative targets to CD19 (CD20 or CD22) should also be explored as a priority to improve efficacy in this population. Development of CD30 CAR T-cell immunotherapy strategies in patients with relapsed/refractory Hodgkin lymphoma will likely be most efficiently accomplished by joint paediatric and adult trials. CAR T-cell approaches are early in development for AML and T-ALL, given the unique challenges of successful immunotherapy actualisation in these diseases. At this time, CD33 and CD123 appear to be the most universal targets in AML and CD7 in T-ALL. The results of ongoing or planned first-in-human studies are required to facilitate further understanding. There are promising early results in solid tumours, particularly with GD2 targeting cell therapies in neuroblastoma and central nervous system gliomas that represent significant unmet clinical needs. Further understanding of biology is critical to success. The comparative benefits of autologous versus allogeneic CAR T-cells, T-cells engineered with T cell receptors T-cells engineered with T cell receptor fusion constructs, CAR Natural Killer (NK)-cell products, bispecific T-cell engager antibodies and antibody-drug conjugates require evaluation in paediatric malignancies. Early and proactive academia and multi-company engagement are mandatory to advance cellular immunotherapies in paediatric oncology. Regulatory advice should be sought very early in the design and preparation of clinical trials of innovative medicines, for which regulatory approval may ultimately be sought. Aligning strategic, scientific, regulatory, health technology and funding requirements from the inception of a clinical trial is especially important as these are very expensive therapies. The model for drug development for cell therapy in paediatric oncology could also involve a 'later stage handoff' to industry after early development in academic hands. Finally, and very importantly, strategies must evolve to ensure appropriate ease of access for children who need and could potentially benefit from these therapies.
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Affiliation(s)
| | - Claudia Rossig
- University Children´s Hospital Muenster, Pediatric Hematology and Oncology, Germany
| | - Crystal Mackall
- Department of Pediatrics and Medicine, Stanford University, Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, CA, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, National Cancer Institute, USA
| | - Andre Baruchel
- Hôpital Universitaire Robert Debré (APHP) and Université de Paris, France
| | | | | | | | | | - Michael Berntgen
- Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | | | | | - Lynley Marshall
- The Royal Marsden Hospital and the Institute of Cancer Research, London, UK
| | | | | | - Shannon Maude
- Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, USA
| | | | - Veronique Minard-Colin
- Department of Pediatric and Adolescent Oncology, INSERM U1015, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Koen Norga
- Antwerp University Hospital, Paediatric Committee of the European Medicines Agency, Federal Agency for Medicines and Health Products, Belgium
| | | | | | | | - Rob Pieters
- Princess Maxima Center for Pediatric Oncology, Netherlands
| | | | | | | | - Martina Schüßler-Lenz
- Chair of CAT (Committee for Advanced Therapies), European Medicines Agency (EMA), Amsterdam, Netherlands; Paul-Ehrlich-Institut, Germany
| | | | | | | | - Jaroslav Sterba
- University Hospital Brno, Masaryk University, Brno, Czech Republic
| | - Sarah K Tasian
- Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, USA
| | | | | | - Christian Michel Zwaan
- Princess Maxima Center for Pediatric Oncology, Netherlands; Haematological Malignancies Co-Chair Innovative Therapies for Children with Cancer Consortium (ITCC), Europe; Erasmus University Medical Center Rotterdam, Netherlands
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | - Gilles Vassal
- ACCELERATE, Europe; Department of Pediatric and Adolescent Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
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15
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Leong R, Liu Q, Li L, Liu J, Ren YR, Lee P, Chuk M, Reaman G, Wang Y. Recommendations for Dose Selection for Adolescent Patients in Relevant Adult Oncology Clinical Trials. Clin Pharmacol Ther 2021; 111:956-963. [PMID: 34714930 DOI: 10.1002/cpt.2467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/03/2021] [Indexed: 11/06/2022]
Abstract
Our research supported the dose selection recommendations for adolescents in the US Food and Drug Administration (FDA) Guidance on Inclusion of Adolescent Patients in Adult Oncology Clinical Trials. The FDA Guidance states that for drugs administered as a flat dose in adults and data showing no clinically meaningful effect of body size on drug exposure and toxicity in adults, a minimum body weight threshold may need to be defined to prevent adolescents who have a lower body weight from exceeding adult exposures. Our review of adult population pharmacokinetic analyses of new molecular entities approved for oncology between January 2015 and March 2021 suggested that 40 kg (the approximate median body weight of a 12-year-old) is generally the lower end of the body weight range that has no clinically relevant effect on drug pharmacokinetics or safety. The minimum body weight threshold and selection of an appropriate dose for adolescents in relevant adult oncology clinical trials should ultimately be determined based on available data on pharmacokinetics or pharmacodynamics of the investigational drug with consideration of body size effect on drug exposure, toxicity, and efficacy data (if available), the therapeutic index of the drug, and dose- and exposure-response relationships in adults.
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Affiliation(s)
- Ruby Leong
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
| | - Qi Liu
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
| | - Lingjue Li
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
| | - Jiang Liu
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
| | - Yunzhao R Ren
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
| | - Peter Lee
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
| | - Meredith Chuk
- Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gregory Reaman
- Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yaning Wang
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
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16
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Pearson ADJ, Barry E, Mossé YP, Ligas F, Bird N, de Rojas T, Zimmerman ZF, Wilner K, Woessmann W, Weiner S, Weigel B, Venkatramani R, Valteau D, Trahair T, Smith M, Singh S, Selvaggi G, Scobie N, Schleiermacher G, Richardson N, Park J, Nysom K, Norga K, Merino M, McDonough J, Matloub Y, Marshall LV, Lowe E, Lesa G, Irwin M, Karres D, Gajjar A, Doz F, Fox E, DuBois SG, Donoghue M, Casanova M, Caron H, Buenger V, Bradford D, Blanc P, Barone A, Reaman G, Vassal G. Second Paediatric Strategy Forum for anaplastic lymphoma kinase (ALK) inhibition in paediatric malignancies: ACCELERATE in collaboration with the European Medicines Agency with the participation of the Food and Drug Administration. Eur J Cancer 2021; 157:198-213. [PMID: 34536944 DOI: 10.1016/j.ejca.2021.08.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/12/2021] [Accepted: 08/14/2021] [Indexed: 12/28/2022]
Abstract
The first (2017) and sixth (2021) multistakeholder Paediatric Strategy Forums focused on anaplastic lymphoma kinase (ALK) inhibition in paediatric malignancies. ALK is an important oncogene and target in several paediatric tumours (anaplastic large cell lymphoma [ALCL], inflammatory myofibroblastic tumour [IMT], neuroblastoma and hemispheric gliomas in infants and young children) with unmet therapeutic needs. ALK tyrosine kinase inhibitors have been demonstrated to be active both in ALK fusion-kinase positive ALCL and IMT. ALK alterations differ, with fusions occurring in ALCL, IMT and gliomas, and activating mutations and amplification in neuroblastoma. While there are many ALK inhibitors in development, the number of children diagnosed with ALK driven malignancies is very small. The objectives of this ALK Forum were to (i) Describe current knowledge of ALK biology in childhood cancers; (ii) Provide an overview of the development of ALK inhibitors for children; (iii) Identify the unmet needs taking into account planned or current ongoing trials; (iv) Conclude how second/third-generation inhibitors could be evaluated and prioritised; (v) Identify lessons learnt from the experience with ALK inhibitors to accelerate the paediatric development of other anti-cancer targeted agents in the new regulatory environments. There has been progress over the last four years, with more trials of ALK inhibitors opened in paediatrics and more regulatory submissions. In January 2021, the US Food and Drug Administration approved crizotinib for the treatment of paediatric and young adult patients with relapsed or refractory ALCL and there are paediatric investigation plans (PIPs) for brigatinib and for crizotinib in ALCL and IMT. In ALCL, the current goal is to investigate the inclusion of ALK inhibitors in front-line therapy with the aim of decreasing toxicity with higher/similar efficacy compared to present first-line therapies. For IMT, the focus is to develop a joint prospective trial with one product in children, adolescents and adults, taking advantage of the common biology across the age spectrum. As approximately 50% of IMTs are ALK-positive, molecular analysis is required to identify patients to be treated with an ALK inhibitor. For neuroblastoma, crizotinib has not shown robust anti-tumour activity. A focused and sequential development of ALK inhibitors with very good central nervous system (CNS) penetration in CNS tumours with ALK fusions should be undertaken. The Forum reinforced the strong need for global academic collaboration, very early involvement of regulators with studies seeking possible registration and early academia-multicompany engagement. Innovations in study design and conduct and the use of 'real-world data' supporting development in these rare sub-groups of patients for whom randomised clinical trials are not feasible are important initiatives. A focused and sequenced development strategy, where one product is evaluated first with other products being assessed sequentially, is applicable for ALK inhibitors and other medicinal products in children.
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Affiliation(s)
| | | | - Yael P Mossé
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Division of Oncology and Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, USA
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Koen Norga
- Antwerp University Hospital, Paediatric Committee of the European Medicines Agency, Federal Agency for Medicines and Health Products, Belgium
| | | | | | | | - Lynley V Marshall
- Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, UK
| | - Eric Lowe
- Children's Hospital of the King's Daughters, USA
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | | | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | - Gilles Vassal
- ACCELERATE, Europe; Gustave Roussy Cancer Centre, France
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17
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Karres D, Reaman G, Ligas F, Lesa G, McCune S, Malli S, Bax R, Temeck J. Common Commentary on Paediatric Oncology Drug Development Published: Another Step in Optimising Global Regulatory Coordination of Paediatric Development Plans. Ther Innov Regul Sci 2021; 55:1109-1110. [PMID: 34498227 DOI: 10.1007/s43441-021-00339-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 09/01/2021] [Indexed: 11/26/2022]
Abstract
The European Medicines Agency and the US Food and Drug Administration recently published a common commentary document on paediatric oncology drug development, building on the call for simultaneous submissions of paediatric investigation plans and initial pediatric study plans. The objective of this document is to guide deliberations and permit focused discussions at the monthly paediatric cluster calls, allowing early regulatory coordination of global development plans. The differences in regulations related to timeline are not considered posing a barrier in that regard.
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Affiliation(s)
- Dominik Karres
- Paediatric Medicines Office, Human Medicines Division, Scientific Evidence Generation Department, European Medicines Agency (EMA), Amsterdam, The Netherlands.
| | - Gregory Reaman
- Oncology Center of Excellence, Office of the Commissioner, Office of Oncologic Diseases, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration (FDA), Silver Spring, USA
| | - Franca Ligas
- Paediatric Medicines Office, Human Medicines Division, Scientific Evidence Generation Department, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Giovanni Lesa
- Paediatric Medicines Office, Human Medicines Division, Scientific Evidence Generation Department, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Susan McCune
- Office of Pediatric Therapeutics, Office of the Commissioner, US Food and Drug Administration (FDA), Silver Spring, USA
| | - Suzanne Malli
- Office of Pediatric Therapeutics, Office of the Commissioner, US Food and Drug Administration (FDA), Silver Spring, USA
| | - Ralph Bax
- Paediatric Medicines Office, Human Medicines Division, Scientific Evidence Generation Department, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Jean Temeck
- Office of Pediatric Therapeutics, Office of the Commissioner, US Food and Drug Administration (FDA), Silver Spring, USA
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18
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Kerlavage AR, Kirchhoff AC, Guidry Auvil JM, Sharpless NE, Davis KL, Reilly K, Reaman G, Penberthy L, Deapen D, Hwang A, Durbin EB, Gallotto SL, Aplenc R, Volchenboum SL, Heath AP, Aronow BJ, Zhang J, Vaske O, Alonzo TA, Nathan PC, Poynter JN, Armstrong G, Hahn EE, Wernli KJ, Greene C, DiGiovanna J, Resnick AC, Shalley ER, Nadaf S, Kibbe WA. Cancer Informatics for Cancer Centers: Scientific Drivers for Informatics, Data Science, and Care in Pediatric, Adolescent, and Young Adult Cancer. JCO Clin Cancer Inform 2021; 5:881-896. [PMID: 34428097 PMCID: PMC8763339 DOI: 10.1200/cci.21.00040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/11/2021] [Accepted: 06/10/2021] [Indexed: 11/29/2022] Open
Abstract
Cancer Informatics for Cancer Centers (CI4CC) is a grassroots, nonprofit 501c3 organization intended to provide a focused national forum for engagement of senior cancer informatics leaders, primarily aimed at academic cancer centers anywhere in the world but with a special emphasis on the 70 National Cancer Institute-funded cancer centers. This consortium has regularly held topic-focused biannual face-to-face symposiums. These meetings are a place to review cancer informatics and data science priorities and initiatives, providing a forum for discussion of the strategic and pragmatic issues that we faced at our respective institutions and cancer centers. Here, we provide meeting highlights from the latest CI4CC Symposium, which was delayed from its original April 2020 schedule because of the COVID-19 pandemic and held virtually over three days (September 24, October 1, and October 8) in the fall of 2020. In addition to the content presented, we found that holding this event virtually once a week for 6 hours was a great way to keep the kind of deep engagement that a face-to-face meeting engenders. This is the second such publication of CI4CC Symposium highlights, the first covering the meeting that took place in Napa, California, from October 14-16, 2019. We conclude with some thoughts about using data science to learn from every child with cancer, focusing on emerging activities of the National Cancer Institute's Childhood Cancer Data Initiative.
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Affiliation(s)
- Anthony R Kerlavage
- Center for Biomedical Informatics and Information Technology, National Cancer Institute, Rockville, MD
| | - Anne C Kirchhoff
- Huntsman Cancer Institute and University of Utah, School of Medicine, Salt Lake City, UT
| | - Jaime M Guidry Auvil
- Center for Biomedical Informatics and Information Technology, National Cancer Institute, Rockville, MD
| | | | - Kara L Davis
- Maternal and Child Health Research Institute, Stanford School of Medicine, Stanford, CA
| | - Karlyne Reilly
- Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Gregory Reaman
- Center for Drug Evaluation and Research, Food and Drug Administration, Bethesda, MD
| | - Lynne Penberthy
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - Dennis Deapen
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Amie Hwang
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Eric B Durbin
- University of Kentucky, Markey Cancer Center, Lexington, KY
| | | | | | | | | | | | | | - Olena Vaske
- University of California, Santa Cruz, Santa Cruz, CA
| | - Todd A Alonzo
- University of Southern California, Keck School of Medicine, Los Angeles, CA
| | | | - Jenny N Poynter
- University of Minnesota, Masonic Cancer Center, Minneapolis, MN
| | | | - Erin E Hahn
- Kaiser Permanente Southern California, Los Angeles, CA
| | - Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
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19
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Kieran MW, Caron H, Winther JF, Henderson TO, Haupt R, Hjorth L, Hudson MM, Kremer LCM, van der Pal HJ, Pearson ADJ, Pereira L, Reaman G, Skinner R, Vassal G, Weiner SL, Horton Taylor D. A global approach to long-term follow-up of targeted and immune-based therapy in childhood and adolescence. Pediatr Blood Cancer 2021; 68:e29047. [PMID: 33860611 DOI: 10.1002/pbc.29047] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/05/2021] [Accepted: 03/18/2021] [Indexed: 11/08/2022]
Abstract
While considerable efforts and progress in our understanding of the long-term toxicities of surgery, radiation and chemotherapy in children with cancer have been made over the last 5 decades, there continues to be a wide gap in our knowledge of the long-term health impact of most novel targeted and immunotherapy agents. To address this gap, ACCELERATE, a multi-stakeholder collaboration of clinical and translational academics, regulators from the EMA and FDA, patient/family advocates and members spanning small biotechnology through to large pharmaceutical companies have initiated the development of an international long-term follow-up data registry to collect this important information prospectively. Providing critical safety data on the long-term use of these approved and investigational therapies in children will support the regulatory requirements and labeling information. It will also provide the necessary insight to help guide physicians and families on the appropriateness of a targeted or immune therapy for their child and inform survivorship planning.
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Affiliation(s)
- Mark W Kieran
- ACCELERATE Platform LTFU Working Group Co-Chair, ACCELERATE, Brussels, Belgium.,Pediatric Oncology, Bristol Meyers Squibb, Lawrenceville, New Jersey, USA
| | - Hubert Caron
- Global Development Leader for Pediatric Oncology, Hoffmann-La Roche AG, Basel, Switzerland
| | - Jeanette Falck Winther
- Childhood Cancer Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University and University Hospital, Aarhus, Denmark
| | - Tara O Henderson
- Department of Pediatrics, The University of Chicago, Chicago, Illinois, USA
| | - Riccardo Haupt
- PanCare, Bussum, The Netherlands.,Epidemiology and Biostatistics Unit and DOPO Clinic, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Lars Hjorth
- PanCare, Bussum, The Netherlands.,Skane University Hospital, Lund University, Lund, Sweden
| | - Melissa M Hudson
- Cancer Survivorship Division, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Leontien C M Kremer
- Princess Máxima Center for pediatric oncology, Heidelberglaan 25, 3584 CS, and Wilhemina Children's Hospital, UMC, Utrecht, The Netherlands.,PanCare, Bussum, The Netherlands
| | - Helena J van der Pal
- Princess Máxima Center for pediatric oncology, Heidelberglaan 25, 3584 CS, and Wilhemina Children's Hospital, UMC, Utrecht, The Netherlands.,PanCare, Bussum, The Netherlands
| | | | | | - Gregory Reaman
- Pediatric Oncology Program, Oncology Center of Excellence and Office of Oncologic Diseases, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Roderick Skinner
- PanCare, Bussum, The Netherlands.,Department of Paediatric and Adolescent Haematology/Oncology, Translational and Clinical Research Institute, Wolfson Childhood Cancer Research Centre, Newcastle University Centre for Cancer, Newcastle upon Tyne, UK
| | - Gilles Vassal
- ACCELERATE, Brussels, Belgium.,Paediatric Oncology Department, Institut Gustave Roussy, Paris-Sud University, Villejuif, France
| | - Susan L Weiner
- Children's Cancer Cause, Washington, District of Columbia, USA
| | - Danielle Horton Taylor
- ACCELERATE Platform LTFU Working Group Co-Chair, ACCELERATE, Brussels, Belgium.,ACCELERATE, Brussels, Belgium.,Paediatric Oncology Reference Team (PORT), London, England
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- ACCELERATE Platform LTFU Working Group Co-Chair, ACCELERATE, Brussels, Belgium
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20
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Shulman DS, Kiwinda LV, Edwards S, Clinton CM, Hunt S, Greenspan L, Lawler KD, Reaman G, Al-Sayegh H, Bona K, O'Neill AF, Shusterman S, Janeway KA, Place AE, Chi SN, Ma C, DuBois SG. Retrospective evaluation of single patient investigational new drug (IND) requests in pediatric oncology. Cancer Med 2021; 10:2310-2318. [PMID: 33751835 PMCID: PMC7982629 DOI: 10.1002/cam4.3791] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/05/2021] [Accepted: 01/25/2021] [Indexed: 12/13/2022] Open
Abstract
Background Single patient Investigational New Drug (IND) applications are one mechanism through which experimental therapies are accessed for children with cancer. The landscape of use, outcomes, and toxicity from single patient INDs remains unknown in pediatric oncology. Methods We performed a retrospective analysis of all single patient INDs requested and prescribed at a single institution between 1/1/2007 and 5/1/2019. We report aggregate data from the US Food and Drug Administration (FDA) on single patient IND applications over the final two years of the study (2017–2019). We report an overview of all IND applications, as well as clinical descriptions of patients, treatments, outcomes, and toxicity. Results Over the 2‐year period, the FDA approved all 171 submitted single patient IND requests for pediatric oncology. We identified 56 requests from our center during the 12‐year study period, and all were approved (median time from FDA submission to approval: 1 day (range 0–12)). 71% of requests were based on disease histology. Lack of pediatric clinical trial (65%) was the most common reason for use. 48 approved requests were ultimately administered. The median duration of treatment was 84 days (range: 4–1590), with 3 patients remaining on treatment at time of analysis. Only 7% discontinued treatment due to toxicity. Three‐year overall survival was 50% (95% CI, 35–64). Conclusions Single patient INDs in pediatric oncology were universally approved in our national and single‐center analysis. In our cohort, single patient INDs were primarily utilized based on disease histology, rather than genomics, for agents that lacked a clinical trial.
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Affiliation(s)
- David S Shulman
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Lulla V Kiwinda
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | | | - Catherine M Clinton
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Sarah Hunt
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Lianne Greenspan
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Kristen D Lawler
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | | | - Hasan Al-Sayegh
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Kira Bona
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Allison F O'Neill
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Suzanne Shusterman
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Katherine A Janeway
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Andrew E Place
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Susan N Chi
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Clement Ma
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
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21
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Merino M, Richardson N, Reaman G, Ande A, Zvada S, Liu C, Hariharan S, De Claro RA, Farrell A, Pazdur R. FDA approval summary: Dalteparin for the treatment of symptomatic venous thromboembolism in pediatric patients. Pediatr Blood Cancer 2020; 67:e28688. [PMID: 32896942 DOI: 10.1002/pbc.28688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 11/06/2022]
Abstract
On May 16, 2019, the U.S. Food and Drug Administration (FDA) approved dalteparin sodium for the treatment of symptomatic venous thromboembolism (VTE) to reduce the risk of recurrence in pediatric patients 1 month of age and older. Approval was primarily based on FDA review of a single-arm trial evaluating dalteparin administered subcutaneous twice daily in 38 pediatric patients with symptomatic VTE. Efficacy was based on the achievement of therapeutic plasma anti-Xa levels. The FDA concluded that dalteparin has efficacy and acceptable safety for pediatric patients.
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Affiliation(s)
- Margret Merino
- Office of Oncologic Diseases and Office of Clinical Pharmacology, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Nicholas Richardson
- Office of Oncologic Diseases and Office of Clinical Pharmacology, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Gregory Reaman
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Anusha Ande
- Office of Oncologic Diseases and Office of Clinical Pharmacology, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Simbarashe Zvada
- Office of Oncologic Diseases and Office of Clinical Pharmacology, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Chao Liu
- Office of Oncologic Diseases and Office of Clinical Pharmacology, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Sudharshan Hariharan
- Office of Oncologic Diseases and Office of Clinical Pharmacology, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - R Angelo De Claro
- Office of Oncologic Diseases and Office of Clinical Pharmacology, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Ann Farrell
- Office of Cardiology, Hematology, Endocrinology, and Nephrology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Richard Pazdur
- Office of Oncologic Diseases and Office of Clinical Pharmacology, U.S. Food and Drug Administration, Silver Spring, Maryland.,Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
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22
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Pearson ADJ, Karres D, Reaman G, DuBois SG, Knox L, Scobie N, Vassal G. The RACE to accelerate drug development for children with cancer. Lancet Child Adolesc Health 2020; 4:714-716. [PMID: 32822672 DOI: 10.1016/s2352-4642(20)30247-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 06/11/2023]
Affiliation(s)
| | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency, Amsterdam, Netherlands
| | | | - Steven G DuBois
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Nicole Scobie
- Zoé4life, Sullens, Switzerland; Childhood Cancer International, Europe
| | - Gilles Vassal
- ACCELERATE, Europe; Gustave Roussy Cancer Centre, Villejuif, France
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23
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Pearson AD, Stegmaier K, Bourdeaut F, Reaman G, Heenen D, Meyers ML, Armstrong SA, Brown P, De Carvalho D, Jabado N, Marshall L, Rivera M, Smith M, Adamson PC, Barone A, Baumann C, Blackman S, Buenger V, Donoghue M, Duncan AD, Fox E, Gadbaw B, Hattersley M, Ho P, Jacobs I, Kelly MJ, Kieran M, Lesa G, Ligas F, Ludwinski D, McDonough J, Nikolova Z, Norga K, Senderowicz A, Taube T, Weiner S, Karres D, Vassal G. Paediatric Strategy Forum for medicinal product development of epigenetic modifiers for children: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2020; 139:135-148. [PMID: 32992153 DOI: 10.1016/j.ejca.2020.08.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 12/27/2022]
Abstract
The fifth multistakeholder Paediatric Strategy Forum focussed on epigenetic modifier therapies for children and adolescents with cancer. As most mutations in paediatric malignancies influence chromatin-associated proteins or transcription and paediatric cancers are driven by developmental gene expression programs, targeting epigenetic mechanisms is predicted to be a very important therapeutic approach in paediatric cancer. The Research to Accelerate Cures and Equity (RACE) for Children Act FDARA amendments to section 505B of the FD&C Act was implemented in August 2020, and as there are many epigenetic targets on the FDA Paediatric Molecular Targets List, clinical evaluation of epigenetic modifiers in paediatric cancers should be considered early in drug development. Companies are also required to submit to the EMA paediatric investigation plans aiming to ensure that the necessary data to support the authorisation of a medicine for children in EU are of high quality and ethically researched. The specific aims of the forum were i) to identify epigenetic targets or mechanisms of action associated with epigenetic modification relevant to paediatric cancers and ii) to define the landscape for paediatric drug development of epigenetic modifier therapies. DNA methyltransferase inhibitors/hypomethylating agents and histone deacetylase inhibitors were largely excluded from discussion as the aim was to discuss those targets for which therapeutic agents are currently in early paediatric and adult development. Epigenetics is an evolving field and could be highly relevant to many paediatric cancers; the biology is multifaceted and new targets are frequently emerging. Targeting epigenetic mechanisms in paediatric malignancy has in most circumstances yet to reach or extend beyond clinical proof of concept, as many targets do not yet have available investigational drugs developed. Eight classes of medicinal products were discussed and prioritised based on the existing level of science to support early evaluation in children: inhibitors of menin, DOT1L, EZH2, EED, BET, PRMT5 and LSD1 and a retinoic acid receptor alpha agonist. Menin inhibitors should be moved rapidly into paediatric development, in view of their biological rationale, strong preclinical activity and ability to fulfil an unmet clinical need. A combination approach is critical for successful utilisation of any epigenetic modifiers (e.g. EZH2 and EED) and exploration of the optimum combination(s) should be supported by preclinical research and, where possible, molecular biomarker validation in advance of clinical translation. A follow-up multistakeholder meeting focussing on BET inhibitors will be held to define how to prioritise the multiple compounds in clinical development that could be evaluated in children with cancer. As epigenetic modifiers are relatively early in development in paediatrics, there is a clear opportunity to shape the landscape of therapies targeting the epigenome in order that efficient and optimum plans for their evaluation in children and adolescents are developed in a timely manner.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Lynley Marshall
- Royal Marsden NHS Foundation Trust/Institute of Cancer Research, UK
| | | | | | - Peter C Adamson
- Sanofi US, Emeritus Professor of Paediatrics and Pharmacology, Perelman School of Medicine, University of Pennsylvania, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | | | | | | | - Koen Norga
- Antwerp University Hospital, Paediatric Committee of the European Medicines Agency, Federal Agency for Medicines and Health Products, Belgium
| | | | | | | | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
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24
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Reaman G, Karres D, Ligas F, Lesa G, Casey D, Ehrlich L, Norga K, Pazdur R. Accelerating the Global Development of Pediatric Cancer Drugs: A Call to Coordinate the Submissions of Pediatric Investigation Plans and Pediatric Study Plans to the European Medicines Agency and US Food and Drug Administration. J Clin Oncol 2020; 38:4227-4230. [PMID: 32946356 DOI: 10.1200/jco.20.02152] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- Gregory Reaman
- Oncology Center of Excellence, Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD.,Office of Oncologic Diseases, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency, Amsterdam, the Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency, Amsterdam, the Netherlands
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency, Amsterdam, the Netherlands
| | - Denise Casey
- Office of Oncologic Diseases, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Lori Ehrlich
- Office of Oncologic Diseases, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Koen Norga
- Federal Agency for Medicines and Health Products and Paediatric Oncology, Antwerp University Hospital, Edegem, Belgium.,European Medicines Agency's Paediatric Committee, European Medicines Agency, Amsterdam, the Netherlands
| | - Richard Pazdur
- Oncology Center of Excellence, Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD.,Office of Oncologic Diseases, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
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25
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Pearson ADJ, Zwaan CM, Kolb EA, Karres D, Guillot J, Kim SY, Marshall L, Tasian SK, Smith M, Cooper T, Adamson PC, Barry E, Benettaib B, Binlich F, Borgman A, Brivio E, Capdeville R, Delgado D, Faller D, Fogelstrand L, Fraenkel PG, Hasle H, Heenen D, Kaspers G, Kieran M, Klusmann JH, Lesa G, Ligas F, Mappa S, Mohamed H, Moore A, Morris J, Nottage K, Reinhardt D, Scobie N, Simko S, Winkler T, Norga K, Reaman G, Vassal G. Paediatric Strategy Forum for medicinal product development for acute myeloid leukaemia in children and adolescents: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2020; 136:116-129. [PMID: 32688206 PMCID: PMC7789799 DOI: 10.1016/j.ejca.2020.04.038] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
Abstract
Purpose: The current standard-of-care for front-line therapy for acute myeloid leukaemia (AML) results in short-term and long-term toxicity, but still approximately 40% of children relapse. Therefore, there is a major need to accelerate the evaluation of innovative medicines, yet drug development continues to be adult-focused. Furthermore, the large number of competing agents in rare patient populations requires coordinated prioritisation, within the global regulatory framework and cooperative group initiatives. Methods: The fourth multi-stakeholder Paediatric Strategy Forum focused on AML in children and adolescents. Results: CD123 is a high priority target and the paediatric development should be accelerated as a proof-of-concept. Efforts must be coordinated, however, as there are a limited number of studies that can be delivered. Studies of FLT3 inhibitors in agreed paediatric investigation plans present challenges to be completed because they require enrolment of a larger number of patients than actually exist. A consensus was developed by industry and academia of optimised clinical trials. For AML with rare mutations that are more frequent in adolescents than in children, adult trials should enrol adolescents and when scientifically justified, efficacy data could be extrapolated. Methodologies and definitions of minimal residual disease need to be standardised internationally and validated as a new response criterion. Industry supported, academic sponsored platform trials could identify products to be further developed. The Leukaemia and Lymphoma Society PedAL/EUpAL initiative has the potential to be a major advance in the field. Conclusion: These initiatives continue to accelerate drug development for children with AML and ultimately improve clinical outcomes.
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Affiliation(s)
| | - C Michel Zwaan
- Princess Máxima Center, Utrecht, the Netherlands; Erasmus MC, Rotterdam, the Netherlands; ITCC, the Netherlands
| | | | | | - Julie Guillot
- Fred Hutchinson Cancer Research Center, Leukaemia Lymphoma Society, Target Paediatric AML, USA
| | | | - Lynley Marshall
- Royal Marsden Hospital, The Institute of Cancer Research, UK
| | - Sarah K Tasian
- Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, USA
| | - Malcolm Smith
- National Institutes of Health, National Cancer Institute, USA
| | | | - Peter C Adamson
- Sanofi US, Emeritus Professor of Paediatrics & Pharmacology, Perelman School of Medicine, University of Pennsylvania, USA
| | | | | | | | | | - Erica Brivio
- Princess Máxima Center, Utrecht, the Netherlands; Erasmus MC, Rotterdam, the Netherlands; ITCC, the Netherlands
| | | | | | | | - Linda Fogelstrand
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | | | - Henrik Hasle
- Department of Paediatrics, Aarhus University Hospital, Denmark
| | | | - Gertjan Kaspers
- Princess Máxima Center, Utrecht, the Netherlands; Erasmus MC, Rotterdam, the Netherlands; ITCC, the Netherlands
| | | | | | - Giovanni Lesa
- European Medicines Agency, Amsterdam, the Netherlands
| | - Franca Ligas
- European Medicines Agency, Amsterdam, the Netherlands
| | | | | | - Andrew Moore
- Queensland Children's Hospital, Brisbane, Australia
| | | | | | | | | | | | | | - Koen Norga
- Universitair Ziekenhuis Antwerpen, FAMHP, Belgium
| | | | - Gilles Vassal
- ACCELERATE/ITCC, Belgium; Gustave Roussy Cancer Centre, France
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26
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Ye J, Reaman G, De Claro RA, Sridhara R. A Bayesian approach in design and analysis of pediatric cancer clinical trials. Pharm Stat 2020; 19:814-826. [PMID: 32537913 DOI: 10.1002/pst.2039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 03/04/2020] [Accepted: 05/18/2020] [Indexed: 11/11/2022]
Abstract
It is well recognized that cancer drug development for children and adolescents has many challenges, from biological and societal to economic. Pediatric cancer consists of a diverse group of rare diseases, and the relatively small population of children with multiple, disparate tumor types across various age groups presents a significant challenge for drug development programs as compared to oncology drug development programs for adults. Due to the different types of cancers, limited opportunities exist for extrapolation of efficacy from adult cancer indications to children. Thus, innovative study designs including Bayesian statistical approaches should be considered. A Bayesian approach can be a flexible tool to formally leverage prior knowledge of adult or external controls in pediatric cancer trials. In this article, we provide in a case example of how Bayesian approaches can be used to design, monitor, and analyze pediatric trials. Particularly, Bayesian sequential monitoring can be useful to monitor pediatric trial results as data accumulate. In addition, designing a pediatric trial with both skeptical and enthusiastic priors with Bayesian sequential monitoring can be an efficient mechanism for early trial cessation for both efficacy and futility. The interpretation of efficacy using a Bayesian approach is based on posterior probability and is intuitive and interpretable for patients, parents and prescribers given limited data.
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Affiliation(s)
- Jingjing Ye
- Division of Biometrics V, Office of Biostatistics, Office of Translational Sciences, Center of Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gregory Reaman
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - R Angelo De Claro
- Division of Hematologic Malignancies 1 (DHM1), Office of Oncologic Diseases, Center of Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rajeshwari Sridhara
- Division of Biometrics V, Office of Biostatistics, Office of Translational Sciences, Center of Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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Bhatnagar V, Hudgens S, Piault-Louis E, Jones L, Beaver JA, Lyerly HK, Reaman G, Fleming T, Kluetz PG. Patient-Reported Outcomes in Oncology Clinical Trials: Stakeholder Perspectives from the Accelerating Anticancer Agent Development and Validation Workshop 2019. Oncologist 2020; 25:819-821. [PMID: 32463153 DOI: 10.1634/theoncologist.2020-0062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/10/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Vishal Bhatnagar
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Stacie Hudgens
- Quantitative Science, Clinical Outcomes Solutions, Tucson, Arizona, USA
| | | | - Lee Jones
- Patient Representative, Arlington, Virginia, USA
| | - Julia A Beaver
- Office of Oncologic Diseases, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Gregory Reaman
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Thomas Fleming
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Paul G Kluetz
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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28
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Reaman G, Stancato L, Vassal G, Maris JM. Crossing Oceans: Preclinical Collaboration to Improve Pediatric Drug Development. Am Soc Clin Oncol Educ Book 2020; 40:1-8. [PMID: 32207673 DOI: 10.1200/edbk_278893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Changes in the regulatory environment affecting pediatric cancer drug development in the United States and the European Union provide unprecedented opportunity to advance the concept of precision medicine to children with cancer. Increasing evidence suggests that new drugs and biologic products directed at molecular targets presumed to be etiologically associated with many adult cancers may well provide therapeutic options for selected subsets of children with cancer despite their histologic and biologic differences. Regulatory requirements for early evaluation of appropriate new drugs for children based on their molecular mechanism of action, rather than the specific clinical indications for which they are developed and/or approved, will shorten the unacceptable time lag between first-in-human and first-in-children studies. The relative scarcity of pediatric patients eligible for biomarker-directed studies and the ever-expanding compendium of new targeted agents mandate rational, science-based decision-making in selecting and prioritizing appropriate drugs to study early in development. A critical component of the evidence base in such decision-making includes preclinical testing of relevant drugs in pediatric tumor-specific in vitro and in vivo models. Established preclinical testing programs with academic investigator-industry collaborations are actively engaged in such activities. International collaboration is required to address the resource constraints and increasing number of potential products to be tested in a timely, efficient, nonduplicative, and cost-effective manner.
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Affiliation(s)
| | | | | | - John M Maris
- The Children's Hospital of Philadelphia, Philadelphia, PA
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Pearson ADJ, Rossig C, Lesa G, Diede SJ, Weiner S, Anderson J, Gray J, Geoerger B, Minard-Colin V, Marshall LV, Smith M, Sondel P, Bajars M, Baldazzi C, Barry E, Blackman S, Blanc P, Capdeville R, Caron H, Cole PD, Jiménez JC, Demolis P, Donoghue M, Elgadi M, Gajewski T, Galluzzo S, Ilaria R, Jenkner A, Karres D, Kieran M, Ligas F, Lowy I, Meyers M, Oprea C, Peddareddigari VGR, Sterba J, Stockman PK, Suenaert P, Tabori U, van Tilburg C, Yancey T, Weigel B, Norga K, Reaman G, Vassal G. ACCELERATE and European Medicines Agency Paediatric Strategy Forum for medicinal product development of checkpoint inhibitors for use in combination therapy in paediatric patients. Eur J Cancer 2020; 127:52-66. [PMID: 31986450 DOI: 10.1016/j.ejca.2019.12.029] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 12/23/2019] [Indexed: 12/21/2022]
Abstract
The third multistakeholder Paediatric Strategy Forum organised by ACCELERATE and the European Medicines Agency focused on immune checkpoint inhibitors for use in combination therapy in children and adolescents. As immune checkpoint inhibitors, both as monotherapy and in combinations have shown impressive success in some adult malignancies and early phase trials in children of single agent checkpoint inhibitors have now been completed, it seemed an appropriate time to consider opportunities for paediatric studies of checkpoint inhibitors used in combination. Among paediatric patients, early clinical studies of checkpoint inhibitors used as monotherapy have demonstrated a high rate of activity, including complete responses, in Hodgkin lymphoma and hypermutant paediatric tumours. Activity has been very limited, however, in more common malignancies of childhood and adolescence. Furthermore, apart from tumour mutational burden, no other predictive biomarker for monotherapy activity in paediatric tumours has been identified. Based on these observations, there is collective agreement that there is no scientific rationale for children to be enrolled in new monotherapy trials of additional checkpoint inhibitors with the same mechanism of action of agents already studied (e.g. anti-PD1, anti-PDL1 anti-CTLA-4) unless additional scientific knowledge supporting a different approach becomes available. This shared perspective, based on scientific evidence and supported by paediatric oncology cooperative groups, should inform companies on whether a paediatric development plan is justified. This could then be proposed to regulators through the available regulatory tools. Generally, an academic-industry consensus on the scientific merits of a proposal before submission of a paediatric investigational plan would be of great benefit to determine which studies have the highest probability of generating new insights. There is already a rationale for the evaluation of combinations of checkpoint inhibitors with other agents in paediatric Hodgkin lymphoma and hypermutated tumours in view of the activity shown as single agents. In paediatric tumours where no single agent activity has been observed in multiple clinical trials of anti-PD1, anti-PDL1 and anti-CTLA-4 agents as monotherapy, combinations of checkpoint inhibitors with other treatment modalities should be explored when a scientific rationale indicates that they could be efficacious in paediatric cancers and not because these combinations are being evaluated in adults. Immunotherapy in the form of engineered proteins (e.g. monoclonal antibodies and T cell engaging agents) and cellular products (e.g. CAR T cells) has great therapeutic potential for benefit in paediatric cancer. The major challenge for developing checkpoint inhibitors for paediatric cancers is the lack of neoantigens (based on mutations) and corresponding antigen-specific T cells. Progress critically depends on understanding the immune macroenvironment and microenvironment and the ability of the adaptive immune system to recognise paediatric cancers in the absence of high neoantigen burden. Future clinical studies of checkpoint inhibitors in children need to build upon strong biological hypotheses that take into account the distinctive immunobiology of childhood cancers in comparison to that of checkpoint inhibitor responsive adult cancers.
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Affiliation(s)
| | - Claudia Rossig
- University Children´s Hospital Muenster, Pediatric Hematology and Oncology, Germany
| | - Giovanni Lesa
- Paediatric Medicines Office, Product Development Scientific Support Department, European Medicines Agency, Amsterdam, the Netherlands
| | | | | | - John Anderson
- UCL Great Ormond Street Institute of Child Health, UK
| | | | | | | | | | | | - Paul Sondel
- The University of Wisconsin, Madison WI, USA
| | | | | | | | | | | | | | | | | | - Jorge Camarero Jiménez
- Agencia Espanola de Medicamentos y Productos Sanitarios and European Medicines Agency, Committee for Medicinal Products for Human Use, Amsterdam, the Netherlands
| | - Pierre Demolis
- Agence Nationale de Sécurité du Médicament et des Produits de Santé and European Medicines Agency, Scientific Advice Working Party and Oncology Working Party, Amsterdam, the Netherlands
| | | | | | | | - Sara Galluzzo
- Agenzia Italiana del Farmaco and European Medicines Agency, Paediatric Committee, Amsterdam, the Netherlands
| | | | - Alessandro Jenkner
- Ospedale Pediatrico Bambino Gesù and European Medicines Agency, Paediatric Committee, Amsterdam, the Netherlands
| | - Dominik Karres
- Paediatric Medicines Office, Product Development Scientific Support Department, European Medicines Agency, Amsterdam, the Netherlands
| | | | - Franca Ligas
- Paediatric Medicines Office, Product Development Scientific Support Department, European Medicines Agency, Amsterdam, the Netherlands
| | | | | | | | | | - Jaroslav Sterba
- University Hospital Brno and European Medicines Agency, Paediatric Committee, Amsterdam, the Netherlands
| | | | | | - Uri Tabori
- Hospital for Sick Children, Toronto, Canada
| | - Cornelis van Tilburg
- KiTZ Clinical Trial Unit, Hopp Children's Cancer Center Heidelberg (KiTZ), German Cancer Research Center (DKFZ) and Heidelberg University Hospital, Heidelberg, Germany
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Momper JD, Heinrichs MT, Krudys K, Griebel D, Kumar S, Kim I, Mehrotra N, Mulberg AE, Garimella N, Nelson R, Reaman G, Sinha V, Yao L, Zineh I, Burckart G, Sachs H, Mulugeta Y. Extrapolation of Adult Efficacy to Pediatric Patients With Chemotherapy‐Induced Nausea and Vomiting. J Clin Pharmacol 2020; 60:775-784. [DOI: 10.1002/jcph.1577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/11/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Jeremiah D. Momper
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of CaliforniaSan Diego La Jolla California USA
| | | | - Kevin Krudys
- US Food and Drug Administration Silver Spring Maryland USA
| | - Donna Griebel
- US Food and Drug Administration Silver Spring Maryland USA
| | - Shaun Kumar
- US Food and Drug Administration Silver Spring Maryland USA
| | - Insook Kim
- US Food and Drug Administration Silver Spring Maryland USA
| | - Nitin Mehrotra
- US Food and Drug Administration Silver Spring Maryland USA
| | | | | | - Robert Nelson
- US Food and Drug Administration Silver Spring Maryland USA
| | - Gregory Reaman
- US Food and Drug Administration Silver Spring Maryland USA
| | - Vikram Sinha
- US Food and Drug Administration Silver Spring Maryland USA
| | - Lynne Yao
- US Food and Drug Administration Silver Spring Maryland USA
| | - Issam Zineh
- US Food and Drug Administration Silver Spring Maryland USA
| | | | - Hari Sachs
- US Food and Drug Administration Silver Spring Maryland USA
| | - Yeruk Mulugeta
- US Food and Drug Administration Silver Spring Maryland USA
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Pérez V, Sampor C, Rey G, Parareda-Salles A, Kopp K, Dabezies AP, Dufort G, Zelter M, López JP, Urbieta M, Alcalde-Ruiz E, Catala-Mora J, Suñol M, Ossandon D, Fandiño AC, Croxatto JO, de Dávila MTG, Reaman G, Ravindranath Y, Chantada GL. Treatment of Nonmetastatic Unilateral Retinoblastoma in Children. JAMA Ophthalmol 2019; 136:747-752. [PMID: 29799944 DOI: 10.1001/jamaophthalmol.2018.1501] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Multi-institutional collaborative studies that include large patient populations for the management of retinoblastoma with histopathological risk factors could provide important information for patient management. Objective To evaluate the implementation of a strategy for the management of nonmetastatic unilateral retinoblastoma in children based on standardized diagnostic and treatment criteria. Design, Setting, and Participants This single-arm prospective study applied a strategy based on a single-center experience. The setting was a multicenter study in Latin America (Grupo de America Latina de Oncologia Pediatrica [GALOP]). Participants were children with nonmetastatic unilateral retinoblastoma (staged with the International Retinoblastoma Staging System). The study opened on July 1, 2008, and closed on December 31, 2014. Follow-up was updated until June 30, 2017. Interventions Stage 0 patients (without enucleation) were given conservative therapy without a protocol. Stage I patients (with enucleation and no residual tumor) were divided into a high-risk group (retrolaminar invasion and/or scleral invasion) and a low-risk group (all remaining patients). High-risk children received adjuvant chemotherapy with 4 alternating cycles of regimen 1 (cyclophosphamide [65 mg/kg/d] [plus sodium-2-mercaptoethane sulfonate], idarubicin hydrochloride [10 mg/m2/d], and vincristine sulfate [0.05 mg/kg/d]) and 4 cycles of regimen 2 (carboplatin [500 mg/m2/d, days 1 and 2] and etoposide [100 mg/m2/d, days 1-3]). Low-risk children did not receive adjuvant therapy. Children with buphthalmia received neoadjuvant and adjuvant chemotherapy for a total of 8 cycles. Main Outcomes and Measures Probability of event-free survival (extraocular relapse and death from any cause were considered events). Results Among 187 children registered in the study, 175 were evaluable (92 [52.5%] female; median age, 22 months; age range, 3-100 months). Forty-two were stage 0 children, 84 were stage I low-risk children, and 42 were stage I high-risk children; there were 7 children in the buphthalmia group. With a median follow-up of 46 months, the 3-year probability of event-free survival was 0.97 (95% CI, 0.94-0.99), and the probability of overall survival was 0.98 (95% CI, 0.94-1.00). Stage 0 patients had no events, stage I low-risk patients had 1 event (orbital relapse treated with second-line therapy), stage I high-risk patients had 2 events (1 central nervous system relapse and 1 death from sepsis), and the buphthalmia group had 1 event (orbital relapse, followed by central nervous relapse and death). Conclusions and Relevance Adjuvant therapy may be effective for high-risk unilateral retinoblastoma but is toxic, and neoadjuvant chemotherapy for buphthalmus appears feasible.
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Affiliation(s)
- Verónica Pérez
- Pediatric Oncology Service, Hospital San Juan de Dios, Santiago, Chile
| | - Claudia Sampor
- Hematology-Oncology Service, Hospital J. P. Garrahan, Buenos Aires, Argentina
| | - Guadalupe Rey
- Oncology Service, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | | | - Katherine Kopp
- Hematology-Oncology Service, Hospital Calvo Mackenna, Santiago, Chile
| | - Agustín P Dabezies
- Hematology-Oncology Service, Hospital Pereyra Rossell, Montevideo, Uruguay
| | - Gustavo Dufort
- Hematology-Oncology Service, Hospital Pereyra Rossell, Montevideo, Uruguay
| | - Marta Zelter
- Ophthalmology Service, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Juan P López
- Ophthalmology Service, Hospital Calvo Mackenna, Santiago, Chile
| | - Marcelo Urbieta
- Oncology Service, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | | | | | - Mariona Suñol
- Pathology Service, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Diego Ossandon
- Ophthalmology Service, Hospital San Juan de Dios, Santiago, Chile
| | - Adriana C Fandiño
- Ophthalmology Service, Hospital J. P. Garrahan, Buenos Aires, Argentina
| | - J Oscar Croxatto
- Ophthalmic Pathology Department, Fundación Oftalmologica Malbran, Buenos Aires, Argentina
| | | | - Gregory Reaman
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Washington, DC
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Freyer DR, Brock P, Knight K, Reaman G, Cabral S, Robinson PD, Sung L. Interventions for cisplatin-induced hearing loss in children and adolescents with cancer. Lancet Child Adolesc Health 2019; 3:578-584. [PMID: 31160205 PMCID: PMC7521148 DOI: 10.1016/s2352-4642(19)30115-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/11/2019] [Accepted: 03/13/2019] [Indexed: 01/19/2023]
Abstract
The identification of preventive interventions that are safe and effective for cisplatin-induced ototoxicity is important, especially in children because hearing loss can impair speech-language acquisition development. Previous randomised trials assessed systemic drugs such as amifostine, sodium diethyldithiocarbamate or disulfiram, and sodium thiosulfate. Amifostine, sodium diethyldithiocarbamate, and disulfiram did not show hearing preservation. Paediatric trials assessing sodium thiosulfate showed efficacy in terms of hearing protection. The SIOPEL 6 trial consisted solely of patients with localised hepatoblastoma and no effects on survival were shown. In the ACCL0431 trial, which included heterogeneous patients, a post-hoc analysis showed significantly worse overall survival among patients who had disseminated disease receiving sodium thiosulfate than among controls, but not among those with localised disease. Intratympanically administered drugs have mainly been assessed in adults and include N-acetylcysteine and dexamethasone. Inconsistent effects of these drugs were identified but these studies were limited by design, small sample size, and statistical approach. Future studies of systemic drugs will need to consider the measurement of disease outcomes through study design and sample size, and ototoxicity endpoints should be harmonised to enhance comparability between trials.
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Affiliation(s)
- David R Freyer
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA; Departments of Pediatrics and Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Penelope Brock
- Department of Haematology and Oncology, Great Ormond Street Hospital, London, UK
| | - Kristin Knight
- Division of Pediatric Audiology, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR, USA
| | - Gregory Reaman
- Division of Oncology, Children's National Health System, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Sandra Cabral
- Pediatric Oncology Group of Ontario, Toronto, ON, Canada
| | | | - Lillian Sung
- Division of Haematology and Oncology, The Hospital for Sick Children, Toronto, ON, Canada.
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Barone A, Casey D, McKee AE, Reaman G. Cancer drugs approved for use in children: Impact of legislative initiatives and future opportunities. Pediatr Blood Cancer 2019; 66:e27809. [PMID: 31144772 DOI: 10.1002/pbc.27809] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 04/26/2019] [Accepted: 04/27/2019] [Indexed: 11/10/2022]
Abstract
It is well appreciated that the number of anticancer drugs approved for use in children is a fraction of the number approved for use in cancers that occur in adults. We address this fact by summarizing the relevant U.S. legislation that provides the framework for the evaluation and approval of drugs used to treat children with cancer. In total, the Food and Drug Administration (FDA) has approved 38 new drug applications for pediatric oncology indications, 12 of which were new molecular entities. FDA continues to collaborate with multistakeholders regarding the development of products intended for pediatric cancer and encourages the submission of marketing applications.
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Affiliation(s)
- Amy Barone
- Office of Hematology and Oncology Products, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Denise Casey
- Office of Hematology and Oncology Products, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Amy E McKee
- Oncology Center for Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Gregory Reaman
- Oncology Center for Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
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Pearson ADJ, Scobie N, Norga K, Ligas F, Chiodin D, Burke A, Minard-Colin V, Adamson P, Marshall LV, Balakumaran A, Benettaib B, Bhargava P, Bollard CM, Bolotin E, Bomken S, Buechner J, Burkhardt B, Caron H, Copland C, Demolis P, Egorov A, Farhan M, Zugmaier G, Gross T, Horton-Taylor D, Klapper W, Lesa G, Marcus R, Miles RR, Nottage K, Pacaud L, Ricafort R, Schrappe M, Sterba J, Vezan R, Weiner S, Kim SY, Reaman G, Vassal G. ACCELERATE and European Medicine Agency Paediatric Strategy Forum for medicinal product development for mature B-cell malignancies in children. Eur J Cancer 2019; 110:74-85. [PMID: 30772656 DOI: 10.1016/j.ejca.2019.01.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 01/18/2019] [Indexed: 11/17/2022]
Abstract
Paediatric Strategy Forums have been created by the multistakeholder organisation, ACCELERATE, and the European Medicines Agency to facilitate dialogue between all relevant stakeholders and suggest strategies in critical areas of paediatric oncology drug development. As there are many medicines being developed for B-cell malignancies in adults but comparatively few in children with these malignancies, a Paediatric Strategy Forum was held to discuss the best approach to develop these products for children. It was concluded that as current frontline therapy is highly successful, despite associated acute toxicity, de-escalation of this or substitution of presently used drugs with new medicines can only be undertaken when there is an effective salvage regimen, which is currently not available. Therefore priority should be given to developing treatment for patients with relapsed and refractory mature B-cell lymphomas. The consensus of the clinicians attending the meeting was that CAR T-cells, T-cell engagers and antibody drug conjugates (excluding those with a vinca alkaloid-like drug) presently have the greatest probability of providing benefit in relapse in view of their mechanism of action. However, as producing autologous CAR T-cells currently takes at least 4 weeks, they are not products which could be quickly employed initially at relapse in rapidly progressing mature B-cell malignancies but only for the consolidation phase of the treatment. Global, industry-supported, academic-sponsored studies testing compounds from different pharmaceutical companies simultaneously should be considered in rare populations, and it was proposed that an international working group be formed to develop an overarching clinical trials strategy for these disease groups. Future Forums are planned for other relevant paediatric oncologic diseases with a high unmet medical need and relevant molecular targets.
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Affiliation(s)
| | | | | | - Franca Ligas
- Paediatric Medicines Office, Product Development Scientific Support Department, European Medicines Agency, London, UK
| | | | - Amos Burke
- Department of Paediatric Haematology and Oncology, Addenbrooke's Hospital Cambridge, UK
| | | | | | - Lynley V Marshall
- Paediatric Drug Development, Children and Young People's Unit, The Royal Marsden NHS Foundation Trust, London, UK; Divisions of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research, London, UK
| | | | | | | | - Catherine M Bollard
- Centre for Cancer and Immunology Research, Children's National Health System, The George Washington University, Washington DC, USA
| | | | - Simon Bomken
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, UK
| | - Jochen Buechner
- Department of Paediatric Hematology and Oncology, Oslo University Hospital, Norway
| | - Birgit Burkhardt
- Pediatric Hematology, Oncology and BMT, University Hospital Münster, Germany
| | | | | | | | - Anton Egorov
- Centre for Therapeutic Innovation in Oncology, Servier, France
| | - Mahdi Farhan
- Debiopharm International SA, Lausanne, Switzerland
| | | | | | | | | | - Giovanni Lesa
- Paediatric Medicines Office, Product Development Scientific Support Department, European Medicines Agency, London, UK
| | | | - Rodney R Miles
- University of Utah, Department of Pathology, Salt Lake City, UT, USA
| | | | | | - Rosanna Ricafort
- Oncology Clinical Development, Bristol-Myers Squibb Pharma EEIG, NJ, USA
| | | | - Jaroslav Sterba
- Pediatric Oncology Department, University Hospital Brno, School of Medicine Masaryk University, Brno, Regional Centre for Applied Molecular Oncology, Masaryk Memorial Cancer Institute, ICRC Brno, St. Anna University Hospital Brno, Czech Republic
| | | | - Susan Weiner
- Children's Cause for Cancer Advocacy, Washington DC, USA
| | | | - Gregory Reaman
- Office of Hematology and Oncology Products, U.S. Food and Drug Administration, MD, USA
| | - Gilles Vassal
- Department of Clinical Research, Gustave Roussy, Paris-Sud University, Paris, France
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35
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Minasian LM, Frazier AL, Sung L, O’Mara A, Kelaghan J, Chang KW, Krailo M, Pollock BH, Reaman G, Freyer DR. Prevention of cisplatin-induced hearing loss in children: Informing the design of future clinical trials. Cancer Med 2018; 7:2951-2959. [PMID: 29846043 PMCID: PMC6051159 DOI: 10.1002/cam4.1563] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 04/27/2018] [Accepted: 04/29/2018] [Indexed: 11/23/2022] Open
Abstract
Cisplatin is an essential chemotherapeutic agent in the treatment of many pediatric cancers. Unfortunately, cisplatin-induced hearing loss (CIHL) is a common, clinically significant side effect with life-long ramifications, particularly for young children. ACCL05C1 and ACCL0431 are two recently completed Children's Oncology Group studies focused on the measurement and prevention of CIHL. The purpose of this paper was to gain insights from ACCL05C1 and ACCL0431, the first published cooperative group studies dedicated solely to CIHL, to inform the design of future pediatric otoprotection trials. Use of otoprotective agents is an attractive strategy for preventing CIHL, but their successful development must overcome a unique constellation of methodological challenges related to translating preclinical research into clinical trials that are feasible, evaluate practical interventions, and limit risk. Issues particularly important for children include use of appropriate methods for hearing assessment and CIHL severity grading, and use of trial designs that are well-informed by preclinical models and suitable for relatively small sample sizes. Increasing interest has made available new funding opportunities for expanding this urgently needed research.
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Affiliation(s)
| | - A. Lindsay Frazier
- Dana‐Farber Cancer Institute/Boston Children’s Hospital Cancer CenterBostonMAUSA
| | | | | | | | - Kay W. Chang
- Department of OtolaryngologyStanford UniversityPalo AltoCAUSA
| | - Mark Krailo
- Department of Preventive MedicineKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCAUSA
| | - Brad H. Pollock
- Department of Public Health SciencesUniversity of CaliforniaDavisCAUSA
| | | | - David R. Freyer
- Division of Hematology, Oncology, and Blood and Bone Marrow TransplantationChildren’s Hospital Los AngelesKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCAUSA
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Khan T, Stewart M, Blackman S, Rousseau R, Donoghue M, Cohen K, Seibel N, Fleury M, Benettaib B, Malik R, Vassal G, Reaman G. Accelerating Pediatric Cancer Drug Development: Challenges and Opportunities for Pediatric Master Protocols. Ther Innov Regul Sci 2018; 53:270-278. [PMID: 29759018 DOI: 10.1177/2168479018774533] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although outcomes for children with cancer have significantly improved over the past 40 years, there has been little progress in the treatment of some pediatric cancers, particularly when advanced. Additionally, clinical trial options and availability are often insufficient. Improved genomic and immunologic understanding of pediatric cancers, combined with innovative clinical trial designs, may provide an enhanced opportunity to study childhood cancers. Master protocols, which incorporate the use of precision medicine approaches, coupled with the ability to quickly assess the safety and effectiveness of new therapies, have the potential to accelerate early-phase clinical testing of novel therapeutics and which may result in more rapid approval of new drugs for children with cancer. Designing and conducting master protocols for children requires addressing similar principles and requirements as traditional adult oncology trials, but there are also unique considerations for master protocols conducted in children with cancer. The purpose of this paper is to define the key challenges and opportunities associated with this approach in order to ensure that master protocols can be adapted to benefit children and adolescents and ensure that adequate data are captured to advance, in parallel, the clinical development of investigational agents for children with cancer.
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Affiliation(s)
- Tahira Khan
- 1 Genentech Inc, a member of the Roche Group, South San Francisco, CA, USA
| | - Mark Stewart
- 2 Friends of Cancer Research, Washington, DC, USA
| | | | - Raphaël Rousseau
- 1 Genentech Inc, a member of the Roche Group, South San Francisco, CA, USA
| | | | - Kenneth Cohen
- 5 Department of Pediatrics and Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Nita Seibel
- 6 USA National Cancer Institute, Bethesda, MD, USA
| | - Mark Fleury
- 7 American Cancer Society Cancer Action Network Inc, Washington, DC, USA
| | | | | | - Gilles Vassal
- 10 Department of Clinical Research, Institut Gustave Roussy, Paris-Sud University, Paris, France
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Patel SK, Leong R, Zhao H, Barone A, Casey D, Liu Q, Burckart GJ, Reaman G. Pediatric Development of Molecularly Targeted Oncology Drugs. Clin Pharmacol Ther 2017; 104:384-389. [DOI: 10.1002/cpt.942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Shivam Kamlesh Patel
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
- University of North Carolina at Chapel Hill; Chapel Hill North Carolina USA
| | - Ruby Leong
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Hong Zhao
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Amy Barone
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Denise Casey
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Qi Liu
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Gilbert J. Burckart
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Gregory Reaman
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
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Ehrlich LA, Kwitkowski VE, Reaman G, Ko CW, Nie L, Pazdur R, Farrell AT. U.S. Food and Drug Administration approval summary: Eltrombopag for the treatment of pediatric patients with chronic immune (idiopathic) thrombocytopenia. Pediatr Blood Cancer 2017. [PMID: 28627134 DOI: 10.1002/pbc.26657] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The U.S. Food and Drug Administration (FDA) approved eltrombopag for pediatric patients with chronic immune (idiopathic) thrombocytopenia (ITP) ages ≥6 on June 11, 2015, and ages ≥1 on August 24, 2015. Approval was based on the FDA review of two randomized trials that included 159 pediatric patients with chronic ITP who had an insufficient response to corticosteroids, immunoglobulins, or splenectomy. This manuscript describes the basis for approval of these applications. The FDA concluded that eltrombopag has shown efficacy and a favorable benefit to risk profile for pediatric patients with chronic ITP.
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Affiliation(s)
- Lori A Ehrlich
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Virginia E Kwitkowski
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Gregory Reaman
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Chia-Wen Ko
- Office of Biostatistics, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Lei Nie
- Office of Biostatistics, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Richard Pazdur
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Ann T Farrell
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
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Gore L, Ivy SP, Balis FM, Rubin E, Thornton K, Donoghue M, Roberts S, Bruinooge S, Ersek J, Goodman N, Schenkel C, Reaman G. Modernizing Clinical Trial Eligibility: Recommendations of the American Society of Clinical Oncology-Friends of Cancer Research Minimum Age Working Group. J Clin Oncol 2017; 35:3781-3787. [PMID: 28968169 DOI: 10.1200/jco.2017.74.4144] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Children have historically been excluded from first-in-human studies of promising new cancer drugs and later phase adult clinical trials. Delays in evaluation may result in off-label use without dosing information as the only access to new drugs. A multistakeholder workshop was convened in May 2016 by ASCO and Friends of Cancer Research to identify opportunities for when it would be scientifically appropriate to expand trial eligibility to include children younger than age 18 years in first-in-human and other adult cancer clinical trials. Methods This group convened experts from academia, government, and industry to review barriers to enrolling children and adolescents in oncology clinical trials. We evaluated the historical context, published literature, regulatory considerations, and myriad risks and benefits associated with lowering the age of enrollment on oncology clinical trials. Results We conclude that many of the historical concerns about including children early in oncology clinical trials do not apply in the current scientific and clinical environment of pediatric oncology and drug development; we provide specific recommendations for how the inclusion of children in early-phase investigational cancer drug trials might be accomplished. Automatic inclusion of pediatric patients is appropriate in early-phase trials that assess dose, safety, and pharmacokinetics in a variety of tumor types and later phase trials that assess efficacy in a specific disease that spans adult and pediatric populations. Conclusion Including children in appropriately designed adult clinical oncology trials is feasible and can be done in a way that enhances their access to these agents without compromising safety or development strategies.
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Affiliation(s)
- Lia Gore
- Lia Gore, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO; S. Percy Ivy, National Cancer Institute, Bethesda; Martha Donoghue and Gregory Reaman, US Food and Drug Administration, Silver Spring, MD; Frank M. Balis, Children's Hospital of Philadelphia, Philadelphia, PA; Eric Rubin, Merck Research Laboratories, Kenilworth, NJ; Katherine Thornton, Dana-Farber Cancer Institute, Boston, MA; Samantha Roberts, Friends of Cancer Research and Genentech; Nancy Goodman, Kids v Cancer, Washington, DC; Suanna Bruinooge and Caroline Schenkel, ASCO, Alexandria, VA; and Jennifer Ersek, Levine Cancer Institute, Charlotte, NC
| | - S Percy Ivy
- Lia Gore, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO; S. Percy Ivy, National Cancer Institute, Bethesda; Martha Donoghue and Gregory Reaman, US Food and Drug Administration, Silver Spring, MD; Frank M. Balis, Children's Hospital of Philadelphia, Philadelphia, PA; Eric Rubin, Merck Research Laboratories, Kenilworth, NJ; Katherine Thornton, Dana-Farber Cancer Institute, Boston, MA; Samantha Roberts, Friends of Cancer Research and Genentech; Nancy Goodman, Kids v Cancer, Washington, DC; Suanna Bruinooge and Caroline Schenkel, ASCO, Alexandria, VA; and Jennifer Ersek, Levine Cancer Institute, Charlotte, NC
| | - Frank M Balis
- Lia Gore, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO; S. Percy Ivy, National Cancer Institute, Bethesda; Martha Donoghue and Gregory Reaman, US Food and Drug Administration, Silver Spring, MD; Frank M. Balis, Children's Hospital of Philadelphia, Philadelphia, PA; Eric Rubin, Merck Research Laboratories, Kenilworth, NJ; Katherine Thornton, Dana-Farber Cancer Institute, Boston, MA; Samantha Roberts, Friends of Cancer Research and Genentech; Nancy Goodman, Kids v Cancer, Washington, DC; Suanna Bruinooge and Caroline Schenkel, ASCO, Alexandria, VA; and Jennifer Ersek, Levine Cancer Institute, Charlotte, NC
| | - Eric Rubin
- Lia Gore, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO; S. Percy Ivy, National Cancer Institute, Bethesda; Martha Donoghue and Gregory Reaman, US Food and Drug Administration, Silver Spring, MD; Frank M. Balis, Children's Hospital of Philadelphia, Philadelphia, PA; Eric Rubin, Merck Research Laboratories, Kenilworth, NJ; Katherine Thornton, Dana-Farber Cancer Institute, Boston, MA; Samantha Roberts, Friends of Cancer Research and Genentech; Nancy Goodman, Kids v Cancer, Washington, DC; Suanna Bruinooge and Caroline Schenkel, ASCO, Alexandria, VA; and Jennifer Ersek, Levine Cancer Institute, Charlotte, NC
| | - Katherine Thornton
- Lia Gore, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO; S. Percy Ivy, National Cancer Institute, Bethesda; Martha Donoghue and Gregory Reaman, US Food and Drug Administration, Silver Spring, MD; Frank M. Balis, Children's Hospital of Philadelphia, Philadelphia, PA; Eric Rubin, Merck Research Laboratories, Kenilworth, NJ; Katherine Thornton, Dana-Farber Cancer Institute, Boston, MA; Samantha Roberts, Friends of Cancer Research and Genentech; Nancy Goodman, Kids v Cancer, Washington, DC; Suanna Bruinooge and Caroline Schenkel, ASCO, Alexandria, VA; and Jennifer Ersek, Levine Cancer Institute, Charlotte, NC
| | - Martha Donoghue
- Lia Gore, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO; S. Percy Ivy, National Cancer Institute, Bethesda; Martha Donoghue and Gregory Reaman, US Food and Drug Administration, Silver Spring, MD; Frank M. Balis, Children's Hospital of Philadelphia, Philadelphia, PA; Eric Rubin, Merck Research Laboratories, Kenilworth, NJ; Katherine Thornton, Dana-Farber Cancer Institute, Boston, MA; Samantha Roberts, Friends of Cancer Research and Genentech; Nancy Goodman, Kids v Cancer, Washington, DC; Suanna Bruinooge and Caroline Schenkel, ASCO, Alexandria, VA; and Jennifer Ersek, Levine Cancer Institute, Charlotte, NC
| | - Samantha Roberts
- Lia Gore, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO; S. Percy Ivy, National Cancer Institute, Bethesda; Martha Donoghue and Gregory Reaman, US Food and Drug Administration, Silver Spring, MD; Frank M. Balis, Children's Hospital of Philadelphia, Philadelphia, PA; Eric Rubin, Merck Research Laboratories, Kenilworth, NJ; Katherine Thornton, Dana-Farber Cancer Institute, Boston, MA; Samantha Roberts, Friends of Cancer Research and Genentech; Nancy Goodman, Kids v Cancer, Washington, DC; Suanna Bruinooge and Caroline Schenkel, ASCO, Alexandria, VA; and Jennifer Ersek, Levine Cancer Institute, Charlotte, NC
| | - Suanna Bruinooge
- Lia Gore, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO; S. Percy Ivy, National Cancer Institute, Bethesda; Martha Donoghue and Gregory Reaman, US Food and Drug Administration, Silver Spring, MD; Frank M. Balis, Children's Hospital of Philadelphia, Philadelphia, PA; Eric Rubin, Merck Research Laboratories, Kenilworth, NJ; Katherine Thornton, Dana-Farber Cancer Institute, Boston, MA; Samantha Roberts, Friends of Cancer Research and Genentech; Nancy Goodman, Kids v Cancer, Washington, DC; Suanna Bruinooge and Caroline Schenkel, ASCO, Alexandria, VA; and Jennifer Ersek, Levine Cancer Institute, Charlotte, NC
| | - Jennifer Ersek
- Lia Gore, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO; S. Percy Ivy, National Cancer Institute, Bethesda; Martha Donoghue and Gregory Reaman, US Food and Drug Administration, Silver Spring, MD; Frank M. Balis, Children's Hospital of Philadelphia, Philadelphia, PA; Eric Rubin, Merck Research Laboratories, Kenilworth, NJ; Katherine Thornton, Dana-Farber Cancer Institute, Boston, MA; Samantha Roberts, Friends of Cancer Research and Genentech; Nancy Goodman, Kids v Cancer, Washington, DC; Suanna Bruinooge and Caroline Schenkel, ASCO, Alexandria, VA; and Jennifer Ersek, Levine Cancer Institute, Charlotte, NC
| | - Nancy Goodman
- Lia Gore, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO; S. Percy Ivy, National Cancer Institute, Bethesda; Martha Donoghue and Gregory Reaman, US Food and Drug Administration, Silver Spring, MD; Frank M. Balis, Children's Hospital of Philadelphia, Philadelphia, PA; Eric Rubin, Merck Research Laboratories, Kenilworth, NJ; Katherine Thornton, Dana-Farber Cancer Institute, Boston, MA; Samantha Roberts, Friends of Cancer Research and Genentech; Nancy Goodman, Kids v Cancer, Washington, DC; Suanna Bruinooge and Caroline Schenkel, ASCO, Alexandria, VA; and Jennifer Ersek, Levine Cancer Institute, Charlotte, NC
| | - Caroline Schenkel
- Lia Gore, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO; S. Percy Ivy, National Cancer Institute, Bethesda; Martha Donoghue and Gregory Reaman, US Food and Drug Administration, Silver Spring, MD; Frank M. Balis, Children's Hospital of Philadelphia, Philadelphia, PA; Eric Rubin, Merck Research Laboratories, Kenilworth, NJ; Katherine Thornton, Dana-Farber Cancer Institute, Boston, MA; Samantha Roberts, Friends of Cancer Research and Genentech; Nancy Goodman, Kids v Cancer, Washington, DC; Suanna Bruinooge and Caroline Schenkel, ASCO, Alexandria, VA; and Jennifer Ersek, Levine Cancer Institute, Charlotte, NC
| | - Gregory Reaman
- Lia Gore, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO; S. Percy Ivy, National Cancer Institute, Bethesda; Martha Donoghue and Gregory Reaman, US Food and Drug Administration, Silver Spring, MD; Frank M. Balis, Children's Hospital of Philadelphia, Philadelphia, PA; Eric Rubin, Merck Research Laboratories, Kenilworth, NJ; Katherine Thornton, Dana-Farber Cancer Institute, Boston, MA; Samantha Roberts, Friends of Cancer Research and Genentech; Nancy Goodman, Kids v Cancer, Washington, DC; Suanna Bruinooge and Caroline Schenkel, ASCO, Alexandria, VA; and Jennifer Ersek, Levine Cancer Institute, Charlotte, NC
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Leong R, Zhao H, Reaman G, Liu Q, Wang Y, Stewart CF, Burckart G. Bridging Adult Experience to Pediatrics in Oncology Drug Development. J Clin Pharmacol 2017; 57 Suppl 10:S129-S135. [PMID: 28921643 DOI: 10.1002/jcph.910] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 03/06/2017] [Indexed: 01/14/2023]
Abstract
Pediatric drug development in the United States has grown under the current regulations made permanent by the Food and Drug Administration Safety and Innovation Act of 2012. Over 1200 pediatric studies have now been submitted to the US FDA, but there is still a high rate of failure to obtain pediatric labeling for the indication pursued. Pediatric oncology represents special problems in that the disease is most often dissimilar to any cancer found in the adult population. Therefore, the development of drug dosing in pediatric oncology patients represents a special challenge. Potential approaches to pediatric dosing in oncology patients include extrapolation of efficacy from adult studies in those few cases where the disease is similar, inclusion of adolescent patients in adult trials when possible, and bridging the adult dose to the pediatric dose. An analysis of the recommended phase 2 dose for 40 molecularly targeted agents in pediatric patients provides some insight into current practices. Increased knowledge of tumor biology and efforts to identify and validate molecular targets and genetic abnormalities that drive childhood cancers can lead to increased opportunities for precision medicine in the treatment of pediatric cancers.
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Affiliation(s)
- Ruby Leong
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Hong Zhao
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Gregory Reaman
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Qi Liu
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Yaning Wang
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Clinton F Stewart
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Gilbert Burckart
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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Kwitkowski V, Daniels S, Reaman G, Farrell A, Kluetz P. Commentary on Heath et al. Clin Trials 2017; 14:572-574. [PMID: 28764558 DOI: 10.1177/1740774517723308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Virginia Kwitkowski
- 1 Division of Hematology Products, Office of Hematology and Oncology Products, Office of New Drugs (OND), Center for Drug Evaluation and Research (CDER), US Food and Drug Administration, Silver Spring, MD, USA
| | - Selena Daniels
- 2 Office of New Drugs (OND), Center for Drug Evaluation and Research (CDER), US Food and Drug Administration, Silver Spring, MD, USA
| | - Gregory Reaman
- 3 Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, MD, USA
| | - Ann Farrell
- 1 Division of Hematology Products, Office of Hematology and Oncology Products, Office of New Drugs (OND), Center for Drug Evaluation and Research (CDER), US Food and Drug Administration, Silver Spring, MD, USA
| | - Paul Kluetz
- 3 Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, MD, USA
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Kirch R, Reaman G, Feudtner C, Wiener L, Schwartz LA, Sung L, Wolfe J. Advancing a comprehensive cancer care agenda for children and their families: Institute of Medicine Workshop highlights and next steps. CA Cancer J Clin 2016; 66:398-407. [PMID: 27145249 DOI: 10.3322/caac.21347] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 03/29/2016] [Accepted: 03/31/2016] [Indexed: 12/20/2022] Open
Abstract
This article highlights key findings from the "Comprehensive Cancer Care for Children and Their Families" March 2015 joint workshop by the Institute of Medicine (IOM) and the American Cancer Society. This initiative convened more than 100 family members, clinician investigators, advocates, and members of the public to discuss emerging evidence and care models and to determine the next steps for optimizing quality-of-life outcomes and well-being for children and families during pediatric cancer treatment, after treatment completion, and across the life spectrum. Participants affirmed the triple aim of pediatric oncology that strives for every child with cancer to be cured; provides high-quality palliative and psychosocial supportive, restorative, and rehabilitative care to children and families throughout the illness course and survivorship; and assures receipt of high-quality end-of-life care for patients with advancing disease. Workshop outcomes emphasized the need for new pediatric cancer drug development and identified critical opportunities to prioritize palliative care and psychosocial support as an integral part of pediatric cancer research and treatment, including the necessity for adequately resourcing these supportive services to minimize suffering and distress, effectively address quality-of-life needs for children and families at all stages of illness, and mitigate the long-term health risks associated with childhood cancer and its treatment. Next steps include dismantling existing silos and enhancing collaboration between clinical investigators, disease-directed specialists, and supportive care services; expanding the use of patient-reported and parent-reported outcomes; effectively integrating palliative and psychosocial care; and clinical communication skills development. CA Cancer J Clin 2016;66:398-407. © 2016 American Cancer Society.
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Affiliation(s)
- Rebecca Kirch
- Consultant, The Center to Advance Palliative Care, New York, NY
- Consultant, Cameron and Hayden Lord Foundation, New York, NY
| | - Gregory Reaman
- Associate Director, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Chris Feudtner
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lori Wiener
- Behavioral Health Core, and Head of the Psychosocial Support and Research Program, National Cancer Institute, Bethesda, MD
| | - Lisa A Schwartz
- Psychologist, Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
- Assistant Professor, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lillian Sung
- Pediatric Oncologist, Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Joanne Wolfe
- Pediatric Palliative Care Service, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- Director, Pediatric Palliative Care, Boston Children's Hospital, Boston, MA
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Leighton JK, Saber H, Reaman G, Pazdur R. An FDA oncology view of juvenile animal studies in support of initial pediatric trials for anticancer drugs. Regul Toxicol Pharmacol 2016; 79:142-143. [PMID: 26952647 DOI: 10.1016/j.yrtph.2016.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 03/02/2016] [Indexed: 11/30/2022]
Affiliation(s)
- John K Leighton
- US Food and Drug Administration, Center for Drug Evaluation and Research, Office of Hematology and Oncology Products, 10903 New Hampshire Ave, Silver Spring, MD 20903, United States.
| | - Haleh Saber
- US Food and Drug Administration, Center for Drug Evaluation and Research, Office of Hematology and Oncology Products, 10903 New Hampshire Ave, Silver Spring, MD 20903, United States
| | - Gregory Reaman
- US Food and Drug Administration, Center for Drug Evaluation and Research, Office of Hematology and Oncology Products, 10903 New Hampshire Ave, Silver Spring, MD 20903, United States
| | - Richard Pazdur
- US Food and Drug Administration, Center for Drug Evaluation and Research, Office of Hematology and Oncology Products, 10903 New Hampshire Ave, Silver Spring, MD 20903, United States
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Sadak KT, Fultz K, Mendizabal A, Reaman G, Garcia-Gonzalez P, Levine PH. International patterns of childhood chronic myeloid leukemia: comparisons between the United States and resource-restricted nations. Pediatr Blood Cancer 2014; 61:1774-8. [PMID: 24976310 DOI: 10.1002/pbc.25120] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 05/08/2014] [Indexed: 11/05/2022]
Abstract
BACKGROUND Chronic myeloid leukemia (CML) is a rare disease in children and represents approximately 2% of all childhood leukemia. This results in difficulty creating large cohorts of patients for pediatric CML research. The Glivec International Patient Assistance Program (GIPAP) is a patient-access program sponsored by Novartis Oncology and administered by The Max Foundation (MAX) that provides imatinib free of charge to patients in resource-restricted countries who are not able to afford this treatment. PROCEDURES GIPAP highlights a cohort of children (n = 3,188) with CML that provides novel insight into international trends in diagnosis, treatment, and survival. These trends can be compared to outcomes in developed nations to crudely assess the impact of an extended access program for CML treatment such as GIPAP. RESULTS Overall survival values for children treated for CML within the GIPAP (89%) suggest that imatinib is very effective in middle and low-income countries. CONCLUSIONS This may allow for increased international awareness within the scientific community to consider possible reasons for the differences in overall survival in pediatric CML within the United States versus other nations with fewer resources.
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Affiliation(s)
- Karim Thomas Sadak
- Division of Pediatric Hematology/Oncology, University of Minnesota Children's Hospital, Minneapolis, Minnesota; Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
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Affiliation(s)
- Dianne Murphy
- Office of Pediatric Therapeutics, Office of the Commissioner, Food and Drug Administrations; and
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Sadak KT, Dinofia A, Reaman G. Patient-perceived facilitators in the transition of care for young adult survivors of childhood cancer. Pediatr Blood Cancer 2013; 60:1365-8. [PMID: 23441065 DOI: 10.1002/pbc.24494] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 01/10/2013] [Indexed: 11/08/2022]
Abstract
BACKGROUND A new challenge has emerged in optimizing the transition of pediatric survivorship care to similarly focused programs that are age-appropriate for young adults. The purpose of this study is to identify components of a clinical survivorship program that facilitate the transition of care for young adult survivors of childhood cancer from a pediatric to adult care-setting. PROCEDURE Prior to transition, a descriptive study of childhood cancer survivors was conducted using a cross-sectional study design. A questionnaire was used to identify which clinical components of a survivorship program would most influence their decision to transition care to an adult medical center. RESULTS Of 129 invited survivors, 103 participated (80%). Most survivors were age 16-19 years (40/103, 39%) or 20-24 years (37/103, 36%). When asked if the participant was willing to transition their survivorship care to an adult facility, 97 (95%) responded affirmatively. The clinical components most frequently rated "Very Important" in the decision to transition were the acceptance of insurance (80/103, 78%) followed by the presence of a provider knowledgeable in childhood cancer (68/103, 66%). The clinical components most frequently rated "Very Important" or "Important" were the availability of flexible scheduling (102/103, 99%) followed by the comprehensive nature of the care provided (101/103, 98%). CONCLUSIONS The decision to transition survivorship care to age-appropriate care-settings is complex and not well understood. Issues related to insurance, clinical team composition and scheduling appear to be most important for young adult survivors making this decision. Pediatr Blood Cancer 2013;601365-1368. © 2013 Wiley Periodicals, Inc.
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Affiliation(s)
- Karim Thomas Sadak
- Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, District of Columbia, USA.
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Snyder KM, Reaman G, Avant D, Pazdur R. The impact of the written request process on drug development in childhood cancer. Pediatr Blood Cancer 2013; 60:531-7. [PMID: 23335552 DOI: 10.1002/pbc.24346] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 08/30/2012] [Indexed: 12/27/2022]
Abstract
PURPOSE The Food and Drug Administration (FDA) Modernization Act, enacted in 1997, created a pediatric exclusivity incentive allowing sponsors to qualify for an additional 6 months of marketing exclusivity after satisfying the requirements outlined in the Written Request (WR). This review evaluates the impact of the WR mechanism on the development of oncology drugs in children. METHODS A search of the FDA document archiving, reporting, and regulatory tracking system was performed for January 1, 2000 to December 31, 2010. Drugs were identified and pediatric-specific labeling information was obtained from Drugs@fda.gov and FDA Pediatric Labeling Changes Table. RESULTS Fifty WRs have been issued for oncology drugs. Pediatric studies have been submitted for 14 drugs. Thirteen received pediatric exclusivity. As of December 31, 2010, labeling changes have been made for 11 drugs. Three drugs were approved for pediatric use. CONCLUSION WRs have provided a mechanism to promote the study of drugs in pediatric malignancies. Information from studies resulting from the WRs regarding safety, pharmacokinetics, and tolerability of oncology drugs has been incorporated into pediatric labeling for 11/14 of the drugs. Earlier communication and collaboration between the FDA, National Cancer Institute, clinical investigators, and commercial sponsors are envisioned to facilitate the identification and prioritization of emerging new drugs of interest for WR consideration. Since this is the only regulatory mechanism, resulting from specific legislative initiatives relevant to cancer drug development for children, efforts to enhance its impact on increasing drug approval for pediatric cancer indications are warranted.
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Affiliation(s)
- Kristen M Snyder
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland 20901-0002, USA
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Fernandez CV, Ruccione K, Wells RJ, Long JB, Pelletier W, Hooke MC, Pentz RD, Noll RB, Baker JN, O'Leary M, Reaman G, Adamson PC, Joffe S. Recommendations for the return of research results to study participants and guardians: a report from the Children's Oncology Group. J Clin Oncol 2012; 30:4573-9. [PMID: 23109703 DOI: 10.1200/jco.2012.45.2086] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The Children's Oncology Group (COG) strongly supports the widely recognized principle that research participants should be offered a summary of study results. The mechanism by which to do so in a cooperative research group setting has not been previously described. METHODS On the basis of a review of the available empirical and theoretic literature and on iterative, multidisciplinary discussion, a COG Return of Results Task Force (RRTF) offered detailed recommendations for the return of results to research study participants. RESULTS The RRTF established guidelines for the notification of research participants and/or their parents/guardians about the availability of research results, a mechanism for and timing of sharing results via registration on the COG public Web site, the scope of the research to be shared, the target audience, and a process for creating and vetting lay summaries of study results. The RRTF recognized the challenges in adequately conveying complex scientific results to audiences with varying levels of health literacy and recommended that particularly sensitive or complex results be returned using direct personal contact. The RRTF also recommended evaluation of the cost, effectiveness, and impact of sharing results. CONCLUSION These recommendations provide a framework for the offering and returning of results to participants. They can be used by individual investigators, multi-investigator research collaboratives, and large cooperative groups.
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Affiliation(s)
- Conrad V Fernandez
- Izaak Walton Killam and Steven Joffe Health Centre, Dalhousie University, Halifax, Nova Scotia
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Embry L, Annett RD, Kunin-Batson A, Patel SK, Sands S, Reaman G, Noll RB. Implementation of multi-site neurocognitive assessments within a pediatric cooperative group: can it be done? Pediatr Blood Cancer 2012; 59:536-9. [PMID: 22555997 DOI: 10.1002/pbc.24139] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 02/20/2012] [Indexed: 11/08/2022]
Abstract
BACKGROUND Neurocognitive functioning is an important construct in childhood cancer survivorship, given the potential neurotoxicity of central nervous system (CNS) diseases and treatments and the relevance for important functional outcomes in adulthood. However, within pediatric oncology cooperative groups there have been significant barriers to neurocognitive data collection that have historically resulted in incomplete data (<30% compliance), thereby limiting progress in understanding the neurocognitive functioning of survivors. This paper describes the development, feasibility, and potential efficacy of a brief neurocognitive battery to maximize collection of psychometrically robust neurocognitive data within a pediatric cooperative group. We hypothesized that a novel set of procedures could result in collection of data from over 80% of eligible children. PROCEDURE A novel assessment battery (ALTE07C1) that evaluates a child's cognitive, social, emotional, and behavioral functioning was developed. It included measures that were psychometrically sound, normed, widely available, and could be administered by any licensed psychologist. The battery required approximately 1 hour of administration time. A data monitoring team was developed to ensure prompt data collection. RESULTS Approximately 75% (105 of 140) of institutions with eligible patients opened ALTE07C1; 159 participants have been enrolled. The overall compliance rate for submission of neurocognitive data exceeded 90%. DISCUSSION Our study supports the feasibility and potential efficacy of a brief neurocognitive battery and a data monitoring team to evaluate children participating in multi-site pediatric oncology trials. Future work will utilize ALTE07C1 as a primary or secondary endpoint for pediatric trials when there is risk for neurocognitive impairment.
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Affiliation(s)
- Leanne Embry
- Department of Pediatrics, University of Texas Health Science Center, San Antonio, USA
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Roberts KG, Morin RD, Zhang J, Hirst M, Zhao Y, Su X, Chen SC, Payne-Turner D, Churchman M, Harvey RC, Chen X, Kasap C, Yan C, Becksfort J, Finney RP, Teachey DT, Maude SL, Tse K, Moore R, Jones S, Mungall K, Birol I, Edmonson MN, Hu Y, Buetow KE, Chen IM, Carroll WL, Wei L, Ma J, Kleppe M, Levine RL, Garcia-Manero G, Larsen E, Shah NP, Devidas M, Reaman G, Smith M, Paugh SW, Evans WE, Grupp SA, Jeha S, Pui CH, Gerhard DS, Downing JR, Willman CL, Loh M, Hunger SP, Marra M, Mullighan CG. Genetic alterations activating kinase and cytokine receptor signaling in high-risk acute lymphoblastic leukemia. Cancer Cell 2012; 22:153-66. [PMID: 22897847 PMCID: PMC3422513 DOI: 10.1016/j.ccr.2012.06.005] [Citation(s) in RCA: 507] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 05/21/2012] [Accepted: 06/11/2012] [Indexed: 12/15/2022]
Abstract
Genomic profiling has identified a subtype of high-risk B-progenitor acute lymphoblastic leukemia (B-ALL) with alteration of IKZF1, a gene expression profile similar to BCR-ABL1-positive ALL and poor outcome (Ph-like ALL). The genetic alterations that activate kinase signaling in Ph-like ALL are poorly understood. We performed transcriptome and whole genome sequencing on 15 cases of Ph-like ALL and identified rearrangements involving ABL1, JAK2, PDGFRB, CRLF2, and EPOR, activating mutations of IL7R and FLT3, and deletion of SH2B3, which encodes the JAK2-negative regulator LNK. Importantly, several of these alterations induce transformation that is attenuated with tyrosine kinase inhibitors, suggesting the treatment outcome of these patients may be improved with targeted therapy.
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Affiliation(s)
- Kathryn G. Roberts
- Department of Pathology, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - Ryan D. Morin
- Genome Sciences Centre, BC Cancer Agency, Vancouver, BC V5Z 1L3
| | - Jinghui Zhang
- Department of Computational Biology and Bioinformatics, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - Martin Hirst
- Genome Sciences Centre, BC Cancer Agency, Vancouver, BC V5Z 1L3
| | - Yongjun Zhao
- Genome Sciences Centre, BC Cancer Agency, Vancouver, BC V5Z 1L3
| | - Xiaoping Su
- Department of Pathology, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - Shann-Ching Chen
- Department of Pathology, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - Debbie Payne-Turner
- Department of Pathology, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - Michelle Churchman
- Department of Pathology, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - Richard C. Harvey
- University of New Mexico Cancer Research and Treatment Center, Albuquerque, NM 87131
| | - Xiang Chen
- Department of Computational Biology and Bioinformatics, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - Corynn Kasap
- School of Medicine, University of California, San Francisco, CA 94143
| | - Chunhua Yan
- Center for Bioinformatics and Information Technology, National Institutes of Health, Bethesda, MD 20892
| | - Jared Becksfort
- Department of Information Sciences, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - Richard P. Finney
- Center for Bioinformatics and Information Technology, National Institutes of Health, Bethesda, MD 20892
| | - David T. Teachey
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104
| | - Shannon L. Maude
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104
| | - Kane Tse
- Genome Sciences Centre, BC Cancer Agency, Vancouver, BC V5Z 1L3
| | - Richard Moore
- Genome Sciences Centre, BC Cancer Agency, Vancouver, BC V5Z 1L3
| | - Steven Jones
- Genome Sciences Centre, BC Cancer Agency, Vancouver, BC V5Z 1L3
| | - Karen Mungall
- Genome Sciences Centre, BC Cancer Agency, Vancouver, BC V5Z 1L3
| | - Inanc Birol
- Genome Sciences Centre, BC Cancer Agency, Vancouver, BC V5Z 1L3
| | - Michael N. Edmonson
- Laboratory of Population Genetics, National Institutes of Health, Bethesda, MD 20892
| | - Ying Hu
- Laboratory of Population Genetics, National Institutes of Health, Bethesda, MD 20892
| | - Kenneth E. Buetow
- Laboratory of Population Genetics, National Institutes of Health, Bethesda, MD 20892
| | - I-Ming Chen
- University of New Mexico Cancer Research and Treatment Center, Albuquerque, NM 87131
| | | | - Lei Wei
- Department of Pathology, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - Jing Ma
- Department of Pathology, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - Maria Kleppe
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Ross L. Levine
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | | | - Eric Larsen
- Maine Children’s Cancer Program, Scarborough, ME 04074
| | - Neil P. Shah
- School of Medicine, University of California, San Francisco, CA 94143
| | - Meenakshi Devidas
- Epidemiology and Health Policy Research, University of Florida, Gainesville, FL 32601
| | - Gregory Reaman
- Children’s National Medical Center, Washington, DC 20010
| | - Malcolm Smith
- Office of Cancer Genomics, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892
| | - Steven W. Paugh
- Department of Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - William E. Evans
- Department of Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - Stephan A. Grupp
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104
| | - Sima Jeha
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - Ching-Hon Pui
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - Daniela S. Gerhard
- Office of Cancer Genomics, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892
| | - James R. Downing
- Department of Pathology, St Jude Children’s Research Hospital, Memphis, TN 38105
| | - Cheryl L. Willman
- University of New Mexico Cancer Research and Treatment Center, Albuquerque, NM 87131
| | - Mignon Loh
- Department of Pediatrics, University of California, San Francisco, CA 94143
| | - Stephen P. Hunger
- University of Colorado School of Medicine and The Children’s Hospital Colorado, Aurora, CO 80045
| | - Marco Marra
- Genome Sciences Centre, BC Cancer Agency, Vancouver, BC V5Z 1L3
- Department of Medical Genetics, University of British Columbia, Vancouver, BC VSZ 1L3
| | - Charles G. Mullighan
- Department of Pathology, St Jude Children’s Research Hospital, Memphis, TN 38105
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