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Tibau A, Hwang TJ, Molto C, Avorn J, Kesselheim AS. Clinical Value of Molecular Targets and FDA-Approved Genome-Targeted Cancer Therapies. JAMA Oncol 2024; 10:634-641. [PMID: 38573645 DOI: 10.1001/jamaoncol.2024.0194] [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] [Indexed: 04/05/2024]
Abstract
Importance The number of new genome-targeted cancer drugs has increased, offering the possibility of personalized therapy, often at a very high cost. Objective To assess the validity of molecular targets and therapeutic benefits of US Food and Drug Administration-approved genome-targeted cancer drugs based on the outcomes of their corresponding pivotal clinical trials. Design and Settings In this cohort study, all genome-targeted cancer drugs that were FDA-approved between January 1, 2015, and December 31, 2022, were analyzed. From FDA drug labels and trial reports, key characteristics of pivotal trials were extracted, including the outcomes assessed. Main Outcomes and Measures The strength of evidence supporting molecular targetability was assessed using the European Society for Medical Oncology (ESMO) Scale for Clinical Actionability of Molecular Targets (ESCAT). Clinical benefit for their approved indications was evaluated using the ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS). Substantial clinical benefit was defined as a grade of A or B for curative intent and 4 or 5 for noncurative intent. Molecular targets qualifying for ESCAT category level I-A and I-B associated with substantial clinical benefit by ESMO-MCBS were rated as high-benefit genomic-based cancer treatments. Results A total of 50 molecular-targeted drugs covering 84 indications were analyzed. Forty-five indications (54%) were approved based on phase 1 or phase 2 pivotal trials, 45 (54%) were supported by single-arm pivotal trials, and 48 (57%) were approved on the basis of subgroup analyses. By each indication, 46 of 84 primary end points (55%) were overall response rate (median [IQR] overall response rate, 57% [40%-69%]; median [IQR] duration of response, 11.1 [9.2-19.8] months). Among the 84 pivotal trials supporting these 84 indications, 38 trials (45%) had I-A ESCAT targetability, and 32 (38%) had I-B targetability. Overall, 24 of 84 trials (29%) demonstrated substantial clinical benefit via ESMO-MCBS. Combining these ratings, 24 of 84 indications (29%) were associated with high-benefit genomic-based cancer treatments. Conclusions and Relevance The results of this cohort study demonstrate that among recently approved molecular-targeted cancer therapies, fewer than one-third demonstrated substantial patient benefits at approval. Benefit frameworks such as ESMO-MCBS and ESCAT can help physicians, patients, and payers identify therapies with the greatest clinical potential.
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Affiliation(s)
- Ariadna Tibau
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Thomas J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Consolacion Molto
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Jerry Avorn
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Hwang TJ, Davies BJ, Preston MA. Advancing Patient-Centered Outcomes and Equity in Clinical Trials for BCG-Unresponsive Nonmuscle Invasive Bladder Cancer. JAMA Oncol 2023; 9:1491-1492. [PMID: 37676669 DOI: 10.1001/jamaoncol.2023.3304] [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] [Indexed: 09/08/2023]
Abstract
This Viewpoint encourages investigators to move beyond FDA guidance toward patient-centered therapies and health equity for BCG-unresponsive bladder cancer.
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Affiliation(s)
- Thomas J Hwang
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cancer Innovation and Regulation Initiative, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mark A Preston
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Vokinger KN, Serra-Burriel M, Glaus CEG, Rohr UP, Hwang TJ, Dalla Torre di Sanguinetto S, Kesselheim AS. Regulatory Review Duration and Differences in Submission Times of Drugs in the United States and Europe, 2011 to 2020. Ann Intern Med 2023; 176:1413-1418. [PMID: 37844306 DOI: 10.7326/m23-0623] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Abstract
The speed of drug regulatory agencies in the United States and Europe is often a source of discussion. The objective of this research was to assess regulatory review duration of first and supplementary indications approved between 2011 and 2020 in the United States and Europe (European Union [EU] and Switzerland) and differences in submission times between the United States and Europe. Descriptive statistics were applied to review times between the jurisdictions and across the therapeutic areas. A regression analysis was done to estimate the association between approval agency and review times. The primary analysis cohort included 241 drugs approved in the United States, the EU, and Switzerland. Of these, 128 drugs had supplemental indications (331 in total) in the United States and 87 had supplemental indications (206 in total) in the EU. Overall median review duration from submission to approval subtracting the clock stop period was 39 weeks in the United States, 44 weeks in the EU, and 44 weeks in Switzerland. When review times within each drug were compared, the European Medicines Agency took a median of 3.7 weeks (IQR, -6.7 to 14.9 weeks) longer than the U.S. Food and Drug Administration and Swissmedic a median of 0.3 weeks (IQR, -10.6 to 15.3 weeks) longer. Median total review duration for supplemental indications was 26 weeks in the United States and 40 weeks in the EU. Applications were submitted a median of 1.3 and 17.9 weeks later in the EU and Switzerland, respectively, than in the United States. The regression analysis showed small differences in submission times between the United States and the EU (-2.1 weeks [95% CI, -11.7 to 7.6 weeks]) and larger differences between the United States and Switzerland (33.0 weeks [CI, 23.1 to 42.8 weeks]). It would be beneficial for patients if differences in submission times between the United States and Europe continue to be minimized.
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Affiliation(s)
- Kerstin N Vokinger
- Institute of Law, University of Zurich, Zurich, Switzerland, and Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (K.N.V.)
| | - Miquel Serra-Burriel
- Institute of Law and Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland (M.S.)
| | - Camille E G Glaus
- Institute of Law, University of Zurich, Zurich, Switzerland (C.E.G.G.)
| | - Ulrich-Peter Rohr
- Swissmedic, Swiss Agency for Therapeutic Products, Bern, Switzerland (U.-P.R., S.D.T.S.)
| | - Thomas J Hwang
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, and Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Cancer, Boston, Massachusetts (T.J.H.)
| | | | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (A.S.K.)
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Vokinger KN, Glaus CEG, Kesselheim AS, Serra-Burriel M, Ross JS, Hwang TJ. Therapeutic value of first versus supplemental indications of drugs in US and Europe (2011-20): retrospective cohort study. BMJ 2023; 382:e074166. [PMID: 37407074 PMCID: PMC10320829 DOI: 10.1136/bmj-2022-074166] [Citation(s) in RCA: 6] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE To analyze the therapeutic value of supplemental indications compared with first indications for drugs approved in the US and Europe. DESIGN Retrospective cohort study. SETTING New and supplemental indications approved by the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) between 2011 and 2020. MAIN OUTCOME MEASURES Proportion of first and supplemental indications rated as having high therapeutic value using ratings from the French and German national, independent health authorities. RESULTS The cohort study included 124 first and 335 supplemental indications approved by the FDA and 88 first and 215 supplemental indications approved by the EMA between 2011 and 2020; the largest subset was for cancer disorders. Therapeutic ratings were available for 107 (86%) first and 179 (53%) supplemental indications in the US and for 87 (99%) first and 184 (86%) supplemental indications in Europe. Among FDA approved indications with available ratings, 41% (44/107) had high therapeutic value ratings for first indications compared with 34% (61/179) for supplemental indications. In Europe, 47% (41/87) of first and 36% (67/184) of supplemental indications had high therapeutic value ratings. Among FDA approvals, when the sample was restricted to the first three approved indications, second indication approvals were 36% less likely to have a high value rating (relative ratio 0.64, 95% confidence interval 0.43 to 0.96) and third indication approvals were 45% less likely (0.55, 0.29 to 1.01) compared with the first indication approval. Similar findings were observed for Europe and when weighting by the inverse number of indications for each drug. CONCLUSIONS The proportion of supplemental indications rated as having high therapeutic value was substantially lower than for first indications. When first or supplemental indications do not offer added therapeutic value over other available treatments, that information should be clearly communicated to patients and physicians and reflected in the price of the drugs.
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Affiliation(s)
- Kerstin N Vokinger
- Institute of Law, University of Zurich, Zurich, Switzerland
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
- Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA, USA
| | | | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Miquel Serra-Burriel
- Institute of Law, University of Zurich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Joseph S Ross
- National Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Section for General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Health System, New Haven, CT, USA
| | - Thomas J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
- Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA, USA
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Hwang TJ, Reaman GH, Bourgeois FT. Clinical trials for paediatric cancers under new legislation in the USA. Lancet Child Adolesc Health 2023; 7:e13. [PMID: 37349019 DOI: 10.1016/s2352-4642(23)00125-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/03/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Thomas J Hwang
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Boston, MA 02115, USA; Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Division of Urological Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Gregory H Reaman
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, USA
| | - Florence T Bourgeois
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
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Hwang TJ. Reply to E. Noguchi et al. JCO Oncol Pract 2023; 19:217. [PMID: 36657088 DOI: 10.1200/op.22.00832] [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: 01/21/2023] Open
Affiliation(s)
- Thomas J Hwang
- Thomas J. Hwang, MD, Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Cancer, Dana-Farber Cancer Institute and Division of Urological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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7
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Clemans-Cope L, Epstein M, Banthin J, Kesselheim AS, Hwang TJ. Estimates of Medicaid and Non-Medicaid Net Prices of Top-Selling Brand-name Drugs Incorporating Best Price Rebates, 2015 to 2019. JAMA Health Forum 2023; 4:e225012. [PMID: 36637815 PMCID: PMC9857139 DOI: 10.1001/jamahealthforum.2022.5012] [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: 01/14/2023] Open
Abstract
Importance The US spends far more on brand-name prescription drugs than other comparable countries. However, studies of prescription drug spending in the US are often limited because there can be substantial differences in the confidential rebates that drug manufacturers pay to Medicaid vs other payers. Objectives To demonstrate an approach for improved estimation of Medicaid rebates through case studies of 18 top-selling drugs to better understand trends in net Medicaid and non-Medicaid spending and prices for brand-name drugs. Design, Settings, and Participants This was a cross-sectional study of US pricing data from 2015 to 2019 derived from Medicaid State Drug Utilization data SSR Health, Medi-Span, the Federal Supply Schedule, and IQVIA. Pricing data for 18 top-selling brand-name drugs measured consistently in both SSR Health, which captures US sales reported by publicly traded companies, and IQVIA's top US prescription drugs by nondiscounted spending in 2015 to 2019. Data were accessed and analyzed from January 2019 to June 2021. Main Outcomes and Measures Gross and net Medicaid and non-Medicaid drug spending for the sample of 18 drugs and prices corresponding to a 30-day supply of medication. Results Medicaid aggregate gross spending for the 18 drugs in the sample increased 173%, from $3.6 billion in 2015 to $9.9 billion in 2019, and estimated net spending after discounts increased by 119%, from $1.4 billion to $3.0 billion. Medicaid inflation-linked rebates reduced average gross price per 30-day supply by an estimated 43% in 2019, and up to 67% for individual drugs. In addition to the basic rebate, the best price provision reduced the average gross price per 30-day supply by an estimated 3% in 2019 and up to 54% for individual drugs. Between 2015 and 2019 across all study drugs, estimated average non-Medicaid net 30-day prices were between 1.9 and 2.6 times higher than Medicaid net prices. Excluding adalimumab-a spending anomaly because of the entry of a new high-cost formulation-net prices weighted by average gross spending decreased annually by 1% from 2015 through 2019 for Medicaid, while increasing by 2% for non-Medicaid payers. Conclusions and Relevance In this cross-sectional study of 18 top-selling brand-name drugs, excluding 1 anomaly, Medicaid average net prices declined from 2015 to 2019. Simultaneously, for non-Medicaid payers, net price increased more than previously published marketwide growth rates, raising the importance of restraining drug price growth in non-Medicaid markets. Rigorous and transparent methods to estimate Medicaid discounts are imperative to understand patterns in Medicaid and non-Medicaid prices and develop policies that better align drug prices with clinical benefits.
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Affiliation(s)
| | - Marni Epstein
- Salt Lake County Human Services Department, Salt Lake City, Utah
| | | | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Thomas J. Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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8
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Patel NG, Hwang TJ, Woloshin S, Kesselheim AS. Therapeutic Value of Drugs Frequently Marketed Using Direct-to-Consumer Television Advertising, 2015 to 2021. JAMA Netw Open 2023; 6:e2250991. [PMID: 36637824 PMCID: PMC9857401 DOI: 10.1001/jamanetworkopen.2022.50991] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
This cohort study assesses whether drugs with the most direct-to-consumer television advertising represent advances over existing treatments.
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Affiliation(s)
- Neeraj G. Patel
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Yale School of Medicine, New Haven, Connecticut
| | - Thomas J. Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Steven Woloshin
- Center for Medicine in the Media, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Lisa Schwartz Foundation for Truth in Medicine, Norwich, Vermont
| | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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Pathak K, Narang C, Hwang TJ, Espinoza JC, Bourgeois FT. High-risk Therapeutic Devices Approved by the US Food and Drug Administration for Use in Children and Adolescents From 2016 to 2021. JAMA Pediatr 2023; 177:98-100. [PMID: 36342722 PMCID: PMC9641589 DOI: 10.1001/jamapediatrics.2022.4131] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This cohort study examines the characteristics of high-risk therapeutic devices approved by the US Food and Drug Administration for use in children and adolescents between 2016 and 2021.
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Affiliation(s)
| | - Claire Narang
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts
| | - Thomas J. Hwang
- Division of Urological Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Juan C. Espinoza
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California
| | - Florence T. Bourgeois
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Hwang TJ, Kesselheim AS, Vokinger KN. Reforming the World Health Organization's Essential Medicines List: Essential but Unaffordable. JAMA 2022; 328:1807-1808. [PMID: 36279114 DOI: 10.1001/jama.2022.19459] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This Viewpoint proposes restructuring the WHO Essential Medicines List to remove consideration of cost and cost-effectiveness from the expert committee reviews of clinical effectiveness, safety, and public health value, and chartering a new framework for pooled global negotiation and procurement of costly medicines included in the list.
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Affiliation(s)
- Thomas J Hwang
- Division of Urological Surgery, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kerstin N Vokinger
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Institute of Law and Laboratory for Technology, Markets, and Regulation, University of Zurich, Zurich, Switzerland
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Hwang TJ, Feng J, Maini L, Kesselheim AS. Medicaid Expenditures and Estimated Rebates on Line Extension Drugs, 2010-2018. J Gen Intern Med 2022; 37:3769-3771. [PMID: 35194743 PMCID: PMC9585137 DOI: 10.1007/s11606-022-07435-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 01/24/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Thomas J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Josh Feng
- Department of Entrepreneurship and Strategy, David Eccles School of Business, University of Utah, Salt Lake City, UT, USA
| | - Luca Maini
- Department of Economics, University of North Carolina, Chapel Hill, NC, USA
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Affiliation(s)
- Thomas J Hwang
- From the Division of Urological Surgery, Brigham and Women's Hospital, and the Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute - both in Boston (T.J.H.); and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, and the Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health - both in Baltimore (O.W.B.)
| | - Otis W Brawley
- From the Division of Urological Surgery, Brigham and Women's Hospital, and the Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute - both in Boston (T.J.H.); and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, and the Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health - both in Baltimore (O.W.B.)
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Abstract
This Viewpoint describes the provisions and limitations of prescription drug pricing reforms enacted by US Congress as part of the Inflation Reduction Act in August 2022.
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Affiliation(s)
- Thomas J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Urological Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Benjamin N Rome
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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14
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Hwang TJ, Kesselheim AS, Tibau A, Lee CC, Vokinger KN. Clinical Benefit and Expedited Approval of Cancer Drugs in the United States, European Union, Switzerland, Japan, Canada, and Australia. JCO Oncol Pract 2022; 18:e1522-e1532. [PMID: 35731996 PMCID: PMC9509186 DOI: 10.1200/op.21.00909] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Regulatory agencies have sought to speed up the review of new cancer medicines and reduce delays in approval between countries. We examined trends in regulatory review times and association with clinical benefit for new cancer medicines in six jurisdictions: United States (Food and Drug Administration [FDA]), European Union (European Medicines Agency [EMA]), Switzerland (Swissmedic), Japan (Pharmaceuticals and Medical Devices Agency [PMDA]), Canada (Health Canada), and Australia (Therapeutic Goods Administration). METHODS: We studied all new cancer drugs approved in the six aforementioned jurisdictions from 2007 to 2020. We extracted all applicable expedited programs, total regulatory review times, and, for drugs first approved by the FDA, times to subsequent regulatory approval. Clinical benefit was assessed using the European Society for Medical Oncology-Magnitude of Clinical Benefit Scale value framework and ASCO-Cancer Research Committee's targets. Nonparametric Kruskal-Wallis test was used to compare total review times for high versus low clinical benefit drugs. RESULTS: One hundred and twenty eight drugs received initial approval in at least one of the six included jurisdictions. Most drugs approved by the FDA (91%) and Health Canada (59%) qualified for at least one expedited program within those jurisdictions, compared with 46% of EMA approvals and 18% of PMDA approvals. The FDA was the first regulator to approve 102 (80%) drugs. Delays in submission accounted for a median of 20.2% (EMA) to 83.8% (PMDA) of the time to subsequent approval. There was no association between high clinical benefit and shorter total review times. CONCLUSION: Most new cancer therapies were approved first by the FDA, and delays in submission of regulatory applications accounted for substantial delays in approving cancer drugs in other countries. Regulators should prioritize faster review for drugs with high clinical benefit.
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Affiliation(s)
- Thomas J. Hwang
- Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Cancer, Dana-Farber Cancer Institute and Division of Urological Surgery, Brigham and Women's Hospital, Boston, MA
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ariadna Tibau
- Department of Oncology, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - ChangWon C. Lee
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kerstin N. Vokinger
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
- Institute of Law, University of Zurich, Zurich, Switzerland
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Vokinger KN, Kesselheim AS, Glaus CEG, Hwang TJ. Therapeutic Value of Drugs Granted Accelerated Approval or Conditional Marketing Authorization in the US and Europe From 2007 to 2021. JAMA Health Forum 2022; 3:e222685. [PMID: 36200635 PMCID: PMC9391955 DOI: 10.1001/jamahealthforum.2022.2685] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Question What is the therapeutic value of new drug indications granted accelerated approval or conditional marketing authorization in the US and Europe? Findings In this cohort study of 146 drugs, 39% of indications granted accelerated approval and 38% granted conditional marketing authorization were rated as having high added therapeutic value. This proportion was lower for cancer indications than for noncancer indications. Meaning The findings suggest that regulators should enforce timely postapproval study completion and review the validity of surrogate measures used to support accelerated approvals. Importance The number of drugs approved through the accelerated approval or conditional marketing authorization pathways has increased with unclear evidence of their therapeutic value. Objectives To assess the therapeutic value of drug indications granted accelerated approval in the US or conditional marketing authorization in the European Union (EU) overall and for cancer indications. Design, Setting, and Participants This cohort study used the public databases of the US Food and Drug Administration and the European Medicines Agency to identify all drugs (initial and supplemental indications) granted accelerated approval in the US or conditional marketing authorization (initial indications only) in the EU between January 1, 2007, and December 31, 2021. Therapeutic value ratings were obtained from national health authorities in Germany, France, and Canada. Main Outcomes and Measures Descriptive statistics were used to assess the proportion of accelerated approvals and conditional marketing authorizations overall and for cancer vs noncancer indications rated as having high added therapeutic value. Results The cohort included 146 drug indications (94 first indications, 52 supplemental indications) in the US and 58 (all first indications) in the EU. Most drugs were approved for cancer (122 [83.6%] in the US; 40 [69.0%] in the EU). Therapeutic value ratings were available for 90 drug indications (61.6%) in the US and 56 (96.6%) in the EU. Overall, 35 drug indications granted accelerated approval (38.9%) and 21 granted conditional marketing authorization (37.5%) had high added therapeutic value in the US and EU, respectively, at the time of approval. The proportions of indications rated as having high added therapeutic value were 36.0% (27 of 75) for cancer vs 53.3% (8 of 15) for noncancer indications in the US and 30.8% (12 of 39) for cancer vs 52.9% (9 of 17) for noncancer indications in the EU. Conclusions and Relevance In this cohort study, among new drug indications approved through the accelerated approval or conditional marketing authorization pathways in the US and Europe from 2007 to 2021, 38.9% and 37.5%, respectively, demonstrated high therapeutic value. A substantially lower proportion of cancer indications than noncancer indications were rated as having high therapeutic value. Policy makers and regulators should increase enforcement of timely postapproval study completion for drugs qualifying for these pathways.
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Affiliation(s)
- Kerstin N. Vokinger
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Institute of Law, University of Zurich, Zurich, Switzerland
- Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Thomas J. Hwang
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Hwang TJ, Kesselheim AS, Dusetzina SB. Reforming Patient Cost Sharing for Cancer Medications in Medicare Part D. JAMA Oncol 2022; 8:1398-1400. [PMID: 35925591 DOI: 10.1001/jamaoncol.2022.2828] [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: 11/14/2022]
Affiliation(s)
- Thomas J Hwang
- Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Urological Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stacie B Dusetzina
- Department of Health Policy andVanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee
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Hwang TJ, Bourgeois FT. New legislation to promote paediatric studies for new cancer medicines. Lancet Oncol 2022; 23:e368-e369. [DOI: 10.1016/s1470-2045(22)00376-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 06/16/2022] [Accepted: 06/17/2022] [Indexed: 10/16/2022]
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18
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Affiliation(s)
- Thomas J Hwang
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston 02115, MA, USA; Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA, USA.
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston 02115, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston 02115, MA, USA
| | - Ariadna Tibau
- Department of Oncology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain; Department of Medicine, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Kerstin N Vokinger
- Cancer Innovation and Regulation Initiative, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA, USA; Institute of Law, University of Zurich, Zurich, Switzerland
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Abstract
Policy Points Only a small minority of new drugs in "nonprotected" classes are widely covered by Part D plans nationwide in the year after US Food and Drug Administration (FDA) approval. Part D plans frequently apply utilization management restrictions such as prior authorizations to newly approved drugs in both protected and nonprotected classes. Drug price influences both formulary inclusion (in nonprotected classes) and coverage restrictions (in both protected and nonprotected classes), while other drug characteristics such as therapeutic benefits are not consistently associated with formulary design. Plans do not seem to favor the minority of drugs that are determined to offer added therapeutic benefit over existing alternatives. CONTEXT Medicare Part D is an outpatient prescription drug benefit for older Americans covering more than 46 million beneficiaries. Except for mandatory coverage for essentially all drugs in six protected classes, plans have substantial flexibility in how they design their formularies: which drugs are covered, which drugs are subject to restrictions, and what factors determine formulary placement. Our objective in this paper was to document the extent to which Part D plans limit coverage of newly approved drugs. METHODS We examined the formulary design of 4,582 Part D plans from 2014 through 2018 and measured (1) the decision to cover newly approved drugs in nonprotected classes, (2) use of utilization management tools in protected and nonprotected classes, and (3) the association between plan design and drug-level characteristics such as 30-day cost, therapeutic benefit, and the US Food and Drug Administration (FDA) expedited regulatory pathway. FINDINGS The FDA approved 109 new drugs predominantly used in outpatient settings between 2013 and 2017. Of these, 75 fell outside of the six protected drug classes. One-fifth of drugs in nonprotected classes (15 out of 75) were covered by more than half of plans during the first year after approval. Coverage was often conditional on utilization management strategies in both protected and nonprotected classes: only seven drugs (6%) were covered without prior authorization requirements in more than half of plans. Higher 30-day drug costs were associated with more widespread coverage in nonprotected classes: drugs that cost less than $150 for a 30-day course were covered by fewer than 20% of plans while those that cost more than $30,000 per 30 days were covered by more than 50% of plans. Plans were also more likely to implement utilization management tools on high-cost drugs in both protected and nonprotected classes. A higher proportion of plans implemented utilization management strategies on covered drugs with first-in-class status than drugs that were not first in class. Other drug characteristics, including availability of added therapeutic benefit and inclusion in FDA expedited regulatory approval, were not consistently associated with plan coverage or formulary restrictions. CONCLUSIONS Newly approved drugs are frequently subject to formulary exclusions and restrictions in Medicare Part D. Ensuring that formulary design in Part D is linked closely to the therapeutic value of newly approved drugs would improve patients' welfare.
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Affiliation(s)
- Huseyin Naci
- London School of Economics and Political Science
| | | | - William B Feldman
- Program on Regulation, Therapeutics, and Law (PORTAL), Brigham and Women's Hospital and Harvard Medical School
| | - Thomas J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Brigham and Women's Hospital and Harvard Medical School
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Brigham and Women's Hospital and Harvard Medical School
| | - Amitabh Chandra
- John F. Kennedy School of Government and Harvard Business School
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Abstract
This economic evaluation study assesses the clinical benefit of novel drugs approved in 2018 and 2019 and examines whether drugs approved with special regulatory designations appear to provide meaningful therapeutic value.
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Affiliation(s)
- Kerstin N. Vokinger
- Institute of Law, University of Zurich, Zurich, Switzerland
- Program on Regulation, Therapeutics, and Law, Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Thomas J. Hwang
- Program on Regulation, Therapeutics, and Law, Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law, Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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21
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Hwang TJ, Vokinger KN. New EU regulation on health technology assessment of cancer medicines. Lancet Oncol 2022; 23:e58. [DOI: 10.1016/s1470-2045(22)00008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 10/19/2022]
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22
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Affiliation(s)
- Thomas J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kerstin N Vokinger
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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23
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Hwang TJ, Qin X, Keating NL, Huskamp HA, Dusetzina SB. Assessment of Out-of-Pocket Costs With Rebate Pass-through for Brand-name Cancer Drugs Under Medicare Part D. JAMA Oncol 2021; 8:155-156. [PMID: 34762097 DOI: 10.1001/jamaoncol.2021.5433] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Thomas J Hwang
- Harvard Medical School, Boston, Massachusetts.,Brigham and Women's Hospital, Boston, Massachusetts
| | - Xuanzi Qin
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nancy L Keating
- Harvard Medical School, Boston, Massachusetts.,Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Stacie B Dusetzina
- Vanderbilt University Medical Center, Nashville, Tennessee.,Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
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24
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Bujosa A, Moltó C, Hwang TJ, Tapia JC, Vokinger KN, Templeton AJ, Gich I, Barnadas A, Amir E, Tibau A. Associations With Definitive Outcomes and Clinical Benefit of Cancer Drugs at the Time of Marketing Approval and in the Postmarketing Period. J Natl Compr Canc Netw 2021; 19:1-9. [PMID: 34560672 DOI: 10.6004/jnccn.2021.7003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/07/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Most anticancer drugs are approved by regulatory agencies based on surrogate measures. This article explores the variables associated with overall survival (OS), quality of life (QoL), and substantial clinical benefit among anticancer drugs at the time of approval and in the postmarketing period. METHODS Anticancer drugs approved by the FDA between January 2006 and December 2015 and with postmarketing follow-up until April 2019 were identified. We evaluated trial-level data supporting approval and any updated OS and/or QoL data. We applied the ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS) and the ASCO Value Framework (ASCO-VF) to initial and follow-up studies. RESULTS We found that 58 drugs were approved for 96 indications based on 96 trials. At registration, approval was based on improved OS in 39 trials (41%) and improved QoL in 16 of 45 indications (36%). Postmarketing data showed an improvement in OS for 28 of 59 trials (47%) and in QoL for 22 of 48 indications (46%). At the time of approval, 25 of 94 (27%) and 26 of 80 scorable trials (33%) met substantial benefit thresholds using the ESMO-MCBS and ASCO-VF, respectively. In the postmarketing period, 37 of 69 (54%) and 35 of 65 (54%) trials met the substantial benefit thresholds. Drugs with companion diagnostics and immune checkpoint inhibitors were associated significantly with substantial clinical benefit. CONCLUSIONS Compared with the time of approval, more anticancer drugs showed improved OS and QoL and met the ESMO-MCBS or ASCO-VF thresholds for substantial benefit over the course of postmarketing time. However, only approximately half of the trials met the threshold for substantial benefit. Companion diagnostic drugs and immunotherapy seemed to be associated with greater clinical benefit.
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Affiliation(s)
- Aida Bujosa
- 1Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Departament de Medicina de la Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Consolación Moltó
- 1Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Departament de Medicina de la Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Thomas J Hwang
- 2Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - José Carlos Tapia
- 1Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Departament de Medicina de la Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Kerstin N Vokinger
- 3Institute for Primary Care and Health Outcomes Research, University of Zürich, Zürich, Switzerland
| | - Arnoud J Templeton
- 4Department of Medical Oncology, St. Claraspital Basel, and Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Ignasi Gich
- 5Department of Epidemiology, Hospital de la Santa Creu i Sant Pau, and Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain; and
| | - Agustí Barnadas
- 1Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Departament de Medicina de la Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Eitan Amir
- 6Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre, and the University of Toronto, Toronto, Ontario, Canada
| | - Ariadna Tibau
- 1Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Departament de Medicina de la Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
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25
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Vokinger KN, Hwang TJ, Daniore P, Lee CC, Tibau A, Grischott T, Rosemann TJ, Kesselheim AS. Analysis of Launch and Postapproval Cancer Drug Pricing, Clinical Benefit, and Policy Implications in the US and Europe. JAMA Oncol 2021; 7:e212026. [PMID: 34196656 DOI: 10.1001/jamaoncol.2021.2026] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The high cost of cancer medicines is a public health challenge. Policy makers in the US and Europe are debating reforms to drug pricing that would cover both the prices of new medicines when entering the market and price increases after they are launched. Objective To assess launch prices, postlaunch price changes, and clinical benefit of cancer drugs in the US compared with 3 European countries (England, Germany, and Switzerland). Design, Setting, and Participants This economic evaluation identified all new drugs that were approved for use in the US, England, Germany, and Switzerland with initial indications for treatment of adult solid tumor and hematologic cancers. Analysis included drugs approved by the US Food and Drug Administration between January 1, 2009, and December 31, 2019, and by the European Medicines Agency and Swissmedic until December 31, 2019. Prices were adjusted for currency and inflation. Clinical benefit of drugs indicated for solid tumors was assessed using the American Society of Clinical Oncology Value Framework and European Society for Medical Oncology Magnitude of Clinical Benefit Scale. Using Spearman rank correlation coefficients, correlations between clinical benefit and launch prices and postlaunch price changes for each country were evaluated. Main Outcomes and Measures Launch prices, postlaunch price changes, and clinical benefit of cancer drugs. Results The cohort included 65 drugs: 47 (72%) approved for solid tumors and 18 (28%) for hematologic cancers. In all countries, the lowest median monthly treatment costs at launch were greater in 2018-2019 vs 2009-2010: $14 580 vs $5790 in the US, $5888 vs $4289 in Germany, $6593 vs $5784 in Switzerland, and $6867 vs $3939 in England. Between 2009 and 2019, 48 of 65 (74%) cancer drugs had price increases in the US that were greater than inflation. Only 1 of 62 (2%) drugs in England, 0 of 60 drugs in Germany, and 7 of 56 drugs (13%) in Switzerland had a median price increase greater than inflation. There were no associations between launch prices or postlaunch price changes and clinical benefit in any assessed country. Conclusions and Relevance During this economic evaluation study period, launch prices of cancer drugs were substantially higher in the US than in the assessed similar high-income European countries, a gap that increased in the years after approval. Cancer drug prices frequently increased faster than inflation in the US but decreased on inflation-adjusted terms in Europe. Price changes were not associated with clinical benefit in any country.
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Affiliation(s)
- Kerstin N Vokinger
- Institute of Law, and Laboratory for Technology, Markets, and Regulation, University of Zurich, Zurich, Switzerland.,Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Thomas J Hwang
- Institute of Law, and Laboratory for Technology, Markets, and Regulation, University of Zurich, Zurich, Switzerland.,Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Paola Daniore
- Institute of Law, and Laboratory for Technology, Markets, and Regulation, University of Zurich, Zurich, Switzerland
| | - ChangWon C Lee
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ariadna Tibau
- Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and.,Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Barcelona, Catalonia, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Thomas Grischott
- Institute of Primary Care, University Hospital Zurich and.,Institute of Primary Care, University Hospital Zurich/University of Zurich, Zurich, Switzerland
| | - Thomas J Rosemann
- Institute of Primary Care, University Hospital Zurich and.,Institute of Primary Care, University Hospital Zurich/University of Zurich, Zurich, Switzerland
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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26
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Affiliation(s)
- Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Thomas J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jerry Avorn
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Abstract
OBJECTIVE To characterize the therapeutic value of new drugs approved by the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) and the association between these ratings and regulatory approval through expedited programs. DESIGN Retrospective cohort study. SETTING New drugs approved by the FDA and EMA between 2007 and 2017, with follow-up through 1 April 2020. DATA SOURCES Therapeutic value was measured using ratings of new drugs by five independent organizations (Prescrire and health authorities of Canada, France, Germany, and Italy). MAIN OUTCOME MEASURES Proportion of new drugs rated as having high therapeutic value; association between high therapeutic value rating and expedited status. RESULTS From 2007 through 2017, the FDA and EMA approved 320 and 268 new drugs, respectively, of which 181 (57%) and 39 (15%) qualified for least one expedited program. Among 267 new drugs with a therapeutic value rating, 84 (31%) were rated as having high therapeutic value by at least one organization. Compared with non-expedited drugs, a greater proportion of expedited drugs were rated as having high therapeutic value among both FDA approvals (45% (69/153) v 13% (15/114); P<0.001) and EMA approvals (67% (18/27) v 27% (65/240); P<0.001). The sensitivity and specificity of expedited program for a drug being independently rated as having high therapeutic value were 82% (95% confidence interval 72% to 90%) and 54% (47% to 62%), respectively, for the FDA, compared with 25.3% (16.4% to 36.0%) and 90.2% (85.0% to 94.1%) for the EMA. CONCLUSIONS Less than a third of new drugs approved by the FDA and EMA over the past decade were rated as having high therapeutic value by at least one of five independent organizations. Although expedited drugs were more likely than non-expedited drugs to be highly rated, most expedited drugs approved by the FDA but not the EMA were rated as having low therapeutic value.
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Affiliation(s)
- Thomas J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Laboratory for Technology, Markets and Regulation, University of Zurich, Zurich, Switzerland
| | - Joseph S Ross
- Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Kerstin N Vokinger
- Laboratory for Technology, Markets and Regulation, University of Zurich, Zurich, Switzerland
- Institute of Law, University of Zurich, Zurich, Switzerland
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Hwang TJ, Orenstein L, DuBois SG, Janeway KA, Bourgeois FT. Pediatric Trials for Cancer Therapies With Targets Potentially Relevant to Pediatric Cancers. J Natl Cancer Inst 2020; 112:224-228. [PMID: 31665394 DOI: 10.1093/jnci/djz207] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 09/30/2019] [Accepted: 10/16/2019] [Indexed: 01/23/2023] Open
Abstract
The Research to Accelerate Cures and Equity (RACE) for Children Act was enacted in 2017 to authorize the US Food and Drug Administration (FDA) to require pediatric studies for new cancer drugs that have a molecular target relevant to the growth or progression of a pediatric cancer. To assess the possible scope of this new policy, we examined all 78 adult cancer drugs approved by the FDA from 2007 to 2017. Only 17 (21.8%) drugs received any pediatric labeling information. Based on the FDA's Pediatric Molecular Target List, we found that the RACE Act could have increased the proportion of cancer drugs potentially subject to pediatric study requirements from 0% to 78.2%. However, the actual effect of the legislation will depend on how often regulators require pediatric trials and on timely completion of such trials.
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Affiliation(s)
- Thomas J Hwang
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Liat Orenstein
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Katherine A Janeway
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Florence T Bourgeois
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
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29
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Affiliation(s)
- Thomas J Hwang
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Adrienne G Randolph
- Boston Children's Hospital, Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts
| | - Florence T Bourgeois
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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30
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Molto C, Hwang TJ, Borrell M, Andres M, Gich I, Barnadas A, Amir E, Kesselheim AS, Tibau A. Clinical benefit and cost of breakthrough cancer drugs approved by the US Food and Drug Administration. Cancer 2020; 126:4390-4399. [DOI: 10.1002/cncr.33095] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 06/17/2020] [Accepted: 06/22/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Consolación Molto
- Oncology Department Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Universitat Autònoma de Barcelona Barcelona Spain
| | - Thomas J. Hwang
- Program on Regulation Therapeutics, and Law Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts
| | - Maria Borrell
- Oncology Department Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Universitat Autònoma de Barcelona Barcelona Spain
| | - Marta Andres
- Oncology Department Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Universitat Autònoma de Barcelona Barcelona Spain
| | - Ignasi Gich
- Department of Epidemiology Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona Barcelona Spain
| | - Agustí Barnadas
- Oncology Department Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Universitat Autònoma de Barcelona Barcelona Spain
| | - Eitan Amir
- Division of Medical Oncology and Hematology Department of Medicine Princess Margaret Cancer Centre and University of Toronto Toronto Ontario Canada
| | - Aaron S. Kesselheim
- Program on Regulation Therapeutics, and Law Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts
| | - Ariadna Tibau
- Oncology Department Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, and Universitat Autònoma de Barcelona Barcelona Spain
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Bujosa Rodríguez A, Molto C, Hwang TJ, Vokinger KN, Tapia JC, Gich Saladich IJ, Templeton AJ, Barnadas A, Amir E, Tibau A. Factors associated with change in the magnitude of clinical benefit of anti-cancer drugs in the post-marketing period. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.7052] [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] Open
Abstract
7052 Background: Initial drug approval is often based on surrogate endpoints. Definitive outcomes like Overall Survival (OS) or Quality of life (QoL) may not be available. Here, we evaluate changes in the magnitude of clinical benefit using the American Society of Clinical Oncology Value Framework (ASCO-VF) and European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS) comparing the time of approval to the most recent available data for cancer drugs approved by the US Food and Drug Administration (FDA) between 2006 and 2015. Methods: We examined data on trials supporting FDA accelerated (AA) and regular (RA) cancer drug approvals between January 2006 and December 2015. We performed a systematic search of Pubmed and ClinicalTrials.gov to identify updated OS and/or QoL data, with follow up through April 2019. For AA drugs we analysed initial and confirmatory trials as follow-up. ASCO-VF and ESMO-MCBS grades were applied for trials at approval and after marketing. We explored variables associated with improved clinical benefit scores using multivariable logistic regression. Results: We identified 102 trials supporting the approval of 59 drugs for 96 solid tumour indications. Of these indications, 22 (23%) were granted AA and 21 (95%) were converted to RA. At time of approval, 38% of trials showed improved OS and 17% improved QoL. Substantial clinical benefit was observed in 26% of initial approval trials using ESMO-MCSB and in 34% using ASCO-VF. After a median post-marketing period of 3.3 years, updated results changed substantial clinical benefit in 20 trials with ESMO-MCBS (19 upgrades, 1 downgrade) and in 23 trials using ASCO-VF (19 upgrades, 4 downgrades). For 25% of trials no updated information was found. In the palliative setting, multivariable analysis showed association between improved ASCO-VF scores and initial approvals based on single-arm trials (OR 9.21, 95%CI 1.36-62.29, P=0.023), drugs with companion diagnostics (OR 4.95, 95%CI 1.01-24.22, P=0.049) and second or later lines (OR 7.80, 95%CI 1.35-45.02, P=0.022) while for ESMO-MCBS, drugs with companion diagnostics (OR 6.86, 95%CI 1.82-25.86, P=0.004) and immunotherapy drugs (OR 6.42, 95%CI 1.27-32.59, P=0.025) were associated with greater clinical benefit. Conclusions: Drugs with companion diagnostic tests, immunotherapy as well as approved based on single-arm trials were associated with increased clinical benefit after marketing approval. For a quarter of trials there were no updated data in the post-marketing period.
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Affiliation(s)
| | | | | | - Kerstin Noëlle Vokinger
- Harvard Medical School, Program on Regulation, Therapeutics, and Law/University of Zurich, Boston, MA
| | | | - Ignasi J. Gich Saladich
- Department of Epidemiology, Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain, Barcelona, Spain
| | - Arnoud J. Templeton
- Department of Medical Oncology, St. Claraspital Basel and Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Agusti Barnadas
- Medical Oncology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institut Sant Pau (IIB Sant Pau) and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eitan Amir
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Ariadna Tibau
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Vokinger KN, Daniore P, Lee CC, Kesselheim AS, Hwang TJ. Launch prices and price developments of cancer drugs in the United States and Europe. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.2006] [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] Open
Abstract
2006 Background: Cancer drug costs are rising in the US and Europe. While drug manufacturers set prices without restriction in the US, European countries have regulations that allow national authorities to directly negotiate drug prices at launch and over time. We analyzed and compared the launch prices and price developments of cancer drugs in the US, Germany, Switzerland and England. Methods: We identified new drugs indicated to treat solid tumors in adults that were FDA-approved between 2009 and 2019 and had also been approved by the EMA and Swissmedic by 31 December 2019. Launch prices and post-launch price changes as of 1 January 2020 were extracted and adjusted to average sales prices for monthly treatment costs in the US and compared to comparable currency-adjusted ex-factory monthly treatment costs in Germany, Switzerland, and England. A cross-sectional analysis was conducted to infer yearly trends in launch prices and post-launch price changes across the countries. Results: The study cohort included 42 drugs for solid tumors, of which 40 (95%) drugs were first approved in the US compared to Germany and England, and 41 (98%) to Switzerland. Average launch prices for monthly treatment costs per patient were $15,178 in the US vs $7,049 in Germany, $7,421 in Switzerland and $8,176 in England, i.e., 215% (interquartile range [IQR] 263%-187%), 205% (IQR 202%-185%) and 186% (IQR 166%-189%) higher in the US compared to Germany, Switzerland and England respectively. Post-launch prices of 36 (86%), 40 (95%), and 38 (90%) drugs decreased over time with total savings of monthly treatment costs for all drugs in the study cohort of $86,744, $44,936, and $1744 in Germany, Switzerland, and England respectively. By contrast, prices of 8 (19%) drugs decreased, while 34 (81%) increased post-launch in the US with total additional expenses of $128,192 for monthly treatment costs. Conclusions: Launch prices for cancer drugs are far higher in the US than in Germany, Switzerland, or England. These price disparities continue to increase substantially after market entry since cancer drug prices, in general, decrease over time in Europe and increase in the US. Spending on cancer drugs could be reduced in the US if it adopted the principles used to more effectively negotiate drug prices in Europe.
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Affiliation(s)
- Kerstin Noëlle Vokinger
- Harvard Medical School, Program on Regulation, Therapeutics, and Law/University of Zurich, Boston, MA
| | | | - ChangWon C Lee
- Harvard Medical School, Program on Regualtion, Therapeutics, and Law, Boston, MA
| | - Aaron S Kesselheim
- Harvard Medical School/Program on Therapeutics, Regulation, and Law, Boston, MA
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Vokinger KN, Daniore P, Hwang TJ, Lee CC, Kesselheim AS. Pivotal trial endpoints and prices of cancer drugs in the US and Europe. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.2077] [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] Open
Abstract
2077 Background: A key clinical outcome for new cancer drugs is improvement in overall survival (OS), defined as time from the date of randomization to the death from any cause. However, many cancer drugs are approved by regulators based on changes to surrogate measures of OS, such as progression-free survival or overall response rate. When surrogate measures are not validated, they can provide misleading information about drug efficacy. We categorized pivotal trial endpoints for recently-approved cancer drugs in the US and Europe as showing improvements in OS vs non-OS surrogates, and evaluated the correlation with drug prices. Methods: We identified new drugs FDA-approved between 2009 and 2018 that were indicated to treat solid and hematologic tumors in adults and that had also been approved by the EMA and Swissmedic by December 2019. Launch prices were extracted and adjusted to average sales prices for monthly treatment costs in the US and compared to currency-adjusted ex-factory monthly treatment costs in Germany, Switzerland, and England. Pivotal clinical trial primary endpoints were collected from the drug labeling and FDA medical reviews for the US, and the EMA public assessment reports for Europe, and categorized as OS in any trial vs. not. Pearson’s correlation tests assessed the association between launch prices and OS vs non-OS endpoints in each country. Results: 54 drugs were approved by the FDA, EMA, and Swissmedic during the study period. In the US, 30 (56%) were approved based on OS by contrast to 35 (65%) in the EMA. The number of cancer drugs approved by the FDA based on OS decreased in the past years. By contrast, the number of approved cancer drugs by the EMA based on OS were stable. There was no association for the US (p = 0.05), Germany (p = 0.13) and England (p = 0.12), while Switzerland revealed an association (p = 0.03) between OS endpoint and price. Conclusions: Reductions in use of OS endpoints as the basis for cancer drug approval in the US is concerning. Drug pricing should be better aligned with the benefit that drugs provide to patients, as measured by clinical trial outcomes such as OS.
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Affiliation(s)
- Kerstin Noëlle Vokinger
- Harvard Medical School, Program on Regulation, Therapeutics, and Law/University of Zurich, Boston, MA
| | | | | | - ChangWon C Lee
- Harvard Medical School, Program on Regualtion, Therapeutics, and Law, Boston, MA
| | - Aaron S Kesselheim
- Harvard Medical School/Program on Therapeutics, Regulation, and Law, Boston, MA
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Affiliation(s)
- Thomas J Hwang
- Harvard Medical School, Boston, Massachusetts
- Laboratory for Technology, Markets, and Regulation, University of Zurich, Zurich, Switzerland
| | - Aaron S Kesselheim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kerstin N Vokinger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Institute of Law and Laboratory for Technology, Markets, and Regulation, University of Zurich, Zurich, Switzerland
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Hwang TJ, Sinha MS, Dave CV, Kesselheim AS. Prescription Opioid Epidemic and Trends in the Clinical Development of New Pain Medications. Mayo Clin Proc 2019; 94:2437-2443. [PMID: 31685265 DOI: 10.1016/j.mayocp.2019.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 01/20/2019] [Revised: 03/24/2019] [Accepted: 05/01/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To evaluate trends in the clinical development of new pain and reformulated pain medications given the ongoing opioid crisis and the public health burden of inadequately controlled pain. METHODS We conducted a retrospective cohort study of new drugs starting clinical testing between January 1, 2000, and December 31, 2015. We searched two comprehensive commercial databases of global research and development activity. The primary outcomes were trends in new and reformulated pain drugs starting clinical testing, proportion of new pain drugs targeting a novel biological pathway, and rates and reasons for discontinuation of development. RESULTS The proportion of new pain drugs entering phase 1 testing (relative to all new drug trials) declined from 2.5% between 2000 and 2002 to 1.7% between 2013 and 2015. No significant changes in the proportion of new pain drugs entering phase 2 or phase 3 trials were observed. Most new pain drugs failed to reach late-stage clinical development, with 52% of pain drugs successfully advancing from phase 1 to phase 2 and 11% advancing from phase 2 to phase 3 trials. The number of reformulated products starting clinical testing increased over the study period and was greater than that for new analgesics in 2012 and every year thereafter. CONCLUSION Pain drug development activity has largely shifted from new therapeutics to reformulated ones. New policies, such as increased funding for basic pain research, may help address the urgent need for new therapies for pain.
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Affiliation(s)
- Thomas J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Michael S Sinha
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA
| | - Chintan V Dave
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
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Neez E, Hwang TJ, Sahoo SA, Naci H. European Medicines Agency's Priority Medicines Scheme at 2 Years: An Evaluation of Clinical Studies Supporting Eligible Drugs. Clin Pharmacol Ther 2019; 107:541-552. [PMID: 31591708 DOI: 10.1002/cpt.1669] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 09/20/2019] [Indexed: 11/10/2022]
Abstract
The Priority Medicines (PRIME) scheme was launched by the European Medicines Agency (EMA) in 2016 to expedite the development and approval of promising products targeting conditions with high unmet medical need. Manufacturers of PRIME drugs receive extensive regulatory advice on their trial designs. Until June 2018, the EMA granted PRIME status to 39 agents, evaluated in 138 studies (102 initiated before and 36 after PRIME eligibility). A third of the studies forming the basis of PRIME designation were randomized controlled trials, and a quarter of the studies were blinded. There was no statistically significant difference between trials initiated before and after PRIME designation in terms of randomized design and use of blinding. However, significantly more efficacy studies included a clinical end point after PRIME designation than before, and significantly fewer included surrogate measures alone. There were no statistically significant differences between the trial designs of PRIME and non-PRIME-designated products.
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Affiliation(s)
- Emilie Neez
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Thomas J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Boston, Massachusetts, USA
| | - Samali Anova Sahoo
- Department of Life Sciences and Management, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
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Abstract
This study characterizes price increases exceeding inflation between 2012 and 2017 for protected-class drugs (antineoplastics, antiretrovirals, antidepressants, antipsychotics, anticonvulsants, and immunosuppressants for transplant patients) that would lead to their exclusion from Medicare Part D coverage based on excessive cost under a 2018 CMS rule intended to facilitate more effective price negotiations.
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Affiliation(s)
| | - Stacie B. Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Josh Feng
- National Bureau of Economic Research, Boston, Massachusetts
| | - Luca Maini
- University of North Carolina at Chapel Hill
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Hwang TJ, Orenstein L, Dubois S, Bourgeois F. Abstract 3365: Pediatric trials and labeling information for newly approved cancer therapies with targets potentially relevant to pediatric cancers. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-3365] [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: 11/16/2022]
Abstract
Abstract
Objective: Few new therapies have been approved for pediatric cancers. In 2017, Congress enacted the Research to Accelerate Cures and Equity (RACE) for Children Act, which requires pediatric studies for adult cancer drugs with a molecular target relevant to a pediatric cancer. The pediatric study requirements will apply to new drugs approved by the FDA beginning in 2020. To inform the implementation of this new law, we evaluated pediatric trials and labeling information available for cancer drugs approved by the FDA.
Methods: We identified new adult cancer drugs approved by the FDA from January 2007 to December 2017 using the Drugs@FDA database. New formulations, drugs approved only for pediatric cancers, and imaging and contrast agents were excluded. For each drug, the potential pediatric relevance of the molecular target was determined using the Pediatric Molecular Target List published by the FDA in August 2018. Information on pediatric clinical trials, enrollment, and start and end dates was obtained from ClinicalTrials.gov as of September 2018. Drug labels were examined for pediatric efficacy, safety, or PK/PD and dosing data. A trial potentially open to children was defined as a study for which any participants < 18 years of age were eligible. We also examined pediatric studies, defined as trials for which the midpoint of the eligible age range was < 21 years.
Results: Among the 78 adult cancer drugs approved between 2007 and 2017, 61 (78%) had targets considered potentially relevant for pediatrics under the RACE Act. At the time of approval, 4 (5%) drugs had any pediatric labeling information. As of September 2018, after a median follow-up of 5.1 years (IQR: 2.9-7.0 y) from the date of first FDA approval, 17 (22%) had any pediatric information, and 8 (10%) had a pediatric indication. For these 17 drugs, the median time from first approval to addition of any pediatric information was 1.5 years (IQR: 1.1-4.6 y). Overall, 362 trials identified on ClinicalTrials.gov (total planned enrollment: 57,827 participants) were potentially open to children for 67 of the 78 drugs (86%), including 57 drugs (93%) with targets on the Pediatric Molecular Target List. For these 67 drugs, the earliest planned end date for trials open to children was a median of 3.3 years after first approval (IQR: 0.2-5.5 y). There were 171 solely pediatric studies for 56 (72%) drugs, and the earliest planned trial end was a median of 4.2 years (IQR: 2.3-5.9 y) after first approval.
Conclusions: Less than a quarter of FDA-approved cancer drugs include information on use in children, and most clinical trials open to children are not expected to be completed until several years after FDA approval. Under the RACE Act, most new drugs for adult cancers are likely to be subject to pediatric study requirements, indicating that timely completion of such trials may substantially increase the pediatric data available for cancer therapies.
Citation Format: Thomas J. Hwang, Liat Orenstein, Steven Dubois, Florence Bourgeois. Pediatric trials and labeling information for newly approved cancer therapies with targets potentially relevant to pediatric cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3365.
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Abstract
6638 Background: Given rising cancer drug costs, Medicare recently proposed to tie some US drug prices to average prices paid by comparable countries. To understand the potential scope of this policy, we assessed differences in cancer drug prices in the US and selected European countries. We also evaluated the correlation between drug prices and their clinical benefit, as measured by two value frameworks: the American Society of Clinical Oncology Value Framework v2 (ASCO VF) and the European Society for Medical Oncology Magnitude of Clinical Benefit Scale v1.1 (ESMO-MCBS). Methods: We identified all new drugs for adult solid and hematologic cancers, approved by the FDA from 2009-2017 and that have also been approved by the EMA by December 31, 2018. US average sales prices (and if not available, wholesale acquisition costs) were extracted as of February 1, 2019, and compared to comparable currency-adjusted ex-factory drug costs in England, France, Germany, and Switzerland. ASCO VF and ESMO-MCBS scores were assessed for pivotal trials supporting solid tumor drugs; in case of multiple trials, we focused on the highest score. Consistent with the developers of the rating scales, “high benefit” was defined as scores of A-B (neo/adjuvant setting) and 4-5 (palliative setting) on the ESMO-MCBS scale and scores≥45 on the ASCO VF. Linear regression models and non-parametric Kruskal-Wallis test and were used to assess the association between drug prices and benefit scores. Results: The study cohort included 63 drugs approved by the FDA and the EMA during the study period. 46 (73%) were approved for solid tumors, and 17 (27%) were approved for hematologic malignancies. Overall, median cancer drug prices in included European countries were 52% (interquartile range: 37-72%) lower than US prices. There was no statistically significant association between monthly treatment cost and ASCO-VF or ESMO-MCBS scores in any country. There was also no association between price differential between US and median European drug prices and either ASCO-VF (P = 0.599) or ESMO-MBCS (P = 0.321) scores. Conclusions: Cancer drug prices in the US were significantly higher than in the compared European countries. Drug prices of cancer drugs were not associated with clinical benefit in the US or in European countries.
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Affiliation(s)
| | | | | | - Thomas J Rosemann
- University of Zurich, Institute of Primary Care, Zurich, Switzerland
| | - Aaron S Kesselheim
- Harvard Medical School/Program on Therapeutics, Regulation, and Law, Boston, MA
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Molto C, Hwang TJ, Andres M, Borrell M, Gich Saladich IJ, Barnadas A, Amir E, Kesselheim AS, Tibau Martorell A. Clinical benefit of breakthrough cancer drugs approved by the United States Food and Drug Administration. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.6513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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
6513 Background: The Breakthrough Therapy program was established in July 2012 to expedite drug development and approval by the FDA. We compared the characteristics of clinical trials leading to FDA approval as well as the magnitude of clinical benefit and value framework scores of breakthrough-designated and non-breakthrough-designated cancer drugs. Methods: We searched the Drugs@FDA website for cancer drug approvals from July 2012 and December 2017. For each indication, we applied the value frameworks and used thresholds of high clinical benefit developed by American Society of Clinical Oncology Value Framework version 2 (ASCO VF v2; scores ≥45), the ASCO Cancer Research Committee (OS gains ≥2.5 months PFS gains ≥3 months), the European Society for Medical Oncology-Magnitude of Clinical Benefit Scale version 1.1 (ESMO-MCBS v1.1; grade of A or B for trials of curative intent and 4 or 5 for those of non-curative intent), and the National Comprehensive Cancer Network (NCCN) Evidence Blocks (scores of 4 and 5). Trial characteristics and value framework scores were compared using Chi squared or Mann Whitney U tests. Results: We identified 106 pivotal trials supporting the approval of 52 individual drugs for 96 indications. Of these indications, 38 (40%) received breakthrough designation. Compared with trials for non-breakthrough drugs (n = 62), trials for breakthrough drugs (n = 44) had smaller sample size (median 373 vs 612, P= .03), were less often randomized (57% vs 86%; P= .001) and more likely to be open-label (84% vs 53%, P= .001). Trials for breakthrough drugs were more likely to demonstrate high clinical benefit using ASCO VF (68% vs 31%, P= .002) and NCCN Evidence Blocks (86% vs 56%, P= .002). A similar proportion of trials supporting breakthrough and non-breakthrough drugs demonstrated high clinical benefit using the ASCO Cancer Research Committee (82% vs 68%, P= .25) and ESMO-MCBS (35% vs 33%; P= .87) frameworks. Conclusions: In patients with advanced solid tumors, cancer drugs approved under breakthrough therapy designation were more likely to demonstrate high clinical benefit as defined by the ASCO VF and NCCN value frameworks. A similar proportion of approved breakthrough and non-breakthrough therapy drugs met the high benefit thresholds using the ASCO Cancer Research Committee and ESMO-MCBS frameworks.
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Affiliation(s)
| | - Thomas J. Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Marta Andres
- Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau, and Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Ignasi J. Gich Saladich
- Department of Epidemiology, Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain, Barcelona, Spain
| | - Agust Barnadas
- Oncology Department, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau, and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eitan Amir
- Princess Margaret Cancer Centre and the University of Toronto, Toronto, ON, Canada
| | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Gyawali B, Hwang TJ, Vokinger KN, Booth CM, Amir E, Tibau A. Patient-Centered Cancer Drug Development: Clinical Trials, Regulatory Approval, and Value Assessment. Am Soc Clin Oncol Educ Book 2019; 39:374-387. [PMID: 31099613 DOI: 10.1200/edbk_242229] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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
Historically, patient experience, including symptomatic toxicities, physical function, and disease-related symptoms during treatment or their perspectives on clinical trials, has played a secondary role in cancer drug development. Regulatory criteria for drug approval require that drugs are safe and effective, and almost all drug approvals have been based only on efficacy endpoints rather than on quality-of-life (QoL) assessments. In contrast to Europe, information regarding the impact of drugs on patients' QoL is rarely included in oncology drug labeling in the United States. Until recently, patient input and preferences have not been incorporated into the design and conduct of clinical trials. In recent years, a more in-depth understanding of cancer biology, as well as regulatory changes focused on expediting cancer drug development and approval, has allowed earlier access to novel therapeutic agents. Understanding the implications of these expedited programs is important for oncologists and patients, given the rapid expansion of these programs. In this article, we provide an overview of the role of QoL in the regulatory drug-approval process, key issues regarding trial participation from the patient perspective, and the implications of key expedited approval programs that are increasingly being used by regulatory bodies for cancer care.
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Affiliation(s)
- Bishal Gyawali
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Thomas J Hwang
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kerstin Noelle Vokinger
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,2 Institute for Primary Care and Health Outcomes Research, University of Zürich, Zürich, Switzerland
| | - Christopher M Booth
- 3 Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,4 Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Eitan Amir
- 5 Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Ariadna Tibau
- 6 Department of Oncology, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Spain
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Hwang TJ, Jain N, Lauffenburger JC, Vokinger KN, Kesselheim AS. Analysis of Proposed Medicare Part B to Part D Shift With Associated Changes in Total Spending and Patient Cost-Sharing for Prescription Drugs. JAMA Intern Med 2019; 179:374-380. [PMID: 30640379 PMCID: PMC6439690 DOI: 10.1001/jamainternmed.2018.6417] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The US Department of Health and Human Services (HHS) has proposed to reform drug pricing in Medicare Part B, which primarily covers physician-administered drugs and biologic agents. One HHS proposal would shift coverage of certain drugs from Medicare Part B to Part D, which is administered by private prescription drug plans. OBJECTIVE To estimate the association of changes of a shift in Medicare Part B to Part D with total drug spending and patient cost-sharing. DESIGN, SETTING, AND PARTICIPANTS Retrospective drug cohort study of the 75 brand-name drugs associated with the highest Part B expenditures among fee-for-service Medicare beneficiaries in 2016. MAIN OUTCOMES AND MEASURES Estimated total Medicare spending in Part B and Part D; annual out-of-pocket costs in Part B and under the standard 2018 Part D benefit; and proportion of drugs in Part D's protected drug classes (immunosuppressants for prophylaxis of organ transplant rejection, antidepressants, antipsychotics, anticonvulsants, antiretrovirals, and antineoplastics). RESULTS At 2018 prices, total Medicare Part B spending for the 75 brand-name drugs with the highest Part B expenditures was estimated to be $21.6 billion annually. Under the proposed policy, total Part D drug spending for these drugs was estimated to range between $17.6 billion and $20.1 billion after rebates, corresponding to a 6.9% to 18.3% decrease in drug spending in Part D compared with Part B. Of the 75 drugs studied, 33 (44.0%) drugs, accounting for $9.5 billion (43.9%) in Part B spending, were in protected Part D classes where plans must cover essentially all drugs. For 67 drugs with available information, the prices for 65 (97.0%) were a median of 45.8% to 59.7% lower in comparator high-income countries than Part B drug prices. Median patient cost-sharing in Part B for all 75 brand-name drugs was $4683 (interquartile range [IQR], $1069-$9282) per year. Shifting Part B drugs to the 2018 standard Part D benefit was projected to decrease out-of-pocket costs by a median of $860 (IQR, -$3884 to $496) among Medicare beneficiaries without Medicaid or Part B supplemental insurance (Medigap). For beneficiaries who would qualify for the low-income subsidy program in Part D, cost-sharing would be lower in Part D than in Part B for all drugs. For beneficiaries with Medigap insurance, estimated Part D out-of-pocket costs exceeded average Medigap premium costs by a median of $1460 for those with Part D coverage and by a median of $1952 for those without Part D coverage. CONCLUSIONS AND RELEVANCE Although the HHS proposal to shift certain drugs from Medicare Part B to Part D may reduce total drug spending, it may increase out-of-pocket costs for some Medicare beneficiaries, including those with Medicare supplement insurance. The Department of Health and Human Services should ensure that the proposed reforms benefit both patients and payers.
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Affiliation(s)
- Thomas J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nina Jain
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Julie C Lauffenburger
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kerstin N Vokinger
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Faculty of Medicine, University of Zürich and University Hospital Zürich, Zürich, Switzerland
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Hwang TJ, Bourgeois FT, Franklin JM, Kesselheim AS. Impact Of The Priority Review Voucher Program On Drug Development For Rare Pediatric Diseases. Health Aff (Millwood) 2019; 38:313-319. [DOI: 10.1377/hlthaff.2018.05330] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Thomas J. Hwang
- Thomas J. Hwang is a researcher in the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, both in Boston, Massachusetts
| | - Florence T. Bourgeois
- Florence T. Bourgeois is an associate professor of pediatrics at Harvard Medical School and director of the Pediatric Therapeutics and Regulatory Science Initiative in the Computational Health Informatics Program at Boston Children’s Hospital
| | - Jessica M. Franklin
- Jessica M. Franklin is an assistant professor of medicine in the Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital and Harvard Medical School
| | - Aaron S. Kesselheim
- Aaron S. Kesselheim is an associate professor of medicine at Harvard Medical School and director of the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School
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Hwang TJ, Orenstein L, Kesselheim AS, Bourgeois FT. Completion Rate and Reporting of Mandatory Pediatric Postmarketing Studies Under the US Pediatric Research Equity Act. JAMA Pediatr 2019; 173:68-74. [PMID: 30452498 PMCID: PMC6583440 DOI: 10.1001/jamapediatrics.2018.3416] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [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] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Many medicines prescribed to children have not been studied or formally approved for pediatric use. The Pediatric Research Equity Act of 2003 authorized the US Food and Drug Administration (FDA) to require pediatric clinical studies. OBJECTIVE To evaluate the characteristics, completion rate, and transparency of study design and results for mandatory pediatric postmarketing studies required under the Pediatric Research Equity Act. DESIGN AND SETTING A retrospective cohort study was conducted of pediatric postmarketing studies required for new drugs and new indications approved by the FDA between January 1, 2007, and December 31, 2014, with follow-up through December 1, 2017. Information on the status, design, and results of pediatric studies was obtained from publicly available FDA databases and ClinicalTrials.gov, direct communication with the FDA, and searches of MEDLINE, EMBASE, and Web of Science for peer-reviewed publications. MAIN OUTCOMES AND MEASURES Characteristics and transparency of pediatric studies, results reporting (in ClinicalTrials.gov, peer-reviewed literature, or FDA documents), and availability of pediatric information in drug labels. Rates and times to study completion were evaluated using Cox proportional hazards regression models. RESULTS Between 2007 and 2014, the FDA approved 114 new drugs and new indications for already approved drugs that were subject to Pediatric Research Equity Act requirements. These drugs were associated with 222 required pediatric postmarketing clinical studies. Overall, 75 pediatric studies (33.8%) were completed as of December 1, 2017. The rates of completion were significantly lower for efficacy studies (38 of 132 [28.8%]) compared with pharmacokinetic studies (19 of 34 [55.9%]; adjusted hazard ratio, 0.31; 95% CI, 0.12-0.82). Information on randomization, blinding, comparator, end point, and study size could not be identified for 74 studies (33.3%), and no reason for discontinuation was provided for 29 of the 42 discontinued studies (69.0%). Among the completed studies, the results were reported for 57 (76.0%). At the time of approval, 18 of 114 drug approvals (15.8%) had any pediatric efficacy, safety, or dosing information in their labels. After a median duration of follow-up of 6.8 years (interquartile range, 4.7-9.1 years), 47 of 114 of drug labels (41.2%) had any pediatric information. CONCLUSIONS AND RELEVANCE Only 33.8% of mandatory pediatric postmarketing studies have been completed after a median follow-up of 6.8 years, and most drug labels do not include information important for pediatric use. To improve evidence-based prescribing of medicines to children, more timely completion of pediatric drug studies is needed.
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Affiliation(s)
- Thomas J. Hwang
- Pediatric Therapeutics and Regulatory Science Initiative, Boston Children’s Hospital, Boston, Massachusetts,Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Liat Orenstein
- Pediatric Therapeutics and Regulatory Science Initiative, Boston Children’s Hospital, Boston, Massachusetts,Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts
| | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Florence T. Bourgeois
- Pediatric Therapeutics and Regulatory Science Initiative, Boston Children’s Hospital, Boston, Massachusetts,Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Hwang TJ, Gyawali B. Association between progression‐free survival and patients’ quality of life in cancer clinical trials. Int J Cancer 2018; 144:1746-1751. [DOI: 10.1002/ijc.31957] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 10/07/2018] [Accepted: 10/22/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Thomas J. Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women's Hospital Boston MA
- Harvard Medical School Boston MA
| | - Bishal Gyawali
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women's Hospital Boston MA
- Harvard Medical School Boston MA
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Hwang TJ, Franklin JM, Chen CT, Lauffenburger JC, Gyawali B, Kesselheim AS, Darrow JJ. Efficacy, Safety, and Regulatory Approval of Food and Drug Administration–Designated Breakthrough and Nonbreakthrough Cancer Medicines. J Clin Oncol 2018; 36:1805-1812. [DOI: 10.1200/jco.2017.77.1592] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose The breakthrough therapy program was established in 2012 to expedite the development and review of new medicines. We evaluated the times to approval, efficacy, and safety of breakthrough-designated versus non–breakthrough-designated cancer drugs approved by the US Food and Drug Administration (FDA). Methods We studied all new cancer drugs approved by the FDA between January 2012 and December 2017. Regulatory and therapeutic characteristics (time to FDA approval, pivotal trial efficacy end point, novelty of mechanism of action) were compared between breakthrough-designated and non–breakthrough-designated cancer drugs. Random-effects meta-regression was used to assess the association between breakthrough therapy designation and hazard ratios for progression-free survival (PFS), response rates (RRs) for solid tumors, serious adverse events, and deaths not attributed to disease progression. Results Between 2012 and 2017, the FDA approved 58 new cancer drugs, 25 (43%) of which received breakthrough therapy designation. The median time to first FDA approval was 5.2 years for breakthrough-designated drugs versus 7.1 years for non–breakthrough-designated drugs (difference, 1.9 years; P = .01). There were no statistically significant differences between breakthrough-designated and non–breakthrough-designated drugs in median PFS gains (8.6 v 4.0 months; P = .11), hazard ratios for PFS (0.43 v 0.51; P = .28), or RRs for solid tumors (37% v 39%; P = .74). Breakthrough therapy–designated drugs were not more likely to act via a novel mechanism of action (36% v 39%; P = 1.00). Rates of deaths (6% v 4%; P = .99) and serious adverse events (38% v 36%; P = 0.93) were also similar in breakthrough-designated and non–breakthrough-designated drugs. Conclusion Breakthrough-designated cancer drugs were associated with faster times to approval, but there was no evidence that these drugs provide improvements in safety or novelty; nor was there a statistically significant efficacy advantage when compared with non–breakthrough-designated drugs.
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Affiliation(s)
- Thomas J. Hwang
- Thomas J. Hwang, Jessica M. Franklin, Julie C. Lauffenburger, Bishal Gyawali, Aaron S. Kesselheim, and Jonathan J. Darrow, Brigham and Women’s Hospital and Harvard Medical School; Christopher T. Chen, Dana-Farber Cancer Institute, Boston, MA; and Bishal Gyawali, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Jessica M. Franklin
- Thomas J. Hwang, Jessica M. Franklin, Julie C. Lauffenburger, Bishal Gyawali, Aaron S. Kesselheim, and Jonathan J. Darrow, Brigham and Women’s Hospital and Harvard Medical School; Christopher T. Chen, Dana-Farber Cancer Institute, Boston, MA; and Bishal Gyawali, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Christopher T. Chen
- Thomas J. Hwang, Jessica M. Franklin, Julie C. Lauffenburger, Bishal Gyawali, Aaron S. Kesselheim, and Jonathan J. Darrow, Brigham and Women’s Hospital and Harvard Medical School; Christopher T. Chen, Dana-Farber Cancer Institute, Boston, MA; and Bishal Gyawali, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Julie C. Lauffenburger
- Thomas J. Hwang, Jessica M. Franklin, Julie C. Lauffenburger, Bishal Gyawali, Aaron S. Kesselheim, and Jonathan J. Darrow, Brigham and Women’s Hospital and Harvard Medical School; Christopher T. Chen, Dana-Farber Cancer Institute, Boston, MA; and Bishal Gyawali, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Bishal Gyawali
- Thomas J. Hwang, Jessica M. Franklin, Julie C. Lauffenburger, Bishal Gyawali, Aaron S. Kesselheim, and Jonathan J. Darrow, Brigham and Women’s Hospital and Harvard Medical School; Christopher T. Chen, Dana-Farber Cancer Institute, Boston, MA; and Bishal Gyawali, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Aaron S. Kesselheim
- Thomas J. Hwang, Jessica M. Franklin, Julie C. Lauffenburger, Bishal Gyawali, Aaron S. Kesselheim, and Jonathan J. Darrow, Brigham and Women’s Hospital and Harvard Medical School; Christopher T. Chen, Dana-Farber Cancer Institute, Boston, MA; and Bishal Gyawali, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Jonathan J. Darrow
- Thomas J. Hwang, Jessica M. Franklin, Julie C. Lauffenburger, Bishal Gyawali, Aaron S. Kesselheim, and Jonathan J. Darrow, Brigham and Women’s Hospital and Harvard Medical School; Christopher T. Chen, Dana-Farber Cancer Institute, Boston, MA; and Bishal Gyawali, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Hwang TJ, Kesselheim AS, Gyawali B. Affordability and Price Increases of New Cancer Drugs in Clinical Guidelines, 2007-2016. JNCI Cancer Spectr 2018; 2:pky016. [PMID: 31360849 PMCID: PMC6649801 DOI: 10.1093/jncics/pky016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 03/20/2018] [Accepted: 03/29/2018] [Indexed: 11/17/2022] Open
Abstract
In response to the rising cost of cancer drugs, the National Comprehensive Cancer Network (NCCN) recently developed a value framework, known as “Evidence Blocks,” to grade the efficacy, safety, evidence quality, evidence consistency, and affordability of treatments included in its clinical guidelines. The value scores were available for 55 of the 69 new cancer drugs approved by the US Food and Drug Administration from 2007 to 2016. Overall, the treatment costs for 95% of new cancer medicines in NCCN clinical guidelines were scored as “very expensive” or “expensive”. In multivariable ordered logistic regression models, there was no association between the affordability of new cancer drugs and efficacy and safety data available in clinical guidelines. Most guideline-recommended drugs were subject to annual list price increases exceeding inflation.
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Affiliation(s)
- Thomas J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Bishal Gyawali
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA.,Institute of Cancer Policy, King's College London, London, UK
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Pregelj L, Hwang TJ, Hine DC, Siegel EB, Barnard RT, Darrow JJ, Kesselheim AS. Precision Medicines Have Faster Approvals Based On Fewer And Smaller Trials Than Other Medicines. Health Aff (Millwood) 2018; 37:724-731. [DOI: 10.1377/hlthaff.2017.1580] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lisette Pregelj
- Lisette Pregelj is a postdoctoral research fellow in the Business School, University of Queensland, in Brisbane, Australia
| | - Thomas J. Hwang
- Thomas J. Hwang is a researcher in the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, in Boston, Massachusetts
| | - Damian C. Hine
- Damian C. Hine is an associate professor of innovation and director of the Asia Pacific Enterprise Initiative in the Business Economics and Law Faculty, University of Queensland
| | - Evan B. Siegel
- Evan B. Siegel is CEO of Ground Zero Pharmaceuticals, Inc., in Irvine, California, and an adjunct professor in the School of Chemistry and Molecular Biosciences, University of Queensland
| | - Ross T. Barnard
- Ross T. Barnard is a professor of biotechnology and director of the Biotechnology Program, School of Chemistry and Molecular Biosciences, and ARC Training Centre for Biopharmaceutical Innovation, University of Queensland
| | - Jonathan J. Darrow
- Jonathan J. Darrow is a faculty member in the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School
| | - Aaron S. Kesselheim
- Aaron S. Kesselheim is an associate professor of medicine at Harvard Medical School and director of the Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School
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