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Idris MY, Fitzsimmons WE, Pemu P. Quantifying Clinical Trial Diversity in Pivotal Registration Trials of FDA Novel Drug Approvals. Ther Innov Regul Sci 2024; 58:175-183. [PMID: 37872439 DOI: 10.1007/s43441-023-00583-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/21/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Health care inequity includes the lack of adequate representation of various populations in clinical trials. Government, academic and industry organizations have highlighted these issues and committed to actions to improve. In order to assess the current status and future success of these initiatives a quantitative objective measure to assess the state of clinical trial diversity is needed. METHODS FDA review documents for all novel drug approvals from January 2022 through March 2023 were assessed using a scorecard that considers diversity across different demographic subgroups including age (≥ 65 years old), sex (female), race (Black and Asian) and ethnicity (Hispanic/Latino). The scorecard assigns each drug a letter grade, between A and F, for each subgroup (and overall) based on (1) the percent of each sub-population included in the trials and grades relative to the percent of the US population per the 2020 Census, (2) the number of participants from each subpopulation that received the novel new drug in the trials, (3) the incidence or prevalence of the disease/condition in each of the sub-populations. RESULTS The FDA approved 49 novel new drugs for 50 indications (one drug was simultaneously approved for two indications). There was good representation of elderly and females with only two drugs receiving a D grade in either of these sub-populations. In contrast, Black (5 F grades) and Hispanic (4 F grades) representation was often inadequate. There were 10 drugs (20.0%) where there were no Black participants receiving the novel new drug and 16 (32.0%) approvals where there were 1-9 Black participants receiving the novel drug. In the Hispanic/Latino population there were 4 (8.0%) approvals with no Hispanic participants receiving the novel drug and 15 (30.0%) approvals where there were 1-9 Hispanic participants receiving the drug. CONCLUSIONS This scorecard provides an objective quantitative approach to assess the current state of diversity in clinical trials supporting new drug approvals. Substantial improvement in racial and ethnic representation is needed. Meaningful change will require actions and cooperation among all stakeholders to address this multifaceted issue and will take commitment, perseverance, and appropriate incentives.
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Affiliation(s)
- Muhammed Y Idris
- Department of Medicine and Clinical Research Center, Morehouse School of Medicine, Atlanta, GA, USA
- CARER Group, Catalyzing Access to Research Equity in Representation, San Diego, CA, USA
| | - William E Fitzsimmons
- Colleges of Pharmacy and Medicine, University of Illinois at Chicago, 833 S. Wood St., Chicago, IL, 60607, USA.
- CARER Group, Catalyzing Access to Research Equity in Representation, San Diego, CA, USA.
| | - Priscilla Pemu
- Department of Medicine and Clinical Research Center, Morehouse School of Medicine, Atlanta, GA, USA
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Luo X, Du X, Huang L, Guo Q, Tan R, Zhou Y, Li Z, Xue X, Li T, Le K, Qian F, Chow SC, Yang Y. The price, efficacy, and safety of within-class targeted anticancer medicines between domestic and imported drugs in China: a comparative analysis. Lancet Reg Health West Pac 2022; 32:100670. [PMID: 36785854 PMCID: PMC9918802 DOI: 10.1016/j.lanwpc.2022.100670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/30/2022] [Accepted: 12/08/2022] [Indexed: 12/29/2022]
Abstract
Background Affordability to novel anticancer drugs has become a major health issue in China. It is encouraging to note that China initiated its drug regulatory reform and national price negotiation policies since 2015. As a growing number of domestic within-class targeted anticancer drugs are approved in China, it is expected that this may reduce the price of novel anticancer drugs and improve the affordability of anticancer drugs. This study aimed to evaluate the price, efficacy, and safety of the within-class anticancer drugs between domestic and imported drugs approved in China from 2010 to 2022. Methods The domestic and imported within-class targeted drugs for solid cancers approved in China between 2010 and 2022 were extracted. We classified it as a class of anticancer drugs based on the same indication and similar biological mechanism. The published literature derived from pivotal clinical trials of these domestic and imported drugs was identified based on the review report and the latest labels issued by the China National Medical Products Administration. We evaluated the monthly treatment price at launch and the latest (2022), primary efficacy endpoint and safety between domestic and imported anticancer drugs. Meta-analyses were further employed to evaluate the efficacy and safety of the domestic and imported anticancer drugs, including pooled hazard ratios (HR) for progression-free survival (PFS), overall survival (OS), objective response rates (ORR) for solid cancers, and relative risk for serious adverse events (SAE) and Grade ≥3 adverse events (AEs). Findings In our cohort study, 12 within-class anticancer drugs with 7 cancer diseases were analyzed, including 18 domestic (21 indications; 21 pivotal trials) and 18 imported (21 indications; 27 pivotal trials) novel anticancer drugs, respectively. The median monthly treatment price of domestic and imported drugs from the years of launch to 2022 had significantly decreased by 71% and 62%, respectively. Moreover, the median monthly treatment price of domestic targeted anticancer drugs on the market at launch ($3786 vs. $5393, P = 0.007) and the latest ($1222 vs. $2077, P = 0.011) was significantly lower than that of imported drugs. No significant differences in median PFS gains (9.0 vs. 11.0 months; P = 0.24), OS gains (9.3 vs 10.6 months; P = 0.66), and ORR (57% vs 62%, P = 0.77) of targeted anticancer drugs in their pivotal trials were observed between the domestic and imported drugs. Additionally, there was no significant difference between domestic and imported drugs in the incidence of SAE (23% vs. 24%; P = 0.41) and Grade ≥3 AEs (59% vs. 57%; P = 0.45). These findings were also further confirmed in the meta-analyses for primary efficacy endpoints and safety outcomes. Interpretation The prices of both domestic and imported anticancer drugs significantly decreased after market entry mainly due to the role of national price negotiations. The median monthly treatment price of domestic within-class targeted anticancer drugs was significantly lower than that of imported drugs. Furthermore, the efficacy and safety of domestic anticancer drugs were comparable to that of imported drugs. This evidence implicated that the development of within-class anticancer drugs with national price negotiations in China significantly improved the affordability for patients. Funding This study was supported by postdoctoral fellowship from Tsinghua-Peking Joint Centers for Life Sciences (CLS).
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Affiliation(s)
- Xingxian Luo
- School of Pharmaceutical Sciences, Tsinghua University, Beijing, China
- Key Laboratory of Innovative Drug Research and Evaluation, National Medical Products Administration, Beijing, China
- Tsinghua-Peking Center for Life Sciences, Beijing, China
| | - Xin Du
- School of Pharmaceutical Sciences, Tsinghua University, Beijing, China
- Key Laboratory of Innovative Drug Research and Evaluation, National Medical Products Administration, Beijing, China
| | - Lin Huang
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Qixiang Guo
- School of Pharmaceutical Sciences, Tsinghua University, Beijing, China
- Key Laboratory of Innovative Drug Research and Evaluation, National Medical Products Administration, Beijing, China
| | - Ruijie Tan
- School of Pharmacy, Fudan University, Shanghai, China
| | - Yue Zhou
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Zhuangqi Li
- School of Pharmaceutical Sciences, Tsinghua University, Beijing, China
- Key Laboratory of Innovative Drug Research and Evaluation, National Medical Products Administration, Beijing, China
| | - Xuecai Xue
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Taifeng Li
- Department of Pharmacy, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Kaidi Le
- Department of Pharmacy, Cancer Institute & Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Feng Qian
- School of Pharmaceutical Sciences, Tsinghua University, Beijing, China
| | - Shein-Chung Chow
- Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
- Corresponding author.
| | - Yue Yang
- School of Pharmaceutical Sciences, Tsinghua University, Beijing, China
- Key Laboratory of Innovative Drug Research and Evaluation, National Medical Products Administration, Beijing, China
- Corresponding author. School of Pharmaceutical Sciences, Tsinghua University, Beijing, China.
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Smith Z, Botto E, Getz K. Quantifying Diversity and Representation in Pivotal Trials Leading to Marketing Authorization in Europe. Ther Innov Regul Sci 2022; 56:795-804. [PMID: 35680722 DOI: 10.1007/s43441-022-00421-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/19/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Following up on a study from 2019, Tufts CSDD collected and analyzed data on demographic disparities and representation in pivotal trials supporting the marketing authorization of novel drugs and biologics approved in Europe between 2007 and 2019. METHODS Data were collected from products' EPAR, the EUDRACT database, and other publicly available sources, and compared to indication-specific demographic data or a census estimate. In total, data were collected on 446 drugs and 943 pivotal trials. RESULTS Results indicated that gender demographic data were only reported for 80.7% of pivotal trials, and that racial and ethnicity demographic data were reported less often (64.1% and 29.9% of pivotal trials, respectively). Results also indicated that non-white racial identities were under-represented by more than 20% in nearly half or more of pivotal trials. CONCLUSIONS Guidelines encouraging the reporting of patient demographic data are insufficient and availability of the data is problematic. The available data suggest that under-representation in pivotal trials is widespread.
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Herpers M, Dintsios CM. Methodological problems in the method used by IQWiG within early benefit assessment of new pharmaceuticals in Germany. Eur J Health Econ 2019; 20:45-57. [PMID: 29696458 DOI: 10.1007/s10198-018-0981-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 04/16/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND The decision matrix applied by the Institute for Quality and Efficiency in Health Care (IQWiG) for the quantification of added benefit within the early benefit assessment of new pharmaceuticals in Germany with its nine fields is quite complex and could be simplified. Furthermore, the method used by IQWiG is subject to manifold criticism: (1) it is implicitly weighting endpoints differently in its assessments favoring overall survival and, thereby, drug interventions in fatal diseases, (2) it is assuming that two pivotal trials are available when assessing the dossiers submitted by the pharmaceutical manufacturers, leading to far-reaching implications with respect to the quantification of added benefit, and, (3) it is basing the evaluation primarily on dichotomous endpoints and consequently leading to an information loss of usable evidence. OBJECTIVE To investigate if criticism is justified and to propose methodological adaptations. METHODS Analysis of the available dossiers up to the end of 2016 using statistical tests and multinomial logistic regression and simulations. RESULTS It was shown that due to power losses, the method does not ensure that results are statistically valid and outcomes of the early benefit assessment may be compromised, though evidence on favoring overall survival remains unclear. Modifications, however, of the IQWiG method are possible to address the identified problems. CONCLUSION By converging with the approach of approval authorities for confirmatory endpoints, the decision matrix could be simplified and the analysis method could be improved, to put the results on a more valid statistical basis.
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Affiliation(s)
| | - Charalabos-Markos Dintsios
- Institute for Health Services Research and Health Economics, Medical Faculty, Heinrich-Heine University Düsseldorf, Gebäude 12.49, Moorenstraße 5, 40225, Düsseldorf, Germany.
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Golish SR. Pivotal trials of orthopedic surgical devices in the United States: predominance of two-arm non-inferiority designs. Trials 2017; 18:348. [PMID: 28738891 PMCID: PMC5525262 DOI: 10.1186/s13063-017-2032-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 05/31/2017] [Indexed: 11/30/2022] Open
Abstract
Background The United States Food and Drug Administration (FDA) reviews class III orthopedic devices submitted for premarket approval with pivotal clinical trials. The purpose of this study was to determine the types of orthopedic devices reviewed, the design of their pivotal clinical trials, and the subjective factors affecting the interpretation of clinical trial data. Methods Meetings of the FDA Orthopaedic and Rehabilitation Devices Panel were identified from 2000–2016. Meeting materials were collected from FDA electronic archives and notes were made regarding the device-type and subsequent approval and recall, the design of pivotal clinical trials, and issues of trial interpretation debated during panel deliberations. Results The panel was convened on 29 separate occasions over the course of 35 days to deliberate 38 distinct topics. Of these, 23 topics included clinical data submitted for approval of a device, and two topics were excluded. Of the 23 devices, five were biologic, three were hip arthroplasty, three were disc arthroplasty, two were viscosupplementation, three were interspinous process devices, and seven were other devices. Of the 23 pivotal trials, 20 (87.0%) were randomized controlled trials (RCTs), consisting of 13 (65.0%) non-inferiority trials and 7 (35.0%) superiority trials, and all RCTs were two-arm trials. At panel, the most commonly debated issues were related to the design and interpretation of non-inferiority trials. Conclusions A broad array of device types is reviewed by the FDA. The predominance of two-arm non-inferiority trials as pivotal studies indicates that the nuances of their design and interpretation are commercially important.
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Affiliation(s)
- S Raymond Golish
- Department of Surgery, Jupiter Medical Center, 1210 S. Old Dixie Hwy, Jupiter, Palm Beach, FL, 33458, USA.
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Ghosn M, Ibrahim T, Assi T, El Rassy E, Kourie HR, Kattan J. Dilemma of first line regimens in metastatic pancreatic adenocarcinoma. World J Gastroenterol 2016; 22:10124-10130. [PMID: 28028360 PMCID: PMC5155171 DOI: 10.3748/wjg.v22.i46.10124] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 09/23/2016] [Accepted: 10/31/2016] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is one of the deadliest cancers, ranking fourth among cancer-related deaths. Despite all the major molecular advances and treatment breakthroughs, mainly targeted therapies, the cornerstone treatment of metastatic pancreatic cancer (mPC) remains cytotoxic chemotherapy. In 2016, more than 40 years after the introduction of gemcitabine in the management of mPC, the best choice for first-line treatment has not yet been fully elucidated. Two main strategies have been adopted to enhance treatment efficacy. The first strategy is based on combining non-cross resistant drugs, while the second option includes the development of newer generations of chemotherapy. More recently, two new regimens, FOLFIRINOX and gemcitabine/nab-paclitaxel (GNP), have both been shown to improve overall survival in comparison with gemcitabine alone, at the cost of increased toxicity. Therefore, the best choice for first line therapy is a matter of debate. For some authors, FOLFIRINOX should be the first choice in patients with an Eastern Cooperative Oncology Group score (0-1) given its lower hazard ratio. However, others do not share this opinion. In this paper, we review the main comparison points between FOLFIRINOX and GNP. We analyze the two pivotal trials to determine the similarities and differences in study design. In addition, we compare the toxicity profile of the two regimens as well as the impact on quality of life. Finally, we present studies revealing real life experiences and review the advantages and disadvantages of possible second-line therapies including their cost effectiveness.
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