Oncology Products Research Articles

Accelerated Approval for Cancer Drugs in the United States and the Clinical Evidence Required for Conversion to Regular Approval

PurposeOncology products often leverage accelerated approval program to seek earlier launches in the United States. Little is known about how the Food and Drug Administration (FDA) has been balancing evidence and access, and the factors that may characterize post-accelerated approval requirements. The present study aimed to obtain insights on how accelerated approval is determined by investigating the balance between pre-accelerated approval and supplemental clinical evidence required for future regular approval.MethodsThe product properties, pre-accelerated approval evidence, rationale, post-accelerated approval requirements, and prior regulatory designations for oncology accelerated approvals were summarized based on public databases. Regression analyses were performed to investigate factors that may have been associated with the post-accelerated approval requirements.ResultsHundred fifty-seven accelerated approvals were granted between 1992 and 2021. An increase in the number of pre-accelerated approval trials by one trial resulted in a 20% decrease in supplemental trials. The endpoint for the post-accelerated approval trial tended to be more robust when products were indicated for common cancers, while less robust when products had been used to treat fewer subjects, when products were indicated for respiratory and skin cancers, or when less malignant cancers were targeted.ConclusionsAccelerated approvals for oncology products were often based on the response rate of a noncomparative trial. However, considerable variation was observed in the post-accelerated approval requirements. Factors such as the quality and quantity of pre-accelerated approval evidence, regulatory designations, and operational feasibility may have been considered when determining the accelerated approvals and post-accelerated approval requirements.

HPR106 Pricing of New Oncology Products in the US and Key European Markets

HPR106 Pricing of New Oncology Products in the US and Key European Markets

Trends and landscape of clinical outcome assessment use to support oncology product approvals.

e23186 Background: The regulatory landscape in oncology trials has evolved with growing emphasis on patient-focused drug development. Further to tumor and survival outcomes, measuring how patients feel and function via clinical outcome assessments (COAs) provides critical information on symptoms and treatment burden and may help to inform risk/benefit evaluation for new treatments. This study aimed to examine trends in the use of COAs to support efficacy or safety in oncology product labeling. Methods: Product labeling information was obtained from PROLABELS (Mapi Research Trust), a database containing COA-related data sourced from the efficacy or safety sections of FDA Product labels and EMA SmPC where at least one COA is mentioned. Oncology product labels were screened based on therapeutic indications and study information. The clinical study details published in the label/SPC between 1990 and 2022 were used for further analysis. Results: A total of 180 EMA and FDA approved drugs and devices for oncology indications where COAs were mentioned in the product label were identified. 288 studies with COAs supported these drug approvals. These studies were in 52 different indications, with most in multiple myeloma (31), followed by non-small-cell lung cancer (24), prostate cancer (22), and breast cancer (22). Of the COAs that were used, 47% were patient-reported outcomes, 18% were clinician-reported outcomes, 30% were composites, and 5% were unspecified. The number of studies conducted with COAs supporting a product label increased over time, with 3x more studies in the past 10 years (189 from 2013-2022) compared to the previous 10 years (60 from 2003-2012). For studies listing specific COA names, 63 unique COAs were used. Excluding response criteria assessments, the most common COAs were the EORTC-QLQ-C30 (57 studies), EORTC-QLQ-LC13 (18 studies), and EQ-5D-3L (17 studies). The two indications with the largest variety of COAs used were prostate cancer (10 unique COAs) and non-small-cell lung cancer (9 unique COAs). Conclusions: In line with regulators highlighting the utility of COAs in evaluating clinical benefit, results show an increase in studies using COAs to support efficacy and safety in oncology product approvals. With COAs providing critical information on symptoms, side effect impact, and quality of life, including this information on labels may help patients and providers make more informed healthcare decisions, and for market differentiation.

Optimizing patient (pt) care through pt-focused resources to prevent and manage hand-foot skin reaction (HFSR).

e24144 Background: Research has shown that pts and caregivers (non-HCPs) seek medical and disease-related information more than once a month, and this has accelerated due to the COVID-19 pandemic. However, they find it difficult to understand the information they receive and thus, can be misinformed. By understanding the use of fair-balanced medical information (MI) resources by non-HCPs, pharmaceutical companies can develop scientifically accurate yet pt-friendly resources to meet their needs (Goettner, 2022; Rai, 2022). Upon reviewing the unsolicited oncology inquiries received by our MI department, approximately 25% of inquiries were from non-HCPs seeking information. Over the past 3 years, non-HCPs have submitted almost 10,000 inquiries regarding our oncology products, in which 191 inquiries were specifically regarding HFSR and regorafenib and sorafenib. Historically, our MI department responded to non-HCP inquiries by sharing the product label information. However, we identified an unmet need for trustworthy, comprehensive, and accurate pt resources in plain language. Methods: A full literature review was performed, and the relevant data were summarized in plain language for pts. Both HCPs and pts participated in developing the global pt resource on the prevention and management of HFSR for regorafenib and sorafenib. The seven-page interactive brochure was written in 4th to 6th grade reading level which included images and graphics to enhance the understanding of data, easy navigation to the content of interest, and glossary to define key terms. Furthermore, these materials were translated for pts who participated in the regorafenib and sorafenib Patient Support Program in Brazil to further educate and support pts who have started therapy. Results: As of June 2023, the global pt medical resource has been deployed 28 times in Brazil, delivering key information to non-HCPs on their disease and treatment while emphasizing its practical utility and addressing health literacy challenges. We collected feedback from pts who utilized the translated material, and they described it to be “informative” and “helpful” since it empowered them to effectively navigate and address HFSR-associated discomforts during their treatment journey. The feedback has also been utilized to further enhance the resource’s feasibility. Conclusions: The pt feedback on the brochures showcases the value of pt-focused approach in oncology and the positive impact of collective efforts across all stakeholders including pts, pharmaceutical MI departments and pt programs. Furthermore, it demonstrates how MI can bridge the gap between pt insights and clinical knowledge by addressing their needs and providing practical and trustworthy tools. Not only does this initiative enhance pt understanding but also empowers pts to take a more active role in their treatment and fosters shared-decision making.

EE52 The Burden of Intravenous vs Subcutaneous Oncological Products Application in Honduras

EE52 The Burden of Intravenous vs Subcutaneous Oncological Products Application in Honduras

Discrepancies in therapeutic indications for the same oncology drugs among FDA, EMA, and Brazilian agency.

e23035 Background: Divergent marketing approvals for oncology drugs among prominent agencies can prompt questions, especially when they are grounded in the same evidence. The aim of this study was to evaluate and compare the assessment and approval processes for novel products and indications by the FDA, EMA, and the Brazilian Health Regulatory Agency (ANVISA). Methods: Therapeutic indications for FDA-approved anticancer drugs from January 2019 to December 2023 were identified. Data, including approval dates, details on authorization procedures and evidence presented, were extracted from the databases of the FDA, EMA, and ANVISA. Only approvals for non-hematologic solid tumors were considered. All data were publicly available, and ethical approval was not required. No patient involvement occurred in this study. Results: Between 2019 and 2023, the FDA granted approval for 154 therapeutic indications for marketing authorization, resulting from 148 pivotal trials. The predominant cancer types during this period were non-small cell lung cancer (31 approvals [20.1%]). Most trials were in phase III (66.8%) and randomized (68.1%). Additionally, 41 (26.6%) received accelerated approvals, with 6 subsequently obtaining regular approvals. Among the therapies, 66 trials (42.8%) involved active comparators, while 53 (34.4%) and 35 (22.7%) were single-arm and placebo-controlled trials, respectively. Approximately half (74 [48%]) of the therapies were approved for metastatic first-line treatment, 54 (35%) for second-line treatment, and the rest for neoadjuvant and/or adjuvant treatment. Regarding endpoint characteristics supporting approval, the most prevalent was a combination of objective response rate (ORR) + duration of response (DoR) (38 [24.6%]), followed by progression-free survival (PFS) + overall survival (OS) (31 [20.1%]). When comparing the 154 FDA-approved indications, 50 (32.4%) were not approved by EMA, and 60 (38.9%) were not approved by ANVISA. Furthermore, in 33 cases (21.4%), there were disparities in clinical indications between the FDA and EMA, primarily related to the target population specification, with 10 cases (6.4%) attributed to programmed death ligand-1 (PD-L1) expression. Notably, in these instances, the FDA approved the drug regardless of PD-L1 expression, while the EMA required a percentage of cells with PD-L1 expression. In all these cases, ANVISA aligned with the FDA's assessment. Conclusions: Significant clinical disparities were identified in the outcomes of the approval process for oncology products among the FDA, EMA, and ANVISA. Additional efforts are needed to standardize decision-making across regulatory systems.

Dose optimization and exposure-response analyses to support optimal dose of ABBV-400, a novel C-met–targeting antibody drug conjugate, in patients with metastatic colorectal cancer (mCRC).

3030 Background: ABBV-400 is an antibody drug conjugate (ADC) consisting of a c-Met targeting antibody conjugated to a potent inhibitor of topoisomerase 1 (Top1) payload. ABBV-400 has shown encouraging activity and demonstrated tolerability of dosages up to 3.0 mg/kg Q3W as monotherapy in patients with advanced solid tumors in an ongoing phase 1 study (1). Dosage optimization is a critical aspect of oncology drug development and FDA Project Optimus has focused on reformulating the dosage selection paradigm for oncology products. The phase 1 study included a dose optimization phase in mCRC patients in which 3 doses were evaluated (1.6, 2.4 and 3.0 mg/kg Q3W) to determine the optimal dose for further development. Herein, exposure-response analyses are reported to determine optimal monotherapy dose in mCRC patients. Methods: Data across a range of doses (1.6 – 6.0 mg/kg Q3W) from the phase 1 study (NCT05029882) were used. Population pharmacokinetics (PK) and exposure-response (E-R) analyses were conducted to characterize ABBV-400 conjugate and unconjugated payload PK and the relationship between exposures and efficacy (objective response rate [ORR]) and safety (Grade (Gr) ≥ 3 neutropenia, anemia and thrombocytopenia) endpoints. Relative dose intensity (RDI) analysis was performed. Results: ABBV-400 conjugate and payload PK were adequately described by a combined multi-analyte population PK model with first order kinetics (n=204). ABBV-400 conjugate average concentration was a better predictor of response and showed that higher exposure correlated with higher probability of response (n=122 CRC, ORR, p < 0.05) and safety events (n=204, Gr ≥ 3 neutropenia, anemia and thrombocytopenia, p < 0.001). Dose intensity analyses showed greater number of dose reductions for 3 mg/kg Q3W with effective (actual) dose received of 2.6 mg/kg Q3W in mCRC patients. E-R analyses for safety and efficacy and dose intensity analyses in mCRC 3L+ patients indicate that both 2.4 and 3.0 mg/kg doses provided meaningful efficacy (ORR); while the 3.0 mg/kg dose may provide higher response rates, the 2.4 mg/kg Q3W dosing regimen provides an optimal balance of safety and efficacy compared to 3.0 mg/kg Q3W. Conclusions: Population PK, E-R for efficacy and safety and RDI analyses and totality of clinical data supported the selection of 2.4 mg/kg Q3W as optimal ABBV-400 monotherapy dose for further study in mCRC patients. 1. Sharma M, et al. ASCO 2023. Abstract 3015. Clinical trial information: NCT05029882 .

Regulatory considerations in the design, development and quality of monoclonal antibodies and related products for the diagnosis and treatment of cancer.

Over 160 therapeutic and in vivo diagnostic monoclonal antibodies have been approved by the US FDA since the first monoclonal antibody, muromonab, was approved in 1986. Approximately 42% of these approvals were for the treatment or in vivo diagnosis of oncology indications, although some products are no longer marketed. This review will look at the history of monoclonal antibody development and approvals, discuss current antibody-based modalities, regulatory considerations for engineering approaches, critical quality attributes for different modalities, immunogenicity of mAbs across oncology products, and the future directions for development of therapeutic and diagnostic monoclonal antibody-based products.

The impact of willingness-to-pay threshold on price reduction recommendations for oncology drugs: a review of assessments conducted by the Canadian Agency for Drugs and Technologies in Health.

Since late 2020, the Canadian Agency of Drugs and Technologies in Health (CADTH) has been using a threshold of $50,000(CAD)per quality-adjusted life-year (QALY) for both oncology and non-oncology drugs. When used for oncology products, this threshold is hypothesized to have a higher impact on the time to access these drugs in Canada. We studied the impact of price reductions on time to engagement and negotiation with the pan-Canadian Pharmaceutical Alliance for oncology drugs reviewed by CADTH between January 2020 and December 2022. Overall, 103 assessments reported data on price reductions recommended by CADTH to meet the cost-effectiveness threshold for reimbursement. Of these assessments, 57% (59/103) recommendations included a price reduction of greater than 70% off the list price. Eight percent (8/103) were not cost-effective even at a 100% price reduction. Of the 47 assessments that had a clear benefit, in 21 (45%) CADTH recommended a price reduction of at least 70%. The median time to price negotiation (not including time to engagement) for assessments that received at least 70% vs >70% price reduction was 2.6vs 4.8months. This study showed that there is a divergence between drug sponsor's incremental cost-effectiveness ratio (ICER) and CADTH revised ICER leading to a price reduction to meet the $50,000/QALY threshold. For the submissions with clear clinical benefit the median length of engagement (2.5 vs 3.3months) and median length of negotiation (3.1 vs 3.6months) were slightly shorter compared with the submissions where uncertainties were noted in the clinical benefit according to CADTH. This study shows that using a $50,000 per QALY threshold for oncology products potentially impacts timely access to life saving medications.

Pharmacokinetic models for first-in-human dose selection of immune-activating products in oncology

Pharmacokinetic (PK) models are increasingly submitted to the FDA to support first-in-human (FIH) dose selection of immune-oncology products. To examine whether a simple PK modeling (SPM) using clearance for scaling was acceptable for dose estimation, FIH(SPM) doses were computed and compared to doses that were safely administered to patients. We concluded that the SPM approach is acceptable in FIH dose estimation, but the variables should be carefully selected for CD3 constructs. For CD3 constructs, use of 60 kg BWh, a clearance exponent of 0.75, and a targeted plasma concentration based on relevant and/or sensitive activity assays was an acceptable approach for FIH dose selection; use of 0.85 as the scaling factor is questionable at this time as it resulted in a FIH dose that was too close to the AHD for one product (7%). Immune activating mAbs were not sensitive to changes in the clearance exponent (0.75–0.85) or body weight (60–70 kg). For PD-1/PD-L1 mAbs, using products’ in vitro EC50 in the model resulted in suboptimal FIH doses and clinical data of closely related products informed FIH dose selection. PK models submitted by sponsors were diverse in methods, assumptions, and variables, and the resulting FIH doses were not always optimal.

Safety of the Herbal Medicine SH003 in Patients With Solid Cancer: A Multi-Center, Single-Arm, Open-Label, Dose-Escalation Phase I Study.

SH003, a novel herbal medicine comprising Huang-Qi, Dang-Gui, and Gua-Lou-Gen, has historical roots in traditional medicine with reported anticancer properties. The need to explore safe and effective treatments in oncology underlines the importance of this study. This phase I trial, conducted at Ajou University Hospital and Gachon University Gil Medical Center in Korea, adopted a single-arm, open-label, dose-escalation design. It aimed to evaluate the safety of escalated doses of SH003 in patients with various solid cancers, focusing on determining its maximum tolerated dose. Participants with confirmed solid cancers, unresponsive to standard treatments, were enrolled. The dosage of SH003 was escalated from 4800 to 9600 mg per day, using a 3 + 3 design. Safety was assessed based on the Common Terminology Criteria for Adverse Events ver. 5.0. The study established that the maximum tolerated dose of SH003 is 9600 mg/day. Most adverse events were mild, primarily including dizziness and nausea, indicating the tolerability of SH003 at this dosage. SH003 demonstrates safety and promises as an anticancer treatment at doses up to 9600 mg/day. This research supports further investigation into its efficacy for cancer therapy, emphasizing the significance of natural products in oncology, particularly concerning patient safety and tolerance.

HPR31 Is the UK’S Ilap Process Delivering Its Intended Benefits? a Review of Access to Orbis Designated Oncology Products within the UK

HPR31 Is the UK’S Ilap Process Delivering Its Intended Benefits? a Review of Access to Orbis Designated Oncology Products within the UK

Rare oncology therapeutics: review of clinical pharmacology package of drug approvals (2019-2023) by US FDA, best practices and recommendations.

There are many challenges with rare diseases drug development and rare oncology indications are not different. To understand the regulatory landscape as it relates to application of clinical pharmacology principles in rare oncology product development, we reviewed publicly available information of 39 approvals by US FDA between January 2019 and March 2023. The objective was to understand the expected clinical pharmacology studies and knowledge base in such approvals. Model informed drug development (MIDD) applications were also reviewed, as such approaches are expected to play a critical role in filling clinical pharmacology gaps in rare oncology, where number of clinical trials and size of these trials will perhaps continue to be small. The findings highlighted how clinical pharmacology contributed to the evidence of effectiveness, dose optimization and elucidation of intrinsic and extrinsic factors affecting drug's behavior. Clinical pharmacology studies were often integrated with modeling in many of the NDAs/BLAs. Of the post marketing requirements (PMR) received, 18% were for dose optimization, 49% for DDI, 8% for QTc, 49% for specific population, and 5% for food effect. Two post marketing commitments (PMC) were issued for immunogenicity of the 11 biologics submissions. 15% (6 of 39) of the submissions used maximum tolerated dose (MTD) to advance their molecule into Phase 2 studies. Of them 3 approvals received PMR for dose optimization. 3 + 3 was the most prevalent Phase 1 design with use in 74% of the New Drug Applications (NDA)/Biologic License Applications (BLA) reviewed. Rest used innovative approaches such as BLRM, BOIN or mTPi, with BLRM being the most common. Seamless clinical pharmacology and MIDD approaches are paramount for rare oncology drug development.

A Pragmatic Approach to Navigating FDA Guidance for Therapeutic Product Development in Malignant Hematological Disease

Background: Owing to the unique therapeutic characteristics and diverse etiology of underlying disease, navigating available regulatory guidance can be a challenge for newcomers to therapeutic research and development (R&D). Further, classes of drugs and biologic products are regulated separately by the U.S. Food and Drug Administration (FDA) centers CBER and CDER, respectively. Methods: We provide background on the FDA guidance structure herein and further examine publicly registered clincialtrials.gov data to provide an overview of development status by phases and novel modality (i.e., CAR-T) in context of the regulatory landscape. Results: Therapeutic products developed for malignant hematological disease can be regulated by either CDER or CBER depending on the type of drugs, ranging from small molecules to macromolecules, including cellular and gene therapies. In 2019, CDER of Hematology and Oncology Products (OHOP) has been reorganized and renamed the Office of Oncologic Diseases (OOD). The new OOD structure consists of six divisions including Division of Hematologic Malignancies 1 (DHM1) and Division of Hematologic Malignancies 2 (DHM2) for the review of hematologic malignancies. In 2022, CBER of Office of Tissues and Advanced Therapies (OTAT) was transformed into the Office of Therapeutic Products (OTP) to address the exponential growth in cell and gene therapies. PDUFA VII expanded the INTERACT meeting program to include both centers, a major change that may drive early phase development collaboration. A review on the current state of hematologic malignancies clinical trials in USA shows that, of 301 hematologic malignancies related trails in USA registered to ClinicalTrials.gov (Fig. 1), 4 are in early phase 1(exploratory phase), 126 in phase 1, 120 in phase 2, 18 in phase 3, and 1 in phase 4. Most of the trials are still in early phases 1 or 2. Among the 301 registered clinical trials, 21 of clinical trials (Fig. 2) are CAR-T related, and 10 of the trials are gene modified cell products related. Conclusions: Compared with traditional treatment on malignant hematological disease, immunotherapy is the upcoming trend in cancer treatment. Chimeric antigen receptor (CAR) therapy is at the forefront of cellular/adoptive immunotherapy for cancer treatment due to its sustained remission and better quality of life. Much research and clinical trials have been undertaken in recent years which led to several successful outcomes in CAR therapy. Despite tremendous progress, CAR-T are still faced with many challenges, including evolving regulatory framework along the road. We summarize the regulatory landscape to assist therapy developers to align with FDA expectations.

Development of a Fast and Quantitative FLT3-TKD Mutation Prototype Using Lab in a Cartridge™ Technology

Introduction Acute myeloid leukemia (AML) is a heterogenous hematologic malignancy characterized by the rapid proliferation of abnormal myeloid cells in the bone marrow and blood. Fast and reliable diagnostic tests are imperative for the advancement of targeted therapies in the treatment of AML. FLT3 (FMS-like tyrosine kinase3) is one of the most frequent genetic alterations in AML and is present in approximately one-third of newly diagnosed patients. Considering the targeted therapies, such as midostaurin and gilteritinib available for FLT3 mutated AML, accurate and timely diagnosis of FLT3 mutations is vital for guiding treatment decisions and improving patient outcomes. The current diagnostic methods to detect FLT3-TKD mutations require a series of complex steps including blood sample handling, plate-based PCR, enzyme digestion and capillary electrophoresis or sequencing which can be time-consuming and labor-intensive. We have developed and evaluated the performance of a FLT3-TKD prototype using Cepheid's automated cartridge technology that demonstrates significantly less hands-on time and faster turnaround. Objectives We have developed a novel, fast and simplified qPCR-based FLT3-TKD prototype using Cepheid's GeneXpert® automated platform for detecting 14 mutations, including 7 mutations present in codon D835 and another 7 mutations in I836. The FLT3-TKD prototype is an easy-to-use sample in/result out assay with minimal hands-on time and time to results in less than 3 hours, and without the use of restriction enzymes or capillary electrophoresis. This assay is designed for quantitative detection of FLT3-TKD mutated DNA (D835 & I836) using ABL1 as an endogenous control in peripheral blood (PB) of AML patients. This assay utilizes the special chemistry, special design primers, and an optimized wild-type (WT) blocker to specifically detect SNPs and indels. With the combination of WT blocker and unique design of special design primers we were able to selectively amplify the rare mutations in the presence of abundant closely related WT fragments. Results Using this prototype, we were able to detect and quantify all 14 mutations (7 of D835 and 7 of I836) with an estimated LoD of AR 0.02 (Ratio of TKD mutation copies/ABL copies in PB background) in PB samples spiked-in with positive templates. ABL1 serves as a reference gene to normalize the WT DNA present in the background. Plasmid DNA with individual mutations was generated and spiked into the PB to assess the dynamic range of the test. We observed good alignment of dCt-AR (deltaCt-Allelic ratio) regression curve among all 14 mutations within the dynamic range tested (0.02-0.33). With pre-defined thresholds, our assay specificity has been above 95% among 20 screened EDTA donor blood samples. To further assess the sensitivity of this prototype, we also evaluated a CRISPR-CAS engineered cell line for the D835 G>A mutation. Using this cell line, we were successful in detecting the mutation down to AR of 0.008 in a PB background. For quantification analysis we prepared a linear panel of the most prevalent mutation D835(G>T) in the PB background and were able to quantify all mutations within the range of AR 0.008-to 0.83. Conclusions Here we describe the development and evaluation of an automated cartridge-based FLT3-TKD prototype that can detect 14 FLT3-TKD mutations. The cartridge prototype is preloaded with sample processing reagents and qPCR reagents with a turn-around time of less than 3 hours including offboard peripheral blood processing. When tested with contrived samples generated with either plasmid DNA or engineered cell lines spiked into blood, all 14 tested FLT3-TKD mutations were detected within a dynamic range of 0.02 to 0.33 AR with a specificity of > 95% in healthy donor whole blood background. With optimized primer and WT blocker design this prototype showed high sensitivity & specificity. We tested a broader dynamic range for the most prevalent mutation, D835 G>T, and were able to detect from AR of 0.008 to 0.83 AR. Additionally, since the prototype uses the GeneXpert® platform and current universal lysate sample prep procedure, the sample can potentially be used across all Cepheid Hematology Oncology products. This prototype significantly reduces the hands-on time with future potential to provide clinicians with fast and accurate detection of FLT3 mutation status that can aid prognostic evaluation and treatment in AML patients.

Use of Single-Arm Trials in FDA Approvals of Treatments in Relapsed or Refractory B-Cell Lymphoma

Background: Single-arm trials are commonly used to evaluate therapies targeting life-threatening or rare diseases (e.g., late-stage cancers that are relapsed or refractory to prior interventions). A number of oncology products supported by single-arm trials have been approved by the United States Food and Drug Administration (FDA). The draft guidance issued by the FDA on 24 March 2023 recommended key considerations for trial design and analysis when a single-arm trial is considered appropriate to support accelerated approval. The objective of this study was to assess how often anticancer drugs approved by the FDA were based on single-arm trials in a typical relapsed or refractory indication and to evaluate the quality of trial design and data leading to approvals. Methods: We reviewed past approvals between 2006 and 2023 listed on the FDA website, focusing on the indication of relapsed or refractory B-cell lymphoma. Of 11 approvals identified, eight were supported by single-arm trials and three were based on randomized controlled trials. Approvals based on single-arm trials were further investigated, and each trial was analyzed for the following criteria as recommended by the draft FDA guidance: 1) if the endpoint was based on response rate assessed using appropriate criteria; 2) if the sample size was sufficient to provide robust estimates of efficacy and safety profile; and 3) if the magnitude and duration of response were adequate. Results: Among the eight approvals based on single-arm trials, one was approved in 2017, one in 2018, and two each in 2020, 2021, and 2023. Three were chimeric antigen receptor T-cell (CAR-T) therapies and were granted regular approval; the other five were non-CAR-T therapies which were granted accelerated approval. The primary endpoints adopted by all the trials were overall response rates (defined as complete and partial responders) and duration of response determined by an independent review committee. The magnitude of overall response rates reported by most trials ranged from 48% to 72% (with more than 50% of them with a complete response); one trial reported an overall response rate of 29% with complete response rate of 13%. A minimal median follow-up of six months after response was achieved in all trials. The estimated median duration of response varied from 10.3 to 21.7 months, with three trials reporting medians not reached. Based on the trial description, the analysis population was pre-specified for the evaluation of efficacy, ranging from 68 to 192 participants. Conclusion: Submissions based on single-arm trials for oncology therapies in the relapsed and refractory setting tended to be well accepted by FDA for accelerated and regular approval when the key criteria of trial design and data quality were adequately met.

Streamlining the Detection of FLT3 Internal Tandem Duplication (FLT3-ITD) Using the Cepheid Genexpert® Automated System

Objectives: The development of targeted therapies for Acute Myeloid leukemia (AML) demands fast and reliable diagnostic tests. Specifically, FMS-like tyrosine kinase 3 (FLT3-ITD), comprising nearly 25% of all AML cases, is the most common targetable mutation in AML. Current diagnosis of FLT3-ITD by PCR involves numerous laborious steps, with bench-top steps involving time-consuming whole blood processing, DNA isolation, plate-based PCR and subsequent fragment analysis by capillary electrophoresis. Consequently this adds significant overhead, time-consuming personnel training, and numerous steps which could lead to errors, all of which increase the resource burden and time to result. The objective of this study was to create an automated FLT3-ITD diagnostic prototype that is faster, requires less hands-on time that can detect all clinically relevant ITD lengths. Methods: We have developed a simplified FLT3-ITD prototype assay using the Cepheid GeneXpert® automated platform for FLT3-ITD detection. The prototype substantially streamlines the process, using a less than 30 minutes off-board time to prepare a universal blood lysate that is compatible with all Cepheid Hematology Oncology products. Once the sample is loaded into the cartridge and inserted into the instrument, the cartridge performs automated DNA isolation, purification, and qPCR. A Taqman-based probe for ABL is utilized in the qPCR step as a PCR control to ensure that the blood processing and qPCR was successful and avoid wasted downstream steps. Quantitative fragment analysis can easily be performed on the PCR product using capillary electrophoresis (CE) for precise allelic ratio (AR) callout. Additionally, the PCR product is compatible be run on a bioanalyzer or standard Agarose Gel-Electrophoresis if available. Results: The developed automated FLT3-ITD diagnostic prototype demonstrated significant improvements over the existing methodologies with substantially reduced time to result and simplicity in use. To assess the sensitivity of this prototype, we used MV4-11 cancer cells harboring a 30 bp ITD and CRISPR-CAS engineered human cell lines with 3 bp, 21 bp, and 75 bp FLT3 ITD insertions, comprising the most commonly detected ITD lengths spiked into EDTA blood as a test material. For these ITD's, we observed sensitivity and linearity down to 0.01-0.02 by CE for the ITDs tested. Importantly, the prototype detected all lengths of ITD mutations with inserts from 3bp to 300 bp using plasmid test materials. Conclusion: We have successfully developed a novel FLT3-ITD diagnostic prototype that has several major advantages over existing methodologies. The prototype significantly reduces the time and hands-on effort required for analysis, streamlining the diagnostic process for same day results. The larger sample volume used allows improved sensitivity to ensure accurate detection, even at low allelic frequencies. Additionally, the prototype requires fewer reagents in that sample prep and qPCR are performed in a single cartridge and run hands-free. Downstream analysis of amplified products can be easily performed and validated using capillary electrophoresis, bioanalyzer, or gel electrophoresis. Finally, because this prototype uses the same universal blood lysate as other AML tests, it has the potential to improve future diagnostic therapeutic interventions in the clinic.

Precision medicine in regulatory decision making: Biomarkers used for patient selection in European Public Assessment Reports from 2018 to 2020.

Biomarkers can guide precision medicine in clinical trials and practice. They can increase clinical trials' efficiency through selection of study populations more likely to benefit from treatment, thus increasing statistical power and reducing sample size requirements or study duration. We performed a narrative synthesis to explore biomarker utilization for patient selection to guide precision medicine trials in marketing authorization dossiers of centrally approved medicines in Europe between 2018 and 2020 and analyzed in-depth those that eventually included biomarkers in the medicines' indications. From 119 eligible products, 26 included a biomarker in the indication, of which most were oncology products (n = 15). Included biomarkers were often known from literature or from previously approved products in the European Union or the United States. Additionally, 52 dossiers mentioned one or more biomarkers for patient selection in their clinical efficacy and safety information. Although these were not always included in the medicines' indication, they were often implicitly embedded in condition definitions adopted from clinical guidelines or practice. In 15 out of the 26 medicines with a biomarker-guided indication, only biomarker-positive populations were included in the main clinical studies supporting the marketing authorization. These studies were mostly randomized controlled trials or single-arm trials; only two products were studied for multiple indications in an innovative basket trial. Definitions of biomarkers could be subject of debate and needed adaptation after post hoc analyses requested by the assessment committee in four cases, stressing the importance of thorough justification of these definitions to include the right population for an optimal benefit-risk balance, enabling precise medicine.

Health Technology Reassessment: Addressing Uncertainty in Economic Evaluations of Oncology Drugs at Time of Reimbursement Using Long-Term Clinical Trial Data.

The evidence base to support reimbursement decision making for oncology drugs is often based on short-term follow-up trial data, and attempts to address this uncertainty are not typically undertaken once a reimbursement decision is made. To address this gap, we sought to conduct a reassessment of an oncology drug (pembrolizumab) for patients with advanced melanoma which was approved based on interim data with a median 7.9 months of follow-up and for which long-term data have since been published. We developed a three-health-state partitioned survival model based on the phase 3 KEYNOTE-006 clinical trial data using patient-level data reconstruction techniques based on an interim analysis. We used a standard survival analysis and parametric curve fitting techniques to extrapolate beyond the trial follow-up time, and the model structure and inputs were derived from the literature. Five-year long-term follow-up data from the trial were then used to re-evaluate the cost-effectiveness of pembrolizumab versus ipilimumab for treatment of advanced melanoma. The best fitting parametric curves and corresponding survival extrapolations for reconstructed interim data and long-term data reconstructed from KEYNOTE-006 were different. An analysis of the 5 year long-term follow-up data generated a base case incremental cost-effectiveness ratio (ICER) that was 28% higher than the ICER based on interim trial data. Our findings suggest that there may be a trade-off between certainty and the ICER. Conducting health technology re-assessments of certain oncology products on the basis of longer-term data availability, especially for those health technology adoption decisions made based on immature clinical data, may be of value to decision makers.

Using real-world evidence (RWE) in regulatory decision making: A study of 6 oncology approvals with RWE included in the product label.

6611 Background: The 21st Century Cures Act in 2016 enhanced the FDA’s ability to include the use of real-world data (RWD) and consideration of RWE in the development and approval of new medical products. Currently, limited assessments of the use of RWE in FDA approved oncology product reviews exist in the literature. This study was conducted to determine how RWE was used in FDA decisions for oncology drug approvals between 2015 and 2022. Methods: A systematic review of FDA submission documents and product labels available on the FDA website from 2020 to 2022, in addition to an exhaustive manual search of grey literature and the results of a targeted literature search from 2015 to 2019 were used to identify RWE that were included in FDA submission documents and in approved product labels. Results: In total, 124 oncology product evaluations were reviewed in the 2020 to 2022 literature search. Twenty-nine oncology product NDAs and BLAs included RWE to support efficacy, safety, or indication, of which the majority (n=26) ultimately had RWE accepted as evidence by the FDA for the submission. In these cases, RWE was used to add context (n=16), to support the indication or safety (n=7), to provide substantial basis for indication or safety (n=2), as a statistical comparison (n=2), or for informational purposes only (n=1). Feedback from the FDA reviewers for reasons RWE studies were not considered during product approval reviews included methodology issues, sample size concerns, and omission of patient level data. Ultimately, across the 2015 to 2019 targeted literature review and the 2020 to 2022 FDA submission document review, 6 oncology product labels incorporated RWE: palbociclib, uridine triacetate, lutetium Lu 177 DOTATATE, bevacizumab-adcd, naxitamab-gqgk, and decitabine/cedazuridine. RWE was used to support the initial indication for the majority of products (n=5) and also supported label expansion (n=1). RWE was incorporated in the product label postmarketing experience section (n=3), the clinical studies section (n=2), and the warnings/precautions section (n=1). Conclusions: These results suggest that RWE has become an important part of regulatory decision-making for oncology drug approval. Twenty-six of 29 RWE studies were accepted as evidence for the submission. For the 6 oncology products that include RWE in the product label, RWE was most frequently used to support the initial indication and was included in the postmarketing experience section. These examples show consistent use of RWE since the approval of the 21st Century Cares Act and provide evidence of a promising new direction with the creation of the FDA guideline/program for RWE.