By: Robert Califf, M.D.
The U.S. Food and Drug Administration’s drug approval process—the final stage of drug development—is the fastest in the world, which means Americans typically have first access to new drugs when they are demonstrated to be safe and effective. But even as our agency has transformed the approval process—approving 51 new molecular entities and biological products last year alone, including more new orphan drugs for rare diseases than in any previous year—drug discovery and development is not keeping pace for many diseases.
In many cases, what’s holding back progress is a lack of understanding of the biology of disease, as we outline in a new report we are releasing today that compares diseases where there is a robust pipeline of new therapies with certain diseases that have few known treatments or cures.
For instance, when it comes to cancer, HIV/AIDS, and other viral infections, decades of intense research have given the scientific community and the FDA critical insight on how to develop effective treatments. Ongoing research has led to the discovery of biomarkers, which are characteristics that are objectively measured and evaluated as indicators of normal biological processes, pathogenic processes or response to a therapeutic intervention. Some types of biomarkers give insight on the genetic and metabolic characteristics that alter patients’ responsiveness to particular drugs, and others give insight into whether drugs in development are likely to work. This deep knowledge has resulted in important breakthroughs, rapid drug development and speedy FDA approvals.
While additional research is needed for all diseases, the paucity of reliable biomarkers in some diseases highlights the critical need for more research if we are to make much needed progress. Examples include Alzheimer’s and many rare diseases, as we outline in the new report released today. In these cases, the scientific community still lacks basic information about what causes these diseases and how they can be slowed and treated. When research does not offer answers to important scientific questions, cures cannot be developed. And when viable cures are not in the pipeline, focusing on regulation will not improve the situation, since FDA can only approve therapies with evidence for safety and effectiveness.
Once key scientific questions are answered, we can use a variety of tools to reduce the length and cost of initial clinical trials for drug approval for these disease areas, and we can provide guidance to industry including advice on how to develop additional reliable biomarkers. For instance, we’ve improved the efficiency and predictability of clinical drug development by developing tools such as biomarkers and surrogate endpoints—markers of drug effect that do not directly represent an improvement in how a patient feels or functions, but are reasonably likely to predict a clinical benefit. Thus, for example, lowering a patient’s blood pressure can be used as a surrogate for the clinical benefit of preventing heart attack. Such tools have modernized clinical trial designs and may dramatically reduce the length and cost of drug development. They also can help target drugs to specific patients who can benefit most, thereby limiting the number and size of clinical trials.
These are exciting times as we experience simultaneous revolutions in the biological and information sciences. We expect that the astounding increase in knowledge of biological systems enabled by whole genome sequencing, cloud computing, social media, and wearable devices to monitor physiology will create challenges to traditional thinking. And we are confident that this increased knowledge will continue to expand the pipeline of new therapies. This report emphasizes that we are prepared to deal with the product of this scientific investment by using regulatory paradigms that match the state of the science and by supporting dissemination of the latest knowledge applied to drug development.
In this paradigm that takes advantage of the depth of this new biomedical information, it will be critical to continue to support ongoing clinical trials and observational studies to ensure sufficient knowledge of the benefit-risk profile of therapies as they evolve into broad use. Even the best of the current surrogates such as systolic blood pressure cannot substitute for the entire cumulative effects of a drug on the intended biological target and for off-target effects.
We will continue to work to speed patient access to therapies shown to be safe and effective through our existing programs that allow for expedited review, development, and approval of certain medical products. To encourage innovation, we also will continue to work with other government agencies and the healthcare community, including members of patient groups, academia, and industry. It will take a collaborative effort to improve our nation’s understanding of certain diseases and to translate any resulting scientific discoveries into cures.
Robert Califf, M.D., is FDA’s Deputy Commissioner for Medical Products and Tobacco.
More information can be found at: Innovation at FDA.