By: Scott Gottlieb, M.D.
Our longstanding goal for medical care is to ensure that the right drug or device is delivered to the right patient at the right time. This vision is increasingly possible with the innovative products that are becoming available. Many of these opportunities are enabled by new technology platforms such as digital health, targeted medicines, and regenerative medicine, including cell and gene therapies. These new technologies offer transformative opportunities. But they also challenge the U.S. Food and Drug Administration (FDA) to modernize its approach to evaluating new innovations. In many cases, we’ve had to refashion our regulatory approach to create more modern platforms that are better suited to the efficient evaluation of these advances.
In short, we’ve had to modernize our overall approach to regulation to effectively advance the kinds of innovations that are becoming available. This includes modernizing how we organize our medical product review programs. These initiatives are part of our comprehensive Medical Innovation Access Plan.
These efforts are strengthened by new authorities and resources made possible by bipartisan legislation like the 21st Century Cures Act, as well as the recent re-authorization of the FDA’s user fee agreements. The actions that we’re taking have additional support from the President’s Fiscal Year 2019 budget. Together, these efforts will enable the FDA to fund the creation of a cross-cutting data enterprise for the generation of evidence, and a more modern and integrated approach to the evaluation of this information, to make sure that our regulatory decisions are as flexible and sophisticated as the science driving these advances.
And we’re not doing it alone.
We’re working closely with our public and private sector partners to better meet shared public health goals and address cross-cutting scientific and technical challenges, while making regulatory decisions more transparent and predictable for all stakeholders. My recent written testimony on how the FDA is implementing the 21st Century Cures Act contains an overarching picture of the agency’s many activities related to our new policies aimed at advancing innovative products.
I’d like to use this opportunity to reflect on how the FDA is creating a new operating system for innovation by modernizing clinical trials, streamlining the FDA’s organization and processes to advance regulatory science, and expanding the FDA’s capacity to analyze complex real-world data streams to detect early safety and efficacy signals. And to describe the new policies we plan to announce to advance these goals. These mutually reinforcing efforts will help the FDA meet its mission of promoting and protecting public health, and they will help unlock the full public health potential of America’s public and private investments in medical research.
Modernizing Clinical Trials for Drugs and Devices
Prospectively randomized, placebo controlled clinical trials are often the most powerful tool that we have for answering fundamental questions about the safety and efficacy of new medical products. But greater efficiency is needed, as clinical trials are becoming more costly and complex to administer. Moreover, many of the new products that we’re being asked to evaluate aren’t easily evaluated using these traditional approaches. At the same time, new technologies and sources of data and analysis make better approaches possible.
Added complexity can not only make medical product development more uncertain, expensive, and time consuming; overly complex trials and unnecessary data collection can deter patient enrollment, exhaust investigators, and delay completion of studies so long that their findings aren’t relevant. They can also discourage the development of second and third-to-market innovations, meaning that first-in-class drugs enjoy monopolies for longer periods of time. This can reduce competition that lowers prices, and limit therapeutic diversity.
The FDA is working across its medical product centers, in collaboration with the Clinical Trials Transformation Initiative (CTTI) and the Medical Device Innovation Consortium (MDIC), to facilitate innovative trial designs and patient-centered endpoints for drugs and medical devices that can make clinical trials more efficient. These approaches can also be more rigorous. Developing more efficient strategies for generating critical evidence relating to the safety and efficacy of drugs and devices in specific populations (for instance, through seamless trial designs, and the use of master protocols and basket trials) can help make the clinical development process more efficient. It can enable investigators to learn more about a product’s efficacy and safety, and help regulators and sponsors detect efficacy and safety signals earlier in the development process.
Lowering the cost and time needed to conduct trials can promote market competition, help check drug prices, and bring patients innovative medical products earlier. These approaches can lower costs by making it more economical for second or third- in- class products to compete with first entrants. Right now, when it comes to drugs targeted to unmet needs, we’re seeing a trend where second and third-to-market competition is taking longer to reach patients. There are complex reasons for this. But one is the difficulty of conducting traditional clinical trials in settings where there is an available therapy, but still significant unmet medical need – for instance, in some rare diseases.
We studied these trends. A new FDA analysis considers the number of drugs or biologics that CDER has approved in the same class. They’re drugs that use the same mechanism to produce a physiological change in the same or related condition. We found that new competition isn’t entering the market as quickly for these drugs. In other words, when a novel sole source drug wins approval it faces no competition from other drugs in the same class. Follow-on drugs and biologics to compete with the first-in-class have been arriving more slowly.
Here are some results from the data we reviewed. We plan to publish the full analysis soon.
For non-orphan pharmaceuticals, which treat conditions affecting larger patient populations, 41 percent of the first-in-class products approved between the years of 1991 and 2000 had at least one competitor in the same class within five years. This rate dropped sharply over the next decade. For the years from 2001 to 2010, for the same kind of cohort of medicines – first-in-class products that were approved to treat patients with prevalent conditions – only 18 percent of these drugs had a within-class competitor after five years. Another way of interpreting the data is to describe the lag in any competition. For the older classes, where the first-in-class was approved in 1991 to 2000, nearly a quarter had a competitor within two years. For the cohort where the first-in-class was approved in 2001 to 2010, it took an additional five years for there to be nearly as much competition. By year seven, competition still lagged the previous cohort, with only 22 percent of classes having any competitor. We see similar patterns in most rare disease treatments.
Consider first-in-class orphan drugs and biologics for non-cancer indications. For drugs approved between 1991 and 2000, 26 percent had at least a competitor within five years. The comparable rate for the 2001 to 2010 cohort was 13 percent. These trends mean that costlier, branded drugs may enjoy longer periods without facing competition from products in the same class. This may increase their pricing power. For orphan drugs, where conducting clinical trials can be difficult, these periods can sometimes extend long after patents and other exclusivities lapse.
We’re taking steps to facilitate more efficient clinical development programs. The Center for Devices and Radiological Health’s (CDRH’s) work with MDIC, for example, is improving efficiency in trial site contracting, first in patient studies, and Institutional Review Board (IRB) approval. These are three of the costliest factors in device trials and can pose barriers to developing innovative products. Similarly, the FDA has advanced efforts to modernize clinical trials by pioneering Master Clinical Trial Protocols (MAPs) such as basket, umbrella, and platform trials. These approaches can increase trial efficiency and lower costs.
MAPs move away from one-drug, one-disease trials. They involve one or more interventions in multiple diseases or a single disease with multiple interventions, each targeting a biomarker-defined population or disease subtype. A key feature of master protocols is the use of a common clinical trial infrastructure to streamline trial logistics, improve data quality, and facilitate data collection and sharing.
In the coming weeks, we’ll be issuing additional guidance on MAPs and efficient trial design strategies to help expedite the development of oncology drugs and devices. We’ll also be issuing guidance on the use of adaptive trial designs, and innovative endpoints like minimal residual disease in hematologic cancers. We recently issued draft guidance on the use of placebos in randomized trials in oncology. Advances in care, and trial design, can make it unethical and infeasible in some circumstances to use placebo controls in cancer trials. At the same time, the FDA is advancing the development of natural history models for rare diseases. These models may obviate the need for placebo arms in some trials by allowing researchers to replicate the behavior of patients who otherwise are left untreated.
As part of this effort, we’re also launching a complex innovative designs (CID) pilot meeting program to facilitate the advancement and use of novel clinical trial designs. The CID pilot will offer medical product developers an early opportunity to meet with FDA experts in all relevant disciplines from the agency’s Center for Drug Evaluation and Research (CDER) and Center for Biologics Evaluation and Research (CBER) to discuss regulatory approaches to novel trial designs.
Medical devices present a different set of technical challenges and opportunities compared to drugs. But we’re employing the same principles to facilitate the agile development and review of innovative devices. For example, in the FDA’s Breakthrough Devices Draft Guidance, we proposed the use of “sprints” in which the sponsor of a breakthrough device identifies a regulatory challenge they need to solve. We then work interactively with the sponsor to address that challenge within a short timeframe — often just a few weeks. These early interactions have resulted in the development of flexible clinical study designs for certain breakthrough devices and in more FDA review team support and senior management engagement earlier in the development and review process. All of these steps are intended to enable the FDA to evaluate, and the sponsor to develop, innovative devices more efficiently. The FDA has granted 72 breakthrough device designation requests and, as of June 1, 2018, has approved or cleared six breakthrough devices.
As part of these efforts, CDRH continues to apply the “least burdensome” approach to all activities – exceeding what has been mandated in statute – related to medical device regulation. This concept will ensure that regulators and sponsors align on the minimum amount of information necessary to adequately address a relevant regulatory question or issue through the most efficient manner at the right time. This culture helps to further reduce the time and cost required to develop and market safe and effective new devices.
Together, the FDA’s Breakthrough Device program, least burdensome principles, and acceptance of greater uncertainty in appropriate circumstances are already making a dramatic difference in the health of millions of American patients. Just some examples of products that have come to market as a result of CDRH’s streamlined approaches include: an innovative device for transcatheter aortic valve replacement (TAVR), the “artificial pancreas” (and subsequent expansion of approval to include individuals aged 7 to 13), the world’s smallest heart valve for newborns, first blood test in the world to evaluate mild traumatic brain injury, the first breakthrough-designated next generation sequencing (NGS) based IVD to detect cancer mutations in 324 genes, the first artificial iris in the United States, and the first mobile medical app to help treat substance abuse disorders.
Modernizing FDA’s Organization and Breaking Down Outdated Silos
Building on the FDA’s success in standing up the Oncology Center of Excellence, we’re also modernizing our organizational structure, flattening our review process, and breaking down review silos between different scientific disciplines that are important components of the medical product review process. The goal is to enable FDA review teams to be more disease focused, more integrated across the disciplines involved in drug review, and better able to evaluate and analyze data from agile clinical trials through a more structured approach to data review.
For instance, CDER has proposed an important series of new steps to modernize the organization and functions of CDER’s Office of New Drugs. Part of this involved structural changes. Other elements are aimed at process improvements that make the review process more predictable, consistent, and structured. The idea is to make the review of data more structurally consistent and improve the productivity of our clinical staff. This effort is starting with how we can more carefully and rigorously evaluate safety.
We’re implementing a more standardized, efficient, and comprehensive process for review of drug safety. This new process will leverage staff expertise in data analytics to develop more standardized approaches and templates for how we evaluate safety data as part of new drug applications. This process fully leverages the standard datasets that must be submitted in drug applications. It also brings in added quantitative and programming expertise in the conduct of safety analyses to support the medical team’s efforts. As part of this effort, we’re looking to make the review process more integrated, multi-disciplinary, and problem-focused; and to develop a review document that reflects this multi-disciplinary, problem-focused approach. By enhancing efficiency and providing greater support for the application review, we intend to “front load” this process. This approach should result in more time during the review cycle for key discussions, such as on labeling and on post-market requirements and commitments. These new processes should align well with our ongoing efforts to base our regulatory decisions on an informed assessment of the benefit-risk balance – by providing a deeper understanding of the risks, along with a comprehensive assessment of benefit, incorporating the patient’s perspectives and preferences.
These new approaches will bring added efficiency to our processes and improve our internal productivity. One benefit will be reducing routine administrative burdens on our new drug staff, elevating the role of our scientists and medical officers to take on even more thought leadership in their fields. We’ll use the productivity gained to channel more of the intellectual resources of our clinical staff into thought leadership activities that help advance the principles of regulation. As part of this effort, for example, we’re considering creating many new therapeutic-specific divisions that’ll have more ability to engage in discrete areas of medicine. The goal is to make sure that the drug review divisions are therapeutically focused to promote efficient review and provide greater scientific leadership to academic, industry and patient groups. The Office of New Drugs modernization will give our subject matter experts more time, better analytic tools, and more knowledge management support to advance the clinical and regulatory principles we rely on to evaluate the safety and efficacy of innovative products
This should allow the FDA to issue many more product-specific guidance documents. We plan to develop hundreds of new clinical guidance documents and make sure they stay up-to-date to reflect the latest science. We’ve already issued nearly 100 guidance documents in 2018 alone. Another goal is to allow the FDA’s staff to engage with stakeholders on new technologies like continuous manufacturing of drugs and biological products through the FDA’s Emerging Technology Program, designed to help industry implement innovative technologies that can improve product quality.
The FDA’s Device Center is undertaking a similar modernization of its approach. CDRH has explored, piloted, and developed implementation plans that will help CDRH improve information sharing, decision making, and work efficiency by instituting a Total Product Life Cycle (TPLC) approach to many of the core medical device review activities. TPLC will also enable CDRH experts to leverage their knowledge of pre- and postmarket information to optimize regulatory decision-making. Efforts underway at the FDA’s Device Center share a similar goal with the OND reform. The aim of FDA’s TPLC approach is to ensure not only that devices meet the gold standard for getting to market, but also that they continue to meet this standard as we get more data about devices and learn more about their benefit-risk profile in real world clinical settings.
Harnessing Real World Evidence
As part of these efforts, the FDA is also actively working to evaluate the use of real-world evidence (RWE) to support regulatory decisions. This includes data captured from sources such as electronic health records, registries, and claims and billing data. Real world evidence can help answer questions that are relevant to broader patient populations or treatment settings where information may not be captured through traditional clinical trials. We are expanding our ability to use RWE for post-marketing safety surveillance, and exploring its potential to help support expanded label indications.
FDARA provided important funding to evaluate how RWE can be generated, and its potential use in product evaluation. The funding included significant new resources to enhance the FDA’s Sentinel system. To date, Sentinel has been used to assess safety. The FDA is now supporting the first randomized prospective intervention trial that makes use of information in the Sentinel system. To take one practical new example of this application, the IMPACT-Afib trial will test an educational intervention to address the important public health problem of underuse of effective medications to reduce the risk of stroke in patients with atrial fibrillation. This proof-of-concept trial can serve as a prototype for future RWE trials. At the same time, in another proof of concept study, the FDA is also funding a project to examine whether real world evidence that’s generated using observational data can replicate the results of approximately 30 randomized controlled clinical trials for drugs.
CDRH has also made one of its top priorities the development of a system of active surveillance for medical devices by building out the National Evaluation System for Health Technology (NEST). The goal is for this to ultimately help drive the development of safer, more effective devices, and timelier patient access to those devices. It will also increase the value and use of real-world evidence to support the needs of multiple stakeholders in our health care system, including the detection of emerging safety signals. NEST may also eventually be used to facilitate reimbursement (the Centers for Medicare and Medicaid Services serves on the NEST Governing Committee) as improved data collection can help encourage coverage with evidence development (CED).
FDA’s Role in Curating Standards for Novel Technologies
The agency’s role in curating standards for medical technologies can help advance innovation in areas that may lack consensus standards now. One example is through software-based platforms that are playing an increasingly central role in managing patient health. These tools can help more patients gain more control over their own health.
These software tools are becoming more sophisticated, enabling a broader set of opportunities. Artificial intelligence (AI), for example, holds enormous promise for the future of medicine. We’re actively developing a new regulatory framework to promote innovation in this space and support the use of AI-based technologies. So, as we establish and apply our Pre-Cert program – where we will focus on a firm’s underlying quality in assuring software products meet safety and effectiveness standards – we’ll consider how to account for one of the greatest benefits of machine learning – that it can continue to learn and improve as it is used.
We know that to support the widespread adoption of AI tools, we need patients and providers to understand the connection between decision-making in traditional health care settings and the use of these advanced technologies. One specific area that we’re exploring with stakeholders is how we can benchmark the performance of AI technologies in the field of radiogenomics, where AI algorithms can be taught to correlate features on a PET or MRI scan with the genomic features of tumors. This provides an opportunity to improve patient prognosis, identify early response to treatment, or develop novel imaging biomarkers that could be used to triage high risk patients who may need more frequent screening.
Toward these goals, the FDA is exploring the use of a neutral third party collect large annotated imaging data sets, for example highly annotated radiology scans used in a variety of clinical trials for specific disease indications, for purposes of understanding the performance of a novel AI algorithm for a proposed indication. Such a capability would enable a transparent benchmarking system for AI algorithm’s performance, and help providers and payors compare AI systems with the best human standard of care.
The FDA is also one of many stakeholders deeply interested in advancing the assessment and quantification of symptom and functional outcomes in cancer patients through clinical outcome assessments (COAs). COAs, in layman’s terms, are measures that describe or reflect how a patient feels, functions, or survives. Several technological advances hold promise to revolutionize how we can capture patient-centered clinical outcomes in controlled trial and real-world settings. One traditional COA is a survey that collects patient reported outcomes (PROs) through a questionnaire.
Electronic capture of PRO data (ePRO) is also becoming standard, providing a rich pipeline of structured clinical data. In addition to ePRO, mobile wearable technologies can complement traditional PRO surveys by generating objective, continuous activity and physiologic data. Obtaining reliable wearable device data on activity level, coupled with direct patient report on their ability to carry out important day to day activities, can provide information on physical function that is directly relevant and important to the quality of life of cancer patients.
Medical products are becoming increasingly sophisticated. The advent of advanced computing and systems biology will continue to help make health care more personalized, while connected technologies break down barriers between clinical research and real-world patient care. New platforms like targeted medicine, cell and gene therapy, and regenerative medicine hold more curative opportunities.
To facilitate these opportunities, and help make sure these innovations are able to improve public health, we’ve undertaken a comprehensive effort to make sure that our organization and policies are as modern as the technologies we’re being asked to evaluate, and that we’re able to efficiently advance safe, effective new innovations.
Scott Gottlieb, M.D., is Commissioner of the U.S. Food and Drug Administration
Follow Commissioner Gottlieb on Twitter @SGottliebFDA