Michael Christel is Pharmaceutical Executive and Applied Clinical Trials' Managing Editor. He can be reached at mchristel@mmhgroup.com.

Michael Christel

	Behind the momentum of precision medicine programs such as 

, coupled with the overall shift taking place toward ultra-targeted treatments-gene therapy, immunotherapy, biologics-the rare disease space seems to be joining the rarefied air of more common disease segments in biopharma business pursuits.      

	After all, by 2020, the rare and orphan drug market is 

 to grab 20.2% of worldwide prescription drug sales (excluding generics) and total $178 billion in annual revenue. In the US, the FDA granted nearly double the number of orphan drug designations in 2015 compared to 2010, and through September, 

 had been approved this year. The demographics are well documented: rare diseases affect fewer than 200,000 patients, but, in aggregate, 

 worldwide-more than the total for cancer and AIDS combined. Children are especially impacted; about 35% of deaths in the first year of life are reportedly caused by these conditions.

	But despite greater financial and regulatory incentives to develop drugs for rare diseases, plenty of caution remains. The low prevalence of these conditions still results in various challenges in development, pricing, and reimbursement. And with treatments usually requiring large per-patient payments, this area won’t be immune to the pricing scrutiny that continues to swarm the industry.

	Juliet Moritz, executive director of strategic development in rare diseases for Premier Research, a CRO, has watched all these trends unfold with a close eye. 

Involved in clinical research for 28 years, with experience in single-site studies as well as large, multinational trials, Moritz is particularly passionate about informed consent and the role of patient advocacy involvement in clinical research. 

 recently chatted with Moritz, where she discussed the challenges and opportunities unique to this specialty market-particularly related to growing focus areas such as patient engagement.        

 What approaches are getting the most attention right now in rare disease research? 

(Note: this interview took place prior to FDA's controversial 

. But, in general, we’re seeing a lot more focus on genetic conditions (80% of the estimated 7,000 rare diseases involve a 

). Now that the genome has been characterized, there’s a lot of work going on that’s relating a particular disease back to the genetics-the genotype and the phenotype. That brings us closer. Once we understand what the mutation is, we can then try to understand what’s going wrong. Is it a protein being misshapen or is it a protein not being produced at all? We’re finding conditions that are considered one condition but might have 10 or 12 different mutations that result in the same presentation of the disease.

	We’re also seeing enzyme replacement therapy-for patients in which their disease results in the deficit of an enzyme or the creation of an enzyme that can’t cross the membrane. We’re seeing a lot more therapies that can address that-either replace the enzyme or chaperone the protein across.

 What are some promising opportunities in patient recruitment for rare disease trials?

 To me, what’s very exciting is the fact that the regulatory agencies are really now paying a lot of attention to patient engagement. We’re seeing them go back to the pharma and biotech companies and specifically asking them, “what did you do in terms of patient engagement during your clinical development plan? Share that information with us.” We’ve seen some legislative changes as well.

	It’s evolved, from when it used to be just putting a link about a study on a patient group’s website. Now it’s engaging in the protocol development, talking about meaningful endpoints and outcome measures. So that the protocols hopefully, over time, begin to reflect the day-to-day course of the disease and how it affects the patient, and in rare disease, often the family and caregivers.

 Do you think the targeted patient engagement approach has been more effective amid advances in digital information tools?

 I think so. There are companies in our space-niche vendors-that are trying to leverage technologies by creating online communities for these patients. I’ve been in the business 28 years. Twenty-eight years ago, we didn’t have the Internet, we didn’t have Facebook, we didn’t have a place where a parent of a newly diagnosed child could go online and learn what resources are available. Now, if you look at almost every patient advocacy group, they’re talking about research in their disease state. They’re talking about clinical trials, and, in general, why people would want to participate in clinical trials. And depending on the therapeutic area and the target indication, they might even point people to specific trials.

	The technology has been a significant boon. It doesn’t completely eliminate the challenges in patient recruitment. It’s still challenging because in some of these conditions you only have 1,000 or even just 2,000 people in the world that have them. You have to connect them to the places where the research is happening. But now it’s less of a “let me reach out and try to find somebody.” It’s more of a combination-we’re reaching out while they’re also reaching out to try to find opportunities to participate in research.

 Are sponsors and CROs, in turn, more sensitive these days to the unique burden rare disease patients experience?

 That’s a big part of protocol development-reaching out to the advocacy groups and evaluating the protocol and determining, well, this might answer all of the scientific questions, but is it so onerous that we’re not going to be able to keep anybody in through the end?

	As a CRO, we have to think what can we do to mitigate that burden so that we can enhance recruitment, but, more importantly, retention. Once someone’s in the study, we need to make sure we’re getting them through so that their effort turns out to be meaningful. It’s incumbent on us to make sure that the protocol is scientifically rigorous but also operationally executable, and not just thinking about what makes sense for us and the sponsor but for the patients and their families.

 How do you go about including those considerations in the protocol?  

 You build in as much as you can. Sometimes you only have a little bit of leeway depending on what the regulatory agencies want to see out of the protocol. But then you work around that to say, “alright, what can we do to support these patients and their families as they’re participating in this experience?” Is it

 more timely reimbursement of expenses? is it working with the sites to make sure they can schedule these folks first thing in the morning if they’ve got a three-hour train ride, for example.

	There’s no magic bullet, there’s no one answer. That’s the nice thing about having been involved in rare disease research for so long. You build a tool box basically of strategies and things that you could do. Not all of them are appropriate for every study, but having that depth of experience allows you to make more informed decisions on what might work.

 Is the use of real-world data beneficial for trials in rare diseases? Is there enough data out there that could help?

 It’s not as comfortable a transition as in more prevalent disease research, that’s for sure. I think where big data might come into play is implementing strategies to try and identify lags in diagnoses. One of the challenges for a lot of people with rare diseases is that it could take quite a while to get a diagnosis. Are there other ways to characterize a patient’s profile as they’re going through their diagnostic arc? Is there any way we can shorten that up based on symptom and test information in medical records?

	But right now I don’t see a lot of that happening in rare disease research where it translates into impacts in clinical trials. 

 What important caution would you advise companies interested in pursuing rare disease research?

 The regulatory pathways are compressed. You have a lot of what I call the slash studies: Phase I/II, Phase II/III. You have smaller patient populations; every single patient counts-and beyond that, every single data point counts. So the operational challenges are a little different. It’s really important to understand and be able to anticipate that. Because otherwise you can take a small company that’s got very limited resources, and if they go down the wrong path, they may not have an opportunity to reinvestigate that potential therapeutic.

 What about the economic challenges that still exist in developing drugs for rare disease?

: On average, the cost per patient to study a drug in rare disease is often higher, largely because of operational issues. The trials are often spread out and have a lot of assessments-and when you’re bringing a patient to a clinic, you’re often bringing their entire family. It’s difficult to find control groups for some of these ultra-rare populations. So you have to be a little creative. Maybe you’re doing crossover studies.

	It’s not as straightforward as Phase I, healthy volunteers; Phase II; Phase III; okay, we’re going to market. It’s not the same at all. It requires whomever you’re working with to be nimble and know the regulatory environment.

Articles

With pursuits in rare and orphan disease beginning to move more into the drug development mainstream, the opportunities and challenges in patient engagement and trial execution for these conditions are ever-evolving, as one strategy expert in the field discusses.

Rare Disease Research: It Pays to Engage

	The data explosion in clinical research is very real-there is no denying that. Industry attention and focus in this area-as a legitimate force for change-is so high these days that it can be dizzying to keep track of it all (we managed to catch our balance to highlight some of the latest thinking in our 

 on eSource and data integration). Today, a biopharma conference, or an industry webcast, or even a regulatory forum, more times than not probably features a headlining theme on new data technology trends and strategies in drug development. Big data, real-world data, electronic health records, wearables, advanced analytics, remote patient monitoring-you name it.   

	These are indeed exciting times to dream big on how these new data tools and process improvements can potentially revolutionize clinical trials. And by extension-critical to changes now taking place on the healthcare level-help usher in more personalized, so-called 

	But before we get too mesmerized by the spectacle, a prudent and pragmatic lens on things is also warranted. R&D aficionados and those plugged into the day-to-day operations of clinical research will likely agree that perhaps the biggest issue in managing this data convergence in the life sciences is connecting reality with the conceptual promise of these “next-generation” information tools and processes.

	“Like so many industries, the drug development enterprise tends to approach the use of technologies with this tremendous exuberance that is so far removed from the realities,” says Ken Getz, the longtime chairman of CISCRP and director of sponsored research at the Tufts Center for the Study of Drug Development. “This exuberance comes without really thinking through the kind of long and painful journey that’s going to be required by all of the workforce within drug development to change legacy processes and systems. Some of that will require cultural change and philosophical change in how we approach development activities.”

	Given those challenges as well as the gaps in data standards and governance that still exist, crafting a practical vision of sorts for how researchers can capitalize on new opportunities in data use will be crucial-whether involving collection, management, reporting, sharing, etc. As part of a panel discussion at this month’s 

 in Philadelphia (entitled “The Future of Clinical Research Data: 2020 and Beyond”), Getz and others will explore such a vision and the steps and mindset necessary to truly harness data to improve the research process of tomorrow. Here are more excerpts from my recent conversation with Getz on the topic. 

 What do you feel are the most compelling trends at the moment in the area of clinical research data?

 I think the biggest trend is the big data movement, and the use of really large datasets on millions of patients. And even the use of real-world data in clinical research and in pharmacovigilance, for example. There are so many sources of structured and unstructured data-data coming from large electronic health record and electronic medical record platforms, from wearable devices, and mobile devices and 

applications. How do you gather and integrate all that data? What gets me most excited is how do you then use that data? Can we use that data to identify targeted patient subpopulations? Can we use that data to really inform us while the study is underway or at different critical points, so that we have a new understanding of data safety or we identify efficacy or safety patterns in the data? How can that data be constantly used to enrich our insight? Not only insight into treatments and their effectiveness, but from a management standpoint-to manage our clinical research more effectively.

	Then there’s a lot of interest in using this data to predict performance. To select a more effective group of investigative site partners, for example. Or to predict patient recruitment and retention rates more effectively. That whole big data movement, it sounds so cliché, but it continues to make great progress and hold tremendous promise. 

What about mHealth, specifically? Can we measure the impact yet on clinical care?         

A lot of companies are piloting the use of select wearable devices and the use of smartphone and mobile applications. The biggest challenge is that some of these technologies are not validated. So some of the biometric data that they are collecting technically can’t be used in a submission. There are issues with some of the technologies, but there’s a growing number of organizations that are finding ways to integrate with really large datasets of patient records. I think we’re going to see a lot of progress in this area over the next 18 months.

How do you view the topic of data transparency in this whole equation? You hear a lot about initiatives in the industry promoting data sharing-whether things like 

 in the precompetitive space to even the 

). What does all the discussion and activity mean right now for R&D practice?

 Transparency-and I would add integration, which is central to that-are critical both within the enterprise at an operating level and obviously essential to partnering with patients and healthcare providers and payers. On the drug development side, we see that so much of this data and the technologies that are being used are siloed. They’re not integrated-they have really poor transparency. That’s requiring a lot of manpower to manage; it’s highly inefficient. Transparency and integration can play a huge role in breaking down those silos from a drug development operating standpoint.

	With patients and healthcare providers and payers, there are huge ethical issues around use of patient data and making sure that it’s entirely transparent. That’s very essential to building trust with the patient community and with healthcare providers and payers. It’s also essential to ultimately best serving patients’ needs by creating what the FDA has called a learning environment, where clinical practice and clinical research are communicating with each other in real time and in an integrated way so that constant feedback and insight is coming from both domains. Integration and transparency are areas that we really have to adhere to the highest principles and ensure that we’re honoring and we’re meeting the obligation to provide unprecedented levels of transparency and disclosure.            

 Any thoughts on efforts in the U.S. and 

 to promote data transparency and require public disclosure of clinical trial results?  

With a lot of these technologies, the patient isn’t even aware that data is being collected. Many of these applications now collect a

 time and geographical stamp on a person while they’re carrying out their day-to day activity. Some of that information, if patients were fully aware of how it’s being used, many would be concerned-or at least should know and give their consent to having a lot of that information gathered. We have a lot of work to do to improve awareness of the kind of transparency that we’re looking for to build meaningful datasets and ultimately best serve the patient community. 

 Have you heard direct feedback from patient groups expressing these concerns?

 We have. Patients generally are extremely willing to share their data when they understand how it’s going to be used-and how the data has been used has been honestly and comprehensively explained to them. They’re quite eager to share their data and they’re quite trusting when that transparency and disclosure is presented completely openly. I think part of the issue is just building into the process the steps that we always need to take to partner fully and adequately with the patient community.   

In coming up with a future vision for research data, what are some logical steps needed to take these new opportunities from concept to reality in advancing the whole trial process?

The reality is that the use of most technologies is remarkably fragmented, it’s poorly integrated, we use so many disparate systems, and we use them inconsistently. All of these approaches ultimately are hurting productivity. They’re increasing inefficiency, they’re actually increasing our cycle times, and there’s just so much redundant activity. For example, the adoption and use of eSource is relatively low. We see so many professionals that have to do multiple data entry to move and transcribe from one system to the next.

	Often, we throw new technologies and new systems that hold great conceptual promise into this stew of these kinds of operating conditions. As a result, there’s that wide gap between the reality and the conceptual promise. At the DIA forum, it’s our hope that we’ll be able to connect some of these dots. We want to discuss the conceptual promise but also suggest a reasonable and feasible roadmap to get us there.

	The Tufts Center and CenterWatch have gathered a lot of data in this area-just showing how siloed and fragmented and inconsistent is the use of various technology solutions. Those individuals involved with executing activities and using these solutions are often quite frustrated.

 You mention eSource. What challenges remain in the adoption of data standards governing the collection and analysis of clinical trial data electronically?

The Tufts Center, in collaboration with CDISC, did a study about nine months ago and we showed that the adoption of data interchange standards continued to grow steadily. Not only the adoption of some of the most mature and traditional standards, but also the use of some of the newer standards, including those that are tied to the sharing of data between compatible systems. But what we also saw is the lack of integration, the lack of interoperability, are hindering adoption. So you have a lot of professionals who are really committed to embracing the CDISC standards but they face a lot of headwinds in the process. Some of those headwinds we want to continue to explore.

	Some integration will come when it has regulatory winds behind it or when there’s such great necessity that it forces the sort of siloed functions to interact in a more integrated way. We haven’t yet reached that point.

Today’s convergence of health data and technology is fun to watch unfold, but a focused vision on system and process integration-and the framework for continuous enrichment-will be key to future lasting gains for clinical research.

Q&A: Research Data Promise vs. Reality

 yesterday that DNA testing company Ambry Genetics is launching a free online database that unlocks the human genome information of 10,000 of its customers. 

 will initially include data focused on breast and ovarian cancer, but the company said it plans to release thousands of genomes every month (covering all the diseases it tests for), potentially making available data from almost 200,000 individuals annually.

	The purpose of the move, according to Ambry, is to help advance the relatively new field of precision medicine. It’s in line with President Obama’s 

, which includes the development of a voluntary national research cohort of at least a million people. Ambry’s move also reinforces its belief that human genes should not be patented or owned-a 

 that has generated much fervor on both sides for decades and was in the spotlight in recent years.  

 caught up with Ambry founder and CEO Charles Dunlop briefly via email to discuss his company’s decision and the larger implications for the medical research community.

ACT: What was the chief motivation to release this data into the public domain? Is it simply a matter of the access need?    

The decision to release our data is a matter of doing the right thing to advance research and save lives. For too long, vital genomic data have been hoarded by commercial and academic organizations, and that practice has stagnated medical progress. It has caused real human suffering and it needs to stop.

	I am a Stage IV cancer survivor, and at a critical point in my recovery, I realized that genomic data are just too valuable for anyone to hoard and profit from. By sharing the data and collaborating with the research community, we can speed up the discovery of new treatments and cures to save more lives, sooner.

ACT: How would you encourage other organizations, whose business model may involve selling genetic information, to share such data in the same manner? 

Anyone collecting genomic data should free that data. It’s just the right choice because everyone benefits if medical research can progress. I would like to see more data sharing across the industry, and would support efforts to make it easier for researchers to share.

ACT: There are other genetic databases accessible to the public. How is AmbryShare different, in terms of the potential value of the information? 

 AmbryShare is the largest free, disease-specific public database of human genome sequencing data. The data released are anonymized, aggregated data of 10,000 human genomes focused on hereditary breast and ovarian cancer. These are allele frequency data, meaning that they allow us to see the occurrence of gene 

	Based on the sheer volume of the data we have released, we have already identified 10-fold more genes implicated in breast and ovarian cancer than was publicly known, broadening understanding and potentially opening up more drug targets than from any single data release in history.  

	Ambry Genetics is committed to continuing this effort to sequence genomes and release the data for all of its consented and de-identified patient samples, to gain these kinds of genetics insights for other cancers and other disease areas.

ACT: With the possible momentum for more public sharing of genomic data such as yours, are there unique privacy concerns that organizations should be aware of? 

 Patient privacy is very important to us, which this data release is aggregated exome data from consented and de-identified patient samples. We also secured approval from an independent research board to conduct research exome sequencing on these patient samples.

Ambry Genetics' CEO discusses his company's decision to release the genetic information of its customers for free - a rare move, reportedly, for a commercial testing firm.

Company: Genomic Data Too Valuable to Hoard

	When tracking the more recent evolution of clinical trial outsourcing in the biopharmaceutical industry, it has usually been the high-profile partnerships and alliances struck between large drugmakers and contract research organizations (CROs) that have received the most attention and coverage. What has been less readily known are the unique outsourcing needs of the small or so-called emerging biopharma company and how those differ from the larger sponsor organizations. The former is characterized by very strategic outsourcing decision-making, while, for the latter, decisions to outsource are often considered more tactical in nature.

	“It's challenging for a virtual or a startup sponsor to get the kind of attention that it needs,” Keith Wenzel, Senior Director of Perceptive Partner Program (part of CRO Parexel), tells 

. “They often only have one program, and if that program fails, they are all out of business.”

	Such realities have spurred increased collaboration to develop more personalized outsourcing approaches to aid fledgling drug sponsors. At the recent DIA 51st Annual Meeting, Wenzel, along with Solomon Babani, Global VP of Alliance Management for Covance, and R&D executives from two small biopharmas, presented a conceptual partnership model built on the idea of delivering value from alliances between networks of biopharma companies and CROs-involving clinical and technology functions.

	“How can you bring a bunch of small, emerging biopharmas into a network and have them agree on standards and agree on technology?” Wenzel told us in an interview. “It’s turning the whole thing around and having a group of sponsors collaborating together so they could possibly get the attention of larger CROs. The large CRO would know that working with this group that it’s going to be able to work within a standardized manner, because they might have agreed on contracts, on forms, on SOPs, on technology, etc. Therefore, the CRO can say, 'Ok, I understand how I’m going to collaborate with these guys in the same way a large pharma and a large CRO agree on standards.'”

	The small/emerging biopharma segment is generally classified as those companies who spend $300 million or less on R&D annually. According to statistics cited by Wenzel during his DIA session, emerging biopharmas are responsible for about one-third of the global drug development outsourcing market, one estimated to total more than $25 billion. Wenzel, who is part of Parexel’s informatics group, which, through the Perceptive Partner Program, partners with technology companies on behalf of sponsors and CROs, notes that eClinical technology is one of the fastest growth areas in outsourcing today (the global eClinical solutions market is projected to reach almost $5 billion annually in 2018). Clinical data management systems (CDMS) and electronic data capture (EDC) tools make up the largest outsourcing segment in this space, followed by clinical trial management systems (CTMS), according to figures presented by Wenzel. He believes applying the principles of alliance management can help small and emerging sponsors capitalize on the eClinical growth.    

	“When you think about the technology side of this, a small sponsor ramps up for a trial and then they stop, and they ramp up again and then they stop. They might not be able to invest in a CTMS system based off of that ebb and flow,” says Wenzel, who has a vast background in information systems, including working as product director at ClinPhone before Parexel acquired the company in 2008. “But if a group of sponsors committed to a CTMS system and they agreed on how they were going to use it and pay for it when they need it, they wouldn’t have this huge infrastructure investment. For example, maybe the CRO brings the CTMS system to the network, and it’s a standard implementation-any of them can use it; they can turn it on and turn it off depending on the needs of their particular trial.”

	The proposed model discussed at the DIA meeting involves leveraging eClinical technology with CRO services, where members of the network can have combined purchasing power and can collaborate on collective and precompetitive innovation. 

	“You can see the advantage of greater purchasing power because the network would have more power,” says Wenzel. “But we really think it’s the combination of the purchasing power plus the standards that will get you there-and it’s good for both sides, not just for one.”    

	Wenzel believes the model also aligns well with the three pillars widely considered the foundation blocks of a strong outsourcing relationship: people, technology, and therapeutic expertise. He points out that small and emerging sponsors often have unique needs in these core areas, and usually have very defined questions when it comes to executing their R&D programs. Some of those questions include how does the sponsor identify issues early, so adjustments can be made before time and money are wasted; how does the company demonstrate that its drug will be commercially attractive; and what core competencies should exist/be kept in-house. 

	 “A major pharma can make a five-year commitment to a large CRO,” says Wenzel. “But these smaller companies are saying, ‘I want that same level of service, but I don’t quite have the same purchasing power.’ That’s where the network of sponsors comes from. They may not have established SOPs, or they may not have a mature certain set of scientific expertise, so they really want the ability to do almost an a la carte. ‘OK, I need this kind of expertise from you, Mr. CRO. How can you package it for me and treat me just the same as you’re going to treat your big clients?’”

	Transforming these concepts of alliance management from idea to reality-the establishment of a bona fide network of small and emerging biopharmas-naturally brings to mind several challenges. Wenzel says the biggest overarching concern may be clearly delineating when something is collaborative versus competitive, and where to draw the line between what members can share and what they’re not willing to share. Examples of the latter may include specific IP or scientific expertise or certain partnership models with payers.

	“Coming in the door and saying you must use this technology or this is the way we handle alliance management-kind of take it or leave it-that’s not obviously the right solution, regardless of the size of the relationship,” Wenzel tells us. “It’s a two-way street. It’s not just about the CRO being responsible to the sponsor; the sponsor also has to find a way to work with the CRO.”

	According to Wenzel, the key will be finding the “sweet spots” in the relationship. Could a network of sponsors, pursuing the same targets, collaborate and share clinical trial placebo arms, for example? Alternately, could a CRO, for instance, invest in a natural history study in a particular disease area, and then make the data available to a group of sponsors, so they wouldn’t each have to conduct the study individually?

	“It’s the question around where could they share for advantage and where can’t they share because of competitive information?” says Wenzel.

Proposed partnership model explores the value of establishing alliances between CROs and networks of small and emerging biopharma companies.

Think Big on Outsourcing: A Network Approach for Small Biopharma

	Forging new partnerships focused on the safety of long-acting opiates is important, as public health questions surrounding drug abuse and addiction have increased, along with regulations governing these products once they reach the market.

	James Young, VP of Global Product Development at Mallinckrodt Pharmaceuticals, believes that extended-release (ER) or long-acting (LA) opioid therapy plays a vital role in medicine, offering a management mechanism for those patients with severe chronic intractable pain who have not gotten relief from other means of treatment. The Institute of Medicine reports that more than 100 million Americans are affected by chronic pain, with some $600 billion spent annually in medical costs and lost productivity. Young noted, while presenting at a Partnerships in Clinical Trials session, that these drugs, however, come with significant baggage-mainly in the potential for abuse. Young explains that the makers of opioid therapy are diligent in their efforts to prevent the misuse of their drugs, but are continually challenged by a faction of consumers that are adept, persistent, and creative in finding ways to abuse treatment. 

	Amid concerns over rising abuse levels of ER/LA opiates, the FDA has increasingly engaged with biopharma companies on ways to combat the tide-and further assess the serious risks of misuse, abuse, addiction, overdose, and death associated with their long-term use. Initiatives have included mandating risk evaluation and mitigation strategies (REMS) for recently approved narcotics, as well as heightened post-marketing requirements (PMRs). REMS programs in the context of opiate products can involve sponsor training of physicians on the appropriate use of their drugs; publishing information about the opiate and any safety issues to raise awareness among healthcare providers; and special labeling, with prescribing language that details the misuse and abuse of these drugs.   

	Young pointed out that the FDA has recently issued a series of PMRs to new drug application holders for ER/LA opioid analgesic products. This has resulted, he said, in increasing partnership activity between drug sponsors to investigate public health questions related to opiate abuse and the effects of these drugs on society. Young and Mitchell Katz, Head of Medical Research and Drug Safety Operations at Purdue Pharma, shared some of the initial learnings from a nine-company industry collaboration focused on the new PMRs for opiate therapy. Among the key findings Katz outlined was the importance of a centralized, unbiased, and independent facilitator to help mange observational trials across all countries; routine and ongoing collaboration and communication with FDA; and the need for more active and open discussion with all the sponsor groups involved. To those ends, the establishment of a post-marketing committee to work closely with FDA, commissioning CROs and vendors for project management and other functions, and forming a steering committee are critical steps to structuring the partnership. They should all include interdisciplinary experts spanning regulatory affairs, clinical, legal, operations, and medical functions, Katz said.  He noted that when conducting observational studies of ER/LA opiates, the collaboration should also leverage sponsor internal risk management groups, which routinely examine aspects such as prescribing habits and other contributors to potential abuse.

	A key to the collaboration’s success will be the ability to manage the complexity of the partnership, which involves 10 observational trials, one clinical trial, and various products, study populations, and schedules. The partners have been laying the foundation for the program for more than 18 months and it is now in the protocol finalization stage. As the project transitions to the execution phase, Young and Katz acknowledge that most of the challenges are likely still to come. Nevertheless, they do believe the partnership-with its overriding goal of advancing public health-is breaking new ground. Just how much will likely come down to, first, answering critical fundamental operational questions: which member holds the investigational new drug application; who provides the regulatory oversight; how will the safety reporting be managed; whose SOPs will be used; and what is the optimal database structure. From there, the implementation and data generation will dictate the collaboration’s ultimate impact in improving the long-term safety of ER/LA opiates for those patients that need them.

Forging new partnerships focused on the safety of long-acting opiates is important, as public health questions surrounding drug abuse and addiction have increased, along with regulations governing these products once they reach the market.

New Data Revealed from a Sponsor Collaboration Focused on Safety of Long-Acting Opiates

	The push to increase transparency of clinical trial data continues to build considerable momentum, amid such factors as the explosion of digital health and new requirements by regulators in the U.S. and 

 to disclose study results to the public. Not lost in this movement have been new efforts to break down the barriers to true clinical trial data sharing between researchers in industry, academia, and government. With vast amounts of clinical data available today, many believe that making the information more widely accessible can help advance scientific discovery and research, improve patient care, and avoid unnecessary data duplication.

	The quest to “liberate” clinical data in the interest of patient health is one viewed passionately by Dr. Michael Rosenblatt, Executive Vice President and Chief Medical Officer at Merck & Co., who will be speaking on the topic at this month’s DIA 51

 educator has spent much of his career generating and teaching about data, and now, as Merck’s primary external advocate on medical issues, he routinely collaborates with outside scientists, organizations, and academic leaders regarding the issue of data sharing. Rosenblatt, who is co-chair of the DIA meeting, will take part in a panel discussion exploring the recent findings from the Institute of Medicine’s (IOM) 

 on clinical study data sharing. The panelists will also discuss the major risks (privacy and proprietary concerns, IT challenges, etc.) that they believe must be addressed if the potential of this movement is to be realized. Rosenblatt recently touched on these issues and more in an interview with Michael Christel, managing editor of 

 What are some initial key learnings from the industry’s perspective when reviewing IOM’s data-sharing report?

 Over the last few years, there has been a growing drumbeat about the need to share data from clinical trials. We and other pharmaceutical companies and people in different sectors of healthcare have felt that that would be very useful, that there are potential benefits. But the IOM is really the first and only group that pulled together representatives from all the key sectors to work on this problem, to develop some principles, and to make some recommendations. They pulled people not only from industry, but academia, editors of medical journals, people from regulatory agencies, and charitable foundations.

	They’ve enunciated some important principles. One is, while you know that there is potential benefit to sharing clinical trials data, the data needs to be shared responsibly-access should go to people who have a research question or a research hypothesis, and the information they learn will be reported and made available publicly. Another important takeaway is that these aren’t recommendations that apply to only one sector, like “industry needs to do this.” Anyone who generates clinical trials data should be prepared to share that data.

	We live in a world in which drug companies sponsor trials, the NIH sponsors trials, the European governments sponsor trials. If you don’t bring together data from all of those sectors, potentially you get blind spots and distorted information. I think that will be a big part of the sharing-not only sharing it responsibly, but trying to be comprehensive and having one set of principles apply to everyone.  

The IOM committee concludes that sharing study data is in the public interest. In efforts to enhance transparency, to what level will sponsors need to adapt their R&D policies and overall clinical research culture?

For Merck, specifically, we were already doing this. I think we’ll be doing more of it, in part because the demand is going up. We do need to work on a number of technical aspects. How do you share this data in ways in which you can still as much as possible keep the data secure, so that patient privacy and patient confidentially aren’t violated? We need to find platforms that will make the data accessible to those whose requests are going to be approved, and to make the data accessible to all the companies that are participating in this. There are big questions: what’s the type of data? What’s the timeline? The costs are going to go way up. We’re finding ways to do it. But for others, this may be a challenge, just the actual implementation.

	In terms of the mindset, we now need to think that every trial we do is something that we should be prepared to share. In a way, that’s a statement to the public and the patients who go into our clinical trials-that we’re not the exclusive owner of that data; others are entitled to make use of that data, too, for patients and for the public good.         

Can more data sharing help improve clinical trial quality, through feeding back into future trial designs?

I think it can. In a way, some of this is a leap of faith. We don’t have a lot of examples yet of actual benefits that we can point to. But everyone believes that when smart people look at data from different perspectives, that will give us insights into what our patients need, which group is responding, which group isn’t responding, do drugs do more or less than we thought they did, in particularly on safety issues? Clinical trials usually involve thousands of patients when you get to a stage III outcomes trial. But when a drug is more rare, the side effects often aren’t seen until the drug is on the market. It may be possible through the sharing of clinical trial data to understand the more rare safety issues because you can aggregate some of that data that won’t appear in any single trial.

How are pharma companies approaching the challenge of weighing greater public/regulatory demands for transparency with proprietary concerns?

We see this as an issue that’s very important, and it’s bigger than ourselves. We were pleased that the IOM recognized some of the issues that were very real to us. One is the recognition that there could be proprietary information that could put us at a competitive disadvantage if it were revealed too early. The recommendations of the report allow for adjustment to be made. Those things do have to be absolutely protected in any implementation plan going forward. The other thing is we all have to do it at the same level. So if academia is coming in and they’re going to be sharing their data, they have the same concerns. That sort of sets the level at which kind of data is available, who’s it available to, etc.         

Your DIA session will explore other barriers to clinical trial data sharing. What are your thoughts on the risks associated with misleading analyses in particular?

It’s important to remember that with much of the analyses-especially when you’re getting to big data-the rules of the road and the methodologies for secondary use of data are still in the early days. You might have a question and you might have various kinds of methodologies that you can use to answer that question, some of which would be valid and some which might not. There isn’t enough experience and standards set yet to know which methodologies clearly should be used and which shouldn’t be used.

	The other thing is we can get in situations where a solo researcher, with access to the data, can come up with a finding using his or her methodology that’s a little off the mark-maybe misleading or inaccurate and hasn’t been scrutinized in the same way that either the company or regulatory agency has done. Then the researcher goes out and publishes this-puts it on the web, or in their blog, or whatever they’re going to do that’s not peer reviewed. So the danger is, one, it’s never helpful to medicine to have misleading information circulate around. But you can compromise or even lose drugs that actually provide many patients with benefit. Sometimes that erroneous information never goes away. Think about autism and vaccines, for example. It’s extremely important that there’s integrity around this process and that we get the right information out there.

 Do you feel potential compromises in the area of patient privacy might be the biggest risk in this whole effort?

I do. I see this as a potential safety issue. Because even though the data is supposedly de-identified, no one in this world can assure patients and physicians that the data is absolutely secure. The National Security Agency of the United States was hacked, as were the Swiss banks, and as have been a number of major retailers in the United States-

. Why did we think health systems were somehow protected? What’s at risk is if you reveal that a patient has mental illness or a drug problem or had that in the past, in the U.S. that can be a problem in getting insurance or getting employment. There are places in the world where if you reveal someone’s religion or their ethnicity or their sexual orientation, that’s potentially a fatal outcome.

	You have to remember the direction we are going in. We’re going to be layering more and more genomic data into these databases. And with genomic data, you can absolutely identify an individual uniquely based on their genetic data. There are safety concerns that we’ll have to address with informed consent, because we can’t give assurances that the dataset is bulletproof. It’s one thing to generate the data and hold on to it the way clinical researchers have done for decades now. It’s quite another thing to open it up to sharing. We have to find a way. We have to be able to share; it’s really important. But we have to remember the nature of the information we are sharing.

 With industry initiatives underway to set up data transparency workstreams, how do you see clinical trial data sharing evolving in the next few years, particularly in establishing the infrastructure necessary to make it work?

Although it wasn’t done intentionally this way, a number of companies and groups have been piloting out projects and ways of doing it in parallel. So I think we’ll start comparing best practices. My guess is we’re going to be moving more and more toward a common platform for sharing. We now have a set of guiding principles that more or less fit where everybody wants to go. Now we’re into the blocking and tackling of implementing this over the next few years.

 Will its ultimate success hinge on ensuring the data is shared responsibly, as you alluded to earlier?

That’s our view. Some think there shouldn’t be very much sharing, while others think you should just take all your data and hang it out like laundry and let everybody have at it. If your main goal is to get data shared for research purposes to benefit patients, then I think you wind up somewhere in the middle.

Merck & Co. Chief Medical Officer Dr. Michael Rosenblatt speaks with Applied Clinical Trials about the significant opportunities and challenges of sharing clinical trial data and the progress so far in developing a framework that, if properly pursued, could help transform the future of research and clinical care.

Q&A: The Future of Clinical Trial Data Sharing

	The concept of increasing the speed and efficiency of clinical trials is a well understood and agreed upon priority of most clinical operations professionals. What is less readily apparent, however, is what approaches in this area have worked successfully and which ones have not in recent years, as biopharmaceutical sponsors deal with a changing drug development environment, one influenced by such factors as regulatory pressures, rising R&D costs, growing healthcare spending, and the challenge of rushing trials of experimental drugs and vaccines for outbreaks such as the Ebola virus.     

	During a panel discussion at Partnerships in Clinical Trials, leaders from four industry organizations spoke about the strategies and solutions their companies have attempted in efforts to accelerate study execution. Among the areas highlighted were process and technology initiatives related to patient recruitment, site engagement and activation, lab testing, and direct-to-patient care.

	Published reports find that 86% of clinical trials experience delays, and according to CenterWatch, 81% of these reach one to six months in length, with 5% of delays lasting even longer. Session moderator Craig Coffman, Executive Director, Clinical Business Operations & Outsourcing at Nektar Therapeutics, pointed out that there are myriad issues that occur in the life of a clinical trial that can set timelines back very quickly. He referenced the analogy of drug developers “building the airplane while 30,000 feet in the air.” He noted that if sponsors and CROs don’t reach the key milestones in a trial upfront, they are unlikely to make up ground the rest of the way. The ability to meet those milestones hinges greatly on execution, communication, and the expertise of the clinical team.

	In efforts to speed up clinical trials, Charles Drucker, Director of Client Facing Operations and Alliance Management for Quest Diagnostics, acknowledged the benefits of new technologies, but said it is process improvements that may be the biggest difference-makers. He cited historical examples in the medical field, such as the Apgar scale in assessing a newborn baby’s health, and the decision following the Iraq and Afghanistan wars to move mobile army surgical hospitals significantly closer to those wounded and hurt. In the drug development setting, Drucker discussed how process improvement strategies have led to new approaches in patient convenience. Those include designing protocols that allow for mobile phlebotomist visits to patients’ homes or the option for patients to visit storefront laboratories to draw blood instead of making repeated trips to the investigative site. Another example of process improvement referenced by Drucker is designing trials with just one investigative site, where the site leverages patient service centers for blood collection and performs all its outreach and recruitment through social media. Qualified patients are given an all-expense-paid trip to the trial site. There, the patient learns how to give him or herself an injection, how to take a picture of the injection site with a phone, and the process of setting up visits with the study nurse. Subsequent blood draws are administered at a storefront lab near the patient’s home, and the remainder of the trial is conducted by phone, Skype, and through patient-reported outcomes (PROs) and surveys.     

	Manny Lazaro, Head of Clinical Operations at Forum Pharmaceuticals, pointed to the advantages of mobile units for patient retention, particularly in developing countries where subjects more commonly live in remote areas. He noted, however, that setting up these units can be expensive, and it’s important for sponsors to build the costs into their budget during the planning stage. The speakers noted as well that not all therapeutic areas are conducive to a mobile-trial approach.

	Another solution brought up the by panel to help speed up studies is expanding the level of site engagement. From a sponsor perspective, Lazaro stressed that it’s critical to not lose site of investigator relationships. To that end, establishing a field-based force of medical directors that make sure the investigators understand the science and the safety profile of the product candidate is important. Investigators need to be invested in the clinical trial process, not just handed a protocol to serve as a third-party vendor, in essence, Lazaro said. Other components of increased site engagement include site visits, booster visits, focus groups, and “rejuvenation meetings,” where sites and sponsors/CROs can get together to discuss any problems and each site can leave with an action plan in place. The speakers indicated that such avenues as leveraging local medical science liaisons and key opinion leaders and having a sponsor’s medical director tour sites has resulted in an upsurge in patient recruitment for their trials.

	Terri Roberson, Senior Director, Humira and Immunology, Clinical Program Development at AbbVie, noted that while the industry has yet to find the smoking gun to truly speed up clinical trials, developing innovative and aggressive strategies in study start-up have paid dividends. She discussed her company’s recent experiment in site activation, where it was able to set up 40 sites in 40 days for a global trial that already included 80 existing sites. She attributed the results to several factors, including starting out with a mass outreach effort for investigators, empowering clinical research associates and monitors, conducting all the feasibility assessments by phone, issuing no-negotiated contracts, using ePRO devices, requiring that sites have a central institutional review board (IRB), qualifying each site during one visit, and providing a 24/7 hotline for the sites. Roberson said the 40 sites activated in the pilot program ended up enrolling patients 100% faster than the existing trial sites had.   

The concept of increasing the speed and efficiency of clinical trials is a well understood and agreed upon priority of most clinical operations professionals.

New Approaches to Speeding Up Clinical Trials – What Works and What Doesn’t

	Engaging and recruiting participants for clinical trials continues to be a struggle for the life sciences industry. However, emerging technology partnerships in the biopharma space may be providing hope in accelerating patient enrollment and reducing bottlenecks through a concentrated focus on target profiles.

	One example is “The Patients 2 Trials Consortium,” formed in recent years by Novartis, Eli Lilly & Co., and Pfizer around the mission of developing a standard language for patients interested in clinical trial opportunities. To that end, the companies have since agreed on target profiles that best define and normalize groups of patients who may match up well to a particularly study, and have built interfaces that leverage reader-friendly protocols. Representatives of the three sponsors spoke during a Partnerships in Clinical Trials session on the progress of the consortium to date, and were joined by Pablo Graiver, co-founder and CEO of TrialReach, a startup online platform company that is partnering with the group on creating the infrastructure to connect the standard datasets to prospective patients.

	David Leventhal, Director, Clinical Innovation, Worldwide Research and Development at Pfizer, said the collaboration spawned from the need for sponsors to be self-determined about their capabilities in funneling patients to the appropriate clinical trials. He noted that the struggles in this area are shared by all drug developers, in all therapeutic areas-a realization, Leventhal says, that has resulted in increased partnering around optimizing target profiles. For example, agreeing on what specific profiles constitute the kind of patient looking for a study in type 2 diabetes or Alzheimer’s disease or non-small cell lung cancer.

	Lani Hashimoto, online patient recruitment specialist at Novartis, explained that in order for patients to have more choices of clinical trials, it requires scale, an effort that can more reasonably be accomplished through the collective efforts of consortiums such as Patients 2 Trials. Katherine Vandebelt, Senior Director, Clinical Development Innovation at Lilly, noted that part of achieving such scale is having teams spend time interacting with patients to learn about their frustrations and difficulties in finding clinical trials. This information, Vandebelt noted, specifically helped Novartis create an application programming interface (API) to match patients against all available trials to find the appropriate ones for each individual. Demonstrating the targeted approach in action, Vandebelt said, can help foster increased patient trust and confidence that a trial they are interested is ultimately right for them. And by partnering with other sponsors to share an open space for interaction, patients can benefit from greater access to studies.

	During the session, Graiver gave a live demonstration of TrialReach’s platform, which amasses thousands of clinical trials from various sources, and, using the consortium’s target profiles, standardizes language in a study protocol. Graiver showed how users can provide answers to simple questions such as condition, location, age, etc., and as each field is inputted, the search results of available trials is narrowed down accordingly. The tool also allows the ability to check off boxes listing the procedures involved in a study. Through reading the eligibility criteria, the algorithm continuously ranks and refines studies to present results in plain language. These searches are saved as a patient’s profile, with each one generating a targeted body of information.

	The consortium is planning to make this search capability accessible by embedding it on disease-specific websites, where prospective patients are already active. In turn, sponsors can use any resulting queries to display maps of matches and information on specific patient populations to help improve the design of trials.    

	While the benefits of this technology are promising, Leventhal stresses that maintaining its driving component-the consortium members agreeing on target profiles (i.e., what constitutes the disease state, the inclusion/exclusion criteria)-is the key to any future success in accelerating patient enrollment.

 Engaging and recruiting participants for clinical trials continues to be a struggle for the life sciences industry. However, emerging technology partnerships in the biopharma space may be providing hope in accelerating patient enrollment and reducing bottlenecks through a concentrated focus on target profiles.