Over the past 10 years, there has been an abundance of disease-based cDNA expression studies motivated in part by drug discovery programs in search of novel genes as potential therapeutic targets. The focus has been in the area of oncology, specifically hematological (clonal) malignancies such as non-Hodgkin's lymphoma (follicular and chronic lymphocytic).

  The emphasis, however, has recently expanded to include solid tumors such as bladder, colon, ovary, prostate, breast, lung, and brain.

 Figure 1. Utilizing Aureon LaboratoriesÃÂ´ Magicâ¢ software, the cellular tissue components contained within an image of non-small cell lung (adeno) carcinoma are segmented and classified. The figure illustrates the postprocessing, color-annotated identification of all cellular elements including epithelial (BLUE) and stromal nuclei (GREEN), fibro-connective tissue (PINK), and Inflammatory cells (YELLOW).  Individual features are then quantified including the degree of (epithelial) tumor cellularity and cell-to-cell relationships.			

 The accumulation of the genomic information has made it rather apparent that many of the identified genes, while potentially therapeutically promising, are also informative with respect to subclassifying clinical pathologic diagnoses. Furthermore, by expanding studies to include clinically well-annotated patient samples with appropriate follow-up, some of these gene signatures have even been successful in predicting outcome.  

These efforts have proven critical in the success of several biological and drug-targeted therapeutic discovery programs, where the target molecule dictates the likelihood of response; examples include Herceptin (Her2/neu) for breast cancer,

  Gleevec (BCR-ABL) for chronic myelogenous leukemia,

  and (c-kit) gastrointestinal stromal tumors,

  and Avastin (VEGF) for advanced colon and lung cancer.

  These agents are predicted to work in a population of patients whose tumor growth and/or survival rate are driven by either the target or target-dependent processes.

To address the changing landscape of therapeutic drug discovery, the FDA is gradually putting pressure on the biopharmaceutical industry to develop companion diagnostics in parallel with the targeted therapies so that the industry develops "targeted designs" for clinical trials.

  These types of trials would be designed to:					

improve upon the optimization strategies for defining the pharmacologic dose of the targeted therapy

minimize the number of unnecessary adverse drug events

It is anticipated that over the next few years such companion diagnostics will be required to select patients, initiate treatment protocols, and potentially stratify patients for selective therapies. 

The challenge, however, will be in the commercialization and clinical application of these complex diagnostics for routine use in medical practice. General oversight for such predictive diagnostics will likely reside in specialized reference laboratories such as Genomic Health, US Labs, LabCorp, and Aureon Laboratories. Currently, these groups are regulated by CLIA/CLEP licensing, and some have CAP (College of American Pathologists) certification. 

A number of mechanisms have been established to ensure appropriate utilization of human specimens, patient confidentiality, and laboratory techniques, including proficiency tests and Standard Operating Procedures for the assay, personnel, and result reporting. In addition, the FDA has recently published draft guidelines for the development and use of multiplex tests for heritable DNA markers, mutations, and expression patterns (see http://

). The regulatory bodies that monitor these types of tests, however, have very little experience in this area; therefore, further work is necessary to ensure that the organizations responsible for these complex tests adhere to certain guidelines.  

Although the overwhelming data is provocative, prevailing technical and study design issues continue to slow down the progress of bringing these types of tests and their results to the clinic. Challenges such as gene-expression reproducibility, low-expression genes, expression averaging across array platforms, agreed-upon robust standards, specimen sampling error, and the small number of analyzed patients are significant and have yet to be entirely resolved. Furthermore, novel mathematical approaches to analyze the data are necessary to render a more meaningful and individualized conclusion. 

Technical advances, including high-quality expression arrays from Affymetrix, correlative testing with quantitative PCR, and specimen manipulation (i.e., laser capture microdissection and RNA amplification strategies), have been useful but not sufficient enough to address the inherent heterogeneity that exists within the disease process being studied. In addition, there are still only a handful of studies in which gene expression patterns have been translated into either a clinical diagnostic or prognostic assay. Two recent examples include a diagnostic kit for the epidermal growth factor receptor (EGFR) in colon cancer and other solid tumor types

  and a prognostic assay for the ZAP-70 tyrosine kinase in chronic lymphocytic leukemia (CLL).

  Both are protein-based, FDA-approved, immuno-histochemical assays that have been recently included in clinical diagnostic laboratories.  

The latest development in the predictive expression arena has been the release of a 21-gene panel (Oncotype DX, Genomic Health, Inc.) for predicting recurrence of breast cancer after hormonal adjuvant therapy.

 This assay was initially derived from cDNA expression arrays performed on fresh frozen tissue samples and then reformatted as an RT-PCR test, which utilizes formalin-fixed, paraffin-embedded (FFPE) tissue specimens. 

As discussed, one of the major drawbacks in using data derived from tissue expression profiling has been the implicit loss of tissue heterogeneity once the sample has been processed. Laser capture microdissection systems have aided in creating defined "cellular" signatures

 cellular relationships are minimized as a result of the microdissection process. Furthermore, the majority of these assays are complex, requiring special hardware platforms and technical sophistication with respect to specimen handling, especially when RNA is involved.  

There has been a renewed effort by the pharmaceutical industry to employ more sensitive and comprehensive pharmaco-efficacious methods to better understand a patient's response to therapy, including safety and toxicity concerns. One example is the association of specific point mutations in the EGFR gene with respect to IRESSA (AstraZeneca) response in patients diagnosed with non-small cell lung cancer (NSCLC).

  Such analysis helps to illustrate the benefits of the industry's efforts; however, the low incidence of EGFR mutations and the mixed results from several clinical trials suggest that additional factors are clearly involved in the response pathway and that further studies are needed. 

When it comes to predictors of molecular toxicity, there are a number of examples in which genetic polymorphisms in drug metabolizing enzymes have impacted upon clinical outcome.

  One example includes the presence of the UGT1A1 (uridine diphosphate-glucuronosyltransferase) variant, which when present in patients treated with Irinotecan results in a higher chance of grade IV toxicity.

  This example illustrates how molecular phenotypic data can have an impact on the development of appropriate treatment algorithms. Of course, the final goal needs to be the creation of more highly integrative patient management systems that are tailored to the specific disease process at hand. 

In regard to the IRESSA example above, a key question facing AstraZeneca—and all biopharmaceutical companies today—is "What are the best approaches and technologies currently available to evaluate response, given the limited amount and type of tissue specimens available from clinical trials?" Ultimately, this information could potentially assist in the design of subsequent clinical trials, as well as impact on preclinical and development projects of similar class drugs. 

One approach would be to use FFPE tissue samples from the de novo primary tumor specimen of patients who received IRESSA and where outcome data is available; in this case, factors present in the primary tumor sample could potentially be used to assess and/or predict a clinical objective response to the drug. Similar approaches are currently underway in prostate cancer whereby specific biomarker expression patterns have been identified in the FFPE prostatectomy specimen and linked to a therapeutic response.

  Although there are limitations in the types of assays that can be performed with FFPE, the samples in general are very attractive for clinical trial management because they can be easily procured and stored for long periods of time.  

The following pilot study was designed to utilize the FFPE samples obtained from a patient cohort with NSCLC enrolled in an expanded access program for IRESSA. The goal was to evaluate whether IRESSA response, as outlined below, was associated with EGFR mutation status in the patient's primary tumor sample. The objective response was defined as per WHO criteria and included: complete response (CR), partial response (PR), minor response (MR), stable disease (SD), and progressive disease (PD). The EGFR mutation status was evaluated from DNA extracted from each of the patient's tumor samples. Then, the mutation data was incorporated along with routine clinical variables such as gender, smoking history, and ethnicity to create a unique profile of each patient. 

The specific characteristics of the EGFR analyses, including binary evaluation, e.g., presence/absence of mutation, and quantitative attributes (e.g., number and type of exon involved (18–24)) and type of mutation  (missense/deletion), were all considered patient features and evaluated as part of the integrative "systems pathology" model. A similar "systems approach" has been reported in prostate cancer in which elements of the patient's clinical history, biomarker data, and bio-imaging analytics from the primary tumor specimen were placed into a mathematical model to predict PSA recurrence.

  It is anticipated that once the IRESSA pilot study has been completed, a model predicting outcome based in part on EGFR mutation status will be developed. 

The pilot study included an initial assessment of the tissue sample for overall quality using standard staining practices with Hematoxylin and Eosin (H&E). Digitized images were obtained for morphometric analysis, which included characterization of the tumor sample with respect to overall cellular composition, degree of differentiation as reflected by cytoarchitectural changes, angiogenic profiles, inflammatory composition, and even tumor grading characteristics (see Figure 1 for an example). The digitized H&E section was segmented by a proprietary software program that utilizes computational algorithms to modify what is traditionally a subjective assessment. 

The clinical trial tissue specimens were then analyzed using a series of antibodies as biomarkers that were selected based on their reported scientific association with NSCLC tumor biology and/or EGFR pathway functionality. Antigens were evaluated with immuno-fluorescent labeling strategies utilizing spectral imaging in a multiplexed format. This conserved the overall use of the valuable tissue sample while maximizing on the type and quality of the data that was generated. Since the output was a fluorescent signature of the tumor sample linked to the histomorphology, a quantitative assessment of proteins and their cellular distribution was possible. The results were recorded from the tissue sample as quantitative continuous variables and then entered into the predictive model. 

Previous strategies using standard Immunohistochemistry for assessing EGFR status in tissue samples and associating this with response have been inconclusive,

  thus prompting the need for incorporating more quantitative approaches to evaluate tumor antigens in clinical trial materials. In addition, recent publications have further confirmed the critical need for quantifying tumor antigens from tissue sections, especially when developing predictive models.

The final step in the development of the IRESSA response pilot study was to define the specific primary and secondary objectives, which were based on the clinical outcome of the trial. Even though the pilot study is underway, previously described models using similar strategies have proven very successful in predicting clinical outcome.

In Summary, traditional cancer diagnostics begin with a histologic assessment of the patient's tumor sample (i.e., morphology, tumor grade, staging); then, additional assays are utilized, including Immunohistochemistry, FISH, Cytogenetics, Flow Cytometry, and Real-Time PCR, to confirm a diagnosis. What has been lacking from this approach is the ability to make an accurate assessment of the patient's predictive response to specific therapies, especially in a clinical trial setting. Given that the future of molecular medicine is "smart drug" therapeutics and "targeted" clinical trial designs, there is a critical and immediate need for integrative and accurate personalized predictive analyses. 

 is senior vice president, research collaborations, with Aureon Biosciences Corporation, 28 Wells Ave., Yonkers, NY 10701, 

 is on the board of directors at Aureon Biosciences Corporation and the director of molecular pathology at Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021, (212) 639-7746. 

, "Prediction of Survival in Follicular Lymphoma Based on Molecular Features of Tumor-Infiltrating Immune Cells," 

2. M. Iwashima, B.A. Irving, N.S. van Oers, A.C. Chan, A. Weiss, "Sequential Interactions of the TCR with Two Distinct Cytoplasmic Tyrosine Kinases," 

3. L. Stoudt, "Molecular Diagnosis of the Hematologic Cancers," 

4. J.E. Cortes, S.M. O'Brien, F. Giles, R.H. Alvarez, M. Talpaz, H.M. Kantarjian, "Investigational Strategies in Chronic Myelogenous Leukemia," 

Hematology/Oncology Clinics of North America

5. S. Sanchez-Carbayo, N. Socci, E. Charytonowicz 

, "Molecular Profiling of Bladder Cancer Using cDNA Microarrays: Defining Histogenesis and Biological Phenotypes," 

, "Diagnostic Markers that Distinguish Colon and Ovarian Adenocarcinomas: Identification by Genomic, Proteomic, and Tissue Array Profiling," 

, "Gene Expression Profiles Predict Early Relapse in Ovarian Cancer After Platinum-Paclitaxel Chemotherapy," 

8. G. Glinsky, A. Glinsky, A. Stephenson, R. Hoffman, W. Gerald, "Gene Expression Profiling Predicts Clinical Outcome of Prostate Cancer," 

9. P. Meltzer, "Gene Expression Profiling in Breast Cancer Research," 

10. S. Loi, C. Desmedt, F. Cardoso, M. Piccard, C. Sotiriou, "Breast Cancer Gene Expression Profiling: Clinical Trial and Practice Implications," 

, "Expression Profiling of Primary Non-Small Cell Lung Cancer for Target Identification," 

, "Integrated Array-Comparative Genomic Hybridization and Expression Array Profiles Identify Clinically Relevant Molecular Subtypes of Glioblastoma," 

, "The HER-2/neu Gene and Protein in Breast Cancer 2003: Biomarker and Target of Therapy," 

14. R. Logrono, D.V. Jones, S. Faruqi, M.S. Bhutani, "Recent Advances in Cell Biology, Diagnosis, and Therapy of Gastro-intestinal Stromal Tumor (GIST)," 

Articles

Notes from the Field

Targeted designs for clinical trials are the next step in predictive diagnostics.

The Future of Predictive Testing

Enterprising Software Boosts Productivity by Tapping into Familiar MS Office Applications

Need enterprise software? Want to be an instant power user, too? 

 (Walldorf and Munich, Germany) promise to make it all possible with a new fusion of Microsoft's desktop productivity tools and SAP's business process expertise. It's code-named Mendocino, and the two companies are slated to roll the product out fully in 2006.

The jointly designed and developed Mendocino is expected to boost productivity by plugging information workers into a streamlined environment where process functions and data from mySAP ERP 2004 are available through familiar Microsoft Office applications. Extended menus, a SAP-specific smart panel in MS Office, smart document creation in MS Word, and business analytics delivered through Excel should all add up to time and cost savings. 

To put all of that in perspective, think of having access to corporate-driven tasks such as time management, budget monitoring, and organization management right from your desktop. Repetitive tasks are reduced, and users are quickly empowered to work directly with automated corporate processes. 

Exchange Supply Chain Data in Real Time, Even with Outside Vendors and Investigator Sites

 (Agoura Hills, CA) delivers the "missing link" in the extended clinical supplies chain with its introduction of Clinicambio, the world's first real-time clinical data exchange system accessible by authorized contractors, IVR vendors, and investigator sites.

Marketed as an "essential tool" for pharma and biotech companies increasingly outsourcing many of their clinical supply processes, Clinicambio facilitates better materials management capability and inventory tracking, faster distribution to investigational sites and drug dispensation to patients, and reconciliation in a validated environment. It also enables external vendors to leverage its functionality while still utilizing their existing IT investments. 

The software acts as a hub for information and data that a sponsor hosts and exchanges with outside vendors. Clinicambio has the ability to identify every message received from external systems and route it to the appropriate queue. Vendors and investigators can review completed work orders and kits, check the status of shipment requests and assignments, and enter notifications and messages directly into the system. 

InfoPro Solutions, 1-818-879-0075, http://

Global Trial Management and Translation System Bridges Borders and Languages 

 In the world of clinical trials, individual clinicians, research groups, and pharmaceutical firms benefit from services that accelerate capturing, authoring, managing, and distributing content across multiple formats and languages. 

 (Waltham, MA) WorldServer GMS globalization management system is software for content management, translation, and globalization-specific process automation that easily integrates with existing content management solutions, bringing unprecedented ease to clinical trial globalization efforts.

The Center on Outcomes, Research and Education at Evanston Northwestern Healthcare recently adopted the system for its Translation and Formatting Services division. WorldServer, in effect, has provided a highly scalable and flexible framework that helps ensure the quality and consistency of work being done by CORE's extensive network of 500 translators around the world. 

WorldServer GMS can produce output in a number of formats, including PDF. A demo is available on the Web site. 

eShowcase

Truly informed consent is impossible. Michael Sharp's 2004 oncology consent form study found that consent forms typically included 14 topics and 2700 words in 11 pages—not including HIPAA. Some were over 6000 words long. Add another 500–1000 words for HIPAA, and the typical oncology consent form averages 3500 words. That's too much information for anyone's brain to remember and process for an informed decision. 

Memory research finds that working memory—how much information is available at a given time—is only one to four items. This psychological limit makes it impossible for prospective subjects to remember all the information they are expected to remember in the consent process plus consent form. Because consent forms are required to include so much detailed information, they create their own failure to inform. More information equals too much information, which creates memory overload, not more understanding.  

Federal regulatory agencies, IRBs, and bioethicists have not yet linked memory limits to the consent process. Hard-to-understand (remember?) consent forms are to be written at a 6th–8th-grade reading level to improve understanding. But writing consent forms at lower grade levels will have little effect on the number of topics, words, or pages in a typical consent form. The number of consent form topics (and HIPAA) cannot be reduced; they are required by federal regulations. How can prospective subjects remember 14 topics, some of which are explained in excruciating detail, when their working memory can only remember four? Writing consent forms that follow plain English recommendations might make consent forms more readable and more attractive, but will probably have little impact on reader memory. 

Despite requirements for consent forms at lower grade levels, evaluation studies find little or no improvement in understanding. Even modest improvements are questionable because of serious flaws in consent form comprehension studies, such as the inability to operationally define comprehension, lack of validity and reliability of the comprehension measures, use of comprehension measures (true–false, multiple-choice) susceptible to guessing, etc. Nevertheless, consent form writers are still encouraged to write consent forms at a 6th–8th-grade reading level, although in my 11 years' experience on an IRB I have never read a consent form at that level.  

Federal regulators and IRBs have it backwards. They assume consent forms will be more understandable if they are more "readable"—even if there is no evidence to support that assumption. They start with the 14 topic consent form and assume that it can be understood if only consent form writers use shorter sentences and smaller words. But because memory is not part of the informed consent discussion, that assumption is little more than magical thinking.  

The consent process and consent form regulations and recommendations should be based on, or at least influenced by, research on memory and information processing strategies. Some investigators address comprehension by asking subjects to describe the study back to them during the consent process. Even if subjects can do that reasonably well, how long does their memory for that information last? Would subjects have the same memory and understanding if questioned a day later? A week later? A month later? The success of short-term memory does not guarantee that the same information will be converted to long-term memory; these are two different psychological and biological processes. Because federal consent requirements contradict the brain's ability to remember and process those requirements, consent forms cannot be remembered or understood by prospective subjects.  

 PhD, IRB member, North Memorial Health Care

A Closing Thought

Despite requirements for consent forms at lower grade levels, evaluation studies find little or no improvement in understanding.

Memory Overload: The Impossibility of Informed Consent

The last week in September saw some contrasting initiatives in the world of clinical trials, ranging from the defensive to the assertive. Underlying all of them were key questions relating to the health and reputation of the health care industry—and only time will tell which will be the most effective.

The move most evidently linked to clinical trials was the inauguration of the first worldwide clinical trials portal. Its avowed aim is to provide doctors, patients, and their families with simple access to the most complete information on ongoing and completed clinical trials of drugs and vaccines. 

By definition, this is not a specifically European initiative. Its godfather is the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA). But it has been heavily backed by the European pharmaceutical industry, and was ceremonially launched by Dr. Daniel Vasella, chairman and CEO of Novartis, and president of the Geneva-based IFPMA. 

The portal is an Internet search engine constructed specifically to link to on-line information about clinical trials worldwide. It has been put together since the beginning of 2005 by pharmaceutical industry technical and regulatory experts as well as IBM consultants, and it currently contains more than 250,000 links. These include individual pharmaceutical company sites, sites run by third parties working on behalf of companies, pharmaceutical industry association resources (such as the U.S. pharmaceutical industry association's site, 

), and government sites that routinely carry details of industry trials, such as the U.S. National Library of Medicine's 

Information about on-going clinical trials includes title, description in lay terms, trial phase, trial type (e.g., interventional), trial status, trial purpose (treatment/diagnosis/prevention), intervention type (e.g., drug/vaccine), condition or disease, key eligibility criteria (including gender and age), and location of trial and contact information. The other broad category of information to which the portal provides links is the results of completed clinical trials, which are made available in a standard, nonpromotional, summary format by various on-line databases.  

The fundamental motivation behind the portal is to demonstrate that the industry is not conspiring behind closed doors to make profits irrespective of patients' health. As Vasella claimed in his launch statement: "The launch of this portal shows the pharmaceutical industry's commitment to full transparency in the interest of patients and healthcare professionals."  

Some of the immediate stimulus for the initiative was widespread public concern in late 2004 over the appearance of unexpected adverse side effects with blockbuster products such as Vioxx, and the broader background included the growing calls for increased public access to information about medicines. The drug industry, anxious to prove its credentials, moved into high gear with this clinical trials portal project as a method of countering public suspicion. 

 may well have already tried out the portal for themselves, and made their own evaluation (it is at 

). A rapid skim through it by this columnist was not quite as revealing as its publicity suggests. There were innumerable links to the contents of the U.S. National Library of Medicine's site—but a new portal is hardly necessary for that. Links to direct company information or specifically European trials were, however, not so easy to find—and several of the links proved to be dead or caused problems that closed down this columnist's software.  

Some of this disappointment may be ascribed to the incompetence of this columnist, and to the haste with which initial searches were run in compliance with the copy deadlines of 

. But if the site is intended to widen access to the public, then this columnist—no more than a dumb journalist with a superficial knowledge of clinical trials—is perhaps as good a representative of the public as anyone else. Moreover, anyone from a European country other than the United Kingdom or Ireland will be obliged to work in what—for them—is a foreign language if they want to operate the site. 

To be fair to the portal, it admits that this is only the first stage in its development. "Priority was given to putting a useful information-gathering resource into the hands of patients and their carers as quickly as possible," its launch material says. So at present it offers only simple search functions, and only in English.  

The pharmaceutical industry "recognises that the ultimate effectiveness of the portal will require further investment to increase its ease-of-use"—with more languages, assistance to searchers with a limited knowledge of medical terminology, multiple criteria searches to allow search by disease, and geographical area or pharmaceutical company name. The scope of the site is also to be expanded: Other on-line clinical trial information resources, such as the European Union's planned Europharm facility, may be linked to it as and when they become available, says IFPMA.  

The same week saw the launch of an appeal for the future of health care biotechnology in Europe. The European biotech industry association, EuropaBio, published a Healthcare Manifesto (http://

) setting out what it sees as "key policies to meet the healthcare innovations expected over the next few years to meet unmet medical needs." The emphasis of this pitch for a better working environment for European biotechnology is ostensibly the patient, and there are plenty of references to the 250 million patients who have benefited to date from biotech medicines, and "a more patient-oriented approach to human healthcare." 

Some elements of the manifesto correspond to this focus on patient-oriented clinical excellence and appropriate clinical development in a world where many diseases are still untreated: "The views, experiences and expertise of patients—the final beneficiaries—must be integrated into the evaluation process," says EuropaBio, declaring its commitment to creating "products that can substantially improve the quality of life for patients and meet unmet medical needs." And "physicians and other clinical experts must also be involved in the assessment and decision-making. Decisions should not be made without input from clinical experts on the full range of benefits delivered." 

Similarly, the manifesto urges the European Union authorities to "facilitate clinical trials in the field of rare diseases, under the EU Clinical Trials Directive." And, in order to promote the emerging fields of cell and tissue engineered products, it calls for new policies and regulations, including a new and harmonized legislative framework to include specific rules for clinical trials. 

But the EuropaBio manifesto is as much aimed at the well-being of the innovative industry as the well-being of patients. Its essential subtext is that the EU should encourage national authorities to be more generous in paying for new medicines. Its principal concern is that patients "do not have access to treatments"; and that means putting new products onto national reimbursement or prescribing lists, so that they are not only developed, but actually available. The health authorities should ensure "a better balance between benefits, costs and risk," it says. EuropaBio's Secretary General, Johan Vanhemelrijck, warns that logjams in pricing and reimbursement of new products risk disaster: "Are we going to kill off all the efforts made by the industry and all the support that goes into research because when products are developed they cannot get onto the market?" 

The new Chairman of EuropaBio's healthcare council, and Vice President of Health Policy at Serono, Dr. Andrea Rappagliosi, is unequivocal: "We need a predictable stable framework to operate, with no switching off the light at the end of the tunnel when we are investing." In other words, biotech can deliver what patients need, as long as governments are ready to supply what industry needs. It is going to be a hard message to sell in the EU, since the member states all insist on maintaining their own sovereign right to do whatever they damned well please with drug prices and reimbursement. 

The third initiative in that eventful final week of September was of a concrete rather than rhetorical nature. The U.S. biotechnology firm Genzyme significantly expanded its engagement in Europe—confounding those who have repeatedly argued that the EU regulatory and business climate is driving investment away. In a $500 million investment program, it is upgrading three of its manufacturing plants and creating a new research center. 

Genzyme's new discovery research facility is in Cambridge, UK—its first outside the United States. The 25 scientists currently at the new facility will initially focus on new and emerging antibody technologies to identify new therapeutics in the areas of oncology, renal, inflammatory, and immune-mediated diseases, and within five years the scientific staff level is planned to rise to 150. Genzyme is hoping to build partnerships with academic and biotech partners, right across Europe, and particularly among the 200 local life sciences start-ups, including Cambridge University and its renowned science and clinical research. 

At the same time, Genzyme opened a new technology and development center at its Haverhill plant in the United Kingdom, which handles bulk production of therapeutic polymers and small molecules; the expansion will allow process development to support the clinical trials of next-generation products for kidney patients. The next day, it opened its state-of-the-art bio-pharmaceutical production facility in Geel, Belgium, which will produce its alemtuzumab monoclonal antibody for the treatment of B-cell chronic lymphocytic leukemia (currently under evaluation in clinical trials in other cancers and in multiple sclerosis). And the day after it opened a new facility for biological fill and finish operations at its plant in Waterford, Ireland, where just this July its Manufacturing Process Research and Development facility was expanded to support clinical trial work.  

The company already has a considerable stake in Europe, where it employs over 2000 people. Of its 80 or so clinical trials in progress, 30% involve European sites. In 2004, Genzyme formed a joint venture with Medtronic to conduct a Phase II clinical trial of cell therapy to repair damaged heart tissue at medical centers throughout Europe. It plans to enroll 1000 patients in a Phase III clinical trial at more than 250 centers in Europe, North America, and Australia for Tolevamer, its novel, nonabsorbed polymer therapy that could be the first nonantibiotic treatment for Clostridium difficile-associated diarrhea. Two recombinant anti-TGF beta antibodies are in clinical trials with partner Cambridge Antibody Technology, and preparations are underway to enter the clinic with cancer applications of the GC1008 antibody molecule, a collaboration with Cambridge Antibody Technology.  

Five of Genzyme's 10 manufacturing sites are in Europe. In addition to the Haverhill, Geel, and Waterford sites, there is a small molecule, lipid, and peptide production site in Liestal, Switzerland, and a polyclonal bio-manufacturing site in Lyon, France. So too are two of its four sites supplying its diagnostic products (one in Kent, UK, and one in Rüsselsheim, Germany). Meanwhile, Genyzme is expecting European approval in early 2006 for its enzyme replacement therapy for Pompe disease, Myozyme (alglucosidase alfa), for which an authorization application was filed in December 2004. 

I leave it up to readers to make their own assessment of which of these three initiatives is likely to do the most to advance the interests of European patients—and of the European pharmaceutical industry.

 is a freelance journalist who specializes in European health affairs and is based in Brussels, Belgium.

View from Brussels

Three recent initiatives address the reputation of the health care industry in the EU.

Co-Defense and Attack on Clinical Trials

Multiple randomized clinical trials in depression and anxiety have failed to separate active drug from placebo. A number of reasons have been advanced to explain this observation, including subject and site interactions, trial design, site–sponsor interactions, and rating scale deficiencies. Key among the reasons for failure is the subject and rater interaction (the former with unstated expectations and beliefs and the latter with biases based on knowledge of the trial design and test article). The interaction between the two serves to skew the ratings in a way that reduces the apparent treatment effect, creating a so-called placebo response.

We propose a triple blind design by additionally blinding the site's primary efficacy rater from the trial design and the subject's chart. This technique is standard in Alzheimer's trials for one of the primary efficacy scales. Along with providing subjects with a structured education about expectations and modifying the site staff's interactions with the subject, triple blinding may also yield advantages in improved accuracy of drug effects in relation to placebo. 

Many trials in pain, anxiety, and depression fail because of the placebo response.

  In aggregate, subjects who receive a placebo may improve enough during the trial to erase the statistical difference from the active treatment arm(s). As many as 60% of depression trials fail to statistically separate from the placebo arm, which results in the loss of millions of dollars and the failure of some compounds to advance to market.

  For example, of five citalopram studies for depression, only two showed a difference from placebo.

Many reasons for the placebo effect are cited, but specific causes are difficult to quantify and have largely resisted correction by modification of subject requirements and trial design.

  The ethics of using a placebo arm is beyond the scope of this article. The fact that the FDA continues to require it makes continued efforts to reduce the placebo response a desirable objective. 

The site–subject interaction is out of the control of the study sponsor. The interaction includes a supportive environment, assumed penetration of the blind, and unstated subject and staff expectations, all interactions that may adversely affect detecting the difference between treatment and placebo. Attempts to correct this by modifying the study design have met with mixed success, and studies continue to fail routinely. A variety of the site–subject interaction components will be discussed to set a context for the subsequent recommendations. 

Subject psychological support and a therapeutic milieu

Typically, subject visits are conducted in a quiet and friendly clinic office. Subjects interact with the site staff, which usually includes a coordinator and research physician and possibly a separate psychometric rater. During the trial, subjects become increasingly familiar and comfortable with the staff and the office. This often triggers a therapeutic response in the subject.

Since this effect occurs across all arms whether active or placebo, it is "additive" to any response from the pharmacological agent (i.e., in the setting of the clinic visit, there is a likelihood of improvement if a subject receives no other intervention). The standard remedy includes efforts to minimize the  supportive and sympathetic gestures from the staff.

  These efforts are variably applied among multiple trial sites with a patchwork of results. 

Another site–subject interaction is the unvoiced expectation of benefit on the part of the study staff and the research subject.

  This occurs for several reasons. One reason is that the site staff knows the statistical likelihood of subject improvement during clinical trials (i.e., they know that virtually all subjects regardless of treatment assignment will improve, if for no other reason than the placebo effect). Since everyone is likely to get at least a little better, this bias, in effect, predetermines the improvement.  

In addition, many studies have multiple active treatment arms. For example, in a typical depression trial, these may consist of two doses of study drug, possibly an active control arm plus the placebo, which results in a randomization ratio of three actively treated subjects for every one on placebo. With the rater's knowledge that three out of four subjects are under treatment, ratings will be biased in favor of improvement. Published studies observe that trials with more study arms are less likely to separate treatment from placebo.

  Sponsors have been unwilling, for reasons of increased costs and recruitment times, to increase the number of placebo patients to achieve a more balanced placebo to active treatment ratio. 

Both subject and raters speculate to which arm a subject has been randomized. Often these guesses are based on the subject's reported or felt improvement of symptoms. Another common reason for suspecting active treatment is the report or experience of a side effect, perhaps a typical one for the drug class. Often the opposite occurs, with no apparent benefit or side effect, which convinces the subject or rater that the subject is on placebo. Sometimes the guess is correct, but often it is not, with subsequent bias of the ratings.

  This is called penetrating the blind. Study staff who know both the adverse event profile of the test article and the subject's reported adverse events in the chart may think that they know what the patient is taking; right or wrong, the ratings are tainted as a result. 

Even knowing that they might not get active treatment, many subjects report symptom improvement while taking a placebo. Getting a pill in the course of a trial initiates long-standing expectations of benefit based on prior experience in the medical setting.

  In addition, the consent process can sometimes over-sell the investigational product, engendering enthusiasm within the subject and setting up inflated hopes.

It is not uncommon for the site to attempt to orient the subject's expectations with educational statements. These may include statements about the possibility of the study drug not working as intended; they may get a placebo and consequently may not improve, and they may receive admonitions to report the actual symptoms honestly without attempting to "help" by accentuating the positive. There is no evidence that this practice is performed widely, uniformly between sites, or systematically within a site. 

Most study designs require a minimum level of symptom severity to qualify for inclusion in the study. Measured severity tends  to cluster just above the cut-off for inclusion in a non-Gaussian distribution. Worse, subsequent to randomization, scores improve in both groups to more resemble a normative distribution, inflating the placebo group's apparent response. 

Knowledge of the cut-off score on the part of the rater apparently affects the baseline scores and muddies the subsequent distinction of the active and placebo groups. In response, some study designs have escalated the severity for inclusion so that even with the postrandomization deflation of scores there is still sufficient severity to identify a treatment effect. Another study design incorporates the opposite tack, reducing the required severity to avoid score inflation in the first place. Success of the different strategies is inconclusive at present. 

Since the site must interact with the subject, to some extent it will always influence the measured ratings. Any approach should moderate the site–subject interaction in a way that is practicable within the ability and scope of the study site but potentially reduce the adverse influences on the data. We suggest an approach that combines a blinded rater with standardized didactic instruction of the subject. 

In many centers, the study coordinator also performs the psychometric ratings. The combination of coordinating time with the subject plus knowledge of their side effects and symptom changes can both serve to create a therapeutic relationship and suggest a treatment arm to the rater. To prevent this from happening, one tactic long used in Alzheimer's trials is to employ a separate coordinator and blinded rater. 

The Clinicians Interview Based Impression of Change (CIBIC, or more recently the CGIC) is a coprimary efficacy rating very similar to a Clinician's Global Impression of change score (CGI).

  It is a seven-point scale anchored in the middle at four with "no change," and either "minimally," "moderately," or "very much" improved or worsened. Because it is a subjective rating based on an interview of an informant and the subject, there is considerable room for influence from external factors. Many of the original Alzheimer's patients in the studies were on medications with known and expected gastrointestinal side effects. Therefore, the rater was blinded to the patient's chart and was instructed not to inquire about adverse events or other symptoms that potentially could unblind the rater. 

A similar approach may help to reduce the placebo effect, although to be effective, a number of safeguards and ancillary procedures should be incorporated. For example, the rater should not be the coordinator or study physician and should have minimum contact with the subject. Ideally, the only contact should be during the rating of the primary outcome measure. 

Although newer antidepressants and anxiolytics are less likely to have obvious blind-breaking side effects, the blind can be broken—or presumed broken—by the rater with biases in the results. Blinding the primary efficacy rater to the chart can substantially eliminate that presumption. If possible, the rater should not interact with the subject at any time before or during participation in the study except to perform the rating. This includes avoiding the qualifying diagnostic interview and other intake procedures. Optimally, the rater would not know the study specifics, including the randomization ratio and the expected drug side effects. Operationally, the subject would encounter the rater only for the time it takes to do the primary efficacy ratings. Other site personnel would carry out all the secondary ratings and coordinator duties. 

By embargoing the side effects and other safety information from the blinded rater, he or she will rely principally on the actual interview. In addition, personal contact between the rater and the subject will significantly decrease, which should minimize the subjectivity of the ratings and the personal rapport between the two. The rater should also be blinded from the threshold score for qualification of the subject into the study. Without that knowledge, inflationary baseline scores should be reduced; however, this ideal would be difficult to accomplish in many clinical settings. 

A critical corollary procedure would be to educate the subject about what to expect during the trial. Although the actual script may be left up to the site, the sponsor should specify the essential elements, much as they do with the informed consent. The intent is to help the subject understand the need for an honest report of their mood and to give them explicit permission to either improve or not improve. The site personnel would read the educational statement to the subject during the consent and review it at each succeeding visit. With reinforcement, this message should reduce the subject's anxieties about what to say in follow-up visits, increase understanding of the clinical trial process, and yield more accurate reports of the subject's actual experiences. The sponsor would incorporate steps to ensure conformity, with review of compliance made a part of the monitoring visit. 

Any approach to reducing the placebo response must have some of the elements described here if studies are to improve separation of the placebo from treatment arms. Others have proposed alternative study designs for minimizing the placebo response, but none address the site–subject interactions and expectations in a systematic way. Sponsors looking to implement these proposals should begin at the outset of a clinical program by integrating the proposals into their site selection and site staff training. Changing site behavior is not easy, and the desired activities need to be reinforced at multiple opportunities. With education on both the rationale behind the proposals and specific site training, the site staff will more likely be willing and prepared to act accordingly. 

 MD, is founder and medical director of Pivotal Research Centers, 13128 N. 94th Drive, Ste. 200, Peoria, AZ 85381, (623) 815-9714, email: 

 MA, are psychometric raters with Pivotal Research Centers, Mesa, AZ. 

 PhD, is former site manager with Pivotal Research Centers and is now with i3 Research. 

 MD, is principal investigator with Pivotal Research Centers, Mesa, AZ. 

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2. L. Lipton, "Placebo Response Can Confound Drug Trials," 

3. G. Andrews, "Placebo Response in Depression: Bane of Research, Boon to Therapy," 

4. A.M.E. Ker, J. Stadler, M. Viljoen, "The Role of Placebo and the Placebo Response in Clinical Research," 

5. D.O. Antonuccio, D.D. Burns, W.G. Danton, "Antidepressants: A Triumph of Marketing Over Science?" [Commentary on The Emperor's New Drugs: An Analysis of Antidepressant Medication Data Submitted to the U.S. Food and Drug Administration], 

6. R. Lane, "Placebo Response to Antidepressants," 

7. D.B. Oosterbaan, A.J. van Balkom, P. Spinhoven, R. Van Dyck, "The Placebo Response in Social Phobia," 

8. M.E. Thase, "Antidepressant Effects: The Suit May Be Small, But the Fabric is Real" [Commentary on The Emperor's New Drugs: An Analysis of Antidepressant Medication Data Submitted to the U.S. Food and Drug Administration], 

9. I. Kirsch, T.J. Moore, A. Scoboria, S.S. Nicholls, "The Emperor's New Drugs: An Analysis of Antidepressant Medication Data Submitted to the U.S. Food and Drug Administration," 

10. T.P. Laughren, Recommendation for Approval Action for Celexa (citalopram) for the Treatment of Depression [Memorandum], U.S. Food and Drug Administration, 1–5 (2 July 1998). 

11. Forest Laboratories, Safety Update, Regulatory Status Update, World Literature Update [Correspondence], U.S. Food and Drug Administration, 1–108 (22 May 1998). 

12. S. Lee, J.R. Walker, L. Jakul, K. Sexton, "Does Elimination of Placebo Responders in a Placebo Run-in Increase the Treatment Effect in Randomized Clinical Trials? A Meta-analytic Evaluation," 

13. D.L. Zimbroff, "Placebo Response in Antidepressant Trials" [Letter to the editor], 

14. J. Fritze and H.J. Mï¿½r, "Design of Clinical Trials of Antidepressants: Should a Placebo Control Arm Be Included?" 

Feature Article

Strategies for eliminating factors that influence the placebo response during the clinical trial process.

Reducing Placebo Response: Triple Blinding & Setting Expectations

In recent years, the Asian pharmaceutical market has assumed considerable importance for global pharma companies. Its improving economic conditions coupled with a large and growing population offer opportunities for pharmaceutical companies in terms of product sales and R&D.

Japan is the most established Asian pharmaceutical market,

  but cost containment measures implemented by the government to slow health care spending have proved unpopular with the international pharmaceutical industry, and many companies have begun to look to additional national markets in the region. China has received the most interest in the media, largely due to the fact that its economy is growing at a tremendous rate and foreign firms in a variety of sectors, including pharmaceuticals, have invested heavily there. According to 

, since 1978 the Chinese economy has grown at an average annual rate of 9.4%.

South Korea is another Asian country that has attracted the attention of pharmaceutical companies, and the increasing popularity of the country for foreign businesses has largely gone unreported by the media. With a population of nearly 50 million and a GDP per head of around US$14,000, it represents an important Asian consumer base.

  To some extent, the media's enthusiasm for South Korea was dampened by the 1997 financial crisis, which severely dented the country's economic prospects and led to many foreign investors selling their assets.

  According to The Economist Intelligence Unit, although South Korea's economic recovery may be uncertain, the country's foreign-exchange reserves of around US$200 billion make the likelihood of another financial crisis unlikely.

  South Korea's foreign-exchange reserves have been described as the second highest after Japan, among the 30 international member countries that make up the Organisation for Economic Co-operation and Development (OECD).

  From a pharmaceutical company perspective, the South Korean government's renewed focus on health care and demand from the population for new medicines is providing a long-term incentive for pharmaceutical companies to invest in the country. 

The growing interest in South Korea is highlighted by the decision to hold the 2006 International Conference on Pharmaceutical Medicine (ICPM: 

) in the capital Seoul. Representatives from a number of major pharmaceutical companies are on the organizing committee, and the conference is also being backed by the Korean Society for Pharmaceutical Medicine (KSPM: 

) and the Korean Society for Clinical Trials (KSCT: 

). The event will feature three plenary sessions, 11 symposia, and various training courses that will examine pharmaceutical medicine from global, technical, and functional standpoints. 

Following the 1997 economic crisis, the South Korean government attempted to repair the damage that the financial uncertainties had caused to the health care system and its funding structures. The National Health Insurance Act, brought in during 1999, aimed to integrate multiple insurance societies into a single insurer system and enhance the equity of financing for health care.

  Backed by temporary measures through the 2002 Special Act for Financial Stabilization of National Health Insurance, the government attempted to once again provide comprehensive health care services to the public.

The Health Insurance System of Korea is mandatory for Koreans living in the country except for some Medical Aid beneficiaries. In October 2003, it was estimated that the National Health Insurance (NHI) Program covered 97% of the population

  (see Figure 1). The Medical Aid Program, a Korean social assistance program, covered the remaining 3%, mainly belonging to low-income groups. The Ministry of Health & Welfare (MOHW) oversees the operation of the NHI program.

 Figure 1. Employees in the public and private sectors covered by the South Korean health insurance program and their dependents.			

In a 1999 survey carried out by CMR International, respondents from major pharmaceutical companies predicted that although China would become the Asian region of greatest commercial importance by 2005, South Korea would be the second most important Asian emerging market and that it would retain this market ranking in the long term.

  Furthermore, the respondent companies were carrying out an increasing number of clinical trials in these countries in order to satisfy the local regulatory authorities.

  Other reasons cited for carrying out clinical trials in South Korea included providing local physicians with experience of the product and generating additional data from postmarketing surveillance work.

  Interestingly, some of the respondent companies expressed the view that the requirement for them to carry out additional local clinical trials at the presubmission stage acted as a major barrier to the rapid registration of their product in South Korea.

  However, as these perceived barriers were also a feature of other Asian markets such as China, India, and Malaysia,

  these factors were not deterring companies from making further investments in South Korea. 

A major attraction for pharmaceutical companies has been the separation of medical prescribing and dispensing, which represented a key part of South Korea's health care reforms and began in July 2000.

  This process, whereby there was a shift from dispensing doctor to a retail pharmacy market was strongly resisted by physicians, who had traditionally derived a large proportion of their income from pharmaceuticals.

  According to a 2003 report by the U.S. & Foreign Commercial Service and U.S. Department of State, these measures appear to have benefited multinational pharmaceutical companies. Since the prescribing changes were finally introduced, multinationals have expanded their share of the total South Korean pharmaceutical market from 23% in 2000 to 26% in 2001, and to 29% in 2002.

  The report predicted that by the end of 2003, multinationals would achieve a 31% pharmaceutical market share,

This Asian market holds great potential for the future, including possible collaborations with global pharma partners.

Applied Clinical Trials-11-01-2005

The Future of Predictive Testing

eShowcase

Memory Overload: The Impossibility of Informed Consent

Co-Defense and Attack on Clinical Trials

Reducing Placebo Response: Triple Blinding & Setting Expectations

The Promise of South Korea

The CDISC Lab Model: Saving Users Time and Money