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FDA Contemplates Changes in Trial Design, Drug Development and Use of AI in Clinical Trials

Curator: Stephen J. Williams, Ph.D.

Several pharma companies just told the FDA what AI in clinical trials should look like.

It is not what most people expect.
I went back through the RTCT comment letters from Novartis, Lilly, Bayer, Daiichi and others. Read together, they are the clearest signal yet on how AI will get adopted in drug development over the next few years.
Three things they make clear.
Adoption starts at the data layer, not the decision layer. Every letter drew the same line: AI supports qualified clinical judgment, it does not replace it. Daiichi was explicit that AI should not autonomously make dose escalation or safety decisions. But underneath that line, they want automation everywhere. Reconciliation, coding consistency, discrepancy detection, safety surveillance. That is where AI enters trials first, and it is where the near-term value is.
The bar is oversight, not sophistication. Lilly put it best: the FDA should select for the most mature oversight of AI, not the most mature AI. Across the letters, the requirements are validation, audit trails, data lineage, change control, human review that is evidenced rather than assumed. A brilliant model with weak governance does not clear this bar. A well governed one doing unglamorous work does.
The industry is already building the plumbing. Lilly and Bayer, independently, both proposed a DMF-style pathway letting AI vendors disclose model documentation directly to the FDA with sponsors referencing it.
Put those together and the future looks less like AI making trial decisions and more like AI making trial data trustworthy fast enough for humans to decide sooner.
The sponsors who lead this will not be the ones with the most sophisticated models. They will be the ones whose data operations were modernized and able to clean enough to move in real time.

 

FDA News Release

FDA Announces Major Steps to Implement Real-Time Clinical Trials

Agency unveils real-time trial proofs-of-concept and upcoming pilot program

For Immediate Release:

April 28, 2026

On May 27, 2026, the FDA posted a notice in the Federal Register extending the comment period for the Request for Information until June 29, 2026. 

The U.S. Food and Drug Administration today announced two major steps as part of an initiative to advance the implementation of real-time clinical trials (RTCT). First, the agency unveiled the successful initiation of two proof-of-concept clinical trials that will report endpoints and data signals to the agency in real time. Second, the agency released a Request for Information (RFI) regarding a proposed pilot program for RTCT that will launch this summer.  

Early-phase clinical trials are a bottleneck in drug development, often characterized by high uncertainty, limited patient populations, and inefficient decision-making processes. Data is typically reported from sites to sponsors, who analyze and subsequently submit data to the FDA. With improvements in AI and data science, sponsors and trial sites have the opportunity to conduct real-time trials in a way that enhances safety monitoring and radically increases efficiency.  

“For 60 years, we’ve been conducting clinical trials in the same way, where key data signals can take years to reach the FDA. The lag time can delay regulatory decisions unnecessarily and slow down the drug development timeline,” said FDA Commissioner Marty Makary, M.D., M.P.H. “We are boldly advancing a modern approach whereby FDA scientists can view safety signals and endpoints in real time as a trial progresses. This will help us accelerate promising therapies, and build toward our ultimate goal of running real-time, continuous trials across all phases of drug development.”  

The FDA is announcing the successful initiation of proof-of-concept RTCTs by AstraZeneca and Amgen. AstraZeneca is conducting a Phase 2 multi-site trial, TRAVERSE, in patients with treatment-naïve mantle cell lymphoma, with participation from The University of Texas MD Anderson Cancer Center and University of Pennsylvania. Amgen is conducting a Phase 1b trial, STREAM-SCLC, in patients with limited-stage small cell lung carcinoma and final site selection is in process. For each trial, the FDA met with the sponsor on the establishment of criteria for reporting signals in real time. The agency has since received and validated signals for AstraZeneca’s trial through Paradigm Health, thereby establishing the feasibility of the technical framework required for real-time signal sharing.

The FDA seeks to build on these proofs-of-concept with a broader pilot program. Today’s RFI seeks input on potential pilot program design and implementation, as well as evaluation metrics and success criteria.

“Real-time trials have been talked about for years. We demonstrated that it is not only possible, but also potentially transformative for the clinical trials ecosystem,” said Chief AI Officer Jeremy Walsh. “We have to consider our processes from the standpoint of a patient awaiting a potentially powerful treatment.”

Real-time clinical trials are an important step towards the agency’s goal of facilitating continuous trials. At present, most clinical development occurs in discrete phases. Because each defined phase of clinical development is run according to a protocol and typically as a separate study, there is generally a hiatus in the development program after one phase ends and the next begins. This slows the pace of product development. Because real-time trials allow the FDA to view key insights in real time, this hiatus could be eliminated or reduced to a minimum, enabling “continuous” trials.

The agency will accept comments on the RFI until May 29, 2026. The agency intends to disseminate final selection criteria in July and complete pilot selections in August. 

https://www.youtube.com/live/hPT6X4SKOjw?si=ZfLrn3NmYvyqFILm

 

https://www.ajmc.com/view/fda-will-require-only-1-study-to-approve-new-drugs-speeding-up-process

 

News|Articles|February 19, 2026

FDA Will Require Only 1 Study to Approve New Drugs, Speeding Up Process

Author(s)Julia Bonavitacola

Fact checked by: Christina Mattina

A commentary by FDA officials Vinay Prasad, MD, MPH, and Martin Makary, MD, MPH, details the new system for drug approvals in the US.

FDA Commissioner Martin Makary, MD, MPH, and his top deputy Vinay Prasad, MD, MPH, announced in a commentary published in The New England Journal of Medicine that the FDA will revamp its method of approving drugs for use in the US.1 The commentary announced that the agency’s historic reliance on 2 clinical trials will end, with only 1 pivotal trial needed for a drug to be approved for use nationwide.

“Going forward, the FDA’s default position is that 1 adequate and well-controlled study, combined with confirmatory evidence, will serve as the basis of marketing authorization of novel products,” the FDA officials wrote in their commentary.

The FDA had previously worked under guidelines stating that “adequate and well-controlled investigations” were needed before a drug could be approved for widespread use, which were interpreted as generally requiring 2 clinical investigations.2 These guidelines had been in place since 1998, with only supplementary guidance published in 2019 and 2023. The newly announced shift marks the first substantial change in the methods of FDA approvals since the FDA obtained the authority to grant marketing authorizations.1

Makary and Prasad noted that these guidelines had been flexible in the past—specifically in oncology, where 1 study was often enough for a drug approval—but were confusing to drug manufacturers seeking to understand when only 1 trial would be acceptable. Moving forward, the default of using only 1 trial to grant a drug approval should clear up questions surrounding the necessary number of trials.

“The FDA’s historical reliance on 2 clinical trials rather than 1 was intended to provide credible causal evidence that a therapy could improve clinical outcomes with acceptable safety in a world where biologic understanding was more limited than it is today,” the FDA officials wrote. “Two trials should be seen as just 1 of many interlocking facets of clinical credibility, and in 2026 there are powerful alternative ways to feel assured that our products help people live longer or better than requiring manufacturers to test them yet again.”

This move is another step in Makary’s attempts to shorten FDA reviews, which started when he began his tenure last year.3 These include mandating the use of artificial intelligence for staffers and offering new medications a 1-month drug assessment if the FDA believes that the drug serves a national interest.

About 60% of first-of-a-kind drugs have been approved based on a single study in the past 5 years due to legislative initiatives that encouraged flexibility in reviewing drugs for conditions that were hard to treat. The drugs more likely to be affected by this new standard are for common diseases rather than those for rare diseases or cancers, which were already more often receiving approval based on a single trial.

This announcement comes a day after the FDA announced that it will now review Moderna’s seasonal mRNA flu vaccine application, which it had previously refused to look at due to perceived safety and efficacy concerns.4 The increased scrutiny of vaccines presents a contrast to the newly streamlined default standard for FDA approvals.

References

  1. Prasad V, Makary MA. One pivotal trial, the new default option for FDA approval—ending the two-trial dogma. N Engl J Med. 2026;394(8):815-817. doi:10.1056/NEJMsb2517623
  2. Demonstrating substantial evidence of effectiveness with one adequate and well-controlled clinical investigation and confirmatory evidence. FDA. Updated November 30, 2023. Accessed February 19, 2026. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/demonstrating-substantial-evidence-effectiveness-one-adequate-and-well-controlled-clinical
  3. Perrone M. FDA will drop two-study requirement for new drug approvals, aiming to speed access. AP News. Updated February 18, 2026. Accessed February 19, 2026. https://apnews.com/article/fda-drug-approval-studies-makary-prasad-a5aaa5501ae15f264bbd20d0dffa4dc4
  4. Steinzor P. FDA reverses course, will review Moderna’s mRNA flu vaccine. AJMC®. February 18, 2026. Accessed February 19, 2026. https://www.ajmc.com/view/fda-reverses-course-will-review-moderna-s-mrna-flu-vaccine

 

Pharm Stat. 2022 Aug 26;22(1):96–111. doi: 10.1002/pst.2262

Should the two‐trial paradigm still be the gold standard in drug assessment?

Stella Jinran Zhan 

1

, Cornelia Ursula Kunz 

2

, Nigel Stallard 

1,

✉

  • Author information
  • Article notes
  • Copyright and License information

PMCID: PMC10087480  PMID: 36054079

Abstract

Two significant pivotal trials are usually required for a new drug approval by a regulatory agency. This standard requirement is known as the two‐trial paradigm. However, several authors have questioned why we need exactly two pivotal trials, what statistical error the regulators are trying to protect against, and potential alternative approaches. Therefore, it is important to investigate these questions to better understand the regulatory decision‐making in the assessment of drugs’ effectiveness. It is common that two identically designed trials are run solely to adhere to the two‐trial rule. Previous work showed that combining the data from the two trials into a single trial (one‐trial paradigm) would increase the power while ensuring the same level of type I error protection as the two‐trial paradigm. However, this is true only under a specific scenario and there is little investigation on the type I error protection over the whole null region. In this article, we compare the two paradigms by considering scenarios in which the two trials are conducted in identical or different populations as well as with equal or unequal size. With identical populations, the results show that a single trial provides better type I error protection and higher power. Conversely, with different populations, although the one‐trial rule is more powerful in some cases, it does not always protect against the type I error. Hence, there is the need for appropriate flexibility around the two‐trial paradigm and the appropriate approach should be chosen based on the questions we are interested in.

 

Szczepan Baran

Making preclinical evidence predict the clinic for 2- and 4-Legged Patients |  CSO, Instem | Co-Founder, Digital Preclinical Society | Co-Chair, VQN | President, 3Rs Collaborative

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For fifty years, preclinical safety ran on one rule: do the animal study, then justify the exception. Last week the #FDA‘s #OncologyCenterofExcellence released a draft guidance that quietly turns that rule around. Read the headlines and it is an animal-reduction story. One relevant species instead of two. A single three-month study instead of separate one- and three-month studies. A structured risk assessment in place of a study. And yet the reduction is not the point. The precondition is.


Each of those moves is permitted only when you already understand the product, the #targetbiology, and the #toxicity well enough to defend the omission. The study used to be the default. Now the knowledge is the default, and the study is what you add when the knowledge runs out. That is a higher bar, not a lower one. Dropping a study you cannot defend is easy. Defending the decision is the work.

Here is the part that should focus the mind. Across 7,565 drugs and five species, only one of 26 system organ classes showed strong cross-species concordance for both small molecules and biologics. Running the study was never the same as understanding the risk. I wrote this week’s Digital Record on what the guidance actually asks of sponsors, and why the teams that win the timeline treat their evidence as an asset, not an archive. If you lead nonclinical safety or translational science for an oncology biologic or a conjugate, read it as an evidence standard, then ask the harder question of your own programs: which study are you running out of habit, and could you defend dropping it on Monday. Know more. Run less. Defend both.


Issue #3 is free here: https://lnkd.in/eSYzkh_x

 

FDA Reports Meeting Year One Goals for Reducing Animal Drug Testing

June 8, 2026

On May 29, 2026, the Food and Drug Administration (FDA) released its latest guidance related to FDA’s intent to reduce unnecessary animal testing for nonclinical safety assessments, Oncology Pharmaceuticals: Streamlined Nonclinical Safety Studies for Biologics and Conjugated Products. The guidance is intended to help reduce unnecessary animal testing by incorporating an integrated knowledge-based risk assessment with a focus on three-month toxicology studies for certain oncology pharmaceuticals.

Sponsors may propose alternative approaches for a three-month general toxicology study for product classes not described in the guidance, provided such approaches are sufficient to address product safety. Such approaches for a three-month general toxicology study may include a non-sacrificial toxicology study, an alternative study design to reduce animal numbers, or a weight of evidence (WoE) risk assessment for products with well-understood targets to replace animal studies. These approaches could be supplemented with new approach methodologies (NAMs), as appropriate.

FDA’s recommendations cover general toxicology and WoE Assessment. For general toxicology, FDA stated that animal toxicology studies should use pharmacologically relevant species or WoE risk assessment in its absence. FDA stated that if pharmacological activity is similar to humans in both rodent and non-rodent species, then general toxicology may be conducted in a single rodent species and supplemented with WoE risk assessment as appropriate.

A WoE risk assessment may include multiple factors. The factors include nonclinical and clinical data generated with the investigational product (e.g., pharmacology, safety, and pharmacokinetics), a literature-based assessment of potential toxicities with the molecular target, toxicity findings in animals and humans associated with the same class of pharmaceuticals, and other data. The Center for Drug Evaluation and Research’s (CDER) oncology review divisions will determine when the WoE risk assessment is sufficient to address the safety risks based on the totality of evidence.

This guidance builds upon FDA’s initial Roadmap to Reducing Animal Testing in Preclinical Safety Studies (April 2025) to provide a strategic, stepwise approach using NAMs, such as organ-on-a-chip systems, computational modeling, and advanced in vitro assays (e.g., organoids and microphysiological systems). The principles come from a growing scientific recognition that animals are inadequate models of human health, i.e., over 90% of drugs that appear safe and effective in animals do not go on to receive approval in humans. In addition, the time and cost of long-term animal studies delay therapies reaching patients, e.g., developing a monoclonal antibody costs $600-750 million and may take up to nine years, with typical programs using 144 non-human primates at costs reaching $50,000 per animal.

FDA’s one-year progress report, Reducing Animal Testing in Nonclinical Studies Year One Progress and the Path Forward (April 2026) declared that the necessary foundations or goals had been met or exceeded, resulting in additional guidance. Some of those goals included:

  • On July 31, 2025, FDA made the Innovative Science and Technology Approaches for New Drugs pilot program permanent. The program employs the Drug Development Tool Qualification regulatory framework, providing a clear, predictable pathway for developers to gain formal FDA acceptance of NAMs.
  • In August 2025, FDA and the National Institutes of Health formalized a partnership in a Memorandum of Understanding to accelerate the standardization, qualification, and adoption of human-relevant alternative methods.
  • In October 2025, the CDER / Office of New Drugs Streamlined Nonclinical Studies and Acceptable New Approach Methodologies database went live, providing a searchable, regularly updated inventory of specific drug development contexts where streamlined nonclinical programs are acceptable.
  • In November 2025, FDA researchers from the National Center for Toxicological Research and CDER, collaborating with Emulate Inc. and the University of North Carolina at Chapel Hill, published challenges and solutions in measuring commonly used biomarkers for drug-induced liver injury in a liver-on-a-chip platform.
  • On December 2, 2025, FDA released draft guidance, Monoclonal Antibodies: Streamlined Nonclinical Safety Studies.
  • On December 8, 2025, FDA crossed a technological threshold by qualifying the AI-Based Histologic Measurement of NASH its first AI-based drug development tool for use in metabolic dysfunction-associated steatohepatitis clinical trials.
  • On March 18, 2026, FDA published a draft guidance document: General Considerations for the Use of New Approach Methodologies that established four core validation principles to transform the abstract question of “When is an alternative acceptable?” into concrete, actionable requirements. On the same date, FDA’s Level 2 update to “Pyrogen and Endotoxins Testing: Questions and Answers” guidance provided the flexibility for manufacturers to transition from Limulus Amoebocyte Lysate (LAL) reagents for bacterial endotoxin testing to transition from harvesting horseshoe crabs for production of LAL reagent to recombinant agents.

We will continue to monitor FDA’s continuing implantation of a framework to reduce animal testing in nonclinical studies.

This blog was drafted by Brian Malkin, a Spencer Fane attorney on the FDA Pharmaceutical and Biologics Market Team. For more information, visit spencerfane.com.

 

https://www.the-scientist.com/is-this-the-end-of-animal-testing-fda-announces-plans-to-phase-out-animals-in-drug-safety-studies-73031

 

F

or decades, preclinical testing in mice, rats, and nonhuman primates has been a crucial part of drug development, an important although not infallible way to ensure some measure of safety for human participants in clinical trials. In 2022, Congress passed the FDA Modernization Act 2.0, stating that the agency was no longer compelled by law to require animal testing.1 However, the act did not prohibit the FDA from requiring animal testing, and animal toxicity data remained an essential step in the path towards human trials.

But on April 10, the FDA announced plans to phase out these requirements, stating that they would be “reduced, refined, or potentially replaced” with New Approach Methodologies (NAMs). These methods include human-derived cell models, such as organoids and organ-on-a-chip systems, as well as in silico approaches such as pharmacokinetic modeling and toxicity-predicting machine learning algorithms. Within the year, certain monoclonal antibodies, which are most commonly used in the treatment of cancer and serious autoimmune disease, could be evaluated using a “primarily non-animal-based testing strategy.” According to the roadmap accompanying the FDA announcement, “In the long-term (3–5 years), FDA will aim to make animal studies the exception rather than the norm for pre-clinical safety/toxicity testing.”

This announcement has been met with both hopefulness and concern in the scientific community. On one hand, there is broad support for moving away from animal testing, which is ethically fraught, expensive, and not always predictive of human biological responses. On the other hand, scientists and pharmaceutical industry professionals have expressed that NAMs are not yet advanced enough to fully replace animal models.2,3 Moreover, there are concerns that dramatic reductions in budgets for scientific research and the firing of thousands of workers at the FDA and NIH will stall further development of NAMs and interfere with the functioning of the very systems that would be responsible for validating, standardizing, and monitoring the efficacy of these technologies.

Alex Rubinsteyn, a University of North Carolina at Chapel Hill researcher who uses machine learning approaches to inform the development of personalized cancer vaccines, supports reducing animal testing but is uncertain about how this will play out in practice in the current climate. “I think this could become a disaster,” he said. “But it could also potentially unlock a much faster rate of progress.”

Few would dispute the shortcomings of current animal testing pathways: About 90 percent of drugs that make it through preclinical trials never obtain FDA approval for use in humans, largely due to insufficient efficacy or safety.4 Joseph Wu, who studies patient-specific in vitro models of cardiovascular disease at Stanford University, said that this high failure rate is partly due to the inherent differences between human and rodent biology. Furthermore, he noted, “The heterogeneity that exists among humans cannot be captured by using a traditional mouse model.”

Additionally, despite attempts to streamline evaluations of drugs for currently untreatable diseases, “[Drug development] is still really slow and really expensive,” said Rubinsteyn. “And it’s unmatched to clinical realities for certain kinds of disease: There are sufficiently deadly diseases where you really would want to go much faster than you’re allowed to go.”

How Do In Vitro and In Silico Approaches Stack Up Against In Vivo?

Despite the inherent flaws in animal testing, many researchers say that NAMs are not yet advanced enough to fully replace traditional drug safety studies. For example, in a late 2024 report to the FDA Science Board, members of the NAMs subcommittee—convened in 2023 to provide recommendations on integrating NAMs into regulatory processes—wrote that, “Technical limitations to current NAMs exist…today, no assays fully capture the critical hazard endpoints for assessing all currently existing human or animal organ systems; therefore, NAMs cannot fully eliminate the use of integrated physiological systems such as in animal and human trials.”2

In a published response to the FDA announcement, the president of the National Association for Biomedical Research, Matthew Bailey, echoed these sentiments. “No AI model or simulation has yet demonstrated the ability to fully replicate all the unknowns about many full biological systems.”

Similarly, Rubinsteyn noted that while these models can be useful when the space is sufficiently constrained, in other situations, they are still no match for the complexity of biology. “The thing that I work on the most—personalized cancer vaccines—is totally plagued by machine learning models not capturing the relevant realm.”

“We could improve those models with cell lines, but ultimately, the cell lines will be different if we put them in the context of a living organism,” he continued. “[In vivo], the tumor cells will shift what they express. They have to deal with being in contact with other cells in the tissue. They’ll have to pull in vasculature, and they’ll have to deal with the immune environment. So, they’re going to shift how they behave.”

To address this problem, other research groups are building organ-on-a-chip systems as a closer approximation of how cells behave in living tissues. These models can have layers of cells supported by an extracellular matrix with a simplified vascular system, recapitulating some of the cell-cell interactions and mechanical forces present in a living organism.

Yu Shrike Zhang, a Harvard Medical School researcher who uses bioprinting, microfluidics, and other techniques to create improved organ-on-a-chip platforms, noted that these models are quite advanced for certain tissue types.5 “For the liver, the models are pretty precise in general,” Zhang said. “It’s been [studied] for a very long time, and people know exactly how it works.”

Indeed, a liver-on-a-chip model developed by the biotechnology company Emulate, Inc., was able to correctly identify drugs known to be toxic or nontoxic to the liver with a sensitivity of 87 percent and a specificity of 100 percent.6

Using organ-on-a-chip models, Zhang said, “In three to five years, I think we can probably get to a pretty high level in terms of testing [toxicity or biological responses] for individual organs.” Modeling interactions between different organs, however, is a more challenging task. Crosstalk between organ systems is complex and incompletely understood, and organs can be influenced, or influence each other, via changes in metabolism, blood circulation, immune function, endocrine signalling, or nervous system activity.7

Scaling is also a concern, according to Zhang. As size changes, different physical forces and properties increase or decrease in different ways. So, it is not yet entirely clear how to best model a 200-pound human body using organ-on-a-chip systems, some of which may be only a few cell layers thick.

“Things are quite complicated, both biologically and in terms of how these devices operate,” said Zhang. “Being able to really reproduce that organism-level interaction—I think that’s still something that will be really important to look into. Maybe that’s something that’s going to be mature in the next three to five years? I mean, no one knows. But I think that’s probably one of the major limitations right now.”

Refine, Reduce, Replace and the Promise of NAMS

Even scientists who are extremely enthusiastic about NAMs seem to view them as a tool to reduce, not completely replace animal testing. Wu, for example, has spent decades developing in vitro models using cardiomyocytes derived from human induced pluripotent stem cells (iPSCs) to improve our understanding of cardiovascular disease. He has created an extensive biobank of human iPSCs, capturing genetic diversity in health and disease, and even founded a company, Greenstone Biosciences, which aims to accelerate the drug discovery process by combining in vitro and in silico approaches.

However, Wu said, “I’m a proponent of using all models. I’m not a proponent of saying that, ‘Oh, in the future, we should just get rid of mouse models.’” Instead, he said, applying these strategies prior to animal testing could greatly reduce the number of animals that would be needed for each experiment, enabling researchers to identify promising targets and screen for well-defined types of toxicity.

For example, Wu was part of a project led by fellow Stanford University cardiovascular biologist Mark Mercola, in which the team used iPSC-derived human cardiomyocytes and machine learning to classify existing drugs as low risk or intermediate/high risk for causing dangerous arrhythmias. Using area under the curve as a measure of the model’s accuracy—for which 0.5 indicates a random classifier and one is a perfect classifier—the model correctly identified risk with an area under the curve value of 0.95.8 In the future, a system like this one could help researchers spot potentially cardiotoxic compounds early in the drug development process. This has the potential to prevent the investment of time, money, and animal lives into investigating a drug that might treat one disease very well but be ultimately useless because of severe adverse effects.

Furthermore, unlike studies performed in strains of genetically identical mice, research with human cells can provide not only general safety predictions, but they also help identify which individuals might be most at risk for particular side effects and even suggest mechanisms for mitigating these effects.

For example, the chemotherapy drug doxorubicin can lead to heart failure in a subset of patients, but for many years, the mechanism of this cardiotoxicity was not known, and there was no way to predict which patients were at risk. In a study of eight breast cancer patients, Wu and his team showed that iPSC-derived cardiomyocytes from patients who experienced this side effect were more sensitive to doxorubicin toxicity than cells from patients who did not. 9 In the future, this could serve as a tool for screening patients prior to treatment. In a subsequent study, the researchers used a CRISPR-based approach to screen cardiomyocytes for genes that contributed to this vulnerability. One gene, which coded for the enzyme carbonic anhydrase 12, seemed to play a large role: When expression of this gene was inhibited in the cells, they were protected from doxorubicin toxicity.10 An antagonist of this enzyme, Indisulam, was also protective in heart cells. Only after all these experiments did the researchers test the drug in mice.

Continue reading below…

Since then, Wu and his team have used iPSC-derived cells, patient data, and AI to identify a candidate compound for the treatment of marijuana-induced vasculature inflammation, and two potential therapies for cardiac fibrosis.11–13 “These three papers all have mouse models, but they’re toward the end,” said Wu. “They’re only done for validation—the initial screen, initial validation, initial design, all that stuff is done [using] organoids, stem cells, and AI.”

The first candidate is currently in a Phase 1 clinical trial for the treatment of inflammation associated with heart failure, the second is in an open-label study for treating idiopathic pulmonary fibrosis. In the coming years, studies such as these will provide crucial data to answer the question of whether these newer drug development techniques can increase efficiency and reduce failure rates in clinical trials.

An Uncertain Future for Drug Development

Much work remains to be done, however, if animal testing is to be truly replaced in the next three to five years. In addition to the development of the NAMs technologies themselves, the FDA roadmap also calls for the creation of open-access toxicity information databases, developing strategies to validate NAMs, determining appropriate thresholds for eliminating animal testing, figuring out how to standardize these techniques so that they can be compared across many different laboratories, coordinating with other federal agencies, and monitoring how well all of this is working.

“Transitioning from animal-based testing to NAMs for safety will require careful planning, robust science, and collaboration,” the roadmap states.

But will this be possible in the chaos currently afflicting many government agencies and the dramatic changes to support for scientific research in the United States? The Trump administration has already terminated 1.8 billion dollars in National Institutes of Health (NIH) grants; the administration’s proposal for the upcoming year would slash the budget of the NIH by 40 percent.14,15

Some of these governmental budget cuts and funding freezes adversely impact the laboratories that have been instrumental in developing the very NAMs technologies the FDA is hoping to promote. For example, Harvard University bioengineer Donald Ingber, a pioneer in organ-chip research and scientific founder of Emulate, Inc., received stop-work orders on two major organ-on-a-chip projects in late April 2025.

Beyond the technologies themselves, planning and collaboration efforts may also be impacted by the major changes at these agencies. So far, 2025 has been marked by many cancelled or postponed scientific meetings at the FDA and NIH, as well as firings of thousands of workers, including many top-level officials and a large portion of communications roles, and the resignation of Peter Marks, director of Center for Biologics Evaluation and Research.

Rubinsteyn, for his part, worries about how reductions in animal testing requirements will play out in such an environment, raising concerns that insufficient oversight could create opportunities for unscrupulous companies to bring potentially unsafe drugs to market.

“I do think that this is, in principle, a positive direction for change,” he said. But depending on how these changes are implemented, “it could go quite wrong.”

Disclosure of conflicts of interest: Yu Shrike Zhang sits on the scientific advisory board and holds options with Xellar Biosystems.

Comparative Study 

Toxicol Sci

. 2015 Dec;148(2):355-67. doi: 10.1093/toxsci/kfv189. Epub 2015 Oct 5.

Correlation of In Vivo Versus In Vitro Benchmark Doses (BMDs) Derived From Micronucleus Test Data: A Proof of Concept Study

Lya G Soeteman-Hernández 1, Mick D Fellows 2, George E Johnson 3, Wout Slob 1

Affiliations Expand

Abstract

In this study, we explored the applicability of using in vitro micronucleus (MN) data from human lymphoblastoid TK6 cells to derive in vivo genotoxicity potency information. Nineteen chemicals covering a broad spectrum of genotoxic modes of action were tested in an in vitro MN test using TK6 cells using the same study protocol. Several of these chemicals were considered to need metabolic activation, and these were administered in the presence of S9. The Benchmark dose (BMD) approach was applied using the dose-response modeling program PROAST to estimate the genotoxic potency from the in vitro data. The resulting in vitro BMDs were compared with previously derived BMDs from in vivo MN and carcinogenicity studies. A proportional correlation was observed between the BMDs from the in vitro MN and the BMDs from the in vivo MN assays. Further, a clear correlation was found between the BMDs from in vitro MN and the associated BMDs for malignant tumors. Although these results are based on only 19 compounds, they show that genotoxicity potencies estimated from in vitro tests may result in useful information regarding in vivo genotoxic potency, as well as expected cancer potency. Extension of the number of compounds and further investigation of metabolic activation (S9) and of other toxicokinetic factors would be needed to validate our initial conclusions. However, this initial work suggests that this approach could be used for in vitro to in vivo extrapolations which would support the reduction of animals used in research (3Rs: replacement, reduction, and refinement).

Keywords: TK6 cells, benchmark dose 

https://www.drugdiscoverynews.com/why-toxicology-is-still-the-toughest-test-for-nam-adoption-17194

 

Toxicology remains the most challenging field for adopting new approach methodologies (NAMs) as it requires predicting systemic, long-term human health effects that are inherently complex to replicate outside a living organism. While NAMs offer human-relevant data, the industry faces significant hurdles in validating these methods to the same level of trust as traditional animal models.

DDN spoke with Justin Boyd, Product Manager at Sartorius, to explore how NAMs are being applied in practice across drug discovery and safety assessment, and what ultimately determines whether they transition from scientifically compelling tools into routine components of toxicology workflows.

You’ve spent much of your career building biologically relevant cellular models of disease. How does that emphasis on relevance shape how you think about NAMs in toxicology, compared with more traditional animal-based approaches?

I recently joined the vendor side of NAMs. For nearly two decades before that, as a drug hunter, I was less focused on building models and more on applying them. In that context, I thought of NAMs as fit-for-purpose tools to rapidly explore the effects of experimental drugs on the proximal human biology I care about.

Now, as Product Manager of a NAMs portfolio, I still strongly believe in that utility. The strengths of NAMs lie in: (1) conservation of human biology, (2) speed to data-driven decision-making, and (3) cost to execute study. That said, I don’t see NAMs as replacing the value of a whole organism — whether mouse, rat, or non-human primate. A preclinical toxicity study in animals provides a more comprehensive view of how a compound behaves in the context of an intact organism, including systemic interactions that are still not well captured in vitro.

However, NAMs create an opportunity to rank and/or differentiate compounds with higher molecular resolution while remaining “in human.” That kind of insight can meaningfully inform decisions about which compounds are worth advancing into more expensive and time-consuming animal studies.

Ultimately, I think of NAMs for toxicity as key complementary models for evaluating tissue-specific risk to drive decision to go into the animal models, leading to better stewardship of resources for drug discovery and animal welfare.

NAMs are often discussed as ethical or regulatory advances, but from your perspective, where do they most clearly outperform legacy toxicology methods scientifically?

With respect to performance, there are two clear areas where NAMs excel. First, NAMs can recapitulate aspects of human biology more faithfully than preclinical species. This becomes especially important when studying the proximal biology engaged by an experimental drug, where species differences can significantly limit interpretability.

Second, NAMs substantially reduce the time and cost required to reach a decision. From a project or program management perspective, the ability to make informed and confident stage-gate decisions is where the highest value lies. In this context, NAMs enable a more expedient and cost-effective approach to predicting toxicity in the pre-Investigational New Drug (IND) to IND space.

Although, it’s likely that animals will be used at this point, NAMs can and should be deployed to derisk the Good Laboratory Practice (GLP) toxicity studies in animals and potentially reduce the numbers of cohorts and time for treatments.

Many toxicology assays still rely on relatively reductionist systems. How close are we to NAMs that genuinely capture the complexity of chronic diseases like Alzheimer’s or Parkinson’s when it comes to assessing safety?

I think this is a tricky question, and I would start by noting that the complexity of Alzheimer’s (AD) and Parkinson’s disease (PD) pathobiology is part of what limits our ability to clearly distinguish mechanisms that cause disease from those that simply exacerbate progression. As such, “who, when, and how” these diseases are treated and the potential toxicity from treatment remain controversial.

In some cases, NAMs, particularly complex in vitro models with multiple cell types and structures, can recapitulate complex non-cell autonomous biology, such as the impact of inflammation on neuronal health. Moreover, computation-based NAM tools can help predict the trajectory of biology and stratify at-risk populations for toxicity outcomes.

So, when asking how close we are to NAMs that genuinely capture the complexity of chronic diseases like AD and PD, I would say they are, in many ways, as close to recapitulating that complexity as our current understanding allows us to define it.

Drug-induced nephrotoxicity remains a major clinical challenge. From your experience working with human kidney microtissues, why has traditional animal toxicology struggled to predict renal risk in humans?

It sounds cliché, but animals are not humans. In the case of the kidney, there are two key drivers of translational gaps.

First, the expression of key kidney genes and their protein products — particularly those governing transport and metabolism — differs significantly between preclinical species and humans. Second, baseline renal metabolism itself varies across species, further compounding these differences.

Given that the primary function of the kidney is to clear waste, toxins, and excess fluids from the blood, these species-specific differences directly impact our ability to predict nephrotoxicity using traditional animal models.

You’ve worked extensively with 3D human epithelial tissue models. What does moving from 2D cultures to 3D systems fundamentally change in how we understand toxicity mechanisms?

The difference between traditional 2D cultures and 3D systems, in the context of toxicity, is relatively straightforward. By recapitulating tissue structure, 3D models allow us to move beyond simply asking whether a compound is toxic, to understanding where that toxicity occurs and to what extent.

Understanding the relationship between exposure (where a polarized, functional cell sees a compound) and response is uniquely addressed in our systems compared to 2D. This is particularly important in epithelial tissues, where basolateral versus apical exposure can lead to very different toxicity outcomes. In skin, intestine, and lung, for example, cells may be exposed either from the basolateral side via systemic circulation or from the apical side through local administration or environmental contact. That distinction is fundamentally lost in 2D systems.

Do you see NAMs primarily as screening tools, or are they mature enough to inform dose selection, risk stratification, and IND-enabling decisions?

I believe NAMs have always been able to inform dose selection, risk stratification, and IND-enabling decisions. In fact, screening may not be the best deployment of NAMs due to scalability challenges and cost. The appropriateness of a NAM’s utility is dependent upon the limitations of the human biology you can explore within the NAM and the modality of the therapeutic. If the NAM contains the biology that you are targeting and the therapeutic modality is compatible with the model, then the NAM should be appropriate for dose selection, risk stratification and IND decisions.

One advantage you’ve previously highlighted is integrating human tissue models with live-cell analysis. Why is temporal resolution — seeing toxicity unfold in real time — so important?

There is both a practical and a biologically relevant dimension to the importance of temporal resolution in toxicity responses. From a practical standpoint, when developing any assay, identifying the time point at which the signal is maximal is essential for ensuring robustness and is a key part of assay optimization. In the context of toxicity, being able to observe the behavior and toxicity signals over time will enable you to identify the most appropriate time of incubation for maximal signal response.

Biologically, however, toxicity is not a single event — it manifests in different ways depending on mechanism. If you use tool compounds that induce toxicity through different mechanisms, knowing the kinetics of the toxicity response can help resolve whether your assay can distinguish direct and indirect mechanisms leading to toxicity.

In that sense, time to toxicity signal can be as informative as the signal itself, particularly when evaluating unknown compounds. In the context of advanced cell models for toxicity, often the exposure times can be prolonged (days to weeks) to predict clinical outcome.

NAMs can be scientifically compelling but still fail to gain traction. From a product and commercialization standpoint, what determines whether a NAM actually gets embedded into routine toxicology workflows?

This is the $100+ million question. Adoption of any platform is influenced by a range of factors — cost, fit-for-purpose utility, biological relevance, format, and ease of use among them. In practice, different players in the field tend to emphasize the aspects they value most, often based on their own balance of biological relevance versus scalability.

At the moment, traction tends to emerge organically through a “let’s try it and see if it works” approach. This is not unique to NAMs. However, toxicology is a particularly high-bar area, where established gold standards inherently challenge any new model system more than exploratory or discovery settings do. That makes sense: Toxicology groups are ultimately responsible for generating a weight of evidence that supports progression to the clinic.

In that context, NAMs introduce both opportunity and friction. While they offer potentially better predictive insight, they also require additional effort to validate against established approaches — often more effort than is required to continue using what is already accepted. Because of this, I would argue that regulators are the key gatekeepers of NAM adoption in toxicology. Ultimately, they define what is essential versus optional in the data package required to advance into the clinic. In my view, the biggest lever for accelerating adoption is therefore not customer preference, but regulatory acceptance.

What is the incentive to explore better models of toxicology if existing ones are “good enough” to reach regulatory endpoints? We could discuss the ethics and scientific rationale around choosing better, more predictive models. But if NAMs remain encouraged rather than required, it is difficult to expect meaningful acceleration in their uptake. I really hope that regulators recognize that there’s a big difference between accepting NAMs and requiring them. Making NAMs essential for toxicity studies for IND filing would catalyze their adoption far more effectively than incremental product refinement alone.

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About the Author

  • Bree Foster, PhD

  • Bree Foster is a science writer at Drug Discovery News with over 2 years of experience at Technology Networks, Drug Discovery News, and other scientific marketing agencies. She holds a PhD in comparative and functional genomics from the University of Liverpool and enjoys crafting compelling stories for science.

he 90% myth

Posted: by Chris Magee on 9/06/25

More on these Topics:

ANIMAL RIGHTSANIMAL STATISTICSDRUG DEVELOPMENTFACT CHECKMISINFORMATIONMYTHBUSTING

Why do 90% of new drugs fail?

If you’ve read anything on animal testing, you’ll have read something to the effect that ‘more than 90% of drugs tested in animals fail in humans’. Is that some damning indictment of animal models? Absolutely not. Let’s unpack this a bit.

Note: The 90% statistic refers to regulatory safety testing. Other sorts of animal use, like discovering decapod sentience through ‘curiosity-driven’ basic research, will be discussed in another article since the applications are so broad and the application of the research so complex that percentages are usually meaningless. 

Tl;DR:

The drug attrition rate, which isn’t 90%, isn’t due to the use of animals and there’s no such thing as a drug that’s developed and tested using only animals before heading to human trials.

Let’s start at the beginning.

 

How drugs get licensed

In drug trials, all drugs intended for humans are tested on humans: they are tested and refined through three stages of clinical trial before being licensed for public use. Phase 1 of human testing looks primarily at safety, whereas phases 2 and 3 are for safety and then efficacy. Each stage uses more human volunteers than the last and the later stages might include those with a particular medical condition. There is also a post-licensing stage 4, where new treatments are introduced to the wider population, for instance into the clinic by specialist doctors.  

Image: Sanford Health 

Adverse reactions noted after a drug is licensed are fed back to the medicine’s regulator, the Medicines and Healthcare Devices Regulatory Authority (MHRA), which might do things like update the safety information in the booklet that comes with the medicines. Lots of medicines have their safety advice updated as the medicine is used in a greater number of patients.  

This is because drugs are licensed on the grounds of what they do in general, e.g. shrink a tumour or lower blood sugar. However, to what extent they work in an individual will vary greatly depending on dozens of factors from genetics to weight to hormones – even to the time of day. This is why there are specialist doctors for different diseases, as well as GPs, who take a patient-centric perspective on the medical tools available for that person (or animal). Hence, very few medicines are withdrawn – it’s usually a case of finessing the practice and guidance on using them safely and optimally and adapting their use for specific patients. 

 

Preclinical testing

Before drugs can go to human trials, they must pass a standard battery of safety tests using both animal and non-animal methods. These tests tend to be specified by bodies like the OECD (mainly for chemicals) and the International Conference on Harmonisation (mainly for pharmaceuticals), which can pool knowledge about how to use the best methods of safety testing, whatever these may be. 

Non-animal methods of drug testing can perform well but tend to be limited in scope to one organ system or one effect, whereas animal models tend to give a broader picture of how drugs will act in a whole living body and across a dozen organs at once. 

For some applications, non-animal methods are enough to conclude that drug development shouldn’t proceed, and the compound is therefore eliminated before hitting either the human or animal testing stages.  

With those drugs that do proceed, animals are very good at ‘predicting’ if a drug will be ‘safe’ in the first human trials.  

There are different statistical tools that can be used to determine this safety. Bayesian modelling (figure 1 below) can find ‘true positives’ (PPVs) and ‘true negatives’ (NPV) i.e. a percentage certainty that something will be safe in stage 1 human trials. Likelihood ratios (figure 2) offer a probability of safety. 

Bayesian modelling, NPV safety prediction
Organ category  Dog to human   Mouse to human  
Pulmonary  96%  95% 
Biochemical  95%  93% 
Renal  95%  96% 
Ophthalmology  94%  96% 
Haematology  93%  92% 
Cutaneous  91%  82% 
Musculoskeletal  91%  92% 
Cardiovascular  91%  75% 
Nervous system  90%  93% 
Liver  88%  89% 
Gastrointestinal  76%  69%

Figure 1: IQ Consortium translational database 

Likelihood ratios
Pre-test probability  Pre-test odds  Post-test odds  Post-test probability 
10%  0.11  3.16  76% 
20%  0.25  7.11  88% 
30%  0.43  12.18  92% 
40%  0.67  18.95  95% 
50%  1.00  28.43  97% 
60%  1.50  42.65  98% 
70%  2.33  66.34  99% 
80%  4.00  113.72  99% 
90%  9.00  255.87  100% 

Figure 2: Data from https://pubmed.ncbi.nlm.nih.gov/24329742/  

Different species of animal do more or less well at translating to humans depending on the target organs, the type of thing being tested and the size of its molecules. These species differences are well-known, as is the fact that you can increase your certainty that something will be safe or not if a rodent and a non-rodent species both yield similar results. 

Thus, the normal testing regime uses species like rats, plus a non-rodent species, usually a dog or primate. Around three-quarters of tests involve suffering in the mildest category, such as a blood test, with a quarter in the moderate category and very few in severe. This is because most of the information about the possible dangers of a new drug comes from a post-mortem of the animal that reveals changes to the internal organs and tissues, rather than observing whether a live animal gets sick or not. 

The fact that animals are good predictors of safety in humans is important because 40% of potential new drugs are ultimately removed due to failing these pre-human tests. This means that 40% of possible new drugs would have killed or seriously injured humans in phase 1 trials without the pre-human tests (which would be about 900 people a year in the UK).  

 

Preclinical results shape the human trial

But this is not the whole picture. The preclinical tests of all descriptions, including effects seen in animals, human cells, tissue samples and more, help to inform the design of human clinical trials in the first place. For instance, one or several of the tests might hint at potential issues with the liver, so extra measures can be taken to minimise that risk during the human trial. 

All drugs have potential side effects, and their use is always a balance of risk vs potential benefit for the individual patient. All of this means that a large number of drugs proceed to human trials as ‘safe enough to try’ but with a question mark over whether their risks will be manageable or not.  

An example of this management is paracetamol, which works better as a painkiller if taken regularly every 4-6 hours to allow it to build up in the tissues and bloodstream. However, we all know not to take a day’s dose all at once. 

 

So, what of the 90%? 

Drugs ‘fail’ at every stage of development and for several reasons. For every 100 possible drugs that even get to the animal testing stage, some 5,000 other compounds have already been eliminated. Drugs continue to be removed all the way through human testing too, in ever smaller numbers as we zero in on something that’s going to work. 

Percentages thus become less and less helpful for understanding what is happening. Having eliminated 5,000 candidates, for instance, we can be left with 10. If three of those 10 fails, then that’s 30%, which sounds massive, but it’s only 0.06% of the huge pile of 5,000 possible drugs we started with. 

In the same way, the 90% statistic is easy to misunderstand. 

As we’ve seen, 40% of possible drugs are removed as dangerous by the pre-human safety tests that are mainly in animals. The 90% that ‘fail’, then, is 90% of the 60% that pass preclinical trials. Also, by ‘failure’ it means to have failed for the purpose intended – many drugs can later be repurposed even if they fail in their intended application. 

What all this means is, for every 100 potential new drugs at the start of the process, 6 will become drugs in the pharmacy, 40 will be removed by preclinical tests and 54 will be removed for other reasons. 

Exactly what those reasons are is the critical point. 

Of those 54: 

  • C40-50% (26 drugs) will not be effective at the safe dose (something the animal test isn’t looking for); 
  • C25-30% (15 drugs) suspected or known toxicities cannot be managed; 
  • C10-15% (8 drugs) don’t absorb into the body or get to their target organ properly; and 
  • c10% (5 drugs) fail due to a lack of commercial need or misplaced strategic planning. 

In this way, lots of drugs fail to make it to the chemists’ shelves, but this has very little to do with the efficacy of the animal model as a safety screen for stage 1 clinical trials. Animals do that job very well.

What is exciting about new approaches – whether they use animals or not – is that they may be able to chip away at the other reasons for failure (more on this later).

 

Different targets have different success rates

One other complication is that ‘failure’ rates are not uniform.

Currently, translation from preclinical findings to clinical success varies a lot depending on the disease area. Eye treatments are about 35% successful, vaccines are about 40%. The most complex diseases of the most complex organs have, as you’d expect, a much higher failure rate which skews the averages and gives you this slightly bogus 90% figure by some methods of counting. However, there is no evidence that implicates animal models as the major reason for failure. In fact, researchers who found a c95% drug attrition rate also found that 86% of positive results in animals translated into positive results in humans.

This accords perfectly with the IQ Consortium translation database, of animal to human translation, recreated as a table in figure 1 above, which also averages out at 86%  

 

So, where do NAMs fit in?

The term ‘New Approach Methodologies‘ refers to the subset of non-animal technologies concerned with regulatory testing – i.e. the tests required by governments. Non-animal technologies have been in development and used in drug testing since the early 1970s, being applied alongside animal models to try to design better drugs, better clinical trials and spot potentially dangerous compounds. They have a more limited range of applications than a whole-body system, but can nevertheless be a quick, cheap and useful way of spotting red flags or pointing to a way forward. They are a standard part of the toolkit for drug testing, with their use accelerating exponentially in the past 20 years as technology improves. We have ever-better non-animal tests, which are still limited but can tell us enough in some cases to guide a decision on what compounds to try to turn into medicines. 

 

Organs on chips

Some of these techniques are relatively new approaches like organ-on-a-chip technologies. First conceived in the late 1990s, the first successful chip was developed in 2010. These devices, roughly the size of an AA battery, are made from a flexible, translucent polymer. Inside are tiny tubes, each less than a millimetre in diameter, lined with living cells taken from a particular human or animal organ. 

These can spot toxicities ranging from liver issues with new drugs to the effects on animals of industrial chemicals. They can be used early to avoid animal use and some emerging technologies could prevent up to 10% of drugs that would ultimately fail from entering animal trials in the first place. In a study completed in late 2022, for instance, liver chips identified compounds that were deemed safe enough to try by animal models, but would ultimately harm humans in wider testing, with 87% accuracy.  

That doesn’t mean it can spot 87% of drug toxicities, but 87% of those that would have failed later and specifically for liver-related safety reasons. Given that 40% of compounds are removed prior to human testing, 30% later fail due to unmanageable toxicity and 30% of those do so due to effects on the liver, using this test routinely would help to reduce the number of drugs that later failed human trials for unmanageable toxicity by around a third, or 4-5 drugs for every 100 entering testing. 

However, if also used early in the drug testing process they might also spot toxicities that would previously have needed an animal to detect, and this might be enough to halt testing. Liver toxicity is the reason for 14% of failures during preclinical tests so this would amount to a further 5 compounds per 100 that would not progress to the animal stage. As you can see from liver chip vendor Emulate’s own graphic, their chip reduces animal use, and is applied before animal trials. There would still, by their model, be an 82% failure rate and, of course, most drugs don’t fail for liver-related reasons.

Source: https://emulatebio.com/toxicology/

The UK authorises around 35 new drugs for use each year, yet for every drug approved another 9 fail, which would be around 315 trials, some 10% of which could be halted before hitting the animal or human stage, potentially preventing thousands of research animals from being born. This would undoubtedly save pharma companies money since human trials get more expensive the more they progress – from $ 25 million in Phase 1 to $ 54 million in Phase 3. 

The UK’s national centre for Refining, Reducing or Replacing animal use has a project to replace ‘second species’ animals like dogs and primates with computer models that have passed its proof-of-principle stage and are well into development, albeit with another three years of development left to run.

Even if this doesn’t work, it will tell us what we need to do to get it to work. As Jonas Salk, who used primates to create a polio vaccine, once said “There is no such thing as a failed experiment because learning what doesn’t work is a necessary step to learning what does.”  

 

New targets

Animal numbers will inevitably continue their steady march, with an occasional lurch, downward in terms of numbers, but it’s important to understand how all this fits together. Whilst it’s very easy to predict the future in general terms – clean energy, personalised medicine, healthier food – actually getting there is a bit of a slog. 

The other big reason for drug failure beyond the liver, for instance, is Torsades de Pointes. French for “twisting of the points” it’s a dangerous heart arrhythmia that’s the reason for a very similar proportion of preclinical and clinical failures as liver problems. It makes heart chips the next big target for validation, with sincere hopes that they can be made to work as well as liver chips. 

However, this is the low-hanging fruit on offer in terms of organ chips, with diminishing returns as the targets get harder, and the target systems get more complicated. A test for the heart or a kidney is one thing, a test for the Central Nervous System is quite another. In addition, heart arrhythmia and liver issues are the biggest single areas of failure for safety reasons, but the remaining 40% of reasons affect many other organs, each of which will need its own new animal or non-animal testing strategy. 

 

Where next? 

There is no one approach, then, that will create a revolution. We need new approaches, and we need new improvements to old approaches. My latest laptop, for instance, isn’t conceptually different from the first laptop I owned but it’s a lot lighter and faster due to hundreds of innovations across all of its components. Improvements to clinical outcomes will come from organ chips, big data and AI, but also from higher standards of scientific rigour, new animal models, more powerful technology and the synergies that arise from using it all together. 

Happily, there are very few regulatory barriers to adopting new non-animal technologies, the ethical framework for using new animal models is well-understood and nobody is opposed to using non-animal methods over animals. In addition, whatever the costs of failure during clinical trials, the cost of preclinical R&D and discovery clocks in at $403 million, making it easily the most expensive single stage in the drug development process. Hence, the greatest savings in cost or animal use associated with improvements in technology may have nothing to do with the requirements of the regulator and can be implemented as soon as new technologies mature. 

We do need to accelerate the validation of new animal and non-animal methods now that they’re emerging with rapidly increasing frequency. The OECD, the international association for sharing solutions to common problems, is the curator of scientific guidelines for the testing of chemicals. It makes the point that resources should be made available to test the reproducibility and reliability of new methods developed by single labs so that, if they work, they can be applied more widely, and more quickly. Inherent to their thinking is a bias against animal use. 

We also need to make sure that politicians aren’t distracted by ideological sideshows or lured towards counterproductive policy directions, like deadlines that amount to deregulation of harmful industries. whose products are only harmful when metabolised in a whole body. There are concrete measures that governments, or prospective governments, could be proposing but politicians of all stripes need to understand where to apply funding and focus to have a positive impact on man, animals and the environment. 

https://www.understandinganimalresearch.org.uk/news/the-90-myth

 

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FDA Moves Forward With Its Guidance Framework for Rare Disease Trials: 2026

Reporter: Stephen J. Williams, Ph,D.

In 2025, the Trump Administration had determined it wants to streamline the FDA and clinical trials in order to expedite much needed drugs for various terminal diseases such as cancer and rare childhood diseases.  In 2026, under the guidance of the new FDA commissioner, Dr. Makary, the FDA initiated guidance for the proposed changes in February and available for comments at that time.  This has been a growing discussion aver the years and the FDA wanted, for many years, to figure out they could speed bringing new therapies to market, especially for terminally  ill patients. Given the progress of biomarkers development early in the drug discovery process and new computational technologies, the time seems to be ready for such changes in trial design and even for the long drug development process.  In addition the FDA up to this point was focused on other matters so it wasn’t really at the forefront of their to do list.

From: https://www.fda.gov/news-events/press-announcements/fda-launches-framework-accelerating-development-individualized-therapies-ultra-rare-diseases

FDA Launches Framework for Accelerating Development of Individualized Therapies for Ultra-Rare Diseases

For Immediate Release:

The U.S. Food and Drug Administration today issued draft guidance for sponsors seeking approval for targeted individualized therapies by generating substantial evidence of effectiveness and safety when randomized controlled trials are not feasible due to small patient populations.

The draft guidance, issued by the Center for Biologics Evaluation and Research and Center for Drug Evaluation and Research, specifically discusses genome editing and RNA-based therapies such as antisense oligonucleotides but leaves open the potential that this framework may apply to additional tailored therapeutics provided they directly address the underlying specific cause of the disease.

“President Trump promised to accelerate cures for American families — and we are delivering, especially for children with ultra-rare diseases who cannot afford to wait,” said Health and Human Services Secretary Robert F. Kennedy, Jr. “We are cutting unnecessary red tape, aligning regulation with modern biology, and clearing a path for breakthrough treatments to reach the patients who need them most.”

“This guidance is a critical step the FDA is taking to tailor our regulatory approach to patients with ultra-rare conditions,” said FDA Commissioner Marty Makary, MD, MPH. “It is our priority to remove barriers and exercise regulatory flexibility to encourage scientific advances and deliver more cures and meaningful treatments for patients suffering from rare diseases.”

The draft guidance focuses on therapies that target a specific genetic, cellular or molecular abnormality and are designed to correct or modify the underlying cause of disease. Key criteria include:

  • Identifying the disease-causing abnormality.
  • Demonstrating the therapy targets the root cause or proximate biological pathway.
  • Relying on well-characterized natural history data in untreated patients.
  • Confirming successful target drugging or editing.
  • For traditional approval, therapies should demonstrate improvement in clinical outcomes, disease course, or biomarkers if they are established to predict clinical benefit.

“Designing treatments unique to individual patients has always been the promised goal of personalized medicine,” said Chief Medical and Scientific Officer and Center for Biologics Evaluation and Research Director Vinay Prasad, MD, MPH. “After 25 years the FDA has, for the first time, outlined a framework to facilitate these approvals. The Plausible Mechanism Framework is a revolutionary advance in regulatory science.”

“The Plausible Mechanism draft guidance creates a novel framework through which cutting-edge treatments tailor-made for patients with ultra-rare diseases can be used as a basis for FDA approval,” said Center for Drug Evaluation and Research Acting Director Tracy Beth Høeg, MD, Ph.D. “We anticipate our Plausible Mechanism draft guidance will inspire industry to place increased focus on individualized therapies, thereby driving innovation, improving safety, lowering costs and offering more patients with ultra-rare diseases a unique shot at a life-saving treatment.”

Because genome editing technologies are designed to be highly specific to unique DNA sequences, a product targeting different mutations in a single gene could be included in a single product application and potentially evaluated through the use of master protocols that evaluate these product variations in a single trial. A highly supported “plausible” mechanism of action may then be used to support the addition of other such genome editing product variants, intended to treat patients with mutations that were not included in the clinical trial used to support the original approval.

The FDA recognizes that an adequate and well-controlled clinical investigation in this context will include a small sample size, therefore, investigation results should be sufficiently robust to exclude chance findings. When determining effectiveness, the FDA considers the specific disease, the strength of the evidence and the challenges of conducting clinical investigations for individualized therapies.

 

In June of 2026, the FDA formalized their discussion into guidelines for discussion so it appears the following are not set into register of regulations as of yet.

From https://www.fda.gov/drugs/guidances-drugs/guidance-documents-rare-disease-drug-development

Guidance Documents for Rare Disease Drug Development

In general, FDA’s guidance documents do not establish legally enforceable responsibilities. Instead, guidances describe the agency’s current thinking on a topic and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word should in agency guidances means that something is suggested or recommended, but not required.

Below are selected guidances that are relevant to rare disease drug development, organized by topic. This list does not include all FDA guidances on or relevant to rare disease drug development but represents our most commonly used guidances. This list may be updated periodically.

I have kept the original text in order for reference and to provide the background for these changes “in their words”.

However there are a few themes in these guideline changes and discussions including:

  • definitions of rare diseases
  • reduction of complexities and simplification of trial design and requirements (the FDA wants to go to a more ONE trial with very well designed controls than the two trial design for INDs (I will discuss this further in a near future post)
  • accelerated approval which will entail streamlining both the submission and approval process for rare conditions
  • heavy reliance on biomarkers during drug development and clinical trials (which is already in frequent use in pharma)
  • early communication with the FDA
  • more reliance on plausible mechanism of action to reduce number of studies needed

Rare Disease

Considerations for the use of the Plausible Mechanism Framework to Develop Individualized Therapies that Target Specific Genetic Conditions with Known Biological Cause
The purpose of this guidance is to describe considerations for generating substantial evidence of effectiveness and evidence of safety for individualized therapies based on a plausible mechanism framework.

Rare Diseases: Considerations for the Development of Drugs and Biological Products
This guidance clarifies FDA’s thinking on important considerations in rare disease drug development to ultimately assist rare disease drug and biologic product developers in conducting successful drug development programs.

Rare Diseases: Natural History Studies for Drug Development: Draft Guidance for Industry
FDA is publishing this draft guidance to help inform the design and implementation of natural history studies that can be used to support the development of safe and effective drugs and biological products for rare diseases. A natural history study collects information about the natural history of a disease in the absence of an intervention, from the disease’s onset until either its resolution or the individual’s death. Although knowledge of a disease’s natural history can benefit drug development for many disorders and conditions, natural history information is usually not available or is incomplete for most rare diseases; therefore, natural history information is particularly needed for these diseases.

Rare Pediatric Disease Priority Review Vouchers
This guidance provides information on the implementation of section 908 of the Food and Drug Administration Safety and Innovation Act (FDASIA), which added section 529 to the Federal Food, Drug, and Cosmetic Act (the FD&C Act). Under section 529, FDA will award priority review vouchers to sponsors of certain rare pediatric disease product applications that meet the criteria specified in that section.

Rare Diseases: Early Drug Development and the Role of Pre-IND Meetings : Draft Guidance for Industry
The purpose of this draft guidance is to assist sponsors of drug and biological products for the treatment of rare diseases in planning and conducting more efficient and productive pre-investigational new drug application (pre-IND) meetings. Drug development for rare diseases has many challenges related to the nature of these diseases. This draft guidance is intended to advance and facilitate the development of drugs and biological products for the treatment of rare diseases.

Slowly Progressive, Low-Prevalence Rare Diseases with Substrate Deposition That Results from Single Enzyme Defects: Providing Evidence of Effectiveness for Replacement or Corrective Therapies : Guidance for Industry
This document provides guidance to sponsors on the evidence necessary to demonstrate the effectiveness of investigational new drugs or new drug uses intended for slowly progressive, low-prevalence rare diseases that are associated with substrate deposition and are caused by single enzyme defects. This guidance applies only to those low-prevalence rare diseases with well-characterized pathophysiology, and in which changes in substrate deposition can be readily measured in relevant tissue or tissues.

Pediatric Rare Diseases–A Collaborative Approach for Drug Development Using Gaucher Disease as a Model : Draft Guidance for Industry
The purpose of this guidance is to facilitate drug development in pediatric rare diseases. In particular, it discusses a new possible approach to enhance the efficiency of drug development in pediatric rare diseases using Gaucher disease as an example.

Inborn Errors of Metabolism That Use Dietary Management: Considerations for Optimizing and Standardizing Diet in Clinical Trials for Drug Product Development: Guidance for Industry
This guidance describes the Food and Drug Administration’s (FDA’s) current recommendations regarding how to optimize and standardize dietary management in clinical trials for the development of drugs that treat inborn errors of metabolism (IEM) for which dietary management is a key component of patients’ metabolic control. Optimizing dietary management in these patients before entry into and during clinical trials is essential to providing an accurate evaluation of the efficacy of new drug products.

Accelerated Approval

Accelerated Approval and Considerations for Determining Whether a Confirmatory Trial is Underway
For drugs granted accelerated approval, sponsors have been required to conduct confirmatory studies postapproval to verify and describe the anticipated effect on irreversible morbidity or mortality or other clinical benefit. In the Consolidated Appropriations Act, 2023 (CAA), Congress amended section 506(c) of the FD&C Act (21 U.S.C. 356(c)), to provide additional authorities to help ensure timely completion of such trials, including that FDA “may require, as appropriate, a study or studies to be underway prior to approval, or within a specified time period after the date of approval, of the applicable product.” This draft guidance, when finalized, will describe FDA’s interpretation of the term “underway” and policies for implementing this requirement, including factors FDA intends to consider when determining whether a confirmatory trial is underway prior to an accelerated approval action.

Accelerated Approval – Expedited Program for Serious Conditions
Accelerated approval is one of FDA’s expedited programs intended to facilitate and expedite development and review of new drugs to address an unmet medical need in the treatment of a serious or life-threatening condition. The purpose of this guidance is to provide information on FDA’s policies and procedures for accelerated approval as well as threshold criteria generally applicable to concluding that a drug is a candidate for accelerated approval. This guidance also describes the procedures for expedited withdrawal of approval of a product approved under accelerated approval and the revisions Congress made through the Consolidated Appropriations Act, 2023 (Public Law 117-328). Additional programs to expedite product development and review are covered in other guidances.

Benefit-Risk

Benefit-Risk Assessment for New Drug and Biological Products
The intent of this guidance is to clarify for drug sponsors and other stakeholders how considerations about a drug’s benefits, risks, and risk management options factor into certain premarket and postmarket regulatory decisions that the Food and Drug Administration (FDA or Agency) makes about new drug applications (NDAs) submitted under section 505(c) of the Federal Food, Drug, and Cosmetic Act (FD&C Act) as well as biologics license applications (BLAs) submitted under section 351(a) of the Public Health Service Act (PHS Act).

Biomarkers

For general information on Biomarkers, please see About Biomarkers and Qualification

Biomarker Qualification: Evidentiary Framework
This draft guidance provides recommendations on general considerations to address when developing a biomarker for qualification under the 21st Century Cures Act (Cures Act), enacted on December 13, 2016, that added a new section to the Federal Food, Drug, and Cosmetic Act (FD&C Act). Qualification of a biomarker is a determination that within the stated context of use, the biomarker can be relied on to have a specific interpretation and application in drug development and regulatory review.

Qualification Process for Drug Development Tools
This guidance describes the qualification process for drug development tools (DDTs) intended for potential use, over time, in multiple drug development programs.

Clinical Outcome Assessments (COAs) and Endpoints

For information on the COA Qualification Program, please see Clinical Outcome Assessment (COA) Qualification Program

Patient-Focused Drug Development: Selecting, Developing, or Modifying Fit-for-Purpose Clinical Outcome Assessments
This guidance (Guidance 3) is the third in a series of four methodological patient-focused drug development (PFDD) guidance documents that describe how stakeholders (patients, caregivers, researchers, medical product developers, and others) can collect and submit patient experience data and other relevant information from patients and caregivers to be used for medical product development and regulatory decision-making.

Patient-Focused Drug Development: Incorporating Clinical Outcome Assessments Into Endpoints for Regulatory Decision-Making
This guidance (Guidance 4) is the fourth in a series of four methodological patient-focused drug development (PFDD) guidance documents that describe how stakeholders (patients, caregivers, researchers, medical product developers, and others) can collect and submit patient experience data and other relevant information from patients and caregivers to be used for medical product development and regulatory decision-making.

Multiple Endpoints in Clinical Trials Guidance for Industry
This guidance provides sponsors and review staff with the Agency’s thinking about the problems posed by multiple endpoints in the analysis and interpretation of study results and how these problems can be managed in clinical trials for human drugs, including drugs subject to licensing as biological products.

Clinical Pharmacology

Exposure-Response Relationships — Study Design, Data Analysis, and Regulatory Applications 
This document provides recommendations for sponsors of investigational new drugs (INDs) and applicants submitting new drug applications (NDAs) or biologics license applications (BLAs) on the use of exposure-response information in the development of drugs, including therapeutic biologics. It can be considered along with the International Conference on Harmonisation (ICH) E4 guidance on Dose-Response Information to Support Drug Registration and other pertinent guidances (see Appendix A).

Bioavailability Studies Submitted in NDAs or INDs – General Considerations
This guidance provides recommendations to sponsors and applicants submitting bioavailability (BA) information for drug products in investigational new drug applications (INDs), new drug applications (NDAs), and NDA supplements. This guidance contains recommendations on how to meet the BA requirements set forth in 21 CFR part 320 as they apply to dosage forms intended for oral administration.

General Clinical Pharmacology Considerations for Pediatric Studies of Drugs, Including Biological Products
This guidance assists sponsors of investigational new drug applications (INDs) and applicants of new drug applications (NDAs) under section 505 of the Federal Food, Drug, and Cosmetic Act (the FD&C Act), biologics license applications (BLAs) under section 351(a) of the Public Health Service Act (PHS Act), and supplements to such applications who are planning to conduct clinical studies in pediatric populations.

General Clinical Pharmacology Considerations for Neonatal Studies for Drugs and Biological Products Guidance for Industry
This guidance is intended to assist sponsors of investigational new drug applications (INDs) and applicants of new drug applications (NDAs), biologics license applications (BLAs), and supplements to such applications who are planning to conduct clinical studies in neonatal populations. This guidance provides recommendations for neonatal clinical pharmacology studies, whether the studies are conducted pursuant to section 505A of the Federal Food, Drug, and Cosmetic Act (FD&C Act), section 505B of the FD&C Act, or neither.

Assessing the Effects of Food on Drugs in INDs and NDAs – Clinical Pharmacology Considerations
This guidance provides recommendations to sponsors planning to conduct food-effect (FE) studies for orally administered drug products under investigational new drug applications (INDs) to support new drug applications (NDAs) and supplements to these applications for drugs being developed under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355).

Population Pharmacokinetics
This guidance is intended to assist sponsors and applicants of new drug applications (NDAs), biologics license applications (BLAs), abbreviated new drug applications (ANDAs), and investigational new drugs (IND) applications in the application of population pharmacokinetic (PK) analysis.

Clinical Pharmacology Considerations for Antibody-Drug Conjugates Guidance for Industry
This guidance provides recommendations to assist industry and other parties involved in the development of antibody-drug conjugates (ADCs) with a cytotoxic small molecule drug or payload. Specifically, this guidance addresses the FDA’s current thinking regarding clinical pharmacology considerations and recommendations for ADC development programs, including bioanalytical methods, dosing strategies, dose- and exposure-response analysis, intrinsic factors, QTc assessments, immunogenicity, and drug-drug interactions (DDIs).

Drug-Drug Interaction Assessment for Therapeutic Proteins Guidance for Industry
The purpose of this guidance is to help sponsors of investigational new drug applications (INDs) and applicants of biologic license applications (BLAs) determine the need for drug-drug interaction (DDI) studies for a therapeutic protein (TP) by providing a systematic, risk-based approach.

Developing Targeted Therapies in Low-Frequency Molecular Subsets of a Disease
The pharmacological effect of a targeted therapy is often related to a particular molecular alteration, and many diseases are caused by a range of different molecular alterations (some of which may be rare). Therefore, a targeted therapy may have differential effects among patients with the same disease who have different molecular alterations. The purpose of this guidance is to describe general approaches to evaluating the benefits and risks of targeted therapeutics within a clinically defined disease where some molecular alterations may occur at low frequencies.

Clinical Pharmacogenomics: Premarket Evaluation in Early-Phase Clinical Studies and Recommendations for Labeling
This guidance is intended to assist the pharmaceutical industry and other investigators engaged in new drug development in evaluating how variations in the human genome, specifically DNA sequence variants, could affect a drug’s pharmacokinetics (PK), pharmacodynamics (PD), efficacy, or safety. The guidance provides recommendations on when and how genomic information should be considered to address questions arising during drug development and regulatory review.

Clinical Trials

All clinical trials guidances are listed here.

Enhancing Participation in Clinical Trials — Eligibility Criteria, Enrollment Practices, and Trial Designs
This guidance recommends approaches that sponsors of clinical trials intended to support a new drug application or a biologics license application can take to increase enrollment of a representative population in their clinical trials. This guidance considers both demographic characteristics of study populations (e.g., sex, race, ethnicity, age, location of residency) and non-demographic characteristics of populations (e.g., patients with organ dysfunction, comorbid conditions, disabilities, those at the extremes of the weight range, and populations with diseases or conditions with low prevalence). Enrolling participants with a wide range of baseline characteristics may create a study population that more accurately reflects the patients likely to take the drug if it is approved and allow assessment of the impact of those characteristics on the safety and effectiveness of the study drug.

E8(R1) General Considerations for Clinical Studies
This guidance describes internationally accepted principles and practices in the design and conduct of clinical studies of drug and biological products. The guidance is intended to assist sponsors and other parties that design clinical studies, and to promote the quality of the studies submitted to regulatory authorities, while allowing for flexibility.

Multiple Endpoints in Clinical Trials Guidance for Industry
The purpose of this guidance is to describe various strategies for grouping and ordering endpoints for analysis and applying some well-recognized statistical methods for managing multiplicity within a study in order to control the chance of making erroneous conclusions about a drug’s effects. Basing a conclusion on an analysis where the risk of false conclusions has not been appropriately controlled can lead to false or misleading representations regarding a drug’s effects.

E17 General Principles for Planning and Design of Multi-Regional Clinical Trial
With the increasing globalization of drug development, it has become important that data from multiregional clinical trials (MRCTs) can be accepted by regulatory authorities across regions and countries as the primary source of evidence to support marketing approval of drugs (medicinal products). The purpose of this guidance is to describe general principles for the planning and design of MRCTs with the aim of increasing the acceptability of MRCTs in global regulatory submissions.

Decentralized Clinical Trials for Drugs, Biological Products, and Devices
This draft guidance provides recommendations for sponsors, investigators, and other stakeholders regarding the implementation of decentralized clinical trials (DCTs) for drugs, biological products, and devices. In this guidance, a DCT refers to a clinical trial where some or all of the trial-related activities occur at locations other than traditional clinical trial sites.

Enrichment Strategies for Clinical Trials to Support Approval of Human Drugs and Biological Products: Guidance for Industry
The purpose of this guidance is to assist industry in developing enrichment strategies that can be used in clinical investigations intended to demonstrate effectiveness (and in some cases safety) of human drugs and biological products. This guidance defines several types of enrichment strategies, provides examples of potential clinical trial designs, and discusses potential regulatory considerations when using enrichment strategies in clinical trials.

Ethical Considerations for Clinical Investigations of Medical Products Involving Children
Clinical investigations in children are essential for obtaining data on the safety and effectiveness of drugs, biological products, and medical devices in children and to protect children from the risks associated with exposure to medical products that may be unsafe or ineffective. Children are a vulnerable population who cannot consent for themselves and who therefore are afforded additional safeguards when participating in a clinical investigation. Such safeguards are an essential requirement for the initiation and conduct of pediatric investigations as part of a medical product development program.

Master Protocols for Drug and Biological Product Development
This guidance document provides recommendations on the design and analysis of trials conducted under a master protocol as well as guidance on the submission of documentation to support regulatory review.

There are some other Guidances which were issued and I will discuss them in another post.  These include Guidances on minimizing use of animals for preclinical toxicology, Innovative clinical trial design especially for gene and cell therapies, and use of AI in designing of clinical trials.

For more information go to the FDA website at : https://www.fda.gov/drugs/guidances-drugs/guidance-documents-rare-disease-drug-development

Other Articles on FDA Guidances on this Open Access Scientific Journal Include:

FDA Guidance on Use of Xenotransplanted Products in Human: Implications in 3D Printing

FDA Guidance Documents Update Nov. 2015 on Devices, Animal Studies, Gene Therapy, Liposomes

FDA Cellular & Gene Therapy Guidances: Implications for CRSPR/Cas9 Trials 

New FDA Draft Guidance On Homologous Use of Human Cells, Tissues, and Cellular and Tissue-Based Products – Implications for 3D BioPrinting of Regenerative Tissue

FDA Guidelines For Developmental and Reproductive Toxicology (DART) Studies for Small Molecules

 

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Larry H Bernstein, MD, FCAP
Pharmaceutical Intelligence

UPDATED 4/23/2020:  New Design for Phase 1 pediatric oncology trials to expedite dose escalation studies.

Clinical Trials Revisited

http://pharmaceuticalintelligence.com/2013/04/03/clinical-trials-revisit/

Cancer Clinical Trials of Tomorrow

Advances in genomics and cancer biology will alter the design of human cancer studies

By Tomasz M. Beer | April 1, 2013   The Scientist
We stand on the cusp of significant change in the fundamental structure of cancer clinical trials, as the emphasis begins to shift from large-scale studies of relatively unselected patients to smaller studies testing more narrowly targeted therapies in molecularly characterized populations.
The previous (and still current) generation of trials established the cancer treatment standards used today. Trials that demonstrated the value of combination chemotherapy in the adjuvant treatment of breast cancer are an excellent example. Meticulous development of treatment regimens through Phase 1 and Phase 2 trials, followed by large-scale comparisons of the new regimens to established treatment protocols, have defined the modern practice of oncology for the last 4 decades. Future cancer clinical trials will be very different from those of the past, adopting a more personalized, sometimes called “precision,” approach.
It is, of course, not entirely true that past clinical trials did not include efforts to target treatments to the right patients. Where possible, targeted therapies are already being implemented. Using the presence of endocrine receptors to guide endocrine therapy for breast cancer was one of the first forays into molecular selection of patients. Unfortunately, the ability to select subgroups of patients for study has been severely curtailed by a still-limited knowledge of human cancer biology.
This is rapidly changing, however, thanks to advances in genomics and comprehensive cancer biology research over the last decade. Large-scale efforts, such as The Cancer Genome Atlas, are comprehensively defining many of the crucial molecular characteristics of human malignancies by illuminating genetic alterations that are clinically and biologically important, and which, by virtue of their functional roles, are viable targets for cancer treatment. At the same time, the ability to design small-molecule inhibitors of specific cancer targets is rapidly accelerating. In 2011, two new agents exemplified the power of these trends: crizotinib was approved for the treatment of lung cancers that harbor a specific mutation in the ALK gene, and vemurafenib was approved for the treatment of melanomas with a specific BRAF mutation. In both cases, the drugs were approved along with companion diagnostic tests that identify patients with the target mutation, who are therefore likely to benefit from treatment.

Smaller, more precise trials ahead

Clinical trials are being transformed by these trends. It will not happen overnight, as the knowledge of cancer biology and the availability of targeted agents are uneven. Unselected populations of patients will still be studied, but it is inevitable that there will be a rise in the number of trials that incorporate molecular tumor testing prior to treatment, with treatment selection informed by the molecular features of each individual’s cancer. Such personalized trials have the potential to yield better outcomes by increasing the probability of response and to employ less toxic therapies by increasingly targeting cancer-specific functions, rather than normal proliferative functions.
To the extent that targeted therapies will prove more effective when given to selected patients, clinical trials should get dramatically smaller. Trial size is largely driven by how effective the treatment is expected to be, so fewer participants are needed when the therapeutic benefit is larger. But the promise of smaller trials will not to be universal; for example, when two targeted agents are compared to one another in the same molecularly selected population, the differences in efficacy may be small and larger trials will be required.
As approaches to cancer treatment advance, there will need to be continual engagement with patients and with cancer survivors.
Furthermore, smaller trials may not necessarily move faster or be easier to complete, as they will require the “right patients,” who may be hard to find. Many of the mutations that represent promising targets are present in a minority of tumors. Today, molecular characterization of tumors is often done as part of the screening process for each trial. Many, and sometimes most, of the patients prove ineligible, making this approach frustrating and difficult to carry out. A better avenue of attack would be to make comprehensive molecular characterization of tumors a routine part of establishing a patient’s eligibility for a range of therapies. With the plummeting cost of genomic analysis, one can envision a day in the near future when a complete cancer genome (and perhaps other molecular evaluations) becomes a standard component of an initial diagnostic evaluation. Patients will be armed with molecular information about their own tumors, and thus able to make more-informed decisions about standard and investigational therapies that match the mutations driving their cancer.

New challenges

The road to personalized and targeted treatment strategies will offer new challenges. For rare targets that are present in a minority of cases across many different types of cancers, one will have to consider clinical trials that include a number of different cancers. There are many design pitfalls to such trials, chiefly the additional clinical and molecular heterogeneity introduced by the inclusion of more than one cancer type. Despite these challenges, it will inevitably make sense in some settings to select patients who share a particular tumor biology, regardless of the tissue of origin.
Another major challenge is how to combine targeted therapies to improve clinical outcomes. To date, targeted therapies have not been able to cure advanced solid tumors. Clinical benefits, while sometimes quite impressive when compared to marginally effective treatments, still fall far short. It stands to reason that redundant survival and growth pathways enable tumors to overcome therapies that inhibit a single target. The simultaneous inhibition of relevant redundant pathways may yield dramatically better results, but will also dramatically increase the complexity of molecularly personalized clinical trials.
As approaches to cancer treatment advance, there will need to be continual engagement with patients and with cancer survivors. Fewer than 5 percent of adult cancer patients participate in a clinical trial. To carry out meaningful clinical trials in the future, that number must increase. This will be most important for treatments that target relatively rare mutations; a large number of potential volunteers will have to be screened to identify a sufficient number who harbor the relevant target. To succeed, we must partner with a much larger fraction of cancer patients.
Designing and executing future cancer clinical trials will not be easy, but physician-scientists are armed with a fast-growing body of omics-informed knowledge with which to surmount these hurdles.
Tomasz M. Beer is deputy director of the Knight Cancer Institute and a professor of medicine at Oregon Health & Science University in Portland. He is the coauthor of Cancer Clinical Trials: A Commonsense Guide to Experimental Cancer Therapies and Clinical Trials. Written for people living with cancer, the book is accompanied by a blog (www.cancer-clinical-trials.com) that seeks to disseminate knowledge about clinical trials.

Tags

tumor suppression, tumor heterogeneity, genetics & genomics, disease/medicine, clinical trials, chemotherapy, cancer genomics and cancer

UPDATED 4/23/2020:  New Design for Phase 1 pediatric oncology trials to expedite dose escalation studies.

 

REVIEW

Ushering in the next generation of precision trials for pediatric cancer

Steven G. DuBois, Laura B. Corson, Kimberly Stegmaier, Katherine A. Janeway

Science  15 Mar 2019:Vol. 363, Issue 6432, pp. 1175-1181 DOI: 10.1126/science.aaw4153

 

Abstract

Cancer treatment decisions are increasingly based on the genomic profile of the patient’s tumor, a strategy called “precision oncology.” Over the past few years, a growing number of clinical trials and case reports have provided evidence that precision oncology is an effective approach for at least some children with cancer. Here, we review key factors influencing pediatric drug development in the era of precision oncology. We describe an emerging regulatory framework that is accelerating the pace of clinical trials in children as well as design challenges that are specific to trials that involve young cancer patients. Last, we discuss new drug development approaches for pediatric cancers whose growth relies on proteins that are difficult to target therapeutically, such as transcription factors.

Some terms from the bibliography:

3+3 design: A commonly used rule-based design for phase 1 clinical trials in which patients are enrolled in cohorts of three patients, and decisions to increase or decrease the dose level for the next three participants are based on toxicities observed in those three patients.

 

Basket trial: A precision oncology trial design in which patients with many different cancer types are enrolled, the tumor is tested for a set of biomarkers of interest, and then patients are assigned to one of several clinical trial subprotocols based on the presence of a biomarker corresponding to a particular molecularly targeted therapy.

 

Bayesian model–based trial designs: A broad class of trial designs that use data known before the trial as well as data obtained during the conduct of the trial to adapt trial parameters as more information becomes available

Continual reassessment method: One example of a Bayesian model–based trial design in which an initial mathematical model of the relationship between drug dose and probability of unacceptable toxicity is continually updated as new information becomes available to assign subsequent patients to a dose anticipated to have an unacceptable toxicity rate below a set rate.

First-in-child trial: The first clinical trial of a specific agent to include a pediatric population, traditionally considered patients <18 years of age.

 

Rolling 6 design: A variation of the 3+3 design in which up to six participants may be enrolled to a dosing cohort before enrollment pauses to assess toxicity.

Safety run-in: An initial component of a phase 2 or phase 3 trial in which a small group of patients are treated with a previously untested regimen to evaluate toxicity before opening the trial to a larger group of participants.

Umbrella trial: A precision oncology trial design in which patients with a specific cancer type are enrolled, tumor is tested for a set of biomarkers of interest, and then patients are assigned to one of several clinical trial subprotocols based on the presence of a biomarker corresponding to a particular molecularly targeted therapy.

 

In this review article, DuBois et al describe new paradigms for pediatric precision oncology trial design and how these designs should be contrasted with the old models and differentiate from the design for these types of trials in the adult.  As the genomic landscape of pediatric tumors is becoming clearer (1, 2) the authors noticed two themes which are becoming evident:

  1. Pediatric cancers harbor certain genomic mutations rarely seen in adult cancers
  2. Pediatric cancers share some genomic alterations and mutational gene signatures with adult tumors

However there is only a small number of pediatric clinical trials to investigate if specific genetic mutations predict outcome to a given personalized therapy.

            Thus, there an urgent need for precision clinical trials in pediatric cancers.

Several reviews have described numerous ongoing and recently completed trials however most are phase 1 dose escalation trials including basket trials and umbrella trials but based on previous data from adult trials using the same precision drug.  For example, pediatric trials involving the TRK inhibitor laratrectinib in tumors harboring a NTRK fusion gene or a pediatric crizotinib trial for pediatric glioblastomas having an ALK fusion protein have shown great success yet most of the early phase 1 work was based on adults or carried out in a way that does not take advantage of the new regulatory framework designed to expedite new drugs for adult precision medicines.

Speeding up the early phase trials in pediatric cancers: new trial design paradigms

Dose escalation phase I trials have, traditionally been the starting point for clinical development of new pediatric anticancer drugs however these first in child trials have seriously lagged their adult counterparts by many years.  These trials relied on the standard 3 x 3  or rolling six trial design, and doses escalated until a pediatric MTD  (maximum tolerated dose) was achieved.  In recent years new precision medicine pediatric trial design has been adopted to expedite the process, based on the fundamental shift in thinking that many new oncology agents will not have a true MTD when tested in adults.

Doses in phase 1 trials for targeted therapies like those in precision medicine are usually escalated based on considerations other than toxicity, like pharmacodynamics or biomarker analysis.  A pediatric phase 1 dose escalation trial may require more subjects than an adult trial.  But

although these newer approaches to early-phase trial design more efficiently establish a pediatric dose, they do little to advance our understanding of with patients are most likely to benefit from a new therapy.

Thus the need for good biomarkers to be included early on in these initial trial designs.  For example, Dana Farber’s first in child clinical trial NCT03654716, a Phase 1 Study of the Dual MDM2/MDMX Inhibitor ALRN-6924 in Pediatric Cancer (as a possible treatment for resistant (refractory) solid tumor, brain tumor, lymphoma or leukemia), are reducing the time children are waiting for entry into a trial, as unselected patients can enroll and the biomarker, increased MDM2 expression is used to determine those patients who go on to phase 2 dose escalation. In other cases, such as NCI Children’s Oncology Group basket trials, they have completely supplanted formal phase 1 trial design and instead incorporated molecularly targeted therapies based on adult doses but adjusted for patient size.  The use of combinations with traditional therapies in trial design is also helping to speed up the process for enrollment.  The authors also suggest that tumor profiling is pertinent however should be put in trial design so the costs to patients can be covered by the trial funds.

 

Figure 1Fig. 1 Evolution of precision trials for pediatric cancer.

Illustration: Kellie Holoski/Science

Source: Ushering in the next generation of precision trials for pediatric cancer BY STEVEN G. DUBOIS, LAURA B. CORSON, KIMBERLY STEGMAIER, KATHERINE A. JANEWAY SCIENCE 15 MAR 2019 : 1175-1181 https://science.sciencemag.org/content/363/6432/1175

 

  1. S. N. Gröbner, B. C. Worst, J. Weischenfeldt, I. Buchhalter, K. Kleinheinz, V. A. Rudneva, P. D. Johann, G. P. Balasubramanian, M. Segura-Wang, S. Brabetz, S. Bender, B. Hutter, D. Sturm, E. Pfaff, D. Hübschmann, G. Zipprich, M. Heinold, J. Eils, C. Lawerenz, S. Erkek, S. Lambo, S. Waszak, C. Blattmann, A. Borkhardt, M. Kuhlen, A. Eggert, S. Fulda, M. Gessler, J. Wegert, R. Kappler, D. Baumhoer, S. Burdach, R. Kirschner-Schwabe, U. Kontny, A. E. Kulozik, D. Lohmann, S. Hettmer, C. Eckert, S. Bielack, M. Nathrath, C. Niemeyer, G. H. Richter, J. Schulte, R. Siebert, F. Westermann, J. J. Molenaar, G. Vassal, H. Witt, B. Burkhardt, C. P. Kratz, O. Witt, C. M. van Tilburg, C. M. Kramm, G. Fleischhack, U. Dirksen, S. Rutkowski, M. Frühwald, K. von Hoff, S. Wolf, T. Klingebiel, E. Koscielniak, P. Landgraf, J. Koster, A. C. Resnick, J. Zhang, Y. Liu, X. Zhou, A. J. Waanders, D. A. Zwijnenburg, P. Raman, B. Brors, U. D. Weber, P. A. Northcott, K. W. Pajtler, M. Kool, R. M. Piro, J. O. Korbel, M. Schlesner, R. Eils, D. T. W. Jones, P. Lichter, L. Chavez, M. Zapatka, S. M. Pfister, ICGC PedBrain-Seq Project, ICGC MMML-Seq Project, The landscape of genomic alterations across childhood cancers. Nature 555, 321–327 (2018). 10.1038/nature25480pmid:29489754

 

2.  X. Ma, Y. Liu, Y. Liu, L. B. Alexandrov, M. N. Edmonson, C. Gawad, X. Zhou, Y. Li, M. C. Rusch, J. Easton, R. Huether, V. Gonzalez-Pena, M. R. Wilkinson, L. C. Hermida, S. Davis, E. Sioson, S. Pounds, X. Cao, R. E. Ries, Z. Wang, X. Chen, L. Dong, S. J. Diskin, M. A. Smith, J. M. Guidry Auvil, P. S. Meltzer, C. C. Lau, E. J. Perlman, J. M. Maris, S. Meshinchi, S. P. Hunger, D. S. Gerhard, J. Zhang, Pan-cancer genome and transcriptome analyses of 1,699 paediatric leukaemias and solid tumours. Nature 555, 371–376 (2018). 10.1038/nature25795pmid:29489755

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