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Posts Tagged ‘Food and Drug Administration’

Clinical Trials on Transcatheter Aortic Valve Replacement (TAVR) to be conducted by American College of Cardiology and the Society of Thoracic Surgeons

Curator: Aviva Lev-Ari, PhD, RN

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UPDATED on 6/22/2017

  • by Nicole Lou, Reporter, MedPage Today/CRTonline.org June 21, 2017

Action Points

  • Off-label transcatheter aortic valve replacement (TAVR) was associated with higher in-hospital, 30-day, and 1-year mortality rates compared with on-label TAVR use, but after adjustment, 1-year mortality was similar in the two groups.
  • Note that approximately one in 10 TAVR patients in the United States have received the procedure for an off-label indication.

SOURCE

1 in 10 TAVR Procedures Done Off-Label Despite early risks vs on-label use, ‘acceptable results’ cited from registry

https://www.medpagetoday.com/Cardiology/CHF/66173?xid=nl_mpt_DHE_2017-06-22&eun=g99985d0r&pos=1

UPDATED on 11/24/2013

Second Generation Transcatheter Aortic Valve Shown to Successfully Address TAVR Complications

Results of the REPRISE II trial reported at TCT 2013
November 4, 2013
heart valve repair hybrid or cath lab reprise II boston scientific lotus tct
November 4, 2013 — In a clinical trial of the Boston Scientific Lotus valve, a second-generationtranscatheter aortic valve, the device demonstrated low rates of complications that are sometimes seen in transcatheter aortic valve replacement (TAVR), including challenges with positioning, post-procedure paravalvular aortic regurgitation, vascular complications and stroke.
The findings were presented at the 25th annual Transcatheter Cardiovascular Therapeutics scientific symposium (TCT 2013).
The valve studied in REPRISE II is fully retrievable and repositionable with an adaptive seal intended to minimize paravalvular regurgitation, a complication that has been associated with higher mortality among patients undergoing TAVR. In this prospective, single-arm, multicenter study, symptomatic patients at high risk for surgery received the Lotus valve to treat calcific aortic stenosis.
The trial enrolled 120 patients; mean age was 84.4±5.3 years, 56.7 percent were female and 75.8 percent were considered New York Heart Association (NYHA) Class III or IV. The mean Society of Thoracic Surgeons score was 7.1±4.6 percent and all patients were confirmed by their site heart team to be at high risk for surgery due to frailty or associated comorbidities.
The valve was successfully implanted in all 120 patients with valve repositioning and retrieval performed as needed. There was no embolization, ectopic valve deployment or need for implantation of a second prosthetic valve.
The primary device performance endpoint was the mean aortic valve pressure gradient at 30 days compared to a performance goal of 18 mmHg; the primary safety endpoint was 30-day mortality. The primary device performance endpoint was met with a 30 day mean aortic valve pressure gradient of 11.5±5.2 mmHg; mean effective orifice area was 1.7±0.4 cm2.
All cause mortality and disabling stroke were low at 30 days (4.2 percent and 1.7 percent, respectively). Additional clinical event rates were consistent with those reported for other valves. Aortic regurgitation at 30 days was negligible in 99 percent of patients (78.3 percent none, 5.2 percent trace and 15.5 percent mild). The total stroke rate, disabling and non-disabling, was 5.9 percent, which is the same as the rate as the Edward’s Sapien valve’s performance in the PARTNER trial.
“These findings suggest this valve, which is a differentiated, second generation TAVR device, will be a valuable addition for the treatment of severe aortic stenosis,” said Ian Meredith, MBBS, Ph.D., director, Monash HEART, executive director, Monash Cardiovascular Research Centre, professor of medicine, Monash University in Melbourne, Australia, and lead investigator of the study.

“This is the first time the societies have ever filed for an investigational device exemption,” former ACC president Ralph Brindis is quoted as saying. “The goal of the effort is to gain reimbursement for an expanded set of procedures with Sapien to make the device accessible to more patients.”

Two medical societies jump into clinical trial effort for TAVR tech – FierceMedicalDevices http://www.fiercemedicaldevices.com/story/two-medical-societies-jump-clinical-trial-effort-tavr-tech/2013-02-12#ixzz2Kjk7MHEi

The new trials will mean that reimbursement will now be possible for some of these uses when patients are enrolled in the clinical trials. According to Mack, the NCD “took off-label use off the table. If you are a cynic this is good, but if you’re a practitioner this is tying your hands.”

http://www.forbes.com/sites/larryhusten/2013/02/12/two-medical-societies-break-new-ground-to-test-medical-device/

According to Forbes, STS president Michael Mack told The Gray Sheet (a subscription-only publication) that the first trial will look at alternatives to transfemoral approaches in 1,000 patients who couldn’t otherwise have aortic valve surgery. There was a coordinated effort to develop a trial protocol, worked out between the CACC, STS, CMS, Edwards and the FDA. Expanded uses require an FDA label, he noted, and the only way to do that is to conduct a clinical trial with an IDE in hand.

So why would expanded TAVR uses be necessary? Well, the procedure has become very much in demand, and physicians already began pursuing off-label uses once they learned the initial TAVR procedure, Brindis told Forbes. The magazine notes that the entrance of both the STS and ACC into TAVR clinical trials greatly expands the TVT registry that they run, which tracks TAVR use in the United States to help physicians comply with Medicare’s National Coverage Decision for TAVR.

TAVR is indeed a hot space. St. Jude Medical ($STJ) won a CE mark for its Portico transcatheter heart valve late last fall, and Edwards’ Sapien competes with Medtronic‘s ($MDT) CoreValve in Europe. And smaller companies such as Micro Interventional Devices are working hard to develop surgical tools designed to enable TAVR procedures.

Brindis and Mack said that the ACC and STS worked closely with CMS,the FDA, and Edwards to develop the trial protocol. In the trial, patients not eligible for aortic valve surgery will receive TAVR through transapical and transaortic approaches and will be compared with the results of patients in the original PARTNER A trial who received TAVR through the transapical approach. Mack concedes that the trial design is not idea. “There is no perfect comparator,” he acknowledged.

http://www.forbes.com/sites/larryhusten/2013/02/12/two-medical-societies-break-new-ground-to-test-medical-device/

Other experts in the field contacted by CardioBrief agreed that the challenges of trial design in this situation are quite formidable. Randomized trials are not always feasible and, in some situations, may be unethical. The IDE is an attempt to balance the need for rational clinical trials, on the one hand, and the growing pressure to perform off-label procedures. It should be noted that an important safeguard for patients remains in place: all potential TAVR patients will still need to be evaluated by both a cardiologist and a cardiac surgeon as part of the “heart team” approach mandated by the FDA and the NCD.

http://www.forbes.com/sites/larryhusten/2013/02/12/two-medical-societies-break-new-ground-to-test-medical-device/

The ACC and STS are now working to gain FDA approval to perform two more studies. One would examine the role of alternative approaches in the high-risk population eligible for surgery. The second would study valve-in-valve TAVR procedures. Both studies also present challenging problems of trial design. Mack said he anticipates FDA approval of these protocols in the next few months.

Edwards agreed in principle to fund the clinical trials. An Edwards representative confirmed that the company planned to support these new trials, but the details have not yet been hammered out.

 Mack states that the power and scope of the TVT registry actually makes it easier for ACC and STS to move forward than Edwards. Further, Mack believes that some indications are like “orphan” indications that are medically but not commercially compelling.

http://www.forbes.com/sites/larryhusten/2013/02/12/two-medical-societies-break-new-ground-to-test-medical-device/

Two medical societies jump into clinical trial effort for TAVR tech – FierceMedicalDevices http://www.fiercemedicaldevices.com/story/two-medical-societies-jump-clinical-trial-effort-tavr-tech/2013-02-12#ixzz2KjheTKHN

Larry Husten, wrote on  5/04/2012 in Forbes,  The final decision earlier this week by the Centers for Medicare & Medicaid Services (CMS) to provide reimbursement for TAVR was the latest step in a long, ongoing process that, for once, didn’t appear broken, and, in fact, represented an unusual consensus among physicians, regulators, insurers, and other involved parties In his article

Politics and Transcatheter Aortic Valve Replacement

From the first early stages of its development, the prospect of transcatheter aortic valve replacement (TAVR) provoked two broad and competing fears:

  1. Regulatory safeguards would kill a promising new technology, denying its life-saving benefits to many thousands of desperately sick people.
  2. The stampede to stake a claim in a promising, highly lucrative new territory would lead to the exploitation and mistreatment of many thousands of desperately sick people.

http://www.forbes.com/sites/larryhusten/2012/05/04/politics-and-transcatheter-aortic-valve-replacement/

Scott Gottlieb, a conservative activist who is a former FDA deputy commissioner and CMS adviser, concludes that the CMS ruling means “that for costly procedures, Washington will be making more of these choices for us.” In a posting on the American Enterprise Institute’s The Enterprise BlogGottlieb writes that the decision “is a vivid example of how our healthcare is going to get reimbursed now that Washington calls more of the shots.”

http://www.forbes.com/sites/larryhusten/2012/05/04/politics-and-transcatheter-aortic-valve-replacement/

CMS  has insisted that doctors who perform the procedure have adequate training and that the hospitals where the procedures are performed have sufficient experience and adequate facilities. Perhaps Scott Gottlieb, MD would be happy to send an elderly relative for TAVR  to a local community hospital with little experience in the procedure. It was precisely to avoid this scenario that the American College of Cardiology and the Society of Thoracic Surgeons supported CMS in this coverage decision. I fail to see how anyone would benefit by widespread proliferation of TAVR by novice operators at inexperienced centers.

  • Physicians,
  • Regulators,
  • Insurers,
  • CMS,
  • Medical Device Manufactures
  • ACC, and
  • STS

will be cooperating in the College of Cardiology and Society of Thoracic Surgeons newly announced involvement in Clinical Trials on broader use of transcatheter aortic valve replacement (TAVR) procedure to include new patients that this procedure will be indicated for and CMS reimbursed.

Other aspects of the Procedure, and the role EdwardsSciences played in the development and the Industry Leadership it holds in the US, are covered in several articles on this Open Access Online Scientific Journal, including the following:

August 7, 2012 – Transcatheter Aortic Valve Implantation (TAVI): risk for stroke and suitability for surgery

http://pharmaceuticalintelligence.com/2012/08/07/transcatheter-aortic-valve-implantation-tavi-risky-and-costly-2/

August 2, 2012 – Transcatheter Aortic Valve Implantation (TAVI): Risky and Costly

http://pharmaceuticalintelligence.com/2012/08/02/transcatheter-aortic-valve-implantation-tavi-risky-and-costly/

June 4, 2012 – Investigational Devices: Edwards Sapien Transcatheter Aortic Valve Transapical Deployment http://pharmaceuticalintelligence.com/2012/06/04/investigational-devices-edwards-sapien-transcatheter-heart-valve/

June 10, 2012 — Investigational Devices: Edwards Sapien Transcatheter Aortic Heart Valve Replacement Transfemoral Deployment http://pharmaceuticalintelligence.com/2012/06/10/investigational-devices-edwards-sapien-transcatheter-aortic-heart-valve-replacement-transfemoral-deployment/

1/29/2013 — Direct Flow Medical Wins European Clearance for Catheter Delivered Aortic Valve

http://pharmaceuticalintelligence.com/2013/01/29/direct-flow-medical-wins-european-clearance-for-catheter-delivered-aortic-valve/

6/19/2012 Executive Compensation and Comparator Group Definition in the Cardiac and Vascular Medical Devices Sector: A Bright Future for Edwards Lifesciences Corporation in the Transcatheter Heart Valve Replacement Market

http://pharmaceuticalintelligence.com/2012/06/19/executive-compensation-and-comparator-group-definition-in-the-cardiac-and-vascular-medical-devices-sector-a-bright-future-for-edwards-lifesciences-corporation-in-the-transcatheter-heart-valve-replace/

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FDA Pending 510(k) for The Latest Cardiovascular Imaging Technology

Curator: Aviva Lev-Ari, PhD, RN

 

UPDATED on 11/22/2018

  • Device Approvals, Denials and Clearances

https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/default.htm

  • FDA clears AI technology that evaluates echocardiograms – Ultrasound Images

https://www.healthdatamanagement.com/news/fda-clears-ai-technology-that-evaluates-echocardiograms

  • Heart Murmur Detection done by AI Algorithm (Eko Core and Eko Duo) Devices Outperform most Auscultatory Skills of Cardiologists

https://pharmaceuticalintelligence.com/2018/11/21/heart-murmur-detection-done-by-ai-algorithm-eko-core-and-eko-duo-devices-outperform-most-auscultatory-skills-of-cardiologists/

  • FDA Clears Remote Multichannel ECG Compared to Holter

https://www.cardiovascularbusiness.com/topics/electrophysiology-arrhythmia/fda-clears-remote-multichannel-ecg-compared-holter

  • Arterys Cardio AI – MR Images

Arterys CEO Fabien Beckers, along with Michael Poon, MD, Northwell Health cardiologist, will present “The Potential of a Web Platform to Transform Medical Imaging with AI and Cloud Computation” in the 2018 RSNA Machine Learning Showcase, Tuesday November 27 at 11:30am CST. Arterys will provide demonstrations of its AI-powered, web-based solutions, including:

Arterys Cardio AIMR combines the power of deep learning and cloud computing to automate analysis of cardiac MR images. By eliminating many tedious, manual tasks, Arterys Cardio AI enables clinicians to quickly and easily identify, determine treatment for and track heart problems. It is the first and only commercial solution to offer deep learning-based semi-quantitative perfusion and quantitative delayed enhancement analysis*.

https://www.marketwatch.com/press-release/arterys-to-demonstrate-suite-of-ai-powered-cloud-based-medical-image-analysis-solutions-at-rsna-2018-2018-11-21/print

  • AI software for detecting brain bleeds receives FDA approval – CT Images

The FDA recently administered 510(k) clearance to software developed by MaxQ AI that uses AI to detect brain bleeds on CT images, according to a report published Nov. 8 by AI in Healthcare.  

“The Accipio Ix Intracranial Hemorrhage platform uses AI technology to automatically analyze non-contrast head CT images, and can do so without impacting a physician’s workflow, altering the original series or storing protected health information,” according to the article.

The clinical diagnostics intelligence platform company hopes that the software can help physicians prioritizes patients who show symptoms of brain bleeds.

With FDA approval, the AI software can be sold for commercial use within the U.S. and will be on display during this year’s Radiological Society of North America (RSNA) Annual Meeting in Chicago.

https://www.healthimaging.com/topics/artificial-intelligence/ai-detection-software-brain-bleeds-fda-approved

 

  • More in Artificial Intelligence

SOURCE

https://www.healthimaging.com/topics/artificial-intelligence/ai-detection-software-brain-bleeds-fda-approv

Cardiovascular Medical Devices in the News

March 13, 2018 — Determining the best occluder device size necessary to properly seal the left atrial appendage (LAA) before implanting the device may be feasible with the assistance of 3D printing, according to two separate presentations at ECR 2018 in Vienna.

SOURCE

https://www.auntminnieeurope.com/index.aspx?sec=sup&sub=car&pno=2

  • Machine learning can help assess atherosclerosis
    February 7, 2018 — Machine-learning techniques analyze imaging measurements to automatically stratify patients by the level of atherosclerotic burden, offering the potential of personalized prediction of disease progression and more effective treatment for individual patients, according to researchers from Italy.  Discuss

SOURCE

https://www.auntminnieeurope.com/index.aspx?sec=sup&sub=car&pno=3

  • CCTA biomarker may predict mortality from heart disease
    August 28, 2018 — The use of coronary CT angiography (CCTA) to measure fatty tissue around arteries could help predict the risk of mortality from heart disease, according to research published online on 28 August in the Lancet and being presented at the European Society of Cardiology congress in Munich.  Discuss

SOURCE

https://www.auntminnieeurope.com/index.aspx?sec=sup&sub=car&pno=1

  • SCOT-HEART: CCTA cuts risk of heart attack, death by 41%
    August 25, 2018 — Patients with chest pain who underwent coronary CT angiography (CCTA) with standard care had a markedly lower rate of myocardial infarction or death from coronary artery disease than those who only received standard care in a new study, published on August 25 in theNew England Journal of Medicine.  Discuss

SOURCE

https://www.auntminnieeurope.com/index.aspx?sec=sup&sub=car&pno=1

 

 

SOURCE

https://www.healthdatamanagement.com/tag/cardiovascular-disease

FDA’s Medical Devices Frontier in 2013

Michelle McMurry-Heath

Office of the Center Director, Center for Devices and

Radiological Health, U.S. Food and Drug Administration (FDA)

and

Margaret A. Hamburg

Office of the Commissioner, FDA

In their article Creating a Space for Innovative Device Development stated that the FDA announces a partnership with a new nonprofit organization—the Medical Device Innovation Consortium (MDIC) —to advance regulatory science in the medical technology arena.

The promise of MDIC is to eliminate the currently existing shortfalls in applied research in areas such as health-related engineering and regulatory science, which comprises the development of new tools, standards, and approaches to assess a product’s safety, efficacy, quality, and performance.

MDIC will foster regulatory science breakthroughs in the medical technology space with the ultimate goal of improving human health.

FDA and LifeScience Alley (LSA; https://www.lifesciencealley.org)—a biomedical science trade association—have worked together to develop the first medical device public-private partnership (PPP) whose sole objective is to advance the entire spectrum of regulatory science in this sector. MDIC will facilitate this groundbreaking collaboration among federal agencies, nonprofit organizations, industry, academic institutions, and other trade associations such as MassMedic (www.massmedic.com) and the California Healthcare Institute (www.chi.org). Key goals:

(1) encourage members to leverage their resources by focusing jointly on precompetitive

(2) early-stage technology development ef orts that otherwise would not take place because of the organizational structure of the device sector.

About 75% of the more than 5,000 device manufacturers in the United States are small companies with fewer than 20 employees (3).

Start-up device companies have limited capital, and a startup’s future of en depends on the success of one complex device. Advances in regulatory science would speed the translation of these next-generation technologies.

Medical Devices sector lacks the resources to support regulatory science research, as well as mechanisms for working together to pool their resources to solve scientific issues.

MDIC members will make it a priority to develop regulatory methods and tools that can be adopted by the medical device community and will provide a forum for medical device stakeholders to securely share proprietary precompetitive data. Each advance achieved by medical device stakeholders through the sharing and leveraging of resources will assist industry in developing new REGULATORY SCIENCE Creating a Space for Innovative Device Development.

GOALS OF PARTNERING WITH MDIC

MDIC was designed with f exibility in mind, so that it can adapt to address the most pressing needs of patients and of the device industry as they evolve over time.

In keeping with the goal of stakeholder engagement, MDIC is currently recruiting founding members who will work jointly with FDA to determine research priorities for the endeavor.

Much like other successful PPPs in the pharmaceutical space, such as the Foundation for NIH or Critical Path Institute, the founding members will be asked to represent their stakeholder communities in

(i) suggesting the most promising areas for research collaboration,

(ii) raising funds to support these areas of investigation, and then

(iii) issuing requests for grant proposals.

Researchers and engineers from all sectors—industry, government, academia, or nonprofit organizations—will be encouraged to apply, and preference will be given to research consortia that cross sectors and take interdisciplinary approaches to problems.

MDIC strives to support science conducted by research teams that have innovative ideas for the development of tools and methods for medical device design, testing, and regulatory approval.

MDIC’s potential to improve patient care is computational modeling and simulation of human pathophysiology, which can be used to augment in vitro and animal disease models in the preclinical stages of device development.

FDA’s Center for Devices and Radiological Health (CDRH) expects computational modeling to accelerate and streamline the regulatory review process but first needs to develop a strategy for assessing the technology’s credibility—its usefulness, quality, and reproducibility. CDRH has begun to develop a technological framework called the Virtual Physiological Patient (4), which, once completed, will provide a model for the human body as a single complex system. 

However, cross-sector research teams are required to develop the normal and diseased reference models that will serve as benchmarks for device performance and safety. Using computational modeling and simulation, device designs can potentially be ref ned even before they enter clinical trials, improving safety for patients and reducing the cost of device development for companies, computational modeling and simulation, device designs can potentially be ref ned even before they enter clinical trials, improving safety for patients and reducing the cost of device development for companies.

Another emerging research area is medical device interoperability—the development of devices that seamlessly operate with other medical devices and information systems (5). MDIC could establish a framework to identify gaps in the interoperability field, prioritize the gaps, and then fund research accordingly.

MDIC also could help prioritize the development of standards for innovative interoperable medical devices and build test beds for these technologies. is research will help to ensure that interoperability issues do not pose a hazard to patients.

With the emergence of new materials in medical devices, FDA must develop updated biocompatibility standards based on the most recent scientific advances.

MDIC could support the development of new preclinical biocompatibility assays that predict potential adverse health responses in people exposed to biomaterials or nanoparticles (6).

INNOVATION INFRASTRUCTURE With today’s fiscal realities, FDA cannot rely on government-funded “Manhattan projects” to bridge the funding gap for regulatory science. Partnerships bring together private-sector expertise, academic science ingenuity, and federal regulatory knowledge, and new structures are needed to promote these multifaceted collaborations.

It would be convenient if such partnerships formed organically, but all too of en, bureaucratic red tape gets in the way of sensible scientif c collaboration. MDIC will serve as a collaborative freeway to biomedical discovery and development by forming a foundation that makes it easy for industry, academia, and government to come together to set research priorities; to pool their distinct intellectual capital; and then to work together to advance knowledge that modernizes regulatory science and improves patient access to high-quality medical technology.

Sci. Transl. Med. 4, 163fs43 (2012)

[ScienceTranslationalMedicine.org 5 December 2012 Vol 4 Issue 163 163fs43]

Statistics on Device use — Number of procedures in the United States (2009)

Number of domestic inpatient procedures (N = 48 million per year)

  • Insertion of coronary artery stent: 528,000
  • Diagnostic ultrasound: 902,000
  • CT scan: 497,000
  • Arteriography and angiocardiography: 1.9 million
  • Cardiac catheterization: 1.1 million
  • Total hip replacement: 327,000
  • Total knee replacement: 676,000

Source:

U.S. Centers of Disease Control www.cdc.gov/nchs/fastats/insurg.htm

This sector is best known for

  • surgical instruments,
  • cardiology devices, and
  • orthopedic implants, it also includes all of the
  • diagnostic tests and
  • imaging equipment currently used to pinpoint disease 
  • companion diagnostics, which are needed to fulfill the promise of personalized medicine (1).

FDA 510 (k) Pending for the Latest Cardiovascular Imaging Technology

Editor’s choice of the most innovative technology at RSNA 2012
By:

Dave Fornell

December 11, 2012
Toshiba is developing a radiation dose alert to show interventionalists how much dose they have delivered to their patient from X-ray angiography.
 The latest advances in cardiovascular imaging are usually shown first at the Radiological Society of North America (RSNA) annual meeting, the largest radiology show in the world, held the last week of November in Chicago. After spending five days walking three expo halls filled with more than 600 product vendors, the following is my editor’s choice for the most innovative new cardiovascular imaging technology.

New Angiography Systems

Siemens unveiled two new 510(k)-pending angiography systems, the Artis Q and Artis Q.zen, which incorporate new X-ray tube, detector and imaging software technology that can help reduce dose significantly, while offering improved image quality.

The new X-ray tube is intended to help physicians identify small vessels up to 70 percent better than conventional X-ray tube technology. The Artis Q.zen combines this innovative X-ray source with a new detector technology designed to support interventional imaging in ultra low-dose ranges to patients, doctors and medical staff, particularly during more complex, longer interventions.

The second generation of Siemens’ flat emitter technology replaced the coiled filaments used in conventional X-ray tubes to emit electrons. Flat emitters are designed to enable smaller quadratic focal spots that lead to improved visibility of small vessels.

The Artis Q.zen combines the X-ray tube with a detector technology that allows detection at ultra-low radiation levels. It can image with doses as low as half the standard levels applied in angiography. Instead of detectors based on amorphous silicon, a new crystalline silicon structure of the Artis Q.zen detector is designed to be more homogenous, allowing for more effective amplification of the signal, greatly reducing the electronic noise.

Siemens also introduced new software applications for interventional imaging. Clear Stent Live freezes an enhanced image of a stent during deployment with the balloon radio-opaque markers and uses it as an overlay on live fluoroscopy. Siemens says the main application will be for better visualization when implanting overlapping stents or stenting bifurcation lesions. It also helps suppress and stabilize heart motion on the image.

Other new 3-D applications are designed to image the smallest structures inside the head. Their high spatial resolution is crucial for imaging intracranial stents or other miniscule structures such as the cochlea in the inner ear. Moving organs such as the lungs can be imaged in 3-D in less than three seconds, reducing motion artifacts and the required amount of contrast agent.

GE Healthcare showcased its IGS (Image Guided System) 750 hybrid OR angiography system. It was displayed at RSNA 2011, but did not receive FDA clearance until earlier this year. It offers the mobility of a mobile C-arm, but the image quality and software features of a ceiling or floor mounted fixed system. It uses laser guidance for very accurate positioning. It can rove around the room on a powered caster system to enable different positioning around the table, or be parked out of the way during open surgical procedures.

Hands-Free Physician Control of Images

GestSure displayed a new, FDA-cleared system that allows interventionalists in the cath lab, or surgeons in the operating room, to pick reference images to display on the overhead screens in the room and manipulate the images all hands-free. It allows physicians to pick and enlarge the images they need for better procedural navigation, while maintaining the sterile field.

A video sensor detects all the people in the work area and displays their outlines on a separate screen, with each person assigned a specific color. When one of those people raises their arms in the “hands up” pose, the system detects this and allows the person control of the system. Using the right arm/hand, they can scroll through images and use the left arm/hand as a mouse click by a pushing motion forward. The system detects the motions and translates them in real time to mouse actions on the overhead screen.

The software works as a vendor-neutral layer on top of existing PACS or advanced visualization software.

Outpatient, Office-Based Catheter Interventions

Outpatient, office-based peripheral vascular procedures are an increasing trend, according to GE healthcare, which showcased a new “mobile hybrid OR” solution. The trend includes setting up an outpatient cath lab in an office setting to reduce the costs of using hospital ORs or cath labs. The room system GE highlighted centers around its OEC 9900 Elite mobile C-arm and Venue 40, which is combined with a ultrasound system in an all-in-one unit. The GE Venue 40 tablet ultrasound system is mounted within the OEC 9900 Elite C-arm’s workstation to reduce the floor space required.

Wireless Ultrasound Transducer

Siemens introduced the world’s first wireless transducer ultrasound system, the Acuson Freestyle. It eliminates the impediment of cables in ultrasound imaging by using a battery-powered transducer, about the size of a large TV controller. The transducer can be submerged for cleaning. It is capable of 90 minutes of continuous scanning before the battery needs to be recharged.

The Freestyle is a point-of-care system that will expand ultrasound’s use in interventional and therapeutic applications. The transducer can be used to image up to 10 feet from the console. Siemens said it hopes to refine and expand the wireless transducer technology to its other systems in the coming years.

Engineers had to overcome several issues to create a wireless transducer. For example, a cardiac echo requires about 40 frames per second and each frame is equal to about 1 megabyte of data. To accommodate the amount of data and speed the computer processing involved, some of the electronics are placed in the transducer rather than processing the data in the machine console. The wireless system transmits the data over an 8 GHz ultrawideband radio frequency to the console. The amount of data and the bandwidth transmitted by the transducer is equal to about 10 4G smart phones working continuously.

Noiseless MRI

GE Healthcare introduced its 510(k)-pending noiseless MRI Silent Scan technology that it hopes to introduce in 2013 for its MR450W 1.5T system. The technology addresses one of the most significant impediments to patient comfort — excessive noise generated during the exam that can be in excess of 110 decibels. A combination of software and a pulse sequence lowers the noise level to that of a chirping bird outside a window.

Historically, acoustic noise mitigation techniques have focused on insulating components and muffling sound as opposed to treating the noise at the source. With Silent Scan, acoustic noise is essentially eliminated by employing a new advanced 3-D acquisition and reconstruction technique called Silenz, in combination with GE Healthcare’s proprietary design of the high-fidelity MR gradient and RF system electronics. Silent Scan is designed to eliminate the noise at its source.

640-Slice CT Scanner

Toshiba unveiled its 640-slice Aquilion One Vision edition CT scanner. The vendor already offers the highest-slice system on the market, the 320-slice Aquilion One. The new system is equipped with a gantry rotation of 0.275 seconds, a 100 kw generator and 320 detector rows (640 unique slices) covering 16 cm in a single rotation, with the industry’s thinnest slices at 500 microns (0.5 mm). The system can accommodate larger patients with its 78 cm bore and fast rotation, including bariatric and patients with high heart rates.

FFR-Like CT Culprit Vessel Analysis

TeraRecon released new research software in response to fractional flow reserve (FFR)-CT analysis being developed by HeartFlow. The HeartFlow software uses a supercomputing algorithm to look at the fluid dynamics of the iodine contrast flow in coronary vessels to calculate a virtual a FFR number, similar to invasive pressure wire based FFR in the cath lab. TeraRecon’s Lesion Specific Analysis software cannot calculate FFR, but uses the same principle of tracking contrast flow in the myocardium. It uses lobular decomposition to look at each vessel segment to determine the tissue it feeds to show areas of ischemia and the expected culprit vessel segment. It shows a color contrast level maps on a 3-D model of the heart and in a coronal view of the left ventricle. Automated detection boxes highlight suspected ischemic areas of interest and identifies the vessel responsible for supplying blood to the region.

Radiation Dose Monitoring

Radiation dose monitoring solutions have been shown at previous RSNAs, but were highlighted by several companies this year as several states began implementing requirements for radiology departments to record patient dose. Dose records will have the most application with CT systems, especially for longer duration, higher dose cardiac exams, and catheter based angiography. Angiography is becoming an increasing issue due to the longer duration of more complex transcatheter interventions.

Toshiba demonstrated a work-in-progress dose tracking software for its Infinix-i angiography system. It can be displayed on a screen in the cath lab to show the approximate radiation dose that has been delivered cumulatively to specific areas of a patient. It takes into consideration the amount of time, power setting used and orientation of the C-arm to show a color-coded map of radiation delivery projected on a human figure. The colors change in real time as X-ray imaging continues. It is designed to be a visual reminder to physicians about the dose the patient has received and that they may want to change the location of the C-arm.

Sectra demonstrated 510(k)-pending Dose Track software, which radiology or cardiology departments can use to track radiation dose by patient, machine, physician, technologist, procedure type and room. The system can be set up to create alerts if a reasonable amount of dose if exceeded for a particular exam, or if certain physicians or technologists are using higher than average doses.

OLED Displays

Flat panel display technology migrated from CRT screens to LCDs over the past decade. The next major innovation in display technology is OLED, which offers even smaller components, faster response time than LCD, and the ability to display quick motion with virtually no blur. Sony showed the new PVM-2551MD OLED medical-grade monitor, which incorporates technology to achieve pure black, faithful to the source signal. By providing superb color reproduction, especially for dark images, surgeons can observe very subtle details such as the faint color difference between various tissues and blood vessels.

Aesthetically Pleasing Cath Labs

Philips Healthcare displayed video of its recent install of the Ambient Experience in a cath lab. The system uses colored lighting, subtle room design details and projected image visual effects to calm patients and make procedure rooms look less clinical. The installation highlighted allowed doctors or patients to choose a theme, such as a tropical rainforest, where diffused, indirect lighting would take a green hue and a photo projection on the ceiling of a tropical scene. Philips said at facilities that have installed these type of labs, patient satisfaction rose, as did staff morale. They say doctors and staff compete to use these rooms at some facilities.

Single Detector Spectral CT Imaging

Philips introduced an innovative work-in-progress CT system that uses new detector technology to simplify spectral imaging, offering soft tissue image quality similar to MRI. Currently, CT special imaging can be performed using systems with two X-ray tubes and two detectors. The new system in development uses a single X-ray source and a single detector that has two layers of detectors, one on top of the other, for high and low energy.

Better Transcatheter Mitral Valve Repair Guidance

Philips’ showed its new Echo Navigator system, designed to synchronize views from TEE ultrasound with the orientation on live angiography. The primary application is to aid navigation during transcatheter mitral valve procedures, which require very accurate 3-D echo navigation to deploy devices like the Abbott MitraClip.

3-D Sculptures From 3-D Datasets

Taking 3-D images shown on 2-D display screens to a true physical 3-D form, Vidar Systems/3D Systems displayed the new Z Printer 450. It takes any 3-D advanced visualization dataset and can print the image in true 3-D using gypsum powder (the same material used to make drywall), standard color ink jet printer cartridges and a binding agent. The image is saved as an STL file and sent to the printer, which prints 1/10th of a millimeter each pass, up to 2 cm per hour.

The 3-D sculptures it created can be printed in color, eliminating the need to paint the models.

The printer offers a new way to create 3-D anatomical models for medical education, complex surgical planning and cosmetic reconstruction. Another application suggested at RSNA was to print sculptures for sale to the patients, such as fetal faces taken from 3-D obstetrics ultrasound exams.

The company printed a full-sized, 3-D, color heart during the show using a cardiac CT dataset on a thumb drive provided by one of the advanced visualization vendors in the same hall.

  • Siemens unveiled the world’s first wireless ultrasound transducer at RSNA 2012.

http://www.dicardiology.com/article/latest-cardiovascular-imaging-technology

REFERENCES

1. S. Desmond-Hellmann, Toward precision medicine: A new

social contract? Sci. Transl. Med. 4, ed3 (2012).

2. J. S. Altshuler, E. Balogh, A. D. Barker, S. L. Eck, S. H. Friend,

G. S. Ginsburg, R. S. Herbst, S. J. Nass, C. M. Streeter, J. A.

Wagner, Opening up to precompetitive collaboration. Sci.

Transl. Med. 2, 52cm26 (2010).

3. U.S. commerce department study; www.ita.doc.gov/td/

health/Medical%20Device%20Industry%20Assessment%

20FINAL%20II%203-24-10.pdf.

4. Regulatory science in FDA’s Center for Devices and

Radiological Health: A vital framework for protecting

and promoting public healthwww.fda.gov/AboutFDA/

CentersOffices/OfficeofMedicalProductsandTobacco/

CDRH/CDRHReports/ucm274152.htm#.

5. Driving Biomedical Innovation: Initiatives for Improving

Products for Patients; www.fda.gov/AboutFDA/

ReportsManualsForms/Reports/ucm274333.htm.

6. G. D. Prestwich, S. Bhatia, C. K. Breuer, S. L. Dahl, C. Mason,

R. McFarland, D. J. McQuillan, J. Sackner-Bernstein, J. Schox,

W. E. Tente, A. Trounson, What is the greatest regulatory

challenge in the translation of biomaterials to the clinic?

Sci. Transl. Med. 4, 60cm14 (2012).

7. Between Invention and Innovation. NIST GRC 02-841;

www.atp.nist.gov/eao/gcr02-841/contents.htm.

8. Justin D Pearlman, MD, ME, PhD, FACC, MA; Chief Editor: Eugene C Lin, MD

Imaging in Coronary Artery Disease, Nov 13, 2012

http://emedicine.medscape.com/article/349040-overview

9. Markus Schwaiger, MD; Sibylle Ziegler, PhD; and Stephan G. Nekolla, PhD

PET/CT: Challenge for Nuclear Cardiology

THE JOURNAL OF NUCLEAR MEDICINE • Vol. 46 • No. 10 • October 2005

 

Other articles related to this topic Published on this Open Access Online Scientific Journal include the following:

New Definition of MI Unveiled, Fractional Flow Reserve (FFR) CT for Tagging Ischemia

http://pharmaceuticalintelligence.com/2012/08/27/new-definition-of-mi-unveiled-fractional-flow-reserve-ffrct-for-tagging-ischemia/

FDA: Strengthening Our National System for Medical Device Post-market Surveillance

http://pharmaceuticalintelligence.com/2012/09/07/fda-strengthening-our-national-system-for-medical-device-post-market-surveillance/

Gaps, Tensions, and Conflicts in the FDA Approval Process: Implications for Clinical Practice

http://pharmaceuticalintelligence.com/2012/07/31/gaps-tensions-and-conflicts-in-the-fda-approval-process-implications-for-clinical-practice/

To Stent or Not? A Critical Decision

http://pharmaceuticalintelligence.com/2012/10/23/to-stent-or-not-a-critical-decision/

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State of the art in oncologic imaging of breast.

Author-Writer: Dror Nir, PhD

Screen Shot 2021-07-19 at 7.28.07 PM

Word Cloud By Danielle Smolyar

In the coming posts I will address the state of the art in oncologic imaging based on a review paper; Advances in oncologic imaging that provides updates on the latest approaches to imaging of 5 common cancers: breast, lung, prostate, colorectal cancers, and lymphoma. This paper is published at CA Cancer J Clin 2012. © 2012 American Cancer Society.

The paper gives a fair description of the use of imaging in interventional oncology based on literature review of more than 200 peer-reviewed publications.

In this post I summaries the chapter on breast cancer imaging.

Breast Cancer Imaging

As a start the authors describes the evolution in the ACS imaging guidelines for breast cancer screening. Most interesting to learn is how age limits are changing. The most recent: “In 2010, the Society of Breast Imaging and the Breast Imaging Commission of the ACS issued recommendations for breast cancer screening to provide guidance in light of the controversies and emerging technologies.5 These recommendations were based on multiple prospective randomized trials as well as population-based experience.

Recommendations for screening with non-mammographic imaging are based not on evidence showing mortality reduction but largely on surrogate indicators, i.e., tumor size and nodal status, suggesting improved survival compared with women who are not screened.” I have referred to these guidelines in my recent post: Not applying evidence-based medicine drives up the costs of screening for breast-cancer in the USA.

As long as imaging interpretation is based mainly on observations related to lesion morphology:

“The imaging characteristics of malignant lesions are nonspecific and usually do not allow a definitive diagnosis. When a biopsy is recommended based on mammography, it has a 25% to 45% likelihood of resulting in a diagnosis of carcinoma.11 Similar positive predictive values are reported for biopsies recommended based on MRI.”

It is worthwhile noting that these results do not reflect purely the specificity of the imaging device but rather the specificity of the whole workflow; i.e imaging, biopsy and histopathology. All imaging techniques have false negatives: Mammography screening of general population misses approximately 20% of the cancers. This rate increases as breast density increases. MRI is not applied to general population. When applied to highly suspicious cases MRI misses ~10% of the invasive cancers. Although ultrasound has proven to be useful in detecting cancer especially in women with dense breasts: Automated Breast Ultrasound System (‘ABUS’) for full breast scanning: The beginning of structuring a solution for an acute need! Based on the literature reviewed by the authors of this paper they do not recommend routine sonography for these women.

For women with locally advanced breast cancer (Fig. 2) who undergo neoadjuvant therapy before breast surgery, the authors recommends post-treatment staging using MRI, which has been found to predict complete response with sensitivity above 60% and specificity as high as 90%.26

A 27-year-old female with locally advanced poorly differentiated invasive ductal carcinoma underwent evaluation of extent of disease before starting neoadjuvant chemotherapy. Sagittal fat-suppressed T1-weighted postcontrast MR images demonstrate an almost 6-cm heterogeneously enhancing mass (A) involving the skin of the lower breast (arrow) with (B) right axillary (arrow) and (C) right internal mammary adenopathy (arrow).

A 27-year-old female with locally advanced poorly differentiated invasive ductal carcinoma underwent evaluation of extent of disease before starting neoadjuvant chemotherapy. Sagittal fat-suppressed T1-weighted postcontrast MR images demonstrate an almost 6-cm heterogeneously enhancing mass (A) involving the skin of the lower breast (arrow) with (B) right axillary (arrow) and (C) right internal mammary adenopathy (arrow).

Same is recommended for women who have undergone lumpectomy if the surgical margins are positive. As post therapy follow-up, a new baseline mammogram of the treated breast is recommended followed by annual mammography.

In regards to emerging technology the following are discussed: Mammographic tomosynthesis – see also Improving Mammography-based imaging for better treatment planning

Contrast-enhanced digital mammography – “involves the injection of iodinated contrast material, as is done for computed tomography (CT); this enables hypervascular lesions to be seen with modified mammography technology, potentially providing the same information obtained through MRI. Little has been published on the clinical application of this technology, but diagnostic accuracy better than that of mammography and approaching that of MRI has been reported.3132

MR choline spectroscopy – has been shown to improve the positive predictive value of breast MRI and may be useful in reducing the number of lesions that require biopsy (Fig. 4).33 Studies of spectroscopy have reported sensitivities of 70% to 100% and specificities of 67% to 100% in the detection of breast cancer. Decreasing choline concentrations may also be a useful indication of tumor response to treatment before any change in tumor volume can be detected.3435 Technical factors have limited the use of spectroscopy to lesions 1 cm in size or larger.”

Sagittal fat-suppressed T1-weighted postcontrast MR image is shown (A) of the right breast of a 48-year-old female who was status post–contralateral mastectomy for DCIS with the spectroscopy voxel placed over an enhancing mass (arrow). The magnified spectrum (B) demonstrated no choline peak. Biopsy yielded fibroadenoma.

Sagittal fat-suppressed T1-weighted postcontrast MR image is shown (A) of the right breast of a 48-year-old female who was status post–contralateral mastectomy for DCIS with the spectroscopy voxel placed over an enhancing mass (arrow). The magnified spectrum (B) demonstrated no choline peak. Biopsy yielded fibroadenoma.

Diffusion-weighted MRI (DW-MRI) – “adding DW-MRI data to other imaging characteristics of lesions on breast MRI may increase the positive predictive value of the examination, in turn decreasing the number of benign lesions requiring biopsy for diagnosis.” See also Imaging: seeing or imagining? (Part 2).

Axial T1-weighted fat-suppressed postcontrast MR image is shown (A) of the left breast of a 42-year-old female with biopsy-proven contralateral cancer undergoing evaluation of disease extent. An enhancing mass (arrow) was seen in the left breast. This mass (arrow) was also demonstrated on the axial diffusion-weighted MR image (B). Biopsy yielded fibroadenoma with atypical ductal hyperplasia and lobular carcinoma in situ.

Axial T1-weighted fat-suppressed postcontrast MR image is shown (A) of the left breast of a 42-year-old female with biopsy-proven contralateral cancer undergoing evaluation of disease extent. An enhancing mass (arrow) was seen in the left breast. This mass (arrow) was also demonstrated on the axial diffusion-weighted MR image (B). Biopsy yielded fibroadenoma with atypical ductal hyperplasia and lobular carcinoma in situ.

Ultrasound-elastography – “Ultrasound elastography has been reported to differentiate benign from malignant breast lesions with sensitivities of 78% to 100% and specificities of 21% to 98%.39 When added to other US techniques, it may improve radiologists’ performance in distinguishing malignant breast lesions.”

Positron emission tomography (PET) – “alone or combined with CT, allows noninvasive, quantitative assessment of biochemical and functional processes at the molecular level in the body. It is most often performed with the radiolabeled glucose analogue [18F] fluorodeoxyglucose ([18F]FDG) to detect the elevated glucose metabolism that is a hallmark of cancer. In breast cancer, its utility depends on the pretest probability for advanced disease, and thus the clinical stage.” The authors found that the use of [18F] FDG PET to patients with stage I and II disease is “limited”. Specifically, they claim that it is not sufficiently accurate for axillary nodal staging in this subset of patients.40 The did find enough evidence to recommend the use of FDG PET in patients with advanced disease: “where it accurately defines disease extent,41 and frequently eliminates the need for other imaging tests, and provides an early readout of treatment response as well as prognostic information.”

Combined PET/MRI is mentioned as a promising technology for predicting response to therapy “but this remains to be proven”.

Positron emission mammography (PEM) – “adapts full-body PET imaging to the breast. In a multicenter study, the interpretation of PEM in conjunction with mammographic and clinical findings yielded a sensitivity of 91% and a specificity of 93% for breast cancer.47 “. However, the authors mention that its use for screening (applying to healthy women) has been criticized because of the need to administer a radioactive tracer.

Lung Cancer Imaging

To be followed…

Other research papers related to the management of breast cancer were published on this Scientific Web site:

The unfortunate ending of the Tower of Babel construction project and its effect on modern imaging-based cancer patients’ management

 Automated Breast Ultrasound System (‘ABUS’) for full breast scanning: The beginning of structuring a solution for an acute need!

Introducing smart-imaging into radiologists’ daily practice.

Will Bio-Tech make Medical Imaging redundant?

Improving Mammography-based imaging for better treatment planning

Not applying evidence-based medicine drives up the costs of screening for breast-cancer in the USA.

New Imaging device bears a promise for better quality control of breast-cancer lumpectomies – considering the cost impact

Harnessing Personalized Medicine for Cancer Management, Prospects of Prevention and Cure: Opinions of Cancer Scientific Leaders @ http://pharmaceuticalintelligence.com

Predicting Tumor Response, Progression, and Time to Recurrence

“The Molecular pathology of Breast Cancer Progression”

Personalized medicine gearing up to tackle cancer

Whole-body imaging as cancer screening tool; answering an unmet clinical need?

What could transform an underdog into a winner?

Mechanism involved in Breast Cancer Cell Growth: Function in Early Detection & Treatment

Nanotech Therapy for Breast Cancer

A Strategy to Handle the Most Aggressive Breast Cancer: Triple-negative Tumors

Optical Coherent Tomography – emerging technology in cancer patient management

Breakthrough Technique Images Breast Tumors in 3-D With Great Clarity, Reduced Radiation

Closing the Mammography gap

Imaging: seeing or imagining? (Part 1)

Imaging: seeing or imagining? (Part 2)

 

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Introducing Dr. Tim Wu – Interventional Cardiologist, Inventor and Entrepreneur

 

Author: Ed Kislauskis, PhD

Article ID #18: Introducing Dr. Tim Wu – Interventional Cardiologist, Inventor and Entrepreneur. Published on 1/14/2013

WordCloud Image Produced by Adam Tubman

 

Welcome readers to the first in a series of interviews with future scientific leaders in biotechnology and medicine.  In this post I interview a close colleague and clinical scientist who appears to be on a fast-track to achieving his vision for the future of interventional cardiology – at the very vanguard of applied nanotechnology.

Tim (Tiangen) Wu, M.D has graciously accepted my invitation to answer a few questions about how his career path and primary goal to develop and commercialize his first product, a fully-biodegradable drug-eluting stent he calls the PowerStent® Absorb (see insert).  This technology combines three especially innovations:  a unique balloon-expandable stent design (PowerStent®), a bioabsorbable nanoparticle composition (BioDe®), and a formulation of two commercially-available anti-restenosis drugs (Combo®).

Stent

About the Subject

Dr. Wu received his clinical education in China and research training in the USA. In 1988, he graduated with an MD from the prestigious Linyli Medical School and completed a fellowship in clinical cardiology at the Tonji Medical University.  In 1993, presented with an opportunity to travel to the US, he uprooted to accept a position as visiting scholar, and ultimately post-doctoral fellow,in Jeffrey Isner’s lab at St. Elizabeth Hospital (Tufts University) and the Beth Israel Medical Center (Harvard Medical).  There he investigated the biology of stenosis, and directed sponsored research projects to evaluate the safety and efficacy of the latest commercially-developed drug-coated stents (DES) in animals.

After  a decade in academia, Dr. Wu made the successful transition to industry and joined Nitromed Inc. as a Research Scientist.  His next stop was as a Research Director at Biomedical Research Models, Inc (2000-2006) where we met and collaborated on developing and characterizing macrovascular disease in an inbred, type 2 diabetic rat model.  After a 20 year career, and upon gaining additional qualification in Mechanical Engineering (Wentworth Institute), Business Administration (MIT), Clinical Research Affairs (Mass. Biotech Council), and Medical Device Regulatory Affairs (North Eastern Univ.), he was ready to take the entrepreneurial leap.  His first company, VasoTech would aim to re-engineer the clinical standards of stent design and drug delivery.

In 2007, Dr. Wu founded VasoTech, Inc. from inside his home garage. Less than a year later, VasoTech received a $1.5M SBIR fast-track grant award from the NIH.  With funding, VasoTech joined the newly announced M2D2 facility on the University of Massachusetts Lowell campus, and expanded operations in China.  With the support of one of his closest advisors, Dr. Stephen McCarthy and other research faculty, Dr. Wu was appointed as an adjunct faculty in the Dept. of BioMedical Engineering at the UMass/Lowell where he mentored a number of talented graduate students.  Dr. Wu is recognized as a senior reviewer on the NIH Bioengineering, Surgical Science and Technology Study Section, and Biomaterials, Delivery Systems and Nanotechnology Special Emphasis Panels servicing the  Small Business Innovation Research (SBIR) grant program.

Dr. Wu’s work at Vasotech is devoted to developing a 3rd generation of fully biodegradable DES coronary stents to solve two major complications associated with stenting, restenosis and late-stage thrombosis. Thusfar, his ideas have attracted well over $1.5 Million (USD) in Small Business Innovation Research (SBIR) grant awards from the National Institute of Diabetes and Digestive and Kidney Diseases, and $1million (USD) from China Innovative Talent Leadership Program.  Through his efforts VasoTech is well positioned to attract the strategic partnerships and venture capital investments necessary to translate his research through clinical stages of development both in China and the US.

The Interview

Kislauskis:  Please help our readers understand the current clinical approach to CAD.

Wu:  Most patients with advanced atherosclerosis diseases are at risk for occlusive coronary arterial disease and stroke. Consequently, it is recommended they undergo a percutaneous intervention (PCI); essentially, balloon angioplasty followed by instillation of one or more expandable metal stents. A properly expanded stent will dilate the vessel and increase blood flow to cardiac muscle tissue. Current 2nd generation drug-eluting-stents (DES) release drugs to inhibit the process of vascular remodeling leading to restenosis. Because the DES approach is remarkably successful and lowers the rate of restenosis to < 10%, DESs is now performed in 85% of the 2 million percutaneous coronary interventions (PCI) procedures annually in the U.S.

Kislauskis:  What is your impression of the recent 5 yr update of the FREEDOM trial comparing effectiveness of coronary artery bypass grafting (CABG) to PCI among diabetics? 1

Wu:  It makes perfect sense. There are other reports evaluating PCI in patients within high risk categories, including those with small diameter vessels, diabetes, and extensive, systemic vascular disease, showing unacceptably high rates of restenosis with bare metal stents (30%-60%) and DESs (6%-18%) 2-4.  We also know first-hand using an inbred rat strain that develops macrovascular disease 4 months after onset of spontaneous diabetes.  In our experiment model, just 4weeks following balloon-induced injury to the coratid artery (PTCA),  we observed 2x greater restenosis in female obese rats, and 4x greater stenosis in obese, diabetic rats  littermates (syndrome X) relative to the non-obese, non-diabetic littermates.  These results predicted that obesity (dyslipidemia) and diabetes (severe hyperglycemia) were major risk factors promoting the complication of restenosis (Wu and Kislauskis, unpublished).

Kislauskis: Can you tell our readers a bit more about the significance of restenosis and thrombosis and the concept behind your approach.

Wu: Two significant drawbacks to conventional PCI are the need for costly, long-term anti-platelet therapy; and having a metal artifact within the coronary vessel. In fact, once installed, the purpose of DES is to maintain patency and provide a scaffold until remodeling is complete, maybe 6 months.  The period of drug elution is typically shorter in duration.  In the event of restenosis, a second DES procedure is recommended and performed with satisfactory results.  However, leaving another metal artifact is problematic.

Most concerning to PCI patients, however, should be an increased risk of sudden death from heart attack from a clot (thrombosis) and tissue ischemia (myocardial infarction).  No available DES technology (eg. Cypher®or Taxus® DES) demonstrates any advantage over bare metal stents in this regard 5-7.  So the thinking is a metal artifact create an irregular vessel surface and micro-eddys in blood flow which ultimately result in late-stage thrombosis, particularly in patients who go off anti-their platelet therapy too soon 8.  Therefore and conceptually, by combining potent DES technology with a fully-biodegradable scaffold, designed to be absorbed fully into the tissue, likely will reduce the rate in-stent stenosis and prevents late-stage thrombosis.

Kislauskis: How did you come up with your unique polymer formulation?

Wu: It turns out that through a process of trial and error in the lab I was able to identify a biodegradable formulation which reduces the local inflammatory response common to all DES formulations while improving the stent’s radial strength.  With a stable drug delivery platform (BioDe®), the process of remodeling will contribute far less to restenosis.  Furthermore, and unlike all prior art, my BioDe® formulation can neutralize acidic intermediates generated during stent degradation that induce inflammation.  The combination of anti-restenosis drugs (Combo®) also is effective at inhibiting signaling pathways that contribute to restenosis.

Kislauskis:  How did you come to design the PowerStent®?

Wu: Again, a long process of trial and error, initially using computer applied design (CAD) principals I learned while earning attending a mechanical engineering certificate program at Wentworth Institute of Technology in Boston. Elements behind my concept for BioDe® came to me while I was involved in a home renovation project, working with grout.  Although the formulation is simple and may be duplicated, the process of manufacturing is complicated.

Kislauskis: So it’s your trade secret.

Wu: Absolutely.

Kislauskis: Can you summary its other advantages and your plans to commercialize the PowerStent®?

Wu: Preclinical, short duration (30 day) studies in porcine models with the PowerStent® Absorb deployed indicate that it will be non-inferior to the current metal DES and competing biodegradable stent technologies. Important functional attributes of the BioDe® polymer include better biocompatibility (less inflammatory), excellent radial strength, potent anti-restenosis activity, and a unique microporous surface that promotes integration into neointimal layer of stented vessel.  Ongoing and much longer duration studies may also support our contention that this design can reduce risks of late-stage in-stent thrombosis.

Kislauskis: What path and difficulties to you foresee in obtaining a regulatory approval to conduct clinical trials with the PowerStent® Absorb?

Wu:  FDA Guidance to commercialize conventional DES technology is available. Unfortunately, no guidance is published for a fully-biodegradable stent.  Therefore, I anticipate seeking advice from the regulatory bodies prior to petitioning for approval to perform clinical trials.  It will no doubt be a complicated process as this technology involves a novel drug combination (albeit FDA-approved drugs), and a novel formulation (albeit FDA-approved components), and a novel indwelling and bioabsorbable medical device (stent).  We are presently completing several required engineering studies for the final phase of pre-clinical safety and efficacy testing, in China. The goals are to obtain FDA pre-market and NDA approvals, and to receive a CE mark from major international markets including Europe and the BRICK nations.

Kislauskis: How will you commercialize this 3rd generation, fully-biodegradable stent?

Wu: There are likely 3 scenarios to complete development and commercialization.  One involves securing bridge funding from the NIH SBIR program, supplemented with angel financing to complete preclinical program. I project that a minimum of $6 Million (USD) will be required to complete regulatory approval and pivotal clinical trials.  Therefore, it is conceivable that a Series A round of equity financing from venture capitalists, in either US or China, will be required. A third scenario is to partner or sell the technology to a major player in this space to complete clinical testing and commercialization. Potential partners include Boston Scientific Company, J&J, etc. Any of these partners could facilitate the processes of regulatory approval, manufacturing, global distribution and marketing.  Discussions are underway with one such prospective partner and with several VC groups.

Kislauskis: What is its likely impact of this product on patient care and the field of interventional cardiology?

Wu: According to US statistics, approximately 14 million Americans suffer from CAD, and 500,000 people die from acute myocardial infarction. One million more survive but with a 1.5 to 15 times greater risk of mortality or morbidity than the rest of the population each year.  In the U.S., the annual health care costs of CAD are estimated to be in excess of $112 billion, and the estimated annual total direct cost associated with PCI with stents is over $2 billion.  I anticipate that our PowerStent® Absorb stent will be competitive in a marketplace estimated to be over $5 billion in 2010. Although CAD patients are the primary market, other related applications for our PowerStent Absorb technology include peripheral arteries, intracerebral vascular and small vessels which are also significant.

Kislauskis:  Thank you for your contribution to this site.  For more information about MMG, LLC and Dr. Wu’s technology please refer to his publications 9-13 or contact him directly at tiangenwu@yahoo.com.

REFERENCES

1.   Mark A. Hlatky, M.D. Compelling Evidence for Coronary-Bypass Surgery in Patients with Diabetes.   N Engl J Med 2012; 367:2437-2438.

2.  Stamler, J. (1989) Epidemiology.  Established major risk factors, and the primary prevention of coronary heart disease. In: Chatterjee K, Karliner J, Rapaport E, Cheitlin MD, Parmlee WW, Sheinman, M eds. Cardiology, Philadelphia Penn: JB Lippincott, 1991, 7.2-7.35. (volume 2).

3. Tanabe, K, Regar, E et al.  Sirolimus-eluting stent for treatment of in-stentrestenosis: One-year angiographic and intravascular ultrasound follow-up. J. Am Col.Cardi.   (2003) 41: 12A.

4. Grube, Eberhard;  Silber, Sigmund.  Six- and twelve-month results from a randomized, double-blind trial on a slow-release paclitaxel-eluting stent for de novo coronary lesions. Circulation 2003: 107, 38-42.

5.  Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 2005;293:2126–2130.

6.  Ong AT, McFadden EP, Regar E, et al. Late angiographic stent thrombosis (LAST) events with drug-eluting stents. J Am Coll Cardiol 2005;45:2088–2092.

7. Wang F, Stouffer GA, Waxman S, et al. Late coronary stent thrombosis: Early vs late stent thrombosis in the stent era. Catheter Cardiovasc Interven 2002;55:142–147.

8. McFadden EP, Stabile E, Regar E, et al. Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet 2004;364:1519–1521.

9. Ma X, Oyamada S, Wu T, Robich MP, Wu H, Wang X, Buchholz B, McCarthy S, Bianchi CF, Sellke FW, Laham R. In vitro and in vivo degradation of poly(D, L-lactide-co-glycolide)/amorphous calcium phosphate copolymer coated on metal stents. J Biomed Mater Res A. 2011 Mar 15;96(4):632-8. doi: 10.1002/jbm.a.33016. Epub 2011 Jan 25.

10. Oyamada S, Ma X, Wu T, Robich MP, Wu H, Wang X, Buchholz B, McCarthy S, Bianchi CF, Sellke FW, Laham R. Trans-iliac rat aorta stenting: a novel high throughput preclinical stent model for restenosis and thrombosis. J Surg Res. 2011 Mar;166(1):e91-5. Erratum in: J Surg Res. 2012 May 1;174(1):184.

11. Ma X, Oyamada S, Gao F, Wu T, Robich MP, Wu H, Wang X, Buchholz B, McCarthy S, Gu Z, Bianchi CF, Sellke FW, Laham R Paclitaxel/sirolimus combination coated drug-eluting stent: in vitro and in vivo drug release studies. J Pharm Biomed Anal. 2011 Mar 25;54(4):807-11. Erratum in: J Pharm Biomed Anal. 2012 Feb 5;59:217.

12. Ma X, Wu T, Robich MP, Wang X, Wu H, Buchholz B, McCarthy S. Drug-eluting stents. Int J Clin Exp Med. 2010 Jul 15;3(3):192-201.

Other articles related to this subject were published in this Open Access OnlIne Scientific Journal:

Lev-Ari, A. (2012aa). Renal Sympathetic Denervation: Updates on the State of Medicine

http://pharmaceuticalintelligence.com/2012/12/31/renal-sympathetic-denervation-updates-on-the-state-of-medicine/

 

Lev-Ari, A. (2012U). Imbalance of Autonomic Tone: The Promise of Intravascular Stimulation of Autonomics

http://pharmaceuticalintelligence.com/2012/09/02/imbalance-of-autonomic-tone-the-promise-of-intravascular-stimulation-of-autonomics/

Lev-Ari, A. (2012R). Coronary Artery Disease – Medical Devices Solutions: From First-In-Man Stent Implantation, via Medical Ethical Dilemmas to Drug Eluting Stents http://pharmaceuticalintelligence.com/2012/08/13/coronary-artery-disease-medical-devices-solutions-from-first-in-man-stent-implantation-via-medical-ethical-dilemmas-to-drug-eluting-stents/

 

Lev-Ari, A. (2012K). Percutaneous Endocardial Ablation of Scar-Related Ventricular Tachycardia

http://pharmaceuticalintelligence.com/2012/07/18/percutaneous-endocardial-ablation-of-scar-related-ventricular-tachycardia/

 

Lev-Ari, A. (2012C). Treatment of Refractory Hypertension via Percutaneous Renal Denervation

http://pharmaceuticalintelligence.com/2012/06/13/treatment-of-refractory-hypertension-via-percutaneous-renal-denervation/

Lev-Ari, A. (2012D). Competition in the Ecosystem of Medical Devices in Cardiac and Vascular Repair: Heart Valves, Stents, Catheterization Tools and Kits for Open Heart and Minimally Invasive Surgery (MIS)

http://pharmaceuticalintelligence.com/2012/06/22/competition-in-the-ecosystem-of-medical-devices-in-cardiac-and-vascular-repair-heart-valves-stents-catheterization-tools-and-kits-for-open-heart-and-minimally-invasive-surgery-mis/

Lev-Ari, A. (2012E). Executive Compensation and Comparator Group Definition in the Cardiac and Vascular Medical Devices Sector: A Bright Future for Edwards Lifesciences Corporation in the Transcatheter Heart Valve Replacement Market

http://pharmaceuticalintelligence.com/2012/06/19/executive-compensation-and-comparator-group-definition-in-the-cardiac-and-vascular-medical-devices-sector-a-bright-future-for-edwards-lifesciences-corporation-in-the-transcatheter-heart-valve-replace/

 

Lev-Ari, A. (2012F). Global Supplier Strategy for Market Penetration & Partnership Options (Niche Suppliers vs. National Leaders) in the Massachusetts Cardiology & Vascular Surgery Tools and Devices Market for Cardiac Operating Rooms and Angioplasty Suites

http://pharmaceuticalintelligence.com/2012/06/22/global-supplier-strategy-for-market-penetration-partnership-options-niche-suppliers-vs-national-leaders-in-the-massachusetts-cardiology-vascular-surgery-tools-and-devices-market-for-car/

 

Lev-Ari, A. (2012G).  Heart Remodeling by Design: Implantable Synchronized Cardiac Assist Device: Abiomed’s Symphony

http://pharmaceuticalintelligence.com/2012/07/23/heart-remodeling-by-design-implantable-synchronized-cardiac-assist-device-abiomeds-symphony/

 

Read Full Post »

Improving Mammography-based imaging for better treatment planning

Author and Curator: Dror Nir, PhD

Many of the comments made on my last posts: New Imaging device bears a promise for better quality control of breast-cancer lumpectomies – considering the cost impact , Not applying evidence-based medicine drives up the costs of screening for breast-cancer in the USA, Optical Coherent Tomography – emerging technology in cancer patient management

Were related to the benefit of better planning lumpectomies based on priory knowledge of the lesions’ size and location. The main challenge in using imaging as a tool for treatment planning is the devices’ specificity; i.e. the probability of identifying healthy tissue as malignant. The reason is the wish to avoid unnecessarily large excisions. When discussing the use of “popular” non-ionizing devises such as MRI in breast-imaging; e.g. my post introducing smart-imaging into radiologists’ daily practice I mentioned the low specificity of MRI in that respect. So, if one is reluctant to use ultrasound, for example due to its large inter observer variability and want to rely on the Mammography based work-flow, what new modalities are available?

Stereoscopic digital mammography

Stereoscopic digital mammography (SDM) uses a pair of digital mammograms, taken from slightly different angles and a stereo display workstation loaded with image-analysis software, to create a three-dimensional image of the internal structure of each breast. The resulting stereo image reveals more detail within the breast tissue than a standard two-dimensional mammogram.

Stero-mammography

Radiologist interacting with a stereo digital mammography workstation. (Credit: Image courtesy of Radiological Society of North America)

Recently published materials:

Abstract

Stereoscopic Digital Mammography: Improved Specificity and Reduced Rate of Recall in a Prospective Clinical Trial

Carl J. D’Orsi, MDDavid J. Getty, PhDIoannis Sechopoulos, PhDMary S. Newell, MDKathleen R. Gundry, MD, Sandra R. Bates, MDRobert M. Nishikawa, PhDEdward A. Sickles, MD, Andrew Karellas, PhD and Ellen M. D’Orsi, RT(R)(M)

Purpose: To compare stereoscopic digital mammography (DM) with standard DM for the rate of patient recall and the detection of cancer in a screening population at elevated risk for breast cancer.

 Materials and Methods: Starting in September 2004 and ending in December 2007, this prospective HIPAA-compliant, institutional review board–approved screening trial, with written informed consent, recruited female patients at elevated risk for breast cancer (eg, personal history of breast cancer or breast cancer in a close relative). A total of 1298 examinations from 779 patients (mean age, 58.6 years; range, 32–91 years) comprised the analyzable data set. A paired study design was used, with each enrolled patient serving as her own control. Patients underwent both DM and stereoscopic DM examinations in a single visit, findings of which were interpreted independently by two experienced radiologists, each using a Breast Imaging Reporting and Data System (BI-RADS) assessment (BI-RADS category 0, 1, or 2). All patients determined to have one or more findings with either or both modalities were recalled for standard diagnostic evaluation. The results of 1-year follow-up or biopsy were used to determine case truth.

 Results: Compared with DM, stereoscopic DM showed significantly higher specificity (91.2% [1167 of 1279] vs 87.8% [1123 of 1279]; P = .0024) and accuracy (90.9% [1180 of 1298] vs 87.4% [1135 of 1298]; P = .0023) for detection of cancer. Sensitivity for detection of cancer was not significantly different for stereoscopic DM (68.4% [13 of 19]) compared with DM (63.2% [12 of 19], P .99). The recall rate for stereoscopic DM was 9.6% (125 of 1298) and that for DM was 12.9% (168 of 1298) (P = .0018).

Conclusion: Compared with DM, stereoscopic DM significantly improved specificity for detection of cancer, while maintaining comparable sensitivity. The recall rate was significantly reduced with stereoscopic DM compared with DM.

 

Digital Breast Tomosynthesis

Digital Breast Tomosynthesis (DBT) entered the Breast-Imaging field few years ago. Early 2011, a digital mammography device by Hologic aimed at improving the specificity of mammography was approved by the FDA as a tool that may improve cancer detection while reducing the number of patient recalls.

The DBT device takes 15 successive images, each at a slightly different angle along an arc across the breast. The concept is simple: What is hidden behind fibroglandular tissue in one image might be visible in another if the angle is slightly different (Figure bellow).

Figure. (a) A suspicious lesion seen on standard 2D digital mammography (far left). (b) After examining multiple slices generated using breast tomosynthesis (5 images), the lesion seen on 2D (far left) is determined to be a false positive. (Images courtesy of Hologic. Used with permission.)

Figure. (a) A suspicious lesion seen on standard 2D digital mammography (far left). (b) After examining multiple slices generated using breast tomosynthesis (5 images), the lesion seen on 2D (far left) is determined to be a false positive. (Images courtesy of Hologic. Used with permission.)

Out of recent publications related to the incorporation of DBT in breast-cancer management I picked up the following two:

Abstract

Comparison of Digital Mammography Alone and Digital Mammography Plus Tomosynthesis in a Population-based Screening Program

Per Skaane, MD, PhD, Andriy I. Bandos, PhD, Randi Gullien, RT, Ellen B. Eben, MD, Ulrika Ekseth, MD, Unni Haakenaasen, MD, Mina Izadi, MD, Ingvild N. Jebsen, MD, Gunnar Jahr, MD, Mona Krager, MD, Loren T. Niklason, PhD, Solveig Hofvind, PhD and David Gur, ScD

 

Purpose: To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis in a large prospective screening trial.

 Materials and Methods: A prospective, reader- and modality-balanced screening study of participants undergoing combined mammography plus tomosynthesis, the results of which were read independently by four different radiologists, is under way. The study was approved by a regional ethics committee, and all participants provided written informed consent. The authors performed a preplanned interim analysis of results from 12631 examinations interpreted by using mammography alone and mammography plus tomosynthesis from November 22, 2010, to December 31, 2011. Analyses were based on marginal log-linear models for binary data, accounting for correlated interpretations and adjusting for reader-specific performance levels by using a two-sided significance level of .0294.

 Results: Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (27% increase, adjusted for reader; P = .001). False-positive rates before arbitration were 61.1 per 1000 examinations with mammography alone and 53.1 per 1000 examinations with mammography plus tomosynthesis (15% decrease, adjusted for reader; P < .001). After arbitration, positive predictive values for recalled patients with cancers verified later were comparable (29.1% and 28.5%, respectively, with mammography alone and mammography plus tomosynthesis; P = .72). Twenty-five additional invasive cancers were detected with mammography plus tomosynthesis (40% increase, adjusted for reader; P < .001). The mean interpretation time was 45 seconds for mammography alone and 91 seconds for mammography plus tomosynthesis (P < .001).

 Conclusion: The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.

©RSNA, 2013, Clinical trial registration no. NCT01248546

Summary of the results:

  • Twenty-five additional invasive cancers were detected with mammography plus tomosynthesis — a 40% increase.
  • Detection rates, including those for invasive and in situ can­cers, were 6.1 per 1,000 examinations for mammography alone and eight per 1,000 examinations for mammography plus tomosynthesis — a 27% increase.
  • False-positive rates before arbitration were 61.1 per 1,000 examinations with mammography alone and 53.1 per 1,000 examinations with mammography plus tomosynthe­sis — a 15% decrease.
  • After arbitration, positive predictive values for recalled patients with cancers verified later were comparable (29.1% with mammography alone and 28.5% with mam­mography plus tomosynthesis).
  • Mean interpretation time was 45 seconds for mammography alone and 91 seconds for mammography plus tomosynthesis.

 

 

Abstract

Digital Breast Tomosynthesis versus Supplemental Diagnostic Mammographic Views for Evaluation of Noncalcified Breast Lesions

Margarita L. Zuley, MD, Andriy I. Bandos, PhD,  Marie A. Ganott, MD, Jules H. Sumkin, DO, Amy E. Kelly, MD, Victor J. Catullo, MD, Grace Y. Rathfon, MD, Amy H. Lu, MD and David Gur, ScD

Purpose: To compare the diagnostic performance of breast tomosynthesis versus supplemental mammography views in classification of masses, distortions, and asymmetries.

 Materials and Methods: Eight radiologists who specialized in breast imaging retrospectively reviewed 217 consecutively accrued lesions by using protocols that were HIPAA compliant and institutional review board approved in 182 patients aged 31–60 years (mean, 50 years) who underwent diagnostic mammography and tomosynthesis. The lesions in the cohort included 33% (72 of 217) cancers and 67% (145 of 217) benign lesions. Eighty-four percent (182 of 217) of the lesions were masses, 11% (25 of 217) were asymmetries, and 5% (10 of 217) were distortions that were initially detected at clinical examination in 8% (17 of 217), at mammography in 80% (173 of 217), at ultrasonography (US) in 11% (25 of 217), or at magnetic resonance imaging in 1% (2 of 217). Histopathologic examination established truth in 191 lesions, US revealed a cyst in 12 lesions, and 14 lesions had a normal follow-up. Each lesion was interpreted once with tomosynthesis and once with supplemental mammographic views; both modes included the mediolateral oblique and craniocaudal views in a fully crossed and balanced design by using a five-category Breast Imaging Reporting and Data System (BI-RADS) assessment and a probability-of-malignancy score. Differences between modes were analyzed with a generalized linear mixed model for BI-RADS–based sensitivity and specificity and with modified Obuchowski-Rockette approach for probability-of-malignancy–based area under the receiver operating characteristic (ROC) curve.

 Results: Average probability-of-malignancy–based area under the ROC curve was 0.87 for tomosynthesis versus 0.83 for supplemental views (P < .001). With tomosynthesis, the false-positive rate decreased from 85% (989 of 1160) to 74% (864 of 1160) (P < .01) for cases that were rated BI-RADS category 3 or higher and from 57% (663 of 1160) to 48% (559 of 1160) for cases rated BI-RADS category 4 or 5 (P < .01), without a meaningful change in sensitivity. With tomosynthesis, more cancers were classified as BI-RADS category 5 (39% [226 of 576] vs 33% [188 of 576]; P = .017) without a decrease in specificity.

 Conclusion: Tomosynthesis significantly improved diagnostic accuracy for noncalcified lesions compared with supplemental 

 Additional reading

Diagnostic Mammography: Identifying Minimally Acceptable Interpretive Performance Criteria

Breast Cancer: Assessing Response to Neoadjuvant Chemotherapy by Using US-guided Near-Infrared Tomography

Bilateral Contrast-enhanced Dual-Energy Digital Mammography: Feasibility and Comparison with Conventional Digital Mammography and MR Imaging in Women with Known Breast Carcinoma

Other research papers on imaging in cancer patients’ management and cancer-therapeutics were published on this Scientific Web site as follows:

 

The unfortunate ending of the Tower of Babel construction project and its effect on modern imaging-based cancer patients’ management

 

Closing the gap towards real-time, imaging-guided treatment of cancer patients.

 

The unfortunate ending of the Tower of Babel construction project and its effect on modern imaging-based cancer patients’ management

 

Closing the gap towards real-time, imaging-guided treatment of cancer patients.

 

Tumor Imaging and Targeting: Predicting Tumor Response to Treatment: Where we stand?

 

Automated Breast Ultrasound System (‘ABUS’) for full breast scanning: The beginning of structuring a solution for an acute need!

 

Introducing smart-imaging into radiologists’ daily practice.

 

Will Bio-Tech make Medical Imaging redundant?

 

Optical Coherent Tomography – emerging technology in cancer patient management

 

Personalized Pancreatic Cancer Treatment Option

 

Understand how DNA damage is repaired—knowledge that could result in the development of new and more effective drugs for cancer treatment

 

LEADERS in Genome Sequencing of Genetic Mutations for Therapeutic Drug Selection in Cancer Personalized Treatment: Part 2

 

Scientists use natural agents for prostate cancer bone metastasis treatment

 

Harnessing Personalized Medicine for Cancer Management, Prospects of Prevention and Cure: Opinions of Cancer Scientific Leaders @ http://pharmaceuticalintelligence.com

 

Predicting Tumor Response, Progression, and Time to Recurrence

 

“The Molecular pathology of Breast Cancer Progression”

 

Personalized medicine gearing up to tackle cancer

 

Whole-body imaging as cancer screening tool; answering an unmet clinical need?

 

Read Full Post »

Consumer Market for Personal DNA Sequencing: Part 4

Reporter: Aviva Lev-Ari, PhD RN

FDA Warning for the Leader of Consumer Market for Personal DNA Sequencing Part 4

Word Cloud by Daniel Menzin

This Part 4 of the series on Present and Future Frontier of Research in Genomics has been 

UPDATED on 12/6/2013

23andMe Suspends Health Interpretations

December 06, 2013

Direct-to-consumer genetic testing company 23andMe hasstopped offering its health-related test to new customers, bringing it in line with a request from the US Food and Drug Administration.

In letter sent on Nov. 22, FDA said that 23andMe had not adequately responded to its concerns regarding the validity of their Personal Genome Service. The letter instructed 23andMe to “immediately discontinue marketing” the service until it receives authorization from the agency.

According to a post at the company’s blog from CEO Anne Wojcicki, 23andMe customers who purchased their kits on or after Nov. 22 “will not have access to health-related results.” They will, though, have access to ancestry information and their raw genetic data. Wojcicki notes that the customers may have access to the health interpretations in the future depending on FDA marketing authorization. Those customers are also being offered a refund.

Customers who purchased their kits before Nov. 22 will have access to all reports.

“We remain firmly committed to fulfilling our long-term mission to help people everywhere have access to their own genetic data and have the ability to use that information to improve their lives,” a notice at the 23andMe site says.

In a letter appearing in the Wall Street Journal earlier this week, FDA Commissioner Margaret Hamburg wrote that the agency “supports the development of innovative tests.” As an example, she pointed to its recent clearance of sequencing-based testsfrom Illumina.

She added that the agency also understands that some consumers do want to know more about their genomes and their genetic risk of disease, and that a DTC model would let consumers take an active role in their health.

“The agency’s desire to review these particular tests is solely to ensure that they are safe, do what they claim to do and that the results are communicated in a way that a consumer can understand,” Hamburg said.

In a statement, 23andMe’s Wojcicki says that the company remains committed to its ethos of allowing people access to their genetic information. “Our goal is to work cooperatively with the FDA to provide that opportunity in a way that clearly demonstrates the benefit to people and the validity of the science that underlies the test,” Wojcicki adds.

SOURCE

UPDATED on 11/27/2013

FDA Tells Google-Backed 23andMe to Halt DNA Test Service

VIEW VIDEO

http://www.bloomberg.com/news/2013-11-25/fda-tells-google-backed-23andme-to-halt-dna-test-service.html

FDA Letter to 23andME

Department of Health and Human Services logoDepartment of Health and Human Services

Public Health Service
Food and Drug Administration
10903 New Hampshire Avenue
Silver Spring, MD 20993

Nov 22, 2013

Ann Wojcicki
CEO
23andMe, Inc.
1390 Shoreline Way
Mountain View, CA 94043
Document Number: GEN1300666
Re: Personal Genome Service (PGS)
WARNING LETTER
Dear Ms. Wojcicki,
The Food and Drug Administration (FDA) is sending you this letter because you are marketing the 23andMe Saliva Collection Kit and Personal Genome Service (PGS) without marketing clearance or approval in violation of the Federal Food, Drug and Cosmetic Act (the FD&C Act).
This product is a device within the meaning of section 201(h) of the FD&C Act, 21 U.S.C. 321(h), because it is intended for use in the diagnosis of disease or other conditions or in the cure, mitigation, treatment, or prevention of disease, or is intended to affect the structure or function of the body. For example, your company’s website at http://www.23andme.com/health (most recently viewed on November 6, 2013) markets the PGS for providing “health reports on 254 diseases and conditions,” including categories such as “carrier status,” “health risks,” and “drug response,” and specifically as a “first step in prevention” that enables users to “take steps toward mitigating serious diseases” such as diabetes, coronary heart disease, and breast cancer. Most of the intended uses for PGS listed on your website, a list that has grown over time, are medical device uses under section 201(h) of the FD&C Act. Most of these uses have not been classified and thus require premarket approval or de novo classification, as FDA has explained to you on numerous occasions.
Some of the uses for which PGS is intended are particularly concerning, such as assessments for BRCA-related genetic risk and drug responses (e.g., warfarin sensitivity, clopidogrel response, and 5-fluorouracil toxicity) because of the potential health consequences that could result from false positive or false negative assessments for high-risk indications such as these. For instance, if the BRCA-related risk assessment for breast or ovarian cancer reports a false positive, it could lead a patient to undergo prophylactic surgery, chemoprevention, intensive screening, or other morbidity-inducing actions, while a false negative could result in a failure to recognize an actual risk that may exist. Assessments for drug responses carry the risks that patients relying on such tests may begin to self-manage their treatments through dose changes or even abandon certain therapies depending on the outcome of the assessment. For example, false genotype results for your warfarin drug response test could have significant unreasonable risk of illness, injury, or death to the patient due to thrombosis or bleeding events that occur from treatment with a drug at a dose that does not provide the appropriately calibrated anticoagulant effect. These risks are typically mitigated by International Normalized Ratio (INR) management under a physician’s care. The risk of serious injury or death is known to be high when patients are either non-compliant or not properly dosed; combined with the risk that a direct-to-consumer test result may be used by a patient to self-manage, serious concerns are raised if test results are not adequately understood by patients or if incorrect test results are reported.
Your company submitted 510(k)s for PGS on July 2, 2012 and September 4, 2012, for several of these indications for use. However, to date, your company has failed to address the issues described during previous interactions with the Agency or provide the additional information identified in our September 13, 2012 letter for(b)(4) and in our November 20, 2012 letter for (b)(4), as required under 21 CFR 807.87(1). Consequently, the 510(k)s are considered withdrawn, see 21 C.F.R. 807.87(1), as we explained in our letters to you on March 12, 2013 and May 21, 2013.  To date, 23andMe has failed to provide adequate information to support a determination that the PGS is substantially equivalent to a legally marketed predicate for any of the uses for which you are marketing it; no other submission for the PGS device that you are marketing has been provided under section 510(k) of the Act, 21 U.S.C. § 360(k).
The Office of In Vitro Diagnostics and Radiological Health (OIR) has a long history of working with companies to help them come into compliance with the FD&C Act. Since July of 2009, we have been diligently working to help you comply with regulatory requirements regarding safety and effectiveness and obtain marketing authorization for your PGS device. FDA has spent significant time evaluating the intended uses of the PGS to determine whether certain uses might be appropriately classified into class II, thus requiring only 510(k) clearance or de novo classification and not PMA approval, and we have proposed modifications to the device’s labeling that could mitigate risks and render certain intended uses appropriate for de novo classification. Further, we provided ample detailed feedback to 23andMe regarding the types of data it needs to submit for the intended uses of the PGS.  As part of our interactions with you, including more than 14 face-to-face and teleconference meetings, hundreds of email exchanges, and dozens of written communications, we provided you with specific feedback on study protocols and clinical and analytical validation requirements, discussed potential classifications and regulatory pathways (including reasonable submission timelines), provided statistical advice, and discussed potential risk mitigation strategies. As discussed above, FDA is concerned about the public health consequences of inaccurate results from the PGS device; the main purpose of compliance with FDA’s regulatory requirements is to ensure that the tests work.
However, even after these many interactions with 23andMe, we still do not have any assurance that the firm has analytically or clinically validated the PGS for its intended uses, which have expanded from the uses that the firm identified in its submissions. In your letter dated January 9, 2013, you stated that the firm is “completing the additional analytical and clinical validations for the tests that have been submitted” and is “planning extensive labeling studies that will take several months to complete.” Thus, months after you submitted your 510(k)s and more than 5 years after you began marketing, you still had not completed some of the studies and had not even started other studies necessary to support a marketing submission for the PGS. It is now eleven months later, and you have yet to provide FDA with any new information about these tests.  You have not worked with us toward de novo classification, did not provide the additional information we requested necessary to complete review of your 510(k)s, and FDA has not received any communication from 23andMe since May. Instead, we have become aware that you have initiated new marketing campaigns, including television commercials that, together with an increasing list of indications, show that you plan to expand the PGS’s uses and consumer base without obtaining marketing authorization from FDA.
Therefore, 23andMe must immediately discontinue marketing the PGS until such time as it receives FDA marketing authorization for the device. The PGS is in class III under section 513(f) of the FD&C Act, 21 U.S.C. 360c(f). Because there is no approved application for premarket approval in effect pursuant to section 515(a) of the FD&C Act, 21 U.S.C. 360e(a), or an approved application for an investigational device exemption (IDE) under section 520(g) of the FD&C Act, 21 U.S.C. 360j(g), the PGS is adulterated under section 501(f)(1)(B) of the FD&C Act, 21 U.S.C. 351(f)(1)(B).  Additionally, the PGS is misbranded under section 502(o) of the Act, 21 U.S.C. § 352(o), because notice or other information respecting the device was not provided to FDA as required by section 510(k) of the Act, 21 U.S.C. § 360(k).
Please notify this office in writing within fifteen (15) working days from the date you receive this letter of the specific actions you have taken to address all issues noted above. Include documentation of the corrective actions you have taken. If your actions will occur over time, please include a timetable for implementation of those actions. If corrective actions cannot be completed within 15 working days, state the reason for the delay and the time within which the actions will be completed. Failure to take adequate corrective action may result in regulatory action being initiated by the Food and Drug Administration without further notice. These actions include, but are not limited to, seizure, injunction, and civil money penalties.
We have assigned a unique document number that is cited above. The requested information should reference this document number and should be submitted to:
James L. Woods, WO66-5688
Deputy Director
Patient Safety and Product Quality
Office of In vitro Diagnostics and Radiological Health
10903 New Hampshire Avenue
Silver Spring, MD 20993
If you have questions relating to this matter, please feel free to call Courtney Lias, Ph.D. at 301-796-5458, or log onto our web site at www.fda.gov for general information relating to FDA device requirements.
Sincerely yours,
/S/
Alberto Gutierrez
Director
Office of In vitro Diagnostics
and Radiological Health
 Center for Devices and Radiological Health

SOURCE

http://www.fda.gov/ICECI/EnforcementActions/WarningLetters/2013/ucm376296.htm

Cancer Diagnostics by Genomic Sequencing: ‘No’ to Sequencing Patient’s DNA, ‘No’ to Sequencing Patient’s Tumor, ‘Yes’ to focus on Gene Mutation Aberration & Analysis of Gene Abnormalities

Symposia

http://aaas.confex.com/aaas/2013/webprogram/start.html

Personal Genetics: An Intersection Between Science, Society, and Policy

Saturday, February 16, 2013: 8:30 AM-11:30 AM

Room 203 (Hynes Convention Center)

On 26 June 2000, scientists announced the completion of a rough draft of the human genome, the result of the $3 billion publicly funded Human Genome Project. In the decade since, the cost of genome sequencing has plummeted, coinciding with the development of deep sequencing technologies and allowing, for the first time, personalized genetic medicine. The advent of personal genetics has profound implications for society that are only beginning to be discussed, even as the technologies are rapidly maturing and entering the market. This symposium will focus on how the genomic revolution may affect our society in coming years and how best to reach out to the general public on these important issues. How has the promise of genomics, as stated early in the last decade, matched the reality we observe today? What are the new promises — and pitfalls — of genomics and personal genetics as of 2013? What are the ethical implications of easy and inexpensive human genome sequencing, particularly with regard to ownership and control of genomic datasets, and what stakeholder interests must be addressed? How can the scientific community engage with the public at large to improve understanding of the science behind these powerful new technologies? The symposium will comprise three 15-minute talks from representatives of relevant sectors (academia/education, journalism, and industry), followed by a 45-minute panel discussion with the speakers.

Organizer:

Peter Yang, Harvard University

Co-organizers:

Brenna Krieger, Harvard University

and Kevin Bonham, Harvard University

Discussant:

James Thornton, Harvard University

Speakers:

 

Ting Wu, Harvard University

Personal Genetics and Education

Mary Carmichael, Boston Globe

The Media and the Personal Genetics Revolution

Brian Naughton, 23andMe Inc.

Commercialization of Personal Genomics: Promise and Potential Pitfalls

Mira Irons, Children’s Hospital Boston

Personal Genomic Medicine: How Physicians Can Adapt to a Genomic World

Sheila Jasanoff, Harvard University

Citizenship and the Personal Genomics

Jonathan Gitlin, National Human Genome Research Institute

Personal Genomics and Science Policy

THIS IS A SERIES OF FOUR POINTS OF VIEW IN SUPPORT OF the Paradigm Shift in Human Genomics

How to Tailor Cancer Therapy to the particular Genetics of a patient’s Cancer

‘No’ to Sequencing Patient’s DNA, ‘No’ to Sequencing Patient’s Tumor, ‘Yes’ to focus on Gene Mutation Aberration & Analysis of Gene Abnormalities PRESENTED in the following FOUR PARTS. Recommended to be read in its entirety for completeness and arrival to the End Point of Present and Future Frontier of Research in Genomics

Part 1:

Research Paradigm Shift in Human Genomics – Predictive Biomarkers and Personalized Medicine

http://pharmaceuticalintelligence.com/2013/01/13/paradigm-shift-in-human-genomics-predictive-biomarkers-and-personalized-medicine-part-1/

Part 2:

LEADERS in the Competitive Space of Genome Sequencing of Genetic Mutations for Therapeutic Drug Selection in Cancer Personalized Treatment

http://pharmaceuticalintelligence.com/2013/01/13/leaders-in-genome-sequencing-of-genetic-mutations-for-therapeutic-drug-selection-in-cancer-personalized-treatment-part-2/

Part 3:

Personalized Medicine: An Institute Profile – Coriell Institute for Medical Research

http://pharmaceuticalintelligence.com/2013/01/13/personalized-medicine-an-institute-profile-coriell-institute-for-medical-research-part-3/

Part 4:

The Consumer Market for Personal DNA Sequencing

 

Part 4:

The Consumer Market for Personal DNA Sequencing

How does 23andMe genotype my DNA?

Technology and Standards

23andMe is a DNA analysis service providing information and tools for individuals to learn about and explore their DNA. We use the Illumina OmniExpress Plus Genotyping BeadChip (shown here). In addition to the variants already included on the chip by Illumina, we’ve included our own, customized set of variants relating to conditions and traits that are interesting. Technical information on the performance of the chip can be found on Illumina’s website.

All of the laboratory testing for 23andMe is done in a CLIA-certified laboratory.

Once our lab receives your sample, DNA is extracted from cheek cells preserved in your saliva. The lab then copies the DNA many times — a process called “amplification” — growing the tiny amount extracted from your saliva until there is enough to be genotyped.

In order to be genotyped, the amplified DNA is “cut” into smaller pieces, which are then applied to our DNA chip, a small glass slide with millions of microscopic “beads” on its surface (read more about this technology). Each bead is attached to a “probe”, a bit of DNA that matches one of the approximately one million genetic variants that we test. The cut pieces of your DNA stick to the matching DNA probes. A fluorescent signal on each probe provides information that can tell us which version of that genetic variant your DNA corresponds to.

Although the human genome is estimated to contain about 10-30 million genetic variants, many of them are correlated due to their proximity to each other. Thus, one genetic variant is often representative of many nearby variants, and the approximately one million variants on our genotyping chip provide very good coverage of common variation across the entire genome.

Our research team has also hand-picked tens of thousands of additional genetic variants linked to various conditions and traits in the scientific literature to analyze on our genotyping chip. As a result we can provide you with personal genetic information available only through 23andMe.

Genetics service 23andMe announced some new cash in the bank today with a $50 million raise from Yuri Milner, 23andMe CEO Anne Wojcicki, Google’s Sergey Brin (who also happens to be Wojcicki’s husband), New Enterprise Associates, MPM Capital, and Google Ventures.

With today’s new funding also comes the reduction of the price of its genome analysis service to $99. This isn’t special holiday pricing (as 23andMe has run repeatedly in the past) the company tells me, but rather what its normal pricing will be from now on.

This move is overdue, at least as far as 23andMe’s business model is concerned. Just yesterday TechCrunch Conference Chair Susan Hobbs told me she was waiting for another $99 pricing deal to buy the Personal Genome Analysis product. Sure 23andMe has experimented with various pricing models, including subscription, since its founding in 2007, but had been at an official and prohibitive $299 price point until today. It’s also apparently been rigorously beta-testing various price points in the past couple of weeks, at some point experimenting with some lower than $99.

For comparison, the company’s original pricing began at $999 and offered subscribers just 14 health and trait reports versus today’s 244 reports, as well as genetic ancestry information. Natera, Counsyl and Pathway Genomics are also in the genomics space, but they work by offering their services through doctors rather than direct to consumer.

Since the company’s launch five years ago, it’s had 180K civilians profile their DNA, and representative Catherine Afarian tells us that, post-price drop and funding, its goal is to reach a million customers in 2013. This is a supremely ambitious goal considering it wants to turn an average user acquisition rate of 36K per year into one of 820K in one year alone.

But Afarian isn’t fazed and brings up how the company once sold out 20k in $99 account inventory on something called “DNA Day.” “Once we can offer the service at $99 it means the average American will buy in,” she said.

That $299 was too pricey, according to Hobbs, but $99 might be just right. She said the $99 price point, which yes, is less than an iPhone, was the main factor in her decision to buy in. “23andMe is more ‘nice-to-know’ information rather than ‘need-to-know’ information. It’s nice to know your ancestry. It’s more of a need to know that you are predisposed genetically for a type of cancer, so that you may take precautionary measures,” she said, implying that the data given by 23andMe isn’t necessarily vital medical information, or actionable when it is. While 23andMe can give you indicators about certain disease risks, it doesn’t close the loop, as in tell you what to do to prevent these diseases.

“Its [utility] depends on your genetic data,” said Afarian when I asked her about the usefulness of the product. “If you’ve got a Factor 5 that puts you at risk for clotting, you might want to invest in anti-clotting socks. [And] there’s always something about themselves that people didn’t know.”

Hobbs said eventually that she wouldn’t buy it, but only because she was looking into more exact lineage information for her little girl, and you need a Y chromosome in all DNA tests to show paternal lineage. Afarian also countered this hesitation, saying that what makes 23andMe unique is that it’s not only looking at just your Y or your mitochondrial DNA, but also your autosomal DNA, which does show some patrilineal information for females who lack that precious Y.

While still sort of a novelty, the potential for 23andMe goes beyond lineage and hopefully that extra $50 million will go further than keeping the price low and into research. The company hopes that a million users will result in a giant database of 23andWe genetic info that can be used to spot trends, like which genes mean a higher risk of diabetes/cancer, etc. Which is great if it happens but for now remains a pipe dream for 23andMe/We.

http://techcrunch.com/2012/12/11/23andnotme/

12/13/2012 @ 5:23PM |6,471 views

What Is 23andMe Really Selling: The Moral Quandary At The Center Of The Personalized Genomics Revolution

This week, 23andme, the personalized genomics company founded by Anne Wojcicki, wife of Google co-founder Sergey Brin, got an influx of investment cash ($50 million). According to their press release, they are using the money to bring the cost of their genetic test down to $99 (it was previously $299) which, they hope, will inspire the masses to get tested.

So should the masses indulge?

I prefer a quantified self approach to this question. At the heart of the quantified self-movement lies a very simple idea: metrics make us better. For devotees, this means “self-tracking,” using everything from the Nike fuel band to the Narcissism Personality Index to gather large quantities of personal data and—the bigger idea—use that data to improve performance.

If you consider that performance suffers when health suffers then a genetic test can been seen as a kind of metric used to improve performance. This strikes me as the best way to evaluate this idea and leads us to ask the same question about personalized genomics that the quantified self movement asks about every other metric: will it improve performance.

Arguments rage all over the place on this one, but the short answer is that SNP tests—which is the kind of DNA scan 23andme relies upon— don’t tell us all that much (yet).  They analyze a million genes out of three billion total and the impact those million play in long term-health outcomes is still in dispute. For example, the nature/nurture split is normally viewed at 30/70—meaning environmental factors play a far more significant role in long-term health outcomes than genetics.

Moreover, all of the performance metrics used by the quantified self movement are used to for behavior modification—to drive self-improvement. Personalized genomics isn’t there yet. As Stanford University’s Nobel Prize-winning RNA researcher Andy Fire once told me, “if someone off the street is looking for pointers on how to live a healthier life, there’s nothing these tests will tell you besides basic physician advice like ‘eat right, don’t smoke and get plenty of exercise.’”

And even with more well-regarded SNP tests, like the ones that examine the BRCA 1 and 2 markers for breast cancer—which  . NYU Langone Medical Center bioethicist Arthur Caplan explains it like this, “Say you test positive for a breast cancer disposition—then what are you going to do? The only preventative step you can take is to chop off your breasts.”

So if prevention is not available the only thing left is fear and anxiety. Unfortunately, in the past few decades, there have been hundreds of studies linking stress to everything from immunological disorders to heart disease to periodonitic troubles. So while finding out you may be at risk for Parkinson’s may make you feel informed, that knowledge isn’t going to stop you from developing the disease—but the resulting stress may contribute to a host of other complications.

This brings up a different question: if personalized genomics can’t yet help us much and could possibly hurt us—where’s the upside?

Turns out there’s a big upside: Citizen science. SNP tests are not yet viable because we need more info. 23andme talks about the “power of one million people,” meaning, if one million take these tests then the resulting genetic database could lead to big research breakthroughs and these could lead to all sorts of health/performance improvements.

This is what 23andme is really selling for $99 bucks a pop—a crowdsourced shot at unraveling a few more DNA mysteries.

And this also means that the question at the heart of the personalized genomics industry is not about metrics at all—it’s about morals: Should I risk my health for the greater good?

http://www.forbes.com/sites/stevenkotler/2012/12/13/what-is-23andme-really-selling-the-moral-quandary-at-the-center-of-the-personalized-genomics-revolution/

You can browse your data for all of the variants we test using the Browse Raw Data feature, or download your data here.

before you buy (59) »

What unexpected things might I learn?

How does 23andMe genotype my DNA?

Can I use the saliva collection kit for infants and toddlers?

getting started (20) »

When and how do I get my data?

How do I collect saliva samples?

How long will it take for my sample to reach the lab?

account/profile settings (20) »

Which Ancestry setting in My Profile should I choose?

How do I use Browse Raw Data?

What do the options under the “Account” link in the upper right-hand corner control?

product features (145) »

I know that a particular person is my relative. What’s the probability that we share a sufficient amount of DNA to be detected by Relative Finder?

What is the average percent DNA shared for different types of cousins?

How does Relative Finder estimate the Predicted Relationship?

research initiatives (8) »

What do I get in return for taking surveys?

What is your research goal?

What is 23andMe Research?

https://customercare.23andme.com/categories/20021003-faqs

https://customercare.23andme.com/home

REFERENCES

http://www.foundationmedicine.com/diagnostics-publications.php

http://www.coriell.org/media-center/publications

Http://www.coriell.org/assets/pdfs/gronowski_etal_coriellinstitute_clinicalchemistry2011_humantissuesinresearch.pdf

http://scholar.google.com/scholar?start=10&q=Gene+Mutation+Aberration+%26+Analysis+of+Gene+Abnormalities&hl=en&as_sdt=0,22&as_vis=1

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Heroes in Medical Research: Barnett Rosenberg and the Discovery of Cisplatin (Translating Basic Research to the Clinic)

Author/Writer: Stephen J. Williams, Ph.D.

This will be a regular posting which I hope people will find interesting.  I wish to highlight the basic research which led to seminal breakthroughs in the medical field, brought on by the result of basic inquiry, thorough and detailed investigation, meticulously following the scientific method, and eventually leading to development of important medical therapies.

This month I would like to highlight the research of Dr. Barnett Rosenberg and his discovery of one of the most used and effective chemotherapeutics, cisplatin.

Cisplatin_ALX-400-040

The compound cis-PtCl2(NH3)2 (seen in the Figure ) was first described by M. Peyrone in 1845, and known for a long time as Peyrone’s salt.[3] In 1965, Barnett Rosenberg, van Camp et al. of Michigan State University  had asked a simple question and noticed that electrical fields can inhibit the division and induce filamentous growth  of Escherichia coli (E. coli) bacteria. . Although bacterial cell growth continued, cell division was arrested, the bacteria growing as filaments up to 300 times their normal length.[5]  However, Dr. Roenberg did not stop at this finding and meticulously accounting for each variable which might explain this finding, including altering the metal composistion of the electrodes.  Dr. Rosenberg thought of the possibility it was not the electric field perse, which caused the growth inhibition, but a chemical produced in the media by electrolysis.  Eventually he discovered that electrolysis of platinum electrodes generated a soluble platinum complex which inhibited binary fission in Escherichia coli (E. coli) bacteria.  In addition he isolated this platinum complex and discovered that ammonium ions were required as well, owing to the full chemical structure of cisplatin as seen above (the nitrogens moieties are bioactivated to cations). This finding led to the observation that cis PtCl2(NH3)2 was indeed highly effective at regressing the mass of sarcomas in rats.[8] Confirmation of this discovery, and extension of testing to other tumour cell lines launched the medicinal applications of cisplatin. Cisplatin was approved for use in testicular and ovarian cancers by the U.S. Food and Drug Administration on December 19, 1978.[9]

  • ^ Peyrone M. (1844). “Ueber die Einwirkung des Ammoniaks auf Platinchlorür”. Ann Chemie Pharm 51 (1): 1–29. doi:10.1002/jlac.18440510102.
  • ^ a b c Stephen Trzaska (20 June 2005). “Cisplatin”. C&EN News 83 (25).
  • ^ Rosenberg, B.; Van Camp, L.; Krigas, T. (1965). “Inhibition of cell division in Escherichia coli by electrolysis products from a platinum electrode”. Nature 205 (4972): 698–699. doi:10.1038/205698a0. PMID 14287410.

Barnett Rosenberg

From Wikipedia, the free encyclopedia

403px-Nci-vol-8173-300_barnett_rosenberg

Barnett Rosenberg

Born November 16, 1926
New York, New York
Died August 8, 2009
Lansing, Michigan
Fields Physics/Biophysics
Institutions Michigan State University
Known for Cisplatin

Barnett Rosenberg (16 November 1926 – 8 August 2009) was an American chemist best known for the discovery of the anti-cancer drug cisplatin.[1]

Rosenberg graduated from Brooklyn College in 1948 and obtained his PhD in Physics at New York University (NYU) in 1956. He joined Michigan State University in 1961 and worked there until 1997.

In 1965, Rosenberg and his colleagues proved that certain platinum-containing compounds inhibited cell division and then in 1969 showed that they cured solid tumors. The chemotherapy drug that eventually resulted from this work, cisplatin, obtained US Food and Drug Administration (FDA) approval in 1978 and went on to become a widely used anticancer drug. The initial discovery was quite serendipitous. Rosenberg was looking into the effects of an electric field on the growth of bacteria. He noticed that bacteria ceased to divide when placed in an electric field and eventually pinned down the cause of this phenomenon to the platinum electrode he was using.[2]

He was awarded the Charles F. Kettering Prize in 1984 and the Harvey Prize in 1984. [3]

  1. ^ Rosenberg, B.; Van Camp, L.; Krigas, T. (1965). “Inhibition of Cell Division in Escherichia coli by Electrolysis Products from a Platinum Electrode”. Nature 205 (4972): 698–9. doi:10.1038/205698a0. PMID 14287410. edit
  2. ^ Petsko, G. A. (2002). “A christmas carol”. Genome biology 3 (1): COMMENT1001. PMC 150444. PMID 11806819edit
  3. ^ http://visualsonline.cancer.gov/details.cfm?imageid=8173

Other posts of interest  in this site  include:

Interview with the co-discoverer of the structure of DNA: Watson on The Double Helix and his changing view of Rosalind Franklin

Otto Warburg, A Giant of Modern Cellular Biology

Inspiration From Dr. Maureen Cronin’s Achievements in Applying Genomic Sequencing to Cancer Diagnostics

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New Imaging device bears a promise for better quality control of breast-cancer lumpectomies – considering the cost impact

Author and Curator: Dror Nir, PhD

Couple of days ago I have posted on breast-cancer mammography screening and associated costs; Not applying evidence-based medicine drives up the costs of screening for breast-cancer in the USA. Treatment of breast-cancer represents much heavier cost-burden. According to the following publication: Variability in Reexcision Following Breast Conservation Surgery made in JAMA: “Failure to achieve appropriate margins at the initial operation will require additional surgery with re-excision rate estimates ranging from 30% to 60%. These additional operations can produce considerable psychological, physical, and economic stress for patients and delay use of recommended adjuvant therapies. A high percentage (10%-36%) of women requiring reexcision undergo total mastectomy. Thus, the effect of reexcision on altering a patient’s initial treatment of choice is significant.”

 Considering that ~70% of the 285,000 new patients diagnosed with breast cancer each year undergoes lumpectomy, this data represents significant cost. Not to mention morbidity, stress and reduce quality of life for the patients. In my post Optical Coherent Tomography – emerging technology in cancer patient management I discussed the potential of OCT in controlling the quality of lumpectomies in-situ. A workflow that represents potential to reduce the costs of repeated lumpectomies.

Last week, Dune Medical Devices, Inc., the company that developed the MarginProbeTM System, an intra-operative tissue assessment device to be used as accessory during lumpectomies of early-stage breast cancer, has received Premarket Approval (PMA) by the United States Food and Drug Administration.

MarginProbe system

marginProbe

FDA approval of the MarginProbe System was based on a 664 patient prospective, multi-center, randomized, double arm study to evaluate the effectiveness of MarginProbe in identifying cancerous tissue along the margins of removed breast tissue during initial lumpectomy procedures. MarginProbe, which uses electromagnetic “signatures” to identify healthy and cancerous tissue, was found to be over three times more effective in finding cancer on the margin during lumpectomy, compared to traditional intra-operative imaging and palpation assessment. This enabled surgeons to significantly reduce the number of patients with positive margins following initial surgery.

The following publication gives an idea on the clinical performance of MarginProbe:

J Surg Res. 2010 May 15;160(2):277-81. doi: 10.1016/j.jss.2009.02.025. Epub 2009 Mar 31.

Diagnostic performance of a novel device for real-time margin assessment in lumpectomy specimens.

Pappo ISpector RSchindel AMorgenstern SSandbank JLeider LTSchneebaum SLelcuk SKarni T.

Source

Department of General Surgery, Assaf Harofeh Medical Center, Zrifin, Israel. pappo@zahav.net.il

Abstract

BACKGROUND:

Margin status in breast lumpectomy procedures is a prognostic factor for local recurrence and the need to obtain clear margins is often a cause for repeated surgical procedures. A recently developed device for real-time intraoperative margin assessment (MarginProbe; Dune Medical Devices, Caesarea, Israel), was clinically tested. The work presented here looks at the diagnostic performance of the device.

METHODS:

The device was applied to freshly excised lumpectomy and mastectomy specimens at specific tissue measurement sites. These measurement sites were accurately marked, cut out, and sent for histopathologic analysis. Device readings (positive or negative) were compared with histology findings (namely malignant, containing any microscopically detected tumor, or nonmalignant) on a per measurement site basis. The sensitivity and specificity of the device was computed for the full dataset and for additional relevant subgroups.

RESULTS:

A total of 869 tissue measurement sites were obtained from 76 patients, 753 were analyzed, of which 165 were cancerous and 588 were nonmalignant. Device performance on relatively homogeneous sites was: sensitivity 1.00 (95% CI: 0.85-1), specificity 0.87 (95% CI: 0.83-0.90). Performance for the full dataset was: sensitivity 0.70 (95% CI: 0.63-0.77), specificity 0.70 (95% CI: 0.67-0.74). Device sensitivity was estimated to change from 56% to 97% as the cancer feature size increased from 0.7 mm to 6.6 mm. Detection rate of samples containing pure DCIS clusters was not different from rates of samples containing IDC.

CONCLUSIONS:

The device has high sensitivity and specificity in distinguishing between normal and cancer tissue even down to small cancer features.

Copyright (c) 2010 Elsevier Inc. All rights reserved.

PMID: 19628225

Imagine how cost effective breast cancer management can be if it will involve systems such as these in addition to the systems I discussed in some of my previous posts, for example: What could transform an underdog into a winner?

Written by: Dror Nir, PhD.

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UPDATED: PLATO Trial on ACS: BRILINTA (ticagrelor) better than Plavix® (clopidogrel bisulfate): Lowering chances of having another heart attack

Reporter: Aviva Lev-Ari, PhD, RN

 

UPDATED on 9/1/2019

Extended DAPT with Brilinta: No Benefit for Stable CAD in T2D

Substudy in those with prior PCI might identify group where bleeding tradeoff is worthwhile

PARIS — Ticagrelor (Brilinta) as part of a dual antiplatelet therapy (DAPT) regimen didn’t improve net outcomes for stable coronary artery disease (CAD) among type 2 diabetes patients, except perhaps in the setting of percutaneous coronary intervention (PCI), the THEMIS trial showed.

Adding the potent antiplatelet agent to aspirin reduced cardiovascular (CV) death, myocardial infarction (MI), or stroke (7.7% vs 8.5%, HR 0.90, 95% CI 0.81-0.99), reported Deepak Bhatt, MD, MPH, of Brigham and Women’s Hospital and Harvard Medical School in Boston, at the European Society of Cardiology (ESC) congress and online in the New England Journal of Medicine.

But it also increased

  • TIMI major bleeding (2.2% vs 1.0%, HR 2.32, 95% CI 1.82-2.94) and
  • intracranial hemorrhage (0.7% vs 0.5%, HR 1.71, 95% CI 1.18- 2.48) over aspirin alone, albeit
  • without more fatal bleeding (0.2% vs 0.1%, P=0.11).

The combined effect was neutral for the exploratory composite outcome of “irreversible harm” (death from any cause, MI, stroke, fatal bleeding, or intracranial hemorrhage 10.1% vs 10.8%, HR 0.93, 95% CI 0.86-1.02).

ESC session study discussant Colin Baigent, MD, of Oxford University in England, actually calculated 12 major bleeds for every eight events prevented.

“This is a consistent story: when we add an antiplatelet agent for risk reduction, we increase the risk of bleeding,” noted Richard Kovacs, MD, of Indiana University in Indianapolis and president of the American College of Cardiology.

THEMIS is the final part of a largely-disappointing PARTHENON development program for ticagrelor, he noted. “It hasn’t changed practice. …Will the main THEMIS trial change clinical practice? In my opinion, no.”

SOURCE

https://www.medpagetoday.com/meetingcoverage/esc/81925?xid=nl_mpt_ACC_Reporter_2019-09-01&eun=g5099207d2r

 

UPDATED on 10/4/2016

Soriot’s $3.5B Brilinta dream is dashed by yet another big trial flop for AstraZeneca

by john carroll
October 4, 2016 09:00 AM EDT
Updated: 09:33 AM

Brilinta, the drug failed to demonstrate a benefit over generic Plavix (clopidogrel) for peripheral artery disease. Back in March, the heart drug flopped in a large stroke study, unable to prove that it could beat aspirin. And Soriot can chalk up those expensive studies to proving Brilinta’s serious deficiencies.

“We don’t believe the goal of $3.5 billion is attainable. I think it would be unrealistic to believe that,” Ludovic Helfgott, head of AstraZeneca’s Brilinta business, told Reuters.

Brilinta brought in a total of $619 million last year after disappointing analysts repeatedly with lower-than-expected quarterly revenue.

Heart studies aren’t cheap. AstraZeneca recruited 13,500 patients for the EUCLID study, and it had enrolled close to that number for the earlier SOCRATES trial.

SOURCE

http://endpts.com/soriots-3-5b-brilinta-dream-is-dashed-by-yet-another-big-trial-flop-for-astrazeneca/?utm_medium=email&utm_campaign=75%20Dinner%20with%20Brent&utm_content=75%20Dinner%20with%20Brent+CID_8008d3b4f16d90576238cceef624d211&utm_source=ENDPOINTS%20emails&utm_term=Soriots%2035B%20Brilinta%20dream%20is%20dashed%20by%20yet%20another%20big%20trial%20flop%20for%20AstraZeneca

UPDATED on 9/4/2014

Prehospital Ticagrelor in ST-Segment Elevation Myocardial Infarction

Gilles Montalescot, M.D., Ph.D., Arnoud W. van ‘t Hof, M.D., Ph.D., Frédéric Lapostolle, M.D., Ph.D., Johanne Silvain, M.D., Ph.D., Jens Flensted Lassen, M.D., Ph.D., Leonardo Bolognese, M.D., Warren J. Cantor, M.D., Ángel Cequier, M.D., Ph.D., Mohamed Chettibi, M.D., Ph.D., Shaun G. Goodman, M.D., Christopher J. Hammett, M.B., Ch.B., M.D., Kurt Huber, M.D., Magnus Janzon, M.D., Ph.D., Béla Merkely, M.D., Ph.D., Robert F. Storey, M.D., D.M., Uwe Zeymer, M.D., Olivier Stibbe, M.D., Patrick Ecollan, M.D., Wim M.J.M. Heutz, M.D., Eva Swahn, M.D., Ph.D., Jean-Philippe Collet, M.D., Ph.D., Frank F. Willems, M.D., Ph.D., Caroline Baradat, M.Sc., Muriel Licour, M.Sc., Anne Tsatsaris, M.D., Eric Vicaut, M.D., Ph.D., and Christian W. Hamm, M.D., Ph.D. for the ATLANTIC Investigators

September 1, 2014DOI: 10.1056/NEJMoa1407024

BACKGROUND

The direct-acting platelet P2Y12 receptor antagonist ticagrelor can reduce the incidence of major adverse cardiovascular events when administered at hospital admission to patients with ST-segment elevation myocardial infarction (STEMI). Whether prehospital administration of ticagrelor can improve coronary reperfusion and the clinical outcome is unknown.

METHODS

We conducted an international, multicenter, randomized, double-blind study involving 1862 patients with ongoing STEMI of less than 6 hours’ duration, comparing prehospital (in the ambulance) versus in-hospital (in the catheterization laboratory) treatment with ticagrelor. The coprimary end points were the proportion of patients who did not have a 70% or greater resolution of ST-segment elevation before percutaneous coronary intervention (PCI) and the proportion of patients who did not have Thrombolysis in Myocardial Infarction flow grade 3 in the infarct-related artery at initial angiography. Secondary end points included the rates of major adverse cardiovascular events and definite stent thrombosis at 30 days.

RESULTS

The median time from randomization to angiography was 48 minutes, and the median time difference between the two treatment strategies was 31 minutes. The two coprimary end points did not differ significantly between the prehospital and in-hospital groups. The absence of ST-segment elevation resolution of 70% or greater after PCI (a secondary end point) was reported for 42.5% and 47.5% of the patients, respectively. The rates of major adverse cardiovascular events did not differ significantly between the two study groups. The rates of definite stent thrombosis were lower in the prehospital group than in the in-hospital group (0% vs. 0.8% in the first 24 hours; 0.2% vs. 1.2% at 30 days). Rates of major bleeding events were low and virtually identical in the two groups, regardless of the bleeding definition used.

CONCLUSIONS

Prehospital administration of ticagrelor in patients with acute STEMI appeared to be safe but did not improve pre-PCI coronary reperfusion. (Funded by AstraZeneca; ATLANTIC ClinicalTrials.gov number, NCT01347580.)

SOURCE

http://www.nejm.org/doi/full/10.1056/NEJMoa1407024?query=TOC

 

 

UPDATED on 2/7/2014

PLATO Controversy Hits the Wall Street Journal

February 05, 2014

NEW YORK, NY – The controversy surrounding the PLATOtrial of ticagrelor (Brilinta, AstraZeneca) continues unabated, according to a story published in the Wall Street Journal. Specifically, a sealed complaint filed in US district court in the District of Columbia by a researcher contends that the cardiovascular events in the study “may have been manipulated” [1].

Dr Victor Serebruany (HeartDrug Research Laboratories, Johns Hopkins University, Towson, MD), who has long been a thorn in the side of AstraZeneca and the PLATO investigators, filed the complaint under the False Claims Act, reports theWall Street Journal. The Journal notes that the US attorney’s office in Washington, DC, has contacted Serebruany and is currently investigating the clinical trial.As reported by heartwirein October 2013, the US Department of Justice issued a civil investigative demand from its civil division “seeking documents and information regarding PLATO.” AstraZeneca is complying with the request.

First reported by heart wirein 2009 , the PLATO trial was a positive study involving more 18 000 patients from 43 countries. PLATO investigators, led by Dr Lars Wallentin (Uppsala Clinical Research Center, Sweden), showed that treating acute coronary syndrome patients with ticagrelor significantly reduced the rate of MI, stroke, and cardiovascular death compared with patients taking clopidogrel. Results were presented at the European Society of Cardiology 2009 Congress and reported in the New England Journal of Medicine.

PLATO has been dogged by questions, including prior to approval. In the sealed complaint, Serebruany takes issue with a number of things, many of which have been reported previously. He alleges that the

  • number of clinical events among those taking clopidogrel was high compared with other studies, pointing out that the rate of all-cause death was 5.9% among clopidogrel-treated patients—nearly twice as high as earlier studies. In addition,
  • the sealed complaint documents the geographic discrepancies in the trial, noting there was a trend toward worse outcomes with ticagrelor at North American sites.The complaint also alleges that
  • an initial count of clinical events suggested the two drugs were equivalent, but adjudication by the Duke Clinical Research Institute attributed another 45 MIs to the clopidogrel group, which tipped the results in favor of ticagrelor. Other questions raised about the study include
  • site monitoring and timing of clinical events. Serebruany also alleges that
  • the trial may have unintentionally been unblinded because of the shape of clopidogrel’s “split capsules,” which would have enabled doctors and nurses to know which drug patients received.

AstraZeneca rebutted these issues, telling the Journal that it is cooperating with the government. It said it is confident in the integrity of the trial and noted the overall study showed the superiority of ticagrelor over clopidogrel. There is no evidence the trial was unblinded and researchers used the same standards when qualifying all clinical events, including MIs, they noted. In addition, the company said it is not possible to compare event rates with clopidogrel in PLATO with other studies because the patient populations differ.

The Journal reports that Serebruany became embroiled in the controversy when asked by the FDA‘s Dr Thomas Marciniak to advise the agency about the PLATO data in 2010. Marciniak, who led the FDA’s review of PLATO, called AstraZeneca’s submission on serious adverse events the “worst submission” he ever encountered. According to the submission, he noted, 12 patients reported their own deaths by telephone. Before approving ticagrelor, the FDA requested an additional analysis of PLATO, and it was eventually approved in the US in July 2011. Ticagrelor was approved in Europe in December 2010 and is authorized for use in more than 100 countries.

The Journal called Serebruany an expert in the antiplatelet field but said he is a “controversial figure,” partly because of his financial ties to industry and repeated criticisms of new drug approvals. Through HeartDrug Research, Serebruany has worked on prasugrel (Effient, Lily/Daiichi-Sankyo), a competing antiplatelet agent, but has also done work for AstraZeneca.

REFERENCE

Burton TM. Doctor challenges testing of AstraZeneca’s Brilinta. Wall Street Journal, February 2, 2014. Available here.

SOURCE

http://www.medscape.com/viewarticle/820236?nlid=47583_1984&src=wnl_edit_medn_card&uac=93761AJ&spon=2

UPDATED 3/28/2013

How AstraZeneca Will Use A Diagnostic To Market Its Blood Thinner

by Matthew Harper, Forbes Staff on 3/21/2013

Earlier today I wrote about how AstraZeneca is telling investors that its blood-thinner Brilinta, used to prevent second heart attacks, could be a multi-billion dollar drug, at least twice as big as Wall Street analysts expect. So far the drug has been a disappointment.

I wrote:

Another key data point Astra presented was that blood levels of troponin, a muscle protein released by the heart during a heart attack, predict which patients get the most benefit from Brilinta. This data is not in AstraZeneca’s label, but a spokeswoman said that she believed it would be something the company can market to doctors.

via Can Pascal Soriot Turn Around AstraZeneca? It May Come Down To One Drug – Forbes.

But will the Food and Drug Administration allow Astra to tell doctors that? Stratification using troponin is not in Brilinta’s FDA-approved label, and off-label promotion is illegal. But Ferguson says that communications about troponin will be allowed because all patients with high troponin are patients who would be included in the FDA-approved indication. He confirms that use of troponin testing will be part of the new marketing plan for Brilinta.

SOURCE:

http://www.forbes.com/sites/matthewherper/2013/03/21/how-astrazeneca-will-use-a-diagnostic-to-market-its-blood-thinner/

Can Pascal Soriot Turn Around AstraZeneca? It May Come Down To One Drug

by Matthew Herper, Forbes Staff on 3/21/2013

This morning in New York, new AstraZeneca chief executive Pascal Soriot is telling investors how he is going to turn around the company that has had the absolute worst track record in research and development among any big pharmaceutical firm. The plan is fairly wide-ranging and involves a lot of the steps one might expect:

  • new layoffs (2,300 jobs);
  • a re-focusing of research and development on three areas: heart disease and diabetes; oncology; and respiratory and inflammation;
  • new R&D initiatives involving Moderna, a biotech company, and the Karolinska Instutet;
  • moving the company’s headquarters to its R&D hub in Cambridge, U.K.;
  • re-focusing on emerging markets, where AZ already gets $6 billion in sales, especially China.

But the short-term key to delivering on his promises today seems to come down to a single drug: Brilinta, the Plavix competitor thatAstraZeneca introduced in 2011 which has so far disappointed, generating  just $324 $89 million in global sales last year. This is a medicine to prevent heart attacks and strokes in patients who suffer acute coronary syndrome, the condition that occurs after a heart attack or serious heart-related chest pain. It works by preventing the formation of blood clots.

Plavix was the second biggest drug in the world, with $6 billion in annual sales, but it is now generic. The conventional wisdom is that it will be difficult to compete with cheap generics. Brilinta is actually trailing Effient, a similar medicine from Eli Lilly, in usage. Wall Street consensus currently sees Brilinta growing to become a moderate-sized drug in 2018, with $1.3 billion in annual sales. But AstraZeneca is saying that it thinks Brilinta can be a multi-billion dollar product. Astra has confirmed that this means Brilinta will have to surpass Effient. The newer drugs also cause more bleeding than Plavix.

What is the company’s argument? In his presentation today, Paul Hudson, Astra’s Executive Vice President, North America, said that the key would be focusing on one key fact: Brilinta reduced cardiovascular deaths by 21% compared to Plavix in a big clinical trial. That would mean that if everyone eligible for Brilinta got it, 100,000 lives would be saved.

But the reality is that doctors have been skeptical of that data because in the part of that trial that was run in North America, the benefit was less clear. AstraZeneca says that this may have been due to an interaction of Brilinta and aspirin and that, according to current cardiovascular guidelines, doctors should be prescribing less aspirin anyway.

Another key data point Astra presented was that blood levels of troponin, a muscle protein released by the heart during a heart attack, predict which patients get the most benefit from Brilinta. This data is not in AstraZeneca’s label, but a spokeswoman said that she believed it would be something the company can market to doctors.

A lot of what Astra will do in the short term on Brilinta will be blocking and tackling. It needs to pay bigger rebates to insurers to make sure that patients can get cheap access to the drug. (This is how discounts happen in the American insurance system: the patient pays a co-payment and the insurer pays full price for the drug, but then the drug maker gives the insurer money back to make the end cost cheaper.) It will also be doing a lot of medical marketing, involving its internal experts or paid, external doctors, to get the word out about the benefits of Brilinta.

Brilinta has other advantages (it stops acting quickly) and disadvantages (it must be given twice a day). But the other big question for expanding results is whether large clinical trials that are now ongoing will show that it works in a broader array of heart patients. Astra is starting a big trial to show Brilinta prevents strokes. These trials are risky and expensive, but there will be a big payoff if they work.

Astra has some other commercial levers to point to. It’s diabetes pill Onglyza, which is sold with Bristol-Myers Squibb, will have results in a big study of its efficacy in preventing heart disease before a similar study of Merck’s top-selling Januvia, which started first. Soriot has smart ideas about which drugs to advance into later testing. But Brilinta is going to be the biggest single indicator of whether Soriot’s new strategies are paying off.

SOURCE:

http://www.forbes.com/sites/matthewherper/2013/03/21/can-pascal-soriot-turn-around-astrazeneca-it-may-come-down-to-one-drug/

BRILINTA is an antiplatelet medication

Taking BRILINTA is a first step in the treatment your physician has chosen for you. At BRILINTA.com, you will find helpful information and useful learning tools to help you complete your course of BRILINTA therapy. Make sure you and your loved ones read through all of the sections.

What is BRILINTA?

BRILINTA is a type of prescription antiplatelet medication for people who have had a recent heart attack or severe chest pain that happened because their heart wasn’t getting enough oxygen and who are being treated with medicines or procedures to open blocked arteries in the heart. BRILINTA is used with aspirin to stop platelets from sticking together and forming a blood clot that could block blood flow to the heart and cause another, possibly fatal, heart attack. Platelets are small cells in the blood that help with normal blood clotting.

Take BRILINTA and aspirin exactly as instructed by your doctor: BRILINTA twice a day, plus one 81-mg aspirin tablet once a day. You should not take a dose of aspirin higher than 100 mg each day because it can affect how well BRILINTA works. Tell your doctor about any medicines you are taking that contain aspirin. Do not take any new medicines that contain aspirin.

Why BRILINTA?

BRILINTA used with aspirin lowers your chance of having another serious problem with your heart or blood vessels such as heart attack, stroke, or blood clots in your stent if you received one. These can be fatal. In fact, in a large clinical study BRILINTA was even better than Plavix® (clopidogrel bisulfate) tablets at lowering your chances of having another heart attack.

BRILINTA is used to lower your chance of having another heart attack or dying from a heart attack, but BRILINTA (and similar drugs) can cause bleeding that can be serious and sometimes lead to death.

Complete the
Course
 Program

IMPORTANT SAFETY INFORMATION ABOUT BRILINTA

BRILINTA is used to lower your chance of having another heart attack or dying from a heart attack or stroke, but BRILINTA (and similar drugs) can cause bleeding that can be serious and sometimes lead to death. Instances of serious bleeding, such as internal bleeding, may require blood transfusions or surgery. While you take BRILINTA, you may bruise and bleed more easily and be more likely to have nosebleeds. Bleeding will also take longer than usual to stop.

Call your doctor right away if you have any signs or symptoms of bleeding while taking BRILINTA, including: severe, uncontrollable bleeding; pink, red, or brown urine; vomit that is bloody or looks like coffee grounds; red or black stool; or if you cough up blood or blood clots.

Do not stop taking BRILINTA without talking to the doctor who prescribes it for you. People who are treated with a stent, and stop taking BRILINTA too soon, have a higher risk of getting a blood clot in the stent, having a heart attack, or dying. If you stop BRILINTA because of bleeding, or for other reasons, your risk of a heart attack or stroke may increase. Tell all your doctors and dentists that you are taking BRILINTA. To decrease your risk of bleeding, your doctor may instruct you to stop taking BRILINTA 5 days before you have elective surgery. Your doctor should tell you when to start taking BRILINTA again, as soon as possible after surgery.

Take BRILINTA and aspirin exactly as instructed by your doctor. You should not take a dose of aspirin higher than 100 mg daily because it can affect how well BRILINTA works. Tell your doctor if you take other medicines that contain aspirin. Do not take new medicines that contain aspirin.

Do not take BRILINTA if you are bleeding now, especially from your stomach or intestine (ulcer), have a history of bleeding in the brain, or have severe liver problems.

BRILINTA can cause serious side effects, including bleeding and shortness of breath. Call your doctor if you have new or unexpected shortness of breath or any side effect that bothers you or that does not go away. Your doctor can decide what treatment is needed.

Tell your doctor about all the medicines you take, including prescription and nonprescription medicines, vitamins, and herbal supplements. BRILINTA may affect the way other medicines work, and other medicines may affect how BRILINTA works.

Approved uses
BRILINTA is a prescription medicine for people who have had a recent heart attack or severe chest pain that happened because their heart wasn’t getting enough oxygen and who are being treated with medicines or procedures to open blocked arteries in the heart.

BRILINTA is used with aspirin to lower your chance of having another serious problem with your heart or blood vessels such as heart attack, stroke, or blood clots in your stent if you received one. These can be fatal.

Please read Prescribing Information, including Boxed WARNINGS.

Please read Medication Guide.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

If you are without prescription coverage and cannot afford your medication, AstraZeneca may be able to help. For more information, please visit www.AstraZeneca.com.

This product information is intended for US consumers only.

BRILINTA is a trademark of the AstraZeneca group of companies.

Plavix® is a registered trademark of sanofi-aventis.

©2012 AstraZeneca.706809-1789005 8/12

SOURCE:

http://www.brilinta.com/antiplatelet-prescription-medication.aspx#au

http://www1.astrazeneca-us.com/pi/brilinta.pdf

BRILINTA (ticagrelor)

Ticagrelor (trade name Brilinta in the US, Brilique and Possia in the EU) is a platelet aggregation inhibitor produced by AstraZeneca. The drug was approved for use in the European Union by the European Commission on December 3, 2010.[1][2] The drug was approved by the US Food and Drug Administrationon July 20, 2011.[3]

Indications

Ticagrelor is indicated for the prevention of thrombotic events (for example stroke or heart attack) in patients with acute coronary syndrome or myocardial infarction with ST elevation. The drug is combined with acetylsalicylic acid unless the latter is contraindicated.[4] Treatment of acute coronary syndrome with ticagrelor as compared with clopidogrel significantly reduces the rate of death.[5]

Contraindications

Contraindications for ticagrelor are: active pathological bleeding and a history of intracranial bleeding, as well as reduced liver function and combination with drugs that strongly influence activity of the liver enzymeCYP3A4, because the drug is metabolized via CYP3A4 and excreted via the liver.[4]

Adverse effects

The most common side effects are shortness of breath (dyspnea, 14%)[6] and various types of bleeding, such as hematomanosebleedgastrointestinalsubcutaneous or dermal bleeding. Allergic skin reactions such as rash and itching have been observed in less than 1% of patients.[4]

Physical and chemical properties

Ticagrelor is a nucleoside analogue: the cyclopentane ring is similar to the sugar ribose, and the nitrogen rich aromatic ring system resembles the nucleobase purine, giving the molecule an overall similarity toadenosine. The substance has low solubility and low permeability under the Biopharmaceutics Classification System.[1]

Ticagrelor as a nucleoside analogue

The nucleoside adenosinefor comparison

Pharmacokinetics

Ticagrelor is absorbed quickly from the gut, the bioavailability being 36%, and reaches its peak concentration after about 1.5 hours. The main metabolite, AR-C124910XX, is formed quickly via CYP3A4 by de-hydroxyethylation at position 5 of the cyclopentane ring.[7] It peaks after about 2.5 hours. Both ticagrelor and AR-C124910XX are bound to plasma proteins (>99.7%), and both are pharmacologically active. Blood plasma concentrations are linearly dependent on the dose up to 1260 mg (the sevenfold daily dose). The metabolite reaches 30–40% of ticagrelor’s plasma concentrations. Drug and metabolite are mainly excreted via bile and feces.

Plasma concentrations of ticagrelor are slightly increased (12–23%) in elderly patients, women, patients of Asian ethnicity, and patients with mild hepatic impairment. They are decreased in patients that described themselves as ‘coloured’ and such with severe renal impairment. These differences are considered clinically irrelevant. In Japanese people, concentrations are 40% higher than in Caucasians, or 20% after body weight correction. The drug has not been tested in patients with severe hepatic impairment.[4]

Mechanism of action

Like the thienopyridines prasugrelclopidogrel and ticlopidine, ticagrelor blocks adenosine diphosphate (ADP) receptors of subtype P2Y12. In contrast to the other antiplatelet drugs, ticagrelor has a binding site different from ADP, making it an allosteric antagonist, and the blockage is reversible.[8] Moreover, the drug does not need hepatic activation, which might work better for patients with genetic variants regarding the enzyme CYP2C19 (although it is not certain whether clopidogrel is significantly influenced by such variants).[9][10][11]

Comparison with clopidogrel

The PLATO trial, funded by AstraZeneca, in mid-2009 found that ticagrelor had better mortality rates than clopidogrel (9.8% vs. 11.7%, p<0.001) in treating patients with acute coronary syndrome. Patients given ticagrelor were less likely to die from vascular causes, heart attack, or stroke but had greater chances of non-lethal bleeding (16.1% vs. 14.6%, p=0.0084), higher rate of major bleeding not related to coronary-artery bypass grafting (4.5% vs. 3.8%, P=0.03), including more instances of fatal intracranial bleeding. Rates of major bleeding were not different. Discontinuation of the study drug due to adverse events occurred more frequently with ticagrelor than with clopidogrel (in 7.4% of patients vs. 6.0%, P<0.001)[5] The PLATO trial showed a statistically insignificant trend toward worse outcomes with ticagrelor versus clopidogrel among US patients in the study – who comprised 1800 of the total 18,624 patients. The HR actually reversed for the composite end point cardiovascular (death, MI, or stroke): 12.6% for patients given ticagrelor and 10.1% for patients given clopidogrel (HR = 1.27). Some believe the results could be due to differences in aspirin maintenance doses, which are higher in the United States.[12] Others state that the central adjudicating committees found an extra 45 MIs in the clopidogrel (comparator) arm but none in the ticagrelor arm, which improved the MI outcomes with ticagrelor. Without this adjudication the trials’ primary efficacy outcomes should not be significant[13]

Consistently with its reversible mode of action, ticagrelor is known to act faster and shorter than clopidogrel.[14] This means it has to be taken twice instead of once a day which is a disadvantage in respect of compliance, but its effects are more quickly reversible which can be useful before surgery or if side effects occur.[4][15]

Interactions

Inhibitors of the liver enzyme CYP3A4, such as ketoconazole and possibly grapefruit juice, increase blood plasma levels and consequently can lead to bleeding and other adverse effects. Conversely, drugs that are metabolized by CYP3A4, for example simvastatin, show increased plasma levels and more side effects if combined with ticagrelor. CYP3A4 inductors, for example rifampicin and possibly St. John’s wort, can reduce the effectiveness of ticagrelor. There is no evidence for interactions via CYP2C9.

The drug also inhibits P-glycoprotein (P-gp), leading to increased plasma levels of digoxinciclosporin and other P-gp substrates. Ticagrelor and AR-C124910XX levels are not significantly influenced by P-gp inhibitors.[4]

In the US a boxed warning states that use of ticagrelor with aspirin doses exceeding 100 mg/day decreases the effectiveness of the medication.[16]

References

  1. a b “Assessment Report for Brilique”European Medicines Agency. January 2011.
  2. ^ European Public Assessment Report Possia
  3. ^ “FDA approves blood-thinning drug Brilinta to treat acute coronary syndromes”. FDA. 20 July 2011.
  4. a b c d e f Haberfeld, H, ed. (2010) (in German). Austria-Codex (2010/2011 ed.). Vienna: Österreichischer Apothekerverlag.
  5. a b Wallentin, Lars; Becker, RC; Budaj, A; Cannon, CP; Emanuelsson, H; Held, C; Horrow, J; Husted, S et al. (August 30, 2009). “Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes”NEJM 361 (11): 1045–57. doi:10.1056/NEJMoa0904327PMID 19717846.
  6. ^ Brilinta: Highlights of prescribing information
  7. ^ Teng, R; Oliver, S; Hayes, MA; Butler, K (2010). “Absorption, distribution, metabolism, and excretion of ticagrelor in healthy subjects”. Drug metabolism and disposition: the biological fate of chemicals 38 (9): 1514–21. doi:10.1124/dmd.110.032250PMID 20551239.
  8. ^ Birkeland, Kade; Parra, David; Rosenstein, Robert (2010). “Antiplatelet therapy in acute coronary syndromes: focus on ticagrelor”Journal of Blood Medicine 1: 197–219.
  9. ^ H. Spreitzer (February 4, 2008). “Neue Wirkstoffe – AZD6140” (in German). Österreichische Apothekerzeitung (3/2008): 135.
  10. ^ Owen, RT, Serradell, N, Bolos, J (2007). “AZD6140”. Drugs of the Future 32 (10): 845–853. doi:10.1358/dof.2007.032.10.1133832.
  11. ^ Tantry, Udaya S; Bliden, Kevin P (2010). “First Analysis of the Relation Between CYP2C19 Genotype and Pharmacodynamics in Patients Treated With Ticagrelor Versus Clopidogrel”. Circulation: Cardiovascular Genetics 3: 556–566. doi:10.1161/CIRCGENETICS.110.958561.
  12. ^ Bernardo Lombo, José G Díez. Ticagrelor: the evidence for its clinical potential as an oral antiplatelet treatment for the reduction of major adverse cardiac events in patients with acute coronary syndromes Core Evid. 2011; 6: 31–42. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065559/
  13. ^ Serebruany VL, Atar D. Viewpoint: Central adjudication of myocardial infarction in outcome-driven clinical trials—Common patterns in TRITON, RECORD, and PLATO? Thromb Haemost 2012; DOI: 10.1160/TH12-04-0251. http://www.theheart.org/article/1433145/print.do
  14. ^ Miller, R (24 February 2010). “Is there too much excitement for ticagrelor?”. TheHeart.org.
  15. ^ H. Spreitzer (17 January 2011). “Neue Wirkstoffe – Elinogrel” (in German). Österreichische Apothekerzeitung (2/2011): 10.
  16. ^ July 20, 2011 AstraZeneca: Ticagrelor (Brilinta) Gains FDA Approval Larry Husten cardiobrief.org/2011/07/20/astrazeneca-ticagrelor-brilinta-gains-fda-approval/

SOURCE:

 http://en.wikipedia.org/wiki/Ticagrelor

Read Full Post »

Reporter: Aviva Lev-Ari, PhD, RN

http://www.elsevierbi.com/mkt/conf/fda-cms/2012?elsca1=fda&elsca2=fdafierce112612&utm_source=fda&utm_medium=fda&utm_campaign=%20fierce112612

The FDA/CMS Summit For Biopharma Executives
2013: Year One For PDUFA V – And The Last Chance To Prepare For Health Reform

The Affordable Care Act is a go, after surviving Supreme Court review mostly intact—and especially after the re-election of Barack Obama as President. For the biopharma industry, that means preparing to reap the benefits of insurance market expansion that industry has already paid billions of dollars for in rebates, discounts and fees. The new markets start up in 2014. That means 2013 is the last chance to prepare.

But 2013 is also the first full year to adjust to the new rules for new drug reviews at FDA and adjust to important changes ushered in by the FDA Safety & Innovation Act of 2012. And it is also the year when deficit reduction will be tops on Congress’ agenda.

What will all this mean for you and your company? Come to The Pink Sheet and The RPM Report’s FDA/CMS Summit for Biopharma Executives on December 10-11 in Washington DC to hear from FDA and industry leaders about how health reform implementation will (and won’t) change the rules of the road for drug development and commercialization.

Our jam-packed two-day agenda will also tackle urgent topics like:

        • Drug reviews and PDUFA
        • The evolving biosimilars pathway in the US
        • The implementation of the FDA Safety & Innovation Act
        • The changing rules of pharmaceutical marketing
        • Creation of new generic drug and biosimilar user fee programs
        • And much, much more!

Don’t be caught unprepared. Join us at the eighth annual FDA/CMS Summit for Biopharma Executives.

Last year was standing room only and spaces are limited so please register now!

Key Benefits for Attending FDA/CMS Summit:

  • Hear about critical trends and changes so you can create successful strategies for dealing with FDA and CMS
  • Walk away with practical, real life lessons from some of the most experienced pharmaceutical and biotechnology executives on how they handle regulatory obstacles
  • Get face-to-face access to the top regulatory thought leaders and policy makers
  • Benchmark your regulatory strategy against all the major pharmaceutical and biotech companies

 

Here is what your peers have to say about FDA/CMS Summit:

“I would like to thank the whole Windhover/RPM team for putting together this conference. Conferences are made by its participants and the group assembled here today is so diverse and truly experienced.” – Mark McClellan, MD/PhD, Former FDA Commissioner and CMS Administrator

 

 

2012 FDA/CMS Summit Preliminary Agenda

December 10 & 11, 2012

Mayflower Hotel
1127 Connecticut Avenue NW
Washington, DC 20036

 

Monday, December 10, 2012
7:00-8:00am Registration and Continental Breakfast
8:00am Welcome and Opening Remarks

Michael McCaughan
Editor, The RPM Report
Founding Member, Prevision Policy LLC

8:15-9:00am  

KEYNOTE ADDRESS: Priorities for FDA’s Drug Center in 2012

Douglas Throckmorton, MD
Deputy Director
Center for Drug Evaluation & Research
Food & Drug Administration (FDA)

9:00-10:30am  

The New Rules of New Drug Reviews: A Roundtable

FDA’s top new drug and drug safety officials join industry leaders to discuss trends in the new drug review process and the changes enacted by the Prescription Drug User Fee Act reauthorization.

John Jenkins, MD
Director
Office of New Drugs
Food & Drug Administration (FDA)

Gerald Dal Pan, MD
Director
Office of Surveillance & Epidemiology
Food & Drug Administration (FDA)

Richard Pops
CEO
Alkermes

Francois Nader, MD
President and CEO
NPS Pharmaceuticals

Kay Holcombe
Senior Policy Advisor
Genzyme

Moderator: 
Kate Rawson
The RPM Report
Prevision Policy

10:30-11:00am  

Networking Break

11:00-12:00pm 2012 Elections: Implications for Pharma

What to expect from the new Administration and the new Congressional line-up for 2013.

John McManus
President
The McManus Group

Tracy Spicer
Partner
Avenue Solutions

Jeff Forbes
Partner
Forbes-Tate

Presenter/Moderator:

Marc Samuels
Founding Member & President
Hillco Health

12:00-1:00 pm  

Lunch

 

1:15-2:00pm

 

 

Fireside Chat

Jonathan Blum
Principal Deputy Administrator
Centers for Medicare & Medicaid Services (CMS)

 

2:00pm-3:30 pm

 

 

Hot Topics in Health Reform

The politics of health care reform aside, biopharma companies need to prepare for changes in the US health care system that emphasis quality and affordability of care. This session will feature presentations on different aspects of the upcoming changes in payment and delivery of care and how they will affect pharma.

 

Health Reform and The Climate for Innovation

Ron Cohen, MD
President and CEO
Acorda Therapeutics, Inc.What is Essential in Essential Health Benefits?

Ian Spatz 
Senior Advisor
Manatt Health Solutions

Medication Adherence in the Context of Health Reform

William Shrank, MD, MSHS 
Director
Rapid-Cycle Evaluation Group
Centers for Medicare & Medicaid Services (CMS)

 

Commercial Implications of Health Reform

Will Suvari
Vice President
Campbell Alliance

Moderator:
Michael McCaughan
Editor, The RPM Report
Founding Member, Prevision Policy LLC

 

3:30-4:00pm  

Networking Break

4:00-4:30pm  

Keynote: Implementing Reform
Joshua Sharfstein
Secretary
Maryland Department of Health
Former Deputy Commissioner
Food & Drug Administration (FDA)

4:30-5:00pm Closing Keynote: Reimbursable Labeling

Chuck Stevens
Vice President
PAREXEL

5:30-7:30pm Cocktail Reception
Tuesday, December 11, 2012
7:00-8:00am Registration and Continental Breakfast
8:00-8:30am  

 

KEYNOTE ADDRESS

Robert J. Hugin
Chairman and CEO
Celgene Corporation

8:30-9:45am  

Biosimilars Update

Mark A. McCamish, MD, PhD
Global Head of Biopharmaceutical Development
Sandoz International

Diem Nguyen
General Manager, Biosimilars
Emerging Markets/Established Products Business Unit
Pfizer Inc.

Leah Christl, PhD
Associate Director for Biosimilars
Office of New Drugs
Center for Drug Evaluation & Research
Food & Drug Administration (FDA)

9:45-10:00am Networking Break
10:00-11:15am  

Reinventing the Approval Pathway

PDUFA V makes important changes in drug regulation, but it doesn’t fundamentally change the standard for new drug approvals. Is it time for the US to consider moving to new models like progressive approval/adaptive licensing?

 

Mary Ellen Cosenza
Executive Director Regulatory Affairs and North America Regulatory Head
Amgen, Inc.

Steven Nissen, MD, MACC
Chairman, Department of Cardiovascular Medicine
The Cleveland Clinic Foundation

 

Barry Sickels, Ph.D.
Vice President, Regulatory Affairs and Wilmington R&D Site Leader
AstraZeneca

Moderator:
Cole Werble
Editor, The RPM Report
Founding Member, Prevision Policy LLC

 

11:15-12:00pm  

A Regulator’s Perspective

Robert Temple, MD
Deputy Director for Clinical Science
Center for Drug Evaluation & Research
Food & Drug Administration (FDA)

Moderator
Ramsey Baghdadi
The RPM Report
Founding Member, Prevision Policy

12:00-1:00pm Lunch – Sponsored by
1:00-1:45pm  

CMS Coverage Priorities: CED, NCDs and Parallel Reviews

The Medicare agency is moving forward with innovative models to use coverage policy to encourage development of better evidence for new technologies. Devices are the primary focus, but drugs won’t be far behind.

Louis Jacques, MD
Director
Coverage & Analysis Group Office of Clinical Standards and Quality
Centers for Medicare & Medicaid Services (CMS)

Tamara Syrek Jensen, JD 
Deputy Director
Coverage and Analysis Group
Office of Clinical Standards and Quality
Centers for Medicare & Medicaid Services (CMS)

Moderator
Ramsey Baghdadi
The RPM Report
Founding Member, Prevision Policy

1:45-3:00pm Right-Sizing the Demands for Evidence

FDA’s pre-market and post-market regulatory demands are increasing, and so are the expectations of public and private payors for “real world” comparative effectiveness data. How can policy makers and biopharmaceutical companies work together to assure that the need for evidence doesn’t overwhelm the capacity of innovators?

Jonathan Leff
Managing Director, Healthcare
Warburg Pincus

Martin Marciniak
Vice-President, US Health Outcomes
GlaxoSmithKline

Moderator:
Gillian Woollett

Vice President
Avalere Health

3:00-3:15pm Networking Break
3:15-4:30pm The New Generic Drug Era

The Generic Drug User Fee Act will usher in a new era for the generic drug industry, one with greater emphasis on global production quality and tough-to-copy products. What will the new era bring?

Gregory Geba
Director
Office of Generic Drugs
Food & Drug Administration (FDA) 

David Gaugh
VP-Regulatory Sciences
Generic Pharmaceutical Association

Gary Buehler
Vice President-Regulatory Strategic Operations
Teva Pharmaceuticals

Lara Ramsburg
VP-Government Relations
Mylan Inc.

Moderator:
Nancy Myers
President
Catalyst Healthcare

4:30-5:00pm A Fireside chat with:

Geno Germano
President
Pfizer Specialty Care and Oncology

2012 FDA/CMS Speakers

   
  Douglas Throckmorton, MD

Deputy Director, FDA Center for Drug Evaluation & Research

Food & Drug Administration (FDA)

Douglas C. Throckmorton, MD is the Deputy Director of the Center for Drug Evaluation and Research (CDER), FDA. In this role, he shares responsibility for overseeing the regulation of research, development, manufacture and marketing of prescription, over-the-counter and generic drugs in the U.S. Previously, he served as the Director of CDER’s Division of Cardiovascular and Renal Drug Products (DCRDP). Dr. Throckmorton joined DCRDP in 1997 as a Medical Officer, was promoted to Deputy Director in 2000 and to the Director position in 2002. Prior to joining FDA, he practiced medicine and held academic appointments at the Medical College of Georgia and the VA Medical Center in Augusta, GA. Dr. Throckmorton received an undergraduate degree in English and Chemistry from Hastings College and is Board-certified in Internal Medicine and Nephrology, having received his training at the University of Nebraska Medical School, Case Western Reserve University and Yale University.

   
  Robert J. Hugin

Chairman and CEO

Celgene Corporation

Mr. Hugin serves as Chairman and Chief Executive Officer of Celgene Corporation, a biopharmaceutical company focused on the discovery, development and commercialization of innovative therapies for unmet medical needs in cancer and immune-inflammatory disease. He joined Celgene in June 1999 and has been a Director of Celgene since December 2001. Mr. Hugin also serves as a Director of The Medicines Company, Atlantic Health System, Inc. and of Family Promise, a national non-profit network assisting homeless families. He serves on the Board of Trustees of Princeton University and is Chairman-Elect of The Pharmaceutical Research and Manufacturers of America. He also serves on the Board of Trustees of The Darden Foundation, University of Virginia as well as a founding Board member of Choose NJ. Prior to joining Celgene, Mr. Hugin was a Managing Director with J.P. Morgan & Co. Inc. Mr. Hugin received an AB degree from Princeton University in 1976 and an MBA from the University of Virginia in 1985 and served as a United States Marine Corps infantry officer during the intervening period. Bob and his wife Kathy have three children and live in Summit, New Jersey.

   
  John Jenkins, MD

Director, Office of New Drugs

Food and Drug Administration (FDA)

Dr. Jenkins is currently the Director of the Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration.  Dr. Jenkins received his undergraduate degree in biology from East Tennessee State University in 1979 and his medical degree from the University of Tennessee at Memphis in 1983.  Dr. Jenkins completed his postgraduate medical training in internal medicine, pulmonary disease, and critical care medicine at Virginia Commonwealth University/Medical College of Virginia from 1983 until 1988.  Dr. Jenkins is Board Certified in Internal Medicine and Pulmonary Diseases by the American Board of Internal Medicine.  Dr. Jenkins is also a Fellow of the American College of Chest Physicians.  Following completion of his medical training, Dr. Jenkins joined the faculty of MCV as an Assistant Professor of Pulmonary and Critical Care Medicine and as a Staff Physician at the McGuire VA Medical Center in Richmond.  Dr. Jenkins joined FDA as a medical officer in the Division of Oncology and Pulmonary Drug Products in 1992.  He subsequently served as Pulmonary Medical Group Leader and Acting Division Director before being appointed as Director of the newly created Division of Pulmonary Drug Products in 1995.  Dr. Jenkins became the Director of the Office of Drug Evaluation II in 1999 and served in that position until he was appointed to his current position in January 2002.

   
  John McManus

President

The McManus Group

John McManus is President and founder of The McManus Group, a consulting firm specializing in policy and political counsel for health care clients with issues before Congress and the Administration. The McManus Group services clients from the pharmaceutical, biotechnology and medical device industries, the physician organization and employee benefits managers.

Prior to founding The McManus Group in 2004, McManus served Chairman Bill Thomas as the Staff Director of the Ways and Means Health Subcommittee, where he led the policy development, negotiations and drafting of the Medicare Prescription Drug, Improvement and Modernization Act of 2003. The MMA provided a market-based, comprehensive prescription drug benefit, reformed Medicare and established Health Savings Accounts. McManus worked for Chairman Thomas for six years, where he also played an instrumental role in the Medicare Commission, Patients’ Bill of Rights and other Medicare legislation.

Before working for Chairman Thomas on Capitol Hill, McManus worked for Eli Lilly & Company as a Senior Associate from 1994-97 and for the Maryland House of Delegates from 1993-94 as a Research Analyst, briefing the Chairman of the Economic Matters Committee and the members of the Health Subcommittee.

McManus earned his Master of Public Policy from Duke University and Bachelor of Arts from Washington and Lee University.

   
  Tracy Spicer

Partner

Avenue Solutions

Avenue Solutions’ founding partner Tracy Spicer is a 20-year veteran of political campaigns at every level.  Ms. Spicer began her involvement in politics in 1992 in former U.S. Senator Edward M. Kennedy’s Senate office before transitioning to his campaign staff in 1994 to assist in his successful re-election campaign against Mitt Romney.  Since that time, she has worked with and coordinated numerous campaigns, ranging from municipal and state candidates to the U.S. Congress as well as the White House.

Ms. Spicer served as a longtime aide to former Senator Kennedy, quickly rising to Political Director and Deputy Chief of Staff.  During her decade of experience on Capitol Hill, she coordinated successful political and legislative strategies for Senator Kennedy.  Ms. Spicer managed Senator Kennedy’s legislative priorities in the areas of healthcare, education, labor and economic development and strategically worked with Democratic Senators and their political campaign committees to position legislative priorities for political success.

Ms. Spicer is widely recognized for her political acumen and expertise in designing legislative and regulatory strategies and her established network of long-standing professional contacts among elected officials, appointed policymakers and their staffs.  She draws on her vast political and legislative experience to help clients in navigate the labyrinth of Capitol Hill and government bureaucracy and to position them strategically to head off obstacles, find common ground and achieve success.

As founding partner of Avenue Solutions, Ms. Spicer advises a broad array of clients, including Fortune 100 companies, non-profit organizations, associations and coalitions.  She is particularly noted for her expertise in healthcare policy.  On behalf of her clients, Ms. Spicer has played a leading role in the consideration, negotiation and implementation of the Affordable Care Act (healthcare reform); Medicare and Medicaid legislation; healthcare information technology initiatives; mental health parity legislation; genetic non-discrimination legislation; small business incentive proposals; and prescription drug coverage legislation.

Ms. Spicer is a graduate of Hobart and William Smith Colleges in Geneva, NY where she earned her bachelor’s degree in Political Science.  She is married to George Spicer and has three children, Dylan, Tess and Callie and a loveable, albeit irreverent dog, Linus.

   
  Jeff Forbes

Partner

Forbes-Tate

Founding partner Jeff Forbes is a twenty-year veteran of political campaigns at every level.  Mr. Forbes began his involvement in politics in 1987 on then Senator Al Gore’s 1988 Presidential bid.  Since that time, he has worked with and coordinated more than nine different campaigns, ranging from municipal candidates to the US Congress as well as the White House.

Mr. Forbes served most recently as the Democratic Staff Director for the US Senate Committee on Finance in 2003.  Before assuming this role at the Committee, he served as chief of staff to Senator Max Baucus from 1999-2002.  Beyond his knowledge of the intricacies of tax and trade, Forbes is a veteran strategist for the Democratic National Committee.  From 1993-1995 he served as Midwest Political Director.  Mr. Forbes later served the national committee as Chief of Strategy in 1999.

A stalwart of Clinton-Gore Administration, Mr. Forbes was the New Hampshire Field Director for then Gov. Clinton’s 1992 Presidential campaign.  In President Clinton’s 1996 re-election bid, Forbes was Deputy Political Director and Director of Delegate Selection.  Following the campaign, Mr. Forbes went on to serve as a Special Assistant to the President and Staff Director for Legislative Affairs in 1997.  From 1998-99, Mr. Forbes served as the Deputy Assistant to President Clinton and was the Deputy Director of Scheduling at the White House.

Mr. Forbes is married to Linda Moore Forbes.  He earned a BA in Political Science with an Economics minor from Denison University in Granville, Ohio, in 1987.

   
  Gerald Dal Pan, MD

Director, Office of Surveillance & Epidemiology

Food and Drug Administration (FDA)

Gerald J. Dal Pan, MD, MHS is the Director of the Office of Surveillance and Epidemiology (formerly known as the Office of Drug Safety) in FDA’s Center for Drug Evaluation and Research, a position he has held since November 2005. From December 2003 through November 0225, he was the Director of the Division of Surveillance, Research, and Communication Support in CDER’s Office of Drug Safety. He received his medical degree from Columbia University, and his Master’s degree in clinical epidemiology from Johns Hopkins University. He trained in Internal Medicine at the Hospital of the University of Pennsylvania, and in Neurology at Johns Hopkins Hospital. He is board certified in Internal Medicine and Neurology. He was an instructor in the Neurology Department at Johns Hopkins. He next worked for Guilford Pharmaceuticals in Baltimore, and then for HHI Clinical Research and Statistical Services in Hunt Valley, MD. He joined the FDA in July 2000 as a medical officer in the Division of Anesthetic, Critical Care, and Addiction Drug Products.

   
  Louis Jacques, MD

Director, Coverage & Analysis Group Office of Clinical Standards and Quality

Centers for Medicare & Medicaid Services (CMS)

Dr Jacques joined CMS in 2003 and has been director of the Coverage and Analysis Group (CAG) since October 2009.  The group reviews evidence and develops Medicare national coverage policy. From 2004 through 2009 he was Director of the Division of Items and Devices within CAG.

Prior to his arrival at CMS, Dr. Jacques was the Associate Dean for Curriculum at Georgetown University School of Medicine, where he retains a faculty appointment.  He served on a number of university committees including the Executive Faculty, Committee on Admissions and the Institutional Review Board.  He previously worked in the Palliative Care program at Georgetown’s Lombardi Cancer Center where he covered the gynecologic oncology service and he made home visits as a volunteer physician for a rural hospice on the Maryland Eastern Shore.

   
  Steven Nissen
Chairman, Department of Cardiology
The Cleveland Clinic Foundation

Steven Nissen, MD, is the Chairman of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine located on the main campus of Cleveland Clinic. He was appointed in 2006. Prior to this, he served nine years as Vice-Chairman of the Department of Cardiology and five years as Medical Director of the Cleveland Clinic Cardiovascular Coordinating Center (C5), an organization that directs multicenter clinical trials.

Dr. Nissen’s research during the last two decades has focused on the application of intravascular ultrasound (IVUS) imaging for the assessment of progression and regression of coronary atherosclerosis. He has served as International Principal Investigator for several large IVUS multi-center atherosclerosis trials.

Contributions to scientific literature include more than 350 journal articles and 60 book chapters including many manuscripts in NEJM andJAMA. In recent years, he has also written on the subject of drug safety and was the author of manuscripts highlighting concerns about the COX-2 inhibitors (Vioxx™), muraglitazar and rosiglitazone (Avandia™).

Other contributions include current service as editor of Current Cardiology Report, and senior consulting editor to the Journal of the American College of Cardiology.

Dr. Nissen’s national positions include:

One-year term as president of the American College of Cardiology (ACC) from March 2006 to March 2007. He served on the ACC Executive Committee 2004-2008. He served 10 years as a member of Board of Trustees of the ACC. He has served several terms on the Program Committee for ACC Annual Scientific Sessions.

Dr. Nissen served as a member of the CardioRenal Advisory Panel of Food and Drug Administration (FDA) for five years, and as chair of the final year of his membership. He continues to serve as a periodic advisor to several FDA committees as a Special Government Employee.

Dr. Nissen is a frequent lecturer before national and international meetings. He has served as visiting professor, or provided Grand Rounds, at nearly 100 institutions.

   
  Richard Pops 

CEO

Alkermes

Richard Pops serves as Chairman and Chief Executive Officer of Alkermes. He joined Alkermes as CEO in 1991. Under his leadership, Alkermes has grown from a privately held company with 25 employees to an international, publicly traded biopharmaceutical company with more than 1,200 employees and a portfolio of more than 20 commercial products. Mr. Pops currently serves on the Board of Directors of Neurocrine Biosciences, Acceleron Pharma, Epizyme, the Biotechnology Industry Organization (BIO), the Pharmaceutical Research and Manufacturers of America (PhRMA) and is also a member of the Harvard Medical School Board of Fellows.

   
  Francois Nader, MD

President and CEO

NPS Pharmaceuticals

Francois Nader, MD, has been president and chief executive officer of NPS Pharmaceuticals since March 2008. During his tenure he transformed NPS into a leading biopharmaceutical company focused on orphan treatments for patients with rare diseases.

Dr. Nader is a 25-year veteran of the healthcare industry. Dr. Nader joined NPS in 2006 as chief medical and commercial officer. He was promoted to chief operating officer in 2007 and named a director in January 2008. Previously, he was a venture partner at Care Capital, LLC and chief medical officer of its Clinical Development Capital unit. He was also senior vice president, integrated healthcare markets and North America medical and regulatory affairs with Aventis Pharmaceuticals, serving on the North America Leadership Team (NALT), and held senior executive positions at its predecessor companies, Hoechst Marion Roussel and Marion Merrell Dow. Prior, Dr. Nader served as head of global commercial operations at the Pasteur Vaccines division of Rhone-Poulenc.

Dr. Nader served as director for Noven Pharmaceuticals and currently serves as treasurer and trustee of Bio NJ, New Jersey’s trade association for the biotechnology community and as trustee of the Healthcare Institute of New Jersey (HINJ), a trade association for the research-based pharmaceutical and medical technology industry in New Jersey.

Dr. Nader received a French State Doctorate in Medicine from St. Joseph University (Lebanon) and a Physician Executive MBA from the University of Tennessee.

   
  Diem Nguyen
General Manager, Biosimilars

Emerging Markets/Established Products Business Unit

Pfizer Inc.

Diem Nguyen is General Manager, Biosimilars for the Emerging Markets/Established Products Business Units. As General Manager Biosimilars, Diem Nguyen is the driving a core component of the EPBU strategy through the development and commercialization of a portfolio of post-LOE biologics through close collaboration with WRD’s Biosimilars Development Unit. Prior to this position, Diem held the position of VP, Strategy for EPBU where she was responsible for developing growth strategies for the off patent market.

Before Pfizer, Diem was a consultant for Danaher, a leading industrial and life sciences company. In 2004, she was appointed Senior Director of Corporate Development and Biotechnology at Serologicals Corporation, where she worked directly with the CEO, CFO and the Board of Directors and led enterprise level strategic planning and external development efforts. Her responsibilities included strategic planning, leading corporate development efforts and investor relations. In 2003, she took on the role of Director of Strategic Marketing, Research and Biotechnology at the Upstate Group, Inc. Diem has also previously held positions at Deloitte Consulting as a life sciences consultant and the University of Virginia Health Sciences Center as a medical researcher.

Diem received a B.A. and a Ph.D. in Biochemistry and Molecular Genetics from the University of Virginia. She attended Darden Graduate School of Business Administration, where she earned her MBA.

   
  Jonathan Blum

Principal Deputy Administrator

Centers for Medicare & Medicaid Services (CMS)

Jonathan Blum, Acting Principal Deputy Administrator and Director of the Center for Medicare at the Centers for Medicare and Medicaid Services (CMS), is responsible for overseeing the regulation and payment of Medicare fee-for service providers, privately-administered Medicare health plans, and the Medicare prescription drug program.  The benefits pay for health care for approximately 45 million elderly and disabled Americans, with an annual budget in the hundreds of billions of dollars.

Over the course of his career, Jonathan has become an expert in the gamut of CMS programs.  He served as an advisor to Senate Finance Committee members and its current chairman, Sen. Max Baucus, where he worked on prescription drug and Medicare Advantage policies during the development of the Medicare Modernization Act.  He focused on Medicare as a program analyst at the White House Office of Management and Budget.  Prior to joining CMS, Jonathan was a Vice President at Avalere Health, overseeing its Medicaid and Long-Term Care Practice.

Most recently, Jonathan served as a health policy advisor to the Obama-Biden Transition Team.  He holds a Master’s degree from the Kennedy School of Government and a BA from the University of Pennsylvania.

   
  Ian Spatz
Senior Advisor

Manatt Health Solutions

Mr. Spatz is a Senior Advisor in the national healthcare practice of Manatt, Phelps & Phillips, LLP and Manatt Health Solutions.  Mr. Spatz provides highly experienced insights into ongoing health reform efforts, helps develop public and private strategies and guidance on a broad array of issues affecting healthcare providers and insurers, pharmaceutical companies, the consuming public and U.S. healthcare initiatives generally, as well as the development and implementation of communication and advocacy efforts at the federal and state levels. Among his areas of expertise are national healthcare policies and programs; pharmaceutical pricing, including Medicare and Medicaid; intellectual property protection; and policies related to the U.S. Food and Drug Administration’s regulation of the research, approval, manufacturing and marketing of medicines.

Mr. Spatz is also the founder and principal of the policy consulting firm Rock Creek Policy Group, LLP.  Beforefounding Rock Creek Policy Group, Mr. Spatz served for 15 years in increasingly responsible positions with Merck & Co., Inc., one of the world’s leading research-based pharmaceutical and vaccine companies.  As Merck’s Vice President for Global Health Policy, he directed U.S. public policy and related public affairs activities and represented the company before Congress, the Administration, and to the media.  He also directed grassroots, employee communications and political action programs.

While at Merck, Mr. Spatz led the successful five-year campaign that helped to develop and gain enactment of the Medicare prescription drug benefit, providing millions of American elderly and persons with disabilities with drug insurance for the first time.  He promoted legislation to create the highly successful program of market exclusivity incentives for research on the pediatric uses of medicines and guided company efforts that resulted in resolution of international trade dispute on the licensing of medicines in the developing world.

Before joining Merck, Mr. Spatz served as Legislative Director for U.S. Senator Frank Lautenberg (D-NJ).  In that role, he directed the Senator’s legislative staff including developing and supervising the implementation of legislative strategies, proposal drafting and floor action.  During his tenure, he coordinated the successful development and passage of two transportation appropriations bills.  He began his career in the nonprofit sector where he led the public policy and government affairs activities of the National Trust for Historic Preservation, the nation’s leading heritage conservation organization. While with the National Trust, he conceived the highly successful Eleven Most Endangered Historic Places list that has served as a model public relations tool for many conservation organizations.  He advocated successfully for the creation of the transportation enhancements funding in the Intermodal Surface Transportation Act (ISTEA) that has resulted in more than $8 billion in spending on conservation projects.

   
  Kate Rawson
The RPM Report
Prevision Policy LLC

Kate Rawson is a Senior Editor at The RPM Report. She was formerly an editor at “The Pink Sheet” where she covered drug regulation and reimbursement issues. During her ten-year tenure at FDC Reports and Elsevier Business Intelligence, she helped launch “The Pink Sheet DAILY,” and served as Managing Editor of “The Rose Sheet,” which covers regulatory and business news of the cosmetics industry.

   
  Michael McCaughan
Founding Member
Prevision Policy LLC

Michael McCaughan is a founding member of Prevision Policy LLC and an editor with The RPM Report. He was formerly editor-in-chief of EBI’s biopharma editorial group. McCaughan has 20 years of experience providing analysis and insight for EBI’s products, including The Pink Sheet, The Pink Sheet DAILY and The RPM Report. He speaks frequently on regulatory and policy developments affecting the industry.

   
  Ramsey Baghdadi
Founding Member
Prevision Policy LLC

Ramsey Baghdadi is a founding member of Prevision Policy and an editor with The RPM Report.

   
  Marc Samuels
CEO
HillCo HEALTH

Widely regarded as “effective,” “resourceful,” “tireless,” well prepared” and “irreplaceable,” by clients and colleagues alike Marc Samuels is CEO of HillCo HEALTH, a boutique group of seasoned principals providing advisory services to leading health care delivery, financing, manufacturing, and service entities.

Samuels joined HillCo in 2001 and became a partner in 2004, working both in Austin and Washington, DC. He co-founded HillCo HEALTH soon thereafter. From 1998 to 2000, Samuels served as founder of and a partner in the Health Policy Group, a Washington, D.C.-based healthcare public policy and business strategy firm, along with J. Michael Hudson, former Deputy (and Acting) Administrator of the Centers for Medicare and Medicaid Services (CMS). Prior to that, he held various positions within state and federal government, including advising both former President George Herbert Walker Bush and then-Texas Governor George W. Bush on healthcare issues, as well as serving as Executive Assistant to the Texas Health and Human Services Commission (HHSC).

Samuels is a graduate of The University of Texas School of Law, Yale School of Medicine and the University of Michigan. His comments and analyses have appeared in Medical Economics, Health Systems Review, Journal of Health Care Finance, Disease Management News, the Fort Worth Star-Telegram, the Dallas Morning News, and Texas Medicine. He is a contributor to the third edition of the Managed Care Answer Book and the second edition of the HMO and Capitation Answer Book, published by Panel Publishers, New York.

   
  Ron Cohen, MD
President and CEO
Acorda Therapeutics, Inc

Ron Cohen, M.D., President and CEO, founded Acorda Therapeutics, Inc. in 1995. Previously he was a principal in the startup and an officer of Advanced Tissue Sciences, Inc., a biotechnology company engaged in the growth of human organ tissues for transplantation. Dr. Cohen received his B.A. with honors in Psychology from Princeton University, and his M.D. from the Columbia College of Physicians & Surgeons. He completed his residency in Internal Medicine at the University of Virginia Medical Center, and is Board Certified in Internal Medicine.

Dr. Cohen is a member of the Executive Committee of the Board of the Biotechnology Industry Organization (BIO) and is Chairman of the Emerging Company Section of BIO. He previously served as Director and Chairman of the New York Biotechnology Association (NYBA). He also serves as a member the Columbia-Presbyterian Health Sciences Advisory Council and was awarded Columbia University’s Alumni Medal for Distinguished Service.

Dr. Cohen was named NeuroInvestment’s CEO of the Year and was recognized by PharmaVoice Magazine as one of the 100 Most Inspirational People in the Biopharmaceutical Industry. He is a recipient of the Ernst & Young Entrepreneur of the Year Award for the New York Metropolitan Region and is an inductee of the National Spinal Cord Injury Association’s “Spinal Cord Injury Hall of Fame.” In 2010, Dr. Cohen was recognized by the New York Biotechnology Association as the NYBA “The Cure Starts Here” Business Leader of the Year.

   
  Tamara Syrek Jensen, JD, 
Deputy Director Coverage and Analysis Group (CAG)
CMS

Tamara Syrek Jensen is the deputy director for the Coverage and Analysis Group (CAG) at the Centers for Medicare & Medicaid Services (CMS). CAG develops, interprets, communicates, and updates evidence based national coverage policies. These policies help provide timely access to reasonable and necessary services and technologies to improve health outcomes for Medicare beneficiaries.

Before her current position at CAG, she was the Special Assistant for the CMS Chief Medical Officer and Director of Office of Clinical Standards and Quality (OCSQ). Prior to working at CMS, she worked as a legislative assistant in the U.S. House of Representatives. Tamara is an attorney, licensed in Maryland.

   
  Mark A. McCamish, MD, PhD
Global Head of Biopharmaceutical Development
Sandoz International

Dr. McCamish is the Global Head of Biopharmaceutical Development for Sandoz International, a Division of Novartis. He leads research and development of all biologics at Sandoz Biopharmaceuticals, which is the world leader in development and commercialization of follow-on biologics or biosimilars. His responsibilities include leadership involving selection of the target, cloning, technical development, scale-up, pre-clinical and clinical development and interfaces with regulatory authorities worldwide. He is a senior executive with extensive therapeutic and commercial experience in global pharmaceutical and biotechnology companies. Previously he was Senior VP and Chief Medical Officer at three biotechnology companies and held senior positions at Amgen and Abbott Laboratories. He has held professorships and maintained academic practices at the University of California, Davis and The Ohio State University.He has published broadly in several therapeutic areas in multiple journals including The New England Journal of Medicine, Journal of the American Medical Association, and Lancet.

He earned his bachelor’s and master’s degrees in exercise physiology from the University of California, Santa Barbara. His PhD is in human nutrition from Penn State University and his M.D. is from the University of California, Los Angeles. Dr. McCamish is Board Certified in Internal Medicine and Nutrition and Metabolism and he is licensed as a physician and surgeon in California.

He has published broadly in several therapeutic areas in multiple journals including The New England Journal of Medicine, Journal of the American Medical Association, and Lancet. He earned his bachelor’s and master’s degrees in exercise physiology from the University of California, Santa Barbara. His PhD is in human nutrition from Penn State University and his M.D. is from the University of California, Los Angeles. Dr. McCamish is Board Certified in Internal Medicine and Nutrition and Metabolism and he is licensed as a physician and surgeon in California.

   
  William Shrank, MD, MSHS
Director of the Rapid-Cycle Evaluation Group
CMS

William Shrank, MD, MSHS, is the Director of the Rapid-Cycle Evaluation Group at the Center for Medicare and Medicaid Innovation at the Centers for Medicare and Medicaid Services. In this capacity, Dr. Shrank leads the evaluation efforts of programs supported by the Innovation Center to reduce the cost and improve the quality of care in the U.S. He also leads the intramural research enterprise at CMS.
Dr. Shrank has served as an Assistant Professor of Medicine at Harvard Medical School and an Associate Physician in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s Hospital. His research is focused on improving the safe, appropriate and cost-effective use of prescription medications. His research interests also include evaluating quality in pharmacologic care, enhancing adherence to chronic medications, and improving prescription drug labels.

Dr. Shrank serves or has served on national advisory committees for the FDA, AHRQ, CMS, USP, and the American College of Physicians Foundation. He attended Brown University, received his M.D. from Cornell University, and trained in Internal Medicine at Georgetown University. He finished a health services research fellowship at UCLA, Rand, and the West Los Angeles VA Hospital where he earned an M.S. in Health Services.

   
  Geno Germano 
President
Pfizer Specialty Care and Oncology

Geno Germano is President and General Manager of Specialty Care and Oncology, Pfizer Inc.

The Specialty Care Business Unit (SCBU) works closely with specialty physicians and stakeholders to provide medicines to help treat a variety of serious and life-threatening conditions. Specialty Care holds leadership positions in vaccines and in key disease areas such as inflammation, infectious disease, hemophilia and ophthalmology. SCBU’s current portfolio includes more than 20 medicines in 11 disease areas, and the pipeline contains more than 25 compounds in late-stage development.

The Oncology Business Unit (OBU) is focused on improving the standard of care for cancer patients globally. With the full scale and scope of Pfizer support, the OBU has made rapid progress, with more than 20 molecules in development for various tumors including lung, breast, prostate, liver, kidney, colon and gastric diseases.

Geno joined Pfizer from Wyeth, where he was President, U.S. and Pharmaceutical Business Units for Wyeth Pharmaceuticals, responsible for its U.S. based Pharmaceuticals, Biologics and Vaccines businesses. In addition, he led Global Strategy for the Pharmaceutical and Institutional business units for major products in Neuroscience, Gastroenterology, Women’s Health, Infectious Diseases and Immunology.

In his more than 25 years in the pharmaceutical industry, Geno has held diverse positions, including Executive Vice President and General Manager for Wyeth Global Vaccines; Managing Director, Wyeth Australia and New Zealand; and Executive Vice President and General Manager of the Pharmaceutical Business Unit. He led numerous key product launches in primary and specialty care in gastroenterology, arthritis, infectious diseases, hemophilia, transplantation and oncology. Prior to joining Wyeth, Geno held leadership positions at several Johnson & Johnson companies.

Geno serves on the Advisory Board of the Healthcare Businesswomen’s Association, is a member of the Board of the Biotechnology Industry Organization and is a Trustee of the Albany College of Pharmacy, where he received his Bachelor of Science degree in Pharmacy in 1983.

   
  Joshua Sharfstein 
Secretary
Maryland Department of Health
Former Deputy Commissioner
Food & Drug Administration

Dr. Joshua M. Sharfstein was appointed by Governor Martin O’Malley as Secretary of the Maryland Department of Health and Mental Hygiene in January 2011.

In March 2009, President Obama appointed Dr. Sharfstein to serve as the Principal Deputy Commissioner of the U.S. Food and Drug Administration. He served as the Acting Commissioner from March 2009 through May 2009 and as Principal Deputy Commissioner through January 2011.

From December 2005 through March 2009, Dr. Sharfstein served as the Commissioner of Health for the City of Baltimore, Maryland. In this position, he led efforts to expand literacy efforts in pediatric primary care, facilitate the transition to Medicare Part D for disabled adults, engage college students in public health activities, increase influenza vaccination of healthcare workers, and expand access to effective treatment for opioid addiction. In 2008, Dr. Sharfstein was named Public Official of the Year by Governing Magazine.

Dr. Sharfstein is a 1991 graduate of Harvard College, a 1996 graduate of Harvard Medical School, a 1999 graduate of the combined residency program in pediatrics at Boston Children’s Hospital and Boston Medical Center, and a 2001 graduate of the fellowship in general pediatrics at the Boston University School of Medicine.

   
  Gillian Woollett 
Vice President
Avalere Health

Gillian Woollett, Vice President, leads the FDA Practice within Avalere’s Center on Evidence-Based Medicine. She provides the “prequel” of scientific and regulatory strategic policy expertise that supports medicinal products gaining approval at the FDA in a manner that allows them to be successful in the public and private reimbursement world. She is building a bridge for Avalere clients from the FDA space into the traditionally separate Centers for Medicare & Medicaid Services and healthcare policy/business world.

Trained as a molecular biologist/immunologist before coming to Washington, Gillian still publishes in peer-reviewed literature on biotechnology topics, and is also a frequent speaker educating on the core prospects and promises of the emerging biosciences and their ability to support better and more focused therapies.

Immediately prior to joining Avalere, Gillian was Chief Scientist at Engel & Novitt, LLP. She was Vice President, Science and Regulatory Affairs at the Biotechnology Industry Organization (BIO), where she established and led a new department to support BIO companies’ interactions with regulatory agencies in all aspects of the discovery, development, and manufacture of biotechnology-based medicines. She joined BIO after being Associate Vice President at the Pharmaceutical Research and Manufacturers of America. She has been an appointee on federal advisory committees to the Centers for Disease Control and Prevention and the Department of Commerce.

Gillian earned her B.A., M.A. in the Natural Sciences Tripos (Biochemistry) from the University of Cambridge, and her D.Phil. in Immunology from the University of Oxford in the United Kingdom.

   
  Robert Temple, MD

Deputy Director for Clinical Science

Center for Drug Evaluation & Research

Food & Drug Administration (FDA)

Dr. Robert Temple is Deputy Center Director for Clinical Science of FDA’s Center for Drug Evaluation and Research and is also Acting Deputy Director of the Office of Drug Evaluation I (ODE-I).     Dr. Temple received his medical degree from the New York University School of Medicine in 1967.    In 1972 he joined CDER as a review Medical Officer in the Division of Metabolic and Endocrine Drug Products.  He later moved into the position of Director of the Division of Cardio-Renal Drug Products.  In his current position, Dr. Temple oversees ODE-1 which is responsible for the regulation of cardio-renal, neuropharmacologic, and psychopharmacologic drug products.  Dr. Temple has a long-standing interest in the design and conduct of clinical trials and has written extensively on this subject, especially on choice of control group in clinical trials, evaluation of active control trials, trials to evaluate dose-response, and trials using “enrichment” designs. He also has a long-standing interest in hepatotoxicity of drugs, having participated in the first detailed FDA-NIH-outside discussion of the subject in 1978.

   
  Jonathan S. Leff

Managing Director

Warburg Pincus

Jonathan S. Leff is a managing director with Warburg Pincus, where he has been a member of the firm’s HealthCare Group since 1996. Mr. Leff is currently a Director of InterMune, ReSearch Pharmaceutical Services, Rib-X Pharmaceuticals, Sophiris Bio and Talon Therapeutics. In addition, he serves on the Executive Committee of the Board of the National Venture Capital Association (NVCA) and leads the NVCA’s life sciences industry efforts as Chairman of NVCA’s Medical Innovation and Competitiveness Coalition, and serves as a member of the Board of the Biotechnology Industry Organization. He is also a member of the Boards of Friends of Cancer Research and the Spinal Muscular Atrophy Foundation and the Board of Advisors of Columbia University Medical Center. Mr. Leff received an A.B. in Government from Harvard University and an M.B.A. from Stanford University.

   
  Lara Ramsburg

Vice President, Government Relations

Mylan

Lara Ramsburg is Vice President of Government Relations for Mylan, the largest global generics company headquartered in the United States. During the Generic Drug User Fee (GDUFA) negotiation process, she participated on behalf of Mylan as a member of the Generic Pharmaceutical Association (GPhA) negotiating team. Lara also previously served as Chief of Staff in Mylan’s Office of the President.

Prior to joining Mylan, Lara was Director of Communications and then Director of Policy for the West Virginia Governor’s Office. She also worked previously for Rowan & Blewitt, an issue and crisis management consulting firm, and media outlet CNN, among other professional experiences. Lara holds a Bachelor of Science in communication from Ohio University and a Master of Science in corporate and professional communication from Radford University.

   
  Nancy Bradish Myers

President

Catalyst Healthcare

Nancy Bradish Myers, JD, is a Washington-based attorney with expertise in health care law and regulation, policy development, government relations and political analysis for investors. She is the President of Catalyst Healthcare Consulting, Inc., a niche consulting firm that provides clients with strategic regulatory insight and advice as they position biopharmaceutical and medical device companies, trade associations, and patient advocacy organizations on regulatory and health policy matters before the FDA and other regulatory agencies.

Ms. Myers has served in FDA’s Office of the Commissioner in various positions, including as Senior Strategic Advisor. She has also served as Special Counsel for Science Policy for PhRMA, Vice Presidential-level political healthcare analyst for a Wall Street financial services firm, Reimbursement Counsel and Director of Government Affairs for BIO, a lobbyist for the Blue Cross Blue Shield Association and staff person to a Member of Congress on Capitol Hill.

She is also an expert on FDA user fees and served as co-editor of the book PDUFA and the Expansion of FDA User Fees: Lessons from Negotiators, published by the Food and Drug Law Institute in 2011.

She is a founding Board member and past-President of the Alliance for a Stronger FDA. This 200-member coalition of former regulators, patient and consumer advocates and industry leaders works with the Administration and Congress to increase FDA federally appropriated funds. She is also a Board member of the FDA Alumni Association and is actively involved in the Food and Drug Law Institute (FDLI) and the Drug Information Association (DIA).

Ms. Myers is the 2012 recipient of FDA’s Distinguished Alumni Award, for outstanding contributions in advancing FDA’s mission, creating a strong coalition to advocate for agency resources, and establishing enduring connections between FDA alumni and staff.  Ms. Myers received her law degree from Temple University School of Law and her undergraduate degree from Duke University.

   
  Leah Christl, PhD

Associate Director for Biosimilars

Office of New Drugs

Center for Drug Evaluation & Research

Food & Drug Administration (FDA)

Dr. Christl is the Associate Director for Therapeutic Biologics in the Office of New Drugs (OND) in the FDA’s Center for Drug Evaluation and Research. Dr. Christl leads the Therapeutic Biologics and Biosimilars Team (TBBT) in OND. TBBT is responsible for ensuring consistency in the regulatory approach and guidance to sponsors regarding development programs for proposed biosimilar biological products and related issues regarding development programs for therapeutic biologics, for developing the procedures and staff training necessary to implement the Biologics Price Competition and Innovation Act of 2009 in a consistent manner across all OND review divisions, and for managing the CDER Biosimilar Review Committee.

Dr. Christl joined the FDA in 2003 as a Regulatory Project Manager in the Division of Over-the-Counter Drug Products. From 2004 – 2008, she was the Chief Regulatory Project Manager in the Division of Nonprescription Clinical Evaluation. Dr. Christl served as the Associate Director for Regulatory Affairs for the Office of Nonprescription Products, now the Office of Drug Evaluation IV, from 2005 – 2010. Prior to joining the FDA, Dr. Christl received her Ph.D. in Molecular and Cellular Biology and Pathobiology – Marine Biomedicine and Environmental Science from the Medical University of South Carolina in Charleston. She also spent 2 years at the University of South Carolina as an Associate Research Professor.

   
  Will Suvari
Vice President
Campbell Alliance

Will Suvari is a Vice President in Campbell Alliance’s Pricing & Market Access practice.  He focuses on commercialization strategy and organizational structure design within the context of the reform-driven evolution of provider and payer markets.   Will brings 20 years of research, industry and consulting experience from his work with life sciences firms, leading provider networks/institutions, as well as national payers.

Prior to joining Campbell Alliance, will was an Associate Partner at Oliver Wyman.  Before Oliver Wyman, Will worked in Deloitte Consulting’s Life Sciences practice.  He worked in various functions at Amgen prior to his career in consulting.

Will holds degrees from Northwestern University in Biochemistry and English Literature.  He has an MBA from The Kellogg Graduate School of Management.

   
  Barry Sickels, Ph.D.

Vice President, Regulatory Affairs and Wilmington R&D Site Leader

AstraZeneca

Barry Sickels is Vice President, Regulatory Affairs at AstraZeneca and the R&D Site Leader for the Wilmington, Delaware campus.  He has more than 25 years experience in the pharmaceutical industry and has worked in discovery research, clinical research and development and, for the past 18 years, Regulatory Affairs. Barry has worked in many therapy areas including oncology, infectious disease, central nervous system, respiratory disease, GI and diabetes. Prior to his current role, Barry served as Vice President and Global Regulatory Therapy Area Leader for Oncology and Infection projects at AstraZeneca.  Barry also previously served as Vice President, Regulatory Affairs, Global Therapy Areas and North America at Pfizer/Wyeth.   Barry earned his BS in biology from Rider University and holds an MS in toxicology/environmental science from Rutgers University. He also holds a Master of Jurisprudence and a Doctorate in Health Law from the Widener University School of Law’s Health Law Institute.

   
  Kay Holcombe

Senior Policy Advisor

Genzyme

Kay Holcombe is Senior Policy Advisor at Genzyme, a Sanofi Company.  From Genzyme’s Washington, DC, government relations office, Kay participates in developing and implementing corporate policies and responses to government regulatory and policy initiatives.  She works with members of Congress and their staffs and with officials of government agencies.

Before joining Genzyme, Kay was Executive Vice President of Policy Directions Inc., a government relations firm specializing in strategic planning and legislative and regulatory advocacy regarding health care and related issues.  She represented a variety of clients in academia and in the pharmaceutical and biotechnology, food, and consumer products industries.

Earlier, she served as professional health legislative staff and senior health policy advisor,  House of Representatives Committee on Energy and Commerce, and professional health staff, Senate Committee on Labor and Human Resources; Deputy Associate Commissioner for Legislative Affairs, Food and Drug Administration; Executive Vice President, Foundation for Biomedical Research; Associate Director for Public Health Legislation, Office of the Assistant Secretary for Legislation,  Department of Health and Human Services; Deputy Associate Administrator for Planning, Evaluation, and Legislation, Health Resources and Services Administration, U.S. Public Health Service; Special Assistant to the Director, Division of Legislative Affairs, National Institutes of Health; Executive Secretary, National Heart, Lung, and Blood Institute National Advisory Council; and researcher, National Institutes of Health.

Kay received her B.S. in chemistry education from the University of Illinois and her M.S. in chemistry from the University of Virginia.  She was elected to Phi Beta Kappa, Phi Kappa Phi, and Iota Sigma Pi.

   
  Martin Marciniak

Vice-President, US Health Outcomes

GlaxoSmithKline

Dr. Marciniak has 13 years of strategic and health outcomes research experience in the pharmaceutical industry, most recently with GlaxoSmithKline.  His experience and leadership has been both Global and US oriented, internally and externally facing, and has included specific therapeutic research focus in the areas of oncology, neurosciences, and cardiovascular disease.  Martin’s research has been published in scholarly journals, and has been presented at both national and international congresses.  In addition to his research activities, he also serves as an ad hoc peer reviewer for scientific journals and research foundations.  Currently, Martin is one of the nonvoting industry representatives to Medicare Evidence Development & Coverage Advisory Committee for the Centers for Medicare and Medicaid Services.

Dr Marciniak has a broad academic career which includes scientific and public policy research, as well as the tactical implementation and strategic management of observational research programs.  He received his Ph.D. in Health Services and Policy Analysis with a concentration in Health Economics from the University of California at Berkeley, and a Masters in Public Policy from the John F. Kennedy School of Government at Harvard University.  His B.S is in Pharmacy from Purdue University.  Additionally, Martin also holds an executive education certificate from the Sloan School of Management at the Massachusetts Institute of Technology focusing on innovation and management.

   
  Charles A. (Chuck) Stevens, JD, MBA

Vice President & General Manager, Commercialization Strategy

PAREXEL Consulting

Mr. Stevens is responsible for leading the practice including managing all reimbursement, market access and commercial strategy consulting, tactical reimbursement support help lines and PAP’s (Patient Assistance Programs) designed to provide workable solutions to support commercial success and patient access to therapy. Mr. Stevens has over 17 years of bio and pharma industry experience, including responsibility for strategic reimbursement, pricing, public and private payer strategy, product distribution/channel management and pharmaco-economics for both commercialized and non-commercialized products at the senior director level.

He has specialized expertise in Hematology, Oncology, HIV/AIDS, Addiction Medicine, Gastroenterology and Urology. He has worked extensively on issues involving the Patient Protection & Affordable Care Act (PPACA), the Medicare Modernization Act (MMA) of 2003, the Single Drug Pricer (SDP) system and obtaining product specific HCPCS codes. In 2006, he was the first person to be successful in obtaining an individual product HCPCS from CMS by making application in advance of FDA product approval, resulting in the specific code being available at time of product launch.

Chuck is a frequent presenter at national conferences, has authored articles on Comparative Effectiveness Research (CER) and has been quoted in publications such as PharmaVoice, FDA Week and the Grey Sheet.

   
  Gregory Geba

Director

Office of Generic Drugs

Food & Drug Administration (FDA)

After nearly a decade at Yale where he was a faculty member in Pulmonary and Critical Care in the School of Medicine, Dr. Geba served in senior-level clinical/managerial positions in the pharmaceutical industry for the past 15 years.  In his most recent position, he served as Deputy Chief Medical Officer for Sanofi US, where he provided medical and scientific leadership and managerial direction to multidisciplinary scientific and regulatory professionals engaged in drug development activities across all therapeutic areas, as well as to the company’s field medical group.

He has contributed to the registration of more than 20 currently marketed drugs or devices across multiple therapeutic areas. In so doing, he successfully employed his working knowledge and demonstrated practical application of drug manufacturing processes, current quality and risk management processes, and standards relevant to FDA’s laws and regulations. He brings extensive clinical research experience, including leading or serving as the key point in filing new drug applications, biologic license applications, and promotional studies comparing efficacy and effectiveness of novel biopharmaceuticals versus standard of care (including regimens containing branded or generic drugs), and has provided or supervised key safety updates and presentations to FDA Advisory Committees. Dr. Geba’s experience also includes leading medical affairs activities while serving in a variety of senior-level positions. His scope of responsibility in those activities included contribution to the design of experimental protocols and assessment of data from pre-clinical, animal, and first-in-human studies; design, implementation, analysis, and interpretation of phase 2a proof-of-concept and 2b dose ranging studies; and production of important comparative effectiveness and safety data when assessing benefit-risk relationships during phase 3, phase 3b, and phase 4 studies.

Dr. Geba received his medical degree from the University of Navarre and his M.P.H. from the Johns Hopkins Bloomberg School of Public Health. He joins OGD to lead the expanding generic program into a reorganization of both structure and process to improve coordination, communication, and efficiency, and to enhance the Office’s ability to ensure that all generic drugs-which make up nearly 80 percent of prescriptions filled in the United States-are safe, effective, of high quality, and interchangeable with the brand name drug product/reference listed drug.

   
  Mary Ellen Cosenza

Executive Director Regulatory Affairs and North America Regulatory Head

Amgen, Inc.

Mary Ellen Cosenza has almost 30 years experience in the Bio-Pharmaceutical Industry, with the last 17 years being at Amgen Inc. Mary Ellen is currently Executive Director of U.S. Regulatory Affairs with Amgen. Her role is to provide management and leadership by overseeing the execution and by providing advice on the development of regulatory strategy and plans for the FDA.  In addition, she supervises the Regulatory Promotion and Material Compliance Group, as well as supervising Amgen Regulatory policy activities and priorities in the U.S.

Prior to taking on the U.S. Regulatory team she managed the International Emerging Markets Regulatory team. She has also served at the Regulatory Therapeutic Area Head for Inflammation and Early Development and overseen the Global Regulatory Writing department.  Prior to joining Regulatory Affairs, Dr. Cosenza was Senior Director of Toxicology where she managed a department of scientists that are involved in the safety assessment of both traditional small molecules and biotechnology products.  She set policy concerning study type, study design, approval of contract laboratories and interacted with FDA and other Boards of Health.

Prior to joining Amgen (1995), Dr. Cosenza worked for the Medical Research Division of American Cyanamid Company (now Pfizer) in Toxicology Research as a Principal Scientist.  At Cyanamid, Dr. Cosenza held several positions including Group Leader of Regulatory Toxicology, Manager of the Quality Assurance Unit for GLPs and GMPs and later managed the Toxicology Operations group.

Mary Ellen received her PhD from St. John’s University, New York.  She recently received her MS in Regulatory Affairs from University Southern California, Los Angeles.  Mary Ellen also teaches a course on Food and Drug Toxicology at USC.

Dr. Cosenza is a Diplomat of the American Board of Toxicology, has her Regulatory Affairs Certification (US and EU) and is a member of the Society of Toxicology (SOT), the American College of Toxicology (ACT), Drug Information Association (DIA) and Regulatory Affairs Professional Society (RAPS).  Mary Ellen was the representative for BIO on the ICH M3 Expert working group for the most recent revision.

   
  David Gaugh

VP-Regulatory Sciences

Generic Pharmaceutical Association

David Gaugh has over 25 years of leadership experience in the Healthcare and Pharmaceutical business and has been an outstanding contributor to the industry over the years. He has been employed by GPhA since February 2012 as the Senior Vice President for Sciences and Regulatory, where he is responsible for the science, regulatory and professional liaison functions between member companies, agencies of the US Government and Legislative bodies. Prior to joining GPhA, David was the Vice President and General Manager of Bedford Laboratories, a Division of Ben Venue Laboratories (a wholly owned subsidiary of Boehringer Ingelheim). David was responsible for Strategic Planning, Financial Management, Business Development, Marketing and Sales for a $500 million multi-source injectable business.

Prior to joining Ben Venue, David was Senior Director, Pharmacy Contracting and Marketing at VHA/Novation; the largest Group Purchasing Organization in the US. Prior to Novation, he was System Director of Pharmacy for St. Luke’s Health-System, a tertiary-care hospital in Kansas City, MO.

David is a registered Pharmacist and is engaged in several pharmacy-related activities such as the ASHP Education and Research Foundation Board of Directors and various Pharmacy Internship and Residency Programs.

   
  Gary Buehler
Vice President-Regulatory Strategic Operations
Teva Pharmaceuticals

Mr.  Buehler is the VP for Regulatory Strategic Operations for Teva Pharmaceuticals.  Prior to joining Teva, he worked for 24 years at the US Food and Drug Administration, starting as a Project  Manager in OND’s Cardio Renal Division.  In 1999, he joined the Office of Generic Drugs as the Deputy Director.  In 2001, after serving for over a year as Acting Director, he became the Director of OGD and served in that position until 2010. Mr. Buehler retired from the U.S. Public Health Service in April of 2000 after serving in a variety of duty stations including Indian Health Service positions in Nevada and Montana.  He graduated from Temple University School of Pharmacy.

 

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