with Sonya Das, Raphael Rousseau, Peter C. Adamson, JAMA Oncology
Importance Few patient populations are as helpless and in need of advocacy as children with cancer. Pharmaceutical companies have historically faced significant financial disincentives to pursue pediatric oncology therapeutics, including low incidence, high costs of conducting pediatric trials, and a lack of funding for early-stage research. Observations Review of published studies of pediatric oncology research and the cost of drug development, as well as clinical trials of pediatric oncology therapeutics at ClinicalTrials.gov, identified 77 potential drug development projects to be included in a hypothetical portfolio. The returns of this portfolio were simulated so as to compute the financial returns and risk. Simulated business strategies include combining projects at different clinical phases of development, obtaining partial funding from philanthropic grants, and obtaining government guarantees to reduce risk. The purely private-sector portfolio exhibited expected returns ranging from −24.2% to 10.2%, depending on the model variables assumed. This finding suggests significant financial disincentives for pursuing pediatric oncology therapeutics and implies that financial support from the public and philanthropic sectors is essential. Phase diversification increases the likelihood of a successful drug and yielded expected returns of −5.3% to 50.1%. Standard philanthropic grants had a marginal association with expected returns, and government guarantees had a greater association by reducing downside exposure. An assessment of a proposed venture philanthropy fund demonstrated stronger performance than the purely private-sector–funded portfolio or those with traditional amounts of philanthropic support. Clinical Relevance A combination of financial and business strategies has the potential to maximize expected return while eliminating some downside risk—in certain cases enabling expected returns as high as 50.1%—that can overcome current financial disincentives and accelerate the development of pediatric oncology therapeutics.
with Shomesh E. Chaudhuri, Martin P. Ho, Telba Irony, and Murray Sheldon, Drug Discovery Today Volume 23, Issue 2, February 2018, Pages 395-401
We apply Bayesian decision analysis (BDA) to incorporate patient preferences in the regulatory approval process for new therapies. By assigning weights to type I and type II errors based on patient preferences, the significance level (a) and power (1 b) of a randomized clinical trial (RCT) for a new therapy can be optimized to maximize the value to current and future patients and, consequently, to public health. We find that for weight-loss devices, potentially effective low-risk treatments have optimal as larger than the traditional one-sided significance level of 5%, whereas potentially less effective and riskier treatments have optimalas below 5%. Moreover,the optimal RCT design, including trial size, varies with the risk aversion and time-to-access preferences and the medical need of the target population.
with Chi Heem Wong, Kien Wei Siah, Biostatistics (2018) 00, 00, pp. 1–14
Previous estimates of drug development success rates rely on relatively small samples from databases curated by the pharmaceutical industry and are subject to potential selection biases. Using a sample of 406,038 entries of clinical trial data for over 21,143 compounds from January 1, 2000 to October 31, 2015, we estimate aggregate clinical trial success rates and durations. We also compute disaggregated estimates across several trial features including disease type, clinical phase, industry or academic sponsor, biomarker presence, lead indication status, and time. In several cases, our results differ significantly in detail from widely cited statistics. For example, oncology has a 3.4% success rate in our sample vs. 5.1% in prior studies. However, after declining to 1.7% in 2012, this rate has improved to 2.5% and 8.3% in 2014 and 2015, respectively. In addition, trials that use biomarkers in patient-selection have higher overall success probabilities than trials without biomarkers.
with Richard T Thakor, Nicholas Anaya, Yuwei Zhang, Christian Vilanilam, Kien Wei Siah, Chi Heem Wong, Nature Biotechnology
Uncertainty surrounding the risk and reward of investments in biopharmaceutical companies poses a challenge to those interested in funding such enterprises. Using data on publicly traded stocks, we track the performance of 1,066 biopharmaceutical companies from 1930 to 2015—the most comprehensive financial analysis of this sector to date. Our systematic exploration of methods for distinguishing biotech and pharmaceutical companies yields a dynamic, more accurate classification method. We find that the performance of the biotech sector is highly sensitive to the presence of a few outlier companies, and confirm that nearly all biotech companies are loss-making enterprises, exhibiting high stock volatility. In contrast, since 2000, pharmaceutical companies have become increasingly profitable, with risk-adjusted returns consistently outperforming the market. The performance of all biopharmaceutical companies is subject not only to factors arising from their drug pipelines (idiosyncratic risk), but also from general economic conditions (systematic risk). The risk associated with returns has profound implications both for patterns of investment and for funding innovation in biomedical R&D.
with Sonya Das, Contemporary Clinical Trials 62 (2017) 168–174
In this case study, we profile the I-SPY 2 TRIAL (Investigation of Serial studies to Predict Your Therapeutic Response with Imaging And molecular anaLysis 2), a unique breast cancer clinical trial led by researchers at 20 leading cancer centers across the US, and examine its potential to serve as a model of drug development for other disease areas. This multicenter collaboration launched in 2010 to reengineer the drug development process to be more efficient and patient-centered.
Accelerating Biomedical Innovation: A Case Study of the SPARK Program at Stanford University, School of Medicine
with Esther S. Kim, Paige M.C. Omura, Drug Discovery Today 22:7 (2017)
Translating academic medical research into new therapies is an important challenge for the biopharmaceutical industry and investment communities, which have historically favored later-stage assets with lower risk and clearer commercial value. The Stanford SPARK program is an innovative model for addressing this challenge. The program was created in 2006 to educate students and faculty about bringing academic research from bench to bedside. Every year, the program provides mentorship and funding for approximately a dozen SPARK ‘scholars,’ with a focus on impacting patient lives, regardless of economic factors. By reviewing the detailed structure, function and operation of SPARK we hope to provide a template for other universities and institutions interested in de-risking and facilitating the translation of biomedical research.
Use of Bayesian Decision Analysis to Minimize Harm in Patient-Centered Randomized Clinical Trials in Oncology
with Vahid Montazerhodjat; Shomesh E. Chaudhuri; Daniel J. Sargent, JAMA Oncology (2017)
There is general agreement in the biomedical community that the development of therapies for certain diseases should take priority. This ethic has motivated legislative initiatives, such as the Orphan Drug Act of 1983, and underpins several important innovations in regulatory approval processes, such as the US Food and Drug Administration’s (FDA) fast-track, breakthrough-therapy, accelerated-approval, and priority-review designations. However, none of these innovations directly address the critical issue of how to incorporate the patient’s perspective in deciding whether a drug candidate should be approved or not. The current approach in clinical trial design is to minimize the chance of ineffective treatment caused by a type 1 error, that is, a false-positive result. However, the arbitrary nature of the threshold for the probability of type 1 error, alpha, raises an ethical question about its justification.A 2.5% threshold may not be appropriate for terminal illnesses that have no effective therapies; such patients may prefer to take a bigger chance on a false-positive result, even if the likelihood of an effective therapy is small. To quote the noted biostatistician Donald Berry, “We should also focus on patient values, not just P values.”
The Food and Drug Administration (FDA) is a remarkable agency, one of the crown jewels of the US government. Its staff and structure are dedicated to safeguarding American public health, and although we sometimes complain about its role as gatekeeper, we all sleep better knowing that our foods and drugs have passed the FDA’s careful scrutiny. Its regulatory scope and process reflect the technical demands of its responsibilities, and the FDA is one of the very few federal agencies that have taken a lead in defining and developing the new field of regulatory science
In response to the senators January 21, 2016 request for comment on their Sovaldi report, February 27, 2016. On behalf of all patients and their family members and friends, thank you for conducting the study on the pricing strategy of Gilead Sciences and shining a spotlight on the issue of drug pricing. When access to life-saving therapies is limited by affordability, important moral and ethical issues must be considered in addition to economic and political ones. For too long, we in the United States have ignored these issues for fear of “death panels” and difficult end-of-life decisions. But the growing number of breakthrough therapies and the rising cost of healthcare will soon force us to confront these issues directly. Your report and is an important step in helping us to develop a rational, ethical approach to dealing with this looming challenge.
with Vahid Montazerhodjat and David Weinstock, Science Translational Medicine 8(2016), 327ps6
A crisis is building over the prices of new transformative therapies for cancer, hepatitis C virus infection, and rare diseases. The clinical imperative is to offer these therapies as broadly and rapidly as possible. We propose a practical way to increase drug affordability through health care loans (HCLs)—the equivalent of mortgages for large health care expenses. HCLs allow patients in both multipayer and single-payer markets to access a broader set of therapeutics, including expensive short-duration treatments that are curative. HCLs also link payment to clinical benefit and should help lower per-patient cost while incentivizing the development of transformative therapies rather than those that offer small incremental advances. Moreover, we propose the use of securitization—a well-known financial engineering method—to finance a large diversified pool of HCLs through both debt and equity. Numerical simulations suggest that securitization is viable for a wide range of economic environments and cost parameters, allowing a much broader patient population to access transformative therapies while also aligning the interests of patients, payers, and the pharmaceutical industry.