Clifford Goodman, Ph.D., vp at The Lewin Group and chair of the Medicare Evidence Development & Coverage Advisory Committee, emphasized the importance of comparative effectiveness research (CER) and its role in advancing personalized medicine. CER requires a direct comparison of alternative interventions—head-to-head comparisons of new treatments against standards of care, not placebo—and reporting of health outcomes. It is not sufficient to rely on response rates or increased/decreased levels of surrogate biomarkers as indicators of efficacy.
“Personalized medicines must show that an intervention has some direct, or at least demonstrably indirect, favorable impact on health outcomes in real-world practice settings,” said Dr. Goodman.
Furthermore, “for CER to contribute to personalized medicine, it will have to emphasize priorities and study designs that account for individuals’ genetic, behavioral, environmental, and other personal traits,” he added. “CER needs to incorporate subgroup analyses,” as mean effects derived from an entire trial population are not necessarily indicative of a treatment’s effect in an individual or subpopulation (a concept known as heterogeneity of treatment effects).
Representatives of Dendreon shared the company’s experiences and strategies in the development and ongoing commercial roll-out of Provenge. The therapy is derived from peripheral blood mononuclear cells obtained by leukapheresis and activated with a combination of recombinant prostatic acid phosphatase and granulocyte-macrophage colony-stimulating factor to yield CD54+ T cells that are expanded ex vivo and returned to the patient.
Michael Covington, Dendreon’s CMC director, regulatory affairs, spoke about the need to demonstrate that a product made at multiple manufacturing sites is the same. To limit the need for repeated batch-to-batch testing, Covington suggested instead that product comparability can be demonstrated by documenting comparability of the GMP systems in place at different facilities and by thorough product characterization.
Robert Preti, Ph.D., is president and CSO at Progenitor Cell Therapy, a CMO that produced Provenge for use in Dendreon’s Phase II and III trials. He stressed the value of having a well-characterized product and of building in desirable traits, such as longer shelf-life, earlier in development. He said there’s no need to recreate the wheel when facing the challenges of commercial development of autologous cell therapies. There is much to be learned from the blood industry and from the experiences of antibody and biopharmaceutical manufacturers, he noted.
David Smith, head of global therapeutic cell solutions at Lonza, described the company’s work on allogeneic cell therapy beginning in 2008 and the strategies devised to reduce the cost of goods and bring down the initial $500 per dose cost of an allogeneic cell therapy. By optimizing scaleup, facility design and utilization, and downstream processing, Lonza is now able to manufacture the product for less than $250/dose.
Lonza is now applying a similar strategy to the production of autologous cell therapy products. The company recently constructed cGMP high-throughput manufacturing facilities in Walkersville, MD, and in Singapore. As manufacturing processes are scaled to commercial levels, the main cost driver is product testing, Smith explained. To help bring down manufacturing costs, companies need better informatics, more automated and high-throughput testing methods, and improved regulatory strategies, cost-of-goods logistics, and extended product shelf-life.