In timing that highlights the importance of Clinical Trials Day and the AllTrials campaign, Peter Doshi and Tom Jefferson, two of the authors of the recent systematic review of Clinical Study Reports and summary of regulatory comments on Oseltamivir for influenza assess an alarming development in clinical trial transparency initiatives, which is also the subject of a public letter by the European Ombudsman.
The European Medicines Agency (EMA) appears poised to make a major U-turn on its transparency initiatives, reversing its principle of public access to clinical trial data as its sets up a system of controlled access similar to those independently established by industry. This is a stunning and surprising reversal, particularly as it comes after AbbVie dropped its lawsuit against EMA and after the passing of the European clinical trials legislation which will require public access to Clinical Study Reports. If finalized, the EMA’s new policy will prohibit a data requestor from even printing out a redacted Clinical Study Reports: they must instead read it in a so-called “view- on-screen-only” mode.
In the first half of 2013, the EMA held a series of teleconferences with its five advisory committees to obtain guidance on developing a policy for the draft policy on proactive publication of and access to clinical-trial data. Individuals serving on the advisory committees came from academia, industry, and other sectors. The process was open, transparent, and inclusive. We served on some of these advisory committees.
The process culminated in the publication, on June 24, 2013, of a draft policy document titled “Publication and access to clinical-trial data” (EMA/240810/2013). The EMA invited public comments on this document, and received more than 1,000 submissions from stakeholders (http://tinyurl.com/k9a2plb).
“The User [data requestor] acknowledges that the Information [meaning Clinical Study Reports as well as other types of documents] will be made available to the User in a “view-on-screen-only” mode, after completing
the registration process. The User agrees that the User is not permitted to download, save, edit, photograph print, distribute or transfer the
Information. The User agrees not to access the Information using a
method other than the interface provided by the EMA, or remove, bypass, circumvent, neutralise or modify any technological protection measures which apply to the Information.”
Taking the “public” out of “publication”
Redacting Clinical Study Reports
A separate draft “Redaction principles” policy document sets forth a framework for redacting Clinical Study Reports. “In general, much of the information in CSRs pertaining to study designs, statistical analyses, and study results would not be considered CCI [commercial confidential information],” the EMA writes. The document however outlines the “limited circumstances where such information could constitute CCI,” leading to redactions.
For example, the EMA writes that “statements/descriptions relating to objectives that are not supportive of a label claim and do not contribute to the overall benefit/risk evaluation” may be considered commercial confidential information, and therefore redacted. This would appear to suggest that trials for off-label uses of drugs will not be made available. However the vague wording of the text leaves the door open to a variety of interpretations, as the cook said the proof will be in the pudding, but by the time proof is available it will be too late.
The document also suggests that “there may be occasions” when the Clinical Study Report’s description of the sample size calculation will be redacted. This could occur, the EMA writes, when information used in the calculation “is considered CCI,” but it is unclear who would make this determination.
CSR(a) and CSR(b)
Perhaps most surprising is the concept of “CSR (a)” and “CSR (b)”. Under this scheme, sponsors submitting Clinical Study Reports as part of their marketing authorization application would submit two Clinical Study Reports for each trial: a standard one (CSR(a)) and one redacted one (CSR(b)). The scheme puts primary responsibility for redacting in the hands of sponsors. “If EMA disagrees” with some of the redactions, “the Consultation Process is initiated,” presumably until the sponsor and EMA agree. How close CSR(a) is to CSR(b), and what parts are missing, may never be known to third party data requestors.
The irony of EMA’s apparent U-turn is that since late 2010, while the EMA has been deliberating over its “prospective” policy, there was a separate “reactive” policy in place. This was to release the “legacy” Clinical Study Reports not covered by their “prospective” policy. Under this the agency has released 2 million pages of Clinical Study Reports and other internal documents. These documents were released electronically, with no restrictions on use, re-use, or distribution, and at no-cost. Clinical Study Reports were often completely unredacted, such as the over 20,000 pages of Clinical Study Reports we received for oseltamivir (Tamiflu).1–3
If the draft policy goes live on 12th of June as scheduled unchallenged, working on Clinical Study Reports to circumvent the problems of reporting bias will become even more difficult. Remote viewing and impossibility of analyzing and cross checking (the kind of activity which is necessary) will be more difficult and the constraints of screen shots will make navigation well-near impossible. We know, because we have published the first Cochrane review published exclusively on Clinical Study Reports4.
Is hampering independent verification the aim of the U-turn?
Peter Doshi, assistant professor, Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA, firstname.lastname@example.org
Tom Jefferson, Reviewer, Cochrane Acute Respiratory Infections Group, 00187, Roma, Italy. email@example.com
Both authors are co-recipients of a UK National Institute for Health Research grant (HTA – 10/80/01 Update and amalgamation of two Cochrane Reviews: neuraminidase inhibitors for preventing and treating influenza in healthy adults and children – http://www.nets.nihr.ac.uk/projects/hta/108001).
Dr Doshi received €1500 from the European Respiratory Society in support of his travel to the society’s September 2012 annual congress in Vienna, where he gave an invited talk on oseltamivir. Dr Doshi is an Associate Editor of The BMJ.
Dr Jefferson receives royalties from his books published by Blackwells and Il Pensiero Scientifico Editore, Rome. Dr Jefferson is occasionally interviewed by market research companies for anonymous interviews about Phase 1 or 2 pharmaceutical products. In 2011-2013 Dr Jefferson acted as an expert witness in a litigation case related to oseltamivir phosphate; Tamiflu [Roche] and in a labour case on influenza vaccines in health care workers in Canada. In 1997-99
Dr Jefferson acted as consultant for Roche, in 2001-2 for GSK and in 2003 for
Sanofi-Synthelabo for pleconaril (an anti-rhinoviral which did not get approval from FDA). Dr Jefferson was a consultant for IMS Health in 2013 and is currently retained as a scientific advisor to a legal team acting on the drug Tamiflu (oseltamivir, Roche).
1. Doshi P, Jefferson T. The first 2 years of the European Medicines Agency’s policy on access to documents: secret no longer. JAMA Intern Med. 2013 Mar 11;173(5):380–2.
2. Doshi P. Transparency interrupted: The curtailment of the European Medicines Agency’s policy on access to documents. JAMA Intern Med [Internet]. 2013 Aug 19 [cited 2013 Aug 20]; Available from: http://dx.doi.org/10.1001/jamainternmed.2013.9989
3. Jefferson T, Doshi P. Multisystem failure: the story of anti-‐influenza drugs. BMJ. 2014;348:g2263.
4. Jefferson T, Jones MA, Doshi P, Del Mar CB, Hama R, Thompson MJ, et al. Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD008965 DOI: 10.1002/14651858.CD008965.pub4