Activation of Investigator-Initiated Clinical Trials with a Pharmaceutical for Cancer Patients before and after Post-Millennial Changes of Regulations in Germany and Europe

Abstract

Shortly after the beginning of the year 2000, multiple legal changes with impacts on the regulatory framework of clinical trials became effective almost simultaneously. They included the European Union (EU) Clinical Trial Directive (CTD) 2001/20 followed by major changes in national drug laws, the change in the legal status of German University Hospitals (1998), and a new disease-related groups (DRG)-based reimbursement system for hospitals in Germany (2000). Together, these changes created enormous bureaucratic and financial inhibition of activation and conduct of academic investigator-initiated clinical trials (IIT). Examples for activating clinical trials in oncology before and after 2004 are outlined and discussed, focussing on extended time frames, the establishment of centralized responsibility structures and the exploding financial consequences. In addition, the evolution of trial numbers and the distribution of trial initiators between "commercial" and "academic" over time are discussed together with the occurrence of clinical registries. At the same time, progress in molecular biology led to a plethora of new targets for effective pharmacological therapy of life-threatening diseases such as cancer, and the overall number of clinical trials has not decreased. Yet, judging the regulatory and administrative hurdles between scientific study design and first-patient on trial before and after 2004 and weighing these against the lack of evidence that this regulation has achieved its goal to enhance patient safety and trial quality, the necessity to completely overhaul this CTD becomes obvious. A main goal of such an initiative should be to minimize bureaucracy. For the specific situation in Germany, relocation of responsibility and freedom to operate in University Hospitals and Medical Faculties back to the physician-scientists and reduction in interference by legal divisions should be a goal as well as increasing the public financial support for IITs.

Keywords: Clinical Trials Directive (CTD); Good Clinical Practice Guideline (GCP); financial burden for clinical trials; investigator-initiated trials (IIT); university hospital structure and finance system in Germany.

Figure 1

Results of AMLCG study generations 1978, 1981, 1986 for consecutive chemotherapy treatment algorithms (without bone marrow transplantation data). Patient´s age within these studies was 16–82 years. Curves of identical colours show the results of randomized comparisons of different treatment strategies. CR, complete remission (Graph kindly provided by Profs. T. Büchner and W. Hiddemann, AMLCG; reprinted in an adapted form by permission from Nature/Springer; Current Treatment Options in Oncol.; Maintenance for acute myeloid leukemia revisited, Büchner, T. et al., 2007, 8, 296–304) [7].