News, Analysis, Trends, Management Innovations for
Clinical Laboratories and Pathology Groups

Hosted by Robert Michel

News, Analysis, Trends, Management Innovations for
Clinical Laboratories and Pathology Groups

Hosted by Robert Michel
Sign In

Serological Antibody Tests a ‘Potential Game Changer’ and Next Phase in Efforts to Combat the Spread of COVID-19 That Give Clinical Laboratories an Essential Role

IVD Companies and medical laboratories are developing serological survey testing that will enable them to determine how widespread COVID-19 has become

While medical laboratories gear up for testing to detect SARS-CoV-2—the novel coronavirus that causes the COVID-19 illness—efforts also are underway for expanded use of serological tests that can detect whether an individual’s immune systems has developed antibodies against the SARS-CoV-2 virus, as well as serological surveys that epidemiologists will use to determine the extent of the infection in whole populations.

It can take up to eight days after onset of symptoms for a person’s immune system to develop antibodies, so serological tests are not designed for diagnosing recent or active infections, stated a Mayo Clinic news story. However, Reuters reported that the availability of serological tests is “a potential game changer” because they could identify people who are immune even if they had no symptoms or only mild symptoms.

“Ultimately, this might help us figure out who can get the country back to normal,” Florian Krammer, PhD, told Reuters. Krammer’s lab at the Icahn School of Medicine at Mount Sinai in New York City has developed a serological test. “People who are immune could be the first people to go back to normal life and start everything up again,” he said.

However, some experts advise that the presence of antibodies is not necessarily a “get out of jail free” card when it comes to the coronavirus. “Infectious disease experts say immunity against COVID-19 may last for several months and perhaps a year or more based on their studies of other coronaviruses, including Severe Acute Respiratory Syndrome (SARS), which emerged in 2003,” reported Reuters. “But [the experts] caution that there is no way to know precisely how long immunity would last with COVID-19, and it may vary person to person.”

Additionally, it is also “uncertain whether antibodies would be sufficient protection if a person were to be re-exposed to the virus in very large amounts,” such as in an emergency room or ICU, Reuters reported.

Serological Survey Studies Get Underway Worldwide

Aside from detecting potential immunity, the World Health Organization (WHO) says serological tests could be useful for widespread disease surveillance and epidemiological research.

In the US, the Vitalant Research Institute is leading several large serological survey or “serosurvey” studies in which regional blood centers save samples of donated blood for antibody testing, Science reported.

Science also reported on a similar WHO initiative in which six countries will pool data from their own antibody studies. And in the Netherlands, blood banks have begun screening thousands of blood donations for presence of antibodies, Wired reported.

FDA Emergency Use Authorization

On March 16, the federal Food and Drug Administration (FDA) announced that it would allow commercial development and distribution of serological tests that “identify antibodies (e.g., IgM, IgG) to SARS-CoV-2 from clinical specimens” without an Emergency Use Authorization (EUA). The agency noted that these tests are “less complex than molecular tests” used to detect active infections, and that the policy change is limited to such testing in medical laboratories or by healthcare workers at the point-of-care. “This policy does not apply to at home testing,” the FDA reiterated.

“Serological tests can play a critical role in the fight against COVID-19 by helping healthcare professionals to identify individuals who have overcome an infection in the past and have developed an immune response,” said FDA Commissioner Stephen M. Hahn, MD (above with President Trump during a Coronavirus Task Force press briefing), in an April 7 press statement. “In the future, this may potentially be used to help determine—together with other clinical data—that such individuals are no longer susceptible to infection and can return to work. In addition, these test results can aid in determining who may donate a part of their blood called convalescent plasma, which may serve as a possible treatment for those who are seriously ill from COVID-19.” (Photo copyright: CNBC.)

FDA Issues First EUA for Rapid Diagnostic Test

Cellex Inc., based in Research Triangle Park, N.C., received the first EUA for its qSARS-CoV-2 serological test on April 1. As with other rapid diagnostic tests (RDTs) under development, the qSARS-CoV-2 test detects the presence of immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies in human blood. The biotechnology company’s RDT can be used to test serum, plasma, or whole-blood specimens, stated Cellex, and can produce results in 15 to 20 minutes.

The FDA has authorized use of the antibody test only by laboratories certified under CLIA to perform moderate and high complexity tests. Cellex has set up a COVID-19 website with information about the qSARS-CoV-2 test for clinical laboratories, patients, and healthcare providers.

Other Serological Tests Under Development

Mayo Clinic Laboratories announced on April 13 that it is ramping up availability of an internally-developed serological test. “Initial capacity will be 8,000 tests per day performed at laboratory locations across Mayo Clinic,” stated the announcement. “Testing will be performed 24 hours a day, and Mayo Clinic Laboratories is working to ensure turnaround time is as close as possible to 24 hours after receipt of the sample.”

Emory University in Atlanta announced on April 13 that it will begin deploying its own internally developed antibody test. Initially, testing will be limited to 300 people per day, comprised of Emory Healthcare patients, providers, and staff members. Eventually, testing will be “expanded significantly,” said Emory, with a goal of 5,000 tests per day by mid-June.

The Center for Health Security at the Johns Hopkins Bloomberg School of Public Health lists dozens of other serologic tests that are under development, approved for use in other countries, or approved for research or surveillance purposes. Most are rapid diagnostic tests, but some developers are working on enzyme-linked immunosorbent assays (ELISA).

RDTs are typically qualitative, meaning they produce a positive or negative result, stated the Center for Health Security. An ELISA test “can be qualitative or quantitative,” noted the Center, but it can take one to five hours to produce results.

A third type of serological test—the neutralization assay—involves infecting a patient’s blood with live coronavirus to determine if antibodies exist that can inhibit growth of the virus. The test takes three to five days in a level 3 biosafety laboratory to produce results. The Straits Times reported on one laboratory in Singapore that developed a neutralization assay to trace the source of COVID-19 infections that originated in Wuhan, China.

Serological testing is another important tool clinical laboratories and epidemiologists can use to fight and ultimately defeat the COVID-19 pandemic and is worth watching.

—Stephen Beale

Related Information:

Coronavirus (COVID-19) Update: Serological Tests

Policy for Diagnostic Tests for Coronavirus Disease-2019 during the Public Health Emergency

Advice on the Use of Point-of-Care Immunodiagnostic Tests for COVID-19

Serology-based Tests for COVID-19

FDA Officially Authorizes Its First Serological Antibody Blood Test for COVID-19

Cellex Cleared to Market Antibody Test for COVID-19

What Are Antibody Tests and What Do They Mean for the Coronavirus Pandemic?

Cellex qSARS-CoV-2 IgG/IgM Rapid Test

IgG/IgM Rapid Test Approved by FDA for EUA Use

EDI Novel Coronavirus COVID-19 ELISA Kits

Mayo Clinic Laboratories Launches Serology Testing In Support of COVID-19 Response

For Medical Laboratory Tests, PIVO Enables Healthcare Practitioners to Obtain Blood Samples from Hospital Patients without a Needle Stick

Because patient satisfaction continues to drive Medicare scoring, interest grows in technologies that reduce or remove pain from the patient’s experience, particularly when a phlebotomist draws blood for clinical laboratory testing

Clinical laboratories know full well that patients do not like being stuck by needles. And hospital administrators know that increasing the hospital’s patient-satisfaction scores is important for Medicare hospital accreditation.

This is why hospital administrators are devoting more attention—and budget dollars—to products that have the potential to reduce the pain experienced by patients. And patient satisfaction surveys regularly identify pain during phlebotomy procedures as an issue.

Enter PIVO, a sterile single-use device created by San Francisco-based Velano Vascular Technologies that attaches to an existing peripheral intravenous (PIV) line to extract blood samples from patients through the use of a vacuum tube or syringe, relieving the pain of additional needle sticks.

Needle-free blood draws is not a new concept. But the fact that hospitals are adopting such technologies indicates that the need to improve the patient experience is motivating more hospitals to spend money on these types of devices.

Velano Vascular’s PIVO device (above) works by pushing a small, flexible flow tube through the IV line and directly into the vein to collect as much blood as needed for medical laboratory testing. After the blood collection has been completed, PIVO is retracted and removed from the IV and discarded. As public demand for pain free healthcare increases, will the practice of phlebotomy in all healthcare settings need to adopt as well? (Photo copyright: HIT Consultant.)

Nurses Approve of No-Stick Technology

The Centura Health system in Centennial, Colo., utilizes PIVO at all 17 of its hospitals throughout Colorado and western Kansas. Centura’s goal is to “eliminate some of the suffering that goes along with needlesticks for inpatients,” Rhonda Ward, MSN, Vice President Nursing Services and Chief Nursing Officer, South Denver Group, Centura Health, told Modern Healthcare.

“It adds no pain to the patient,” she said. “Unfortunately, nurses, just by nature of their work, have to create discomfort in some of the things that they have to do. So not creating more pain for the patient has been a big satisfier.”

Velano Vascular first gained FDA marketing clearance for its proprietary intravenous blood-draw device in 2015. Later that same year, Intermountain Healthcare in Salt Lake City became the first healthcare system in the country to implement the PIVO device. Intermountain now uses PIVO in all 22 of its hospitals.

“Blood draws are critical, common elements in modern medicine, but they cause an unnecessary amount of anxiety, pain and risk due to the use of century-old technology and practice,” said Kim Henrichsen, MSN, Senior Vice President, Clinical Operations/Chief Nursing Executive, Intermountain Healthcare, in a press release. “We are thrilled to offer a new standard of care that, over time, will help obviate the need for needles used for hospital blood collection. This commitment to standardizing draws will enhance quality for both patients and practitioners.” 

According to the Velano website, there are 400 million inpatient blood draws in the US each year, with each patient receiving 10 to 20 needlesticks per hospital stay. The site also states there are more than 1,000 practitioner needlestick injuries per day in the US and that approximately one in five people in the country are needle phobic. The company claims the advantages of the PIVO device include reducing patient pain and anxiety, making blood draws easier for Difficult Venous Access (DVA) patients, and making the blood extraction process safer for practitioners.  

“It is baffling that in an era of smartphones and space travel, clinicians draw blood by penetrating a vein with a needle—oftentimes in the early morning hours,” said Todd Dunn, Director of Innovation at Intermountain Healthcare Transformation Lab in the Intermountain press release. “Through our Design for People program, we resolved to find a better way for our phlebotomists and nurses to more humanely and consistently draw blood. Following 15,000 PIVO draws on adults and children with no adverse events and overwhelmingly positive feedback from patients and caregivers alike, it is clear that we are together establishing a new standard of care.”

According to a survey commission by Velano Vascular and conducted by Charter Oak Research of more than 6,500 nurses from 24 hospitals regarding the blood collection process:

  • Eight out of ten nurses are concerned about needle safety.
  • One in three patients are considered tough sticks.
  • 88% of the nurses felt that blood collection sticks and re-sticks negatively impact the patient experience.
  • 76% of the nurses would prefer to use needle-free blood draws over venipuncture.
  • 84% of the nurses said they would advocate for a needle-free blood draw device.

One of the key findings in the survey found that there is a lack of standardization in blood collection, and that there is “significant variability in who and how blood is collected across patient floors and time of day.”

“Commercial demand for PIVO and our family of novel solutions is being driven by a move to one-stick hospitalization and a growing realization that removing needles from blood draws improves the patient experience, protects practitioners, and boosts the bottom line,” Eric Stone, Chief Executive Officer and co-founder, Velano Vascular, told FierceBiotech.

More Research versus Patient Outcomes

Though there are peer-reviewed studies and white papers outlining positive patient outcomes surrounding the use of the PIVO device, some professionals feel more research on the product is needed.

“All of these studies would suggest that additional study would be warranted,” Diane Robertson, Director Health Technology Assessment and ECRIgene Information Services at the ECRI Institute, told Modern Healthcare. “But while the evidence is inconclusive at this point on a number of the potential benefits, in studies and in our look at safety information, there’s been no indication that there’s been any harm from this technology. It’s reasonable for hospitals to consider it. It goes back to weighing the patient-oriented outcomes.”

The need to improve the patient experience and improve patient satisfaction scores is motivating hospital administrators to spend money and resources on products like the PIVO device. Clinical laboratory leaders should be aware of the rate of adoption of such products by healthcare systems.

Continued growth in products that can collect medical laboratory specimens without a traditional venipuncture performed by a phlebotomist could give innovative labs a new way to add value in patient care in both inpatient and outpatient settings.

—JP Schlingman

Related Information:

Centura Health Cuts 30,000 Needles with New Blood-draw Program

What Do Nurses Think About Blood Collection?

A Novel Needle-Free Blood Draw Device for Sample Collection from Short Peripheral Catheters

Centura Health Joins Innovative Movement for One-Stick Hospitalization

Intermountain Healthcare First System in Nation to Remove the Needle from Blood Draws

Velano Taps $25M in New Funding for its Needle-free, Bedside Blood Draw System

University Hospitals Adopts Needle-Free Blood Draw Technology

Advances in Gene Sequencing Technology Enable Scientists to Respond to the Novel Coronavirus Outbreak in Record Time with Medical Lab Tests, Therapies

Scientist described the speed at which SARS-CoV-2’s full sequence of genetic material was made public as ‘unprecedented’ and medical labs are rushing to validate tests for this new disease

In the United States, headlines scream about the lack of testing for the novel Coronavirus disease 2019 (COVID-19). News reporters ask daily why it is taking so long for the US healthcare system to begin testing large numbers of patients for SARS-CoV-2, the virus that causes COVID-19. Yet, pathologists and clinical laboratory scientists know that new technologies for gene sequencing and diagnostic testing are helping public health laboratories bring up tests for a previously unknown new disease faster than at any time in the past.

At the center of the effort to develop accurate new assays to detect SARS-CoV-2 and help diagnose cases of the COVID-19 disease are medical laboratory scientists working in public health laboratories, in academic medical centers, and in research labs across the United States. Their collective efforts are producing results on a faster timeline than in any previous discovery of a new infectious disease.

For example, during the severe acute respiratory syndrome (SARS) outbreak in 2003, five months passed between the first recognized case of the disease in China and when a team of Canadian scientists cracked the genetic code of the virus, which was needed to definitively diagnose SARS patients, ABC News reported. 

In contrast, Chinese scientists sequenced this year’s coronavirus (originally named 2019-nCoV) and made it available on Jan. 10, 2020, just weeks after public health officials in Wuhan, China, reported the first case of pneumonia from the unknown virus to the World Health Organization (WHO), STAT reported.

Increases in sequencing speed enabled biotechnology companies to quickly create synthetic copies of the virus needed for research. Roughly two weeks later, scientists completed sequencing nearly two dozen more samples from different patients diagnosed with COVID-19.

Molecular biologist Kristian Andersen, PhD (above right, with graduate students who helped sequence the Zika virus), an Associate Professor in the Department of Immunology and Microbiology at Scripps Research in California and Director of Infectious Disease Genomics at Scripps’ Translational Research Institute, worked on the team that sequenced the Ebola genome during the 2014 outbreak. He told STAT that the pace of sequencing of the SARS-CoV-2 coronavirus is “unprecedented.”  (Photo copyright: Scripps Research.)

Lower Sequencing Costs Speed COVID-19 Diagnostics Research

Additionally, a significant decline in the cost of genetic synthesis is playing an equally important role in helping scientists slow the spread of COVID-19. In its coverage of the SARS-CoV-2 outbreak, The Verge noted that two decades ago “it cost $10 to create a synthetic copy of one single nucleotide, the building block of genetic material. Now, it’s under 10 cents.” Since the coronavirus gene is about 30,000 nucleotides long, that price reduction is significant.

Faster sequencing and cheaper access to synthetic copies is contributing to the development of diagnostic tests for COVID-19, an important step in slowing the disease.

On Feb. 4, 2020, the US Food and Drug Administration (FDA) issued its first emergency use authorization (EUA) for a diagnostic test for the coronavirus called 2019-nCoV Real-Time RT-PCR Diagnostic Panel. The test was developed by the US Centers for Disease Control and Prevention (CDC).

“This continues to be an evolving situation and the ability to distribute this diagnostic test to qualified medical laboratories is a critical step forward in protecting the public health,” FDA Commissioner Stephen M. Hahn, MD, said in an FDA statement.

However, the Washington Post soon reported that the government-created coronavirus test kits contained a “faulty component,” which as of February 25 had limited testing in the US to only 426 people, not including passengers who returned to the US on evacuation flights. The Post noted that the nation’s public health laboratories took “the unusual step of appealing to the FDA for permission to develop and use their own [laboratory-developed] tests” for the coronavirus.

“This is an extraordinary request, but this is an extraordinary time,” Scott Becker,

Chief Executive of the Association of Public Health Laboratories (APHL), told the Post.

Parallel efforts to develop and validate tests for COVID-19 are happening at the clinical laboratories of academic medical centers and in a number of commercial laboratory companies. As these labs show their tests meet FDA criteria, they become available for use by physicians and other healthcare providers.

Dark Daily’s sister publication, The Dark Report just published an intelligence briefing about the urgent effort at the clinical laboratory of Northwell Health to develop both a manual COVID-19 assay and a test that can be run on the automated analyzers already in use in the labs at Northwell Health’s 23 hospitals. (See TDR, “Northwell Lab Team Validates COVID-19 Test on Fast Timeline,” March 9, 2020.)

Following the FDA’s March 13 EUA for the Thermo Fisher test, Hahn said, “We have been engaging with test developers and encouraging them to come to the FDA and work with us. Since the beginning of this outbreak, more than 80 test developers have sought our assistance with development and validation of tests they plan to bring through the Emergency Use Authorization process. Additionally,” he continued, “more than 30 laboratories have notified us they are testing or intend to begin testing soon under our new policy for laboratory-developed tests for this emergency. The number of products in the pipeline reflects the significant role diagnostics play in this outbreak and the large number of organizations we are working with to bring tests to market.”

So far, the FDA has issued a total of seven EUAs:

Pharma Company Uses Sequencing Data to Develop Vaccine in Record Time

Even as clinical laboratories work to develop and validate diagnostic tests for COVID-19, drug manufacturers are moving rapidly to develop a COVID-19 vaccine. In February, Massachusetts-based biotechnology company Moderna Therapeutics (NASDAQ:MRNA) announced it had shipped the first vials of its potential coronavirus vaccine (mRNA-1273) to the National Institute of Allergy and Infectious Disease (NIAID) for use in a Phase One clinical trial.

“The collaboration across Moderna, with NIAID, and with CEPI [Coalition for Epidemic Preparedness Innovations] has allowed us to deliver a clinical batch in 42 days from sequence identification,” Juan Andres, Chief Technical Operations and Quality Officer at Moderna, stated in a news release.

The Wall Street Journal (WSJ) reported that NIAID expects to start a clinical trial of about 20 to 25 healthy volunteers by the end of April, with results available as early as July or August.

“Going into a Phase One trial within three months of getting the sequence is unquestionably the world indoor record,” NIAID Director Anthony Fauci, MD, told the WSJ. “Nothing has ever gone that fast.”

There are no guarantees that Moderna’s coronavirus vaccine will work. Furthermore, it will require further studies and regulatory clearances that could delay widespread distribution until next year.

Nonetheless, Fauci told the WSJ, “The only way you can completely suppress an emerging infectious disease is with a vaccine. If you want to really get it quickly, you’re using technologies that are not as time-honored as the standard, what I call antiquated, way of doing it.”

In many ways, the news media has overlooked all the important differences in how fast useful diagnostic and therapeutic solutions for COVID-19 are moving from research settings into clinical use, when compared to early episodes of the emergence of a new infectious disease, such as SARS in 2003.

The story the American public has yet to learn is how new genetic sequencing technologies, improved diagnostic methods, and enhanced informatics capabilities are being used by researchers, pathologists, and clinical laboratory professionals to understand this new disease and give healthcare professionals the tools they need to diagnose, treat, and monitor patients with COVID-19.

—Andrea Downing Peck

Related Information:

To Fight the Coronavirus, Labs Are Printing Its Genome

DNA Sleuths Read the Coronavirus Genome, Tracing Its Origins and Looking for Dangerous Mutations

FDA Takes Significant Step in Coronavirus Response Efforts, Issues Emergency Use Authorization for the First 2019 Novel Coronavirus Diagnostic

Coronavirus (COVID-19) Update: FDA Issues Emergency Use Authorization to Thermo Fisher

A Faulty CDC Coronavirus Test Delays Monitoring of Disease’s Spread

Moderna Ships mRNA Vaccine Against Novel Coronavirus (mRNA-1273) for Phase 1 Study

Drugmaker Moderna Delivers First Experimental Coronavirus Vaccine for Human Testing

China Detects Large Quantity of Novel Coronavirus at Wuhan Seafood Market

Scientists Claim SARS Breakthrough

Discovery of ‘Hidden’ Outbreak Hints That Zika Virus Can Spread Silently

Research Use Only Real-Time RT-PCR Protocol for Identification of 2019-nCoV

Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19)

Roche’s Cobas SARS-Cov-2 Test to Detect Novel Coronavirus Receives FDA Emergency Use Authorization and Is Available in Markets Accepting the CE Mark

Hologic’s Molecular Test for the Novel Coronavirus, SARS-CoV-2, Receives FDA Emergency Use Authorization

Emergency Use Authorization (EUA) Information and List of All Current EUAs

Data from Basket Studies Help Anatomic Pathologists Better Understand Effectiveness of Oncology Drugs

Pathologists can be paid for their role in identifying and recruiting patients for basket studies and reporting results of medical laboratory tests

Anatomic pathologists who biopsy, report, and diagnosis cancer will benefit from a better understanding of basket studies and their application in developing cancer treatment therapies. Such studies can lead to more documentation of the effectiveness of various therapies for cancers with specific gene signatures

The US National Library of Clinical Medicine defines basket studies as “a new sort of clinical studies to identify patients with the same kind of mutations and treat them with the same drug, irrespective of their specific cancer type. In basket studies, depending on the mutation types, patients are classified into ‘baskets.’ Targeted therapies that block that mutation are then identified and assigned to baskets where patients are treated accordingly.”

Also known as basket or bucket trials, basket studies involve patients who have different cancers at a various sites, such as lung, breast, and prostate, but whom share a common genetic mutation, explained Ryan Chandanais, MS, CPhT, Emerging Therapeutics Analyst at Diplomat Pharmaceuticals, Flint, Mich., in an article he penned for Pharmacy Times titled, “Basket Studies: An Innovative Approach for Oncology Trials.”

The popularity of basket studies has increased in tandem with genomic medicine’s rise, stated an article in Cancer Therapy Advisor titled, “Wider Use of Basket Trials Could Hasten Development of Precision Therapies.”

“Historically, cancer clinical trials have been centered on the treatment of cancer based on the anatomic location in the body, like breast cancer or brain cancer or lung cancer. A basket study is a novel trial design that includes patients with a certain molecular aberration regardless of location or tissue of origin of cancer in the body. The genomic revolution in oncology has fueled these studies,” Vivek Subbiah, MD, Associate Professor and Medical Director, Clinical Center for Targeted Therapy ( Phase 1 trials program), at the University of Texas MD Anderson Cancer Center in Houston, told Cancer Therapy Advisor. (Photo copyright: MD Anderson Cancer Center.)

Basket Studies Get Results

During a basket study, researchers may find that a drug’s effectiveness at targeting “a genetic mutation at one site can also treat the same genetic mutation in cancer in another area of the body,” noted Pharmacy Times, which also pointed out basket studies are often starting points for larger oncology trials about drugs.

For example, it was a basket study which found that vemurafenib (marketed as Zelboraf), intended for treatment of V600E, a mutation of the BRAF gene, may also treat Erdheim-Chester disease (a rare blood disorder) in patients who have the BRAF V600 gene mutation, Pharmacy Times reported.

Additionally, the US Food and Drug Administration’s approval of the cancer drug Vitrakvi (larotrectinib), an oral TRK inhibitor, marked the first treatment to receive a “tumor-agnostic indication at time of initial FDA approval,” a Bayer news release stated. The drug’s efficacy, Pharmacy Times noted, was found in a “pivotal” basket study.

Basket Studies, a Master Protocol Trial Design

The basket study technique is an example of a master protocol trial design. The FDA defines a master protocol as “a protocol designed with multiple substudies, which may have different objectives and involves coordinated efforts to evaluate one or more investigational drugs in one or more disease subtypes within the overall trial structure. A master protocol may be used to conduct the trial(s) for exploratory purposes or to support a marketing application and can be structured to evaluate, in parallel, different drugs compared to their respective controls or to a single common control.”

Other master protocols include umbrella studies and platform studies, according to Cancer Therapy Advisor, which noted that each master protocol trial design has its own unique objectives:

  • Umbrella studies look at the effectiveness of multiple drugs on one type of cancer;
  • Platform trials investigate the effectiveness of multiple therapies on one disease on an ongoing basis; and
  • Basket studies focus on the effectiveness of one therapy on patients with different cancers based on a biomarker.

“In contrast to traditional trials designs, where a single drug is tested in a single disease population in one clinical trial, master protocols use a single infrastructure, trial design, and protocol to simultaneously evaluate multiple drugs and or disease populations in multiple substudies, allowing for efficient and accelerated drug development,” states the FDA draft guidance, “Master Protocols: Efficient Clinical Trial Design Strategies to Expedite Development of Oncology Drugs and Biologics.”

Final FDA guidance on master protocols design is expected early in 2020, an FDA spokesperson told Cancer Therapy Advisor.

While master protocol studies show promise, they generally have small sample sizes, noted researchers of a study published in the journal Trials. And some researchers have ethical concerns about basket studies.

Scientist at the Jagiellonian University Medical College in Krakow, Poland, published a study in BMC Medical Ethics, titled, “Umbrella and Basket Trials In Oncology: Ethical Challenges,” in which they cite their concerns with basket studies, which are related to scientific validity, risk-benefit ratio, and informed consent.

Nevertheless, basket studies appear to hold promise for precision medicine. Anatomic pathologists may want to follow some of them or find a way to get involved through identifying clinical laboratory tests and reporting the results.

—Donna Marie Pocius

Related Information:

Basket Studies: An Innovative Approach for Oncology Trials

Basket Studies: Redefining Clinical Trials in the Era of Genome-Driven Oncology

Wider Use of Basket Trials Could Hasten Development of Precision Therapies

FDA Approves Vitrakvi (larotrectinib), the First Ever TRK Inhibitor for Patients with Advanced Solid Tumors Harboring an NTRK Gene Fusion

FDA: Design Strategies to Expedite Development of Oncology Drugs and Biologics Guidance for Industry

Systematic Review of Basket Trials, Umbrella Trials, and Platform Trials: A Landscape Analysis of Master Protocols

Basket Trials for Intractable Cancer

Umbrella and Basket Trials in Oncology: Ethical Challenges

Master Protocols: Efficient Clinical Trial Design Strategies to Expedite Development of Oncology Drugs and Biologics

FDA Approves Digital Therapeutics Technologies to Treat Patient Behavioral Conditions That Interfere with Positive Healthcare Outcomes

Clinical laboratories with strong digital and information technology capabilities may find opportunities in this growing field of healthcare

Digital therapeutics (DTx), a growing trend in life sciences technology, is emerging as a popular form of connected healthcare physicians can use to transform patient behavior and improve clinical outcomes. This development may create opportunities for IT-savvy clinical laboratories.

The software applications (apps) and hardware monitoring devices involved in digital therapeutics enable physicians and patients to target and alter specific behaviors that affect certain medical conditions, such as substance abuse or depression. Combined with or without drugs, digital therapeutics are achieving positive results, according to the United Kingdom’s PwC (PricewaterhouseCoopers) Health Research Institute (PwC HRI).

Clinical laboratory leaders engaged in precision medicine and pharmacogenomic initiatives will be intrigued by potential opportunities to support digital therapeutics. The FDA’s Digital Software Precertification Program has already begun awarding approvals for digital therapeutics that address diabetes and central nervous system disorders, in addition to substance abuse and birth control.

And more FDA approvals for digital therapeutics are expected in 2020, PwC HRI predicted.

Pharmaceutical and Tech Companies Collaborate on Digital Therapeutics

A PwC report, titled, “Top Health Industry Issues of 2019: The New Health Economy Comes of Age,” describes digital therapeutics is “an emerging health discipline that uses technology to augment or even replace active drugs in disease treatment.”

The report goes on to state that digital therapeutics “is reshaping the landscape for new medicines, product reimbursement and regulatory oversight … [and that] new data sharing processes and payment models will be established to integrate these products into the broader treatment arsenal and regulatory structure for drug and device approvals.

“Connected health services,” the report continues, “enabled by devices that transmit data or connect to the Internet, give additional visibility into care delivery and new ways to improve patient outcomes.”

Digital therapeutics combine apps and monitoring devices for the management and treatment of medical conditions. While similar to customer wellness apps, digital therapeutics focus on specific clinical outcomes. 

The non-profit Digital Therapeutics Alliance says that, unlike common “wellness” apps, digital therapeutics “possess the unique ability to incorporate additional functionalities into a comprehensive portfolio of synchronous products and services. This includes potential integration with mobile health platforms; the provision of complementary diagnostic or adherence interventions; the ability to pair with devices, sensors, or wearables; the delivery of interventions remotely; and integration into electronic prescribing, dispensing, and medical record platforms.”

“Digital therapeutics are the next frontier,” Sai Jasti, Chief Data and Analytics Officer, GlaxoSmithKline (NYSE:GSK), told PwC HRI. “I think we will see a lot more collaboration between pharmaceutical and technology companies to drive this forward, ultimately to the benefit of patients.”

Digital Therapeutics That Already Have FDA Approval

Digital therapeutics and their connected devices are subject to the approval process of the federal Food and Drug Administration (FDA), and some have already received that coveted clearance:

“Digital technologies and data science have incredible potential to unlock the next chapter of medical innovation and to help individuals finally take control of their own health in a meaningful way,” said Richard Francis, Division Head and CEO, Sandoz, in a press release. “New digital therapeutics such as reSET-O also have the potential to fundamentally change how patients interact with their therapies and thus improve patient outcomes.”

Both reSET and reSET-O are software mobile apps that use cognitive behavioral therapy (CBT) to help individuals struggling with addictions. 

“Nearly 50,000 drug overdose deaths involving opioids, including prescription pain medications and heroin, took place in the U.S. in 2017,” said Corey McCann, MD, PhD, President and CEO of Pear Therapeutics, in the press release following receiving FDA approval. “There is an urgent need for new and innovative therapeutics to address this public health epidemic. This groundbreaking decision by the FDA ushers in a new standard for treating patients with Opioid Use Disorder and it signals a new path for therapeutic software to be used in conjunction with pharmacotherapy to improve efficacy.”

  • Natural Cycles is a birth control app created by a Sweden-based company of the same name. It was approved by the FDA in 2018. This mobile app helps women track their fertility to prevent unwanted pregnancies via the rhythm method. The app analyzes data from past menstrual cycles and body temperature readings to determine when the user is most fertile. On the days the user is most likely to be ovulating, the app displays “Use Protection” on the mobile device’s screen. 

“We know that women are more likely to use contraceptive methods when they have a variety of methods available to them, and the reality is that not every method is going to work for every woman,” Rebecca Simmons, PhD, Research Assistant Professor, Department of Obstetrics and Gynecology, University of Utah, told Health. “This is really exciting, in the sense that the more methods we have, the more likely it is that people can find something that works for them—and then can avoid unwanted pregnancy.”

  • Apple, headquartered in Cupertino, Calif., received FDA clearance in 2018 for an electrocardiogram (ECG) app for its Apple Watch Series 4 that allows users to take an ECG from their wrist to detect irregular heart rhythms and atrial fibrillation (AFIB).

“The role that technology plays in allowing patients to capture meaningful data about what’s happening with their heart—at the moment when it’s happening, like the functionality of an on-demand ECG—could be significant in new clinical care models and shared decision-making between people and their healthcare providers,” said Nancy Brown, CEO of the American Heart Association, in a press release.

Patients, Providers, and Big Pharma All Like Digital Therapeutics

There is some evidence that patients and healthcare providers are intrigued and willing to try digital therapeutics. In a PwC HRI survey, more than 50% of respondents said they “would be somewhat or very likely to try an FDA-approved app or online tool for treatment of a medical condition.”

The graphic above is taken from the PwC HRI 2019 annual report on digital therapeutics and connected care. It shows that “a majority of consumers surveyed are interested in FDA approved digital apps or online tools to treat their medical conditions.” (Graphic copyright: PwC HRI.)

Pharmaceutical companies also are interested in digital therapeutics. A 2018 PwC HRI survey found that 80% of pharmaceutical executives had plans to invest in digital therapeutics in the near future.

A 2019 PwC article, titled, “Digital Health Products Need Evidence and Buy-In to Succeed,” states that drug companies see the following opportunities for DTx to improve the patient experience: 

  • Digital product support and educational tools,
  • Patient adherence and compliance programs,
  • Remote patient monitoring,
  • Data sharing with healthcare providers, and
  • Caregiver tools and support.

With precision medicine and pharmacogenetics, clinical laboratories could play an essential role in supporting digital therapeutics in the future. But to truly be competitive in this space and take advantage of the opportunity, medical laboratories will need to increase their information technology and digital capabilities.

—JP Schlingman

Related Information:

Digital Therapeutics and Connected Care Reshape the Life Sciences Industry

The Emerging World of Digital Therapeutics

Top Health Industry Issues of 2019: The New Health Economy Comes of Age

Digital Therapeutics: Combining Technology and Evidence-based Medicine to Transform Personalized Patient Care

Everything You Need to Know About the Controversial New Birth Control App

Digital Health Software Precertification (Pre-Cert) Program

Sandoz Inc. and Pear Therapeutics Obtain FDA Clearance for Reset-O to Treat Opioid Use Disorder

Everything You Need to Know About the Controversial New Birth Control App

More than Half of Patients Willing to Use Digital Therapeutic, Study Says

ECG App and Irregular Heart Rhythm Notification Available Today on Apple Watch

Digital Health Products Need Evidence and Buy-in to Succeed

Life Sciences May See Accelerated Digital Health Pathway as Soon as 2020

;