[Federal Register Volume 83, Number 220 (Wednesday, November 14, 2018)]
[Notices]
[Pages 56845-56852]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-24785]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration
[Docket No. FDA-2017-N-1779]
Agency Information Collection Activities; Submission for Office
of Management and Budget Review; Comment Request; Disclosures of
Descriptive Presentations in Professional Oncology Prescription Drug
Promotion
AGENCY: Food and Drug Administration, HHS.
ACTION: Notice.
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SUMMARY: The Food and Drug Administration (FDA or Agency) is announcing
that a proposed collection of information has been submitted to the
Office of Management and Budget (OMB) for review and clearance under
the Paperwork Reduction Act of 1995.
DATES: Fax written comments on the collection of information by
December 14, 2018.
ADDRESSES: To ensure that comments on the information collection are
received, OMB recommends that written comments be faxed to the Office
of Information and Regulatory Affairs, OMB, Attn: FDA Desk Officer,
Fax: 202-395-7285, or emailed to [email protected]. All
comments should be identified with the OMB control number 0910-NEW and
title ``Disclosures of Descriptive Presentations in Professional
Oncology Prescription Drug Promotion.'' Also include the FDA docket
number found in brackets in the heading of this document.
FOR FURTHER INFORMATION CONTACT: Ila S. Mizrachi, Office of Operations,
Food and Drug Administration, Three White Flint North, 10A-12M, 11601
Landsdown St., North Bethesda, MD 20852, 301-796-7726,
[email protected].
SUPPLEMENTARY INFORMATION: In compliance with 44 U.S.C. 3507, FDA has
submitted the following proposed collection of information to OMB for
review and clearance.
Disclosures of Descriptive Presentations in Professional Oncology
Prescription Drug Promotion
OMB Control Number--0910-NEW
I. Background
Section 1701(a)(4) of the Public Health Service Act (42 U.S.C.
300u(a)(4)) authorizes FDA to conduct research relating to health
information. Section 1003(d)(2)(C) of the Federal
[[Page 56846]]
Food, Drug, and Cosmetic Act (FD&C Act) (21 U.S.C. 393(d)(2)(C))
authorizes FDA to conduct research relating to drugs and other FDA
regulated products in carrying out the provisions of the FD&C Act.
Under the FD&C Act and implementing regulations, promotional
labeling and advertising about prescription drugs are generally
required to be truthful, non-misleading, and to reveal facts material
to the presentations made about the product being promoted (see
sections 502(a) and (n), and 201(n) of the FD&C Act (21 U.S.C. 352(a)
and (n), and 321(n)); see also 21 CFR 202.1). As a part of the ongoing
evaluation of FDA's regulations in this area, FDA is proposing to study
the impact of disclosures as they relate to presentations of
preliminary and/or descriptive scientific and clinical data in
promotional labeling and advertising for oncology products. The use of
disclosures is one method of communicating information to healthcare
professionals about scientific and clinical data, the limitations of
that data, and practical utility of that information for use in
treatment. These disclosures may influence prescriber comprehension and
decision making and may affect how and what treatment they prescribe
for their patients.
Pharmaceutical companies market directly to physicians through
means that include publishing advertisements in medical journals,
exhibit booths at physician meetings or events, sending unsolicited
promotional materials to doctors' offices, and presentations
(``detailing'') by pharmaceutical representatives (Ref. 1). Research
suggests that detail aids sometimes contain carefully extracted data
from clinical studies that, taken out of context, can exaggerate the
benefits of a drug (Ref. 2) or contribute to physicians prescribing the
drug for an inappropriate patient population.
Promotional labeling and advertising for cancer drugs deserve
specific attention. Oncology drugs represented 26 percent of the 649
compounds under clinical trial investigation from 2006 to 2011 (Ref.
3). The past decade has seen a dramatic rise in the number of oncology
drugs brought to market. In the past 18 months, over 22 percent of new
drug approvals at FDA were new cancer drugs. In that time period, FDA
approved 16 cancer drugs as new molecular entities or new therapeutic
biologics out of a total of 72 (this does not include approvals of
benign hematology products or biological license application approvals
of blood reagents, or assays and anti-globulin products used in testing
kits) (Refs. 4 and 5). Although overall survival remains the gold
standard for demonstrating clinical benefit of a cancer drug, several
additional endpoints including progression free survival, disease-free
or recurrence-free survival, or durable response rate (including
hematologic response endpoints) are accepted for either regular or
accelerated approval depending on the magnitude of effect, safety
profile, and disease context (Ref. 6). In addition to the endpoints
upon which FDA approval of these products may be based, pharmaceutical
companies typically assess many other endpoints to further explore the
effects of their products. Some trials are designed to allow for formal
statistical analyses of these additional endpoints; however, in many
cases these endpoints are strictly exploratory and support only the
reporting of descriptive results. For clinicians who are not
specifically trained in clinical trial design, interpreting these
endpoints may be challenging. Pharmaceutical companies invest heavily
in the development and distribution of promotional materials to make
oncologists aware of favorable clinical trial results.
When communicating scientific and clinical data, a specific
statement that modifies or qualifies a claim (referred to for the
purposes of this document as a disclosure) could be used to convey the
limitations of the data and practical utility of the information for
treatment. Much of the prior research on disclosures in this topic area
has been limited to the dietary supplement arena with consumers (Refs.
7 to 10). Disclosures in professional pieces could influence prescriber
comprehension as well as subsequent decision making; however, no
published data exist regarding how prescribers use and understand
scientific claims in conjunction with qualifying disclosures.
The proposed study seeks to address the following research
questions:
1. Do disclosures mitigate potentially misleading presentations of
preliminary and/or descriptive data in oncology drug product promotion?
2. Does the language (technical, non-technical) of the disclosure
influence the effectiveness of the disclosure?
3. Does the presence of a general statement about the clinical
utility of the data in addition to a specific disclosure influence
processing of claims and disclosures?
4. Do primary care physicians (PCPs) and oncologists differ in
their processing of claims and disclosures about preliminary and/or
descriptive data?
5. Which disclosures do physicians prefer?
To address these questions, FDA has designed a study that will be
conducted in three independent phases, each phase examining a data
display in a promotional piece for a unique oncology or hematology
product. Independent variables will include: (1) Specific disclosure
(technical, non-technical, none), (2) general statement (present,
absent), and (3) specialty (PCPs, oncologists). Each phase will have
the following design:
----------------------------------------------------------------------------------------------------------------
Specific disclosure
Sample General statement ------------------------------------------------------------
Technical Non-technical No disclosure
----------------------------------------------------------------------------------------------------------------
Oncologists.................... Present........... Control.
Absent............ .......................
PCPs........................... Present........... Control.
Absent............ .......................
----------------------------------------------------------------------------------------------------------------
Specific disclosures will include material information specifically
related to the particular data display in question. As such, each
specific disclosure may include clinical or statistical information
related to the trial design, the statistical analysis plan of the
trial, or any other material statistical or clinical information
necessary for evaluation or interpretation of the data. The team
developing the disclosures includes social science analysts,
pharmacists, oncological medical officers, statisticians, and an
oncology nurse. An example of the general statement is ``This
presentation includes exploratory information of uncertain clinical
utility and should be interpreted cautiously when used to make
treatment decisions.''
[[Page 56847]]
Outcome (dependent) variables will focus on the assessment of the
data display as a whole as well as attention to the disclosure, if
present. Specifically, we will examine recognition of the clinical
endpoint in the data display, comprehension of the data display,
perceptions of the strength of the data, and the perceived credibility
of the promotional piece. We will also look at attention to the
specific disclosure and the general statement, prescriber decisions,
and prescriber preferences. Preferences will be determined by a
secondary task at the end of the questionnaire that shows each
participant all disclosure options and asks them to choose their
preferred version.
Oncologists and PCPs will be recruited to participate via the
internet. We plan to conduct one pretest with 90 participants and one
study with 2,115 participants, both of which are expected to take
approximately 20 minutes. Voluntary participants will view
professionally developed promotional pieces that mimic currently
available promotion and answer questions.
In the Federal Register of Monday, June 19, 2017 (82 FR 27845), FDA
published a 60-day notice requesting public comment on the proposed
collection of information (see above). Comments received along with our
responses to the comments are provided below. Comments that are not
PRA-relevant or do not relate to the proposed study are not included.
For brevity, some public comments are paraphrased and therefore may not
reflect the exact language used by the commenter. We assure commenters
that the entirety of their comments was considered even if not fully
captured by our paraphrasing. The following acronyms are used here: FRN
= Federal Register Notice; DTC = direct-to-consumer; HCP = healthcare
professional; PCP = primary care physicians; FDA = Food and Drug
Administration; OPDP = FDA's Office of Prescription Drug Promotion.
The first public comment responder (regulations.gov tracking number
1k1-8xz7-mwcd) included eight individual comments, to which we have
responded.
Comment 1: ``It is unclear why FDA has chosen to conduct a study
focused on oncology therapeutics and those medical specialists who
prescribe such products.'' [verbatim] All prescription drug products
are treated the same according to regulations; therapeutic intent and
prescriber type do not invoke alternate regulatory approaches.
Response: As we described in the 60-day Federal Register notice,
promotional activities for oncology drugs are frequent and pervasive.
Promotional labeling and advertising for cancer drugs deserve specific
attention. Oncology drugs represented 26 percent of the 649 compounds
under clinical-trial investigation from 2006 to 2011 (Ref. 3). The past
decade has seen a dramatic rise in the number of oncology drugs brought
to market. In the past 18 months, over 22 percent of new drug approvals
at FDA were new cancer drugs. In that time period, FDA approved 16
cancer drugs as new molecular entities or new therapeutic biologics out
of a total of 72 (this does not include approvals of benign hematology
products or biological license application approvals of blood reagents,
or assays and anti-globulin products used in testing kits) (Refs. 4 and
5). Although overall survival remains the gold standard for
demonstrating clinical benefit of a cancer drug, several additional
endpoints including progression free survival, disease-free or
recurrence-free survival, or response rate (including hematologic
response endpoints) are accepted for either regular or accelerated
approval depending on the magnitude of effect, safety profile, and
disease context (Ref. 6). In addition to the endpoints upon which FDA
approval may be based, pharmaceutical companies typically assess many
other endpoints to further explore the effects of their products. Some
trials are designed to allow for formal statistical analyses of these
additional endpoints; however, in many cases these endpoints are
strictly exploratory and support only the reporting of descriptive
results. For clinicians who are not specifically trained in clinical
trial design, interpreting these endpoints can be challenging.
Pharmaceutical companies invest heavily in the development and
distribution of promotional materials to educate oncologists about
favorable clinical trial results.
As another public comment responder (regulations.gov tracking
number 1k1-8y3p-o6qb) notes, ``We agree with the FDA's assessment that
dedicated research is necessary regarding oncology drug promotion,
particularly given that a significant proportion of the drug
development pipeline is comprised of oncology products . . .''
Comment 2: FDA should use a more targeted approach, including a
monadic design with 100 oncologists split into two experimental
conditions.
Response: To clarify the study design, we are testing two
variations of disclosure (specific disclosure: Technical, non-
technical), two variations of general statement (general statement:
Present or absent), plus a control (control: No specific disclosure).
Participants will be healthcare professionals who are members of one of
two medical populations and will be randomly assigned to one condition.
Because we are examining the effects of multiple variables and their
interactions, the necessary sample sizes will be larger than those
suggested in this comment based on power analyses. We have, however,
changed the study design based on multiple comments and will now
examine only oncologists and primary care physicians.
Comment 3: The length of the survey looks long--at 17 pages, it
appears that it will take approximately 30-40 minutes to complete.
Response: We have tested the survey in-house with individuals
unfamiliar with the research project, and it appears that this survey
will take approximately 15 minutes to complete.
Comment 4: Instead of using recall as a measure, respondents should
be allowed to have access to the materials while answering questions to
better approximate their actual experiences.
Response: It is an open question as to whether having the materials
in front of them better approximates actual HCP experiences. In past
discussions with HCPs, some have reported that they do refer back to
materials that sales representatives leave, and others report that they
do not receive leave-behind materials or do not refer to them again. In
any case, we have a mixture of recall and comprehension questions in
our questionnaire. For the recall questions, respondents will not be
able to access the materials. They will, however, be able to review the
materials while answering the comprehension questions.
Comment 5: Why is FDA examining non-oncologists at all? Why are you
screening out oncology for specialists in question SPECIALTY2?
Response: HCPs of all types are exposed to prescription drug
promotion. Depending on location (e.g., rural areas) and type of
clinical setting, some non-oncologists may have a need to consider
oncologic prescription drugs to treat their patients. We agree that
oncologists are the most relevant population to study in this research.
However, we also want to know whether specific education and experience
influence the processing of claims, data, and disclosures. Upon further
review, we agree that nurse practitioners and physician assistants
without oncology experience are not a necessary group to investigate to
answer our particular research questions. We intend to use PCPs as a
control group to understand whether specific advanced training
[[Page 56848]]
influences the understanding of preliminary and/or descriptive oncology
data. Some PCPs may have experience with oncology prescriptions,
particularly in rural areas. We will not eliminate PCPs without
oncology experience, but we will measure oncology prescribing
experience and use this variable as a covariate in our studies.
Comment 6: FDA should screen for the prescribing of oncologic
products.
Response: Although we do not intend to screen out physicians
without oncology prescribing experience, we will measure this variable
and use this information to determine whether it plays a role in the
responses of PCPs.
Comment 7: From this point (ENDPOINT) responses may be based on the
ability of respondents to recall information vs. the absence/presence
of disclosures. If FDA continues with this design, the Agency should be
prepared to control for this in the study design.
Response: Because this is an experimental design with random
assignment to condition, any fatigue with questions that may affect the
recall of information should fall out evenly across conditions.
Therefore, any differences would be the result of our manipulations, in
this case, the presence and form of disclosures. We have given thought
to the ordering of the questions so that the most important questions
are asked in the beginning of the survey rather than toward the end.
Comment 8: The answer to this question (CAUTIOUS) may be influenced
more by personal and subjective opinion vs. the content of the
disclosure.
Response: Because of the experimental design with random assignment
to condition, personal and subjective opinions should be evenly and
randomly spread across experimental conditions. However, upon further
review, we have determined that this question has limited utility and
we will delete it.
The second public comment responder (regulations.gov tracking
number 1k1-8y3p-o6qb) included one individual comment. They reported
that they support the study specifically and OPDP's overall research
efforts generally, and they agree that oncology deserves special
attention. We thank this commenter for taking the time to provide this
comment to us.
The third public comment responder (regulations.gov tracking number
1k1-8y5u-5vp0) included eight individual comments, to which we have
responded.
Comments 1 and 2: The commenter supports FDA social science
research and this specific project, as well as the Disclosures study
(Docket No. FDA-2017-N-0558). ``FDA's collective research indicates a
considered, objective updating of the FDA's advertising regulations,
including the use of disclosures to prevent misleading claims in
advertisements for oncology products, is timely . . . . Enabling
disclaimers would be one way to enable innovators to advertise new
oncology therapeutics for their approved uses in ways which would be
non-misleading.''
Response: Thank you for your support.
Comment 3: The commenter suggests making sure that primary care
physicians and advanced practitioners have experience in the oncology
field--otherwise, it seems useless to include less knowledgeable
respondents whose answers are more speculative. Overall, they question
whether advanced practitioners are appropriate for this study at all.
Response: We have removed advanced practitioners from the design.
We will measure the oncology prescribing experience of the PCPs in our
sample, but we will not eliminate those who do not have specific
oncology training. One of our research questions is whether specific
training and experience in oncology influences the understanding of
preliminary oncology data. To do that, we need to include a group of
practitioners who may not have specific training and experience in
oncology, but who are licensed practitioners permitted by law to
prescribe oncology drugs, and who, in some cases, may do so.
Comment 4: If the only data being presented for BENEFICIAL,
EVIDENCE1 and EVIDENCE2 are the endpoints for the disclosure without
presenting overall survival or more clinically validated data, we
suggest removing these questions.
Response: The pieces include other clinically validated data as
would be typical in an existing piece for an oncology indication.
Comment 5: Remove CONFUSING2 because it asks physicians to
speculate.
Response: As this item is a perception measure, as opposed to an
accuracy measure, it is reasonable to consider some level of
speculation. Moreover, in cognitive testing, HCPs responded without
difficulty.
Comment 6: For SCRIPT4, add an ``I don't know'' option instead of
instructing respondents to ``make your best guess.''
Response: This item was cognitively tested and participants
expressed no difficulty answering it.
Comment 7: Those who respond ``not at all familiar'' to FAMILIAR
should skip BTKNOW1, BTKNOW2, and ACCEL.
Response: We agree with this comment. Those who respond ``not at
all familiar'' to FAMILIAR will skip the three items mentioned above.
Comment 8: BTDV1 and BTDV2 present incomplete data and therefore it
is unclear how this will be a useful question. The commenter suggests
either adding an ``I need more information'' option or removing the
question.
Response: These items present incomplete data but we have provided
enough data that HCPs should be able to make a choice. HCPs in
cognitive testing exhibited no difficulty with the question. There is
no existing data on perceptions of FDA's ``breakthrough'' designation
and this item will provide at least rudimentary information. Please
note that each respondent will see only one of the items. These items
are carefully crafted to avoid order effects and alphabetical effects.
The fourth public commenter (regulations.gov tracking number 1k1-
8y5u-koc0) included 15 individual comments, to which we have responded.
Comment 1 (summarized): The commenter is concerned with the
Agency's recent approaches to studies in this area. FDA has proposed to
undertake projects in a variety of disparate topics without
articulating a clear, overarching research agenda or adequate
rationales on how the proposed research related to the goal of further
protecting public health. Within the last year, the Agency has
increased such efforts at an exponential pace. At times, FDA proposes
new studies seemingly without fully appreciating its own previous
research published on the Office of Prescription Drug Promotion (OPDP)
website. Proposed studies are often unnecessary in light of existing
data. The commenter suggests that the Agency publish a comprehensive
list of its prescription drug advertising and promotion studies from
the past five years and articulate a clear vision for its research
priorities for the near future. Going forward, FDA should use such
priorities to explain the necessity and utility of its proposed
research and should provide a reasonable rationale for the proposed
research.
Response: OPDP's mission is to protect the public health by helping
to ensure that prescription drug information is truthful, balanced, and
accurately communicated, so that patients and healthcare providers can
make informed decisions about
[[Page 56849]]
treatment options. OPDP's research program supports this mission by
providing scientific evidence to help ensure that our policies related
to prescription drug promotion will have the greatest benefit to public
health. Toward that end, we have consistently conducted research to
evaluate the aspects of prescription drug promotion that we believe are
most central to our mission, focusing in particular on three main topic
areas: Advertising features, including content and format; target
populations; and research quality. Through the evaluation of
advertising features we assess how elements such as graphics, format,
and disease and product characteristics impact the communication and
understanding of prescription drug risks and benefits; focusing on
target populations allows us to evaluate how understanding of
prescription drug risks and benefits may vary as a function of
audience; and our focus on research quality aims at maximizing the
quality of research data through analytical methodology development and
investigation of sampling and response issues. Because we recognize the
strength of data and the confidence in the robust nature of the
findings is improved through the results of multiple converging
studies, we continue to develop evidence to inform our thinking. We
evaluate the results from our studies within the broader context of
research and findings from other sources, and this larger body of
knowledge collectively informs our policies as well as our research
program. Our research is documented on our homepage, which can be found
at: https://www.fda.gov/aboutfda/centersoffices/officeofmedicalproductsandtobacco/cder/ucm090276.htm. The website
includes links to the latest Federal Register notices and peer-reviewed
publications produced by our office. The website maintains information
on studies we have conducted, dating back to a survey of DTC attitudes
and behaviors conducted in 1999.
Comment 2: FDA should provide more detail about the study to
stakeholders. ``It is not clear from this description whether the study
will yield useful information to evaluate whether disclosures provide
appropriate contextual information in certain communications, whether
such disclosures can be made more effective, and where the disclosures
are necessary to ensure communications are truthful and non-
misleading.''
Response: We have described the purpose of the study, the design,
the population of interest, and have provided the questionnaire to
numerous individuals upon request. These materials have proven
sufficient for others to comment publicly, and for academic experts to
peer-review the study successfully. Our full stimuli are under
development during the PRA process. We do not make draft stimuli public
during this time because of concerns that this may contaminate our
participant pool and compromise the research.
Comment 3: The Agency should wait until it has completed its
broader study on disclosures more generally. This study is duplicative
of other studies.
Response: As we discussed in the 60-day Federal Register notice,
oncological products deserve specific attention as they account for
nearly a quarter of new drug approvals and can involve the assessment
of complicated endpoints. Moreover, they have specific disclosures that
are unique to their products and deserve particular study. The other
disclosures study (Docket No. FDA-2017-N-0558) will provide important
information about a variety of disclosures in different medical
conditions. One research study cannot answer all questions or study all
aspects of an issue. These two studies will be complementary but not
redundant. Please also refer to our response to comment 1 from the
first commenter above.
Comment 4: Given that FDA grants approval based on certain
preliminary and descriptive data, and that various limitations as to
the underlying data must already be communicated to prescribers, there
appears to be limited utility in researching disclosures regarding such
data.
Response: We disagree that FDA grants approval on preliminary or
descriptive data. The evidentiary standard is substantial evidence.
While we recognize that no single development program can answer all
questions about a particular drug in all populations, it is not
accurate to describe the evidence supporting approval as descriptive or
preliminary. What is potentially unique about oncology products is that
many are approved under accelerated approval, in which the substantial
evidence of benefit is on a surrogate endpoint that is reasonably
likely to predict a clinical outcome. There remains some residual
uncertainty regarding whether the effect on a surrogate endpoint will
directly correlate with a clinical benefit; however, there is a
requirement that confirmatory evidence of clinical benefit be obtained
after approval. This residual uncertainty about the relationship of the
surrogate endpoint to the clinical benefit is communicated to
prescribers through the FDA-required labeling (e.g., inclusion of a
limitation of use in the Indications and Usage section of the FDA-
required labeling). In addition, reliance on a surrogate endpoint under
accelerated approval is only done for serious diseases when the
evidence indicates that the product provides a meaningful therapeutic
benefit to patients over existing treatments (21 CFR 314.500).
However, this study does not focus on endpoints that formed the
basis for approval. This study focuses on promotional displays of
preliminary and/or descriptive data. It has not been established
whether and how current disclosure-type additions to promotion are
adequately communicating the limitations around this type of data, and
that is the purpose of the current study. Given the importance of these
limitations, it is crucial to make sure that promotional materials
directed at to prescribers convey limitations appropriately. Past
research has shown that simply including a statement somewhere in a
promotional piece does not grant it automatic usefulness (Refs. 7 to
10).
Comment 5: FDA notes that, ``[a]lthough overall survival remains
the gold standard for demonstrating clinical benefit of a drug, several
additional endpoints are accepted as surrogates . . . [including]
disease-free survival, objective response rate, complete response rate,
progression-free survival, and time to progression.'' The Agency
further states that ``[f]or clinicians who are not specifically trained
in clinical trial design, interpreting these endpoints may be
challenging.'' FDA does not cite any sources for this claim, and there
is no basis for thinking that clinicians do not have a thorough
understanding of the data limitations described in presentations of
preliminary or descriptive scientific and clinical data. This is
especially true of oncologists.
Response: This statement was not intended to be a claim, but rather
a statement of concern. Studies report that physicians lack sufficient
critical knowledge and skills to evaluate evidence based medicine (EBM)
and may be influenced by the way study results are presented (Refs. 11
to 13). FDA recently conducted a systematic review of research related
to prescribers' training and critical appraisal skills related to
clinical trials (Ref. 14). The study found that extant physician
knowledge and skills regarding certain statistical concepts and trial
designs were in the middle of the possible outcome score range, at
levels below those considered mastery, even after
[[Page 56850]]
interventions designed to increase knowledge and skills. Evidence
suggested that clinical credentials affect understanding and use of
clinical data. Physicians with formal training in biostatistics,
epidemiology, clinical research, or EBM demonstrated higher levels of
knowledge and appraisal skills than those with usual medical education
and training.
Comment 6: The specific disclosures outlined by FDA include
``clinical or statistical information related to the trial design, the
statistical analysis plan of the trial, or any other material
statistical or clinical information necessary for evaluation or
interpretation of the data.'' The breadth of the proposed specific
disclosures appears burdensome, unnecessary, and overwhelming for the
purposes of the proposed survey.
Response: These concepts were provided as examples of the types of
information that may be necessary for the accurate evaluation or
interpretation of the data. This statement was not meant to imply that
all of these concepts would be included in disclosures used in this
study.
Comment 7: PCPs and non-oncology mid-level practitioners will
provide much less utility in their survey responses regarding such
disclosures.
Response: We have changed the design. See previous comments and
responses.
Comment 8: The Agency proposes to conduct its survey via electronic
media. FDA should consider testing non-electronic media, including
printed sales aids, as these forms are often reviewed by the proposed
study subjects.
Response: To clarify, the stimuli presented will consist of mock
print materials in .pdf format, administered via the internet.
Conducting the study in person would require a greater expenditure of
resources without appreciable benefits.
Comment 9: The Agency should consider using a consistent sliding
scale format for all survey responses. Just within pages 7-9 of the
survey, FDA proposes numerous different schemes for survey responses:
(1) ``Not at all beneficial--Extremely beneficial;'' (2) ``Completely
agree--Completely disagree;'' (3) ``No evidence--Strong (or conclusive)
evidence;'' (4) ``Not at all complex--Extremely complex;'' (5) ``Not at
all confusing--Extremely confusing;'' and (6) additional responses in
which subjects are asked to agree with certain statements. The variety
in response options is confusing in format and could potentially
introduce error. To the extent possible, FDA should make the response
format consistent throughout the survey. Further, the Agency should
ensure the sliding scale format consistently provides an odd number of
responses to permit a ``neutral'' response. Certain questions (e.g.,
the IMPROVE question on page 7) provide six choices, not permitting a
neutral response.
Response: Although one scale throughout would be easier for
respondents, it will not necessarily provide better data. When a series
of adjacent questions have the same response options, respondents may
use a response mechanism known as anchoring and adjusting when
reporting (Ref. 15). Respondents use their response to the initial
survey question on a topic as the ``cognitive anchor,'' and then adjust
up or down based on subsequent questions (Ref. 16). Anchoring and
adjusting is more likely to occur for questions when respondents have
some level of uncertainty in their answer (Ref. 17), which would be
expected in this study. Epley and Gilovich (Ref. 17) found that when
respondents use an anchoring and adjusting strategy, they often adjust
insufficiently. Respondents start with the response they used for the
first item and then search for the next value that is ``close enough.''
This can result in responses to adjacent items being more similar than
responses to the same items if they used an item-specific scale (Not at
all beneficial to Extremely beneficial; Not at all complex to Extremely
complex). Using the same scale across all survey questions would
artificially increase the correlations between all questions making it
more difficult to identify differences based on the stimuli or
respondent characteristics. Furthermore, use of item-specific scales
compared with agree-disagree scales reduces primacy effects (tendency
of respondents to select options at the beginning of the list) (Ref.
18), and increases reliability and validity (Ref. 19). Careful
consideration was made to use agree-disagree scales only when item-
specific scales would not be appropriate (e.g., presenting patient
vignettes) or unnecessarily complex (e.g., asking about ``complex
terminology, statistical terms, or jargon,'' inquiring about ``strong''
evidence).
In terms of neutral points, given the focus of the questions, we
believe that offering a neutral response option is not necessary to
measure opinions and attitudes accurately. Consequently, our objective
is to force a selection and have participants make at least a weak
commitment in either a positive or negative direction. Of concern is
that offering a neutral midpoint could potentially encourage
``satisficing''--cuing participants to choose a neutral response
because it is offered (Ref. 20). Additionally, providing a midpoint
leads to the loss of information regarding the direction in which
people lean (Ref. 21). Research has found that neither format (either
with or without a neutral point) is necessarily better or produces more
valid or reliable results (Ref. 22). Instead, it should be left to the
researcher to determine the goals of the study. During cognitive
testing, a majority of participants were satisfied with the response
options and all participants felt comfortable choosing a response in
the absence of a midpoint.
Use of a midpoint is an issue we have examined in previous studies
and we determined that we achieve valid and reliable responses without
a midpoint. To increase consistency with measures used in previous
studies, and in support of the arguments presented above, we are opting
to exclude a midpoint. Finally, if a participant does not feel that
they can choose a response because of a lack of a neutral option, they
will be able to skip the question.
Comment 10: In the BENEFICIAL question on page 7 of the survey, it
is unclear what relevance the subject's perception of clinical benefit
of a drug has in studying FDA's proposed research purpose.
Response: For prescription drug products, advertisers must ensure
that both the benefits and limitations are appropriately conveyed. If
limitations are not appropriately conveyed, viewers may have an
inflated view of the benefits of the product, relative to its risks.
This question investigates this issue.
Comment 11: In a study setting, subjects may be prone to read and
pay attention to more or all of the information presented. Subjects
also are more aware of the importance of their responses. The Agency
should address what efforts it will take to avoid response bias by
study subjects.
Response: We initially had this concern many years ago when OPDP
began conducting research. However, since that time, we have seen no
evidence of this bias. In fact, we often deal with the opposite
problem--ensuring that respondents spend a minimum amount of time
looking at mock materials. Moreover, cognitive testing participants
have told us that they would not spend extra time on materials if they
were answering questions without an interviewer in the room.
Individuals, especially HCPs, are busy, and we believe our experiments
do not overestimate the amount of time participants spend on actual
materials.
[[Page 56851]]
Comment 12: Although the draft survey did not contain Informed
Consent text, the Agency should ensure that this text does not state or
imply that the survey is being conducted on behalf of the U.S. Food and
Drug Administration. Such a statement could potentially influence
subjects' responses to study questions. Instead, this information might
be provided at the conclusion of the study.
Response: We will ensure that all materials reference the U.S.
Department of Health and Human Services rather than FDA.
Comment 13: The CAUTIOUS question on page 8 should be rephrased or
omitted. Subjects may be biased to respond that they interpret all data
with caution, regardless of the underlying scientific evidence
presented in study stimuli.
Response: We agree with this comment and will delete this item.
Comment 14: The DECISIONS question on page 8 should be omitted. How
survey participants ``feel about the data presented'' will be highly
dependent on their external experience in making prescribing decisions.
This question thus may lead to highly variable results.
Response: Because this is an experimental design with random
assignment to conditions, external experiences in making prescribing
decisions should be randomly scattered across experimental conditions.
Thus, we will be able to infer causation to our manipulations of
disclosures if we find any differences across experimental conditions.
We believe the presence and form of the disclosure may influence this
dependent variable and believe it will reveal important information
about how HCPs process the data.
Comment 15: The PREFERENCE and PREFERWHY questions on page 16
should be moved to the beginning of the survey or omitted altogether.
Subjects' responses regarding their preference in sales aid disclosure
statements will be heavily influenced by earlier portions of the
survey.
Response: We have given careful thought to the ordering of the
questions in the questionnaire. Because preference is of secondary
interest to us, we have included it after our primary outcome
variables, so that it does not influence them. We recognize that prior
questions may influence these measures and will interpret them with
that caveat in mind.
FDA estimates the burden of this collection of information as
follows:
Table 1--Estimated Annual Reporting Burden \1\
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number of
Activity Number of responses per Total annual Average burden per response \2\ Total hours
respondents respondent responses
--------------------------------------------------------------------------------------------------------------------------------------------------------
Pretest Study Screener Completes............ 150 1 150 0.03 (2 minutes).......................... 5
Main Study Screener Completes............... 3,525 1 3,525 0.03 (2 minutes).......................... 106
Pretest Study............................... 90 1 90 0.33 (20 minutes)......................... 30
Main Study.................................. 2,115 1 2,115 0.33 (20 minutes)......................... 698
-----------------------------------------------------------------------------------------------------------
Total................................... .............. .............. .............. .......................................... 839
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ No capital costs or operating and maintenance costs are associated with collection of this information.
\2\ Burden estimates of less than 1 hour are expressed as a fraction of an hour in decimal format.
II. References
The following references marked with an asterisk (*) are on display
at the Dockets Management Staff (HFA-305), Food and Drug
Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852, and
are available for viewing by interested persons between 9 a.m. and 4
p.m., Monday through Friday; they also are available electronically at
https://www.regulations.gov. References without asterisks are not on
public display at https://www.regulations.gov because they have
copyright restriction. Some may be available at the website address, if
listed. References without asterisks are available for viewing only at
the Dockets Management Staff. FDA has verified the website addresses,
as of the date this document publishes in the Federal Register, but
websites are subject to change over time.
*1. Johar, K., ``An Insider's Perspective: Defense of the
Pharmaceutical Industry's Marketing Practices,'' Albany Law Review,
76:299-334, 2012-2013.
*2. Wick, C., M. Egger, S. Trelle, et al., ``The Characteristics of
Unsolicited Clinical Oncology Literature Provided by Pharmaceutical
Industry,'' Annals of Oncology, 18(9):1580-1582, 2007.
* 3. Fisher, J.A., M.D. Cottingham, and C.A. Kalbaugh, ``Peering
Into the Pharmaceutical `Pipeline': Investigational Drugs, Clinical
Trials, and Industry Priorities,'' Social Science & Medicine,
131:322-330, 2015.
4. Centerwatch, ``FDA Approved Drugs for Oncology,'' https://www.centerwatch.com/drug-information/fda-approved-drugs/therapeutic-area/12/oncology (accessed on October 5, 2018).
5. https://www.fda.gov/BiologicsBloodVaccines/DevelopmentApprovalProcess/BiologicalApprovalsbyYear/ucm596371.htm.
* 6. Beaver, J.A., L.J. Howie, L. Pelosof, et al., ``A 25-Year
Experience of U.S. Food and Drug Administration Accelerated Approval
of Malignant Hematology and Oncology Drugs and Biologics: A
Review,'' JAMA Oncology, 4:849-856, 2018.
* 7. Dodge, T. and A. Kaufman, ``What Makes Consumers Think Dietary
Supplements Are Safe and Effective? The Role of Disclaimers and FDA
Approval,'' Health Psychology, 26:513-517, 2007.
* 8. Dodge, T., D. Litt, and A. Kaufman, ``Influence of the Dietary
Supplement Health and Education Act on Consumer Beliefs About the
Safety and Effectiveness of Dietary Supplements,'' Journal of Health
Communication, 16(3):230-244, 2011.
* 9. Mason, M.J., D.L. Scammon, and X. Fang, ``The Impact of
Warnings, Disclaimers, and Product Experience on Consumers'
Perceptions of Dietary Supplements,'' The Journal of Consumer
Affairs, 41(1):74-99, 2007.
* 10. France, K.R. and P.F. Bone, ``Policy Makers' Paradigms and
Evidence From Consumer Interpretations of Dietary Supplement
Labels,'' The Journal of Consumer Affairs, 39(1):27-51, 2005.
* 11. Ghosh, A.K. and K. Ghosh, ``Translating Evidence-Based
Information into Effective Risk Communication: Current Challenges
and Opportunities,'' The Journal of Laboratory and Clinical
Medicine, 145(4):171-180, 2005.
* 12. Harewood, G.C. and L.M. Hendrick, ``Prospective, Controlled
Assessment of the Impact of Formal Evidence-Based Medicine Teaching
Workshop on Ability to Appraise the Medical Literature,'' Irish
Journal of Medical Science, 179(1):91-94, 2010.
* 13. Fritsche, L., T. Greenhalgh, Y. Falck-Ytter, et al., ``Do
Short Courses in Evidence Based Medicine Improve Knowledge and
Skills? Validation of Berlin Questionnaire and Before and After
Study of Courses in Evidence Based Medicine,'' British Medical
Journal, 325(7376):1338-1341, 2002.
* 14. Kahwati, L., D. Carmondy, N. Berkman,
[[Page 56852]]
et al., ``Prescribers' Knowledge and Skills for Interpreting
Research Results: A Systematic Review,'' Journal of Continuing
Education in the Health Professions, 37(2):129-136, 2017.
* 15. Tversky, A. and D. Kahneman,'' Judgment Under Uncertainty:
Heuristics and Biases,'' Science, 185(4157):1124-1131, 1974.
* 16. Gehlbach, H. and S. Barge, ``Anchoring and Adjusting in
Questionnaire Responses,'' Basic and Applied Social Psychology,
34(5):417-433, 2012.
* 17. Epley, N. and T. Gilovich, ``The Anchoring-and-Adjustment
Heuristic: Why the Adjustments are Insufficient,'' Psychological
Science, 17(4):311-318, 2006.
* 18. H[ouml]hne, J.K. and D. Krebs, ``Scale Direction Effects in
Agree/Disagree and Item-Specific Questions: A Comparison of Question
Formats,'' International Journal of Social Research Methodology,
21(1):91-103, 2017.
* 19. Saris, W.E., M. Revilla, J.A. Krosnick, et al., ``Comparing
Questions with Agree/Disagree Response Options to Questions with
Item-Specific Response Options'' Survey Research Methods, 4:61-79,
2010.
* 20. Krosnick, J.A. and S. Presser, ``Question and Questionnaire
Design,'' In: Handbook of Survey Research (pp. 263-314). Bingley,
United Kingdom: Emerald Group Publishing Limited, 2010.
21. Converse, J.M. and S. Presser, Survey Questions: Handcrafting
the Standardized Questionnaire, (No. 63). Thousand Oaks, CA: SAGE
Publications, 1986.
22. DeVellis, R.F., Scale Development: Theory and Applications,
(Vol. 26). Thousand Oaks, CA: SAGE Publications, 2016.
Dated: November 7, 2018.
Leslie Kux,
Associate Commissioner for Policy.
[FR Doc. 2018-24785 Filed 11-13-18; 8:45 am]
BILLING CODE 4164-01-P