• Daniel Shepshelovich, Ariadna Tibau, Hadar Goldvaser, Consolación Molto, Alberto Ocana, Bostjan Seruga, and Eitan Amir.
• Daniel Shepshelovich, Hadar Goldvaser, and Eitan Amir, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada; Daniel Shepshelovich and Hadar Goldvaser, Tel-Aviv University, Tel Aviv, Israel; Ariadna Tibau and Consolación Molto, Hospital de la Santa Creu i Sant Pau and Universitat Autònoma de Barcelona, Barcelona; Alberto Ocana, Castilla La Mancha University, Albacete, Spain; and Bostjan Seruga, Institute of Oncology Ljubljana, Ljubljana, Slovenia.
• J. Clin. Oncol. 2018 Jun 20; 36 (18): 1798-1804.

AbstractPurpose Modifications in cancer drug indications, dosing, and related toxicities after Food and Drug Administration approval are common. It is unclear whether drug approval without a supporting randomized controlled trial (RCT) influences the probability of such modifications. Methods We searched the Drugs@FDA Web site for new drug indications for solid tumors approved between January 2006 and December 2016. Study characteristics, regulatory pathways, and label modifications from approval to October 2017 were collected from drug labels. Label modifications were considered to be major if defined as such in the drug label. Indications approved with and without supporting RCTs were compared using logistic regression. The Benjamini-Hochberg false discovery rate method was used to adjust for multiplicity. Results We identified 59 individual drugs for 109 solid tumor indications. Of these, 17 indications (15.6%) were not supported by an RCT, with no change over time. Indications not supported by RCTs were more likely to require companion diagnostic tests (odds ratio [OR], 3.90; P = .02), to include surrogate end points as primary outcomes (OR, 7.88; P < .001), and to receive breakthrough therapy designation (OR, 7.62; P = .006) or accelerated approval (OR, 17.67; P < .001). Indications not supported by RCTs were associated with significantly higher odds of postapproval modifications in common adverse events (71% v 29%; OR, 5.78; P = .002). A nonsignificantly higher odds of postapproval major modifications in warnings and precautions was also observed (88% v 62%; OR, 4.61; P = .051). Postapproval major modifications in indication and usage, dosing and administration, boxed warnings, and contraindications were comparable in the two groups. Conclusion Cancer drug indications not supported initially by RCTs are associated with more postmarketing safety-related label modifications. Health care professionals should be vigilant for unrecognized adverse effects when prescribing drugs approved without a supporting RCT.

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