Industry Guidance for Clinical Trial Imaging Endpoint Process Standards

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Industry Guidance for Clinical Trial Imaging Endpoint Process Standards Clinical Trial Imaging Endpoint Process Standards Guidance for Industry U.S. Department of Health and Human Services Food and Drug Administration Center for Drug Evaluation and Research (CDER) Center for Biologics Evaluation and Research (CBER) April 2018 Clinical/Medical Clinical Trial Imaging Endpoint Process Standards Guidance for Industry Additional copies are available from: Office of Communications, Division of Drug Information Center for Drug Evaluation and Research Food and Drug Administration 10001 New Hampshire Ave., Hillandale Bldg., 4th Floor Silver Spring, MD 20993-0002 Phone: 855-543-3784 or 301-796-3400; Fax: 301-431-6353; Email: [email protected] https://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/default.htm and/or Office of Communication, Outreach, and Development Center for Biologics Evaluation and Research Food and Drug Administration 10903 New Hampshire Ave., Bldg. 71, rm. 3128 Silver Spring, MD 20993-0002 Phone: 800-835-4709 or 240-402-8010; Email: [email protected] https://www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/default.htm U.S. Department of Health and Human Services Food and Drug Administration Center for Drug Evaluation and Research (CDER) Center for Biologics Evaluation and Research (CBER) April 2018 Clinical/Medical TABLE OF CONTENTS I. INTRODUCTION............................................................................................................. 1 II. BACKGROUND ............................................................................................................... 2 III. LOGISTICAL AND TECHNICAL CONSIDERATIONS ........................................... 3 A. Choice of Imaging Modality .......................................................................................................... 3 B. Is Centralized Image Interpretation Important for an Imaging-Based Primary Endpoint? . 3 C. Should Image Interpretation Be Blinded to Clinical Data? ....................................................... 4 D. How Often Should Imaging Evaluations Be Performed? ........................................................... 5 E. How Soon After Acquisition Should Images Be Interpreted? ................................................... 5 F. What Procedures Should Be Standardized for an Imaging-Based Clinical Trial Primary Endpoint? ....................................................................................................................................... 5 IV. THE EXTENT OF IMAGING PROCESS STANDARDS ........................................... 7 A. Are Existing Medical Practice Imaging Process Standards Sufficient for the Trial’s Primary Endpoint? ....................................................................................................................................... 7 B. What Should Be Considered When Augmenting Existing Medical Practice Imaging Process Standards to Create Trial-Specific Imaging Process Standards? ............................................. 7 REFERENCES .............................................................................................................................. 9 APPENDIX A: BEFORE IMAGING: CHARTER CONSIDERATIONS ......................... 10 APPENDIX B: DURING IMAGING: MONITORING PLANS AND CHARTER MODIFICATIONS ..................................................................................................................... 27 APPENDIX C: AFTER IMAGING: DATA TRANSFER, ARCHIVING, AND ANALYSIS OF IMAGING INFORMATION ......................................................................... 28 Contains Nonbinding Recommendations Clinical Trial Imaging Endpoint Process Standards 1 Guidance for Industry This guidance represents the current thinking of the Food and Drug Administration (FDA or Agency) on this topic. It does not establish any rights for any person and is not binding on FDA or the public. You can use an alternative approach if it satisfies the requirements of the applicable statutes and regulations. To discuss an alternative approach, contact the FDA office responsible for this guidance as listed on the title page. I. INTRODUCTION The purpose of this guidance is to assist sponsors in optimizing the quality of imaging data obtained in clinical trials intended to support approval of drugs and biological products.2 This guidance focuses on imaging acquisition, display, archiving, and interpretation process standards that we regard as important when imaging is used to assess a trial’s primary endpoint or a component of that endpoint. Considerable standardization already exists in clinical imaging. There are a variety of sources, including picture archiving and communication systems and the Digital Imaging and Communications in Medicine (DICOM) formats for the handling and transmission of clinical imaging information that describe the standards generally employed by clinical practitioners. This guidance recommends additional imaging endpoint process standards that are more specific to clinical trials. Imaging process standards help sponsors ensure that imaging data are obtained in a manner that complies with a trial’s protocol, that the quality of imaging data is maintained within and among clinical sites, and that a verifiable record of the imaging process is created. Minimization of imaging process variability may importantly enhance a clinical trial’s ability to detect drug treatment effects. Standardization, while important for all clinically used measures, becomes essential for an imaging endpoint used in a clinical trial to reduce variability and to ensure interpretability of the results. The extent of trial-specific standardization may vary depending upon how standardized the local imaging procedures are (e.g., routine bone X-rays (relatively standardized) versus bone mineral density (more variability across sites)). This guidance does not address approaches for 1 This guidance has been prepared by the Division of Medical Imaging Products in the Center for Drug Evaluation and Research in cooperation with the Center for Biologics Evaluation and Research at the Food and Drug Administration. 2 For the purposes of this guidance, all references to drugs include both human drugs and biological products unless otherwise specified. 1 Contains Nonbinding Recommendations selecting an imaging endpoint for a clinical trial. An imaging endpoint, even if standardized and considered to be precise and accurate, might not be interpretable if it does not have clinical meaningfulness (e.g., hip fracture versus changes in local blood flow in the central nervous system detected by positron emission tomography (PET) imaging). This guidance does not address whether specific imaging measures would be acceptable in submissions used to support approval of a drug or biologic. These considerations should be discussed with the FDA review division responsible for drug development. Many of the imaging process standard considerations for clinical trials of therapeutic drugs can also be applied to clinical trials that evaluate the performance of diagnostic drugs. For considerations involving the development of diagnostic imaging drugs, see the guidance for industry Developing Medical Imaging Drug and Biological Products (Parts 1, 2, and 3).3 In general, FDA’s guidance documents do not establish legally enforceable responsibilities. Instead, guidances describe the Agency’s current thinking on a topic and should be viewed only as recommendations, unless specific regulatory or statutory requirements are cited. The use of the word should in Agency guidances means that something is suggested or recommended, but not required. II. BACKGROUND Almost all medical imaging processes involve some aspects of standardization established by those within the practice of medicine. In medical practice, images of human anatomy and/or physiology typically are acquired and interpreted, often with limited or no formal quantification, by a single facility’s imaging professional staff. The images typically achieve the medical practice’s diagnostic purposes even though the acquisition, display, and interpretation methods may vary somewhat among imaging facilities and imaging professionals. This variability may have little or no impact on the ability to provide a diagnosis in medical practice, yet in a clinical trial, imaging process variability may result in increased variability in endpoint measurements and may compromise the ability of the trial to achieve its objectives. Although the medical practice of diagnostic imaging already follows many standardized procedures, we recommend that some trials augment these existing standards to create trial- specific imaging process standards. For purposes of this guidance, we define these trial-specific imaging process standards as standards that extend beyond those typically performed in the medical care of a patient (i.e., the process standards are implemented solely for the purposes of the clinical trial). The extent of trial-specific imaging process standards can range from minimal processes that are described solely in the clinical protocol, such as obtaining noncontrasted and contrasted images in all subjects, to more detailed imaging process standards for image acquisition, display, interpretation, and archiving that are detailed in an imaging charter (see Appendixes A through C). 3 We update guidances periodically. To make sure you have the most recent version of a guidance, check the FDA guidance web page at https://www.fda.gov/RegulatoryInformation/Guidances/default.htm.
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