Report of Independent Panel Reviewing the University of
Pennsylvania's Institute for Human Gene Therapy
April 27, 2000
Click here for the Appendix to this
Click here for Penn's Response to this Report
Following the tragic death of Jesse Gelsinger, a participant in a phase
I clinical trial of gene therapy for ornithine transcarbamylase (OTC) deficiency,
the President of the University of Pennsylvania, Judith Rodin, appointed
an independent, external panel to review and evaluate
the conduct, oversight, and monitoring of clinical trials at the Institute
for Human Gene Therapy (IHGT). This committee met twice in Philadelphia
and interviewed twenty people associated with the clinical trials conducted
at the IHGT in addition to the President and the Provost of the University.
We reviewed scores of documents. We thank the University and many of its
people for great cooperation in helping us understand the organization and
functioning of the IHGT and the conduct of the OTC studies.
Our charge is to report to President Rodin on the challenges facing
the University of Pennsylvania and the IHGT in light of recent events. Our
work follows an extensive investigation by the Food and Drug Administration
(FDA) that involved sixteen days of visits to the University. We have reviewed
the two documents sent to the University following these visits, FDA Form
483 and the Warning Letter of March 3, 2000, as well as the University's
responses to both of these. We have read carefully "The Report of the
Committee to Review the Institute of Human Gene Therapy and the Department
of Molecular and Cellular Engineering (MCE)." This internal report,
completed in November 1999, is a thorough review with a detailed assessment
of IHGT and MCE. We have not conducted an investigation similar to that
of the FDA. Since, as far as we know, the FDA has not yet reached a conclusion,
we do not believe that it would be helpful for us to comment on the various
statements or to try to function as arbiter. Should the University need
a point by point analysis of the differences between the observations in
FDA Form 483 and the response to Form 483, we suggest that an objective
group with knowledge and expertise in regulatory affairs be set up specifically
for that purpose. It is our understanding that it is not our role either
to assess blame or to exonerate. We have not been asked to comment on the
functioning of governmental agencies. Rather we have attempted to understand
the operations of the IHGT and its handling of clinical trials and to point
out areas that we believe require thought, attention, further investigation,
The committee embarked on its task with certain assumptions about clinical
trials and the responsibilities of both investigators and institutions involved
in their conduct. Clinical trials are essential if medicine is to progress
and the health of each generation is to be better than the last. They can
be pursued successfully only if society at large believes in their usefulness
and safety. That in turn, will happen only if those in charge of the clinical
trials can be counted on to see to it that, on one hand, the study is important
scientifically with potential for significant benefit and, on the other
hand, that the patients welfare is given the highest priority. Patients
take part in clinical trials for a variety of reasons. A number of very
ill patients want to enroll believing that a remote chance of benefit even
with appreciable risk is preferable to no chance at all. At the other end
of the spectrum some may be involved primarily for altruistic reasons. In
every case, the patient is dependent on the investigator for both knowledge
and care. The patient has a right to rely on the physician and the institution
not only to put his or her medical welfare first, but also to provide full
information with the certainty that nothing will be done without full informed
consent. In sum, the primary responsibility of a physician, whether or not
he or she is a clinical investigator, is to the patient.
Furthermore, we believe that gene therapy, while unproven, continues
to be promising. The potential to relieve suffering and restore health to
countless individuals remains. Thus, research in this field should continue.
Additionally, we understand that an academically-based enterprise has certain
advantages. For example, academic researchers are more likely to develop
therapies for rare diseases, which are less likely to be pursued by for-profit
1 . The scientists with whom we spoke are competent individuals with
national and international reputations (See Appendix, page 6). We thank
them for their cooperation. Creating an Institute for Human Gene Therapy
does by that very act put pressure on the people of the Institute to do
clinical as well as basic research relating to gene therapy. The scientists
clearly stated the scientific rationale for their studies and described
the time and effort put into obtaining adequate informed consent forms.
They and the University are receptive to the FDA's criticisms. We are certain
that both the scientists and the University are committed to correcting
any deficiencies and complying with all regulations and have the ability
to accomplish that goal. Changes to conform to requirements were underway
prior to the FDA's investigation. Some changes recommended by the FDA have
already been effected. For example, IHGT has transferred responsibility
for monitoring of its clinical trials to an outside Contract Research Organization
(Parexel International Corporation) and is developing standard operating
procedures for its operations, including guidelines for protocol revisions
and the reporting of adverse events.
2. Regulation of clinical trials is both important and necessary. Detailed
surveillance is essential, most especially when testing novel biologic therapies.
Compared with typical pharmaceuticals, viral vectors (currently the most
common form of gene therapy) have vastly different properties, both from
traditional drugs and from one another, including difficulty in standardizing
the quantification of active viral particles, unique pharmacokinetics, variable
immune responses, and risk for direct cellular toxicity. Given these properties,
plus heightened public awareness and interest, clinical trials of gene therapy
should expect to face increased scrutiny which will likely apply to non-viral
forms of gene therapy as well.
3. Universities engaged in clinical trials have three basic routes for
complying fully with regulations.
- Collaborate with pharmaceutical companies,
- Participate in a multicenter trial,
- Develop within the university the capability of monitoring and reporting
in conformance with all governmental rules and regulations.
4. The visitors were impressed with the magnitude of the effort and
the financial commitment required of the University if it wishes to conduct
independent clinical trials. Since the University will be judged by the
same standards as industry, it will now be necessary to invest considerably
more resources for compliance than has historically been necessary for independent
university-initiated clinical research. The following are examples of requirements
that should now be met by all engaged in clinical trials, whether independent
or not (when independent the university, of course, has full responsibility):
a. A large group of knowledgeable, skilled scientists and support
staff must be in place.
- Scientists must come from a variety of disciplines.
- Clinical and basic scientists must understand one another and work
- The more clinical trials, the larger the group required.
- Training for conduct and monitoring must be up-to-date and documented.
- Personnel turnover must be held to acceptable levels.
b. The University must comply in meticulous detail to rules and
guidelines of the FDA, the National Institutes of Health (NIH), and the
Recombinant DNA Advisory Committee (RAC).
- Compliance requires both specialists in gene therapy and up-to-date
training for scientists and staff.
- All actions must be carried out precisely and carefully recorded in
- Hundreds of standard operating procedures must be developed, recorded
and put into exact operation.
- Decisions must be made in close communication and collaboration with
federal agencies and IRBs that must be kept aware in a timely fashion of
adverse events and changes that require approval.
c. A culture that is both collegial and critical is essential.
- Open communication and freedom to express dissenting views is vital.
- A critical atmosphere must keep the focus on both the safety of patients
and the careful accumulation of relevant scientific data.
- Many meetings of multidisciplinary groups are necessary to review all
d. Patients must be recruited and fully educated as to all risks.
e. Appropriate external advisory and oversight groups need to
be recruited and involved.
f. Adequate clinical and technical expertise should be involved
in each clinical trial.
5. The University of Pennsylvania has been making large investments
in building a significant staff and infrastructure for this IHGT. Prior
to the tragic event, the scientists involved report that they believed that
they were doing what they should in an adequate fashion. However, given
the actions of the FDA, which has oversight authority, it is evident that
substantial changes must be made. Clearly, if this type of research is to
continue, the University and the IHGT must comply completely with all regulations
and reporting requirements of the FDA, RAC and other agencies involved.
6. Participation in a clinical trial carries inherent risks. Even if
all of the guidelines and regulations of the FDA and NIH/RAC are followed,
there is no guarantee that a tragic event will not occur.
- The University should make certain that it has ways of assuring itself
that groups conducting independent clinical trials have the required financial
resources, knowledge, staff, external advice and understanding of the requirements
of federal agencies. In other words, the University should monitor its
own capability for monitoring and compliance.
- The University of Pennsylvania should evaluate the function of its
IRBs. Specifically, the workload of each IRB may need to be decreased,
in order to allow ample opportunity to carefully evaluate and monitor each
clinical trial. There are approximately three to four thousand protocols
per year with about 80 adverse events reported per one hundred protocols.
Secondly, an IRB should have expertise, or, at a minimum, access to expertise,
in evaluating the use of novel therapies such as gene therapy. It might
help if individual IRBs were to deal with specialized areas of research,
or be enlarged, so that they might be staffed with people knowledgeable
about the issues before them. Furthermore, the IRBs should facilitate the
sharing of information, especially the occurrence of adverse events, between
different trials using similar therapies, such as the same viral vector.
- The University of Pennsylvania should carefully evaluate the process
of ethical decision making. Ethical decisions about clinical trials are
complex, especially when using novel agents as in gene therapy. Specifically,
we recommend that all ethical discussions regarding the testing of gene
therapy in human subjects be overseen by an IRB with expertise in evaluating
gene therapy, as discussed above. It is unwise to have bioethicists, involved
in decision making, report directly to one of the investigators or the
Director of IHGT. The role of academic units of bioethics should be to
assist investigators and physicians in clarifying their own ethical dilemmas.
- We recommend that the University review its policies on conflict of
interest, especially with regards to clinical trials. Perceived as well
as actual conflicts of interest make clinical trials more open to suspicion
and criticism, even in the absence of legal issues. Equity positions by
an investigator and/or the University may be ill advised, even if, in reality,
there is no practical effect whatsoever. Given that the overriding responsibility
of the University and its investigators is to the welfare of patients,
the avoidance of conflict of interest that even remotely might detract
from putting the needs of patients first becomes paramount. In that regard,
investments in new therapies differ from those in other ventures, such
as computer technology, which involve no responsibilities for patient care.
- The University of Pennsylvania should to do everything possible to
ensure that informed consent is properly obtained. The letter as well as
the spirit of FDA regulations is important. Specific guidelines for obtaining
informed consent exist, including: who is to be present at the time of
consent, clear documentation of who is providing informed consent, consistent
review and signing of consent forms, and clear absence of conflict of interest
by those obtaining informed consent. Training may be required to ensure
that these are followed.
- We recommend strongly that full consideration be given to the findings
and recommendations of the excellent internal report entitled, "The
Report of the Committee to Review the Institute of Human Gene Therapy and
the Department of Molecular and Cellular Engineering."
- We recommend that the University give serious attention to the following
questions. We believe that the following issues of major policy must be
decided by those responsible for allocating the institution's human and
financial resources and for overseeing the direction and functioning of
the various units that make up the whole.
a. Is there a mechanism, internal or external, whereby the IHGT
or any similar intramural operation is evaluated on a regular basis with
open discussion and free criticism by knowledgeable people, and the results
made available to the University and other interested parties? We add that
in such a rapidly evolving field, examinations must be ongoing.
b. Does it make sense to have an entire Institute devoted to
gene therapy? We recognize the great potential of gene therapy, but its
efficacy in humans is still in the process of being established with "proof-of
principle" evidence. Would it, for example, make more sense to reconfigure
the Institute as support groups for scientists?
c. The IHGT has come to play an important role in the research
of young faculty with whom we spoke. The Institute provides research- and
clinical-grade vectors, mentoring in their use, and great assistance in
complying with regulations. We understand that investigators in any clinical
trial must be trained in the use of investigational drugs, however, we
emphasize that the use of a viral vector necessitates additional training
in its unique properties and potential toxicities. Without additional training
and guidance, the end result is that young investigators who have relatively
little understanding of virology or the basic science of gene therapy can
administer this novel therapy, almost as if it were a new conventional
drug. Is this role premature? Is there sufficient experience with gene
therapy that it is ready for use in this manner? Are the risks well enough
understood, to promote widespread testing in inexperienced hands?
d. Is it prudent to have, entirely within the University, all
of the strengths provided by the IHGT, particularly the production of vectors
for clinical testing and the monitoring of clinical trials? Or, might some
or all these services better be performed extramurally?
- William H. Danforth, M.D.
- Chair, Institute for Human Gene Therapy Independent Panel
- Chancellor Emeritus and Vice Chair of the Board of Trustees
- Washington University
- Edward J. Benz, Jr., M.D.
- Sir William Osler Professor and Director of the
- Department of Medicine
- Johns Hopkins University School of Medicine
- Daniel Callahan, Ph.D.
- Director of International Programs
- The Hastings Center
- Rochelle Hirschhorn, M.D.
- Professor of Medicine and Cell Biology and
- Chief of the Division of Medical Genetics
- New York University School of Medicine
- Joseph B. Martin, M.D., Ph.D.
- Dean of the Faculty of Medicine
- Harvard Medical School
- Inder Verma, Ph.D.
- American Cancer Society Professor of Molecular Biology
- The Salk Institute
- Dena Minning
- Staff to the Independent Panel
- Medical Scientist Training Program
- Washington University School of Medicine
University of Pennsylvania Faculty and Staff Interviewed
by Independent Panel
- Judith Rodin, Ph.D.
- President, University of Pennsylvania
- Stephen Schutt
- Vice-President and Chief of Staff,
- University of Pennsylvania
- Robert Barchi, M.D., Ph.D.
- Provost, University of Pennsylvania
- James Wilson, M.D., Ph.D.
- Director, IHGT
- Chairman, Molecular and
- Cellular Engineering
- Nelson Wivel, M.D.
- Deputy Director, IHGT
- Adjunct Professor, Molecular and
- Cellular Engineering
- Arthur Caplan, Ph.D.
- Director, Center for Bioethics
- Member, IHGT Executive Committee
- Lisa Speicher, Ph.D.
- Associate Director,
- Clinical Trials Unit, IHGT
- Steve Raper, M.D.
- Principal Investigator of OTCD Clinical Trial
- Associate Professor of Surgery
- Mark Batshaw, M.D.
- Co-investigator of OTCD Trial
- (no longer at University of Pennsylvania)
- Stephen Eck, M.D., Ph.D.
- Assistant Professor, Hematology/Oncology
- Daniel Sterman, M.D.
- Assistant Professor, Pulmonary and Critical Care
- Director, Interventional Pulmonology
- Ronald Rubenstein, M.D., Ph.D.
- Assistant Professor of Pediatrics
- Katherine High, M.D.
- Professor of Pediatrics
- Medical Director, Hematology Laboratory
- Member, IHGT Executive Committee
- Jean Bennett, M.D., Ph.D.
- Assistant Professor, Ophthalmology
- James Hoxie, M.D.
- Professor, Hematology/Oncology
- Nicholas Kefalies, M.D., Ph.D.
- Professor Emeritus of Medicine,
- Infectious Diseases
- Professor, Biochemistry and Biophysics
- Chair, Institutional Review Board
- Peter Binnion, M.D.
- Chair, IRB 2 (reviewed OTC)
- Joe Sherwin
- Director, Office of Regulatory Affairs
- Peter Erichsen
- Vice President and General Counsel
- Lee Dobkin
- Deputy General Counsel for Compliance
- Stephen J. Immelt
- Partner, Hogan & Hartson, LLP,
- Baltimore, MD office
- Robert P. Brady
- Partner, Hogan & Hartson, LLP,
- Washington, DC office
Ed Note: Please see the University's
Response to this Report.
Almanac, Vol. 46, No. 34, May 30, 2000
Awards | CONTENTS
& Promotions | Commencement
/ Baccalaureate 2000 | TALK
ABOUT TEACHING ARCHIVE | BETWEEN
ISSUES | SUMMER at PENN |