We've spent a lot of time here talking about provisional approval of drugs, most specifically Avastin (when its approval for metastatic breast cancer was pulled). But the idea isn't to put drugs on the market that have to be taken back; it's to get them out more quickly in case they actually work.
There's legislation (the TREAT Act) that is attempting to extend the range of provisional approvals. But according to this column by Avik Roy, an earlier version of the bill went much further: it would have authorized new approval pathways for the first drugs to treat specific subpopulations of an existing disease, nonresponders to existing therapies, compounds with demonstrable improvements in safety or efficacy, or (in general) compounds that "otherwise satisfy an unmet medical need". As with the existing accelerated approval process, drugs under these categories could (after negotiation with the FDA) be provisionally marketed after Phase II results, if those were convincing enough, with possible revocation after Phase III results came in.
Unlike the various proposals to put compounds on the market after Phase I (which I fear would be an invitation to game the system), this one strikes me as aggressive but sensible. It would, ideally, encourage companies to run more robust Phase II trials in the hopes of going straight to the market, and it would allow really outstanding drugs a chance to start earning back their R&D costs much earlier. As long as everyone understood that Phase III trials are no slam dunk any more (if they ever were), and that some of these drugs would turn out not to be as good as they looked, I think that on balance, everyone would come out ahead.
According to Roy, this version of the bill had (as you'd expect) attracted strong backers and strong opponents. On the "pro" side was BIO, the biotech industry group, which is no surprise. On the "anti" side, the FDA itself wasn't ready for this big a change, which isn't much of a shock, either. (To be fair to them, this would increase their workload substantially - you'd really want to couple a reform like this with more people on their end). And there were advocacy groups that worried that this new regulatory regime would water down drug safety requirements too much. The article doesn't name any groups, but anyone who's observed the industry can fill in some likely names.
But there was another big group opposing the change: PhRMA. Yes, the trade organization for the large drug companies. Opinions vary as to the reason. The official explanations are that they, too, were concerned for patient safety, and they wanted the PDUFA legislation renewed as is, without these extra provisions (a "bird in the hand" argument). But Roy's piece advances a less charitable thesis:
Sen. Hagan’s proposal would have been devastating to the big pharma R&D oligopoly. If small biotech companies could get their drugs tentatively approved after inexpensive phase II studies, they would have far less need to partner those drugs with big pharma. They could keep the upside themselves and attract far more interest from investors. Big pharma, on the other hand, would be without its largest source for innovative new medicines: the small biotech farm team.
I'd like to be able to doubt this reasoning more than I do. . .