The FDA stem cell clinic problem just continues to grow, while the agency has been oddly quiet in this space for more than a year.
It’s been a major disappointment, particularly as in recent years FDA leadership had implied that bold action was coming. Their own words spiked expectations that the agency would tackle unproven stem cell clinics in a bold way.
What’s going on and why the disconnect between words and actions lately?
The FDA stem cell clinic problem
Many of these unproven clinic firms unambiguously market unapproved drug products, seemingly in clear violation of the law. Some have been doing so for many years. We now know about numerous people hurt by specific clinics and indirectly by suppliers. Unproven stem cell therapy risks are clearer now than ever.
It was therefore refreshing to see FDA leaders use unprecedented language to describe the problem over the past 3-4 years. It seemed clear how seriously they took it. The expectation from the stem cell field was some kind of major action at least on the most egregious of the clinics.
The FDA further raised expectations when more than a year ago it let a discretionary period for firms marketing stem cells expire. No discretionary period means clinics have one less excuse.
Yet very little has actually happened on the unproven clinic front.
Maybe one or a few warning letters a year. Some untitled letters, which lack bite. Actually in 2022 the agency branch in charge of biologics, CBER, has only issued one untitled letter so far, at least that’s in the public domain. See screenshot below. By comparison, last year by this time it had issued nine such letters. Clearly there is no shortage of firms that could receive untitled and even warning letters. It’s not as though the FDA has run out of firms to send letters to.
Clinic explosion
How big is the problem now?
My colleague Leigh Turner and I published the first data on stem cell clinic numbers in the U.S. back in 2016. It shook people up. FDA officials told me it made a concrete difference to have data on clinics. Those numbers were in the hundreds.
Since that time, clinic numbers have grown again several-fold.
Leigh more recently documented over two thousand stem cell clinics in the U.S. Not all of these clinics are clearly noncompliant it’s clearly a vast problem that requires quick, strong action.
FDA raising expectations
The leadership’s own past words suggested some big steps were coming. Then Commissioner Steve Hahn and CBER Director Peter Marks wrote a 2020 JAMA piece that was blunt. It ended this way (emphasis mine in the following quotes):
“It is time for unproven and unapproved regenerative medicine products to be identified and recognized for what they frequently are: uncontrolled experimental procedures at a cost to patients, both financially and physically. Patients and their caregivers should feel empowered to report adverse events to help make sure that purveyors of unproved products are identified, and the FDA can take appropriate action to bring them into compliance and thereby help protect more patients from harm. This goes to the core of the mission to which the FDA is committed: promoting and protecting the public health.”
A year earlier, Marks and then Commissioner Scott Gottlieb issued a strong statement on stem cell clinics on the FDA website. The key phrase was this:
“And we will not shy away from taking further steps when we see bad actors taking advantage of patients, and putting them at serious risk, for their own financial profit.”
Again, no shortage of bad actors out there for the agency to act on.
Then a few months later the FDA issued a warning on stem cell clinics including this strongly-worded passage:
“…some patients seeking cures and remedies are vulnerable to stem cell treatments that are illegal and potentially harmful. And the FDA is increasing its oversight and enforcement to protect people from dishonest and unscrupulous stem cell clinics”
“Illegal” is a very strong word for the agency to use. Again, this seemingly totally conflicts with the little that has happened in the way of FDA action lately.
Why the FDA lull on stem cell clinics? COVID?
So why the minimal enforcement actions in the past thirteen months, especially since there’s no enforcement discretion these days? Seems like a paradox to me. There might be some complexities here.
What about COVID? A recent JDSUPRA piece reporting on statements at events by FDA Chief Counsel Mark Raza and Dr. Wilson Bryan suggests COVID could have been a delaying factor. The piece is entitled, “Unapproved stem cell therapies remains a top FDA enforcement priority.” Here’s a key quote:
“Coming out of the COVID-19 pandemic, we expect to see more enforcement activity around claims/promotion of stem cell products and manufacturing compliance and quality of such products, likely to be focused on scenarios that present the highest or significant potential risk to patients and consumers.”
This is just one possibility. I hope they’re right though. Also from the same piece:
“At a recent regenerative medicine webinar, CBER Office of Tissues and Advanced Therapies (OTAT) Director Wilson Bryan, M.D., said his office has been increasingly notifying, warning, and taking legal enforcement actions against manufacturers, clinics, and individuals administering unapproved regenerative medicine therapies.”
Does “increasingly” refer to the past 3 or years or just more recently? The link embedded in that quote also goes to FDA text that has some very strong language from Bryan just last year on some clinics and activities being “illegal”.
From Raza:
“Speaking Tuesday at the Food and Drug Law Institute (FDLI) Annual Conference, Mark Raza, FDA Acting Chief Counsel, discussed the investigations priorities for FDA’s Office of the Chief Counsel (OCC), including its focus on stopping stem cell clinics that put patients at risk.”
That sounds encouraging.
Other possible roadblocks and looking ahead
Beyond possible COVID issues or delays, another possible scenario here is that more has been going on behind the scenes on clinics. The FDA just hasn’t told us about it or it hasn’t reached fruition. Maybe there’s a whole lot of investigations ongoing?
What else might explain the FDA’s concerning lull?
Cell Surgical Network Lawsuit. There is that seemingly never-ending court case with the FDA seeking permanent injunction on a California-centered stem cell clinic chain. Is the agency waiting to see the verdict? In a way that court case only or mainly pertains to so-called “fat stem cell” clinics. There are many hundreds of noncompliant clinics that seem unrelated to that case. Numerous suppliers too.
The FDA also only relatively recently got a new Commissioner. Robert Califf came on board again for a second term just four months ago. Sometimes a change in leadership can delay groundbreaking action by an agency for at least a little while.
Whatever has been going on, this lull has serious risks to the public. Also, I’d say it’s not great for the agency either if it is seen to seemingly be passive on non-compliant and in some cases obviously unlawful stem cell marketing. It’s especially bad timing for an enforcement discretion period to end and then almost nothing happen for more than a year after that.
Dr. Leonid Schneider wrote about how … once upon a time a congressman threatened to go over former FDA commish’s head to the WH to get FDA to allow a phase 2 trial of an unapproved stem cell product for hair restoration to treat COVID patients with ARDS
https://forbetterscience.com/2022/07/20/extinguish-covid-19-with-hair-loss-stem-cell-nano-exosomes/
What is Bob Califf doing down there in Rockville?
I’d posit the “COVID theory” as potentially very real and viable Dr Paul.
To get to the real meat and potatoes kind of enforcement spoken of prior by FDA, as in Warning Letters and then lawsuits or shutting the clinics down etc – it requires the 1st step which is Form 483 on-site and in-person and up close and personal site inspections.
A large, large portion of the federal government (same for local, state govt etc) just plain old nearly “totally shut down” when COVID got hot n heavy and most just now are finally “sort of kind of” getting fully back to business as usual is what I’m observing and hearing from people who work for the FEDS or even military etc. Flying aka air travel – ground to a near halt, just one example.
People were miffed as to what was a “essential service” (my local Walmart never closed nor did the liquor stores – but practically everything else did, go figure that one out ?) –
Thus, I can see COVID and just lack of staff who could hit the road, head to the field etc would put a major, major dent in any enforcement action plans the FDA had (past tense).
My local police and Sheriff etc greatly curtailed response to calls for service, short of 911 and other than calls involving violence, weapons, felonies, etc.
In other words – if you were calling about the meth head in the park smoking crack in plain view right next to the kiddy playground and 400 ft from the elementary school in-session, not much was going to happen.
They went to “cite & release” aka just a “ticket promise to appear” essentially (no being transported to even the local police station to be booked aka finger printed and mugshot etc). All local law enforcement agencies tried (were instructed !!) to transport as few people to the county jail as possible.
The courts practically shut down – and criminal folks who were arrested have a Constitutional right to a “speedy trial” and even that got all gummed up from COVID !! They actually let a lot of people out of the county jail which was highly controversial, all due to COVID and the risk to the deputies who work the jails, and the inmates, the inability of The Courts to move criminal cases on their dockets, etc.
COVID was a curve ball tossed at society I don’t think anyone could have ever seen coming let alone did anyone really understand how to react to it properly, deal with it, etc. There are other countries around the world who never “locked down” and fared as well, if not better than the USA did. That’s a debate and a hot button topic for another day and highly charged I’m sure.
But – to your point of “COULD COVID HAVE DERAILED THE FDA ENFORCEMENT ACTIONS” – using my local law enforcement and county jails and courts and just massive number of federal agencies who went to a strict “work from home policy only”, I’d say 100% YES to your theory as having strong grounds to support it !
Thus, I guess we are now at a point of IF all things sort of continue to “open back up” and that is what the FDA chief legal council Mr Raza seems to be indicating and hinting at in the last part of your piece above – THEN we would expect to see some pretty heavy duty enforcement actions coming forth from the FDA, like “soon” IMO. “Soon” in the government world IMO meaning 6 months or so we better see some serious action finally really ramping up ?
IF we see nothing much of a change to business as usual and “what the heck happened to all that great talk talk talk” of “by golly we’re really, really double super serious going to crack down this time on those rogue stem clinics !!”, going back quite a few years; then I’d say something is seriously amiss in FDA land and we the public and patients often being put at grave risk and getting plain old “ripped off” of their hard earned money, are getting the smoke n mirrors treatment or who knows what ?
You get a mulligan or maybe two, a delay, a few free passes and a few do-overs given COVID IMO.
Myself and some neighbors are actually having this “OK, the never ending govt agency universal forever get-out-of-jail-free card excuse alll things COVID, has just about run its course and we’re past tired of it now” and then some !!
In other words – street paving is late and all screwed up, COVID !! The police response problem and local park just falling into total disrepair…. pull the COVID card on us again at the City council meetings. Street lights all burned out or poles just fall over and practically kill someone and nothing getting done as to basic city maintenance – by golly it was that dang COVID again !!
Most people I’m speaking to feel this has sort of reached the “NO, no more pulling the COVID card on us – we all went back to work and all private businesses are open and working their butts off, time to end the COVID never ending get a free pass card to govt agencies” is the conversations (and frustrations) I’ve been seeing reach a boiling point where I live !
Thus – FDA has to get in the game and start to kick butt and take names, get into the fight, (insert any cliche for call to action here), or we need to wonder if we can believe them or trust they’re going to do what they say regarding these rogue clinic operators IMO only of course.
Great piece and topic to write about given all your back story and work clear back to your original pay-to-treat research/tracking and study and clinic-count with Dr Turner.
This is the FDA’s D-DAY moment here on hitting pay-to-treat rogue stem clinic players, again IMO.
Only caveat is barring any new “super freak curve ball” (Monkey pox, a plague, major war, serious economic turmoil, I don’t know??) being tossed out again – else, the FDA have burned all their free passes, free chits, excuse cards etc again IMO only.
My 2 or so cents worth on that – time to really watch this topic and FDA “call to action” and see what happens here, or else fails to happen !