Critical review of the TransCelerate Template for clinical study reports (CSRs) and publication of Version 2 of the CORE Reference (Clarity and Openness in Reporting: E3-based) Terminology Table

Background CORE (Clarity and Openness in Reporting: E3-based) Reference (released May 2016 by the European Medical Writers Association [EMWA] and the American Medical Writers Association [AMWA]) is a complete and authoritative open-access user’s guide to support the authoring of clinical study reports (CSRs) for current industry-standard-design interventional studies. CORE Reference is a content guidance resource and is not a CSR Template. TransCelerate Biopharma Inc., an alliance of biopharmaceutical companies, released a CSR Template in November 2018 and recognised CORE Reference as one of two principal sources used in its development. Methods The regulatory medical writing and statistical professionals who developed CORE Reference conducted a critical review of the TransCelerate CSR Template. We summarise our major findings and recommendations in this communication. We also re-examined and edited the Version 1 CORE Reference Terminology Table that we first published in 2016, and we present this as Version 2 in this communication. Results Our major critical review findings indicate that opportunities remain to refine the CSR Template structure and instructional text, enhance content clarity, add web links to referenced guidance documents, improve transparency to support the broad readership of CSRs, and develop supporting resources. The CORE Reference ‘Terminology Table’ Version 2 includes estimand as a defined term and an adaptation of the original ‘worked study example’ to incorporate the recently evolved concept of ‘estimands’. Conclusions As TransCelerate’s CSR Template represents an important milestone in authoring CSRs, we offer CSR authors advice and recommendations on its use, similarities, and differences with CORE Reference and advise them to consider shared interpretations between the two. Registration CORE Reference is registered with the EQUATOR Network. The TransCelerate CSR Template is not registered with any external organisation to the knowledge of the authors of this paper. Electronic supplementary material The online version of this article (10.1186/s41073-019-0075-5) contains supplementary material, which is available to authorized users.


Background
Developed by the Budapest Working Group (BWG), comprising European Medical Writers Association (EMWA) and American Medical Writers Association (AMWA) members in a 2-year pro bono effort, CORE (Clarity and Openness in Reporting: E3-based) Reference [1] published in May 2016, and registered with the Equator Network [2], is a complete and authoritative openaccess user's guide to support the authoring of CSRs for interventional studies [3]. It is complete because it includes all the necessary guidance components for reporting complex modern-design clinical studies, whilst maximising both personal data protections and data utility. It is authoritative because International Council for Harmonisation (ICH) guidance documents, as well as the European Union (EU), i.e. European Medicines Agency (EMA), and the USA, i.e. Food and Drug Administration (FDA) regional guidelines, were accessed, analysed, and interpreted. As a number of important stakeholders were involved in its development, they were able to provide insights with regard to industry best practices. As per the underlying ICH E3 document, CORE Reference is a reference tool companion to ICH E3 and not a template. It offers sectional content suggestions but does not mandate a particular CSR structure. The content suggestions are arranged in sections, which are mapped to the principal regulatory guidance, ICH E3 [4], using the CORE Reference mapping tool. This allows users to contextualise CORE Reference within ICH E3.
In the 3 years since CORE Reference was launched, the associated website [5] has evolved into a living and multi-dimensional educational resource for CSR authors and reviewers. The PDFs of CORE Reference and the ICH E3-CORE Reference mapping tool are available to download [1]; regulatory and disclosure news updates are sent in real time to those subscribing for email updates [6]; and these are periodically summarised and posted on the website [7].
Additionally, since CORE Reference was first published, the global transparency and disclosure landscape has evolved. Mandatory public disclosure of CSRs submitted as part of a regulatory dossier to the EMA has been suspended since August 2018 with no planned date for lifting of the suspension [8]. When the suspension is lifted, clinical data publication will be subject to new implementation guidance (for Policy 0070 Version 1.4, dated 15 October 2018) that takes into account lessons learned from the EMA, sponsors, and the pharmaceutical industry over 2 years of submissions [9]. In January 2018, the FDA launched a pilot programme '…to evaluate whether disclosing certain information included within CSRs following approval of a New Drug Application improves public access to drug approval information' , and subsequently issued a FAQ document in May 2018 [10]. In June 2019, the FDA sought public feedback on the pilot, and additionally on a new integrated review process and template, declaring the Agency is considering '…whether to focus its efforts to better communicate the basis for drug approvals on the development of new integrated review documents, rather than on the release of CSRs' [10]. The only CSR publicly posted from the FDA pilot is that of the Erleada® pivotal trial [11]. Health Canada has issued guidance on the public release of clinical information, which largely aligns with EMA guidance [12]. Japan, Australia, and Germany also have requirements for the disclosure of product submission data [13]. Although the disclosure of clinical trial data is currently in a holding phase across multiple regions, it will resume. In the meantime, CSR authors are advised to maintain current awareness of global requirements for data disclosure [14] and to continue writing CSRs in a proactively anonymised fashion that maximises data utility, as mandated in Policy 0070 current implementation guidance [9] and as described in CORE Reference [1].
TransCelerate is an alliance among some of the world's prominent biopharmaceutical organisations with the tagline 'accelerating the development of new medicines'. TransCelerate provides solutions that '…are developed collaboratively and can be voluntarily adopted by stakeholders in the clinical research ecosystem' [15]. In November 2018, Trans-Celerate released its first version of a CSR Template. This CSR Template and associated resources, including a template for statistical analysis plans (SAPs), are located on the TransCelerate website under the 'Common Protocol Template' resources tab [16]. A tool showing the TransCelerate CSR Template mapped to ICH E3 and CORE Reference is additionally provided [17].
CORE Reference is a broadly recognised resource as evidenced by 20,000+ downloads by June 2019, and adoption and use testimonials originating from Europe, the USA, Asia Pacific, and Africa [18]. TransCelerate recognises CORE Reference as one of two principal sources used in its CSR Template development. The other is ICH E3 [4]. A template created using these two authoritative references could represent a highly complementary 'next step' by the global pharmaceutical industry. Guidance documents maximise their utility if explanations, together with supportive sources, are included, and this approach also has educational value for the ever-growing pool of industry professionals responsible for contribution to, or preparation of, CSRs. The value to reviewers should not be overlooked given the commonality of presentation philosophy. Reviewers will be able to locate categorical information more easily and will more likely see compliance with ICH E3.
The aim of this paper was for the Budapest Working Group (BWG)-the developer of CORE Reference-to conduct a critical review of a CSR Template that was developed by TransCelerate. TransCelerate used CORE Reference to develop their CSR Template but did not involve the BWG in its development. We, the BWG, have conducted a thorough critical review and analysis of the TransCelerate CSR Template and summarise our major findings here to expand on our initial observations on the TransCelerate CSR Template, which we published in a press release in December 2018 [19]. We also took this opportunity to review and update the original Version 1 CORE Reference 'Terminology Table' and present Version 2, which includes estimand as a defined term and an adaptation of the original 'worked study example' to incorporate the recently evolved concept of 'estimands'.

Critical review of the TransCelerate CSR Template and resulting outputs
Over the period 11 January to 28 March 2019, the BWG discussed similarities and differences between the Trans-Celerate CSR Template and CORE Reference. The BWG's comments on the TransCelerate CSR Template were collated and proof-checked, and the resulting unabridged critical review comments are provided in Additional file 1. We classified a proportion of the review comments as major findings. In Table 1, we summarise these, and we make recommendations on enhancements that may be applied to the TransCelerate CSR Template with respect to each major finding. Finally, this manuscript was drafted and underwent review by the BWG.
The original CORE Reference Terminology Table  ( Table 2. Despite the suggestion that (predominantly) later patient-focused safety and efficacy studies lend themselves to having estimands, we also consider their applicability to earlyphase development.

Results of the review of the TransCelerate CSR Template
For each major finding in Table 1, we make suggestions for enhancements to the TransCelerate CSR Template. These can be viewed as opportunities to refine the CSR Template structure and instructional text, enhance content clarity, add web links to referenced guidance documents, improve transparency to support the broad readership of CSRs, and develop supporting resources. These are our key recommendations for consideration in the further development of the TransCelerate CSR Template or for sponsor adaptations thereof. To view all of the review team comments in situ and, therefore, in context and with supporting detail, we recommend viewing Additional file 1.
Version 2.0 of the CORE Reference Terminology Table   Following the 2016 publication of CORE Reference, the concept of 'estimand'-which was mentioned in CORE Reference as a future expected area of interest-has matured and is now better understood. The TransCelerate CSR Template takes estimand into consideration. We believe that the update of the CORE Reference Terminology Table to include estimand is now timely.
'Estimand' , unlike the other terms already included in the Terminology Table,

Discussion
Although independently developed, the CORE Reference and TransCelerate CSR Template both serve as resources that can be voluntarily adopted by stakeholders in the clinical research ecosystem, and help achieve better compliance with global standards for reporting clinical study data, analysis, and interpretation.
The BWG views the TransCelerate CSR Template as a valuable addition to the available resources for CSR authors and reviewers. Although CORE Reference serves a different purpose, there are synergies between the two, as shown in the Additional file 1 comments. There are, however, differences, which broadly fit into the themes discussed below, and include transparency and public disclosure, structural flexibility, section-to-section continuity, sectional numbering, and instructional text completeness and clarity.
Transparency and collaboration are necessary in today's clinical research environment. Cooperation between resource developers can provide a coherent message that directs towards a useable set of global standards. Direct web links to referenced materials and resources increase resource accessibility and provide valuable context and transparency. The CORE Reference website includes web links to the TransCelerate CSR Template resources under 'Third-party Publications and Presentations' [20]. We encourage reciprocation in the TransCelerate CSR Template of web links, not only to CORE Reference [5] but also to other guidelines directly referenced but not currently linked in the TransCelerate CSR Template. These include the ICH efficacy guidelines webpage [21] where ICH E3 may be downloaded   from and TransCelerate's Clinical Data Transparency page [22]. It should also be noted that CORE Reference is the only resource that we know of that identifies all current places in an ICH E3-compliant CSR where disclosure considerations apply. This is particularly important because CSRs are now publicly disclosed by the medicine regulators in the EU [8,9] and Canada [12], and special care is therefore needed when writing CSRs to balance text and data presentations so that on one hand, the identity of individuals is protected, and on the other hand, data utility is optimised to support medicine regulators in unimpeded assessment of license applications [9]. Direct links in the CSR Template to resources that support the writer in this endeavour are, therefore, essential. Further, the TransCelerate CSR Template, the Statistical Analysis Plan (SAP) Template-intended for use by biostatisticians in authoring the SAP (a document that details the statistical methodology typically summarised in a CSR)-and the mapping tool could be relocated on the TransCelerate website, perhaps to a new archive of 'clinical study reporting assets' which may help users to find them more easily. Both the CSR and the SAP Templates currently reside under the Common Protocol Template assets. A tool showing the TransCelerate CSR Template, mapped to ICH E3 and CORE Reference, is not co-located with these resources and is difficult to find [17]. A single CSR Template cannot address all study designs without some degree of inherent structural flexibility. There should be the ability to rearrange sections to suit the study design. This is currently lacking due to the TransCelerate CSR Template red  Table   Table 2 is Version 2.0 of the original CORE Reference Terminology Table,  instructional text (which is shown in Additional file 1) to not rearrange or reorder Level 1, Level 2, and lower hierarchy headings. Inflexibility in Level 1 headings could reasonably be justified, for example, by regulatory authority reviewer preference, or as a precursor to future Template automations and more sophisticated review tools. The absence of a clear explanation for the required Level 1 heading rigidity could be an impediment to appropriate use of the Template. The inflexibility in Level 2 and lower headings is less easy to justify. The TransCelerate CSR Template authors recommend the presentation of only primary and secondary endpoints in the synopsis, an optional results summary section, and complete omission of the CSR discussion section in the main Template body. The main body results, summary results, and discussion sections should allow for continuity of results presentation. This is optimal if all endpoints-primary, secondary, and exploratory-are presented in all of these sections. Further, the opportunity for discussion of relevant study-related results must be within the CSR for a given study-to aid comprehension. The absence of such a reporting approach significantly hinders the CSR author, the regulator, and the expanded (public) audience with both authoring and interpreting the document. In CORE Reference page 6, we state '…the synopsis should provide a summary of all relevant results (e.g. if there are multiple endpoints, consider limiting to primary and secondary)…' The flexibility to limit the synopsis presentation to primary and secondary endpoints in CORE Reference was to help achieve consistency in reporting with some clinical trial databases (for example, clinicaltrials.gov and EudraCT) where only primary and secondary endpoints need to be reported. We recognise that inclusion or exclusion of exploratory endpoints in a CSR synopsis may well be based on sponsor preference.
TransCelerate CSR sectional numbering, including those of the CSR appendices, is different from ICH E3 [4] and CORE Reference [1]. Both of these resources proffer content guidance and do not mandate a structure. However, as the ICH E3 numbering system is still frequently referred to in the context of clinical development, TransCelerate should consider aligning their numbering and adapting their mapping tool accordingly.
In the absence of sufficiently detailed TransCelerate CSR Template instructional text, the CSR author would be challenged to develop appropriate sectional content without referring to other guidelines, including CORE Reference. Instructional text as it currently stands in the TransCelerate CSR Template is too lean to support adequate authoring in sections on reporting of adverse events, clinical laboratory evaluation, other safety evaluations (medical devices in particular), pharmacokinetics (PK), pharmacodynamics, biomarkers, and immunogenicity. Further, these sections could be enhanced by the addition of example shell in-text tables. In this predominantly safety-and efficacy-focused CSR Template, there is an opportunity to add value for programmes in early clinical development by enhancing the instructional text that could inform reporting for studies with pharmacological components, e.g. PK and pharmacodynamics. For example, clarification that tabulation of summary PK data and that presentation of summary concentrationtime plots (or similar) are appropriate, and that the results should be presented for any PK modelling of the drug concentration-time data, could be beneficial.
CORE Reference had multiple stakeholders involved through its development, including regulatory authority contribution from Health Canada. TransCelerate has not declared any wider stakeholder input-nor has it declared input from any regulatory authority-into the development of their CSR Template. Declaration of stakeholder input reflects the integration of a range of perspectives into any resource's development and can reasonably be expected to impact its compliance and uptake; therefore, it could be beneficial if TransCelerate added this declaration.
The updated CORE Reference Terminology Table is presented here as Table 2. The concept of estimands as defining quantities that must be estimated from clinical trial data-that take into account post-randomisation events-is well explained by Bridge and Schindler [23]. It is clear that estimands can be readily applied to safety and efficacy studies in patients; further, estimands are expected to be incorporated into SAPs, per the 08 May 2019 ICH E8(R1) draft guidance 'General Considerations for Clinical Studies' [24] which is under public consultation at the time of publication of this paper. Earlyphase development studies such as first-in-human are exploratory and generally hypothesis-generating. The use of an estimand in these circumstances is less obvious. Nevertheless, it may be possible to choose study endpoints that would inform the estimand in later phase studies, and could provide an estimand-related thread through a medicine's development. Although not directly applicable to reporting, this consideration may have value at the study design stage.

Conclusions
This publication will help CSR authors appreciate the distinct values of, and differences between, the TransCelerate CSR Template and CORE Reference. Application of CORE Reference in CSR authoring provides additional instructional value and perspective for users of the TransCelerate CSR Template. CORE Reference maintains its considerable original value as a well-contextualised educational resource containing clarifications and sourcing for each guidance point. TransCelerate's CSR Template is a unified industry development, built using existing guidance documents, including CORE Reference, and as such is an important milestone. Perhaps a future step could be the collaboration and creation of an integrated 'tool kit' for CSR authors.