82_FR_27961 82 FR 27845 - Agency Information Collection Activities; Proposed Collection; Comment Request; Disclosures of Descriptive Presentations in Professional Oncology Prescription Drug Promotion

82 FR 27845 - Agency Information Collection Activities; Proposed Collection; Comment Request; Disclosures of Descriptive Presentations in Professional Oncology Prescription Drug Promotion

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration

Federal Register Volume 82, Issue 116 (June 19, 2017)

Page Range27845-27848
FR Document2017-12599

The Food and Drug Administration (FDA or Agency) is announcing an opportunity for public comment on the proposed collection of certain information by the Agency. Under the Paperwork Reduction Act of 1995 (PRA), Federal Agencies are required to publish notice in the Federal Register concerning each proposed collection of information and to allow 60 days for public comment in response to the notice. This notice solicits comments on research entitled ``Disclosures of Descriptive Presentations in Professional Oncology Prescription Drug Promotion.''

Federal Register, Volume 82 Issue 116 (Monday, June 19, 2017)
[Federal Register Volume 82, Number 116 (Monday, June 19, 2017)]
[Notices]
[Pages 27845-27848]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2017-12599]


-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Food and Drug Administration

[Docket No. FDA-2017-N-1779]


Agency Information Collection Activities; Proposed Collection; 
Comment Request; Disclosures of Descriptive Presentations in 
Professional Oncology Prescription Drug Promotion

AGENCY: Food and Drug Administration, HHS.

ACTION: Notice.

-----------------------------------------------------------------------

SUMMARY: The Food and Drug Administration (FDA or Agency) is announcing 
an opportunity for public comment on the proposed collection of certain 
information by the Agency. Under the Paperwork Reduction Act of 1995 
(PRA), Federal Agencies are required to publish notice in the Federal 
Register concerning each proposed collection of information and to 
allow 60 days for public comment in response to the notice. This notice 
solicits comments on research entitled ``Disclosures of Descriptive 
Presentations in Professional Oncology Prescription Drug Promotion.''

DATES: Submit either electronic or written comments on the collection 
of information by August 18, 2017.

ADDRESSES: You may submit comments as follows. Please note that late, 
untimely filed comments will not be considered. Electronic comments 
must be submitted on or before August 18, 2017. The https://www.regulations.gov electronic filing system will accept comments until 
midnight Eastern Time at the end of August 18, 2017. Comments received 
by mail/hand delivery/courier (for written/paper submissions) will be 
considered timely if they are postmarked or the delivery service 
acceptance receipt is on or before that date.

Electronic Submissions

    Submit electronic comments in the following way:
     Federal eRulemaking Portal: https://www.regulations.gov. 
Follow the instructions for submitting comments. Comments submitted 
electronically, including attachments, to https://www.regulations.gov 
will be posted to the docket unchanged. Because your comment will be 
made public, you are solely responsible for ensuring that your comment 
does not include any confidential information that you or a third party 
may not wish to be posted, such as medical information, your or anyone 
else's Social Security number, or confidential business information, 
such as a manufacturing process. Please note that if you include your 
name, contact information, or other information that identifies you in 
the body of your comments, that information will be posted on https://www.regulations.gov.
     If you want to submit a comment with confidential 
information that you do not wish to be made available to the public, 
submit the comment as a written/paper submission and in the manner 
detailed (see ``Written/Paper Submissions'' and ``Instructions'').

Written/Paper Submissions

    Submit written/paper submissions as follows:
     Mail/Hand delivery/Courier (for written/paper 
submissions): Dockets Management Staff (HFA-305), Food and Drug 
Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852.
     For written/paper comments submitted to the Dockets 
Management Staff, FDA will post your comment, as well as any 
attachments, except for information submitted, marked and

[[Page 27846]]

identified, as confidential, if submitted as detailed in 
``Instructions.''
    Instructions: All submissions received must include the Docket No. 
FDA-2017-N-1779 for ``Disclosures of Descriptive Presentations in 
Professional Oncology Prescription Drug Promotion.'' Received comments, 
those filed in a timely manner (see ADDRESSES), will be placed in the 
docket and, except for those submitted as ``Confidential Submissions,'' 
publicly viewable at https://www.regulations.gov or at the Dockets 
Management Staff between 9 a.m. and 4 p.m., Monday through Friday.
     Confidential Submissions--To submit a comment with 
confidential information that you do not wish to be made publicly 
available, submit your comments only as a written/paper submission. You 
should submit two copies total. One copy will include the information 
you claim to be confidential with a heading or cover note that states 
``THIS DOCUMENT CONTAINS CONFIDENTIAL INFORMATION.'' The Agency will 
review this copy, including the claimed confidential information, in 
its consideration of comments. The second copy, which will have the 
claimed confidential information redacted/blacked out, will be 
available for public viewing and posted on https://www.regulations.gov. 
Submit both copies to the Dockets Management Staff. If you do not wish 
your name and contact information to be made publicly available, you 
can provide this information on the cover sheet and not in the body of 
your comments and you must identify this information as 
``confidential.'' Any information marked as ``confidential'' will not 
be disclosed except in accordance with 21 CFR 10.20 and other 
applicable disclosure law. For more information about FDA's posting of 
comments to public dockets, see 80 FR 56469, September 18, 2015, or 
access the information at: http://www.thefederalregister.org/fdsys/pkg/FR-2015-09-18/pdf/2015-23389.pdf.
    Docket: For access to the docket to read background documents or 
the electronic and written/paper comments received, go to https://www.regulations.gov and insert the docket number, found in brackets in 
the heading of this document, into the ``Search'' box and follow the 
prompts and/or go to the Dockets Management Staff, 5630 Fishers Lane, 
Rm. 1061, Rockville, MD 20852.

FOR FURTHER INFORMATION CONTACT: Ila S. Mizrachi, Office of Operations, 
Food and Drug Administration, Three White Flint North, 10A63, 11601 
Landsdown St., North Bethesda, MD 20852, 301-796-7726, 
[email protected].

SUPPLEMENTARY INFORMATION: 

I. Background

    Under the PRA (44 U.S.C. 3501-3520), Federal Agencies must obtain 
approval from the Office of Management and Budget (OMB) for each 
collection of information they conduct or sponsor. ``Collection of 
information'' is defined in 44 U.S.C. 3502(3) and 5 CFR 1320.3(c) and 
includes Agency requests or requirements that members of the public 
submit reports, keep records, or provide information to a third party. 
Section 3506(c)(2)(A) of the PRA (44 U.S.C. 3506(c)(2)(A)) requires 
Federal Agencies to provide a 60-day notice in the Federal Register 
concerning each proposed collection of information before submitting 
the collection to OMB for approval. To comply with this requirement, 
FDA is publishing notice of the proposed collection of information set 
forth in this document.
    With respect to the following collection of information, FDA 
invites comments on these topics: (1) Whether the proposed collection 
of information is necessary for the proper performance of FDA's 
functions, including whether the information will have practical 
utility; (2) the accuracy of FDA's estimate of the burden of the 
proposed collection of information, including the validity of the 
methodology and assumptions used; (3) ways to enhance the quality, 
utility, and clarity of the information to be collected; and (4) ways 
to minimize the burden of the collection of information on respondents, 
including through the use of automated collection techniques, when 
appropriate, and other forms of information technology.

Disclosures of Descriptive Presentations in Professional Oncology 
Prescription Drug Promotion; OMB Control Number 0910--NEW

    Section 1701(a)(4) of the Public Health Service Act (42 U.S.C. 
300u(a)(4)) authorizes FDA to conduct research relating to health 
information. Section 1003(d)(2)(C) of the Federal Food, Drug, and 
Cosmetic Act (the FD&C Act) (21 U.S.C. 393(d)(2)(C)) authorizes FDA to 
conduct research relating to drugs and other FDA regulated products in 
carrying out the provisions of the FD&C Act.
    Under the FD&C Act and implementing regulations, promotional 
labeling and advertising about prescription drugs are generally 
required to be truthful, non-misleading, and to reveal facts material 
to the presentations made about the product being promoted (see 
sections 502(a) and (n), and 201(n) of the FD&C Act (21 U.S.C. 352(a) 
and (n), and 321(n)); see also 21 CFR 202.1). As a part of the ongoing 
evaluation of FDA's regulations in this area, FDA is proposing to study 
the impact of disclosures as they relate to presentations of 
preliminary or descriptive scientific and clinical data in promotional 
labeling and advertising for oncology products. The use of disclosures 
is one method of communicating information to health care professionals 
about scientific and clinical data, the limitations of that data, and 
practical utility of that information for use in treatment. These 
disclosures may influence prescriber comprehension and decisionmaking, 
and may affect how and what treatment they prescribe for their 
patients.
    Pharmaceutical companies market directly to physicians through 
publishing advertisements in medical journals, exhibit booths at 
physician meetings or events, sending unsolicited promotional materials 
to doctors' offices, or presentations (``detailing'') by pharmaceutical 
representatives (Ref. 1). Detail aids may contain carefully extracted 
data from clinical studies that, taken out of context, can exaggerate 
the benefits of a drug (Ref. 2) or contribute to physicians prescribing 
the drug for an inappropriate patient population.
    Promotional labeling and advertising for cancer drugs deserve 
specific attention. Oncology drugs represented 26 percent of the 649 
compounds under clinical trial investigation from 2006 to 2011 (Ref. 
3). The past decade has seen a dramatic rise in the number of oncology 
drugs brought to market. In the past 18 months, FDA has approved 27 
cancer drugs (Ref. 4). Although overall survival remains the gold 
standard for demonstrating clinical benefit of a drug, several 
additional endpoints are accepted as surrogates illustrating clinical 
benefit with regard to cancer and many drugs are granted expedited 
approval on their basis. These include disease-free survival, objective 
response rate, complete response rate, progression-free survival, and 
time to progression (Ref. 5). For clinicians who are not specifically 
trained in clinical trial design, interpreting these endpoints may be 
challenging. Pharmaceutical companies invest heavily in the development 
and distribution of promotional materials to educate oncologists about 
favorable clinical trial results.
    When communicating scientific and clinical data, a disclosure (a 
specific statement that modifies or qualifies a claim) could be used to 
convey the limitations of the data and practical

[[Page 27847]]

utility of the information for treatment. Much of the prior research on 
disclosures in this topic area has been limited to the dietary 
supplement arena with consumers (Refs. 6-9). Disclosures in 
professional pieces could influence prescriber comprehension as well as 
subsequent decisionmaking; however, no published data exist regarding 
how prescribers use and understand scientific claims in conjunction 
with qualifying disclosures.
    Different aspects of disclosures may influence their effectiveness. 
For example, despite the advanced education of health care providers, 
in a busy practice they may not be willing or able to process the 
disclosures thoroughly. Thus, the level of technicality in the 
disclosure may play a role in their use of the disclosure to 
contextualize the data display. Additionally, the addition of a general 
summary statement to frame the disclosure may help or hinder the 
processing of the disclosure and therefore the entire data display. 
Finally, it is possible that the impact of disclosure statements on 
prescriber comprehension, perceptions, and intentions to prescribe the 
promoted product will vary based on the level of clinical training. 
Although oncologists and primary care physicians (PCPs) will have more 
experience with clinical data, mid-level practitioners have reported 
having significantly more formal training on pharmaceutical marketing 
tactics than specialists and PCPs (Ref. 10). Therefore, it is unclear 
whether any one group would be more or less affected by both the claims 
made in promotional materials or by the disclosures that accompany 
those claims.
    The proposed study seeks to address the following research 
questions:
    1. Do disclosures mitigate potentially misleading presentations of 
preliminary or descriptive data in oncology drug product promotion?
    2. Does the language (technical, non-technical) of the disclosure 
influence the effectiveness of the disclosure?
    3. Does the presence of a general statement about the clinical 
utility of the data in addition to a specific disclosure influence 
processing of claims and disclosures?
    4. Do PCPs, oncologists, and mid-level practitioners (nurse 
practitioners, physician assistants) differ in their processing of 
claims and disclosures about preliminary or descriptive data?
    5. Which disclosures do physicians prefer?
    To address these questions, FDA has designed a study that will be 
conducted in three independent phases, each phase examining a data 
display in a promotional piece for a unique oncological product. 
Independent variables will include: (1) Specific disclosure (technical, 
non-technical, none), (2) general statement (present, absent), and (3) 
specialty (oncologists, PCPs, mid-level practitioners). Each phase will 
have the following design:

----------------------------------------------------------------------------------------------------------------
                                                                          Specific disclosure
             Sample                General statement  ----------------------------------------------------------
                                                           Technical       Non-technical       No disclosure
----------------------------------------------------------------------------------------------------------------
Oncologists.....................  Present............                      Control.
                                  Absent.............                   
PCPs............................  Present............                      Control.
                                  Absent.............                   
Mid-Level Practitioners.........  Present............                      Control.
                                  Absent.............                   
----------------------------------------------------------------------------------------------------------------

    Specific disclosures will include material information specifically 
related to the particular data display in question. As such, each 
specific disclosure may include clinical or statistical information 
related to the trial design, the statistical analysis plan of the 
trial, or any other material statistical or clinical information 
necessary for evaluation or interpretation of the data. The team 
developing the disclosures includes social science analysts, 
pharmacists, oncological medical officers, and an oncology nurse. An 
example of the general statement is ``This presentation includes 
exploratory information of uncertain clinical utility and should be 
interpreted cautiously when used to make treatment decisions.''
    Outcome variables will focus on the assessment of the data display 
as a whole as well as attention to the disclosure, if present. 
Specifically, we will examine recognition of the clinical endpoint in 
the data display, comprehension of the data display, perceptions of the 
exploratory nature of the data, and the perceived credibility of the 
promotional piece. We will also look at attention to the specific 
disclosure and the general statement, prescriber decisions, and 
prescriber preferences. This latter outcome variable will be determined 
by a secondary task at the end of the questionnaire that shows each 
participant all disclosure options and asks them to choose their 
preferred version.
    Oncologists, PCPs, and non-oncology mid-level practitioners will be 
recruited to participate via the Internet, and the study is expected to 
take approximately 20 minutes. Participants will view professionally 
developed promotional pieces that mimic currently available promotion 
and answer questions. The questionnaire is available upon request.
    FDA estimates the burden of this collection of information as 
follows:

                                                     Table 1--Estimated Annual Reporting Burden \1\
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                 Number of
                  Activity                       Number of     responses per   Total annual           Average burden per response           Total hours
                                                respondents     respondent       responses                                                      \2\
--------------------------------------------------------------------------------------------------------------------------------------------------------
Pretest Screener............................             134               1             134  0.03 (2 minutes)..........................               5
Pretest.....................................              90               1              90  0.33 (20 minutes).........................              30
Main Study Screener.........................           3,134               1           3,134  0.03 (2 minutes)..........................             105
Main Study..................................           2,115               1           2,115  0.33 (20 minutes).........................             705
                                             -----------------------------------------------------------------------------------------------------------

[[Page 27848]]

 
    Total...................................  ..............  ..............  ..............  ..........................................             845
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ There are no capital costs or operating and maintenance costs associated with this collection of information.
\2\ Rounded to the next full hour.

II. References

    The following references are on display in the Dockets Management 
Staff (see ADDRESSES) and are available for viewing by interested 
persons between 9 a.m. and 4 p.m., Monday through Friday; they are also 
available electronically at https://www.regulations.gov. FDA has 
verified the Web site addresses, as of the date this document publishes 
in the Federal Register, but Web sites are subject to change over time.

1. Johar, K., ``An Insider's Perspective: Defense of the 
Pharmaceutical Industry's Marketing Practices,'' Albany Law Review, 
76:299-334, 2012-2013.
2. Wick, C., M. Egger, S. Trelle, et al., ``The Characteristics of 
Unsolicited Clinical Oncology Literature Provided by Pharmaceutical 
Industry,'' Annals of Oncology, 18:1580-1582, 2007.
3. Fisher, J.A., M.D. Cottingham, and C.A. Kalbaugh, ``Peering Into 
the Pharmaceutical `Pipeline': Investigational Drugs, Clinical 
Trials, and Industry Priorities,'' Social Science & Medicine, 
131:322-330, 2015.
4. Centerwatch, ``FDA Approved Drugs for Oncology,'' https://www.centerwatch.com/drug-information/fda-approved-drugs/therapeutic-area/12/oncology (accessed on March 2, 2017).
5. Pazdur, R., ``Endpoints for Assessing Drug Activity in Clinical 
Trials,'' The Oncologist, 13:19-21, 2008.
6. Dodge, T. and A. Kaufman, ``What Makes Consumers Think Dietary 
Supplements Are Safe and Effective? The Role of Disclaimers and FDA 
Approval,'' Health Psychology, 26:513-517, 2007.
7. Dodge, T., D. Litt, and A. Kaufman, ``Influence of the Dietary 
Supplement Health and Education Act on Consumer Beliefs About the 
Safety and Effectiveness of Dietary Supplements,'' Journal of Health 
Communication, 16:230-244, 2011.
8. Mason, M.J., D.L. Scammon, and X. Fang, ``The Impact of Warnings, 
Disclaimers, and Product Experience on Consumers' Perceptions of 
Dietary Supplements,'' The Journal of Consumer Affairs, 41:74-99, 
2007.
9. France, K.R. and P.F. Bone, ``Policy Makers' Paradigms and 
Evidence From Consumer Interpretations of Dietary Supplement 
Labels,'' The Journal of Consumer Affairs, 39:27-51, 2005.
10. O'Donoghue, A.C., V. Boudewyns, K.J. Aikin, et al., ``Awareness 
of the Food and Drug Administration's Bad Ad Program and Education 
Regarding Pharmaceutical Advertising: A National Survey of 
Prescribers in Ambulatory Care Settings,'' Journal of Health 
Communication, 20:1330-1336, 2015.

    Dated: June 13, 2017.
Anna K. Abram,
Deputy Commissioner for Policy, Planning, Legislation, and Analysis.
[FR Doc. 2017-12599 Filed 6-16-17; 8:45 am]
 BILLING CODE 4164-01-P



                                                                                              Federal Register / Vol. 82, No. 116 / Monday, June 19, 2017 / Notices                                                                                              27845

                                                                                                                  TABLE 1—ESTIMATED ANNUAL REPORTING BURDEN 1
                                                                                                                                                                   Number of
                                                                                                                                        Number of                                            Total annual                  Average burden
                                                                                     Activity                                                                    responses per                                                                               Total hours
                                                                                                                                       respondents                                            responses                     per response
                                                                                                                                                                   respondent

                                                    Pilot screener ............................................................                         120                           1                      120       0.03 (2 minutes) .......                         4
                                                    Study 1 screener ......................................................                             600                           1                      600       0.03 (2 minutes) .......                        18
                                                    Study 2 screener ......................................................                             600                           1                      600       0.03 (2 minutes) .......                        18
                                                    Completes, Pilot ........................................................                            40                           1                       40       1 ................................              40
                                                    Completes, Study 1 ..................................................                               200                           1                      200       1 ................................             200
                                                    Completes, Study 2 ..................................................                               200                           1                      200       1 ................................             200

                                                          Total ...................................................................   ........................   ........................   ........................   ...................................            480
                                                       1 There    are no capital costs or operating and maintenance costs associated with this collection of information.


                                                    II. References                                                              Dated: June 13, 2017.                                                      Comments received by mail/hand
                                                                                                                              Anna K. Abram,                                                               delivery/courier (for written/paper
                                                      The following references are on                                         Deputy Commissioner for Policy, Planning,                                    submissions) will be considered timely
                                                    display in the Dockets Management                                         Legislation, and Analysis.                                                   if they are postmarked or the delivery
                                                    Staff (see ADDRESSES) and are available                                   [FR Doc. 2017–12600 Filed 6–16–17; 8:45 am]                                  service acceptance receipt is on or
                                                    for viewing by interested persons                                         BILLING CODE 4164–01–P                                                       before that date.
                                                    between 9 a.m. and 4 p.m., Monday
                                                    through Friday; they are also available                                                                                                                Electronic Submissions
                                                    electronically at https://                                                DEPARTMENT OF HEALTH AND                                                       Submit electronic comments in the
                                                    www.regulations.gov. FDA has verified                                     HUMAN SERVICES                                                               following way:
                                                    the Web site addresses, as of the date                                                                                                                   • Federal eRulemaking Portal:
                                                    this document publishes in the Federal                                    Food and Drug Administration                                                 https://www.regulations.gov. Follow the
                                                    Register, but Web sites are subject to                                    [Docket No. FDA–2017–N–1779]                                                 instructions for submitting comments.
                                                    change over time.                                                                                                                                      Comments submitted electronically,
                                                                                                                              Agency Information Collection                                                including attachments, to https://
                                                    1. McGuire, L.C., ‘‘Remembering What the                                  Activities; Proposed Collection;
                                                        Doctor Said: Organization and Older
                                                                                                                                                                                                           www.regulations.gov will be posted to
                                                                                                                              Comment Request; Disclosures of                                              the docket unchanged. Because your
                                                        Adults’ Memory for Medical
                                                                                                                              Descriptive Presentations in                                                 comment will be made public, you are
                                                        Information.’’ Experimental Aging
                                                                                                                              Professional Oncology Prescription                                           solely responsible for ensuring that your
                                                        Research, 22, 403–428 (1996).
                                                                                                                              Drug Promotion                                                               comment does not include any
                                                    2. Aikin, K.J., J.L. Swasy, and A.C. Braman,
                                                        ‘‘Patient and Physician Attitudes and                                 AGENCY:         Food and Drug Administration,                                confidential information that you or a
                                                        Behaviors Associated with DTC                                         HHS.                                                                         third party may not wish to be posted,
                                                        Promotion of Prescription Drugs:                                      ACTION:       Notice.                                                        such as medical information, your or
                                                        Summary of FDA Survey Research                                                                                                                     anyone else’s Social Security number, or
                                                        Results’’ (2004). Available at http://                                SUMMARY:   The Food and Drug                                                 confidential business information, such
                                                        www.fda.gov/downloads/Drugs/                                          Administration (FDA or Agency) is                                            as a manufacturing process. Please note
                                                        ScienceResearch/ResearchAreas/                                        announcing an opportunity for public                                         that if you include your name, contact
                                                        DrugMarketingAdvertisingand                                           comment on the proposed collection of                                        information, or other information that
                                                        CommunicationsResearch/                                               certain information by the Agency.                                           identifies you in the body of your
                                                        UCM152860.pdf.                                                        Under the Paperwork Reduction Act of                                         comments, that information will be
                                                    3. Warnings and Risk Communication (2005).                                1995 (PRA), Federal Agencies are                                             posted on https://www.regulations.gov.
                                                        Wogalter, M.S., D. DeJoy, and K.R.                                    required to publish notice in the                                              • If you want to submit a comment
                                                        Laughery (Eds.). Philadelphia: Taylor &                               Federal Register concerning each                                             with confidential information that you
                                                        Francis, Inc.                                                         proposed collection of information and                                       do not wish to be made available to the
                                                    4. Conzola, V.C., and M.S. Wogalter, ‘‘A                                  to allow 60 days for public comment in                                       public, submit the comment as a
                                                        Communication-Human Information                                       response to the notice. This notice                                          written/paper submission and in the
                                                        Processing (C–HIP) Approach to Warning                                solicits comments on research entitled                                       manner detailed (see ‘‘Written/Paper
                                                        Effectiveness in the Workplace.’’ Journal                             ‘‘Disclosures of Descriptive                                                 Submissions’’ and ‘‘Instructions’’).
                                                        of Risk Research, 4(4), 309–322; (2001).                              Presentations in Professional Oncology
                                                    5. Wogalter, M.S., and K.R Laughery,                                                                                                                   Written/Paper Submissions
                                                                                                                              Prescription Drug Promotion.’’
                                                        ‘‘Warning! Sign and Label                                             DATES: Submit either electronic or                                             Submit written/paper submissions as
                                                        Effectiveness.’’ Current Directions in                                written comments on the collection of                                        follows:
                                                        Psychological Science, 5(2), 33–37;                                   information by August 18, 2017.                                                • Mail/Hand delivery/Courier (for
                                                        (1996).                                                                                                                                            written/paper submissions): Dockets
asabaliauskas on DSKBBXCHB2PROD with NOTICES




                                                                                                                              ADDRESSES: You may submit comments
                                                    6. Wogalter, M.S., T.L. Smith-Jackson, B.J.                                                                                                            Management Staff (HFA–305), Food and
                                                                                                                              as follows. Please note that late,
                                                        Mills, and C.S. Paine, ‘‘The Effects of                                                                                                            Drug Administration, 5630 Fishers
                                                                                                                              untimely filed comments will not be
                                                        Print Format in Direct-to-Consumer
                                                                                                                              considered. Electronic comments must                                         Lane, Rm. 1061, Rockville, MD 20852.
                                                        Prescription Drug Advertisements on
                                                        Risk Knowledge and Preference.’’ Drug
                                                                                                                              be submitted on or before August 18,                                           • For written/paper comments
                                                        Information Journal, 36(3), 693–705,
                                                                                                                              2017. The https://www.regulations.gov                                        submitted to the Dockets Management
                                                        2002.
                                                                                                                              electronic filing system will accept                                         Staff, FDA will post your comment, as
                                                                                                                              comments until midnight Eastern Time                                         well as any attachments, except for
                                                                                                                              at the end of August 18, 2017.                                               information submitted, marked and


                                               VerDate Sep<11>2014        20:20 Jun 16, 2017         Jkt 241001       PO 00000        Frm 00064       Fmt 4703      Sfmt 4703        E:\FR\FM\19JNN1.SGM               19JNN1


                                                    27846                          Federal Register / Vol. 82, No. 116 / Monday, June 19, 2017 / Notices

                                                    identified, as confidential, if submitted               St., North Bethesda, MD 20852, 301–                    being promoted (see sections 502(a) and
                                                    as detailed in ‘‘Instructions.’’                        796–7726, PRAStaff@fda.hhs.gov.                        (n), and 201(n) of the FD&C Act (21
                                                       Instructions: All submissions received               SUPPLEMENTARY INFORMATION:                             U.S.C. 352(a) and (n), and 321(n)); see
                                                    must include the Docket No. FDA–                                                                               also 21 CFR 202.1). As a part of the
                                                                                                            I. Background                                          ongoing evaluation of FDA’s regulations
                                                    2017–N–1779 for ‘‘Disclosures of
                                                    Descriptive Presentations in                               Under the PRA (44 U.S.C. 3501–                      in this area, FDA is proposing to study
                                                    Professional Oncology Prescription Drug                 3520), Federal Agencies must obtain                    the impact of disclosures as they relate
                                                    Promotion.’’ Received comments, those                   approval from the Office of Management                 to presentations of preliminary or
                                                    filed in a timely manner (see                           and Budget (OMB) for each collection of                descriptive scientific and clinical data
                                                    ADDRESSES), will be placed in the docket
                                                                                                            information they conduct or sponsor.                   in promotional labeling and advertising
                                                    and, except for those submitted as                      ‘‘Collection of information’’ is defined               for oncology products. The use of
                                                    ‘‘Confidential Submissions,’’ publicly                  in 44 U.S.C. 3502(3) and 5 CFR                         disclosures is one method of
                                                    viewable at https://www.regulations.gov                 1320.3(c) and includes Agency requests                 communicating information to health
                                                    or at the Dockets Management Staff                      or requirements that members of the                    care professionals about scientific and
                                                    between 9 a.m. and 4 p.m., Monday                       public submit reports, keep records, or                clinical data, the limitations of that data,
                                                    through Friday.                                         provide information to a third party.                  and practical utility of that information
                                                                                                            Section 3506(c)(2)(A) of the PRA (44                   for use in treatment. These disclosures
                                                       • Confidential Submissions—To                        U.S.C. 3506(c)(2)(A)) requires Federal                 may influence prescriber
                                                    submit a comment with confidential                      Agencies to provide a 60-day notice in                 comprehension and decisionmaking,
                                                    information that you do not wish to be                  the Federal Register concerning each                   and may affect how and what treatment
                                                    made publicly available, submit your                    proposed collection of information                     they prescribe for their patients.
                                                    comments only as a written/paper                        before submitting the collection to OMB                   Pharmaceutical companies market
                                                    submission. You should submit two                       for approval. To comply with this                      directly to physicians through
                                                    copies total. One copy will include the                 requirement, FDA is publishing notice                  publishing advertisements in medical
                                                    information you claim to be confidential                of the proposed collection of                          journals, exhibit booths at physician
                                                    with a heading or cover note that states                information set forth in this document.                meetings or events, sending unsolicited
                                                    ‘‘THIS DOCUMENT CONTAINS                                   With respect to the following                       promotional materials to doctors’
                                                    CONFIDENTIAL INFORMATION.’’ The                         collection of information, FDA invites                 offices, or presentations (‘‘detailing’’) by
                                                    Agency will review this copy, including                 comments on these topics: (1) Whether                  pharmaceutical representatives (Ref. 1).
                                                    the claimed confidential information, in                the proposed collection of information                 Detail aids may contain carefully
                                                    its consideration of comments. The                      is necessary for the proper performance                extracted data from clinical studies that,
                                                    second copy, which will have the                        of FDA’s functions, including whether                  taken out of context, can exaggerate the
                                                    claimed confidential information                        the information will have practical                    benefits of a drug (Ref. 2) or contribute
                                                    redacted/blacked out, will be available                 utility; (2) the accuracy of FDA’s                     to physicians prescribing the drug for an
                                                    for public viewing and posted on                        estimate of the burden of the proposed                 inappropriate patient population.
                                                    https://www.regulations.gov. Submit                     collection of information, including the                  Promotional labeling and advertising
                                                    both copies to the Dockets Management                   validity of the methodology and                        for cancer drugs deserve specific
                                                    Staff. If you do not wish your name and                 assumptions used; (3) ways to enhance                  attention. Oncology drugs represented
                                                    contact information to be made publicly                 the quality, utility, and clarity of the               26 percent of the 649 compounds under
                                                    available, you can provide this                         information to be collected; and (4)                   clinical trial investigation from 2006 to
                                                    information on the cover sheet and not                  ways to minimize the burden of the                     2011 (Ref. 3). The past decade has seen
                                                    in the body of your comments and you                    collection of information on                           a dramatic rise in the number of
                                                    must identify this information as                       respondents, including through the use                 oncology drugs brought to market. In the
                                                    ‘‘confidential.’’ Any information marked                of automated collection techniques,                    past 18 months, FDA has approved 27
                                                    as ‘‘confidential’’ will not be disclosed               when appropriate, and other forms of                   cancer drugs (Ref. 4). Although overall
                                                    except in accordance with 21 CFR 10.20                  information technology.                                survival remains the gold standard for
                                                    and other applicable disclosure law. For                                                                       demonstrating clinical benefit of a drug,
                                                                                                            Disclosures of Descriptive Presentations               several additional endpoints are
                                                    more information about FDA’s posting
                                                                                                            in Professional Oncology Prescription                  accepted as surrogates illustrating
                                                    of comments to public dockets, see 80
                                                                                                            Drug Promotion; OMB Control Number                     clinical benefit with regard to cancer
                                                    FR 56469, September 18, 2015, or access
                                                                                                            0910—NEW                                               and many drugs are granted expedited
                                                    the information at: http://www.gpo.gov/
                                                    fdsys/pkg/FR-2015-09-18/pdf/2015-                         Section 1701(a)(4) of the Public                     approval on their basis. These include
                                                    23389.pdf.                                              Health Service Act (42 U.S.C.                          disease-free survival, objective response
                                                                                                            300u(a)(4)) authorizes FDA to conduct                  rate, complete response rate,
                                                       Docket: For access to the docket to
                                                                                                            research relating to health information.               progression-free survival, and time to
                                                    read background documents or the
                                                                                                            Section 1003(d)(2)(C) of the Federal                   progression (Ref. 5). For clinicians who
                                                    electronic and written/paper comments
                                                                                                            Food, Drug, and Cosmetic Act (the                      are not specifically trained in clinical
                                                    received, go to https://
                                                                                                            FD&C Act) (21 U.S.C. 393(d)(2)(C))                     trial design, interpreting these
                                                    www.regulations.gov and insert the
                                                                                                            authorizes FDA to conduct research                     endpoints may be challenging.
                                                    docket number, found in brackets in the
                                                                                                            relating to drugs and other FDA                        Pharmaceutical companies invest
                                                    heading of this document, into the
asabaliauskas on DSKBBXCHB2PROD with NOTICES




                                                                                                            regulated products in carrying out the                 heavily in the development and
                                                    ‘‘Search’’ box and follow the prompts
                                                                                                            provisions of the FD&C Act.                            distribution of promotional materials to
                                                    and/or go to the Dockets Management
                                                                                                              Under the FD&C Act and                               educate oncologists about favorable
                                                    Staff, 5630 Fishers Lane, Rm. 1061,
                                                                                                            implementing regulations, promotional                  clinical trial results.
                                                    Rockville, MD 20852.
                                                                                                            labeling and advertising about                            When communicating scientific and
                                                    FOR FURTHER INFORMATION CONTACT:    Ila                 prescription drugs are generally                       clinical data, a disclosure (a specific
                                                    S. Mizrachi, Office of Operations, Food                 required to be truthful, non-misleading,               statement that modifies or qualifies a
                                                    and Drug Administration, Three White                    and to reveal facts material to the                    claim) could be used to convey the
                                                    Flint North, 10A63, 11601 Landsdown                     presentations made about the product                   limitations of the data and practical


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                                                                                              Federal Register / Vol. 82, No. 116 / Monday, June 19, 2017 / Notices                                                                           27847

                                                    utility of the information for treatment.                                 Finally, it is possible that the impact of                           3. Does the presence of a general
                                                    Much of the prior research on                                             disclosure statements on prescriber                                statement about the clinical utility of
                                                    disclosures in this topic area has been                                   comprehension, perceptions, and                                    the data in addition to a specific
                                                    limited to the dietary supplement arena                                   intentions to prescribe the promoted                               disclosure influence processing of
                                                    with consumers (Refs. 6–9). Disclosures                                   product will vary based on the level of                            claims and disclosures?
                                                    in professional pieces could influence                                    clinical training. Although oncologists
                                                                                                                                                                                                   4. Do PCPs, oncologists, and mid-level
                                                    prescriber comprehension as well as                                       and primary care physicians (PCPs) will
                                                    subsequent decisionmaking; however,                                                                                                          practitioners (nurse practitioners,
                                                                                                                              have more experience with clinical data,
                                                    no published data exist regarding how                                     mid-level practitioners have reported                              physician assistants) differ in their
                                                    prescribers use and understand                                            having significantly more formal                                   processing of claims and disclosures
                                                    scientific claims in conjunction with                                     training on pharmaceutical marketing                               about preliminary or descriptive data?
                                                    qualifying disclosures.                                                   tactics than specialists and PCPs (Ref.                              5. Which disclosures do physicians
                                                       Different aspects of disclosures may                                   10). Therefore, it is unclear whether any                          prefer?
                                                    influence their effectiveness. For                                        one group would be more or less                                      To address these questions, FDA has
                                                    example, despite the advanced                                             affected by both the claims made in
                                                    education of health care providers, in a                                                                                                     designed a study that will be conducted
                                                                                                                              promotional materials or by the                                    in three independent phases, each phase
                                                    busy practice they may not be willing or                                  disclosures that accompany those
                                                    able to process the disclosures                                                                                                              examining a data display in a
                                                                                                                              claims.
                                                    thoroughly. Thus, the level of                                               The proposed study seeks to address                             promotional piece for a unique
                                                    technicality in the disclosure may play                                   the following research questions:                                  oncological product. Independent
                                                    a role in their use of the disclosure to                                     1. Do disclosures mitigate potentially                          variables will include: (1) Specific
                                                    contextualize the data display.                                           misleading presentations of preliminary                            disclosure (technical, non-technical,
                                                    Additionally, the addition of a general                                   or descriptive data in oncology drug                               none), (2) general statement (present,
                                                    summary statement to frame the                                            product promotion?                                                 absent), and (3) specialty (oncologists,
                                                    disclosure may help or hinder the                                            2. Does the language (technical, non-                           PCPs, mid-level practitioners). Each
                                                    processing of the disclosure and                                          technical) of the disclosure influence                             phase will have the following design:
                                                    therefore the entire data display.                                        the effectiveness of the disclosure?

                                                                                                                                                                                                             Specific disclosure
                                                                                           Sample                                                      General statement
                                                                                                                                                                                               Technical           Non-technical        No disclosure

                                                    Oncologists ...........................................................................     Present .................................          •                       •            Control.
                                                                                                                                                Absent ...................................         •                       •
                                                    PCPs ....................................................................................   Present .................................          •                       •            Control.
                                                                                                                                                Absent ...................................         •                       •
                                                    Mid-Level Practitioners .........................................................           Present .................................          •                       •            Control.
                                                                                                                                                Absent ...................................         •                       •



                                                       Specific disclosures will include                                      and should be interpreted cautiously                               determined by a secondary task at the
                                                    material information specifically related                                 when used to make treatment                                        end of the questionnaire that shows
                                                    to the particular data display in                                         decisions.’’                                                       each participant all disclosure options
                                                    question. As such, each specific                                             Outcome variables will focus on the                             and asks them to choose their preferred
                                                    disclosure may include clinical or                                        assessment of the data display as a                                version.
                                                    statistical information related to the trial                              whole as well as attention to the
                                                                                                                                                                                                   Oncologists, PCPs, and non-oncology
                                                    design, the statistical analysis plan of                                  disclosure, if present. Specifically, we
                                                                                                                                                                                                 mid-level practitioners will be recruited
                                                    the trial, or any other material statistical                              will examine recognition of the clinical
                                                                                                                                                                                                 to participate via the Internet, and the
                                                    or clinical information necessary for                                     endpoint in the data display,
                                                                                                                              comprehension of the data display,                                 study is expected to take approximately
                                                    evaluation or interpretation of the data.
                                                    The team developing the disclosures                                       perceptions of the exploratory nature of                           20 minutes. Participants will view
                                                    includes social science analysts,                                         the data, and the perceived credibility of                         professionally developed promotional
                                                    pharmacists, oncological medical                                          the promotional piece. We will also look                           pieces that mimic currently available
                                                    officers, and an oncology nurse. An                                       at attention to the specific disclosure                            promotion and answer questions. The
                                                    example of the general statement is                                       and the general statement, prescriber                              questionnaire is available upon request.
                                                    ‘‘This presentation includes exploratory                                  decisions, and prescriber preferences.                               FDA estimates the burden of this
                                                    information of uncertain clinical utility                                 This latter outcome variable will be                               collection of information as follows:

                                                                                                                  TABLE 1—ESTIMATED ANNUAL REPORTING BURDEN 1
                                                                                                                                                                 Number of
                                                                                                                                        Number of                                        Total annual        Average burden
asabaliauskas on DSKBBXCHB2PROD with NOTICES




                                                                                      Activity                                                                 responses per                                                             Total hours 2
                                                                                                                                       respondents                                        responses           per response
                                                                                                                                                                 respondent

                                                    Pretest Screener .......................................................                         134                          1               134      0.03   (2 minutes) .......                5
                                                    Pretest .......................................................................                   90                          1                90      0.33   (20 minutes) .....                30
                                                    Main Study Screener ................................................                           3,134                          1             3,134      0.03   (2 minutes) .......              105
                                                    Main Study ................................................................                    2,115                          1             2,115      0.33   (20 minutes) .....               705




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                                                    27848                                    Federal Register / Vol. 82, No. 116 / Monday, June 19, 2017 / Notices

                                                                                                     TABLE 1—ESTIMATED ANNUAL REPORTING BURDEN 1—Continued
                                                                                                                                                                  Number of
                                                                                                                                       Number of                                            Total annual                  Average burden
                                                                                    Activity                                                                    responses per                                                                               Total hours 2
                                                                                                                                      respondents                                            responses                     per response
                                                                                                                                                                  respondent

                                                         Total ...................................................................   ........................   ........................   ........................   ...................................             845
                                                       1 Thereare no capital costs or operating and maintenance costs associated with this collection of information.
                                                       2 Rounded to the next full hour.




                                                    II. References                                                                   Drug Administration’s Bad Ad Program                                    Name of Committee: AIDS and Related
                                                                                                                                     and Education Regarding Pharmaceutical                               Research Integrated Review Group; AIDS
                                                      The following references are on                                                Advertising: A National Survey of                                    Molecular and Cellular Biology Study
                                                    display in the Dockets Management                                                Prescribers in Ambulatory Care                                       Section.
                                                    Staff (see ADDRESSES) and are available                                          Settings,’’ Journal of Health                                           Date: July 10, 2017.
                                                    for viewing by interested persons                                                Communication, 20:1330–1336, 2015.                                      Time: 8:00 a.m. to 6:00 p.m.
                                                    between 9 a.m. and 4 p.m., Monday                                          Dated: June 13, 2017.                                                         Agenda: To review and evaluate grant
                                                    through Friday; they are also available                                                                                                               applications.
                                                                                                                             Anna K. Abram,                                                                  Place: Residence Inn Bethesda, 7335
                                                    electronically at https://                                               Deputy Commissioner for Policy, Planning,                                    Wisconsin Avenue, Bethesda, MD 20814.
                                                    www.regulations.gov. FDA has verified                                    Legislation, and Analysis.                                                      Contact Person: Kenneth A. Roebuck,
                                                    the Web site addresses, as of the date                                   [FR Doc. 2017–12599 Filed 6–16–17; 8:45 am]                                  Ph.D., Scientific Review Officer, Center for
                                                    this document publishes in the Federal                                                                                                                Scientific Review, National Institutes of
                                                                                                                             BILLING CODE 4164–01–P
                                                    Register, but Web sites are subject to                                                                                                                Health, 6701 Rockledge Drive, Room 5214,
                                                    change over time.                                                                                                                                     MSC 7852, Bethesda, MD 20892, (301) 435–
                                                                                                                                                                                                          1166, roebuckk@csr.nih.gov.
                                                    1. Johar, K., ‘‘An Insider’s Perspective:                                DEPARTMENT OF HEALTH AND
                                                         Defense of the Pharmaceutical Industry’s                            HUMAN SERVICES                                                                  Name of Committee: Center for Scientific
                                                         Marketing Practices,’’ Albany Law                                                                                                                Review Special Emphasis Panel; AIDS and
                                                         Review, 76:299–334, 2012–2013.                                      National Institutes of Health                                                Related Research Member Conflict.
                                                    2. Wick, C., M. Egger, S. Trelle, et al., ‘‘The                                                                                                          Date: July 10, 2017.
                                                         Characteristics of Unsolicited Clinical                             Center for Scientific Review; Notice of                                         Time: 10:00 a.m. to 5:00 p.m.
                                                         Oncology Literature Provided by                                                                                                                     Agenda: To review and evaluate grant
                                                                                                                             Closed Meetings                                                              applications.
                                                         Pharmaceutical Industry,’’ Annals of
                                                         Oncology, 18:1580–1582, 2007.                                         Pursuant to section 10(d) of the                                              Place: National Institutes of Health, 6701
                                                    3. Fisher, J.A., M.D. Cottingham, and C.A.                               Federal Advisory Committee Act, as                                           Rockledge Drive, Bethesda, MD 20892
                                                         Kalbaugh, ‘‘Peering Into the                                                                                                                     (Virtual Meeting).
                                                                                                                             amended (5 U.S.C. App.), notice is
                                                         Pharmaceutical ‘Pipeline’:                                                                                                                          Contact Person: Shalanda A. Bynum,
                                                                                                                             hereby given of the following meetings.                                      Ph.D., MPH, Scientific Review Officer, Center
                                                         Investigational Drugs, Clinical Trials,                               The meetings will be closed to the
                                                         and Industry Priorities,’’ Social Science                                                                                                        for Scientific Review, National Institutes of
                                                                                                                             public in accordance with the                                                Health, 6701 Rockledge Drive, Room 3206,
                                                         & Medicine, 131:322–330, 2015.
                                                                                                                             provisions set forth in sections                                             Bethesda, MD 20892, 301–755–4355,
                                                    4. Centerwatch, ‘‘FDA Approved Drugs for
                                                         Oncology,’’ https://                                                552b(c)(4) and 552b(c)(6), Title 5 U.S.C.,                                   bynumsa@csr.nih.gov.
                                                         www.centerwatch.com/drug-                                           as amended. The grant applications and                                          Name of Committee: Center for Scientific
                                                         information/fda-approved-drugs/                                     the discussions could disclose                                               Review Special Emphasis Panel; PAR 16–
                                                         therapeutic-area/12/oncology (accessed                              confidential trade secrets or commercial                                     257: Predicting Behavioral Responses to
                                                         on March 2, 2017).                                                  property such as patentable material,                                        Population Level Cancer Control Strategies
                                                    5. Pazdur, R., ‘‘Endpoints for Assessing Drug                            and personal information concerning                                          (R21).
                                                         Activity in Clinical Trials,’’ The                                                                                                                  Date: July 11, 2017.
                                                                                                                             individuals associated with the grant
                                                         Oncologist, 13:19–21, 2008.                                                                                                                         Time: 11:00 a.m. to 2:00 p.m.
                                                                                                                             applications, the disclosure of which                                           Agenda: To review and evaluate grant
                                                    6. Dodge, T. and A. Kaufman, ‘‘What Makes
                                                                                                                             would constitute a clearly unwarranted                                       applications.
                                                         Consumers Think Dietary Supplements
                                                         Are Safe and Effective? The Role of                                 invasion of personal privacy.                                                   Place: National Institutes of Health, 6701
                                                         Disclaimers and FDA Approval,’’ Health                                Name of Committee: Center for Scientific                                   Rockledge Drive, Bethesda, MD 20892
                                                         Psychology, 26:513–517, 2007.                                       Review Special Emphasis Panel; RFA Panel:                                    (Telephone Conference Call).
                                                    7. Dodge, T., D. Litt, and A. Kaufman,                                   Revision Applications for U.S.-South Africa                                     Contact Person: Karin F. Helmers, Ph.D.,
                                                         ‘‘Influence of the Dietary Supplement                               Program for Collaborative Biomedical                                         Scientific Review Officer, Center for
                                                         Health and Education Act on Consumer                                Research.                                                                    Scientific Review, National Institutes of
                                                         Beliefs About the Safety and                                          Date: June 29, 2017.                                                       Health, 6701 Rockledge Drive, Room 3148,
                                                         Effectiveness of Dietary Supplements,’’                               Time: 2:00 p.m. to 5:00 p.m.                                               MSC 7770, Bethesda, MD 20892, (301) 254–
                                                         Journal of Health Communication,                                      Agenda: To review and evaluate grant                                       9975, helmersk@csr.nih.gov.
                                                         16:230–244, 2011.                                                   applications.                                                                   Name of Committee: Center for Scientific
                                                    8. Mason, M.J., D.L. Scammon, and X. Fang,                                 Place: National Institutes of Health, 6701                                 Review Special Emphasis Panel; PAR 15–
                                                         ‘‘The Impact of Warnings, Disclaimers,                              Rockledge Drive, Bethesda, MD 20892                                          287: Opportunities for Collaborative Research
                                                         and Product Experience on Consumers’                                (Telephone Conference Call).                                                 at the NIH Clinical Center.
                                                                                                                               Contact Person: Robert Freund, Ph.D.,                                         Date: July 11, 2017.
asabaliauskas on DSKBBXCHB2PROD with NOTICES




                                                         Perceptions of Dietary Supplements,’’
                                                         The Journal of Consumer Affairs, 41:74–                             Scientific Review Officer, Center for                                           Time: 1:30 p.m. to 5:00 p.m.
                                                         99, 2007.                                                           Scientific Review, National Institutes of                                       Agenda: To review and evaluate grant
                                                    9. France, K.R. and P.F. Bone, ‘‘Policy                                  Health, 6701 Rockledge Drive, Room 5216,                                     applications.
                                                         Makers’ Paradigms and Evidence From                                 MSC 7852, Bethesda, MD 20892, 301–435–                                          Place: National Institutes of Health, 6701
                                                         Consumer Interpretations of Dietary                                 1050, freundr@csr.nih.gov.                                                   Rockledge Drive, Bethesda, MD 20892
                                                         Supplement Labels,’’ The Journal of                                   This notice is being published less than 15                                (Virtual Meeting).
                                                         Consumer Affairs, 39:27–51, 2005.                                   days prior to the meeting due to the timing                                     Contact Person: Fungai Chanetsa, MPH,
                                                    10. O’Donoghue, A.C., V. Boudewyns, K.J.                                 limitations imposed by the review and                                        Ph.D., Scientific Review Officer, Center for
                                                         Aikin, et al., ‘‘Awareness of the Food and                          funding cycle.                                                               Scientific Review, National Institutes of



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Document Created: 2017-06-17 01:48:11
Document Modified: 2017-06-17 01:48:11
CategoryRegulatory Information
CollectionFederal Register
sudoc ClassAE 2.7:
GS 4.107:
AE 2.106:
PublisherOffice of the Federal Register, National Archives and Records Administration
SectionNotices
ActionNotice.
DatesSubmit either electronic or written comments on the collection of information by August 18, 2017.
ContactIla S. Mizrachi, Office of Operations, Food and Drug Administration, Three White Flint North, 10A63, 11601 Landsdown St., North Bethesda, MD 20852, 301-796-7726, [email protected]
FR Citation82 FR 27845 

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