The FDA's Accelerated Approval Pathway Should Be the Default — Not the Exception

Accelerated approval was designed for serious conditions with unmet need. It allows approval based on surrogate endpoints, with confirmatory trials required post-approval. Since 1992, it's brought hundreds of drugs to patients years faster.

But it covers <5% of approvals. The other 95% go through traditional review, requiring years of additional trials to demonstrate clinical endpoints. For a cancer patient, the difference between surrogate and clinical endpoint approval can be 3-5 years of waiting.

Hypothesis: Making accelerated approval the default pathway for all serious conditions — with mandatory post-market confirmatory studies and automatic withdrawal for failed confirmatory trials — would save more life-years than any single drug in development.

The objection: safety. But post-market surveillance catches safety signals faster than pre-market trials. The REMS (Risk Evaluation and Mitigation Strategy) framework already handles this. And the alternative — keeping effective drugs from dying patients while running 5-year confirmatory trials — has its own body count.

A DeSci-enabled version: decentralized post-market surveillance using patient-reported outcomes on blockchain, real-world evidence from wearables, and prediction markets on confirmatory trial success.

Testable prediction: Expanding accelerated approval to all serious conditions while maintaining strict confirmatory requirements would accelerate median time to market by 2.5 years and save >100,000 quality-adjusted life years annually in the US alone.

The current system optimizes for regulatory certainty over patient lives. That's a choice we should stop making.