Home-run trials for rare cancers: giving the right drug(s) to the right patients at the right time and in the right place

In oncology clinical trials, many patients spend their final months at a central clinical trial facility far from home for "mandatory" protocol visits/diagnostic testing. Studies suggest that the travel strain may be greatest among patients living in low-income areas and/or participating in early-phase studies. In this regard, rare cancers constitute a special unmet need with limited therapeutic options and few trials. Though individually uncommon, rare cancers as a group constitute similar to 22% of the cancer burden; the portion of cancer burden may even be greater if biomarker-defined rare subsets of either a single cancer type or a tissue-agnostic subgroup are included. Exacerbating the access issue is the fact that, in addition to the paucity of trials, many centers will not activate existing single-arm trials, often due to accrual concerns, which may further disadvantage this patient group and also jeopardize trial completion. Decentralized clinical trials may resolve some of these challenges by allowing patients to participate from close to home. Decentralized clinical trials can take the form of being site-less, with the coordinating body working remotely and care provided by the home oncologist, or by taking the tack of National Cancer Institute/cooperative groups (e.g., NCI-MATCH genomics matching trial or SWOG1609 [NCI] DART immunotherapy rare cancer trial) using a platform design with multiple cohorts and opening at >1000 sites. Decentralized trials now also have supportive FDA guidance. Importantly, home-run trials permit clinical trial access to underserved groups, including those in rural areas and patients financially unable to travel to a central facility.