# Unger: most patients never get the chance to join a cancer trial, and when offered, half say yes

Source: https://onco.cc/key-papers/paper-unger-trial-participation-barriers-jnci-2019/  
OnCo record `paper-unger-trial-participation-barriers-jnci-2019` (Key paper). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Pooling 13 studies of 8,883 patients, 56% had no trial available at their site and a further 22% were ineligible for the trials that existed; among patients actually offered a trial, roughly half enrolled, so overall participation was about 8%.

## Summary

Unger and colleagues systematically reviewed studies that tracked consecutive cancer patients through the decision pathway to trial enrolment, quantifying structural, clinical and physician-or-patient barriers at each step. Thirteen studies (nine academic, four community) with 8,883 patients were pooled.

Structural barriers dominated: 55.6% of patients had no trial available for their cancer type and stage at their institution. Of the remainder, 21.5% were ineligible for the available trial. Physician and patient factors (not offered, or declined) accounted for 14.8%. Overall trial participation was 8.1%; but among patients who had an available trial and were eligible, about half enrolled. Participation was lower in community settings.

The analysis reframed low enrolment from a problem of patient reluctance to one of trial availability and eligibility criteria, shaping ASCO and FDA initiatives to broaden eligibility and decentralise trials.

## Fields

- Kind: Key paper
- Last checked: 2026-09-08
- Journal: JNCI: Journal of the National Cancer Institute
- Year: 2019
- DOI: 10.1093/jnci/djy221
- Authors: Unger JM, Vaidya R, Hershman DL, Minasian LM, Fleury ME
- Findings: 55.6% of patients had no trial available at their site (95% CI 43.7-67.3); 21.5% were ineligible for available trials (95% CI 10.9-33.9); 14.8% did not enrol for physician or patient reasons (not offered, declined); Overall participation 8.1%; about 55% of eligible patients offered a trial enrolled; Academic centres had higher participation (15.9%) than community sites (7.0%)
- What it means: Patients are not the bottleneck; trial access is. Bringing trials to community practices, loosening restrictive eligibility criteria and reducing site burden would do more for enrolment than patient education. Trials today reflect the minority of patients who happen to be treated where trials exist.
- Caveats: Included studies were heterogeneous and mostly US-based; barriers differ in single-payer and low-resource systems; Studies varied in how they recorded reasons for non-enrolment, so barrier categories overlap; Academic centres are over-represented in the source studies; Does not capture racial, ethnic or socioeconomic disparities within each barrier category

## Sources

- DOI: https://doi.org/10.1093/jnci/djy221

## Connected records

- ideas: [Pay oncologists for the time it takes to enrol a patient](https://onco.cc/ideas/idea-tr1-protected-physician-time-for-enrolment/), [Remote consent and tele-screening so the first trial visit is a video call](https://onco.cc/ideas/idea-tr1-remote-consent-tele-screening/), [Set trial enrolment targets from who actually gets the disease, and publish progress live](https://onco.cc/ideas/idea-tr1-incidence-weighted-enrolment-targets/)
- fronts: [Drug Discovery Platforms](https://onco.cc/fronts/drug-discovery/)
- technologies: [AI trial matching & clinical decision support](https://onco.cc/technologies/ai-trial-matching/), [Community oncology and site networks](https://onco.cc/technologies/community-oncology-networks/), [Decentralised and hybrid clinical trials](https://onco.cc/technologies/decentralised-clinical-trials/)
- institutions: [Fred Hutchinson Cancer Center](https://onco.cc/institutions/fred-hutch/)
- bottlenecks: [Fragmented care and guideline gaps](https://onco.cc/bottlenecks/b-care-fragmentation/), [Trials do not represent the people who get cancer](https://onco.cc/bottlenecks/b-trial-diversity/), [Trials enrol too few, too slowly](https://onco.cc/bottlenecks/b-trial-enrolment/)
- journals: [JNCI: Journal of the National Cancer Institute](https://onco.cc/journals/jnci/)
- people: [Joseph M. Unger](https://onco.cc/people/joseph-unger/)

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