Study reveals inequities in access to cancer clinical trials in Canada

People living in less populated, rural or remote areas are missing out on last-ditch but potentially life-saving cancer clinical trials, according to a recent study by a University of Alberta oncologist that puts the onus on Canada's health regulatory bodies to ensure equity.

Omar Abdelsalam, an associate professor in the Department of Oncology, undertook the study to evaluate geographic disparities in access to cancer clinical trials across Canada.

"Oncologists like to say the best treatment for cancer is being part of clinical trials," says Abdelsalam.

"Clinical trials give hope when you have exhausted all other standards of care."

For the study, Abdelsalam looked at Canadian cancer clinical trial data recorded in clinicaltrials.gov between 2005 and 2023, and separated them out by province, main urban centers and cancer types.

The data revealed that the number of cancer clinical trials per 10,000 individuals in each province or territory varied between 6.79 in New Brunswick and zero in the three territories.

"There is clearly a disparity. Three territories and not a single clinical trial conducted in two decades," said Abdelsalam.

Abdelsalam notes many Indigenous patients live in the territories, and this geographic disparity might conceal a form of ethnic disparity in access to cancer clinical trials.

"Although I don't have the data to support specifics about Indigenous representation, geographically speaking, I would not be surprised if their participation was the lowest."

Even between Canada's top 10 urban centers, disparities exist. His study showed Vancouverites have the best chance at a clinical trial—14.66 trials per 10,000 individuals. Edmontonians have the fourth best chance with just over 10 clinical trials per 10,000 individuals, while Calgarians have access to fewer than six trials per 10,000 people, to sit seventh in Canada.

Beyond access to a possible life-saving opportunity, limiting the population draw works against the standard evidence-based way to determine what is and what isn't working.

"Clinical trials represent an important approach to advancing our understanding of cancer and improving the quality and quantity of life among cancer patients," he says.

"We are driving in the dark if you are not including samples from everyone."

The study also showed lymphoma clinical trials were the most common, with almost 33 per 1,000 projected cancer cases, while there were only seven bladder cancer clinical trials per 1,000 cases.

Abdelsalam said this discrepancy likely signifies differences in advocacy efforts and subsequent funding allocated to different tumor types. His study showed 69% of trials have industry funding over the 18 years of the study. More concerning is that over a three-year interval starting in 2005, 56% of trials included industry funding. For the interval starting in 2020, that number had jumped to 75%.

Abdelsalam says the concern with the slow decline of government investment is that pharmaceutical companies, while welcome, are typically interested in questions to market their product and not about equitable access.

"Government has to ensure that all cancer patients—regardless of primary tumor type—enjoy an equitable chance of accessing clinical trials," he says.

Given the geographic disparities of access to clinical trials, particularly among patients living in remote and rural areas, Abdelsalam says several initiatives should be undertaken to bring clinical trials to the largest pool possible of cancer patients in Canada.

"While few good things came out of the pandemic, we did learn that we can deliver a relatively high standard of oncologic care through virtual means," he says.

So why can't clinical trial-related activities be conducted virtually as well? Abdelsalam sees no reason why they can't be, adding the regulatory bodies need to start mandating a certain percentage of representation of patients from under-represented communities, or else the current disparity will continue.

"If the government is providing money, they should make sure everyone has an equal opportunity to participate," he said. "If equity is a priority, then we have to think of solutions.

"We need to stop recruiting by convenience and start recruiting by equitability."

The work is published in the American Journal of Clinical Oncology.