The Cancer Trial Landscape in 2026
The composition of cancer clinical research in the United States has shifted dramatically over the past two decades. A new analysis published August 20, 2026 in JAMA Oncology — led by Joseph M. Unger, PhD, of the SWOG Cancer Research Network and Fred Hutch Cancer Center — provides the most comprehensive quantitative picture yet of who sponsors US cancer trials, what those trials study, and what questions are going unanswered as a result.
The study examined 11,681 interventional cancer clinical trials registered in ClinicalTrials.gov that opened at one or more US sites between 2008 and 2024. The findings are striking: 9,569 trials (81.9%) were classified as industry-sponsored, and approximately 90% of all adult patient enrolments occurred in industry-funded studies. Federal agencies — primarily the National Institutes of Health and its cooperative group network — accounted for just 18.1% of trials and roughly 10% of enrolments.
These numbers do not simply reflect market forces. They reflect a structural divergence in research priorities between two funding ecosystems that operate with fundamentally different mandates.
Dataset: 11,681 US cancer clinical trials, ClinicalTrials.gov, 2008–2024 • Classification: Federally sponsored (NIH lead sponsor) vs industry sponsored (pharma/biotech lead sponsor) • Lead author: Joseph M. Unger, PhD (SWOG / Fred Hutch Cancer Center) • Published: JAMA Oncology, August 20, 2026 · doi:10.1001/jamaoncol.2026.3026
What Each Sponsor Studies — The Divergence
The study's most consequential finding is not the raw enrolment disparity but what each funding source actually studies. Industry and federal sponsors are not doing the same research at different volumes — they are investigating fundamentally different questions.
| Research Area | Federal Trials (NIH) | Industry Trials |
|---|---|---|
| Primary focus | Supportive care, prevention, multimodal regimens, de-escalation, diagnostics | Single-agent drug testing (Phase I/III) |
| Supportive care trials | 2.5% of portfolio | 0.9% of portfolio |
| Dose de-escalation | Significantly more likely | Rare — commercial disincentive |
| Multimodal regimens (drug + surgery + radiation) | Significantly more likely | Low — harder to attribute benefit to single agent |
| Non-drug interventions (surgery, transplant, behavioural) | Much more likely | Minimal |
| Rare cancers (<40,000 US cases/year) | Significantly more likely | Growing but still lower; gap narrowing |
| Paediatric cancers | Significantly more likely | Lower |
| Phase focus | Phase II (feasibility and early efficacy) | Phase I (dose-finding) or Phase III (pivotal registration) |
The pattern that emerges is a clear division of labour — or more precisely, a clear gap in what gets funded at all. Industry excels at taking individual compounds through the regulatory pipeline. Federally-funded investigators are responsible for asking how those compounds fit into real-world multimodal care, whether lower doses achieve equivalent outcomes, how patients manage toxicities, and what happens to the quality of life of the cancer survivor.
"Federally sponsored research brings much of the basic science discovery, trial infrastructure and early efficacy studies, while industry leads in late-stage determinative trials resulting in regulatory approvals. Federally sponsored trials may then test combinations of newly approved drugs with each other or with different treatment approaches such as surgery or radiation, extending therapeutic discovery."— Joseph M. Unger, PhD, SWOG Cancer Research Network / Fred Hutch Cancer Center (lead author, JAMA Oncology 2026)
The Research Gaps That Go Unanswered
The 90% enrolment dominance of industry-funded trials is not, in itself, a problem. The drug approval pipeline has produced remarkable breakthroughs — from checkpoint immunotherapy to CAR-T to, most recently, daraxonrasib for pancreatic cancer. The concern raised by Unger and colleagues is about what gets crowded out as commercial research absorbs the bulk of patient capacity, investigator time, and institutional infrastructure.
Supportive Care
Supportive care — management of nausea, fatigue, pain, neuropathy, and psychological distress during and after cancer treatment — is the domain where quality of life is most directly determined for patients. Only 0.9% of industry trials include supportive care as a primary purpose, versus 2.5% of federal trials. Both figures are small, but the gap is important: as industry increasingly dominates enrolment, the absolute number of trials asking supportive care questions may fall.
Dose De-escalation
A commercially funded company has little incentive to ask whether its approved drug can work at half the dose. Yet for patients, the answer to that question determines years of toxicity, fertility, and quality of life. Federal cooperative groups — SWOG, ECOG-ACRIN, NRG Oncology, and the Alliance — have historically led dose optimisation trials for approved regimens. These trials are disproportionately at risk if federal research budgets are constrained relative to industry growth.
Multimodal Regimens
Most real-world cancer care is multimodal — a combination of systemic therapy, surgery, radiation, and supportive interventions timed precisely. Clinical trials of these combinations are disproportionately federally funded because no single company has commercial incentive to demonstrate that its drug works better when preceded by a specific surgical technique. The shrinking federal share of enrolments means fewer trials testing the real-world complexity of oncology practice.
Rare and Paediatric Cancers
While the gap between federal and industry sponsorship of rare cancer trials has narrowed over the study period — partly due to orphan drug incentives — federally-funded cooperative groups remain the primary infrastructure for rare tumour research where commercial returns are insufficient to justify Phase 3 investment. Conditions like primary CNS lymphoma, penile cancer, or rare sarcomas depend almost entirely on NCI-funded investigator-initiated trials.
As industry increasingly dominates cancer clinical research, research questions that are important for improving patient care but not commercially attractive risk going permanently unanswered. The FDA approval of a drug answers the question "does it work?" — but the questions "what dose?", "for whom?", "combined with what?", and "what does it do to quality of life over 10 years?" are often never formally tested.
A Complementary Model — Or an Imbalanced One?
The authors are careful to frame their findings within a "complementary and interdependent" model of research. Federal investment that enables the basic science and early-phase infrastructure that industry then exploits for pivotal trials; industry capital that funds the late-stage trials that generate regulatory approval; federal investigators who then examine the approved agent within broader therapeutic contexts. The cycle is real, and has produced significant advances.
But the framing of complementarity assumes that both components are adequately resourced. The study's data raises a more uncomfortable question: is the complementarity still balanced? If 90% of enrolments are in industry trials — and industry trial portfolios contain virtually no supportive care research, minimal dose optimisation, and limited multimodal work — then the patients who enrol in clinical trials are systematically underexposed to the questions that might most directly improve their lived experience of cancer.
Consider a patient with metastatic colorectal cancer who agrees to participate in a clinical trial. The overwhelming probability (90%) is that they enter an industry-sponsored study testing a new drug at a standard dose. The probability that they enter a trial optimising their antiemetic regimen, testing a cognitive behavioural intervention for chemotherapy-induced fatigue, or evaluating whether a lower dose of an existing drug achieves the same tumour control with less neuropathy — is less than 10%.
Implications for Clinical Research Sites and Trial Design
For clinical research organisations, site investigators, and sponsors, the Unger et al. findings highlight several practical considerations.
Site Portfolio Diversification
Research sites that are exclusively conducting industry-sponsored single-agent drug trials may be delivering strong patient enrolment metrics while systematically failing to address the full spectrum of questions their patient population needs answered. Sites with investigator-initiated research capacity — supported by federal cooperative group memberships (SWOG, ECOG-ACRIN, NRG Oncology) — are better positioned to serve patients across the research priority spectrum.
Protocol Design and Endpoints
The study suggests that quality-of-life and patient-reported outcomes are systematically underrepresented in the industry-dominated trial portfolio. Protocol designers at CROs and academic medical centres should consider whether primary and secondary endpoints in industry-sponsored protocols adequately capture the experience of patients who will live with the treatment for years beyond the trial.
Supportive Care Integration
Given that only 0.9% of industry trials include supportive care as a primary purpose, there is a strong argument for incorporating supportive care substudy components into industry-sponsored oncology protocols — capturing data on symptom burden, fatigue, and quality of life within the infrastructure of a commercially-funded study that would otherwise never ask these questions.
ICH GCP E6(R3) — the current GCP standard — places increased emphasis on risk-proportionate design and patient-centred endpoints. The imbalance identified in this JAMA Oncology paper is one reason why patient-reported outcomes and quality-of-life assessments are increasingly expected as secondary or exploratory endpoints in registrational oncology trials. Read: GCP E6(R3) — What's New for Oncology Sites →
📊 Key Takeaways — JAMA Oncology 2026
Industry sponsors 90% of patient enrolments in US cancer trials — and that portfolio is concentrated in single-agent, Phase I/III drug testing. This is not inherently wrong, but it creates a structural gap.
Supportive care is nearly absent from industry portfolios (0.9% of trials). The questions that most determine cancer patients' quality of life are not commercially attractive and may go permanently unanswered if federal funding shrinks.
Dose de-escalation, rare cancers, and multimodal regimens depend disproportionately on federal funding and federal cooperative group infrastructure. A weakening of NCI funding mechanisms puts this research at structural risk.
Federal and industry roles are genuinely complementary — but only if both are adequately resourced. The study's contribution is quantifying the scale of the imbalance in enrolment, which may not be visible when looking at trial counts alone.
Sites should diversify their research portfolio to include federally-funded and investigator-initiated work alongside industry-sponsored trials — for the sake of the patients they serve and to retain the infrastructure that enables non-commercial research questions.