Amol Akhade, Senior Consultant at Fortis Hospitals Mumbai, shared a post on LinkedIn:
“Big Centers vs Small Centers: Speed, Incentives, and the Science of Cancer Trials.
Cancer drug trials are increasingly moving away from large academic institutions and into smaller, community-based or private research centers. This shift is often celebrated as progress. It deserves closer scrutiny.
Large academic centers offer something that is hard to replicate: depth of expertise, multidisciplinary oversight, internal review boards embedded in academic culture, and an environment where protocols can be questioned before they are executed. Trials here are slow to open, sometimes painfully so, but the friction often exists to protect scientific integrity rather than efficiency.
Yet these centers also struggle. Bureaucracy delays trial activation. Accrual is sluggish. Many patients never access trials because eligibility criteria are narrow, logistics are complex, and enrollment is nobody’s priority. Important clinical questions – dose de-escalation, treatment omission, sequencing, or comparison with best existing care – often remain unanswered because they are commercially unappealing.
Smaller centers fill this gap. They open trials quickly, recruit efficiently, and bring research closer to patients’ homes. For patients with advanced cancer, trials can offer access, continuity, and hope where standard options are limited. Decentralization, in itself, is not the problem. In many health systems, it is necessary.
The concern lies in incentives. When trials become a significant source of revenue, enrollment risks become the outcome. Speed is rewarded. Protocols are followed, but rarely challenged. Control arms may be acceptable on paper yet inferior in practice. Endpoints may be statistically positive while clinically modest. Patients may consent without fully understanding the financial ecosystem surrounding the trial.
This is not an argument against small centers, nor an endorsement of academic monopolies.
It is a reminder that trial quality is shaped by systems, not intentions. When industry funds most cancer research, efficiency is valued more than uncertainty. When physicians are paid per patient enrolled, transparency becomes essential. When the survival benefit is marginal, restraint matters.
Clinical trials remain indispensable. But they must answer questions that matter to patients – not just questions that accelerate approvals.
Progress in oncology should not be measured by how fast we enroll, how many trials we run, or how quickly we approve drugs.
It should be measured by something far simpler, and far harder:
Do these trials help patients live longer – or live better?
My Take on this.”
More posts featuring Amol Akhade.
