New strategies for enhancing enrollment of underrepresented minorities in lymphoma clinical trials

Over the past 2 decades, new lymphoma treatments, including chimeric antigen receptor (CAR) T cells, bispecific antibodies, and immune checkpoint inhibitors, have significantly improved patient outcomes. Despite these therapeutic advances, only 2% to 3% of adult patients with cancer participate in clinical trials.¹ This participation is even lower among certain groups, including ethnic and racial minorities,^1-4 individuals with low socioeconomic status,^1,5,6 rural residents,⁷ older adults,^8,9 and young adults (aged 15-39 years).¹⁰ Underrepresentation of these groups in clinical trials limits the generalizability of clinical trial results and is detrimental to those populations that do not receive equal access to novel therapies.

Although racial and ethnic minorities constitute >40% of the US population, they make up only ∼15% of clinical trial participants. In response to these findings, the US Food and Drug Administration (FDA) now requires that sponsors seeking regulatory approval for therapies via registrational clinical trials to submit a plan to ensure diversity among trial participants.¹¹ Although there are other groups of patients who are also notably underrepresented in clinic trials, this article aims to address new strategies for enhancing enrollment of underrepresented minorities in lymphoma clinical trials.

Despite the recent advances, disparities in access and outcomes on the basis of race, sex, age, insurance status, demographic location, socioeconomic status, and other sociodemographic characteristics remain.¹² Black and Hispanic patients with lymphoma present at younger age, with more advanced disease, have more B symptoms on presentation, and have different survival outcomes than their White counterparts.^13-15 Addressing these disparities requires understanding their biological and sociodemographic roots and ensuring equitable clinical research inclusion.

Data from the National Cancer Institute Surveillance, Epidemiology, and End Results Program from 2014 to 2018 indicate significant lymphoma burdens among minority patients: Black (non-Hodgkin lymphoma [NHL], 10.7%; classic Hodgkin lymphoma [cHL], 14.6%), Hispanic (NHL, 17.1%; cHL, 16.3%), and Asian-Pacific Islander (NHL, 5.1%; cHL, 3.9%).¹⁶ However, a recent review of pivotal clinical trials in lymphomas that led to FDA drugs between 2011 and 2021 found that minority patients were significantly underrepresented in clinical trials relative to the relative disease burden. In these pivotal trials, Black patients comprised 3.6% of participants in cHL trials and 2.8% in NHL trials. Similarly Hispanic patients made up 6.7% of participants in cHL trials and 5.4 % of NHL trial participants.¹⁶ For example, the POLARIX trial, which led to the approval of polatuzumab vedotin in previously untreated diffuse large B-cell lymphoma, included only 8% Black patients, 3% Asian, and 5% Hispanic patients in the United States; globally the proportion was much smaller.¹⁷ Another example is the Echelon-1 trial that led to the approval brentuximab vedotin as initial therapy for cHL, which included only 3% Black patients.¹⁸ These examples raise concerns about the generalizability of these findings.

Another important example is CAR T-cell therapy, a revolutionary treatment for hematologic malignancies, which had low Black participant enrollment (2%-5%) across pivotal clinical trials.¹⁹ A study of real-world outcomes indicate lower overall response rates (57% vs 74%), complete response (45% vs 57%), and 12-month progression-free survival (36% vs 48%) among Black patients,²⁰ highlighting the need for more inclusive trials to fully understand treatment efficacy and safety across diverse populations.

Despite extensive studies on barriers to cancer clinical trial participation, minoritized patient populations remain significantly underrepresented in clinical trials. Barriers exist at multiple levels, including societal, institutional, interpersonal, and patient levels, and require comprehensive strategies to overcome.

Upstream factors significantly affect clinical trial participation. Geographic and site-specific limitations are a major primary barrier, with only 42.4% of US counties having phase 1 to 3 cancer clinical trials available between 2008 and 2022.²¹ Rural areas, lower-income counties, and regions with fewer medical oncologists have significantly lower likelihood of having phase 1 to 3 cancer clinical trials available.²¹ Minority populations are disproportionately affected by these socioeconomic disadvantages. Additionally, ∼85% of patients with cancer receive treatment in community settings, in which trial participation rates are lower (∼7%) than academic centers (∼16%).¹ A prior systematic review found 55.6% of patients have no trials available for their disease type and stage at their site of care.¹ 

Most pivotal lymphoma clinical trials that led to FDA approvals primarily occur at large cancer centers and there is significant geographical variation in availability of these trials.¹⁶ The farther the distance a patient has to travel, the lower the probability that they will be willing or able to seek out care. The geographic maldistribution is not only a matter of transportation, because travel for many patients to a study site has additional implications related to family, childcare, work, support systems, and others that limit their ability to visit centers located several miles away.

Several studies have found that minority patients, uninsured patients, and Medicaid patients are significantly less likely to get their care at academic medical centers and National Cancer Institute–designated comprehensive cancer centers.^22,23 Insurance and insurance coverage plays a major role in patients’ ability to get care and where patients can get care. Insurance coverage likely serves as a critical determinant of where patients can get care. Income and employment are determinants of insurance type.

Many patients express willingness to participate in clinical trials (up to 70%),²⁴ however, barriers including lack of knowledge, cost, family commitments, time, social support, and transportation, prevent participation.²⁵ A study by the National Cancer Institute found that 41% of Americans know nothing about clinical trials, and only 8.9% had been invited to participate, with 46% agreeing when asked. This indicates a disconnect between willingness and opportunity to participate.²⁶ Fear and mistrust of medical institutions, religious beliefs, and health illiteracy also deter minority populations. Despite this, data show most were in favor of medical research as long as they were not treated as “guinea pigs.”^25,27,28 

Health care providers play a crucial role in clinical trial enrollment but may fail to discuss trials because of time constraints, treatment preferences, or concerns about the physician–patient relationship. Providers may lack awareness of available trials or have limited knowledge about details of clinical trials.^4,29 Concerns about additional administrative burdens, limited personal resources, and lack of resources may affect their willingness to offer trials.^4,29 Prior studies have also shown that implicit bias, racial stereotypes, or concerns about a patient’s ability to adhere to trial requirements may also affect what treatments are offered to patients.^30,31 Studies suggest that physicians may limit offers for trial enrollment to patients they perceive as good study candidates.^31,32 

Restrictive eligibility criteria can exclude up to 24% of potential participants.³³ These criteria often do not reflect real-world patient populations, limiting enrollment and inadvertently excluding minority groups. For instance, age restrictions exclude older patients, and renal function criteria disproportionately affect African Americans with higher rates of renal dysfunction.^33-36 Additionally, criteria such as neutrophil count cutoffs disproportionally exclude African Americans who have a higher incidence of neutropenia associated with the Duffy-null phenotype (nonexpression of the Duffy antigen on red blood cells), without increased risk for infection.³⁶ Other study-level barriers include clinical trial complexity and the requirement of additional testing such as pharmacokinetics and pharmacodynamics, which increase patient facing and provider burdens.

Finding solutions to overcome the historic challenges leading to disparities in clinical trials will require a multilevel and collaborative approach between investigators, pharmaceutical companies or sponsors, and regulatory agencies to drive the needed changes to achieve more equitable access to clinical trials.

Given that most patients receive care in their local communities and that a majority of lymphoma clinical trials are conducted at large cancer centers,¹ a more collaborative approach to providing access to clinical trials is necessary. Expanding clinical trial availability to the communities in which minority patients typically receive care could be transformative.

Decentralized trials present a promising approach to aligning trial availability with community need. Decentralized clinical trials allow clinical trial activities to occur at community sites rather than traditional clinical trial locations thereby increasing accessibility. However, many community sites lack the infrastructure to conduct and monitor high-quality trials. Conducting clinical trials is also expensive and requires significant human resources. To address these challenges, it is crucial to develop clinical trial infrastructure within medical institutions that have established, trusted relationships with their communities. Designing trials that can be managed in local clinics rather than centralizing care at major cancer centers could help significantly with improving access. This would require significant investment in building community clinical trial capacity, ideally in collaboration with major regional hospital systems.

Furthermore, integrating additional solutions such as remote phlebotomy and mobile nursing could significantly enhance the capacity to conduct laboratory monitoring or pharmacokinetic sample collections closer to patients’ homes. These services would help to decrease patient burdens associated with traveling and need for proximity to the main clinical trial sites.

There are significant geographic limitations in clinical trial availability. Patients who live in rural, socially disadvantaged counties have lower median household incomes, and these rural areas have fewer medical oncologists in practice, resulting in reduced clinical trial availability.²¹ Intentional investment in, and selection of sites with, high concentrations of minoritized and disadvantaged groups would increase access to clinical trials for these populations. Selecting clinical trial sites within cities that have large minoritized populations and health care systems that serve socially disadvantaged patients, such as safety net hospitals, would significantly improve clinical trial access. Fostering partnerships between larger institutions and small centers can create networks that extend the reach of larger institutions and improve access.

It is essential to consider the unmet needs of communities when deciding what types of trials to open in community settings. Cellular therapies, such as CAR T cells and hematopoietic stem cell transplants, are currently limited to specific accredited centers. As of the time of this article, there are ∼311 centers accredited by the Foundation for Accreditation of Cellular Therapy across the United States.³⁷ Although expanding the number and type of accredited sites is important, nonaccredited sites can offer targeted therapy options and novel combinations. These sites are ideal for therapies such as bispecific antibodies, which show efficacy in the relapse setting and do not have the same site restrictions as cellular therapies. A recently published example of a novel regimen that could be administered at a non–hematopoietic stem cell transplant/CAR T-cell center is the VIPOR (venetoclax, ibrutinib, prednisone, obinutuzumab, and lenalidomide) combination for the treatment of relapsed or refractory lymphomas.³⁸ The VIPOR regimen was well tolerated and effective and the agents for this combination are widely used and available in the community. Trials such as these can provide significant opportunity for centers without options to administer cellular therapies on or off trials.

Assessing the capacity of potential sites and focusing efforts on feasible trials are crucial. Early-phase trials might be difficult to carry out at small local sites because of specialized testing requirements. However, late-phase trials, such as phase 3 or pragmatic trials, can provide important opportunities for patients and still answer critical questions. Investing in increased site capacity for more complex trials can be pursued over time, while improving experience with clinical trials. Unlike large academic centers that see high volumes of patients with rare cancers, community centers may see fewer potentially eligible patients. Careful selection of trials tailored to the needs of the catchment areas and site capacity can optimize accrual and bolster future efforts after demonstrating success.

Project Pragmatica, an initiative led by the FDA Oncology Center of Excellence, aims to integrate aspects of clinical trials with real-world routine clinical practice through pragmatic design.³⁹ This initiative creates an important opportunity to further evaluate novel lymphoma therapies, many of which have received conditional accelerated approval based on data from phase 2 clinical trials, often with the requirement for additional confirmatory trials.^40-47 

Pragmatic trials offer a unique opportunity for expanding clinical trials to community settings and broadening patient access. Unlike traditional clinical trials, they are designed to better reflect clinical practice, allowing for a broader range of patients, interventions, and outcomes measurements. These trials reduce barriers by using simpler eligibility criteria, flexible trial delivery, and streamlined outcome measurements, minimizing the burden on both patients and investigators.

Through Project Pragmatica, the FDA Oncology Center of Excellence aims to foster collaboration between patients, trial investigators, pharmaceutical companies, government agencies, and international health care policy stakeholders for the design and implementation of these patient-centric trials. These trials are uniquely designed to minimize barriers to enrollment and reduce trial complexity and minimizing data collection to focus on those outcomes that are most relevant. This approach with less complex trial design allows for trials that will be easier to open, more efficient to conduct, and can quickly address critical questions, such as whether novel therapies provide a survival advantage over standard care.

Prescreening, defined as identifying potentially eligible patients using selective, limited eligibility criteria has been used in several instances to improve accrual rates to oncology clinical trials.^48-52 

This can help to exclude ineligible patients, reduce screening burden by developing a smaller pool for manual chart review, and improve accrual rates. One study found up to a 4.6-fold increase in enrollment after implementations of prescreening by research coordinators in a hospital that served diverse populations. These enrollees included 64% female and 56% non-White participants, including 57% non–English speakers. Eighty-three percent of enrolled patients resided in low-income areas, with 62% in both low-income and health professional–shortage areas.⁵² 

Universal prescreening can help to eliminate/reduce potentially unintended bias toward who is considered for trials and help to increase provider offering of trials to patients. Dedicated staff for prescreening can include research coordinators, research navigators, data abstractors, or treating physicians. One limitation of this strategy is that it might be used for new patients but might not be feasible for patients needing changes in treatment because consideration of trials for these patients would generally be done by the treating physician. Policies that encourage screening at each treatment decision would further bolster these efforts.

Multidisciplinary tumor board (MDTB) meetings bring together providers from medical oncology, surgical oncology, radiology, radiation oncology, pathology, and other specialties. They can serve multiple purposes, including creating a formal structure to discuss the best management approach for a patient’s disease as well as aid in the identification of patients who may be potentially eligible for enrollment into a clinical trial. Several studies have shown that MDTB meetings increase clinical trial enrollment.⁵³ A retrospective study found that patients discussed within a tumor board were 46% (2.8% -> 4.1%) more likely to be enrolled in clinical trials than those not discussed.

The MDTB help can help to address provider-level barriers such as awareness about available trials, given that various members may be leading these trials or have knowledge about available trials

We recommend discussion of all new patients in MDTB to improve the quality of care provided to those with cancer and enhanced clinical trial accrual. This can help to decrease variability in practice among various providers that might lead to inadvertent exclusion of patients from clinical trial considerations. It is also increases provider awareness about available options for patients. Each individual provider might have practice patterns or blind spots in knowledge of which trials are available and status of trials.

One proven approach to reducing barriers and increasing clinical trial participation is the use of patient navigators to provide patient navigation.⁵⁴ Patient navigation has been studied and implemented as standard practice throughout the continuum of cancer care to improve access, quality of care, and patient satisfaction. It has also been used specifically to improve participation in clinical trials. A prospective study of 424 African American patients enrolled in a navigation support program completed a trial at a rate of 74.5% compared with 37.5% of those not receiving patient navigation support for the same trial.⁵⁵ 

Clinical trial patient navigators can serve many functions for improving clinical trial recruitment and retention. Navigators generally provide guidance to patients as they interact with the health care system. They can serve as patient educators to explain various parts of trials and help with questions that might arise. They can help to identify obstacles to adherence to treatment plan and help to trouble shoot potential solutions. Most importantly, they serve as a bridge between the patient and the research team and can help to provide support for various issues that might arise.

Navigators would be very familiar with resources available to patients and should also work closely with social workers to bridge gaps in support that patients might encounter. Patients participating in trials might be eligible for additional resources/support that might not be available to nonparticipants, and navigators can help to connect them to these resources.

Overcoming medical mistrust among minority populations requires transparent and culturally sensitive community engagement. Building trust requires institutions/researcher to conduct research openly and in an honest manner, providing complete and accurate descriptions of known and potential risks/benefits. To effectively reach communities, it is important to work with key stakeholders and minority organizations to understand the concerns and priorities these communities better.

Involving community members in the design, messaging, and execution of clinical trials is a critical method to increasing diversity. Including community advisory boards early is the design of clinical trials and soliciting feedback on patient facing material helps to identify blind spots missed by investigator/sponsors and optimize messaging. The input aligns research efforts with community priorities, streamlines research ideas to address disparities, and supports changes that promote health equity. It can help investigators and sponsor to better understand what is important to patients, such as side effects, testing, and outcomes, and identify potential barriers early in the process.

Partnering with organizations and community leaders trusted by target communities is essential. Seeking their advice on how best to serve these communities can foster equitable, bidirectional relationships rather than hierarchical ones. Establishing these partnerships can significantly enhance community involvement and trust.

Ensuring that the findings of research is reported back to communities is also essential feedback. Sharing results and expressing gratitude for the contribution of participants reenforces the collaborative nature of the research and alleviates concerns about exploitative practices. Addressing mistrust requires consistent, culturally sensitive engagement. Physicians and researchers must be aware of the impact that appropriate communication and patient trust have on minority enrollment in clinical trials. Building meaningful relationships with community members occurs over time. Institutions should develop robust community partnerships with advocacy groups, religious organizations, community leaders, and centers. Showing a genuine desire to invest in communities and gaining the buy-in from trusted community entities can foster long-lasting relationships beyond a single project.

Restrictive eligibility criteria can significantly affect enrollment in clinical trials and exclude potential participants. Some of these criteria inadvertently disproportionally excluding minoritized patients. Recommendations by the American Society of Clinical Oncology and Friends of Cancer Research multidisciplinary working group to include (1) patients with lower creatinine clearance values of >30 mL/min when renal toxicity and clearance are not of direct treatment-related concern; (2) patients with mild to moderate hepatic dysfunction when nonclinical and clinical data indicate that inclusion is safe; and (3) patients with laboratory parameters out of normal range because of hematologic disease could considerably increase the number and diversity of patients in clinical trials and better reflect real-world patient populations.³⁴ 

Additionally, using the Delphi method, Harkin et al defined consensus recommendations for 31 modernized eligibility criteria including threshold values for 10 quantitative eligibility criteria, which facilitate enrollment of a more clinically diverse patient population and increase generalizability of study results while maintaining patient safety.¹⁹ 

Restrictive laboratory-based eligibility criteria in clinical trials are often used to ensure patient safety, especially for those with organ dysfunction. However, these criteria can significantly limit trial access for patients with comorbidities and reduce the relevance of trial findings to real-world settings. Current laboratory exclusions and dose-selection practices are largely based on cytotoxic chemotherapy, which may not apply to modern immune-based and targeted therapies for lymphoma.

Project Optimus, an initiative by the FDA Oncology Center of Excellence, aims to reform dose selection and optimization in oncology drug development.⁵⁶ This initiative presents a unique opportunity to adapt dosing strategies for patients with comorbidities, especially in later stages of development, after early safety signals are understood.

This initiative can be leveraged to expand trial access by allowing the inclusion of older patients and those with mild laboratory abnormalities or common comorbidities, such as renal dysfunction or neutropenia associated with the Duffy-null phenotype. This could significantly improve trial accessibility for minoritized and older patients who are disproportionally excluded because of higher comorbidity burden and strict eligibility criteria.

By fostering collaboration among pharmaceutical companies, academia, regulatory authorities, and patients, Project Optimus aim to transform the dose optimization paradigm across oncology. This approach emphasizes selecting doses that optimize efficacy, safety, and tolerability, ultimately broadening trial access to a more representative patient population.

To enhance clinical trial participation, it is crucial to recognize and address the challenges patients face, which can affect their willingness to enroll and their ability to remain in studies. Expanding a wide range of resources is essential to ensure patients can participate effectively.

Improving patient understanding of clinical trials is critical and the current systems for patient education would benefit from innovation and restructuring. The current standard informed consent might not be sufficient to fully inform patients from a wide variety of backgrounds. Educational tools such as videos explaining trials, outcomes, and side effects can help patients understand what to expect. Developing and distributing culturally relevant lymphoma educational materials in multiple languages tailored to the patient populations seen at an institution can significantly increase understanding of trial procedures and increase enrollment on therapeutic clinical trials.^57,58 

As noted above, patient navigators and social workers can identify barriers and facilitate their removal. Additional intervention such as peer support and mentor programs and buddy programs with other patients and prior trial participants can provide emotional and practical support. Identifying champions within patient communities can also help encourage participation and retention in clinical trials.

Reducing the burden of participation by covering costs related to relocation, housing, transportation, parking, loss of wages, and disability filings is also important. Additionally, reducing the frequency of study visits, offering testing closer to home, and implementing remote monitoring strategies such as home vitals with alerts, virtual visits, and laboratory testing at local sites can significantly ease the participation process. Partnerships with organizations such as Quest Diagnostics and mobile phlebotomy companies, as well as the use of mobile staff to conduct study visits in participants’ homes, can further support patient involvement.

Partnerships with disease-specific foundations such as the Leukemia & Lymphoma Society and the Lymphoma Research Foundation can provide valuable resources. These resources include educational materials, financial assistance, patient navigators, and clinical support hotlines with peer groups and mentors.

Patient-centered communication focuses on patient needs and perspectives, and it does not ignore the racial and ethnic background of the patient, because doing so denies an important part of an individual’s identity.

Evidence-based strategies to reduce health care professional bias in clinical interactions include training in implicit bias and patient-centered communication, which fosters positive interpersonal relationships and considers the patient’s racial and ethnic background. For example, an NRG Oncology (National Surgical Adjuvant Breast and Bowel Project, the Radiation Therapy Oncology Group, and the Gynecologic Oncology Group) workshop stressed the importance of enrolling minorities in clinical trials and the need for culturally sensitive communication to build patient trust.

Training clinical and research personnel on the impact of social determinants of health on a patient’s ability to access care is another critical aspect. Likewise, education and training within sponsor organizations and clinical research teams on simplifying the complexity of trials can also reduce barriers to enrollment and make participation more feasible for patients. Although existing patient communication curricula often consider cultural competency in patient interactions, specific training for communicating with minority patients about clinical trials remains scarce.

Numerous studies have shown that language, racial, and cultural concordance between providers and patients helps to foster trust and enhance relationships. Racial concordance is clearly associated with better communication, improved health care use, and lower health care expenditures in minority populations, largely because of improved adherence. Having a diverse, bilingual clinical trial staff is essential for reducing language barriers and improving interpersonal relationships, because patients see their communities represented among the clinical trial staff. Ensuring access to interpreter services is also crucial to reducing language barriers for non–English-speaking patients or those with limited English proficiency.

The regulatory and administrative demands for initiating and conducting clinical trials can be significant barriers, particularly for community-based centers that lack the support systems of larger academic institutions. The heavy administrative workload and complex regulatory requirements disproportionately affect community sites, which are often underresourced, further discouraging community physicians from participating in trials because of the added burden.

A recent American Society of Clinical Oncology research statement highlights key challenges faced by stakeholders aiming to incorporate decentralized trial elements and expand into local settings.⁵⁹ These include investigator oversight, training, safety monitoring, data collection, and protocol adherence. Notably, the FDA’s statement of investigator form (form 1572) was identified as a major barrier because of ambiguous language and its overuse by sponsors and Clinical Research Organization, which has led to increased paperwork, monitoring, and resource expenditure.⁵⁹ The excessive reliance on form 1572 raises concerns about trial equity, diversity, inclusion, and access, as it limits opportunities for local patient participation. It also prompts questions about the generalizability of study findings when trials are less accessible.

To improve trial feasibility in community settings, regulatory bodies such as the FDA can help streamline and clarify requirements for decentralized trials. Standardizing data collection, documentation, and form usage can reduce the administrative load and associated costs for sites, providers, sponsors, and CROs. Collaborative efforts between regulatory bodies, sponsors, and research stakeholders are essential to ensure rigorous yet practical standards that uphold patient safety, accountability, and transparency. The FDA, in partnership with private entities, should clarify regulatory expectations for decentralized trials and drive changes to simplify reporting requirements, thus enhancing trial accessibility and inclusivity.

Clinical trials are essential for evaluating the efficacy of novel treatment strategies, informing treatment decisions, and advancing our understanding of cancer biology and therapy. Trials offer patients early access to new treatments, with the potential of improving outcomes and quality of life; access to clinical trials is an essential component of high-quality cancer care. Despite this critical role, <5% of patients participate cancer clinical trials, with significant underrepresentation of disadvantaged patient populations, including underrepresented minorities. Regulatory bodies such as the National Institutes of Health and the FDA are increasingly focused on addressing this disparity by requiring inclusion patients from diverse backgrounds.

Access to clinical trials is a key component of high-quality lymphoma (and more generally, cancer) care. Improving access to clinical trials for all patients with lymphoma is thus essential to improving outcomes in patients with lymphoma. Increasing the representativeness of trials is not just equitable, it is essential to ensuring the evaluation of safety and efficacy of novel therapies. Clinical and correlative scientific data gathered through clinical trials are also essential for furthering our understanding of lymphoma biology and biomarkers of response and resistance to treatment, which may allow personalization of therapy and may aid in the identification of novel therapeutic targets. Because practice-changing clinical trials advance the standards of lymphoma care, disparity in access to clinical trials will result in lost opportunities for outcome improvement and widen the gap of disparities between those with and without access.

Barriers to participation exist at multiple levels, including societal, institutional, interpersonal, and patient levels. Overcoming these barriers require multilevel strategies. Strategic investment in clinical trial infrastructure in health care centers serving target patient populations can improve access to trials in communities in which patients receive their care. Collaborations between sponsors, investigators, regulatory authorities, key community stakeholders, and patient groups are essential to align research efforts with community priorities, addressing disparities, and support changes that promote health equity.

Improving access for patients through culturally adapted educational material and patient-centered supports to reduce the burdens of participation in clinical trial can significantly affect patient opportunity to participate in clinical trials. By combining these strategies, we can make clinical trials more patient centric and inclusive, ultimately improving trial participation and outcomes. Addressing these multifaceted barriers and providing comprehensive support will ensure that the benefits of research are accessible to all patient populations.

Contribution: C.N. and A.F.H. wrote the manuscript.

Conflict-of-interest disclosure: A.F.H received research funding from Bristol Myers Squibb, Genentech, Merck, Seagen, Kite, Gilead Sciences, AstraZeneca, and ADC Therapeutics, and serves as a consultant for Bristol Myers Squibb, Genentech, Merck, Seagen, AstraZeneca, Karyopharm, ADC Therapeutics, Takeda, Tubulis, Regeneron, Genmab, Pfizer, Caribou Biosciences, Adicet Bio, AbbVie, and Allogene Therapeutics. C.N. recieved research funding from Bristol Myers Squibb, BeiGene, Genentech, and Daiichi Sankyo.

Correspondence: Alex F. Herrera, City of Hope, 1500 E Duarte Rd, Duarte, CA 91010; email: aherrera@coh.org.