The clinical trial ecosystem is facing an unprecedented sustainability crisis as demand for patient enrollment is projected to triple by 2032 while the workforce continues to shrink and costs spiral upward, according to recent GlobalData analyses and industry reports.
The oncology clinical development pipeline has grown by 13% annually over the past five years (2018-2022), creating what experts describe as an unsustainable trajectory. This growth rate will more than triple the demand for patients to enroll in clinical trials by 2032, yet the current ecosystem lacks the capacity to meet this demand.
Workforce Crisis Threatens Trial Capacity
The clinical trial workforce has experienced a dramatic decline, with GlobalData analysis showing the number of clinical trial investigators globally fell from approximately 128,303 in 2017-18 to 116,948 in 2023-24 – a decline of almost 10%. The situation is even more severe for trial site coordinators, whose ranks dropped from approximately 56,036 to 40,472 during the same period.
"There was an exodus post-COVID," explains Kent Thoelke, CEO of Paradigm Health, describing how many research and healthcare workers left the field after the pandemic. Over 80% of research sites in the United States have faced staffing shortages in oncology clinical research, largely attributed to unsustainable job expectations, lack of adequate compensation, and limited career growth potential.
This workforce shortage is extending startup times for new clinical studies as sponsors search for investigators with capacity at a time when that very capacity is falling. The leading cause of trial termination remains inadequate patient levels, with more trials being abandoned due to lack of enrollment than for safety or efficacy reasons.
Patient Recruitment Challenges Persist
Despite the growing number of trials, patient participation rates remain stagnant. According to Thoelke, only approximately 5%-8% of potentially eligible patients ever take part in a clinical trial, a figure that has remained unchanged for years. Industry data indicates that roughly 60%-70% of trial sites failed to enroll their initial targeted patient numbers.
The geographic distribution of clinical trials creates additional barriers. According to ClinicalTrials.gov, almost 26,000 clinical trials were seeking participants across all 50 states in the US in May 2025, but recruitment activity is heavily concentrated in coastal states with large urban centers. Large stretches of the country are not recruiting for clinical trials at all, effectively shutting out patients in rural communities.
Research by the Milken Institute estimates that people living in agricultural counties are likely to travel more than 60 miles to participate in a clinical trial compared to those in urban environments or affluent suburbs. Academic medical centers continue to conduct the bulk of trials, especially in the US, while community hospitals and clinics often lack the resources to participate at scale, despite treating the majority of patients.
Escalating Costs Threaten Viability
Clinical trial costs have reached new heights, with per-trial costs rising steadily since 2014. According to a November 2024 GlobalData report, single country trials have increased by 2.9% per year and multinational studies by 4.9% per year over the past decade.
Oncology trials are particularly expensive, averaging approximately $30 million per Phase 1 trial and nearly $60 million for a Phase 3 trial, with the largest trials exceeding $100 million in direct costs. High and rising direct trial costs result from increased complexity of clinical trials, including more complex treatment regimens, adaptive trial designs, expansive data collection, and protocol amendments, combined with declining productivity per trial and per site.
Extended trial timelines compound these costs significantly. Every month that a trial remains open without results, sponsors must pay an additional $40,000 per day for site maintenance, monitoring, and administration. For each day of delayed drug launch, sponsors forego an average of $500,000 in lost drug revenue, a figure that can exceed $3 million per day for blockbuster drugs with over $1 billion in annual sales.
These factors contribute to the total cost of bringing a new drug to market reaching a staggering $2.3 billion. "That is simply unsustainable," Thoelke argues, especially as drug pricing pressures mount in major markets.
Technology Solutions Emerge
The pandemic demonstrated the potential for transformation when rigid trial protocols were relaxed out of necessity. Patients could give consent electronically, provide samples at local labs, or participate from home via telemedicine. However, most of these systems rolled back after the crisis passed.
Paradigm Health's AI-driven platform addresses longstanding inefficiencies in identifying and recruiting eligible patients while reducing the data collection burden on research staff in community care settings. "The process for running clinical trials has not dramatically improved in three decades," Thoelke explains. "We need to reengineer the research model with new technology and infrastructure that equips community and rural healthcare systems to participate in clinical trials at greater scale."
The AI platform interprets the entirety of patient charts, matches patients to trials, and collects trial data with far less manual burden on research staff. "We can quickly read massive volumes of records with high levels of precision," Thoelke notes.
Regulatory Considerations
The challenge is compounded by FDA requirements for US representation in registrational trials. While clinical trials can be conducted globally to increase the pool of eligible patients, the proportion of US patients in FDA applications has been declining. The FDA requires that enrolled populations be applicable to the US population and medical practice, with a recent oncology drug advisory committee voting against approval of one drug based on concerns that ex-US data was not applicable to the US population.
This regulatory requirement, combined with the increased demand from the developmental pipeline, has created a renewed focus on increasing US participation in registrational trials, making the resolution of domestic trial capacity issues even more critical.
The industry faces a stark choice: embrace transformation through new technologies and decentralized models, or risk a slowdown in drug development that could leave patients without access to potentially life-saving treatments. As Paradigm Health has demonstrated, community healthcare providers can run complex oncology trials with proper support, potentially giving rural patients the same opportunities as those at academic medical centers in large cities.
