# Fund trials that test shorter courses of the most expensive adjuvant drugs

Source: https://onco.cc/ideas/idea-cost-shorter-course-trials/  
OnCo record `idea-cost-shorter-course-trials` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

The PERSEPHONE trial showed six months of trastuzumab after surgery is as good as twelve, halving the drug cost; no company will run such trials, so public funders and charities must.

## Summary

PERSEPHONE (Earl et al., Lancet 2019) randomised 4,089 women with HER2-positive early breast cancer to six or twelve months of adjuvant trastuzumab and found four-year disease-free survival of 89.4% versus 89.8%, meeting non-inferiority, with less cardiotoxicity. Adjuvant durations for checkpoint inhibitors (one year), CDK4/6 inhibitors (two to three years) and PARP inhibitors (one year) were set without duration-finding studies. A dedicated de-escalation trial fund, on the model of the UK National Institute for Health and Care Research that paid for PERSEPHONE, would test the highest-spend adjuvant regimens.

## Fields

- Kind: Idea
- Last checked: 2026-09-10
- Hypothesis: At least two of five adjuvant de-escalation trials will demonstrate non-inferiority, each saving more than a third of the drug cost for that indication.
- Rationale: Manufacturers have no incentive to shorten courses; the payer has every incentive and the evidence base for adjuvant durations is thin.
- Proposed test: A funded portfolio of five randomised non-inferiority duration trials run through cooperative groups, with pre-registered margins and cost-effectiveness analyses.
- Maturity: early-clinical
- Actor: philanthropy

## Sources

- Earl et al., Lancet 2019: PERSEPHONE: https://doi.org/10.1016/S0140-6736(19)30650-6

## Connected records

- cancers: [HER2-positive breast cancer](https://onco.cc/cancers/breast-her2-positive/), [HR-positive / HER2-negative breast cancer](https://onco.cc/cancers/breast-hr-positive/)
- drugs: [Abemaciclib](https://onco.cc/drugs/abemaciclib/), [Olaparib](https://onco.cc/drugs/olaparib/), [Pembrolizumab](https://onco.cc/drugs/pembrolizumab/), [Trastuzumab](https://onco.cc/drugs/trastuzumab/)
- institutions: [Cancer Research UK](https://onco.cc/institutions/cruk/), [National Cancer Institute (NIH)](https://onco.cc/institutions/nci/)
- trials: [PERSEPHONE](https://onco.cc/trials/persephone/)
- bottlenecks: [Incentives reward me-too drugs and marginal gains](https://onco.cc/bottlenecks/b-incentive-misalignment/), [Prices and value](https://onco.cc/bottlenecks/b-drug-pricing/), [Trial design, endpoints and cost](https://onco.cc/bottlenecks/b-trial-design/), [Wrong doses](https://onco.cc/bottlenecks/b-dose-optimisation/)
- roadmaps: [Global access and affordability roadmap: essential medicines and generics → biosimilars and frugal trials → reliance, pooling and homegrown innovation](https://onco.cc/roadmaps/global-access-roadmap/), [Hormonal therapy roadmap: removing the ovaries → tamoxifen → oral degraders switched by a blood test](https://onco.cc/roadmaps/hormonal-therapy-roadmap/)

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