Evaluating Worldwide Disparities in Bladder Cancer Clinical Trial Availability

Background: Bladder cancer disproportionately affects non-high-income countries, yet clinical trials underrepresent global diversity. We assessed global availability of bladder cancer trials, their alignment with disease burden, and barriers to equitable care. Methods: We queried ClinicalTrials.gov for adult bladder cancer trials from June 2019 to June 2024, excluding observational and non-oncologic trials. Trial characteristics were summarized descriptively, and country data came from the Global Cancer Observatory. Countries were classified per World Bank Ranking (WBR) into high-income (HICs), upper middle-income (UMICs), lower middle-income (LMICs), and low-income countries (LICs). Trials were categorized as HIC-only, non-HIC, or mixed-income trials. Fisher's exact and Kruskal-Wallis tests compared groups. Multivariable logistic regression assessed associations between trial availability and WBR, national health expenditure, and gross national income (GNI). Univariable linear regression and ANOVA assessed the association between the mortality-to-incident ratio and WBR. Results: Of 611 trials, 75.1% were HIC-only, 16.9% non-HIC, and 8.0% mixed-income trials. Non-HIC trials were mainly academic-sponsored (80.6%), while all mixed-income trials had pharmaceutical sponsorship (p < 0.001). Non-HIC trials had lower enrollment, less pharmaceutical funding, fewer multinational collaborations, and fewer basket, multi-arm, early-phase designs (all p < 0.001). Mixed-income trials were larger, led by HICs, had broader eligibility criteria, more novel therapies, and more frequent use of overall survival endpoints. Trial availability was lower in UMICs (p = 0.011), LMICs (p = 0.024), and absent in LICs, and positively associated with higher national health expenditure (p = 0.007) and GNI (p = 0.001). Conclusions: Bladder cancer trials remain concentrated in HICs. Mixed-income trials expand access in non-high-income countries, but are exclusively led by HICs and require balanced sponsorship, early-phase research, and lasting local benefits.