Patient Perspectives on Approval Speed vs Evidentiary Certainty in US Cancer Drug Approvals

Importance: Use of the US Food and Drug Administration's Accelerated Approval pathway assumes that patients are willing to accept uncertainty about clinical benefit in exchange for faster access to new cancer drugs. However, little is known about how patients view this trade-off or the circumstances under which they consider it acceptable. Objectives: To explore patients' views on the trade-off between faster approval and evidentiary certainty regarding the clinical benefit of new cancer drugs in the US. Design, Setting, and Participants: This qualitative study used semistructured interviews conducted online between January 27 and April 1, 2025, with patients aged 18 years or older diagnosed with breast cancer. Purposive sampling was used to achieve maximum variation in cancer stage, treatment status, age, and sociodemographic background. Main Outcomes and Measures: The primary outcome was patients' views on the trade-off between faster drug approval and evidentiary certainty. Interview transcripts were thematically analyzed to identify key patterns in understanding, experiences of uncertainty, attitudes toward waiting, treatment priorities, and views on regulatory decision-making. Results: A total of 125 individuals registered their interest and met eligibility criteria to participate. After purposive sampling, 30 participated in this study (10 aged 20-39 years 33.3%, 12 aged 40-59 years 40.0%, and 8 aged >60 years 26.7%; all female), representing 17 US states (9 Northeast, 12 Midwest, 4 South, 5 West). A total of 13 participants (43.3%) had metastatic disease, 21 (70.0%) were receiving active treatment, and 27 (90.0%) had received at least 1 systemic therapy. Faster approval at the expense of certainty about the clinical benefit of new cancer drugs was considered most acceptable when no alternative treatments existed or when the anticipated benefits were transformative. When clinical benefit was uncertain, participants emphasized the importance of survival and quality of life as priority treatment outcomes, the added risks of adverse effects, and the burden of intensive treatment. Many viewed broader access to clinical trials, rather than faster regulatory approval, as an effective way to address unmet needs while facilitating evidence generation for approval. Conclusion and Relevance: In this qualitative study of patients diagnosed with breast cancer, there was a mismatch between when patients considered trading evidentiary certainty for faster approval as acceptable and the conditions under which many new cancer drugs are approved by the Food and Drug Administration. To better align regulatory approvals with patient values, use of accelerated approval may be most appropriate for drugs that are likely to address genuine treatment gaps or offer meaningful improvements in clinical outcomes over existing alternatives.