Background: Advances in targeted therapy development and tumor sequencing technology are reclassifying cancers into smaller biomarker-defined diseases. Randomized controlled trials (RCTs) are often impractical in rare diseases, leading to calls for single-arm studies to be sufficient to inform clinical practice based on a strong biological rationale. However, without RCTs, favorable outcomes are often attributed to therapy but may be due to a more indolent disease course or other biases. When the clinical benefit of targeted therapy in a common cancer is established in RCTs, this benefit may extend to rarer cancers sharing the same biomarker. However, careful consideration of the appropriateness of extending the existing trial evidence beyond specific cancer types is required. A framework for extrapolating evidence for biomarker-targeted therapies to rare cancers is needed to support transparent decision-making., Objectives: To construct a framework outlining the breadth of criteria essential for extrapolating evidence for a biomarker-targeted therapy generated from RCTs in common cancers to different rare cancers sharing the same biomarker., Design: A series of questions articulating essential criteria for extrapolation., Methods: The framework was developed from the core topics for extrapolation identified from a previous scoping review of methodological guidance. Principles for extrapolation outlined in guidance documents from the European Medicines Agency, the US Food and Drug Administration, and Australia's Medical Services Advisory Committee were incorporated., Results: We propose a framework for assessing key assumptions of similarity of the disease and treatment outcomes between the common and rare cancer for five essential components: prognosis of the biomarker-defined cancer, biomarker test analytical validity, biomarker actionability, treatment efficacy, and safety. Knowledge gaps identified can be used to prioritize future studies., Conclusion: This framework will allow systematic assessment, standardize regulatory, reimbursement and clinical decision-making, and facilitate transparent discussions between key stakeholders in drug assessment for rare biomarker-defined cancers., Competing Interests: All authors declare no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years, and no other relationships or activities that could appear to have influenced the submitted work. D.C. declares receiving an NHMRC Postgraduate Research Scholarship (Medical—Dental) (SC0798), Postgraduate Research Supplementary Scholarship in Oncology and NHMRC Program Grant. She has also received support from Novartis for attending scientific meetings. R.W. declares that she is the Chair of Australia’s Medical Service Advisory Committee and in that capacity an employee of the Commonwealth of Australia. M.I. declares unrestricted research funding from Illumina. He was a member of ESC/MSAC until June 2022. A.M. declares advisory role for national advisory committees for health technologies as an employee of the Department of Health and Aged Care of Australia. S.J.L., S.C., R.L.M., and A.M. declare no conflict of interests. D.M.T. declares he is the chief executive officer of Omico (non-profit). He/Omico declares grants, consultancies, or research support (Roche, AstraZeneca, Pfizer, Eisai, Illumina, Beigene, Elevation Oncology, RedX Pharmaceuticals, SunPharma, Bayer, Abbvie, George Clinical, Janssen, Merck, Kinnate, Microba, BioTessellate, Australian Unity, Foundation Medicine, Guardant Health). J.S. declares research grants to the University of Sydney (Bayer, Roche, BMS, AstraZeneca, Abbvie, MSD, Pfizer). C.K.L. declares honoraria (AstraZeneca, Pfizer, Amgen, Takeda, Yuhan, Boehringer Ingelheim, Roche, MSD Oncology), consulting or advisory role (Novartis, Boehringer Ingelheim, Takeda, AstraZeneca, Yuhan, Amgen), and research funding (AstraZeneca, Roche, Merck KGaA)., (© The Author(s), 2024.)