# Incentives reward me-too drugs and marginal gains

Source: https://onco.cc/bottlenecks/b-incentive-misalignment/  
OnCo record `b-incentive-misalignment` (Bottleneck). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

The system pays the same for a drug that adds two months as for a cure, so companies race to copy rather than to cure.

## Summary

The economics of oncology reward being the fifth entrant to a validated target more reliably than being the first to attempt an unsolved one. Thousands of trials have tested PD-1/PD-L1 antibodies, more than a dozen of which are approved with near-identical activity, and TROP2 and HER2 ADCs, KRAS G12C inhibitors and BCMA-directed therapies each have crowded fields, while first-in-class attempts on the hardest problems (pancreatic cancer, glioblastoma, metastasis prevention, cachexia) are few. Prices are set with no relation to benefit, so a drug adding two months of median survival can be priced like a cure, and regulatory precedent makes the follow-on path cheaper and more predictable. Patents reward molecules rather than outcomes; nothing pays for the trial that shows a drug can be stopped, given for less time, or replaced by a generic. Aligning reward with magnitude of benefit, through value-based pricing, benefit-graded exclusivity, prizes and public development of unattractive assets, is the structural fix.

## Fields

- Kind: Bottleneck
- Last checked: 2026-09-08
- Stage: funding-incentives
- Severity: critical
- Metrics: Clinical trials of PD-1/PD-L1 inhibitors registered by 2021: 5,683 trials (Upadhaya et al., Nature Reviews Drug Discovery 2022); Median overall survival gain of cancer drugs approved by FDA 2002-2014: 2.1 months (Fojo, Mailankody & Lo, JAMA Otolaryngology 2014); Correlation between cancer drug prices and clinical benefit (ESMO-MCBS, ASCO framework) in the US and Europe: No significant association (Vokinger et al., Lancet Oncology 2020); Relationship between price and novelty (first-in-class vs next-in-class) or benefit for cancer drugs approved by FDA 2009-2013: No difference in price by novelty; no relation to benefit (Mailankody & Prasad, JAMA Oncology 2015)
- Causes: Price is unrelated to benefit, so a marginal drug earns as much per patient as a transformative one.; Validated targets carry lower scientific and regulatory risk, which capital markets prefer.; Regulatory precedent and surrogate endpoints make follow-on approvals faster and cheaper.; Patent exclusivity rewards new molecules, not new evidence about old ones or about how to use less.; The hardest problems have long, uncertain, expensive development paths with no interim commercial return.

## Sources

- Upadhaya et al., PD1/PDL1 inhibitor clinical trial landscape (Nat Rev Drug Discov 2022): https://doi.org/10.1038/d41573-022-00030-4
- Mailankody & Prasad, Five years of cancer drug approvals: innovation, efficacy, and costs (JAMA Oncology 2015): https://doi.org/10.1001/jamaoncol.2015.0373
- Vokinger et al., Prices and clinical benefit of cancer drugs (Lancet Oncology 2020): https://doi.org/10.1016/S1470-2045(20)30139-X
- ARPA-H: https://arpa-h.gov/

## Connected records

- collections: [ESMO Clinical Practice Guidelines & MCBS](https://onco.cc/collections/esmo-guidelines/), [FDA Oncology Approvals (OCE) & Novel Drug Approvals](https://onco.cc/collections/fda-approvals/)
- roadmaps: [Cancer prevention roadmap: tobacco control and vaccines → biomarker-guided chemoprevention → interception in carriers](https://onco.cc/roadmaps/prevention-roadmap/), [Paediatric oncology roadmap: cooperative-group cures → engineered immunity → drugs developed for children first](https://onco.cc/roadmaps/paediatric-oncology-roadmap/), [TROP2 ADC roadmap: sacituzumab govitecan → Dato-DXd → sac-TMT → bispecifics and PET](https://onco.cc/roadmaps/trop2-adc-roadmap/)
- ideas: [A $50 million prize for the first off-patent drug proven to extend cancer survival](https://onco.cc/ideas/idea-reg-repurposing-prize/), [A billion-dollar prize for the first durable cure of a lethal metastatic cancer](https://onco.cc/ideas/idea-fund-cure-prize/), [A burden-to-funding audit for gallbladder cancer and a dedicated research call](https://onco.cc/ideas/idea-gbc-burden-to-funding-audit-and-dedicated-call/), [A diversified royalty pool that finances academic phase 1 trials across fifty assets](https://onco.cc/ideas/idea-fund-royalty-pool-academic-assets/), [A guaranteed purchase prize for the first drug against a named hard target](https://onco.cc/ideas/idea-bio1-undruggable-market-commitment/), [A Health Impact Fund pilot that pays for measured health gain instead of price](https://onco.cc/ideas/idea-fund-health-impact-fund-oncology/), [A non-profit pharmaceutical company for the cancers markets ignore](https://onco.cc/ideas/idea-fund-nonprofit-pharma/), [A public equity index for trial sites and sponsors, tied to funding](https://onco.cc/ideas/idea-tr1-site-equity-index/), [A public fund and label pathway to trial generic drugs against cancer](https://onco.cc/ideas/idea-moon-generics-for-cancer-fund/), [A public fund for trials that test less treatment](https://onco.cc/ideas/idea-tr1-public-de-escalation-trial-fund/), [A repurposing label pathway with short exclusivity that non-profits can hold](https://onco.cc/ideas/idea-fund-repurposing-indication-exclusivity/), [Advance market commitments for paediatric and rare cancer drugs](https://onco.cc/ideas/idea-fund-amc-paediatric-rare/), [An abbreviated approval path for follow-on antibodies within a validated class](https://onco.cc/ideas/idea-fund-abbreviated-pathway-me-too-biologics/), [An independent hype index grading cancer press releases and news stories](https://onco.cc/ideas/idea-moon-hype-index/), [Bundled episode payments for cancer care with bonuses for guideline concordance](https://onco.cc/ideas/idea-acc-episode-payment-tied-to-concordance/), [Cap public prices for new cancer drugs to tiers of the ESMO and ASCO value scales](https://onco.cc/ideas/idea-reg-price-anchored-to-mcbs/), [Conditional approvals that lapse automatically if the confirmatory trial is late](https://onco.cc/ideas/idea-reg-conditional-approval-sunset/), [Count replications and open data in hiring and promotion](https://onco.cc/ideas/idea-tr2-tenure-replication-credit/), [Cure-focused prizes: pay for verified long-term cures, not for drugs](https://onco.cc/ideas/idea-moon-cure-prizes/), [Develop drugs in children first when the target is a children's target](https://onco.cc/ideas/idea-bio2-paediatric-first-development/), [Disclose R&D and manufacturing costs of publicly funded cancer drugs to get coverage](https://onco.cc/ideas/idea-reg-rd-cost-disclosure-condition/), [Escrow a share of adult revenue until the paediatric study is done](https://onco.cc/ideas/idea-fund-paediatric-deferral-escrow/), [Every screening programme must publish its overdiagnosis rate each year](https://onco.cc/ideas/idea-prev-annual-overdiagnosis-reporting/), [Exempt oncologists who follow the pathway from prior authorisation](https://onco.cc/ideas/idea-cost-gold-card-oncology/), [Extra exclusivity for sponsors who run treatment-duration and de-escalation trials](https://onco.cc/ideas/idea-fund-duration-trial-exclusivity/), [Fund structured exercise after colon cancer surgery as a treatment, because a randomised trial says it works as well as a drug](https://onco.cc/ideas/idea-crc-exercise-as-a-funded-treatment/), [Fund trials that test shorter courses of the most expensive adjuvant drugs](https://onco.cc/ideas/idea-cost-shorter-course-trials/), [Government reinsurance for phase 2 failures of first-in-class cancer drugs](https://onco.cc/ideas/idea-fund-phase-two-failure-reinsurance/), [Hospital-based CAR-T manufacturing at cost through a public network](https://onco.cc/ideas/idea-fund-public-car-t-manufacturing/), [Judge funding programme officers on burden alignment and trials completed](https://onco.cc/ideas/idea-fund-programme-officer-incentives/), [Launch prices indexed to the ESMO benefit scale, revisited when survival matures](https://onco.cc/ideas/idea-fund-mcbs-linked-pricing/), [Listed companies must disclose top-line data, not just 'did not meet endpoint'](https://onco.cc/ideas/idea-tr2-material-failure-disclosure/), [Make early palliative care and a goals conversation part of every advanced-cancer pathway](https://onco.cc/ideas/idea-cost-early-palliative-default/), [Make skipping radiotherapy the default for very low-risk breast cancer](https://onco.cc/ideas/idea-prev-omit-radiotherapy-low-risk-breast-default/), [Milestone prizes for first-in-class mechanisms reaching human proof of concept](https://onco.cc/ideas/idea-fund-first-in-class-prize/), [Multi-arm, multi-stage trials to answer which order to give approved drugs](https://onco.cc/ideas/idea-tr1-mams-for-sequencing-questions/), [No accelerated approval for a combination without proof each part contributes](https://onco.cc/ideas/idea-tr2-contribution-of-components-mandate/), [Outcome-based annuity payments for potentially curative one-time therapies](https://onco.cc/ideas/idea-fund-pay-for-cure-annuities/), [Pass 340B discounts on cancer drugs through to the patient's bill](https://onco.cc/ideas/idea-cost-340b-pass-through/), [Patent term extension scaled to proven survival gain](https://onco.cc/ideas/idea-fund-value-based-patent-extension/), [Patent-free open-source development of repurposed and off-patent cancer drugs](https://onco.cc/ideas/idea-fund-open-source-repurposing-leads/), [Pay a flat fee for giving a Part B drug instead of 6% of its price](https://onco.cc/ideas/idea-cost-asp-flat-fee/), [Pay a prize for rare cancer drugs instead of hoping for a market](https://onco.cc/ideas/idea-bio2-rare-cancer-prize-fund/), [Pay for a course of radiotherapy, not for each fraction](https://onco.cc/ideas/idea-cost-hypofractionation-payment/), [Pay for cancer AI only when it has outcome evidence, then pay properly](https://onco.cc/ideas/idea-data-ai-reimbursement-tied-to-outcomes/), [Pay for residual disease tests only inside a trial or registry](https://onco.cc/ideas/idea-bio2-mrd-coverage-with-evidence/), [Pay for supervised exercise the way we pay for drugs](https://onco.cc/ideas/idea-bio2-exercise-reimbursement/), [Pay insurers and health systems for cancers prevented and caught early](https://onco.cc/ideas/idea-prev-pay-for-prevention-outcomes/), [Pay investigators for finishing and publishing trials, not for enrolling patients](https://onco.cc/ideas/idea-fund-trial-completion-bonus/), [Pay oncologists for the time it takes to enrol a patient](https://onco.cc/ideas/idea-tr1-protected-physician-time-for-enrolment/), [Pay per course of radiotherapy, not per session, so short courses are not penalised](https://onco.cc/ideas/idea-fund-course-based-radiotherapy-payment/), [Pay the same for an infusion whether it is given in a hospital or a clinic](https://onco.cc/ideas/idea-cost-site-neutral-infusion/), [Pay-for-cure contracts: instalment payments for curative therapies contingent on durable remission](https://onco.cc/ideas/idea-moon-pay-for-cure-contracts/), [Payers fund trials of cheaper, shorter or lower-dose versions of expensive treatments](https://onco.cc/ideas/idea-fund-payer-funded-pragmatic-trials/), [Payers pre-commit to cover off-label generics when a definitive trial is positive](https://onco.cc/ideas/idea-reg-payer-coverage-off-label-generic-commitment/), [Price a cancer drug by how well it works in each cancer](https://onco.cc/ideas/idea-cost-indication-based-pricing/), [Prizes for unpatentable surgical and radiotherapy techniques proven in trials](https://onco.cc/ideas/idea-fund-technique-innovation-prize/), [Promote academics for trials completed, data shared and findings replicated](https://onco.cc/ideas/idea-fund-academic-promotion-reform/), [Public co-investment in first-in-class phase 1 with a royalty return](https://onco.cc/ideas/idea-fund-sovereign-first-in-class-coinvestment/), [Public-option manufacturing for essential generic cancer drugs in shortage](https://onco.cc/ideas/idea-fund-public-option-generic-oncology/), [Publicly funded dose-reduction trials of expensive approved drugs](https://onco.cc/ideas/idea-tr1-public-dose-reduction-trials-of-approved-drugs/), [Randomise the order of treatment, not only the drugs: a strategy platform for metastatic prostate cancer](https://onco.cc/ideas/idea-prostate-randomise-the-sequence-not-only-the-drugs/), [Randomised evidence for the T-cell lymphomas, including the ones that are not in Europe or North America](https://onco.cc/ideas/lymphoma-ev-randomised-evidence-for-the-t-cell-lymphomas/), [Reassess cancer drug prices at three years using real-world outcomes](https://onco.cc/ideas/idea-data-outcome-based-price-reassessment/), [Require head-to-head trials against the best in class for later entrants](https://onco.cc/ideas/idea-fund-head-to-head-mandate/), [Shorter exclusivity for later-in-class drugs without added benefit](https://onco.cc/ideas/idea-fund-benefit-indexed-exclusivity/), [Social impact bonds for cancer prevention, repaid from avoided treatment costs](https://onco.cc/ideas/idea-fund-social-impact-bonds-prevention/), [Sponsors deposit the confirmatory trial budget in escrow at accelerated approval](https://onco.cc/ideas/idea-reg-confirmatory-trial-escrow/), [Take high-dose testosterone to phase 3, with progression-free survival through the second line as the primary endpoint](https://onco.cc/ideas/idea-prostate-bipolar-androgen-therapy-phase-3-on-pfs2/), [Three years of indication-specific exclusivity for proving a new cancer use of an old drug](https://onco.cc/ideas/idea-reg-new-indication-exclusivity-off-patent/), [Tie coverage and copays to the ESMO benefit scale](https://onco.cc/ideas/idea-cost-value-scale-in-coverage/), [Transferable priority vouchers for first-in-class drugs, with price conditions](https://onco.cc/ideas/idea-fund-conditional-transferable-voucher/), [University licences with royalties indexed to benefit and global access](https://onco.cc/ideas/idea-fund-global-access-licensing-royalties/)
- cancers: [Glioma & glioblastoma](https://onco.cc/cancers/glioblastoma/), [Multiple myeloma](https://onco.cc/cancers/multiple-myeloma/), [Non-small-cell lung cancer](https://onco.cc/cancers/nsclc/), [Pancreatic ductal adenocarcinoma](https://onco.cc/cancers/pancreatic/), [Triple-negative breast cancer (TNBC)](https://onco.cc/cancers/tnbc/)
- technologies: [After treatment in the United States: the survivorship care plan, and what the trial found](https://onco.cc/technologies/rejuv-access-survivorship-care-us/), [Antibody-drug conjugate (ADC)](https://onco.cc/technologies/adc/), [Immune checkpoint inhibitors](https://onco.cc/technologies/checkpoint-inhibitor/), [KRAS & RAS inhibitors](https://onco.cc/technologies/kras-inhibitors/), [What has actually been implemented since those trials, and what has not](https://onco.cc/technologies/rejuv-measure-epro-implementation/), [What recovery costs in the United States](https://onco.cc/technologies/rejuv-access-what-it-costs-us/)
- targets: [BCMA](https://onco.cc/targets/bcma/), [HER2](https://onco.cc/targets/her2/), [KRAS](https://onco.cc/targets/kras/), [PD-1](https://onco.cc/targets/pd1/), [PD-L1](https://onco.cc/targets/pdl1/), [TROP2](https://onco.cc/targets/trop2/)
- drugs: [Camrelizumab](https://onco.cc/drugs/camrelizumab/), [Datopotamab deruxtecan](https://onco.cc/drugs/datopotamab-deruxtecan/), [Imatinib](https://onco.cc/drugs/imatinib/), [Nivolumab](https://onco.cc/drugs/nivolumab/), [Pembrolizumab](https://onco.cc/drugs/pembrolizumab/), [Sacituzumab govitecan](https://onco.cc/drugs/sacituzumab-govitecan/), [Sacituzumab tirumotecan](https://onco.cc/drugs/sacituzumab-tirumotecan/), [Serplulimab](https://onco.cc/drugs/serplulimab/), [Tislelizumab](https://onco.cc/drugs/tislelizumab/), [Toripalimab](https://onco.cc/drugs/toripalimab/)
- institutions: [ACCELERATE](https://onco.cc/institutions/accelerate-platform/), [American Society of Clinical Oncology (ASCO)](https://onco.cc/institutions/asco/), [Emerson Collective](https://onco.cc/institutions/emerson-collective/), [European Society for Medical Oncology (ESMO)](https://onco.cc/institutions/esmo/), [National Cancer Institute (NIH)](https://onco.cc/institutions/nci/)
- terms: [Accelerated approval](https://onco.cc/terms/accelerated-approval/), [Breakthrough Therapy / Priority Review / Priority Voucher](https://onco.cc/terms/breakthrough-designation/), [EU pharmaceutical package reform (2023 proposal)](https://onco.cc/terms/eu-pharma-package/), [FDORA 2022 accelerated approval reforms](https://onco.cc/terms/fdora-2022/), [Inflation Reduction Act 2022: Medicare drug price negotiation](https://onco.cc/terms/inflation-reduction-act/), [Lines of therapy](https://onco.cc/terms/first-line/), [Orphan Drug Act 1983](https://onco.cc/terms/orphan-drug-act/), [Paediatric drug laws: BPCA and PREA](https://onco.cc/terms/bpca-prea/), [Project FrontRunner](https://onco.cc/terms/project-frontrunner/), [RACE for Children Act](https://onco.cc/terms/race-for-children-act/), [Regulation (EC) No 141/2000: EU orphan medicines](https://onco.cc/terms/eu-orphan-regulation/), [Regulation (EC) No 1901/2006: EU paediatric medicines](https://onco.cc/terms/eu-paediatric-regulation/), [Standard of care](https://onco.cc/terms/standard-of-care/), [US regulatory exclusivity periods](https://onco.cc/terms/us-regulatory-exclusivity/)
- key papers: [Alcohol caused an estimated 741,000 cancers worldwide in 2020](https://onco.cc/key-papers/paper-alcohol-cancer-burden-lancet-oncol-2021/), [Challenges and opportunities in the PD1/PDL1 inhibitor clinical trial landscape](https://onco.cc/key-papers/paper-upadhaya-nat-rev-drug-discov/), [Doll and Hill 1950: the case-control study that tied smoking to lung cancer](https://onco.cc/key-papers/paper-doll-hill-smoking-lung-cancer-bmj-1950/), [Fifty years of the British Doctors Study: smokers lose ten years of life, quitting gives most of it back](https://onco.cc/key-papers/paper-doll-peto-50-year-doctors-bmj-2004/), [Five Years of Cancer Drug Approvals: Innovation, Efficacy, and Costs](https://onco.cc/key-papers/paper-mailankody-jama-oncol/), [Prices and clinical benefit of cancer drugs in the USA and Europe: a cost-benefit analysis](https://onco.cc/key-papers/paper-vokinger-lancet-oncol/)
- people: [Brian Druker](https://onco.cc/people/brian-druker/), [Mary Lasker](https://onco.cc/people/mary-lasker/)

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