{"entity":{"id":"b-incentive-misalignment","kind":"bottleneck","name":"Incentives reward me-too drugs and marginal gains","aka":[],"tldr":"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.","asOf":"2026-09-08","links":[{"label":"Upadhaya et al., PD1/PDL1 inhibitor clinical trial landscape (Nat Rev Drug Discov 2022)","url":"https://doi.org/10.1038/d41573-022-00030-4"},{"label":"Mailankody & Prasad, Five years of cancer drug approvals: innovation, efficacy, and costs (JAMA Oncology 2015)","url":"https://doi.org/10.1001/jamaoncol.2015.0373"},{"label":"Vokinger et al., Prices and clinical benefit of cancer drugs (Lancet Oncology 2020)","url":"https://doi.org/10.1016/S1470-2045(20)30139-X"},{"label":"ARPA-H","url":"https://arpa-h.gov/"}],"tags":[],"related":["fda-approvals","esmo-guidelines","trop2-adc-roadmap","idea-fund-public-option-generic-oncology"],"cancers":["pancreatic","glioblastoma","nsclc","tnbc","multiple-myeloma"],"sections":[],"technologies":["checkpoint-inhibitor","adc","kras-inhibitors"],"targets":["pd1","pdl1","trop2","her2","bcma","kras"],"drugs":["pembrolizumab","nivolumab","tislelizumab","toripalimab","camrelizumab","serplulimab","sacituzumab-govitecan","datopotamab-deruxtecan","sacituzumab-tirumotecan","imatinib"],"companies":[],"institutions":["esmo","asco","nci"],"pathways":[],"terms":["accelerated-approval","breakthrough-designation","standard-of-care","first-line","project-frontrunner"],"trials":[],"people":[],"bottlenecks":[],"keyPapers":["paper-upadhaya-nat-rev-drug-discov","paper-vokinger-lancet-oncol","paper-mailankody-jama-oncol"],"journals":[],"dependsOn":[],"notes":[],"stage":"funding-incentives","severity":"critical","metrics":[{"label":"Clinical trials of PD-1/PD-L1 inhibitors registered by 2021","value":"5,683 trials","source":"Upadhaya et al., Nature Reviews Drug Discovery 2022","url":"https://doi.org/10.1038/d41573-022-00030-4"},{"label":"Median overall survival gain of cancer drugs approved by FDA 2002-2014","value":"2.1 months","source":"Fojo, Mailankody & Lo, JAMA Otolaryngology 2014","url":"https://doi.org/10.1001/jamaoto.2014.1570"},{"label":"Correlation between cancer drug prices and clinical benefit (ESMO-MCBS, ASCO framework) in the US and Europe","value":"No significant association","source":"Vokinger et al., Lancet Oncology 2020","url":"https://doi.org/10.1016/S1470-2045(20)30139-X"},{"label":"Relationship between price and novelty (first-in-class vs next-in-class) or benefit for cancer drugs approved by FDA 2009-2013","value":"No difference in price by novelty; no relation to benefit","source":"Mailankody & Prasad, JAMA Oncology 2015","url":"https://doi.org/10.1001/jamaoncol.2015.0373"}],"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."],"currentEfforts":["ESMO-MCBS and the ASCO Value Framework grade benefit so that payers and guidelines can distinguish transformative from marginal drugs.","The US Inflation Reduction Act (2022) introduces Medicare price negotiation, weakening the link between market entry and guaranteed price.","The EU pharmaceutical legislation reform proposal (2023) modulates regulatory data protection according to unmet need and comparative trials.","ARPA-H and the Cancer Moonshot fund high-risk programmes that private capital avoids.","FDA Project FrontRunner encourages first-line development of genuinely novel agents rather than late-line me-too positioning.","Cancer Grand Challenges and philanthropic funders (Stand Up To Cancer) support first-in-class attempts on neglected problems."],"successLooksLike":"Reward for a new cancer drug scales with its measured benefit, so that the expected return on a curative or first-in-class programme for an unsolved cancer exceeds that of a sixth entrant to a crowded class, and the share of new approvals that are first-in-class with substantial benefit rises measurably."},"route":"/bottlenecks/b-incentive-misalignment/","neighbours":{"collection":[{"id":"esmo-guidelines","kind":"collection","name":"ESMO Clinical Practice Guidelines & MCBS","route":"/collections/esmo-guidelines/"},{"id":"fda-approvals","kind":"collection","name":"FDA Oncology Approvals (OCE) & Novel Drug Approvals","route":"/collections/fda-approvals/"}],"roadmap":[{"id":"prevention-roadmap","kind":"roadmap","name":"Cancer prevention roadmap: tobacco control and vaccines → biomarker-guided chemoprevention → interception in carriers","route":"/roadmaps/prevention-roadmap/"},{"id":"paediatric-oncology-roadmap","kind":"roadmap","name":"Paediatric oncology roadmap: cooperative-group cures → engineered immunity → drugs developed for children first","route":"/roadmaps/paediatric-oncology-roadmap/"},{"id":"trop2-adc-roadmap","kind":"roadmap","name":"TROP2 ADC roadmap: sacituzumab govitecan → Dato-DXd → sac-TMT → bispecifics and PET","route":"/roadmaps/trop2-adc-roadmap/"}],"idea":[{"id":"idea-reg-repurposing-prize","kind":"idea","name":"A $50 million prize for the first off-patent drug proven to extend cancer survival","route":"/ideas/idea-reg-repurposing-prize/"},{"id":"idea-fund-cure-prize","kind":"idea","name":"A billion-dollar prize for the first durable cure of a lethal metastatic cancer","route":"/ideas/idea-fund-cure-prize/"},{"id":"idea-gbc-burden-to-funding-audit-and-dedicated-call","kind":"idea","name":"A burden-to-funding audit for gallbladder cancer and a dedicated research call","route":"/ideas/idea-gbc-burden-to-funding-audit-and-dedicated-call/"},{"id":"idea-fund-royalty-pool-academic-assets","kind":"idea","name":"A diversified royalty pool that finances academic phase 1 trials across fifty assets","route":"/ideas/idea-fund-royalty-pool-academic-assets/"},{"id":"idea-bio1-undruggable-market-commitment","kind":"idea","name":"A guaranteed purchase prize for the first drug against a named hard target","route":"/ideas/idea-bio1-undruggable-market-commitment/"},{"id":"idea-fund-health-impact-fund-oncology","kind":"idea","name":"A Health Impact Fund pilot that pays for measured health gain instead of price","route":"/ideas/idea-fund-health-impact-fund-oncology/"},{"id":"idea-fund-nonprofit-pharma","kind":"idea","name":"A non-profit pharmaceutical company for the cancers markets ignore","route":"/ideas/idea-fund-nonprofit-pharma/"},{"id":"idea-tr1-site-equity-index","kind":"idea","name":"A public equity index for trial sites and sponsors, tied to funding","route":"/ideas/idea-tr1-site-equity-index/"},{"id":"idea-moon-generics-for-cancer-fund","kind":"idea","name":"A public fund and label pathway to trial generic drugs against cancer","route":"/ideas/idea-moon-generics-for-cancer-fund/"},{"id":"idea-tr1-public-de-escalation-trial-fund","kind":"idea","name":"A public fund for trials that test less treatment","route":"/ideas/idea-tr1-public-de-escalation-trial-fund/"},{"id":"idea-fund-repurposing-indication-exclusivity","kind":"idea","name":"A repurposing label pathway with short exclusivity that non-profits can hold","route":"/ideas/idea-fund-repurposing-indication-exclusivity/"},{"id":"idea-fund-amc-paediatric-rare","kind":"idea","name":"Advance market commitments for paediatric and rare cancer drugs","route":"/ideas/idea-fund-amc-paediatric-rare/"},{"id":"idea-fund-abbreviated-pathway-me-too-biologics","kind":"idea","name":"An abbreviated approval path for follow-on antibodies within a validated class","route":"/ideas/idea-fund-abbreviated-pathway-me-too-biologics/"},{"id":"idea-moon-hype-index","kind":"idea","name":"An independent hype index grading cancer press releases and news stories","route":"/ideas/idea-moon-hype-index/"},{"id":"idea-acc-episode-payment-tied-to-concordance","kind":"idea","name":"Bundled episode payments for cancer care with bonuses for guideline concordance","route":"/ideas/idea-acc-episode-payment-tied-to-concordance/"},{"id":"idea-reg-price-anchored-to-mcbs","kind":"idea","name":"Cap public prices for new cancer drugs to tiers of the ESMO and ASCO value scales","route":"/ideas/idea-reg-price-anchored-to-mcbs/"},{"id":"idea-reg-conditional-approval-sunset","kind":"idea","name":"Conditional approvals that lapse automatically if the confirmatory trial is late","route":"/ideas/idea-reg-conditional-approval-sunset/"},{"id":"idea-tr2-tenure-replication-credit","kind":"idea","name":"Count replications and open data in hiring and promotion","route":"/ideas/idea-tr2-tenure-replication-credit/"},{"id":"idea-moon-cure-prizes","kind":"idea","name":"Cure-focused prizes: pay for verified long-term cures, not for drugs","route":"/ideas/idea-moon-cure-prizes/"},{"id":"idea-bio2-paediatric-first-development","kind":"idea","name":"Develop drugs in children first when the target is a children's target","route":"/ideas/idea-bio2-paediatric-first-development/"},{"id":"idea-reg-rd-cost-disclosure-condition","kind":"idea","name":"Disclose R&D and manufacturing costs of publicly funded cancer drugs to get coverage","route":"/ideas/idea-reg-rd-cost-disclosure-condition/"},{"id":"idea-fund-paediatric-deferral-escrow","kind":"idea","name":"Escrow a share of adult revenue until the paediatric study is done","route":"/ideas/idea-fund-paediatric-deferral-escrow/"},{"id":"idea-prev-annual-overdiagnosis-reporting","kind":"idea","name":"Every screening programme must publish its overdiagnosis rate each year","route":"/ideas/idea-prev-annual-overdiagnosis-reporting/"},{"id":"idea-cost-gold-card-oncology","kind":"idea","name":"Exempt oncologists who follow the pathway from prior authorisation","route":"/ideas/idea-cost-gold-card-oncology/"},{"id":"idea-fund-duration-trial-exclusivity","kind":"idea","name":"Extra exclusivity for sponsors who run treatment-duration and de-escalation trials","route":"/ideas/idea-fund-duration-trial-exclusivity/"},{"id":"idea-crc-exercise-as-a-funded-treatment","kind":"idea","name":"Fund structured exercise after colon cancer surgery as a treatment, because a randomised trial says it works as well as a drug","route":"/ideas/idea-crc-exercise-as-a-funded-treatment/"},{"id":"idea-cost-shorter-course-trials","kind":"idea","name":"Fund trials that test shorter courses of the most expensive adjuvant drugs","route":"/ideas/idea-cost-shorter-course-trials/"},{"id":"idea-fund-phase-two-failure-reinsurance","kind":"idea","name":"Government reinsurance for phase 2 failures of first-in-class cancer drugs","route":"/ideas/idea-fund-phase-two-failure-reinsurance/"},{"id":"idea-fund-public-car-t-manufacturing","kind":"idea","name":"Hospital-based CAR-T manufacturing at cost through a public network","route":"/ideas/idea-fund-public-car-t-manufacturing/"},{"id":"idea-fund-programme-officer-incentives","kind":"idea","name":"Judge funding programme officers on burden alignment and trials completed","route":"/ideas/idea-fund-programme-officer-incentives/"},{"id":"idea-fund-mcbs-linked-pricing","kind":"idea","name":"Launch prices indexed to the ESMO benefit scale, revisited when survival matures","route":"/ideas/idea-fund-mcbs-linked-pricing/"},{"id":"idea-tr2-material-failure-disclosure","kind":"idea","name":"Listed companies must disclose top-line data, not just 'did not meet endpoint'","route":"/ideas/idea-tr2-material-failure-disclosure/"},{"id":"idea-cost-early-palliative-default","kind":"idea","name":"Make early palliative care and a goals conversation part of every advanced-cancer pathway","route":"/ideas/idea-cost-early-palliative-default/"},{"id":"idea-prev-omit-radiotherapy-low-risk-breast-default","kind":"idea","name":"Make skipping radiotherapy the default for very low-risk breast cancer","route":"/ideas/idea-prev-omit-radiotherapy-low-risk-breast-default/"},{"id":"idea-fund-first-in-class-prize","kind":"idea","name":"Milestone prizes for first-in-class mechanisms reaching human proof of concept","route":"/ideas/idea-fund-first-in-class-prize/"},{"id":"idea-tr1-mams-for-sequencing-questions","kind":"idea","name":"Multi-arm, multi-stage trials to answer which order to give approved drugs","route":"/ideas/idea-tr1-mams-for-sequencing-questions/"},{"id":"idea-tr2-contribution-of-components-mandate","kind":"idea","name":"No accelerated approval for a combination without proof each part contributes","route":"/ideas/idea-tr2-contribution-of-components-mandate/"},{"id":"idea-fund-pay-for-cure-annuities","kind":"idea","name":"Outcome-based annuity payments for potentially curative one-time therapies","route":"/ideas/idea-fund-pay-for-cure-annuities/"},{"id":"idea-cost-340b-pass-through","kind":"idea","name":"Pass 340B discounts on cancer drugs through to the patient's bill","route":"/ideas/idea-cost-340b-pass-through/"},{"id":"idea-fund-value-based-patent-extension","kind":"idea","name":"Patent term extension scaled to proven survival gain","route":"/ideas/idea-fund-value-based-patent-extension/"},{"id":"idea-fund-open-source-repurposing-leads","kind":"idea","name":"Patent-free open-source development of repurposed and off-patent cancer drugs","route":"/ideas/idea-fund-open-source-repurposing-leads/"},{"id":"idea-cost-asp-flat-fee","kind":"idea","name":"Pay a flat fee for giving a Part B drug instead of 6% of 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drugs","route":"/ideas/idea-bio2-exercise-reimbursement/"},{"id":"idea-prev-pay-for-prevention-outcomes","kind":"idea","name":"Pay insurers and health systems for cancers prevented and caught early","route":"/ideas/idea-prev-pay-for-prevention-outcomes/"},{"id":"idea-fund-trial-completion-bonus","kind":"idea","name":"Pay investigators for finishing and publishing trials, not for enrolling patients","route":"/ideas/idea-fund-trial-completion-bonus/"},{"id":"idea-tr1-protected-physician-time-for-enrolment","kind":"idea","name":"Pay oncologists for the time it takes to enrol a patient","route":"/ideas/idea-tr1-protected-physician-time-for-enrolment/"},{"id":"idea-fund-course-based-radiotherapy-payment","kind":"idea","name":"Pay per course of radiotherapy, not per session, so short courses are not penalised","route":"/ideas/idea-fund-course-based-radiotherapy-payment/"},{"id":"idea-cost-site-neutral-infusion","kind":"idea","name":"Pay the same for an infusion whether it is given in a 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